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Recent advances in antibody technology to harness T cells for cancer immunotherapy, particularly in the difficult-to-treat setting of relapsed/refractory acute lymphoblastic leukemia (r/r ALL), have led to innovative methods for directing cytotoxic T cells to specific surface antigens on cancer cells. One approach involves administration of soluble bispecific (or dual-affinity) antibody-based constructs that temporarily bridge T cells and cancer cells. Another approach infuses ex vivo-engineered T cells that express a surface plasma membrane-inserted antibody construct called a chimeric antigen receptor (CAR). Both bispecific antibodies and CARs circumvent natural target cell recognition by creating a physical connection between cytotoxic T cells and target cancer cells to activate a cytolysis signaling pathway; this connection allows essentially all cytotoxic T cells in a patient to be engaged because typical tumor cell resistance mechanisms (such as T-cell receptor specificity, antigen processing and presentation, and major histocompatibility complex context) are bypassed. Both the bispecific T-cell engager (BiTE) antibody construct blinatumomab and CD19-CARs are immunotherapies that have yielded encouraging remission rates in CD19-positive r/r ALL, suggesting that they might serve as definitive treatments or bridging therapies to allogeneic hematopoietic cell transplantation. With the introduction of these immunotherapies, new challenges arise related to unique toxicities and distinctive pathways of resistance. An increasing body of knowledge is being accumulated on how to predict, prevent, and manage such toxicities, which will help to better stratify patient risk and tailor treatments to minimize severe adverse events. A deeper understanding of the precise mechanisms of action and immune resistance, interaction with other novel agents in potential combinations, and optimization in the manufacturing process will help to advance immunotherapy outcomes in the r/r ALL setting.

Allogeneic hematopoietic cell transplantation (HCT) may produce long-term survival in AML after relapse or primary induction failure (PIF). However, outcomes of HCT performed for AML not in remission are historically poor given high relapse rates and transplant-related mortality. Preliminary studies suggest conditioning with clofarabine and myeloablative busulfan (CloBu4) may exert significant anti-leukemic effects without excessive toxicity in refractory hematologic malignancies. A prospective multicenter phase II trial was conducted to determine the efficacy of CloBu4 for patients proceeding directly to HCT with AML not in remission. Seventy-one patients (median age: 56 years) received CloBu4. At day 30 after HCT, 90% achieved morphologic remission. The incidence of non-relapse mortality and relapse at 2 years was 25% and 55%, respectively. The 2-year overall survival (OS) and event-free survival (EFS) were 26% and 20%, respectively. Patients entering HCT in PIF had significantly greater EFS than those in relapse (34% vs 8%; P<0.01). Multivariate analysis comparing CloBu4 with a contemporaneous cohort (Center for International Blood and Marrow Transplantation Research) of AML not in remission receiving other myeloablative conditioning (n=105) demonstrated similar OS (HR: 1.33, 95% confidence interval: 0.92–1.92; P=0.12). HCT with myeloablative CloBu4 is associated with high early response rates and may produce durable remissions in select patients with AML not in remission.

Optic neuritis is often the initial presentation of multiple sclerosis (MS). As established by the Optic Neuritis Treatment Trial, an abnormal baseline brain MRI is a strong predictor of MS after isolated optic neuritis in adults. However, the rate of conversion to MS after optic neuritis in children based upon brain MRI findings is unknown.

Purpose An apparent life-threatening event (ALTE) refers to the sudden occurrence in an infant of a breathing abnormality, color change, or alteration in muscle tone or mental status. The finding of retinal hemorrhage in an infant who has experienced an ALTE strongly suggests the possibility of shaken baby syndrome. Previous ALTE studies have reported the frequency of this specific ocular abnormality but have not reported other ocular findings and their possible diagnostic significance.Methods This study reviews ophthalmologic findings from a series of 120 patients with ALTE who underwent eye examinations as part of their inpatient evaluation. Details of the history, physical examination, diagnostic testing, and discharge diagnosis were abstracted from the medical record while the patient was in the hospital.Results Ten patients (8.3%) had positive findings, including retinal hemorrhages in four of the six patients with shaken baby syndrome, the only ophthalmologic finding that helped establish the cause of an ALTE.Conclusions Since the funduscopic examination can help identify child abuse as the cause of an apparent life-threatening event, ophthalmologists play a critical role in the early evaluation of infants who have experienced such an event.

