Feasibility and limitations of bone marrow transplantation in children

Bone marrow transplantation (BMT) has been used increasingly for the treatment of patients with a variety of hematological, immunological and oncological diseases. Originally a highly experimental and often unsuccessful procedure, it has become the treatment modality of choice for selected leukemias, severe aplastic anemia, genetic diseases and solid tumors. Despite the overall success of bone marrow transplantation, a number of serious and potentially fatal complications may occur. Conditioning regimens include chemotherapeutic and radiotherapeutic techniques immunosuppressive enough to allow engraftment of genetically foreign marrow. Graft-versus-host disease (GvHD) is one of the major clinical problems complicating allogeneic BMT. Two forms have been described, acute and chronic GvHD. BMT recipients frequently develop infections complications.     

Prognostic aspects of aplastic anemia in pregnancy. Experience on six cases and review of the literature

Our resent experience on six cases of aplastic anemia complicated with pregnancy is described. In addition, 43 similar cases were collected from the literature and reviewed to analyze some prognostic aspects of this relatively rare but potentially serious complication. Clinical and hematological data were treated to extract some clinically meaningful factors in relation to the success and failure of pregnancy. Among initial hematological parameters, no significant difference was found between successful and unsuccessful cases with an exception of hemoglobin concentration. The patients diagnosed as aplastic anemia prior to conception demonstrated an better outcome of pregnancy as well as survival rate of mother when compared with those diagnosed during pregnancy. Mortality has apparently improved after the late 1950's. Success rate of pregnancy before 1958 was 21%, while it was 67% and 71% in the era of 1959-1969 and after 1970, respectively. However, hemorrhage and infection remained to be two major causes of maternal death in both eras. Based on these observations, the currently recommendable attitude to this complication is discussed.     

Agranulocytosis, aplastic anemia, and leukemia: relevance to arachidonic acid metabolism

Several agents including drugs, chemicals and viruses are known to induce agranulocytosis, aplastic anemia, and leukemia. The recent identification, characterization and cloning of several peptide regulatory factors, including granulocyte-macrophage-colony stimulating peptide regulatory factor (GM-CSF), erythropoietin, and interleukins and a study of their actions, suggest that agents producing agranulocytosis, aplastic anemia, and leukemia may interfere with the action of these factors. The agents that are capable of inducing these diseases and the various peptide regulatory factors have positive and/or negative actions on the prostaglandin system. Prostaglandins are known to be involved in the maturation and differentiation of the progenitor cells of the bone marrow and in erythropoietin-mediated erythropoiesis. Since prostaglandins influence immune response, modify genetic damage induced by drugs and chemicals, modulate gene action, and have feed-back control on the actions of peptic regulatory factors, it is likely that prostaglandins are involved in the pathogenesis of agranulocytosis, aplastic anemia, and leukemia. If so, this may lead to new therapeutic strategies in these hematological conditions.     

Antibiotic therapy of abscess of the lung and bronchiectasis

A clinical evaluation of phenylbutazone and Butapyrin(R) (a mixture of phenylbutazone and aminopyrine) was made in 409 patients who had a variety of rheumatic diseases. Preliminary European claims were substantiated.In gout a specific favorable effect was brought about by phenylbutazone alone. Effects equivalent to the previously reported favorable response to Butapyrin (Irgapyrin) were observed when its constituent phenylbutazone was used alone. The drug had a suppressive effect in a high percentage of patients with rheumatoid arthritis, ankylosing spondylitis, arthritis with psoriasis and mixed arthritis (rheumatoid arthritis plus osteoarthritis). Favorable effect in peritendinitis of the shoulders, osteoporosis of the spine and acute lumbosacral strain also was noted. Toxicity resulted in discontinuance of medication in 10 per cent of patients with each drug. Manifestations of toxicity generally included fluid retention, nausea and rash, but there were several instances of transitory leukopenia and anemia. There was one instance of agranulocytosis with Butapyrin but none with phenylbutazone.dagger Aggravation of peptic ulcer occurred in ten patients with hemorrhage in two. Generally the toxicity was of a low order as compared with that of other drugs having an antirheumatic effect.     

