Myasthenia gravis as an unusual non-hematological autoimmune manifestation of a relapsed chronic lymphocytic leukemia - clinical case and review of literature

BACKGROUND

Autoimmune phenomena are well known to complicate chronic lymphocytic leukemia (CLL) and occur in 10% to 25% of the cases. Although less common, non-hematological autoimmune manifestations have been reported. Myasthenia gravis (MG) is an autoimmune disease of the neuromuscular junction, characterized by fatigable weakness of the extraocular, bulbar, and limb musculature. The co-existence of MG and CLL is exceedingly rare and there are very few cases reported in literature.

CASE PRESENTATION

We present a case of a 63-year-old female patient with a severe form of MG which is likely related to a relapse of CLL. Treatment with combined targeted and immunotherapy was initiated with acceptable tolerability.

CONCLUSIONS

Targeted agents and monoclonal antibodies exert complex activities on the patient's immune system. It will be of interest to assess their role in managing autoimmune complications, accompanying CLL.

Prediction of survival in infants with congenital diaphragmatic hernia and the response to inhaled nitric oxide

The use of inhaled nitric oxide (iNO) in treating pulmonary hypertension in infants with congenital diaphragmatic hernia (CDH) is controversial. Our aims were to identify factors associated with survival in CDH infants and whether this was influenced by the response to iNO. Results of CDH infants treated in a tertiary surgical and medical perinatal centre in a ten year period (2011-2021) were reviewed. Factors affecting survival were determined. To assess the response to iNO, blood gases prior to and 30 to 60 min after initiation of iNO were analysed and PaO₂/FiO₂ ratios and oxygenation indices (OI) calculated. One hundred and five infants were admitted with CDH; 46 (43.8%) infants died. The CDH infants who died had a lower median observed to expected lung to head ratio (O/E LHR) (p < 0.001) and a higher median highest OI on day 1 (HOId1) (p < 0.001). HOId1 predicted survival after adjusting for gestational age, Apgar score at 5 min and O/E LHR (odds ratio 0.948 (95% confidence intervals 0.913-0.983)). Seventy-two infants (68.6%) received iNO; 28 survived to discharge. The median PaO₂ (46.7 versus 58.8 mmHg, p < 0.001) and the median PaO₂/FiO₂ ratio (49.4 versus 58.8, p = 0.003) improved post iNO initiation. The percentage change in the PaO₂/FiO₂ ratio post iNO initiation was higher in infants who survived (69.4%) compared to infants who died (10.2%), p = 0.018.

CONCLUSION

The highest OI on day 1 predicted survival. iNO improved oxygenation in certain CDH infants and a positive response was more likely in those who survived.

WHAT IS KNOWN

• The use of iNO is controversial in infants with CDH with respect to whether it improves survival.

WHAT IS NEW

• We have examined predictors of survival in CDH infants including the response to iNO and demonstrated that the highest oxygenation index on day 1 predicted survival (AUCROC =0.908). • Certain infants with CDH responded to iNO and those with a greater response were more likely to survive.

[Can we do therapy without a therapist? Active components of computer-based CBT for depression]

OBJECTIVES

Computer-delivered Cognitive Behavioral Therapies (C-CBT) are emerging as therapeutic techniques which contribute to overcome the barriers of health care access in adult populations with depression. The C-CBTs provide CBT techniques in a highly structured format comprising a number of educational lessons, homework, multimedia illustrations and supplementary materials via interactive computer interfaces. Programs are often administrated with a minimal or regular support provided by a clinician or a technician via email, telephone, online forums, or during face-to-face consultations. However, a lot of C-CBT is provided without any therapeutic support. Several reports showed that C-CBTs, both guided or unguided by a therapist, may be reliable and effective for patients with depression, and their use was recommended as part of the first step of the clinical care. The aim of the present qualitative review is to describe the operational format and functioning of five of the most cited unguided C-CBT programs for depression, to analyze their characteristics according to the CBT's principles, and to discuss the results of the randomized clinical trials (RCT) conducted to evaluate its effectiveness, adherence and user's experience.

METHODS

We analyzed five C-CBTs: Beating The Blues (BTB), MoodGYM, Sadness, Deprexis and Overcoming Depression on the Internet (ODIN) and 22 randomized controlled studies according to 5 dimensions: General characteristics; Methodology, structure and organization; Specific modules, themes and techniques: Clinical indications, recruitment mode, type of users with depression, type and mode of therapist's support, overall therapeutic effects, adherence and user's experience.