To locate general anesthetic binding sites on ligand-gated ion channels, a diazirine derivative of the potent intravenous anesthetic, R-(+)-etomidate (2-ethyl 1-(1-phenylethyl)-1H-imidazole-5-carboxylate), has been synthesized and characterized. R-(+)-Azietomidate [2-(3-methyl-3H-diaziren-3-yl)ethyl 1-(1-phenylethyl)-1H-imidazole-5-carboxylate] anesthetizes tadpoles with an EC50 of 2.2 μM, identical to that of R-(+)-etomidate. At this concentration both agents equally enhanced GABA-induced currents and decreased binding of the caged-convulsant [³⁵S]TBPS to GABAA receptors. In all of the above actions R-(+)-azietomidate is about an order of magnitude more potent than S-(−)-azietomidate, an enantioselectivity comparable to etomidate's. R-(+)-Azietomidate also inhibits acetylcholine-induced currents in nicotinic acetylcholine receptors, with about twice the potency of the parent compound. [³H]Azietomidate photoincorporated into Torpedo nicotinic acetylcholine receptor-rich membranes. Desensitization decreased photoincorporation into the δ-subunit and increased that into the α-subunit. The latter increase was confined to a proteolytic fragment containing the first three transmembrane segments. Thus, R-(+)-azietomidate is a potent stereoselective general anesthetic and an effective photolabel.

New studies and drug tests suggest that new, more effective therapies for Alzheimer's disease may be close to completion. For many years, acetylcholinesterase inhibitors were the only possible treatments; however, current research points to new possibilities. This article discusses current trends and future possibilities such as new acetylcholinesterase inhibitors, antioxidants, estrogen replacement therapy, and nonsteroidal antiinflammatory drugs. [ABSTRACT FROM AUTHOR]

Four of 10 patients who were enrolled on protocols of high-dose immunosuppression with peripheral blood stem cell rescue for MS experienced neurologic worsening while receiving recombinant human granulocyte colony-stimulating factor. There was improvement when methylprednisolone was given to three of the patients, but one patient died of respiratory failure. The mechanism of the neurologic worsening is uncertain.

Ethanol enhances the gating of a family of related ligand-gated ion channels including nicotinic acetylcholine, serotonin type 3, gamma-aminobutyric acid-A, and glycine receptors. This common action may reflect shared molecular and kinetic mechanisms. In all of these receptors, ethanol enhances multichannel currents elicited with low agonist concentrations, but not with high agonist concentrations. A single mutation in the nicotinic receptor beta subunit, betaT263I, causes ethanol to enhance multichannel currents elicited with both low and high acetylcholine concentrations. Based on the ratios of acetylcholine EC50s in the presence and absence of ethanol, this mutant's sensitivity to enhancement is similar to wild type. Ethanol enhancement of betaT263I receptor activation shows no voltage dependence. In the presence of ethanol, the apparent single-channel conductance of the betaT263I receptor is reduced and the apparent channel lifetime is lengthened. Both the 28% increase in maximal current and the 2-fold reduction in EC50 observed at 300 mM ethanol are quantitatively predicted by simulation of a simple kinetic scheme in which ethanol increases by 4-fold the ratio of microscopic opening rate (beta) to closing rate (alpha) for acetylcholine-bound betaT263I receptors. We conclude that ethanol enhancement of betaT263I currents reflects stabilization of its open-channel state relative to agonist-bound closed states. Ethanol effects in wild-type receptors can also be explained by this mechanism.

