Clonal heterogeneity in chronic lymphocytic leukemia cells: superior response to surface IgM cross-linking in CD38, ZAP-70-positive cells.

Background Patients with chronic lymphocytic leukemia whose cells express CD38 and ZAP-70 and utilize unmutated Ig VH region genes have a very poor prognosis. We studied whether cells expressing CD38 and ZAP-70 are more susceptible to stimulation through B-cell receptors than are cells that do not express CD38 and ZAP-70.Design and Methods CD38-positive and CD38-negative leukemic cells were separated from single cases and compared for their response to B-cell receptor cross-linking and ZAP-70 expression. Cohort studies were also carried out by measuring the apoptotic response to surface immunoglobulin M (IgM) cross-linking in 82 patients with chronic lymphocytic leukemia and the protein tyrosine phosphorylation induced by surface IgM in 21 patients.Results CD38-positive cells, isolated from cases of chronic lymphocytic leukemia classified as CD38-positive or CD38-negative, expressed more ZAP-70 than the corresponding CD38-negative cells, exhibited more robust protein tyrosine phosphorylation and had a greater tendency to apoptosis upon B-cell receptor cross-linking. In the cohort studies, surface IgM-induced protein tyrosine phosphorylation correlated significantly with CD38 and ZAP-70 expression and with the absence of Ig VH gene mutations. Apoptosis induced by surface IgM cross-linking correlated significantly only with the proportion of CD38-positive cells. Difficulties in finding more definitive correlations were probably related to imprecision in the in vitro test system and in the definition of cases as positive or negative.Conclusions Collectively, these data indicate that CD38-positive, ZAP-70-positive cells have a greater capacity for signaling through the B-cell receptor and suggest a function for B-cell receptor signaling in promoting chronic lymphocytic leukemia cell expansion, especially within the CD38-positive fraction of the leukemic clone

Cytocompatible and Anti-bacterial Adhesion Nanotextured Titanium Oxide Layer on Titanium Surfaces for Dental and Orthopedic Implants

It is widely recognized that surface nanotextures applied on a biomaterial can affect wettability, protein absorption and cellular and/or bacterial adhesion; accordingly, they are nowadays of great interest to promote fast osseointegration and to maintain physiological healing around biomedical implants. In order to be suitable for clinical applications, surface nanotextures must be not only safe and effective, but also, they should be produced through industrial processes scalable to real devices with sustainable processes and costs: this is often a barrier to the market entry. Based on these premises, a chemical surface treatment designed for titanium and its alloys able to produce an oxide layer with a peculiar sponge like nanotexture coupled with high density of hydroxyl group is here presented. The modified Ti-based surfaces previously showed inorganic bioactivity intended as the ability to induce apatite precipitation in simulated body fluid. Physicochemical properties and morphology of the obtained layers have been characterized by means of FESEM, XPS, and Zeta-potential. Biological response to osteoblasts progenitors and bacteria has been tested. The here proposed nanotextured surfaces successfully supported osteoblasts progenitors' adhesion, proliferation and extracellular matrix deposition thus demonstrating good biocompatibility. Moreover, the nanotexture was able to significantly reduce bacteria surface colonization when the orthopedic and the periodontal pathogens Staphylococcus aureus and Aggregatibacter actinomycetemcomitans strains were applied for a short time. Finally, the applicability of the proposed surface treatment to real biomedical devices (a 3D acetabular cup, a dental screw and a micro-sphered laryngeal implant) has been here demonstrated

