Raimundo García

Pharmacological Profiles of Acute Myeloid Leukemia Treatments in Patient Samples by Automated Flow Cytometry: A Bridge to Individualized Medicine

BACKGROUND We have evaluated the ex vivo pharmacology of single drugs and drug combinations in malignant cells of bone marrow samples from 125 patients with acute myeloid leukemia using a novel automated flow cytometry-based platform (ExviTech). We have improved previous ex vivo drug testing with 4 innovations: identifying individual leukemic cells, using intact whole blood during the incubation, using an automated platform that escalates reliably data, and performing analyses pharmacodynamic population models. PATIENTS AND METHODS Samples were sent from 24 hospitals to a central laboratory and incubated for 48 hours in whole blood, after which drug activity was measured in terms of depletion of leukemic cells. RESULTS The sensitivity of single drugs is assessed for standard efficacy (EMAX) and potency (EC50) variables, ranked as percentiles within the population. The sensitivity of drug-combination treatments is assessed for the synergism achieved in each patient sample. We found a large variability among patient samples in the dose-response curves to a single drug or combination treatment. CONCLUSION We hypothesize that the use of the individual patient ex vivo pharmacological profiles may help to guide a personalized treatment selection.

Acute Myeloblasts Leukemia with Minimal Myeloid Differentiation (FAB AML-M0): A Study of Eleven Cases

The main clinical, morphological, cytochemical, immunological features and therapy results of eleven patients diagnosed as acute myeloblastic leukemia M0 (AML-M0) are reported here. There were no clinical characteristics, abnormalities on physical examination or initial laboratory parameters that distinguished these eleven patients. Bone marrow aspirates were hypocellular in four patients. The leukemic cells were undifferentiated by light microscopy and myeloperoxidase (MPO) and/or Sudan Black B (SBB) stains were negative in all cases. Myeloid differentiation antigens were present on the leukemic cells of all eleven patients, whereas B and T cell markers were clearly negative except for CD4 and CD7 antigens. Whatever the treatment employed survival was very short. Eight of the eleven patients were treated and two achieved complete remission (CR) but only one of them is alive in continuous CR. Our results like those previously reported, suggest that AML-M0 patients have a very poor prognosis with standard induction therapies and should perhaps be considered for experimental therapeutic approaches.

Emergency contraception in Cuba with 10 mg of mifepristone

Background Mifepristone in a dose of 10 mg is an effective emergency contraceptive when administered up to 120 hours after unprotected coitus. Methods Between May 2003 and February 2005, we conducted in Cuba a single-arm trial to evaluate the effectiveness of 10 mg mifepristone for emergency contraception up to 6 days after unprotected coitus. A total of 635 women who requested emergency contraception after a single act of unprotected intercourse were included in the study. Results After treatment there were 7/635 (1.1%) pregnancies (95% CI 0.4–2.3%). Pregnancy that might have occurred was prevented in 88.0% of the cases (95% CI 77.1–95.1%). The most common side effects reported by participants were fatigue (10.7%), dizziness (6.1%) and nausea (4.9%); vomiting was only reported by 0.6%. In 38/635 (6.0%) women menstruation was delayed more than 7 days. Conclusions Mifepristone 10 mg administered is an effective emergency contraceptive with an acceptable profile of side effects up to five days, but greater studies are necessary to verify its efficacy up to 6 days after unprotected intercourse.

A prognostic model for survival after salvage treatment with FLAG-Ida +/− gemtuzumab-ozogamicine in adult patients with refractory/relapsed acute myeloid leukaemia

