Drug resistance in chronic lymphocytic leukaemia

Krooninen lymfaattinen leukemia (KLL) on länsimaiden yleisin leukemia, Suomessa uusia tapauksia ilmaantuu noin 200 vuodessa. Se on yleensä hitaasti etenevä tauti ja taudin kulkua voidaan ennustaa kliinisten löydösten ja leukemiasolujen pintaproteiinien, kromosomimuutosten, immunologisen kypsyyden ja solunsisäisten proteiinien avulla. Hoidot solusalpaajilla aloitetaan tyypillisesti vasta seurannan jälkeen, jos tauti muuttuu nopeasti eteneväksi tai aiheuttaa yleisoireita. Lääkeresistenssi muodostuu yleensä hoidon suurimmaksi ongelmaksi ja usein ilmenee monilääkeresistenssiä. Lääke- ja säderesistenssiä on tutkittu runsaasti, mutta kliinisesti merkittäviä tuloksia niin ennustetekijöistä kuin mekanismeista on vähän. Tässä väitöstyössä arvioitiin KLL-solujen monilääkeresistenssiä ja aiemman lääkehoidon, solujen pintaproteiinien, immunologisen kypsymisen ja solukuolemaan liittyvien geenien ilmenemisen merkitystä lääkeresistenssin ennustajina KLL:ssa. Solut altistettiin yhdeksälle lääkeaineelle ja kahdelle eri säteilylajille ja näistä altistuksista määritettiin annospitoisuudet, joilla saavutetaan 80 % vähenemä soluissa. Leukemiasoluista määritettiin 34 pintaproteiinin pitoisuudet, immunologista kypsymistä arvioitiin määrittämällä solujen vasta-ainereseptoreita koodittavien geenien uudelleen järjestäytymistä ja niistä määritettiin myös seitsemän solukuolemaan liittyvän geenin ilmenemiset. Monilääkeresistenssi oli tämän tutkimuksen mukaan yleisempää aiemmin hoidetuilla potilailla kuin hoitamattomilla, mutta lääkeresistenssi ei välttämättä kehittynyt käytössä ollutta lääkeainetta kohtaan. Lääke- ja säderesistenssin ja pintaproteiinien välillä ei löytynyt tilastollisesti merkitsevää riippuvuutta. CD80-pintaproteiini jakoi fludarabiinin ja klorodeoksyadenosiinin vasteet kahteen ryhmään: CD80:n ilmeneminen KLL-soluissa herkisti ne näille lääkkeille, kun taas kaikilla resistenteillä potilailla CD80:n ilmeneminen KLL-soluissa oli heikko tai negatiivinen. Immunologisesti kypsempien ja epäkypsempien ryhmien välillä ei ollut merkitsevää eroa lääkeherkkyyksissä. Solukuolemaan johtavien geenien korkeampi ilmeneminen ei herkistänyt soluja lääkkeille tai sädetykselle. Myöskään solukuolemalta suojaavien geenien korkeampi ilmeneminen ei johtanut lääke- tai säderesistenssiin. Lääkehoito altistaa lääke- ja säderesistenssille. Lääkeresistenssi ei aina kehity hoidossa käytettyä lääkettä kohtaan, vaan lääkehoito voi altistaa lääkeresistenssin kehittymisen myös muita lääkeaineita kohtaan. Fludarabiinin ja klorodeoksyadenosiinin lääkevasteita voidaan ennustaa CD80:n ilmenemisen perusteella. Immunologisella kypsymisellä tai solukuolemaan liittyvien geenien ilmenemisellä ei näyttäisi olevan yhteyttä lääke- tai säderesistenssiin.Background: Chronic lymphocytic leukaemia (CLL) is the most common type of leukaemia in the Western countries. Typically, it is a slowly progressing disease, and treatment by cytostatics is initiated after follow-up in a situation where the patient has an aggressive disease or develops general symptoms. The major obstacle in treatment is drug resistance and, moreover, multidrug resistance. Extensive research into the mechanisms or prognostic factors for chemo- or irradiation resistance has produced few clinically encouraging results. Aims: To evaluate (I) multidrug resistance in CLL and to define the impact of (I) previous chemotherapy, (II) surface antigens, (III) the mutation status of the immunoglobulin variable region (IgHV) genes as well as (IV) programmed cell death, apoptosis, associated gene transcripts in drug and irradiation resistance in CLL. Material and methods: Peripheral blood samples from a cohort of 36 CLL patients were collected and mononuclear cells, containing mainly CLL cells, were isolated. Nine drugs and two types of irradiation were selected according to their usefulness in CLL therapy or on the basis of their otherwise interesting mechanism of action. Doses causing 50 or 80% inhibition of living cells were measured from prednisolon (ID50) and from all other drugs and irradiations (ID80), respectively. In total, 2,376 duplicated cell cultures were performed to determinate these ID80 or ID50 values. Expressions of 34 surface antigens were analysed by means of flow cytometry. PCR assays were used to determine the mutation status of the IgHV genes. Apoptosis-associated gene mRNA expressions (anti-apoptotic: Bcl2, Mcl1, Bcl2a1, Bcl2l1; and pro-apoptotic: Bax, Myc, Dapk1) were analysed with QRT-PCR. Results: Multidrug resistance was more common in the previously treated CLL group than the untreated group, but concordances between drug therapy and in vitro drug resistance were poor. Statistically significant correlation was confirmed between the sensitivities of the same-group drugs chlorodeoxyadenosine and fludarabine. Correlation between two P-glycoprotein-dependent drugs, vincristine and doxorubicin, was not demonstrated (I). There were no correlations between the investigated surface antigens and drug or irradiation sensitivities. The nucleoside analogues (chlorodeoxyadenosine and fludarabine) responses could be divided in two groups by their CD80 expression; every patient expressing the CD80 surface antigen was sensitive to nucleoside analogues, whereas all resistant cases had low or negative CD80 expression (II). IgHV mutation status divided the CLL patients in two groups, unmutated (67%) and mutated (33%), but statistically significant differences could not be confirmed in the drug or irradiation sensitivities between these groups (III). A higher amount of cell-death-inductive pro-apoptotic gene transcripts did not induce drug or irradiation sensitivity, and a higher amount of cell-death-preventive anti-apoptotic gene transcripts did not induce drug or irradiation resistance (IV). Conclusion: Chemotherapy induces drug and irradiation resistance. Drug resistance does not always develop against the used chemotherapeutic agent, as chemotherapy may also expose to drug resistance against some other agents. CD80 could be a surrogate chemosensitivity marker for nucleoside analogues. The IgHV genes mutation status or apoptosis-associated genes are not determinants of drug or irradiation resistance in vitro

