Infusion of platelets transiently reduces nucleoside overload in MNGIE

Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is caused by thymidine phosphorylase (TP) deficiency, which leads to toxic accumulations of thymidine (dThd) and deoxyuridine (dUrd). In this work, we report that infusion of platelets from healthy donors to patients with MNGIE restored transiently circulating TP and reduced plasma dThd and dUrd levels, suggesting that treatments to achieve permanent restoration of circulating TP such as allogeneic stem cell transplantation or gene transfer might be therapeutic.

Relevance of genetically determined host factors to the prognosis of meningococcal disease

To assess the relevance of genetically determined host factors for the prognosis of meningococcal disease, Fc gamma receptor IIA (FcgammaRIIA), the tumor necrosis factor alpha (TNF-alpha) gene promoter region, and plasminogen-activator-inhibitor-1 (PAI-1) gene polymorphisms were studied in 145 patients with meningococcal disease and in 290 healthy controls matched by sex. Distribution of FcgammaRIIA, TNF-alpha, and PAI-1 alleles was not significantly different between patients and controls. Patients with the FcgammaRIIA-R/R 131 allotype scored > or =1 point in the Barcelona prognostic system more frequently than patients with other allotypes (odds ratio, 18.6; 95% confidence interval, 7.1-49.0, P<0.0001), and they had a higher risk of sequelae (odds ratio, 3.5; 95% confidence interval, 1.1-11.7; P=0.03). Fc gamma receptor IIA polymorphism was associated with markers of disease severity, but TNF-alpha and PAI-1 polymorphisms were not.

Improvement in quality of life in patients with advanced Parkinson's disease following bilateral deep-brain stimulation in subthalamic nucleus

In this article we investigate the changes observed in the scales that quantify the quality of life (PDQ-39) in patients that have already completed 1 and 2 years of bilateral subthalamic stimulation (DBS-STN). Fourteen patients were evaluated 1 year after DBS-STN; the evaluation was repeated on 11 of them, 2 years after surgery. All of them suffered from Parkinson's disease with a 14.3 (+/-5.7) years history of motor complications. Patients were selected according to CAPSIT criteria. All of them were implanted bilateral electrodes in the subthalamic nucleus. The parameters applied were UPDRS II, UPDRS III, PDQ-39, and the scale of quality of life for caregivers (SQLC). Scorings in motor scales (UPDRS III) improved 45% in relation to the first year, and 48% in relation to the second year (P < 0.001). Patient's quality of life (PDQ-39 summary index) improvement was 62% 2 years after surgery (P < 0.001), and caregivers' quality of life improvement was 68% (P = 0.002) by the same time. DBS-STN is a therapy that efficiently improves the quality of life of selected patients with Parkinson's disease. This improvement is still present 2 years after surgery and has a positive impact on caregivers quality of life.

Cutaneous ulcers with type I cryoglobulinemia treated with plasmapheresis

Severe necrotic cutaneous ulcers and kidney involvement secondary to type I cryoglobulinemia can be a therapeutic challenge. Plasmapheresis has been reported useful to treat autoimmune diseases such as thrombotic thrombocytopenic purpura, systemic lupus erythematosus, myasthenia gravis and Goodpasture's syndrome. We report the case of a patient who presented necrotic lesions with kidney involvement due to type I cryoglobulinemia (Ig G kappa) that evolved to a multiple myeloma. Treatment with high doses of corticosteroid plus cyclophosphamide did not control the disorder. Therapy with plasmapheresis produced a marked decrease in cryoglobulin levels and a subsequent relevant clinical improvement of cutaneous lesions and renal function. In cryoglobulinemia, plasmapheresis can be used as effective adjunt therapy to minimize cutaneous, renal and/or neurologic involvement.

[Bilateral subthalamic nucleus deep-brain stimulation (STN-DBS) in Parkinson's disease: initial experience in Cruces Hospital]

INTRODUCTION

Clinical outcomes of Parkinson's disease patients treated for 12 months with STN-DBS were analyzed. PATIENTS ADN METHODS: Twelve patients were selected using the CAPSIT protocol criteria and placement of electrodes in the appropriate target was performed according to results of fusion image techniques and intraoperative microrecording.

RESULTS

A reduction in motor UPDRS (44 %) and activities of daily living (58 %) scores during <<off>> phases were observed. <<On>> time with dyskinesias was reduced (86 %), while severe dyskinesias disappeared. Levodopa dosage was also lowered (44 %). Patients and caregivers showed a clear-cut benefit on quality of life (58 % and 61 % respectively). No cognitive deterioration was observed and morbidity was in the same range as that published by other teams.

CONCLUSION

Bilateral STN-DBS is an effective symptomatic therapy for complicated Parkinsońs disease patients. It improves the quality of life of patients and their caregivers and allows a reduction of levodopa dosage.

[Neuropsychological changes and bilateral subthalamic deep brain stimulation in Parkinson's disease]

INTRODUCTION

To investigate neuropsychiatric changes in Parkinson's disease (PD) patients after 12 months of bilateral subthalamic deep brain stimulation (DBS-STN).

SUBJECTS

Nine out of 23 patients with PD subjected to DBS-STN were included. The mean follow-up of this cohort was 12 months, mean disease duration 14.2 5.5 years and mean UPDRS motor score in <<off>> 43.2 13.7.

METHODS

Patients were selected on the basis of CAPSIT criteria. They underwent bilateral implant of stimulators in STN under stereotactic conditions. Quality of life scale (PDQ 39), depression scale (Brev-Cet), frontal function test (Stroop, Wisconsin, verbal fluency) and memory evaluation (Barcelona test) were monitored at baseline in <<on>> medication and after 12 months in <<on>> medication/<<on>> stimulation.