To overcome the difficulties of locating the molecular sites of general anesthetic action, we synthesized a novel photoactivable general anesthetic, 3-(2-hydroxyethyl)-3-n-pentyldiazirine (3-diazirinyloctanol), which anesthetized tadpoles with an ED50 of 160 μM. Subanesthetic concentrations of 3-diazirinyloctanol enhanced GABA-induced currents in GABAA receptors, an effect that has been implicated in general anesthetic action. It also enhanced [³H]muscimol binding to this receptor. In muscle nicotinic acetylcholine receptors (nAcChoR), it inhibited the response to acetylcholine with an IC50 of 33 μM. 3-Diazirinyloctanol's pharmacological actions were comparable to those of octanol. 3-(2-Hydroxyethyl)-3-[4,5-³H2]-n-pentyldiazirine photoincorporated into Torpedo nAcChoR-rich membranes mainly in the α subunit with 70% being in a proteolytic fragment containing the M4 transmembrane segment. Agonist enhanced the photolabeling 10-fold in a fragment containing the M1, M2, and M3 transmembrane segments. Thus, 3-diazirinyloctanol is a novel general anesthetic that acts on, and can be photoincorporated into, postsynaptic receptors.

Accelerated fibrinogen disappearance in diabetic patients is reversible with normalization of blood glucose. To define the time course of this reversal, we measured 125I-fibrinogen disappearance in 19 diabetic patients experiencing acute changes in blood glucose, as monitored and controlled by a microprocessor-controlled closed loop insulin infusion system (artificial beta cell). The data were corrected for blood volume dilutional changes and fit to a model describing two sequential exponential functions and a single exponential function. The sequential model provided the best fit for all but one patient. This indicates that there were two distinct rates of fibrinogen disappearance and suggests that the time course of reversal of accelerated fibrinogen disappearance in diabetic patients is very rapid, if not immediate. Rapid fibrinogen turnover during hyperglycemia was temporally associated with vascular volume changes, reflected as dilutional changes of 51Cr-RBC concentrations. These findings were also associated with an increase in pulse pressure during hyperglycemia, suggesting blood volume expansion due to an osmotic mechanism. The results of this study suggest a picture of vascular volume expansion and contraction, perhaps secondary to the osmotic effects of hyperglycemia. Accelerated fibrinogen turnover associated with these events may be related to increased vascular permeability and/or increased fibrin formation. These events, in concert, may contribute to the initiation and/or propagation of diabetic vascular sequelae.

Bone marrow transplantation has become the treatment of choice for patients with severe aplastic anemia who are fortunate enough to have allogeneic sibling donors. As patients have been transplanted earlier in the course of their disease, significant improvements have been obtained in long-term survival. However, in patients who have been sensitized by previous blood product transfusions, graft rejection continues to be a significant problem and second transplants when performed are frequently unsuccessful. This case report deals with a patient with myositis ossificans progressiva (MOP) who developed severe idiopathic aplastic anemia. He rejected his first graft after 160 days. However, he was successfully reingrafted with marrow from the same donor using a different conditioning regimen.