Aplastic anemia associated with lithium therapy

A case is reported of fatal aplastic anemia developing in a 50-year-old woman who received lithium carbonate in the generally accepted dosage for a manic-depressive disorder. The serum lithium had been determined at regular intervals and never exceeded what is considered a safe level. Patients for whom lithium is prescribed should have periodic hematologic examinations.     

PHENYLBUTAZONE (BUTAZOLIDIN) AND BUTAPYRIN?—A Study of Clinical Effects in Arthritis and Gout

A clinical evaluation of phenylbutazone and Butapyrin® (a mixture of phenylbutazone and aminopyrine) was made in 409 patients who had a variety of rheumatic diseases. Preliminary European claims were substantiated.In gout a specific favorable effect was brought about by phenylbutazone alone.Effects equivalent to the previously reported favorable response to Butapyrin (Irgapyrin) were observed when its constituent phenylbutazone was used alone. The drug had a suppressive effect in a high percentage of patients with rheumatoid arthritis, ankylosing spondylitis, arthritis with psoriasis and mixed arthritis (rheumatoid arthritis plus osteoarthritis). Favorable effect in peritendinitis of the shoulders, osteoporosis of the spine and acute lumbosacral strain also was noted.Toxicity resulted in discontinuance of medication in 10 per cent of patients with each drug. Manifestations of toxicity generally included fluid retention, nausea and rash, but there were several instances of transitory leukopenia and anemia. There was one instance of agranulocytosis with Butapyrin but none with phenylbutazone.^† Aggravation of peptic ulcer occurred in ten patients with hemorrhage in two. Generally the toxicity was of a low order as compared with that of other drugs having an antirheumatic effect.     

Acquired aplastic anemia: Is bystander insult to autologous hematopoiesis driven by immune surveillance against malignant cells?

We previously reported a serendipitous finding from a patient with refractory severe aplastic anemia who had gotten an unexpected hematological response to treatment with gut-cleansing preparations (GCPs). This patient experienced three recurrences over the ensuing one year of intermittent GCP treatments, with each recurrence occurring 7-8 wk from a GCP. After his third recurrence, he was prescribed successive treatment with rifampicin, berberine, and monthly administered GCP for 4 mo, and he developed an erythroid proliferative neoplasma and an overwhelming enteropathy, and eventually died of septic shock. Laboratory investigations had validated the resolution of myelosuppression and the appearance of malignant clonal hematopoiesis. From the treatment process and laboratory investigations, it is reasonably inferred that the engagement of gut inflammation is critically required in sustaining the overall pathophysiology of acquired aplastic anemia probably by creating a chronic inflammatory state. Incorporation of rifampicin, berberine, and monthly GCP into cyclosporine can enhance the immunosuppressive effect. In a subgroup of acquired aplastic anemia patients whose pathogenesis is associated with genotoxic exposure, the suppressed normal hematopoiesis may result from the bystander insult that is mediated by the soluble inflammatory cytokines generated in response to the immunogenic products of damaged hematopoietic cells in the context of chronic inflammatory state and may offer a protective antineoplastic mechanism against malignant proliferation.     

Relevance of clonogenic assays in hematotoxicology

Clonogenic assays have been established in hematology for 30 years. They have been widely used in fundamental studies on hematopoiesis and they are also routinely used in clinical hematology to confirm diagnosis or to predict time to recovery in cases of bone marrow failure. Their use in toxicological studies is more recent. Adverse effects of xenobiotics can induce hematological problems and pathologies such as neutropenia, thrombocytopenia, anemia, and aplastic anemia. Three clonogenic assays are proposed for granulopoiesis, megakaryopoieisis and erythropoieisis. Hematopoietic progenitors from murine or human origin can be cultured in the presence of xenobiotics using validated protocols to complete standard animal toxicological studies. These clonogenic assays can help to predict adverse effects of drugs or toxicants. Clonogenic assays using white blood cell progenitors (CFU-GM culture) have recently been validated by ECVAM and can be used routinely. Megakaryocyte progenitor (CFU-MK) culture is under development and prevalidation in toxicological studies supported by ECVAM. Red blood cells progenitor culture (BFU-E) has been proposed but needs international validation to be recognized. This revised version was published online in July 2006 with corrections to the Cover Date.     

Oxidation sensitivity may be a useful tool for the detection of the hematotoxic potential of newly developed molecules: application to antipsychotic drugs.