RESULTS

The patients' motor scores improved on an average of 40.2 % (p = 0.0002) in <<off>> medication situation and 58 % in quality of life scores. We observed a benefit in depression scores (52 %, p = 0.003). Immediate verbal memory improved as well, 25 % (p = 0.04) in recall memory and 14 % (p = 0.02) in recognition memory. No changes were observed in visual memory, verbal fluency and/or global cognitive tests.

CONCLUSION

DBS-STN in PD patients seems to be an effective tool for improving their quality of life, due to its benefits on motor function, verbal memory and mood. Bilateral DBS-STN did not affect either verbal fluency or executive functions in our patients. Neuropsychological assessment is a good tool for selection and study of the operated patients.

Functional effects of the ABO locus polymorphism on plasma levels of von Willebrand factor, factor VIII, and activated partial thromboplastin time

Lower levels of factor VIII and von Willebrand factor (vWF) have been reported in individuals with blood type O compared with individuals with other ABO blood types. However, this relationship has been demonstrated only by association studies and not by linkage studies. Also, it is not clear whether the ABO locus exerts a functional effect directly on these plasma factors or whether the ABO locus is in linkage disequilibrium with another locus that controls these factors. To distinguish between these 2 possibilities, we applied new statistical methods combining linkage and association tests in a pedigree-based sample. In contrast to most previous studies that used the ABO phenotypes, our study used the ABO genotypes, permitting us to distinguish AO from AA and BO from BB. Our results clearly showed significant linkage between the ABO locus and vWF antigen (P=0.00075). In addition, factor VIII coagulant activity and activated partial thromboplastin time showed suggestive linkage with the ABO locus (P=0.10 and P=0.13). All 3 plasma phenotypes showed significant differences between OO and non-OO genotypes. In addition, vWF antigen exhibited significant differences between O heterozygotes and non-OO homozygotes. This study is unique because it used a combined linkage and association test, which indicated that the ABO locus itself has a functional effect on these plasma phenotypes.

Mobilization kinetics of peripheral blood progenitor cells after IAPVP-16 salvage chemotherapy plus G-CSF in lymphoproliferative disorders

We have explored the efficacy of salvage chemotherapy combination, IAPVP-16 (ifosfamide 5 g/m2 on day 1; VP-16 100 mg/m2 on days 1-3; ara-C 1.2 g/m2/12 h on days 1 and 2; methylprednisolone 80 mg/m2 on days 1-5) plus G-CSF for PBPC mobilization. This protocol was used in 45 patients with relapsed or refractory lymphoproliferative diseases who underwent 85 leukaphereses. In 41 patients > 2 x 106/kg CD34+ cells were obtained after a median of two procedures. The median number of CD34+ cells harvested was 3.2 x 106/kg per apheresis and 8.4 x 106/kg per patient. Seven of 10 patients who had failed previous mobilization attempts achieved more than 2 x 106 CD34+ cells/kg in a maximum of three aphereses. A history of previous mobilization failure and a low platelet count (<150 x 109/l) negatively influenced the CD34+ cell yield in univariate and multivariate analyses. A good correlation was found between the circulating CD34+ cells/microl and the CD34+ cells and CFU-GM in the leukaphereses products (r = 0.93 and r = 0.73, P < 0.001), and > or =17 CD34+ cells/microl predicted the achievement of > 2 x 106/kg CD34+ cells in a single leukapheresis in more than 90% of cases. IAPVP-16 plus G-CSF may be specially indicated in tandem transplantations or CD34+ selection and in patients who have failed previous mobilization attempts.

[Opercular epileptic syndrome: an unusual form of benign partial epilepsy in childhood]

INTRODUCTION

Functional opercular syndrome in childhood is an exceptional form of presentation of benign partial epilepsy with centro-temporal rolandic spikes (BECRS).

CLINICAL CASES

We studied the evolution of four patients, three of them followed for more than 15 years. Two were siblings, and their father suffered from BECRS with permanent language problems (verbal dyspraxia) and difficulty of protunding his tongue in adulthood. A third patient suffered benign familial neonatal convulsions (BFNC). In all four patients the actual illness begun as a BECRS with opercular troubles as an ictal phenomena. At about four years of age, the opercular disfunction became evident, with severe drooling, facial hypomobility and speech disturbance which waxed and vanished along weeks, months or years, apparently not ictal. Antiepileptic drugs not only were unable to control this situation but also, some of them, like carbamazepine, even worsened the opercular disfunction, increased the number of seizures and enhanced the neuropsychologic disfunction. Only clobazam could achieve the control on opercular disfunction. After 16 years, no further treatment was needed for all patients. There were some permanent sequelae, as speech and orolingual dyspraxia and different neuropsychologic problems.

CONCLUSION

Of noteworth the best performance was attained by the patient treated with clobazam on monotherapy.

The placental blood program of the Barcelona Cord Blood Bank

Cord blood has recently become an alternative to bone marrow transplantation, generating the need for cord blood banks where large numbers of frozen cord blood units can be stored. The Barcelona Cord Blood Bank (bcB) was created in October 1995. Initially, several methods for volume reduction were tested, including Ficoll, Percoll, Gelatin and HES sedimentation. Of these, HES sedimentation (88% +/- 11 CD34+ cells recovery) was the one chosen for routine banking. Up to November 1997, the bank has processed 754 units with a median of 1.05 x 10(9) nucleated cells and 2.5 x 10(6) CD34+ cells stored per unit. Nine of these units have been shipped for transplantation.