The combination of fludarabine, cytarabine, idarubicin, and granulocyte colony‐stimulating factor (FLAG‐Ida) is widely used in relapsed/refractory acute myeloid leukaemia (AML). We retrospectively analysed the results of 259 adult AML patients treated as first salvage with FLAG‐Ida or FLAG‐Ida plus Gentuzumab‐Ozogamicin (FLAGO‐Ida) of the Programa Español de Tratamientos en Hematología (PETHEMA) database, developing a prognostic score system of survival in this setting (SALFLAGE score). Overall, 221 patients received FLAG‐Ida and 38 FLAGO‐Ida; 92 were older than 60 years. The complete remission (CR)/CR with incomplete blood count recovery (CRi) rate was 51%, with 9% of induction deaths. Three covariates were associated with lower CR/CRi: high‐risk cytogenetics and t(8;21) at diagnosis, no previous allogeneic stem cell transplantation (allo‐SCT) and relapse‐free interval <1 year. Allo‐SCT was performed in second CR in 60 patients (23%). The median overall survival (OS) of the entire cohort was 0·7 years, with 22% OS at 5‐years. Four independent variables were used to construct the score: cytogenetics, FLT3‐internal tandem duplication, length of relapse‐free interval and previous allo‐SCT. Using this stratification system, three groups were defined: favourable (26% of patients), intermediate (29%) and poor‐risk (45%), with an expected 5‐year OS of 52%, 26% and 7%, respectively. The SALFLAGE score discriminated a subset of patients with an acceptable long‐term outcome using FLAG‐Ida/FLAGO‐Ida regimen. The results of this retrospective analysis should be validated in independent external cohorts.

Imipenem/Cilastatin with or without Glycopeptide as Initial Antibiotic Therapy for Recipients of Autologous Stem Cell Transplantation: Results of a Spanish Multicenter Study

We analyzed the efficacy of imipenem/cilastatin alone (group I, 197 patients) or in combination with a glycopeptide (group I + G, 231 patients) as first-line antibiotic therapy for 2 consecutive cohorts of autologous stem cell transplantation (ASCT) recipients with febrile neutropenia. From June 2001 to June 2002, patients received imipenem/cilastatin (500 mg/6 hours), and from July 2002 to December 2003, they received imipenem/cilastatin as for group I plus a glycopeptide (vancomycin, 1 g/12 hours or teicoplanin, 400 mg/day). Fever of unknown origin accounted for 33.5% of episodes (66 patients) in group I and 50% of episodes (116 patients) in group I + G (P = .005). Bacteremia occurred in 55 patients (28%) in group I and in 51 patients (22%) in group I + G (P = .16). Resolution of fever without modification of the therapy regimen was observed in 108 patients (55%) and 159 patients (69%) in groups I and I + G, respectively (P = .003). The median interval to defervescence (4 days) and overall mortality were similar between groups. Inclusion of a glycopeptide in the initial antibiotic regimen for febrile neutropenia results in a higher success rate without modifying the regimen. However, glycopeptide inclusion does not improve the interval to defervescence or mortality rate.

rHuEPO in the management of pregnancy complicated by anti‐Dib

Recent data have shown that significant levels of cellular prion protein (PrPC) are found within human blood. However, although PrPC is expressed by PLTs, WBCs, and RBCs, the majority of PrPC is detected within the plasma fraction by dissociation-enhanced fluoroimmunoassay (DELFIA, Wallac, United Kingdom).1 This is particularly relevant as PrPSC can also be found within the plasma fraction in animal models of the disease.2 In their recent TRANSFUSION article, Simak and coworkers3 reported that PrPC is expressed on endothelial cells and is released during apoptosis, on membrane microparticles that are also detectable in human plasma. We have performed similar experiments with human umbilical vein endothelial cells (HUVECs) and report comparable findings. In addition, we have also used human microvascular endothelial cells (HMEC-1).4 Both cell types were found to express PrPC mRNA, and flow cytometric analysis of HUVECs demonstrated a similar quantity of cell surface PrPC as reported by Simak et al.3 The HMEC-1 cells were found to express double the amount of surface PrPC. Simak and colleagues3 measured the release of microparticles associated with PrPC from apoptotic endothelial cells by flow cytometry and demonstrated that endothelial-derived microparticles within both cell culture and blood plasma express PrPC, suggesting that they could contribute to the plasma pool of PrPC. To clarify the contribution of microparticles to the PrPC present in endothelial cell supernatants, we have measured PrPC by DELFIA before and after ultracentrifugation of HUVEC and HMEC-1 cell supernatants at 100,000 g for 2 hours. We then resuspended the microparticle precipitates (verified by flow cytometry with annexin V labeling) and measured the PrPC concentration by DELFIA. There was a slight decrease of signal in the ultracentrifuged supernatant, indicating that a small proportion of PrPC was associated with insoluble material (Fig. 1). There was no detectable PrPC within the resuspended microparticle precipitates. Similar results were obtained with normal human plasma before and after ultracentrifugation (Fig. 1). Ultracentrifugation removed both microparticles and a small proportion of the PrPC DELFIA signal, supporting the data of Simak et al.3 It has already been shown that blood plasma infectivity is not eliminated by high-speed centrifugation in a mouse model of CJD, indicating that the infectivity is present in the soluble plasma fraction.2 We conclude that it is likely that endothelial cell microparticles do express PrPC, but that most PrPC released by endothelial cells and within human blood plasma is in soluble form. Richard Starke, BSc Haemostasis Research Unit University College London 3rd Floor Jules Thorn Building 48 Riding House Street London W1N 8AA, UK e-mail: r.starke@ucl.ac.uk Paul Harrison, BSc, PhD, MRCPath Oxford Haemophilia Center Churchill Hospital Headington Oxford, UK Olive Drummond, GIBiol Ian Macgregor, BSc, PhD Products and Components R & D Group National Science Laboratory Scottish National Blood Transfusion Service Edinburgh, UK Ian Mackie, BSc, PhD, FIBMS, FRCPath Samuel Machin, MB ChB, FRCP, FRCPath Haemostasis Research Unit University College London 3rd Floor Jules Thorn Building 48 Riding House Street London W1N 8AA, UK