Balloon Eustachian Tuboplasty : Systematic Review of Long-term Outcomes and Proposed Indications

Balloon Eustachian tuboplasty (BET) aims to improve the function of the Eustachian tube (ET). The objective of this study was to review the long-term outcome of BET and present the process and results of outlining indications for BET by the Finnish Otosurgical Society. The literature review is based on a database search performed in May 2017. The search resulted in 100 individual articles, which were screened for relevance. Five articles fulfilled the inclusion criteria (follow-up >= 12 months). Five additional articles (follow-up, 6-11 months) were analyzed to obtain supportive information. The proposed BET indications were constituted in the 2016 annual meeting of the Finnish Otosurgical Society. The workshop included a review of the Eustachian tube physiology, middle ear aeration mechanisms, and BET outcome studies. Thereafter, the members of the Society first voted and then discussed 14 cases in order to conclude whether BET was indicated in each case, and subsequently, a consensus statement on the indications for BET was outlined. The long-term follow-up studies were heterogeneous regarding the Eustachian tube dysfunction (ETD) definition, patient selection, follow-up duration, additional treatments, and outcome measures. The current, but limited, evidence suggests that BET is effective in the long-term. However, more long-term studies with uniform criteria and outcome measures as well as placebo-controlled studies are needed. The proposed indications for BET by the Finnish Otosurgical Society include chronic bothersome symptoms referring to ETD, ETD-related symptoms when pressure changes rapidly, or recurring serous otitis media. With the current evidence, we suggest treating only adults with BET.Peer reviewe

Vaikean kuulovian merkitys ja hoito

publishedVersionPeer reviewe

Nocardia Farcinica Mastoiditis and Epidural Abscess in an Immunocompetent Patient : A Rare Entity