Antiepileptic drugs and atypical evolution of idiopathic partial epilepsy

Six patients with classic benign epilepsy of childhood with centrotemporal spikes, treated with carbamazepine (four patients) or sodium valproate (two patients) evolved atypically because the epileptic disorder, diffusion of the electroencephalographic (EEG) discharges during wakefulness, and continuous spike-and-wave during slow sleep associated with severe neuropsychologic abnormalities worsened. These features appeared after a seizure-free interval varying for 2 weeks to 1 year 6 months after initiating therapy and remitted when the previous anticonvulsant drug was discontinued and either substituted with another drug or the patient was left without any treatment. Once the initial antiepileptic drug was discontinued and after a period roughly proportional to the duration of the clinical-EEG complication, the evolution of the patients' seizures was not unusual for this type of epilepsy, with patients eventually becoming free of both seizures and medication and reaching normal school achievement. The clinical complications cannot be attributed solely to the drugs. It must also be related to the underlying substract (i.e., the specific epileptic syndrome involved) that in some patients becomes susceptible to atypical evolution when either product is administered.

Collection of peripheral blood progenitor cells for autografting with low-dose cyclophosphamide plus granulocyte colony-stimulating factor

BACKGROUND AND OBJECTIVE

The combination of high or intermediate-dose cyclophosphamide (CY) plus granulocyte colony-stimulating factor (G-CSF) is useful to mobilize hematopoietic progenitor cells to peripheral blood, but the patients require hospitalization. The aim of this study was to evaluate the efficiency of low-dose CY plus G-CSF (5 ug/kg/day s.c.) as an outpatient treatment in order to collect enough progenitor cells for hematopoietic rescue in autologous peripheral blood transplantation (APBSCT).

DESIGN AND METHODS

We analyzed twenty-eight consecutively treated patients with lymphoma or multiple myeloma. The number of CD34+ cells in blood samples was determined from day +7. Leukapheresis (LKP) began when the absolute number of CD34+ cells in peripheral blood was > 2500/mL and the apheresis product was assayed for mononuclear cells (MNC), granulocyte-macrophage colony-forming units (CFU-GM), total nucleated cells (tNC) and CD34+ cells.

RESULTS

Twenty-eight outpatients with advanced hematologic malignancies (13 non-Hodgkin lymphoma, NHL; 10 Hodgkin's disease, HD; and 5 multiple myeloma, MM), median age 44 years (range 23-65) received a single dose of CY (1.5 g/m2 i.v. day 0) followed by G-CSF (5 ug/kg/day s.c.) from day +1 to the end of LKP. Considering patients who had successful mobilization (64%), a median of 7.1 x 10(6)/kg CD34+ cells (range 3.5-11.9), 5.7 x 10(5)/kg CFU-GM (range 1.5-9.2), 4.4 x 10(8)/kg MNC (range 1.9-7.9) were collected. Treatment was well tolerated and none of these patients was hospitalized due to neutropenic fever. Only one patient received two packed red blood cells following chemotherapy. Autologous peripheral blood stem cell transplantation (APBSCT) has been performed in 18 patients (64%). The mean number of days to achieve > 0.5 x 10(9) PMN/L and > 20 x 10(9) PLT/L was 12 (10-17) and 12.6 (8-24), respectively.

INTERPRETATION AND CONCLUSIONS

Considering a pre-established threshold of 2.5 x 10(6)/kg CD34+ cells to proceed to APBSCT, the mobilization therapy was successful in 64% of the patients but was unsuccessful in 10 patients (5 NHL, 4 HD and 1 MM). Hematopoietic recovery was complete and stable in all patients. Low-dose CY plus G-CSF is efficient to collect enough PBSC for hematopoietic rescue after myeloablative therapy in patients with lymphoprolipherative disorders or multiple myeloma.

Efficient peripheral blood stem cell mobilization with low-dose G-CSF (50 microg/m2) after salvage chemotherapy for lymphoma

We compared the use of low-dose G-CSF (50 microg/m2/day), following salvage chemotherapy, for mobilization of PBSC with the results obtained in a comparable historical control group who received a standard dose of G-CSF (5 microg/kg/day, approximately 200 microg/m2/day). Thirty adult patients with relapsed or refractory lymphoma were treated with ifosfamide, VP-16, intermediate-dose Ara-C, methylprednisolone (IAPVP-16) and G-CSF 5 microg/kg/day (group A, n = 15) or 50 microg/m2/day (group B, n = 15) from day 6 until the end of leukaphereses. The duration of neutropenia and thrombocytopenia were equal in both groups. A median of two (1-3) leukaphereses were performed in both groups to harvest >3.5 x 10(6)/kg CD34+ cells. The numbers of circulating CD34+ cells on the first day of leukocyte recovery were similar in both groups in those patients mobilized after a first cycle of IAPVP-16. The numbers of circulating CD34+ cells were similar in patients mobilized after a first and after a second IAPVP-16 in group A. In the low-dose group (group B), however, the numbers of circulating CD34+ cells were significantly lower in those mobilized after a second than after a first course. Additionally, the product of the first leukapheresis contained significantly fewer CD34+ cells in those mobilized after a second course only in group B, with no differences in group A. Nevertheless, the final products harvested did not differ in the content of MNC, CFU-GM and CD34+ cells, suggesting that these differences are not clinically important. These results indicate that the use of low-dose G-CSF (50 microg/m2/day) is as effective as 5 microg/kg/day in accelerating neutrophil recovery and mobilizing CD34+ cells after a first cycle of IAPVP-16 salvage chemotherapy, resulting in a substantial decrease in costs, while more heavily pretreated patients may require higher doses of G-CSF for an equivalent mobilization.