Lead (Pb2+) is known to alter the permeability of brain capillaries. A possible mechanism for this alteration may be related to the ability of Pb2+ to substitute for Ca2+. Products derived from phospholipid metabolism, namely eicosanoids and diacylglycerol, control endothelial permeability, are partly regulated by intracellular Ca2+, and thus may be sensitive to Pb2+. We asked in this study whether Pb2+ increased arachidonic acid release or stimulated phosphatidylcholine breakdown in an in vitro model of brain capillaries, namely cultured bovine retinal endothelial (BRE) cells. Pb2+ stimulated arachidonic acid release and phosphatidylcholine and phosphatidylinositol metabolism in the presence of ionomycin, but not by itself. More arachidonic acid was released than phosphorylcholine in BRE cells stimulated with ionomycin and Pb2+, but the magnitudes of these responses were similar in cells exposed to ionomycin plus Ca2+. Ionomycin plus Pb2+ or plus Ca2+ resulted in the activation of phospholipase A₂, since an increase in lysophosphatidylcholine and arachidonic acid was observed. Protein kinase C was not required for arachidonic acid release because release was observed in cells with a down-regulated enzyme. Ionomycin plus other metals (La3+, Cd2+, or Mg2+) did not result in arachidonic acid release, but Cd2+ or Co2+ inhibited arachidonic acid release by more than 80% when cells were exposed to ionomycin with either Pb2+ or Ca2+. Thapsigargin or maitotoxin plus Ca2+ increased arachidonic acid release that was inhibited by the receptor-dependent calcium channel antagonist SK&F 96365 but not by the voltage-dependent calcium channel antagonist nifedipine. However, thapsigargin or maitotoxin plus Pb2+ failed to stimulate arachidonic release. Since in this in vitro model Pb2+ stimulated phospholipid metabolism solely in the presence of an ionophore, the increase in permeability observed in Pb2+-exposed animals is probably not due to a release of metabolites of arachidonic acid.Copyright 1994, 1999 Academic Press, Inc.

We evaluated nine patients with external opthalmoparesis and increased intracranial pressure. The eye movements normalized when the intracranial pressure was controlled. Investigations for an underlying cause of elevated cerebrospinal fluid pressure are warranted when ocular motility disorders are present.

Article abstract-Parenchymatous intracerebral hemorrhage (ICH) is a serious, infrequent complication of thrombolytic therapy for acute myocardial infarction. We studied the clinical and radiologic features, manner of presentation, associated factors, and temporal course in 23 patients with ICH associated with 150 mg or 100 mg recombinant tissue-type plasminogen activator (rt-PA) and heparin therapy for acute myocardial infarction in the Thrombolysis in Myocardial Infarction (TIMI) II Pilot and Randomized Clinical Trial. In TIMI II, 13 of the 23 ICH patients developed or maintained systolic blood pressure >=160 mm Hg or diastolic blood pressure >=90 mm Hg during the rt-PA infusion and before the onset of neurologic symptoms. Six patients (26%) had life-threatening ventricular arrhythmias, five before onset of neurologic symptoms. A decreased level of consciousness was the earliest neurologic abnormality in 15 (65%) and the most common initial physical finding (in 19, or 82%). Onset was usually gradual (70%), but time to maximal deficit was frequently (61%) within 6 hours of onset. The locations of the primary ICH sites were lobar in 16 (70%), thalamic in four (17%), and brainstem-cerebellum in three (13%), but the putamen was never the primary site. Multiple lobar hemorrhages occurred in six cases (26%). The timing and size of ICH was similar among patients treated with 150 mg rt-PA and 100 mg rt-PA. Brain CT demonstrated an arteriovenous malformation in one case. Four patients had hypofibrinogenemia, which was profound in three patients. Pathologic findings were available for five patients. Of these, three patients had cerebral amyloid angiopathy, and one had hemorrhagic transformation of an ischemic cerebral infarction found at autopsy. We conclude that ICH following rt-PA and heparin therapy for acute myocardial infarction presents as a distinctive clinical syndrome. Intracerebral bleeding after combined thrombolytic and antithrombotic therapy may be associated with cerebral amyloid angiopathy and other vascular lesions. Acute or persistent hypertension before or during rt-PA infusion, life-threatening ventricular arrhythmias, and hypofibrinogenemia, either alone or in combination, may play roles in some cases. Care should be exercised when considering thrombolytic therapy for patients with risk factors for ICH.