Traffic Lights Fuzzy Control Proposals to Improve Vehicular Flow

The present work proposes the application of diffuse systems in traffic lights, for the road control of urban transit in the city of Nogales, Sonora, Mexico. Given the vehicular problematic of the city it is intended to look for options to make the vehicular traffic more agile, with this in mind three proposals of diffuse control design were formulated. These proposals are part of an interdisciplinary project that intends to optimize the operation and reduce the implementation cost of traffic lights.

An ex vivo native environment precision medicine test shows high clinical correlation with responses to first line acute myeloid leukemia treatment

P Preventive and Personalized Medicine (PPPM) as the healthcare model of the near future and its tool, i.e., Translational Medicine (TraMed), represent an innovative model of healthcare services to consolidate advanced healthcare and robust platform for relevant branches of predictive diagnostics, personalized therapeutics and preventive drugs. To achieve the implementation of PPPM concept into practice, it is necessary to create a new strategy based upon the sub-clinical recognition of biomarkers long before the disease clinically manifests itself. This strategy would secure preventive measures whose personalization could have a significant influence on demographics! Meanwhile, penetration of new technologies into the market would demand the reforms not only in the area of healthcare but in medical education as well. Therefore, the problem of the preparation of specialists of the newest generation to secure priority in growing up medical doctors as creative artists is becoming particularly urgent and would require significant revision of training programs and curricula of the higher education as applicable to the medical schools. Modernization and integration of widely accepted medical and teaching standards require consolidation of both the life sciences and medicine that may become the conceptual basis for the medical curricula. The main goal of this training is not to achieve advanced training and expansion of technological skills but to provide development of novel multifaceted approaches to build academic schools of the newest generations and to outline curricula and courses to suit markets of the newest medical platforms. PPPM consists of a wide variety of tests and tools including so much complicated areas as networking, mathematic modeling, nanotools and nanotechnologies, cloudy and mobile technologies to suit the requests and standards of the new healthcare model. Coordinated measures to optimize the progress should be well-focused on solving the accumulating problems in healthcare and the concomitant economic burden that societies across the globe are facing more and more. Taking into consideration the current trends and personal experience, we have made first steps towards direct involvement in the modernization of the healthcare model. Guided by the above-mentioned facts, a non-canonical approach has become setting up under the aegis of EPMA (Brussels, EU), PMC (Washington, DC, USA) and ISPM (Tokyo, Japan) a unique team of medical students, young researchers, entrepreneurs in drug designing, clinicians and administrators of the future to come. Used as an educational-methodical kernel is a three-level basic education system (undergraduate, graduate, and postgraduate) to suit the continuing education. Group and individual vectors as part of the basic inventory are represented by translational medicine, bioinformatics, drug design, translational tools, regulatory courses, etc. The model for accelerated development of continuous vocational education (CVE) in PPPM and TraMed is based on the combinatorial approaches (competence, moduletype approach, personal activity, program-design and problem-oriented) to the elucidation of innovative processes of modernization of the existing educational model. The application of the model for development of CVE has required a new type of the infrastructure of the curricula. PPPM whilst secured by the upgraded educational system would offer great and real promise for the future. And the next generations will speak about the XXI century as a time, when healthcare services became predictive and preventive and its outcomes secured and guaranteed!RESULTS Background: We have overcome the limitations of 40 years of ex vivo testing. The aim of this study is to