[Isolated thrombocytopenia in pregnancy. Etiopathogenic study and therapeutic approach in 60 patients]

BACKGROUND

We analyze the etiopathogenesis and clinical and immunohematological characteristics of 60 pregnant women with isolated thrombocytopenia (TP) (platelet count < 150 x 10(9)/l); and the frequency of TP and hemorrhagic complications in their newborn. We suggest the therapeutic approach for each maternal TP type.

PATIENTS AND METHODS

We performed: clinical history, platelet count (EDTA K3, sodium citrate, microscopic exam) and investigation of antiplatelet antibodies (immunofluorescence) in all pregnant women. A familial history and ultrastructure of platelets were studied when hereditary macrothrombocytopenia (HM) was suspected. A Levine's test of homogenicity of variances was applied to compare the mean platelet count in each diagnostic group. A linear regression between maternal and newborn platelet counts was performed.

RESULTS

In 37 thrombocytopenic women (62%) no antiplatelet antibodies were found, and the clinical history was negative for previous TP or abnormal bleeding. Four patients (7%) were diagnosed as pseudothrombocytopenia EDTA-mediated, and eight (13%) of HM. Finally, an autoimmune etiology was suspected in 11 women (18%) and antiplatelet antibodies were detected in 9. Mean platelet counts of mother with immune TP did not show statistically significant differences with other diagnostic groups. Abnormal bleeding was not observed in any patient or newborn. There was no correlation between platelet counts of mothers and newborns. Platelet count obtained by skull bone punction led to unnecessary caesarians in four cases.

CONCLUSIONS

The frequency of immune thrombocytopenia in pregnant women is low (18%). There is a high prevalence of benign TP (62%). The pseudothrombocytopenias and HM are frequent findings (20%), and special care is advisable in these cases to avoid unnecessary therapeutic procedures.

Hereditary macrothrombocytopenia and pregnancy

INTRODUCTION

Hereditary macrothrombocytopenias (HM) are a group of infrequent disorders characterized by hereditary giant platelets. Little has been published about the course of these diseases during pregnancy and delivery.

SUBJECTS AND METHODS

Forty consecutive thrombocytopenic pregnant women were studied. Platelet count, mean platelet volume and blood smear examination were performed. Platelet antibodies were studied by immunofluorescence. Familial study, bleeding time, ultrastructural platelet examination, a von Willebrand disease screening and aggregation tests were carried out when HM was suspected.

RESULTS

Four cases of HM were diagnosed. Giant platelets were observed in all cases, with the typical ultrastructural pattern. Döhle-like cytoplasmic inclusions in granulocytes were observed in one case. Platelet antibodies were detected in only one case. No prophylactic measures to prevent haemorrhage were adopted, and all patients underwent vaginal deliveries. Haemorrhagic events were absent in both mothers and children.

CONCLUSIONS

The prevalence of HM in pregnant trombocytopenic women is higher than assumed. Prophylactic treatment should be avoided in the absence of a history of haemorrhagic complications and obstetrical risk factors.

Blood transfusions in laryngeal cancer: effect on prognosis

METHODS

To evaluate the influence of homologous perioperative transfusion on oncologic control and survival in patients with larynx and hypopharynx carcinomas, we conducted a retrospective study of 269 patients with larynx and hypopharynx carcinoma treated by major surgical procedures. A total of 20 variables were analyzed for each patient.

RESULTS

Perioperative transfusion was required in 86 (32%) patients, with packed red blood cells being used in all cases. Recurrence at a local, regional, or distant level was 31% for nontransfused and 35% for transfused patients. The 5-year adjusted survival was 68% for patients without transfusion and 63% for patients with transfusion. Neither the univariate nor the multivariate analysis showed that perioperative transfusion or the number of units of packed red blood cells used had any prognostic capacity.

CONCLUSIONS

Homologous perioperative transfusion did not imply a significant risk regarding global control or survival in our larynx or hypopharynx cancer patients.

[Post-transfusion purpura. Description of 2 cases diagnosed at the same hospital in a 6-month period]

Two new cases of postransfusional purpura diagnosed at the same hospital within the space of six months are described. This finding supports the idea that despite being an infrequent disorder, a substantial rise in PTP cases inside and outside our country, has been recorded. This increase has coincided with a greater interest in platelet immunology and, particularly, in complications associated with blood transfusion. Both cases constitute an example of the clinical epidemiological profile which characterizes the patients suffering from this disorder. The patients are two women aged 74 and 60 years who after 8 and 9 days, respectively, of being transfused with red cells developed a severe thrombocytopenia accompanied by generalized haemorrhagic diathesis. The serological studies performed revealed the presence, in both patients, of an HPA-1a platelet specific antibody. The platelet genotyping enabled us to confirm this specificity after detecting an HPA-1 (a-b+) platelet genotype. The treatment with immunoglobulins at high doses proved to be effective in both cases. The adsorption-elution experiments of the antibody versus HPA-1 (a + b) platelets were positive in the patient with the highest antibody titre (1024). This finding support the most recent hypothesis concerning the pathogenic mechanism of PTP. According to this theory, the antibody, which is detected in the acute phase of the PTP, would not yet have acquired the restricted specificity corresponding to it. This could enable it to react with a structure shared by the HPA-1a positive and HPA-1a negative platelets.