Allogeneic bone marrow transplantation from histocompatible sibling donors was performed in six patients with extranodal involvement of high grade lymphoma during first complete remission. Five patients had lymphoblastic lymphoma and one had diffuse undifferentiated lymphoma. The cytoreductive/immunosuppressive regimen consisted of total body irradiation and high dose cyclophosphamide. Four patients are alive in complete remission at 8 months, 14 months, 21 months and 47 months post transplantation. One patient who relapsed 7 months after his initial transplantation underwent a second transplantation but another relapse 17 months later led to his death. One patient died of chronic graft-versus-host disease and at autopsy there was no evidence of lymphoma. These data demonstrate that allogeneic bone marrow transplantation can produce durable remissions in patients with high grade lymphoma who present with bone marrow, central nervous system and/or skin involvement.

Five patients with hematologic malignancies who had relapsed between seven months and eight years after their primary bone marrow transplants were prepared with high dose busulfan/etoposide for second marrow transplanatations from the same donors who had provided the marrow for the primary transplants. The preparatory regimen was well tolerated. All patients engrafted and entered complete remission. Two patients are alive and in continued remission two and ten months after second transplant. One patient died with acute respiratory failure after two months and two patients relapsed again eight and 17 months after second marrow transplantation. The combination busulfan/etoposide may prove to be a suitable preparatory regimen for second bone marrow transplant attempts in selected patients.

General anesthetics depress central nervous system excitability via a mechanism that probably involves effects on synaptic ion channels, but the fundamental molecular nature of the site where they act is unknown. Although the importance of hydrophobicity for general anesthetic drug potency has long been established, it remains uncertain whether these "nonspecific" drugs act on membrane proteins directly or by modification of the physical properties of the lipid membrane or the lipid-protein interface. We find that specific mutations in the acetylcholine receptor pore-forming M2 domains enhance the sensitivity of the receptor to the general anesthetics isoflurane, hexanol, and octanol, suggesting that these agents act by binding directly to a discrete protein site at or near these residues. The sensitivity of the receptor to block by general anesthetics increases with increased hydrophobicity of these residues, demonstrating that hydrophobic forces dominate the interaction of drugs with their protein site. Furthermore, octanol inhibits both wild-type and mutant nicotinic acetylcholine receptors preferentially after channel opening, which is consistent with a mechanism where drugs bind within the receptor's pore. Similar sites on postsynaptic ion channels in brain may represent general anesthetic targets for modulating consciousness.

The enantiomers of pentobarbital had four different actions on the nicotinic receptor-rich membranes from Torpedo electroplaques. (i) Both inhibited cholinergically stimulated cation flux through the receptor's channel, with IC50 values of approximately 25 microM and extremely weak stereoselectivity. (ii) (R)-(+)-[14C]Pentobarbital bound to a saturable site with an apparent dissociation constant of 100 microM, a Hill coefficient of 1.2, and a stoichiometry of 1:1 with the acetylcholine binding sites. (S)-(-)-Pentobarbital also displaced (+)-[14C]pentobarbital but its IC50 was 4-fold higher than that of the (+)-enantiomer under the same conditions. (iii) Both enantiomers caused a stereoselective allosteric inhibition of [3H]acetylcholine binding, which occurred over the same concentration range and with the same stereoselectivity as barbiturate binding. (iv) Above 1 mM, pentobarbital caused an unexpected and sudden increase in [3H]acetylcholine binding, which lacked significant stereoselectivity. These results are consistent with a model where low concentrations of pentobarbital act on the receptor by binding to allosteric sites that have higher affinity but lower stereoselectivity for the open channel conformation than for the resting conformation, whereas the highest concentrations of pentobarbital act by nonspecific mechanisms mediated by general membrane perturbations.