Some antipsychotic agents have been found to produce agranulocytosis and aplastic anemia. The oxidation phenomena and/or the formation of free radicals has been suggested to be causally related to various hematological disorders, e.g., agranulocytosis. Using five experimental conditions, we tested the oxidative potential of compounds with and without a history of hematological side effects, e.g., agranulocytosis and aplastic anemia. A statistical analysis was undertaken for each experimental condition and a multivariate analysis combining all results was performed. Two peroxidase-induced free radical models did not successfully discriminate between drugs with and without a history of causing hematologic problems (<70%). The lipid peroxidation system provided even less satisfactory discrimination, with only 56.25% correct classification. However, an 87.5% correct classification was obtained when using the oxidation potentials of these drugs determined at pH 4.7 and at pH 7.4. A multivariate analysis taking into account the five variables provided 87.5% success in classification. The two clusters were better discriminated in terms of a "distance coefficient." In a second analysis, the putative antipsychotic pyridobenzodiazepine analogues (JL5, JL8, JL18, and JL25) were classified in the cluster of toxic compounds, while the oxa- and thiazepine analogues (JL2, JL3, and JL13) were classified as nontoxic compounds. On the other hand, a few metabolites of clozapine and fluperlapine were classified in the toxic compound group. The procedure described herein is, to our knowledge, the first which classifies molecules of different structures as well as different pharmacological profiles according to their hematotoxic potential. Such a procedure could be used to predict drug-induced hematological side effects.     

Improvement of anemia by recombinant erythropoietin in patients with myelodysplastic syndromes and aplastic anemia

Eight patients with myelodysplastic syndromes (MDS) and four patients with aplastic anemia (AA) were treated with recombinant erythropoietin (rEpo) to investigate its effect on the anemia of these patients. rEpo was administered by i.v. injection three times a week for at least four weeks. The doses were 3,000, 6,000, or 12,000 U/day. Despite an elevated "endogenous" Epo level, a greater than 1.5 g/dl increase in hemoglobin (Hb) concentration was observed in one patient with refractory anemia (RA), one patient with refractory anemia with excess of blasts (RAEB), and one patient with AA. A greater than 50% decrease in red cell transfusion requirement was observed in one patient with RA and one patient with AA. One RA patient and one AA patient have received rEpo as maintenance therapy for more than 64 and 100 weeks, respectively. They no longer need red cell transfusions and have had a normal Hb concentration and normal ferrokinetics. No side effect was seen. These results indicate that rEpo may benefit some patients with MDS and AA who are dependent on red cell transfusions while further studies will be necessary to elucidate the mechanism by which rEpo stimulates erythropoiesis and improves anemia in patients with these diseases.     

Evaluation of concentration and storage effects of mitomycin C in the diagnosis of Fanconi anemia among idiopatic aplastic anemia patients

BACKGROUND:

Fanconi anemia (FA) is a rare autosomal recessive genetic disorder that shows an increased sensitivity to the intercalating agents such as mytomycin C (MMC), measured as chromosomal aberrations. This study was conducted to differentiate between FA and “idiopathic” aplastic anemia on the basis of induced chromosomal breakage study with MMC.

MATERIALS AND METHODS:

MMC stress tests in different final concentrations of 20 and 50 ng/ml of MMC were conducted on peripheral blood lymphocytes from 32 patients with aplastic anemia and 13 healthy controls. Fifty nanograms per milliliter of MMC from old, fresh and frozen stocks was used to check the sensitivity of diagnosis on FA-diagnosed patients. Statistical analysis was used for the assessment of aberrations, including chromatid and chromosome breaks and exchanges.

RESULTS:

Eight patients (25%) with a very high percentage of chromosomal breakage were diagnosed as FA on the basis of the chromosomal breakage study. Six of these patients exhibited congenital anomalies at presentation, while another two lacked such anomalies or had minor physical problems. Freshly made MMC has shown more sensitivity to detect FA patients compared with frozen or 1-week-old MMC stock.

CONCLUSIONS:

The study indicates that freshly made MMC stress test provides an unequivocal means of differentiation between FA and “idiopathic” aplastic anemia. Further, the study, the first of its kind from Iran, stresses on the need for conducting this test in all aplastic anemia cases, even those without congenital anomalies, for accurate and timely diagnosis of FA to implement appropriate therapy.     