RESULTS

The C-CBT have a secured free or pay-to-use access in different languages (English, German, Dutch, and Chinese) but not in French. The programs may be accessed at a medical center or at home via a CD-ROM or via an Internet connection. Some C-CBTs are very close to textual self-helps provided via an E-learning mode (Sadness, MoodGYM, ODIN), others adopt interactive software technologies (Deprexis, BTB), but their interactivity and the possibility of personalization is low. The C-CBTs use similar principles and techniques as in face-to -face CBT (e.g. self-evaluation, psychoeducation, cognitive restructuring, cognitive restructuring of schema, behavioral activation and agenda setting, problem solving techniques, communication and crisis management techniques, relaxation, principles of positive psychology and relapse prevention, positive reinforcement methods, motivational feedbacks, social learning, homework assignments and progress monitoring). The results of the 22 RCSs showed that both the effectiveness and the adherence of the unguided C-CBT is high with self-referred active help-seekers with major depression, but the latter is low with users who are depressed out-patients referred by general practitioners or clinicians. The presence of therapist support improves the effectiveness and the adherence of the C-CBT, especially in clinical out-patients.

CONCLUSIONS

In light of the existing insight of the advantages and the inconvenient of the C-CBT, the actual challenge is to find its optimal clinical indication and the modality of its effective use in clinical populations.

[Individual responses of arterial pressure to geomagnetic activity in practically healthy subjects]

Dynamic analysis of arterial blood pressure in relation to the Earth's magnetic field perturbations was performed in 77 practically healthy volunteers (staff of Bulgarian Academy of Sciences). Almost half of them proved magneto-sensitive, i.e. experienced AP elevation with increased geomagnetic activity. The probability of development of magnetic sensitivity was independent of age and gender but increased in volunteers having even mild cardiovascular pathology. These subjects complained of worsened health condition upon a rise in geomagnetic activity. However, some volunteers reported deteriorated well-being without AD elevation. It means that AD measurement may be insufficient for reliable monitoring magnetic sensitivity.

Exact solution of the isovector neutron-proton pairing Hamiltonian

The complete exact solution of the T = 1 neutron-proton pairing Hamiltonian is presented in the context of the SO(5) Richardson-Gaudin model with nondegenerate single-particle levels and including isospin symmetry-breaking terms. The power of the method is illustrated with a numerical calculation for for 64Ge for a pf + g9/2 model space which is out of reach of modern shell-model codes.

Influence of local geomagnetic storms on arterial blood pressure

This study attempts to assess the influence of local geomagnetic storms at middle latitudes on some human physiological parameters. The blood pressure (bp), heart rate and general well-being of 86 volunteers were measured, the latter by means of a standardised questionnaire, on work days in autumn, 2001 (1 Oct to 9 Nov), and in spring, 2002 (8 April to 28 May). These timespans were chosen as periods of maximal expected geomagnetic activity (GMA). Altogether, 2799 recordings were obtained and analysed. A four factor analysis of variance (MANOVA) was employed to check the significance of the influence of four factors (local GMA level; sequence of the days of measurements covering up to 3 days before and after geomagnetic storms; sex and the presence of medication) on the physiological parameters under consideration. Post hoc analysis was performed to elicit the significance of differences in the factors' levels. Arterial bp was found to increase with the increase of the GMA level, and systolic and diastolic bp were found to increase significantly from the day before till the second day after the geomagnetic storm. These effects were present irrespective of sex and medication.

Early events in the life cycle of JC virus as potential therapeutic targets for the treatment of progressive multifocal leukoencephalopathy

The human polyomavirus, JC virus (JCV), is the etiological agent of progressive multifocal leukoencephalopathy (PML). PML occurs almost exclusively in the setting of severe and prolonged immunosuppression and it remains an important and life-threatening complication in the acquired immunodeficiency syndrome (AIDS) population. Several drugs that target DNA replication have shown efficacy at inhibiting JCV replication in vitro but none to date have shown in vivo efficacy. The authors' laboratory has been studying early events that contribute to infection of susceptible cells by JCV. They previously demonstrated that infection of glial cells by JCV requires clathrin-dependent endocytosis and that this early step in the viral life cycle can be blocked by the antipsychotic drug, chlorpromazine. As chlorpromazine is associated with the development of extrapyramidal symptoms that may be heightened in AIDS patients, the authors sought to test the atypical antipsychotic, clozapine, for antiviral activity against JCV. In this report, the authors show that clozapine is as effective as chlorpromazine at inhibiting infection. They further demonstrate that low-dose combinations of both drugs synergistically inhibit infection.