We describe here a deletion of 34 nucleotides from the 3' end of the first intervening sequence of the β-globin gene covering the AGGC splice junction, and the insertion of 32 nucleotides of the δ-globin gene at the same location. This gene rearrangement was detected in three members of an African-American family. The proband, a 28-year-old female, and her mother had a history of chronic anemia. One of her two brothers, who inherited the same gene defect, was apparently healthy with no symptoms of hemolytic anemia. The proband, her father, and her two brothers, including the one who carried the β-globin gene rearrangement, were found to be heterozygous for a-thalassemia-2 (-α3.7). Although the AGGC splice junction is disrupted (AGGC→AGAT), the invariant AG has remained intact after this gene rearrangement. Our investigations could not detect any defect in RNA processing in the affected β-globin genes. The discrepancies between the phenotypes and the globin chain synthesis ratios of the mother, her daughter, and her son who inherited the same gene defect at their β-globin genes, remain unexplained.

Infiltration of extrahemopoietic tissue with leukemic cells was evaluated as a prognostic indicator in 18 patients with acute leukemia undergoing bone marrow transplantation. When compared to 107 patients who did not have extramedullary leukemia at any time prior to marrow grafting, the patients with leukemic invasion into organs outside the hemopoietic system had a significant increase of leukemic recurrence and a significant decrease in survival after marrow transplantation. Extramedullary leukemia may be a negative prognostic indicator for bone marrow transplantation candidates.

This is the first report of a successful bone marrow transplantation for chronic myelomonocytic leukemia. A 41-year-old woman with chronic myelomonocytic leukemia received, as primary treatment, a novel preparatory regimen consisting of high dose fractionated total body irradiation and high dose VP-16 chemotherapy followed by allogeneic marrow transplantation from her histocompatible brother. The patient is now more than two years after marrow transplantation with normal blood counts and a normal bone marrow which is of donor type. For younger patients with this disease who have a histocompatible sibling donor, bone marrow transplantation may represent a valid therapeutic option with curative potential.

This study was designed to assess the reliability and validity of a Quality of Life (QOL) instrument on a sample of 179 allogeneic Bone Marrow Transplant (BMT) survivors. The QOL-BMT tool was developed specifically for this population and was based on the investigators' prior research and a conceptual model of Quality of Life. Patients who were at least 100 days post BMT completed the 30 item visual analogue questionnaire. The instrument measured physical symptoms (e.g., weight loss, frequent colds, skin changes, cataracts, sexual problems), psychological to illness, social concerns (e.g., relationship adjustment, return to work), and spiritual well-being (e.g., sense of control, future goals). Psychometric analysis of the instrument included measures of reliability and validity. The study findings demonstrate the unique aspects of QOL dimensions in BMT survivors and the value of QOL assessment in clinical practice and research.

Sixty-nine patients with acute nonlymphocytic leukemia in first remission received total-body irradiation and chemotherapy followed by allogeneic bone marrow transplantation from Mstocompatible sibling donors, Patient age was between 1 and 41 years: 20 patients 1– 19 years (group 1); 27 patients 20–29 years (group 2); and 22 patients 30–41 years (group 3). Two pretrans-plant radiochemotherapy regimens were employed: The first 45 patients received total-body irradiation (in a single dose) with cytosine arabinoside and cyclophosphamide; the next 24 patients received total-body irradiation (in a fractionated schedule) with cyclophosphamide alone. For all patients, actuarial disease-free survival is 51 (37 of 69 patients are alive and in continuous remission between 5 months and 9.3 years, median 3.7 years). For group 1 actuarial survival is 56, group 2 48, and group 3 48. When analyzed for pretransplant factors that might predict disease-free survival after bone marrow transplantation neither patient age, white cell count at the time of diagnosis, FAB leukemic subtype, length of time before achieving remission, nor length of time between remission and bone marrow transplantation were established as prognostic.