Bone marrow depressant and leukemogenic actions of benzene

Chronic benzene toxicity is expressed as bone marrow depression resulting in leucopenia, anemia or thrombocytopenia. With continued exposure the disease progresses to pancytopenia resulting from a bone marrow aplasia. In recent years evidence has accumulated implicating benzene in the etiology of leukemias in workers in industries where benzene was heavily used. It has been suggested that leukemia is as frequent a cause of death from chronic benzene exposure as is aplastic anemia. This review explores some current ideas on the mechanisms by which benzene may produce these diseases and emphasizes recent work suggesting that the causative agent is a metabolite of benzene.     

集落刺激因子治疗重型再生障碍性贫血疗效和安全性的Meta 分析

目的:通过Meta分析评价粒系或粒单系集落刺激因子(G-CSF或GM-CSF)对接受免疫抑制治疗(IST)的重型再生障碍性贫血(SAA)患者的疗效和安全性。方法:使用相关检索词检索MEDLINE、Cochrane Library、EMBASE、CNKI及CBM数据库,检索时间1990年1月～2011年12月。纳入G-CSF或GM-CSF治疗SAA的随机对照研究。用Review Manager4.2统计软件对数据进行Meta分析。结果:共纳入4篇文献,共466例SAA患者。Meta分析结果显示:①IST疗效:G-CSF/GM-CSF组与对照组的SAA患者对比,近远期疗效与生存率均无显著差异:总体生存率[OR=1.15,95%C(I0.73,1.82),P=0.54]、完全缓解率[OR=1.20,95%CI(0.71,2.02),P=0.50]、早期总体有效率[OR=1.61,95%CI(0.85,3.03),P=0.14]、远期总体有效率[OR=1.17,95%CI(0.78,1.74),P=0.45];②IST相关感染:IST治疗早期感染发生率、严重感染发生率、感染相关死亡率方面均未优于对照组;③G-CSF/GM-CSF组的复发率低于对照组,差异显著[OR=0.57,95%C(I0.35,0.93),P=0.02];④G-CSF/GM-CSF组远期随访发生克隆性病变的发生率与对照组无统计学差异,恶性肿瘤(MDS/AML)发生率[OR=0.90,95%CI(0.41,1.99),P=0.79]、PNH发生率[OR=1.48,95%CI(0.65,3.33),P=0.35]。结论:G-CSF/GM-CSF应用于接受IST治疗的SAA患者,尚不能证明具有提高总体生存率、完全缓解率、总体有效率、减少感染和感染相关死亡率等优势。虽然有可能降低复发率,也不增加远期克隆性病变发生率,但还需要更严格设计的大样本双盲随机对照试验,并进行更为长期的随访研究。     

Karyotype and in vitro-response to GM-CSF. Analysis of bone marrow cultures in leukemia, myelodysplasia and aplastic anemia

The influence of GM-CSF on bone marrow cultures from 13 patients with aplastic anemia, MDS and acute leukemia was studied in a short-term suspension culture system. In each case combined cytogenetic and proliferation analyses were performed with respect to the question, whether chromosome aberrations play a role in the in vitro response to GM-CSF and in order to search for stimulating effects on malignant cells. The responsiveness was compared of aplastic and myelodysplastic cultures on the one hand and of leukemic cells on the other. Our results show that myelodysplastic and aplastic cells display a tendency for reduced susceptibility to GM-CSF as compared to healthy controls, while in leukemic bone marrow the response to the growth factor was significantly enhanced, indicating a leukemia-specific response pattern. In the majority of leukemias analyzed, the presence of cytogenetically abnormal cells in cultures with excessive response to GM-CSF can be taken as a proof for stimulation of malignant cells. The significance of these findings for pathogenesis and prognosis in aplastic anemia, myelodysplasia and leukemia is discussed.     