Nocardia is regarded as an opportunistic pathogen primarily affecting the respiratory system, whereas Nocardia farcinica is the species of the Nocardia family that is most frequently blamed for central nervous system impairment. The authors present the first case of mastoiditis caused by Nocardia farcinica, accompanied by intracranial complications. An immunocompetent 74-year-old woman who reported a three-week left ear discharge and a two-week facial nerve palsy was referred to our department. MRI revealed mastoiditis and epidural abscess. The bacterial cultures obtained during the surgical management of the patient confirmed the presence of Nocardia farcinica. Targeted antibiotic therapy was subsequently administrated, gradually resulting in favourable outcomes. Nocardia species provoke a disseminated infection that emerges not only among the immunosuppressed individuals but can also affect the healthy population. The nonspecific clinical manifestations in addition to the difficulties identifying the pathogen, remain obstacles to a punctual diagnosis. However, the combination of surgical debridement and antibiotic treatment with trimethoprim and sulfamethoxazole is considered the most appropriate management, leading to propitious results.publishedVersionPeer reviewe

Computational fluid dynamics calculations in inferior turbinate surgery : a cohort study

Purpose: To investigate how the results of nasal computational fluid dynamics (CFD) simulations change due to inferior turbinate surgery and how the results correlate with patient specific subjective assessment and volumetric results in the nasal cavities. Methods: The steady inspiratory airflow of 25 patients was studied pre- and postoperatively with heat transfer from the mucous membrane by performing CFD calculations to patient-specific nasal cone beam computed tomography images. These results were then compared to the severity of the patients’ nasal obstruction Visual Analogue Scale (VAS) and Glasgow Health Status Inventory assessments, and acoustic rhinometry measurements. Results: Total wall shear forces decreased statistically significantly (p < 0.01) in the operated parts of the inferior turbinates. Patients’ subjective nasal obstruction VAS assessment changes between the pre- and postoperative conditions correlated statistically significantly (p = 0.04) with the wall shear force results. Conclusion: Inferior turbinate surgery lead to decreased total wall shear force values postoperatively. Changes in subjective nasal obstruction VAS results against total wall shear force changes between the pre- and postoperative conditions were statistically significant. CFD data have a potential to be used for the evaluation of nasal airflow.Peer reviewe

Computational fluid dynamics assessed changes of nasal airflow after inferior turbinate surgery

Objective: To demonstrate how Computational Fluid Dynamics (CFD) simulations can reveal important airflow changes in the nasal cavities due to surgical interventions. Material and methods: The steady inspiratory airflow of eight patients was studied pre- and postoperatively with heat transfer from the mucous membrane by performing CFD calculations to patient specific cone beam computed tomography (CBCT) images. Eight patients with the largest distance from pre- and postoperative mean changes in inferior turbinate volumetry and Visual Analogue Scale (VAS) results were selected. Results: Calculated CFD heat transfer results from the anterior parts of the inferior turbinates, where surgical interventions were performed, decreased significantly. The heat transfer results were in line with VAS changes. Conclusion: Surgical interventions reduced heat transfer in the operated parts of the inferior turbinates and were in line with VAS changes. CFD is an option in assessing patient well-being as a function of airflow parameters from mucous membrane with larger data sets. The limitations of the study were the small sample size and the preliminary nature of the study.publishedVersionPeer reviewe

Ultra-low-dose CBCT scan : rational map for ear surgery

Purpose: This study will evaluate the clinical quality and usability of peripheral image data from the temporal bone area obtained using a sinonasal ultra-low-dose (ULD) cone-beam computed tomography (CBCT) scan and compare them to those obtained using a high-resolution (HR) CBCT. Methods: The population consisted of 66 anatomical sites (ears of 33 subjects) imaged using two modalities: an HR CBCT (Scanora 3Dx scanner; Soredex, Tuusula, Finland) and a ULD CBCT (Promax 3D Mid scanner; Plandent, Helsinki, Finland). The image quality (IQ) for every anatomical site in each image was rated using a Likert scale from 0 to 5. Results: The quality of ULD CBCT scans was clinically sufficient in over 95% of the assessed images of the sigmoid sinus, jugular bulb, epitympanum and mastoid antrum as well as external acoustic meatus (all p > 0.05 compared to HR CBCT). The IQ was clinically sufficient in 75–94% of the assessed images of the scutum, mastoid segment of the facial nerve, cochlea and semicircular canals (all p < 0.05 compared to HR CBCT). The overall IQ of the HR CBCT scans was good or excellent. Conclusion: CBCT imaging and the data at image margins are underutilized. CBCT can produce excellent structural resolution with conventional imaging parameters, even with off-focus images. Using ultra-low doses of radiation, the produced IQ is clinically sufficient. We encourage ear surgeons to check the patients’ imaging history and to consider the use of imaging modalities that involve lower radiation doses especially when conducting repetitive investigations and with children.publishedVersionPeer reviewe