Study of asbestos exposure in some applications of asbestos materials in the chemical industry

This study is designed to determine the effects of short-term asbestos exposure on workers in the production of asbestos gaskets and filter materials for technological equipment in the chemical industry. The workers from the "Cathode workshop", "Diaphragm electrolysis", "Polymers" Co., Devnja (12 operators) who operate the installation of asbestos diaphragms manufacture and installation of electrolysis cells, and the staff of the "Mechanical" shop of "Nephtochim" Co., Burgas, engaged in the cutting of gaskets made of pressed asbestos-polymer boards (6 workers), were studied. The hygienic normative standards and methodology for measuring and assessment of the asbestos exposure, used all over the world were applied: mean shift count concentration of respirable asbestos fibres; entire shift personal sampling (BSS 2200-85), PCOM light microscopy (BSS 16909-89). The level of asbestos exposure registered was in the range 0.04 to 0.38 f/cm3 for the operators in the "Diaphragm electrolysis" shop and for the staff in the "Mechanical" shop of "Nephtochim" Co. from 0.04 to 0.43 f/cm3. The established concentrations are acceptable according to the requirements of the official hygienic threshold limit value (TLV) in Bulgaria (1 f/cm3), but because asbestos is a human cancerogen and there is tendency for regular revision with the intention of decreasing the hygienic TLV, the asbestos occupational exposure of these groups of workers cannot be accepted as safe. The statements made increase the necessity of dust control by technical preventive means and the medical control of the workers exposed to asbestos-related injuries.

[Complex radioisotope diagnosis of thyroid gland diseases in vivo and in vitro]

A variety of in vivo and in vitro methods: radioactive iodine accumulation, thyroid suppression and stimulation test, a scintigraphic study and a radioimmunoassay to determine triiodothyronine-binding capacity (free T3), thyroxine (T4) concentration and the effective thyroxine ratio (ETR), was used for diagnostic specification and accurate planning of therapy of patients with thyroid diseases. The suppression test combined with the results of the in vitro analysis (free T3, T4 and ETR) was decisive for establishing diagnosis.

[Carcinoembryonic antigen, its clinical and prognostic significance in malignant tumors of the gastrointestinal system]

A radioimmunoassay to determine the CEA level in 100 patients with GIT malignant tumors was performed. The test was shown to be of particular value for making a preoperative prognosis of the disease. In operated on patients it could be used for early diagnosis of recurrences and metastases. The dynamic performance of the test made it possible to evaluate therapeutic efficacy.

Investigations of serum testosterone levels in patients with laryngeal cancers

Serum testosterone levels were determined by a radioimmunological method in 102 patients with laryngeal carcinoma and in a control group of 10 healthy men. All patients were examined before the initiation of any operative or radiation therapy and after termination of treatment. The testosterone levels in the cancer patients showed a tendency toward higher values when compared with a control group of healthy men. These results indicate that hormone preparations could be considered as part of the therapy of laryngeal carcinomas.

[Quality control in acid-base and gas analysis of the blood]

The data from the intra-laboratory qualitative control art analyzed--accuracy and reproducibility of the results from the determinations of pH, pCO2 and pO2. Reproducibility is followed day by day and the accuracy of the results from the determinations of pH, pCO2, and pO2. The determinations were performed as follows: pH--by micro-electrode, pCO2--by equilibrium and by selective electrode, pO2--by electrode, Clark type with apparatuses VME 22, VME 32 and automatic analyser for blood-gas analysis ABL 2 (Radiometer). Acidbasol and Versatol Acid-Base were used as control materials in the three ranges: normal, acid and alkaline. Reproducibility of the results as regards time, presented by variation coefficient (VC), followed up for a period of 9 months by the control materials Acidbasol with ABL 2 apparatus proved to be very good in the three ranges tested for pH and pCO2. Results dispersion is higher with pO2 determinations, even higher with the low values. The accuracy of the results from pH and pCO2, determinations for the same period was within the allowable limits. A very good reproducibility of pH and pCO2 was indicated by the reproducibility data in time of the results from pH and pCO2 determinations from one year with the three apparatuses, making use of the control serum Versatol Acid-Base for the three ranges. Better variation coefficients by equilibrium method were established for the higher values of pCO2 with its automatic determination. High reliability of the investigation methods was established be the results from the systematic qualitative control of acid-base and blood-gas parameters.