At nicotinic acetylcholine receptors, short chain n-alcohols (alkanols) have excitatory actions, whereas long chain alkanols inhibit channel activity. This study tests a previously proposed unitary hypothesis that suggests that these contrasting actions can be accounted for by interaction at just one hydrophobic site within the ion channel lumen. All alkanols bind to this site, but only long chain alkanols are large enough to completely block the channel. Short chain alkanols are too small to cause any channel occlusion, and in binding to the site they stabilize the open state of the receptor and enhance ion flux. In this study, we assay integrated agonist-stimulated ion efflux over 15 msec, as a measure of receptor activity. In nicotinic acetylcholine receptor-rich membrane vesicles from Torpedo, we show that, in contradiction to this elegant model, long chain and short chain alkanols appear to act at different sites. Firstly, ethanol and octanol do not compete for a single site on the receptor. Secondly, alkanol chain length dependencies for inhibition and for flux enhancement are significantly different. Thirdly, intermediate length alkanols do not partially inhibit channels, as required by the model; high concentrations of these alkanols completely inhibit the response. Fourthly, careful measurements, including determination of the free alkanol concentration, of inhibitory potencies of alkanols from propanol to decanol show no evidence for a steric contribution to the ability of an alkanol to inhibit the ion channel. Furthermore, our results suggest that the inhibitory effect of long chain alkanols may be mediated by a discrete site on nicotinic acetylcholine receptors, whereas there is no evidence that a protein site is involved in the excitatory mechanism of short chain alkanols. Indeed, it seems more likely that short chain alkanols may have a nonspecific site of action.

Plasma PCR for human cytomegalovirus (CMV) DNA was compared with bronchoalveolar lavage (BAL) fluid culture as an indicator for disseminated CMV infection. Thirteen (32.5%) of 40 consecutive bone marrow transplant (BMT) recipients were BAL fluid culture positive for CMV on day 35 post-BMT, and 9 (69%) of the 13 had positive plasma PCRs between days 28 and 49. Of the 27 with negative BAL fluid cultures, 2 (7%) had positive plasma PCRs (P < 0.001). Plasma CMV DNA in BMT recipients is a useful clinical marker for serious infection.

Patients with acute lymphoblastic leukemia who have poor prognostic features at diagnosis usually have a short disease-free survival in spite of successful remission induction. Those poor risk features are: age over 30 years, a white blood cell count over 25,000/μl, certain translocations of chromosomes, and requirement for more than six weeks of induction chemotherapy to attain a complete remission. We have used high-dose radiochemotherapy to prepare 39 patients with acute lymphoblastic leukemia in first complete remission (1 infant and 38 adults; median age 23 years) for bone marrow transplantation from histocompatible sibling donors. Thirty-one of the 39 patients in this study had one (n=23) or more (n=8) poor risk features: age (n=7); high white blood cell count (n=19); translocations (n=4), or resistance to initial induction therapy (n=11). Currently, 26 patients are surviving for 4–72 months (median 18 months) following marrow grafting and are in complete remission. One of the surviving patients had two marrow transplant procedures because of recurrent leukemia. Actuarial survival in complete remission is 63 for the entire group of 39 patients and is 60 if the eight patients who had no poor risk features are excluded from analysis. The following causes for failure were observed: leukemic relapse was encountered in four patients between 3 and 17 months after BMT for an actuarial relapse rate of 16; bacterial sepsis was the cause of death in two patients; graft-versus-host disease and/or interstitial pneumonia led to the demise of seven patients, and one patient died with leukoencephalopathy. It appears that high-dose radiochemotherapy followed by bone marrow transplantation from a histocompatible sibling donor during first complete remission can result in a high disease-free survival rate for younger adults with poor-risk acute lymphoblastic leukemia. This concept needs to be tested in prospective trials comparing bone marrow transplantation with chemotherapy.