The Detection of Bacteria in the Maxillary Sinus Secretion of Patients With Acute Rhinosinusitis Using an Electronic Nose : A Pilot Study

Objective: Detecting bacteria as a causative pathogen of acute rhinosinusitis (ARS) is a challenging task. Electronic nose technology is a novel method for detecting volatile organic compounds (VOCs) that has also been studied in association with the detection of several diseases. The aim of this pilot study was to analyze maxillary sinus secretion with differential mobility spectrometry (DMS) and to determine whether the secretion demonstrates a different VOC profile when bacteria are present. Methods: Adult patients with ARS symptoms were examined. Maxillary sinus contents were aspirated for bacterial culture and DMS analysis. k-Nearest neighbor and linear discriminant analysis were used to classify samples as positive or negative, using bacterial cultures as a reference. Results: A total of 26 samples from 15 patients were obtained. After leave-one-out cross-validation, k-nearest neighbor produced accuracy of 85%, sensitivity of 67%, specificity of 94%, positive predictive value of 86%, and negative predictive value of 84%. Conclusions: The results of this pilot study suggest that bacterial positive and bacterial negative sinus secretion release different VOCs and that DMS has the potential to detect them. However, as the results are based on limited data, further conclusions cannot be made. DMS is a novel method in disease diagnostics and future studies should examine whether the method can detect bacterial ARS by analyzing exhaled air.publishedVersionPeer reviewe

Differentiation of aspirated nasal air from room air using analysis with a differential mobility spectrometry-based electronic nose : a proof-of-concept study

Over the last few decades, breath analysis using electronic nose (eNose) technology has become a topic of intense research, as it is both non-invasive and painless, and is suitable for point-of-care use. To date, however, only a few studies have examined nasal air. As the air in the oral cavity and the lungs differs from the air in the nasal cavity, it is unknown whether aspirated nasal air could be exploited with eNose technology. Compared to traditional eNoses, differential mobility spectrometry uses an alternating electrical field to discriminate the different molecules of gas mixtures, providing analogous information. This study reports the collection of nasal air by aspiration and the subsequent analysis of the collected air using a differential mobility spectrometer. We collected nasal air from ten volunteers into breath collecting bags and compared them to bags of room air and the air aspirated through the device. Distance and dissimilarity metrics between the sample types were calculated and statistical significance evaluated with Kolmogorov-Smirnov test. After leave-one-day-out cross-validation, a shrinkage linear discriminant classifier was able to correctly classify 100% of the samples. The nasal air differed (p < 0.05) from the other sample types. The results show the feasibility of collecting nasal air by aspiration and subsequent analysis using differential mobility spectrometry, and thus increases the potential of the method to be used in disease detection studies.acceptedVersionPeer reviewe

Development of otology specific outcome measure : Ear Outcome Survey-16 (EOS-16)

Purpose: An important outcome measure of patient care is the impact on the patient's health-related quality of life (HRQoL). Current ear-specific HRQoL instruments are designed for one diagnosis and emphasize different subdivisions such as symptoms, hearing problems, psychosocial impact, and the need for care. The optimal length of the recall period has not been studied. For these reasons, a new survey is needed that would cover most chronic ear diseases. Methods: A preliminary 24-item survey (EOS-24) was created. Untreated adult patients (included n = 186) with one of seven different chronic otologic conditions from all university hospitals in Finland were recruited to respond to EOS-24 and the 15D general HRQoL instrument. The recruiting otologists evaluated the severity of the disease and the disability caused by it. A control group was recruited. Based on the patients' responses in different diagnosis groups, the items were reduced according to pre-defined criteria. The resulting survey was validated using a thorough statistical analysis. Results: The relevance and necessity of the original 24 items were thoroughly investigated, leading to the exclusion of 8 items and the modification of 1. The remaining 16 items were well-balanced between subdivisions and were useful in all seven diagnosis groups, thus constituting the final instrument, EOS-16. The most suitable recall period was three months. Conclusions: EOS-16 has been created according to the HRQoL survey guidelines with a versatile nationwide patient population. The survey has been validated and can be used for a wide range of chronic ear diseases as a HRQoL instrument. (C) 2021 PLA General Hospital Department of Otolaryngology Head and Neck Surgery. Production and hosting by Elsevier (Singapore) Pte Ltd.Peer reviewe