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

2003-07

Background and Objectives. B-cell chronic lymphocytic leukemia (B-CLL) results from the accumulation of monoclonal CD5 + B cells. Despite its homogeneity at cellular level, B-CLL is clinically heterogeneous. Clinical studies indicate that CD38 + B-CLL are characterized by a more aggressive clinical course than are CD38 − B-CLL. On the basis of these studies and considering the established correlation between specific chromosome aberrations and the clinical course of B-CLL, it is possible that CD38 + B-CLL cases are also characterized by specific subsets of chromosomal alterations. Design and Methods. Comparative genomic hybridization (CGH) was performed on purified B-cells from peripheral blood of 52 patients with B-CLL in order to detect chromosome imbalance. The immunophenotype of the patients, including CD38 expression, was also determined by flow cytometry. The results of CGH experiments were then compared with CD38 expression. Results. We found a clear correlation between the presence of chromosomal imbalances and CD38 expression: 13/16 CD38 + cases had chromosome imbalances, most of them (12/13) correlated with a poor prognosis. Among the CD38 − B-CLL patients, only 8/36 displayed chromosome imbalances; the only three cases with loss in 13q as a single aberration, considered a good prognostic marker, were in this group. Moreover, we found that cytogenetic alterations were also more complex in the CD38 + B-CLL subset, since 9/10 with two or more aberrations were in the CD38 + group. Interpretation and Conclusions. Collectively, the data reinforce the value of CD38 as a prognostic factor and indicate that genotypic/phenotypic features distinguish B-CLL subsets. Key words: B-CLL, molecular cytogenetics, chromosome aberrations, immunophenotype, CD38. from the progressive accumulation of monoclonal CD5-positive B cells. Despite its homogeneity at cellular level, B-CLL is clinically heterogeneous since some patients survive for a long time without therapy, while others progress towards more advanced stages and die despite aggressive treatment. Design and Methods Clinical features of patients Fifty-two patients with B-CLL (32 males and 20 females) were studied. Their characteristics are described in n.a. data not available; *from diagnosis. © F e r r a t a S t o r t i F o u n d a t i o n haematologica/journal of hematology vol. 88 CGH To increase the sensitivity of the CGH, B cells were purified from PBMC by removing monocytes and CD3 + T cells by adherence to plastic surfaces and magnetic beads, respectively. DNA extraction and CGH were performed as described elsewhere. Digital image analysis Image acquisition, processing, and evaluation were performed as described elsewhere. Results Identification of two groups of B-CLL according to CD38 expression The purified malignant B-CLL cells from 52 patients were double stained with CD38 and CD19 monoclonal antibodies. Two groups of B-CLL, i.e. CD38 + and CD38 − B-CLL, were identified using the cut-off limit of 30%, already utilized in previous studies. CGH analysis Chromosome imbalances were detected by CGH. Two examples of merged CGH images and the relative mean profiles of ten metaphases with chromosomal imbalances are shown in Discussion Samples from 52 patients with typical B-CLL, diagnosed according to morphology and surface phenotype, were subjected to CGH analysis in order to obtain a comprehensive view of chromosomal gains and losses and to identify copy number aberrations specific for this pathology. To increase the sensitivity of CGH, we purified B-cells from the peripheral blood of B-CLL patients when there were less than 90% B cells. Twenty-one out of 52 (40%) patients showed chromosome imbalances; 11/21 had single imbalances, whereas the remaining 10 patients had two or more chromosome alterations. Thirty-three per cent of patients had received chemotherapy before cytogenetic analysis. The presence of patients subjected to therapy in the cohort can hardly be avoided in this kind of study. As an example, a recent study based on a large cohort of patients included a similar percentage of treated patients as did our study. Imbalances involving chromosomes 11, 12, 13 and 17 are among the most important factors in predicting survival: patients with 17p deletions are those with the worst prognosis, followed by patients with 11q deletion, those with 12q trisomy, and those with normal karyotypes, whereas patients with 13q deletions as the sole abnormality have the longest estimated survival times. This finding is possibly explained by the fact that our cohort included only patients with typical morphology/immunophenotype and that there were fewer patients with advanced stage disease. It has been demonstrated that atypical morphology and advanced stage disease correlate with loss in 17p. The B-CLL cases in this study could be subdivided into two groups according to the surface expression of CD38 by the malignant cells. This confirms previous findings from our laboratory and is also in line with data reported by others. The striking finding of this study was the clear correlation existing between the presence of chromosomal abnormalities and CD38 expression by the malignant cells. Thirteen out of 16 CD38 + patients also had chromosomal abnormalities, whereas, among the 36 CD38 − patients only 8 displayed chromosomal imbalances. These differences are highly significant (p=0.0001). Three out of the 8 CD38 − patients with chromosomal alterations had a loss in 13q as a single aberration, which generally correlates with a good prognosis, 3 patients had rare alterations, the prognostic value of which remains to be determined, while the remaining 2 patients had aberrations correlated with a poor prognosis (-11q; +12). Twelve of 13 CD38 + patients with chromosomal alterations displayed aberrations that are correlated with a poor clinical outcome (-11q; +12; -17p), whereas one patient had a gain in © F e r r a t a S t o r t i F o u n d a t i o n Chromosome aberrations and CD38 expression in B-CLL haematologica/journal of hematology vol. 88(07):july 2003 775 chromosome 3q, which is rarely found in B-CLL and is hence of undetermined prognostic value. Moreover, of the 10 patients with two or more chromosome imbalances (another marker of poor prognosis) detected in this study, 9 were within the CD38 + group. Remarkably, among the cases with the highest values of CD38 expression, 3 cases had simultaneous gain of chromosomes 12 and 18. Gain of chromosome 18 never appeared alone, but was always associated with gain of chromosome 12. Although this association has already been described in B-CLL by classical cytogenetic studies, 24,40 its significance and real frequency are not well documented. This is, in part, because most of the studies on chromosomal aberrations in large cohorts of B-CLL patients were performed with FISH using a panel of probes not including the chromosome 18 probe. Our data are in keeping with the recent observations that the unbalanced distribution of genomic aberrations in IgVH high mutation and low mutation subgroups might point toward a distinct biological background in such B-CLL subgroups and may in part, explain their different behaviors. 14 In the study by Kröber et al., 14 genomic aberrations and VH mutation status appeared to have a complementary role in estimating prognosis. Although CD38 expression has been proposed as an easily performed surrogate of VH mutational status analysis 4 its prognostic value is not completely clarified. Moreover, the relationship between CD38 expression and chromosomal aberrations has not been extensively studied. In a recent paper, Chevallier et al. Concerning the prognostic significance of CD38 expression in multivariate analysis, the authors suggested that a much larger group of patients was needed. Oscier et al. 36 showed that the mean survival of patients with loss in 17p was the shortest (47 months). In the present study the groups of patients with and without chromosomal alterations do not differ in terms of survival (not shown) probably since all but 2 patients are still alive. However, the simple patient in our cohort with loss in 17p at diagnosis was followed for only 1 year and was experiencing a poor clinical course. The different biological properties showed by B-CLL cells, including the expression of CD38, can help to explain the differences in the patients' outcomes. Recent studies, including those from our laboratory, 7,41 demonstrated that CD38 + B-CLL cells with unmutated VH/VL region genes have a viable IgM initiated signal transduction pathway. This pathway can lead to proliferation/differentiation or apoptosis depending on co-signals received by the cells in vitro. In contrast, most of the CD38 − mutated B-CLL cells do not respond to signals delivered to surface Ig. Therefore, the interaction between the cells and the environment via B-cell receptor is much less marked in CD38 − mutated cases than in CD38 + unmutated cases. These data suggest that CD38 + B-CLL cells are likely to be continuously stimulated via surface Ig. This is related to the fact that surface Ig, encoded by unmutated VH/VL genes, retain natural antibody activity and hence can react continuously with autoantigens in vivo. In the case of surface CD38-negative, mutated B-CLL cells, it is unlikely that the B-cell receptor can exert a promoting role on cell expansion since there is a not a viable IgM signal transducing pathway. Moreover, Ig encoded by mutated VH/VL genes rarely have natural antibody activity and, therefore, can rarely encounter the appropriate foreign antigen. Collectively, these considerations raise the issue of whether antigenic stimulation in B-CLL continues to exert a promoting effect on the growth of the malignant cells following transformation, and whether this is the reason for the clinical differences in B-CLL. Finally, it is unlikely that CD38 is solely a marker of cellular differentiation and clinical course. It is more probable that it also functions as a signaling molecule and, therefore may be directly involved in differences in disease severity. CD38 is known to play a role as an accessory molecule in B-cell receptor mediated signal transduction, 42,43 as well as regulating cell apoptosis in certain normal B-cell subsets. A number of conclusions can be drawn from this study. First, considering the increasing recognition of the importance of chromosome alterations in predicting the clinical outcome of B-CLL, the observation that chromosomal alterations are significantly more frequent within the CD38-positive cases lends further support to the prognostic value of the surface marker, CD38. Second, the finding that CD38 + cases can be subdivided into two groups (i.e. with and without chromosomal alterations) may lead to the delineation of further prognostic subsets of B-CLL. Third, the paucity of chromosomal alter- © F e r r a t a S t o r t i F o u n d a t i o