Characterization of antibodies directed against platelet cryptantigens detected during the immunological study of 356 consecutive patients with presumed autoimmune thrombocytopenia (AITP)

Cryptic antigens are detected by antibodies present in a wide spectrum of patients with or without thrombocytopenia, and even in healthy individuals. They are produced for unknown reasons and do not react with antigens of native platelets, but only with altered platelets. Cryptantigen antibodies may not only result in spuriously low platelet counts, but also in 'falsely' positive tests for platelet antibodies. We report our experience in the characterization of the different types of antibodies directed against cryptantigens of platelets: EDTA-dependent antibodies, PFA-dependent antibodies, EDTA-PFA-dependent antibodies and cold agglutinins. These antibodies were detected in the course of the serological study of 37 patients from a group of 356 (10%) whose blood was sent to our laboratory for platelet antibody testing. Pseudothrombocytopenia was diagnosed in 24 cases. Twenty-one of these showed EDTA-dependent or EDTA-PFA-dependent platelet agglutination and three were due to the presence of cold agglutinins. In 13 patients the thrombocytopenia was genuine. Eleven of these presented EDTA-dependent or EDTA-PFA-dependent antibodies in their serum and in the two remaining cases PFA-dependent antibodies were found. Cryptantigen antibodies were also detected in 9 out of 228 (4%) blood donors who were used as healthy controls in the platelet immunofluorescence test. In the light of the results obtained we put forward some guidelines to detect the presence of these antibodies and establish an accurate serological and clinical diagnosis of the autoimmune thrombocytopenias.

[Blood donors seropositive for type 1 human immunodeficiency virus (HIV-1). Epidemiologic characteristics and clinical course]

PURPOSES

To evaluate retrospectively the epidemiologic profile and clinical course of the HIV-positive voluntary blood donors in the Sant Pau's Hospital Blood Bank (Barcelona-Spain) between 1986 and 1993.

PATIENTS AND METHODS

A total of 119,345 blood donors were studied, and fifty seven such cases were identified. Risk behavior, causes of failure of the pre-donation procedures and clinical stage were analyzed. A follow-up of their infection was performed by the Infectious Disease Unit.

RESULTS

The mean age of 57 seropositive donors was 31 +/- 8 years. Prevalence of HIV-1 infection among donors was 0.48 per 1000. Forty four (77%) were male and 13 (23%) female. Forty three (75%) were first time donors while 14 (25%) were repeat donors. The causes for the failure of the self-deferral questionnaire were: 42 subjects did not consider that they had engaged in "risk" behavior, seven donors lied in order to know if they were HIV carriers and two cases were driven to donate due to social or family pressure. The distribution of these donors according to risk behaviour was: 30 (53%) heterosexual, 11 (20%) homosexual, 11 (20%) intravenous drug users and five (7%) with no identified risk. It was noted that HIV infection progressed more rapidly to AIDS in HIV - positive homosexual donors than in heterosexual subjects (p < 0.05).

CONCLUSIONS

Heterosexual donors who maintain sexual contacts with different partners without prophylactic measures for HIV infection currently represent the highest risk group for transfusion-related HIV infection. Clinical evolution of HIV infection was faster and more devastating in the homosexual group than in the heterosexual group.

Efficacy of screening donors for antibodies to the hepatitis C virus to prevent transfusion-associated hepatitis: final report of a prospective trial

Routine screening of blood donors for anti-hepatitis C virus (HCV) has been implemented in most developed countries. However, the independent efficacy of such screening has not been established in a controlled, prospective study. We tracked 478 patients transfused with anti-HCV-negative blood by first-generation enzyme-linked immunoassay (EIA) between July 1989 and May 1990 and compared the incidence of transfusion-associated hepatitis and HCV infections with that found among 280 patients transfused with blood unscreened for anti-HCV during the immediately preceding year. Of the 280 patients who had received transfusions before donors were screened for anti-HCV, 27 (9.6%) developed posttransfusion hepatitis and 1 additional patient seroconverted to anti-HCV without evidence of hepatitis, for a risk of posttransfusion HCV infection of 10.7% (28 of 262 recipients seronegative for anti-HCV before transfusion). Of the 478 patients transfused after July 1989 with blood screened for anti-HCV, only 9 (1.9%) developed posttransfusion hepatitis for a risk reduction of 80%. Seven of the 9 residual cases of hepatitis were caused by HCV (7 of 456 recipients seronegative before transfusion or 1.5%) for a risk reduction of transfusion-associated HCV infection of 86%. In retrospect, an anti-HCV positive donor was detected by second-generation immunoassay in 4 (57%) of the 7 HCV cases from the study cohort and in 19 of the 23 (83%) cases from whom all donor samples were available for testing in the historical cohort. No additional infectious donors were detected by third-generation immunoassay or serum HCV-RNA by polymerase chain reaction.(ABSTRACT TRUNCATED AT 250 WORDS)

Combined autoimmune cytopenias

BACKGROUND

Autoimmune neutropenia (AIN) can occur in association with autoimmune hemolytic anemia (AIHA) and/or immune thrombocytopenic purpura (ITP), although these associations have not been studied in detail.

METHODS AND RESULTS

Twenty cases of AIN were found in a group of 55 adults with unexplained neutropenia over a five-year period. Eight subjects with AIN had an associated AIHA and/or ITP (AIN+ITP, n = 2; AIN+AIHA, n = 2; AIN+ITP+AIHA, n = 4). Thorough investigations identified no underlying disease in four patients, and none has appeared during follow-up. Of the other 4, one was found to have been suffering from systemic lupus erythematosus when the combined immunocytopenia was diagnosed, one patient from idiopathic myelofibrosis, one from a combined variable immunodeficiency and the other from disseminated tuberculosis. These last three conditions, while sometimes associated with autoimmune cytopenias, has not been previously reported together with combined immunocytopenias. All patients responded to immunosuppressors, although severe infectious complications occurred in two, leading to death from Pneumocystis carinii pneumonia and to irreversible neurologic damage from Listeria monocytogenes meningitis, respectively.