Pathophysiological Scenario of Hematopoietic Disorders: A Comparative Study of Aplastic Anemia,Myelodysplastic Syndrome and Leukemia in Experimental Animals

The conversion of physiology to pathophysiology in hematological disorders viz: aplastic anemia, myelodysplastic syndrome (MDS) and leukemia in murine models was the subject of study in the present programme. Peripheral blood hemogram, spleno-somatic index, bone marrow smear study, cytochemical staining of marrow, cell release kinetics study during marrow explants culture, hematopoietic niche assessment, chromosomal aberration study, plasma membrane stability study of marrow cells, lysosomal membrane and mitochondrial membrane stability study and innate immune parameters were performed in the aplastic anemia, leukemia and MDS mouse model. In bone marrow aplasia, peripheral blood pancytopenia, marrow hypocellularity, decreased marrow cellular viability, deterioration of bone marrow hematopoiesis as well as hematopoietic microenvironment and extramedullary hematopoiesis were noticed. In addition, disruption of mitochondrial and lysosomal membrane integrity along with reduction of innate immune parameters were found in the hematopoietic suppressed condition. Surprisingly, no noticeable chromosomal aberration was found in the aplastic condition. Ineffective marrow hematopoiesis together with the disruption of hematopoietic microenvironment was observed in MDS. Also, extramedullary hematopoiesis, increased marrow cellular death, chromosomal aberration and loss of innate immunity were the common events. During leukemia, the number of functionally and structurally immature cells in the peripheral blood and bone marrow was increased together with malignant conversion of hematopoietic cells in the presence of malignancy supportive stromal microenvironment. Chromosomal aberration, decrease of cell mediated immunity with least mitochondrial apoptotic damage were also found in leukemic condition as well.     

Laboratory diagnostics of infections caused by cytomegalovirus and parvovirus B19 in patients with secondary immunodeficiency

To improve the quality of diagnostics and treatment of patients with immunodeficient states, two groups of patients were examined for the presence of cytomegalovirus (CMV) infection, among them 1,348--with clinical manifestations of CMV infection (group 1) and 335 hematological patients (group 2); in addition, 36 patients with secondary immunodeficiency and 31 patients with aplastic and hemolytic anemia, or with anemia of unclear origin were examined for the presence of parvovirusinfection (B19). The results of enzyme immunoassay, polymerase chain reaction and immunofluorescence tests active CMV infection, confirmed by determination of IgM, low avidity IgG, antigen and DNAemia, was registered in group 2 more often than in group 1. Examinations on the presence of parvovirus infection revealed that in anemia patients with the low level of IgG or its absence IgM was also detected more often than in group 1. In mixed infection caused by CMV and parvovirus B19 the disease took a more severe course than in monoinfection, which was probably due to the parallel action exerted by parvovirus on erythrocyte production in hematopoiesis and by CMV on the monocytic and macrophagal row of cell.     

四物汤对再生障碍性贫血小鼠骨髓细胞增殖的影响研究

目的研究四物汤对再生障碍性贫血（AA）小鼠骨髓细胞体外增殖的影响,探讨其治疗AA的机制。方法采用流式细胞仪、骨髓造血祖细胞培养等技术,检测四物汤对AA小鼠骨髓细胞的增殖变化。结果 四物汤能促进骨髓有核细胞进入G2／S期、增加CFU—GM、CFU-E、BFU-E集落数,且与自然恢复组有明显增强的差异。结论 四物汤在体内有促进AA小鼠骨髓细胞增殖的作用,为补血药治疗AA提供了实验与理论依据。     

Acetanilide Oxidation in Phenylbutazone-associated Hypoplastic Anaemia

Acetanilide like phenylbutazone is paraoxidized by the liver endoplasmic reticulum as a primary biotransformation step. Both compounds were given at different times to each of 10 healthy volunteer subjects and the plasma disappearances measured. Correlation was shown between plasma clearance values of the two compounds (r = + 0·7067; P < 0·05).Eight patients with hypoplastic anaemia after phenylbutazone therapy were investigated. Plasma clearance values and half lives of acetanilide were measured in this group of patients and compared with those of a group of 30 healthy volunteer controls. There was a significant decrease in clearance (P < 0·01) and lengthening of half lives (P < 0·001 in the patients with phenylbutazone-associated hypoplasia. Five patients with idiopathic aplastic anaemia—that is, without history of antecedent phenylbutazone ingestion—were similarly investigated with acetanilide and there was no significant difference between the results in these patients and those in the control group.It is suggested that relatively poor paraoxidation of phenylbutazone producing high blood concentrations on a given dose may be a factor responsible for the drug-associated hypoplasia even though it does not explain the similar pattern of adverse reactions reported in association with oral administration of the metabolite oxyphenbutazone.