The human cytomegalovirus (HCMV) a-sequence (a-seq) is located in the joining region between the long (L) and short (S) unique sequences of the virus (L-S junction), and this hypervariable junction has been used to differentiate HCMV strains. The purpose of this study was to investigate whether there are differences among strains of human cytomegalovirus which could be characterized by polymerase chain reaction (PCR) amplification of the a-seq of HCMV DNA and to compare a PCR method of strain differentiation with conventional restriction fragment length polymorphism (RFLP) methodology by using HCMV junction probes. Laboratory strains of HCMV and viral isolates from individuals with HCMV infection were characterized by using both RFLPs and PCR. The PCR assay amplified regions in the major immediate-early gene (IE-1), the 64/65-kDa matrix phosphoprotein (pp65), and the a-seq of the L-S junction region. HCMV laboratory strains Towne, AD169, and Davis were distinguishable, in terms of size of the amplified product, when analyzed by PCR with primers specific for the a-seq but were indistinguishable by using PCR targeted to IE-1 and pp65 sequences. When this technique was applied to a characterization of isolates from individuals with HCMV infection, selected isolates could be readily distinguished. In addition, when the a-seq PCR product was analyzed with restriction enzyme digestion for the presence of specific sequences, these DNA differences were confirmed. PCR analysis across the variable a-seq of HCMV demonstrated differences among strains which were confirmed by RFLP in 38 of 40 isolates analyzed. The most informative restriction enzyme sites in the a-seq for distinguishing HCMV isolates were those of MnlI and BssHII. This indicates that the a-seq of HCMV is heterogeneous among wild strains, and PCR of the a-seq of HCMV is a practical way to characterize differences in strains of HCMV.

Whipple's disease of the central nervous system (CNS) may be associated with normal intestinal histology as a result of minimal or patchy involvement. The diagnosis is difficult and is frequently made post mortem. We studied 6 patients with clinically suspected CNS Whipple's disease; 2 had oculomasticatory myorhythmia (OMM) fitting criteria for a diagnosis of definite CNS Whipple's disease. One of the 2 had duodenal histology highly suggestive of Whipple's disease; the other 5 patients had normal duodenal histology. DNA was extracted from paraffin‐embedded duodenal tissues in all patients and frozen pontine tissue in 1. Two primer pairs (WF‐WR, W3F‐W2R) were used in separate polymerase chain reactions (PCRs) to amplify fragments of Tropheryma whippelii16S rDNA from these tissue samples. PCR amplicons were detected only in the duodenal tissues from the 2 patients with OMM. The sequences of these amplicons were identical to the corresponding region of the previously published Tropheryma whippelii16S rDNA sequence. PCR‐based assays of intestinal or brain tissue may be of value for confirming, and possibly refuting, a clinical diagnosis of CNS Whipple's disease in a patient with any combination of dementia, supranuclear gaze palsy, hypothalamic manifestations, myoclonus, seizures, ataxia, or OMM, especially when tissue histology is unrevealing.

Negatively charged phospholipids accelerate blood coagulation; one suggestion is that the binding of the gamma-carboxyglutamic acid-containing zymogens to these lipid surfaces increases their effective concentration as substrates. Alternatively, the charged phospholipids could enhance the direct interaction of substrate with the catalytic complex, which is localized at the membrane surface. We distinguished the alternatives by using prothrombin fragment 1 to compete with the substrate for membrane binding sites without interfering with the direct enzyme-substrate interaction. In a tissue factor-factor VIIa system containing neutral phospholipids (to which the substrate does not bind), prothrombin fragment 1 had no significant effect on factor X activation (Km, 877 +/- 111 nM and 791 +/- 103 nM, with and without prothrombin fragment 1, respectively). In contrast, in a system containing 30% phosphatidylserine, prothrombin fragment 1 displaced phospholipid-bound factor X, increasing the free factor X concentration and the reaction velocity in all 22 determinations. As the velocity increases correlated only with the free factor X concentration, we conclude that the free factor X concentration controls this reaction velocity. The Km in the 30% phosphatidylserine system, calculated using free factor X concentration, was 41 +/- 5 nM and 63 +/- 9 nM, with and without prothrombin fragment 1, respectively. Thus, the negatively charged lipids decreased the intrinsic Km by over 90%. The methodology employed should be applicable to ligand-receptor systems in which ligand binds nonspecifically to the membrane surface.