CONCLUSIONS

We conclude that combined autoimmune cytopenias are frequently observed in patients with AIN, and a thorough search for associated conditions can lead to unsuspected diagnoses.

Comparative study of two high doses of lymphoblastoid interferon in the treatment of chronic hepatitis C: influence on the levels of ALT, viraemia and histologic activity

Ninety consecutive patients with chronic hepatitis C were included in a randomized, uncontrolled trial to compare the efficacy of two treatment regimens, 10 MU (group A) vs 5 MU (group B), of lymphoblastoid interferon, in a step-down schedule for 24 weeks. All of the patients had antibodies against the hepatitis C virus, and all but one were HCV RNA positive in serum. The origin of the infection was attributed to blood transfusion in 30 patients and classified as sporadic in 60 patients. During treatment reduction in the ALT levels as well as the elimination of viraemia was observed in both treated groups, although these changes did not correlate significantly with the interferon dose. Nine months after the end of therapy, a sustained response was achieved in 13.6% (12/88) of the patients. Relapse in group B (87.5%) was significantly higher than in group A (59.1%). The percentage of cases which remained with undetectable HCV RNA was significantly higher for the sustained responders (66.7%) than for the non-responders (11.8%) and relapser patients (2.4%). Repeated liver biopsies showed an overall significant reduction of all the subindices of histological activity from patients with sustained response, except for fibrosis. In short: the 10 MU dosing regimen of lymphoblastoid interferon was as efficient as the 5 MU dose as it brought about a similar improvement in ALT levels, histological activity and elimination of viraemia, albeit 10 MU proved significantly more effective in the prevention of a relapse among the responders after 24 weeks therapy.

Prevalence of thyroid autoantibodies is not increased in blood donors with hepatitis C virus infection

Serum autoimmune reactions are found in many patients with hepatitis C. A high prevalence of thyroid dysfunction and antithyroid antibodies in patients with chronic hepatitis C was recently reported. We have compared the prevalence of thyroid dysfunction and antithyroid peroxidase antibodies in blood donors with hepatitis C virus (HCV) infection (study group) and in seronegative anti-HCV donors (control group). One hundred and ninety-two blood donors were studied: 96 were anti-HCV positive by ELISA 2 (48 males and 48 females; age 48 +/- 12.9 years, mean +/- SD), and 96 were HCV seronegative (55 males and 41 females; age 37 +/- 14.8 years). In all patients, serum TSH (0.25-4.2 mU/l) and fT4 (9-23 pmol/l) were measured by immunochemiluminiscent assays and antithyroid peroxidase antibodies (normal < 100 U/ml) by RIA. In all anti-HCV positive donors, hepatitis C viremia was tested using the nested polymerase chain reaction. Thyroid dysfunction was found in three females (3.1%) in the anti-HCV positive group (three cases of hypothyroidism), and in four (4.1%) anti-HCV negative blood donors (three cases of hypothyroidism, two females and one male; one case of hyperthyroidism, a female), (p = NS). Antithyroid peroxidase antibody titers were above normal values in 5 (5.2%) anti-HCV positive individuals and in eight (8.3%) anti-HCV negative blood donors (p = NS). These results do not show an increase prevalence of thyroid dysfunction and antithyroid peroxidase antibodies in blood donors with HCV infection when compared with a control group.

Demonstration of HCV-RNA and HBV-DNA in the serum of HBsAg negative patients with hepatocellular carcinoma

Forty patients with chronic liver disease and HCC were analyzed for infection with hepatitis C (HCV) and hepatitis B (HBV) viruses. All patients were negative for HBsAg, 16 were alcoholics, 6 had previous blood transfusions and 18 had sporadic chronic hepatitis. Antibodies to HCV were determined by EIA 2nd generation. HBV-DNA was detected by PCR using primers of the precore region. Analysis of HCV-RNA was done with nested PCR amplifying the 5' non-coding region of the HCV genome, using primers complementary to nucleotides 1-20 and 305-320 and nested primers complementary to nucleotides 21-31 and 271-286 of the HCV-J1. Anti-HCV were positive in 35/40 patients (87.5%). HCV-RNA was detected by PCR in 34 patients (85%) all of them positive for the anti-HCV. HCV-RNA was detected in 70.5% of the alcohol abusers, in 100% of patients with history of transfusion(s) and 94.1% of patients with cryptogenic chronic liver disease. HBV-DNA was detected in only 2 patients. In conclusion, there is a high rate of HCV and a low rate of HBV viremia detected by PCR in Spanish patients with HCC HBsAg negative. No patient without anti-HCV presents HCV-RNA. Our results suggest that persistent HCV replication may play a role in hepatic carcinogenesis, as HBV-DNA could be found in only 5% of our HCC patients.

[Thrombocytopenia associated with human immunodeficiency virus infection. Immunologic study of 60 patients addicted to parenteral drugs]

BACKGROUND

The immunologic study of 60 intravenous drug addict patients who were seropositive for the human immunodeficiency virus (HIV) and who developed thrombocytopenia (TP) is reported with the aim of establishing the relation of possible pathogenic factors which may trigger this complication.

METHODS

In all the patients the presence of antiplatelet antibodies was studied by direct and indirect immunofluorescence together with crypto-antibodies, immune complexes, lymphocytotoxic antibodies, antiphospholipid antibodies, immunoglobulins, lymphocytic populations and subpopulations and serology against different infectious agents.