Risk of second cancer in patients with hairy cell leukemia: long-term follow-up

The purpose of the present study was to assess the risk of second cancers in patients with hairy cell leukemia (HCL)

Analysis of Frequency and Risk Factors for Developing Bisphosphonate Associated Osteonecrosis of the Jaw.

Although the evidence available associating bisphosphonates (BP) with osteonecrosis of the jaw (ONJ) is far from conclusive, the growing literature reports strongly suggest a strict relationship between them. The real frequency of this complication is unknown because of the recent observation of this condition, the bias related to retrospective studies and the wide-spread use of this supportive therapy. Aims of this research were to look for additional risk factors for developing ONJ and to determine the frequency of this event in the subgroup of patients affected by Multiple Myeloma (MM) treated with BP. We asked 49 GISL centers to participate in a retrospective multicenter study filling out a form containing several queries, including sex and age, anamnesis for smoke habit, anemia and thrombotic events, type and time of neoplasia diagnosis, treatment and neoplasia status, odonthoiatric anamnesis, type and duration of therapy with BP, microbial isolation in site of lesion, specific treatment for osteonecrosis, number of patients (pts) affected by MM treated with BP from 2002 to 2005. Fifteen centers decided to participate in the study and 12 had cases of osteonecrosis. ONJ was reported in 19 pts. Sixty % were females and the median age was 65 ys. Sixteen had MM, 1 breast cancer, 1 prostatic cancer, 1 osteoporosis steroid related. Median time from diagnosis of cancer was 54 months and median duration of treatment with BP was 34 months. Thirteen events manifested between 20 and 60 months. Of the 19 pts, 8 had received zolendronate, 2 pamidronate and 9 both drugs. None had radiotherapy on head and neck, while two received total body irradiation. In these two cases, ONJ was associated with necrosis of the pelvis. The 2 solid tumors were treated with ormonal therapy. All MM pts had received one or more line of treatment including, VAD, MP, steroids and thalidomide alone or in combination, as well as high dose melphalan, as part of autologous bone marrow transplant. ONJ involved the mandible in 14 pts, the maxilla in 3 and both in 2. Symptoms included local pain and discomfort. In 17 cases CT scan was the strumental procedure used to identifiy the lesion. In 14 pts biopsy was performed excluding localization of neoplasia in 11 cases. Microbiological evaluation of the lesion was positive in 11 pts, with 6 cases of Actynomices. In 12 patients ONJ was apparently spontaneous; in 7 occurred after dental procedures. Parodonthopaties were present in 10 pts. In 11 cases ONJ was complicated by fistula, exposed bone or abscess. BP were stopped in 17 pts. Antibiothic therapy was administered in 17 cases; 7 pts underwent hyperbaric oxygen therapy and 8 surgical debridement. Several pts improved but none were cured. Considering only the MM subgroup 16 cases of ONJ were identified among 888 pts treated with BP between 2002 and 2005, with a frequency of 1.8%. Utilizing the data collected by our retrospective study a fine statistical analysis is not applicable. However, in MM pts the frequency of steroid treatment, parodonthopaties and anemia was particularly high, respectively 100%, 56%, and 56%, supporting the idea that these are additional risk factors for developing ONJ

Fludarabine, cyclophosphamide and lenalidomide in patients with relapsed/refractory chronic lymphocytic leukemia. A multicenter phase I–II GIMEMA trial

The activity and safety of a regimen combining lenalidomide with fludarabine and cyclophosphamide (FC) was investigated in patients with relapsed/refractory (R/R) chronic lymphocytic leukemia (CLL). Treatment consisted of six monthly courses of the FC regimen combined with 14 days of lenalidomide given at the starting dose of 2.5 mg during course 1. The maximum tolerated dose of lenalidomide was 5 mg. Forty patients were assessed for response, 66% were IGHV unmutated, 45% showed deletion 11q or 17p. The overall response and complete remission rates were 62.5% and 22.5%, respectively, the median progression-free and overall survival (OS) were 19 and 45 months, respectively. Grade 3–4 granulocytopenia was observed in 65% of cases, severe infections in 7.5%, the lenalidomide-related toxicity was mild. In conclusion, the results of this study demonstrate that low-dose lenalidomide associated with the FC schedule is an effective treatment for R/R patients with CLL, associated with an acceptable safety profile