determine the ability of Vivias novel test (based on studying the ex-vivo sensitivity to drugs) to predict the complete remission (CR) rates after induction chemotherapy with cytarabine (Ara-C) and idarubicin (Ida) in 1st line AML.. Material and Methods: This has been an observational clinical trial where bone marrow samples from adult patients diagnosed with de novo AML in Spanish centers from the PETHEMA group were included. Whole marrow samples maintaining their Native Environment were incubated for 48h in well plates containing Ara-C, Ida, or their combination. Pharmacological responses are calculated using population models. Induction response was assessed according to the Cheson criteria (2003). Patients attaining a CR/CRi were classified as responders and the remaining as resistant. Results: 390 patient samples were used to calculate the dose response (DR) curves for Ara-C alone, Ida alone, and their synergism. For clinical correlation we used 142 patients with median 56 years. The strongest clinical predictors were the Area Under the Curve (AUC) of the DR of Ara-C (P=1.34E-05), and the AUC of IDA (P=3.9E-05). The GAM models revealed a significant relationship (RSquare=0.452 and deviance explained=45%) between these predictors and higher probabilities of post-induction resistance. Fig 1A shows a table illustrating the correlation between clinical outcome (columns) and the test predictions (lines). Using the cut off determined by the GAM models. The test obtain a high Specificity and Positive Protective Value (95% and 80,77%) and a lower sensitivity (50%) with a general prediction of a 81,69%. Interestingly, the 5 cases that the test identify as resistant but were clinically sensitive have high level of minimal residual disease. On the other hand, the test does not properly identify 21/142 that are clinically resistant and the test predicts as sensitive (bottom left quadrant right panel). This mismatched subgroup mimics the problems from molecular markers where a resistant clone present in a minority of leukemic cells cannot be detected yet drives the patient response. Consistent with this analysis, adding the cytogenetic risk factor to the ex vivo results, identifying the high risk population by molecular markers that might be present in a minority of the cells, significantly improves the correlation; Fig. 1B shows the 90% overall correlation achieved in 117 patient samples adding the cytogenetic risk factor, with a major improvement in the sensitivity from 50% to 72%. Both approaches lead to substantial improvements in estimated overall survival. ABSTRACT© 2019 The Egyptian Journal of Internal Medicine | Publ Background/purpose of the study Chronic hepatitis C virus (HCV) infection is considered one of the major healthproblems.About170millionpatientswere infectedwithHCVworldwide.Till few years, Egypt was considered the highest HCV prevalent country worldwide, with predominant genotype number 4. The host immunity plays a major role in HCV infection with evolving data confirming the role of T-helper 17 cells in the formation of chronic HCV infection. The aim of our work was to determine the role of interleukins 17A (IL17A), 17F (IL17F) in the formation of chronic hepatitis C infection. Patients and methods We classify the patients into two groups: the first group included 51 chronic HCV patients who did not take antiviral therapy (the study group) and the second group included 51 healthy blood donors (as a control group). The levels of IL17A and IL17F in the serum of both groups were measured using the sandwich enzymelinked immunosorbent assay method. Results The serum values of IL17A were higher in patients with chronic HCV than the other group with the mean values being 52.9±32.6 pg/ml in the patient group and 17.1 ±10.4 pg/ml in the control group. IL17F was slightly higher in the HCV patient group than the control group, but it was statistically insignificant. Moreover, there were significant positive correlations between IL17A and alanine aminotransferase, viral load, and degree of liver fibrosis. Conclusion Patients with chronic HCV infections had a higher serum level of IL17A than the normal persons and it is positively correlated with alanine aminotransferase, viral load, and degree of liver fibrosis. This suggests its pivotal role in the formation of chronic HCV infection; so, it can be used as a new marker for disease progression due to its positive correlation with the severity of liver injury.