RESULTS

Antiplatelet antibodies were detected in 71% of the patients of which 50% corresponded to immunoglobulins of IgG class, 12% to IgM, 21% to IgG plus IgM, 7% IgM plus IgA, 5% to IgG plus IgA and 5% IgG plus IgM plus IgA. In these patients a characteristic membrane fluorescence pattern was observed in which the fluorescein is distributed forming a thick, hard point. In 3 patients EDTA dependent crypto-antibodies were detected which in one case determined pseudothrombocytopenia. The immune complexes were demonstrated in 50% of the cases. Other findings were: hypergammaglobulinemia (86%), decrease in the CD4 population (47%), CD4/CD8 ratio < 1 (71%), lymphocytotoxic antibodies (70%), antiphospholipid antibodies (60%), and seropositivity for cytomegalovirus (62%), Epstein-Barr virus (10%) and hepatitis B virus (anti-HBc 75%, HBsAg 33%).

CONCLUSIONS

Thrombocytopenia associated to infection by the human immunodeficiency virus in intravenous drug addict patients is due to the concurrence of multiple factors. The relevance of each may vary according to the risk practice of the collective analysed and even within the same group of some individuals or others. The numerous serologic findings in these patients fundamentally express the existence of a chronic polyclonal stimulation of B cells which may be initiated by the action of the drug itself and which becomes aggravated during the course of the multiple acquired infections among which that due to the human immunodeficiency virus is of note.

[Frequency of platelet alloantigens in the Spanish population]

PURPOSE

The aim of this study is to investigate the distribution and incidence of platelet alloantigens in Spain and to compare this frequency with that found in other populations.

MATERIAL AND METHODS

Five hundred blood donors were phenotyped for the HPA-1a (Zwa), HPA-3a (Bak(a)), HPA-4a (Yukb/Pen(a)) y HPA-4b (Yuk(a)). One hundred of these donors were also phenotyped for the HPA-5a (Br(a)) antigen. Furthermore, we also phenotyped a group of 50 black individuals from a community of west African immigrants who live in the province of Barcelona. The typing of all the antigens except those of the HPA-5 system was carried out using the technique of Indirect Immunofluorescence. To type the antigens of the HPA-5 system the MAIPA technique was employed.

RESULTS AND CONCLUSIONS

The incidence of the different platelet specific antigens in the Spanish population is, in general, the same as that detected in the other European countries and in the white population of the USA. In Europe and North America, the HPA-1a antigen is the most important of all owing to its involvement in alloimmune clinical disorders. In Asia, this role seems to be played by the HPA-4b antigen. Moreover, polymorphism for the HPA-1a allele does not seem to exist. The incidence of the HPA-5b (Br(a)) antigen in Spain, which is higher than that for France and Germany, suggests a high involvement of this antigen in our country in different alloimmune processes. The preliminary data obtained in a group of black west Africans suggest the absence on polymorphism for the HPA-1a allele and that the incidence of the remaining antigens is comparable to that of the Spanish population.

New contribution to the genetics of the Basques: heterogeneity in the esterase D subtype distribution

A random sample of 1,491 individuals from three Basque provinces was studied for the red-cell esterase D (ESD) polymorphism by means of isoelectric focusing. The following allele frequencies were observed: Vizcaya, ESD*1 = 0.933, ESD*2 = 0.058, ESD*5 = 0.009; Guipuzcoa, ESD*1 = 0.938, ESD*2 = 0.053, ESD*5 = 0.009; and Alava, ESD*1 = 0.894, ESD*2 = 0.088, ESD*5 = 0.018. The Basques from Vizcaya and Guipuzcoa display the lowest values for allele ESD*5 of any European population studied to date. The value obtained for this allele in the Basque population of Alava is significantly higher than those found in the other two Basque samples. This, together with the fact that Basques from Alava display the lowest ESD*1 frequency of any Basque series, suggests that there are genetic differences between Basque provinces.

[Indications for the use of platelets, plasma and anti-hemorrhagic drugs]

During the last years, the use of hemoderivatives has largely increased. Their use carries a high risk for post-transfusion reactions and for transmission of severe infectious diseases. In a high percentage of cases the use of these compounds is inadequate. At the present time there are pharmacologic (desmopressin, antifibrinolytics, vitamin K) and nonpharmacologic strategies (autotransfusion, hemodilution, intra and postoperative recovery of blood) directed to avoid or to decrease the need for transfusion. We review all these strategies and we propose some criteria for transfusion of plasma and platelets, as well as attitudes for particular situations.

High-dose chemotherapy with bone marrow rescue for treatment of Hodgkin's disease

Between December 1st 1984 and July 1st 1991, 20 patients, 11 males and 9 females, median age 36 years (range 14-54) with Hodgkin's disease were treated with high dose chemo-radiotherapy followed by autologous bone marrow rescue. At the time of autologous bone marrow transplantation, 8 patients were in complete remission, 9 in sensitive relapse and 3 were resistant to conventional treatments. There were 3 early procedure-related deaths: 1 cardiac failure due to cyclophosphamide treatment, 1 veno-occlusive disease, and 1 patient died from CMV interstitial pneumonitis, 4 months after ABMT. Of the 17 other patients, 15 are alive, 12 in complete remission, 2 in relapse and 1 patient is not evaluable due to short-follow-up follow-up. Disease free survival is 65% at 20 months with a follow-up of 60 months. There is a trend for a better disease-free survival in patients in complete remission at the time of autologous bone marrow transplantation vs patients in sensitive relapse, although it does not reach statistical significance (80% vs 37%).

High rate of infectivity and liver disease in blood donors with antibodies to hepatitis C virus

OBJECTIVE

To determine the epidemiologic, clinical, serologic, and histologic importance of antibodies to hepatitis C virus (anti-HCV) in blood donors.

DESIGN

Cross-sectional identification and prospective evaluation of seropositive donors; retrospective assessment of infectivity; and nested case-control study for risk factors.

SETTING

Liver unit of a referral-based university hospital.

SUBJECTS

Of 30,231 consecutive donors, 368 (1.2%) were found to be anti-HCV-reactive by enzyme-linked immunosorbent assay (ELISA). Two hundred and fifty-four of these 368 donors were evaluated for risk factors by comparison with 284 age- and sex-matched controls. Eighty-six spouses of seropositive donors were also evaluated.

MEASUREMENTS AND MAIN RESULTS

Twenty-four percent of the seropositive donors had a history of percutaneous exposure to blood. This rate increased to 45% when only those donors confirmed to be anti-HCV positive by a second-generation recombinant immunoblot assay (RIBA-2) were considered. A family history of liver disease (odds ratio, 2.8; 95% Cl, 1.6 to 4.8), previous blood transfusion (odds ratio, 6.1; 95% Cl, 3 to 12.5), and a history of tattooing or intravenous drug abuse (odds ratio, 8.4; 95% Cl, 2.3 to 31) were associated with anti-HCV seropositivity. An elevated alanine aminotransferase (ALT) level was found in 58% of the seropositive donors. Of the 150 donors tested, 104 (69%; Cl, 62% to 77%) were confirmed by RIBA-2 to be anti-HCV positive. Of the 105 donors who had a biopsy, 16% had normal histologic findings, 11% had minimal changes, 21% had chronic persistent hepatitis, 45% had chronic active hepatitis, and 7% had active cirrhosis. All 77 donors with RIBA-2-confirmed seropositivity had histologic abnormalities. Of 43 donors evaluated in an infectivity study, 82% were implicated in previous HCV transmission. Only 2.3% of the spouses were anti-HCV positive. The ELISA, RIBA-2, and ALT results correlated with infectivity and abnormal histologic findings.

CONCLUSIONS

In our geographic area, almost 70% of donors who are anti-HCV positive by ELISA are confirmed to be positive by RIBA-2; most of these donors appear to be chronic carriers of HCV and have substantial liver disease.

Infantile spasms treated with high doses of sodium valproate: initial response and follow-up

A long-term follow-up study of 42 patients with West syndrome treated with high doses of sodium valproate is presented. Control of the hypsarrhythmic EEG pattern was achieved after two weeks for over three-quarters of the patients with sodium valproate doses of 100 to 300mg/kg/day. Recurrence of hypsarrhythmia was observed most often in patients treated with doses lower than 200mg/kg/day. Other types of seizures appeared in half of the patients followed beyond two years of age. Monotherapy throughout follow-up was possible for 30 patients. Autism occurred in only one infant, and 12 achieved normal mental status. The most common side-effects were asymptomatic thrombocytopenia, vomiting and mild somnolence. Hepatic enzymes were not altered.

[Pure sensory hemisyndromes caused by infarctions in the pons]

This study reports 3 cases of pure hemisensory syndrome due to lacunar infarction at the pons, demonstrated by magnetic resonance. In all patients somatosensory evoked potentials were abnormal. In two out of the 3 cases these potentials remained abnormal even after clinical exploration normalized. Due to the distribution of the sensitive pathways it may be assumed that the hemisensory syndrome would be caused by lesions located from the cortex to the pons. By means of clinico-pathological correlations the hemisensory syndrome was attributed to lesions exclusively located at the cerebral cortex or at the thalamus. However, in 1984 the first case of hemisensory syndrome due to pontine infarction was demonstrated by computerized tomography. After this report a series of approximately 10 patients have been published in the english and french literature. None of them had data on somatosensory potentials. In our experience the study of somatosensory evoked potentials has a high sensitivity. It appears that the distribution of the sensitive defect is independent of the location of the structural lesion.

[Non-hemolytic transfusion reactions of the febrile type]

The results of a hundred cases of febrile non haemolytic transfusion reactions are presented. We used the techniques that would best identify the different causes of these reactions. Most of these antibodies were anti HLA. Platelet and granulocyte-specific antibodies were seldom detected. The nature of the antibodies was specified by their different reactivity with the cells of various donors, by applying a panel of cells from typed donors and by absorption experiments. The study of the donor sera enabled us to elucidate the causes of some reactions. Nevertheless, in a significant percentage of cases it was not possible to determine the cause of the reaction, especially in the case of reactions secondary to platelet transfusions. Finally, we analyzed the reasons that could account for these phenomena.

[DNA polymorphisms as implant markers in allogeneic bone marrow transplantation. Preliminary evaluation]

After allogeneic bone marrow transplantation (BMT), patient hematopoietic and lymphoid cells are replaced by cells derived from the donor marrow. To document and characterize successful engraftment, host and donor cells must be distinguished from each other. We have used DNA sequence polymorphism analysis in 6 patients, at times varying, to determine reliably the host or donor origin of posttransplant cell populations and to compare these results with those obtained using red blood cell antigens and cytogenetics. Initially full engraftment was documented in all patients. In 1 patient a mixed lymphohematopoietic chimerism was documented 6 months after BMT and it reverted to donor hematopoiesis at 1 year post BMT. Posttransplant leukemic relapse was studied in two patients and shown to be of host origin in both cases. The DNA restriction fragment length polymorphisms (RFLP), are a powerful tool for the documentation of engraftment after BMT, to document mixed lymphohematopoietic chimerism and for the evaluation of leukemic relapse.