Wednesday, November 30, 2011

Iran: is this a prelude to war?

A few straws in the wind in Iran.

I have been keeping a weather eye on what has been happening in Iran over November. Of course the longstanding issue is over what has been going on with the development of nuclear power in that country. While Iran claims that they are developing a nuclear option to provide power and medical supplies, the US is pretty sure that they are developing a bomb. Why should we believe otherwise? It's a strange fact that people tell lies and there are always some gullible people who believe them.

Here is the gist of a speech that even Obama gave a couple of weeks ago:

Barack Obama to consider all options to stop Iran getting nuclear weapons

US president Barack Obama has said economic sanctions against Iran to contain Tehran's nuclear ambitions have "enormous bite," and he will consult with other nations on additional steps to ensure that Iran does not acquire an atomic weapon.

14th November 2011:

Mr Obama expressed confidence that Russia and China in particular understand the threat of a nuclear armed Iran would pose and said their leaders agree that Iran cannot develop nuclear weapons and trigger a nuclear arms race in the region.

The president, answering questions at a press conference during an Asia-Pacific economic summit, did not specifically say he would consider military action if Tehran were to persist in arming itself with a nuclear weapon. But he added: "We are not taking any options off the table. Iran with nuclear weapons would pose a threat not only to the region but also to the United States."

A report on Friday from the International Atomic Energy Agency provided new evidence that Iran's nuclear program includes clandestine efforts to build a bomb. The report, circulated among the UN watchdog agency's member countries, includes satellite images, letters, diagrams and other documents. It alleges Iran has been working to acquire equipment and weapons design information, testing high explosives and detonators and developing compute models of a warhead's core. Taken together, it's the most unequivocal evidence yet that the Iranian program ranges far beyond enriching uranium for use in energy and medical research, which is what Tehran says it's for.

In meetings on Saturday with Russian President Dmitry Medvedev nor Chinese President Hu Jintao, Mr Obama sought to rally support for putting new pressure on Iran's regime. But there was little public sign either country was ready to drop its opposition to additional sanctions. Four rounds of UN sanctions have caused economic hardship in Iran, but have yet to force any change in the nuclear program.

Remember back to Suez in 1956? At this time Britain, France and Israel entered into a conspiracy to stop Col Nasser from nationalizing the Suez Canal. They were stymied by the US using its financial muscle to threaten to paralyze the markets in London and threaten the British economy. Now with international markets especially in the Eurozone so vulnerable it is possible that the freedom to act politically by the West would be compromised. So I was heartened to read this in the afternoon editions today:

The Bank of England, together with the Federal Reserve, the European Central Bank, the Bank of Japan, the Swiss National Bank and the Bank of Canada, today announced co-ordinated action to enhance their capacity to provide liquidity support to the global financial system. In a dramatic move welcomed warmly by the markets the banks said that their actions aimed to ease strains in financial markets and alleviate the effects of such strains on the supply of credit to households and businesses and thus boost economic activity.

A couple of days ago this was in the news:

Mystery explosion rocks Iran city

A large explosion has been reported in the Iranian city of Isfahan as the regime issued conflicting reports apparently designed to deny any suggestions of a sabotage attack on its nuclear facilities. Officials gave varying accounts of a "huge explosion" in the ancient city, which hosts one of Iran's main facilities for refining uranium in its nuclear programme. While some sources told news agencies there had been a blast on military facilities, others said there had been a fireball at a petrol station. Residents of the city were independently telling relatives and friends overseas that the city had been shaken by a massive blast in the early afternoon.

The reports immediately prompted speculation that Iran had suffered another sabotage attack, just two weeks after a blast at a missile base gave rise to similar suspicions. Isfahan is home to Iran's largest facility for research and development of ballistic missiles. Multiple reports said the blast did not emanate from the nuclear facility.

Then yesterday we had this:

Iranian hardliners storm British Embassy in Tehran.

Two British Embassy compounds were stormed mid-afternoon on Tuesday during a demonstration in the street outside the main building in downtown Tehran, smashing windows, torching a car and burning the British flag in protest against new sanctions imposed by London.

Protesters also broke into the residential compound at Qolhak in north Tehran, a sprawling, wooded property which used to be the embassy's summer quarters. The scenes at the British embassy in Tehran inevitably conjured up memories of the hostage crisis at the nearby US mission that erupted in 1979, during Iran’s Islamist revolution. Then, as now, the mob that stormed the building was led by militant youngsters - but there the similarity ends. The students behind the assault on the US embassy held 52 American nationals hostage for 444 days, with the connivance of the regime.

Privately, Iranian diplomats were disturbed and confused by the scenes in the British embassy. At a time when London has dealt a severe blow to Iran's economy by severing the country's ties with the UK financial system, they hoped to stress the suffering this decision would inflict on ordinary Iranians. Instead, their embassy in London has been shut down and the latest deterioration in diplomatic relations will dominate the agenda.

All this undoubtedly reflects deep divisions within Iran's regime. The two men at the pinnacle of the country's opaque power structure, President Mahmoud Ahmadinejad and Ayatollah Ali Khamenei, the supreme leader, have become bitter rivals. Beneath them, factional struggles have taken over the government, complicated by the approach of presidential elections in 2013. In simple terms, the supreme leader's allies have supported the mob who stormed the embassy; the president's friends have voiced their disquiet. In the shifting sands of Iranian politics, Mr Ahmadinejad appears to be the unlikely voice of moderation in this particular dispute.

From the British Foreign Secretary, William Hague:

The Iranian Chargé in London is being informed now that we require the immediate closure of the Iranian Embassy in London and that all Iranian diplomatic staff must leave the United Kingdom within the next 48 hours.

If any country makes it impossible for us to operate on their soil they cannot expect to have a functioning Embassy here.

This does not amount to the severing of diplomatic relations in their entirety. It is action that reduces our relations with Iran to the lowest level consistent with the maintenance of diplomatic relations.

The House will understand that it remains desirable for British representatives to be in contact with Iranian representatives, for instance as part of any negotiations about their nuclear programme or to discuss human rights. But it does mean that both Embassies will be closed.

We wish to make absolutely clear to Iran and to any other nation that such action against our Embassies and such a flagrant breach of international responsibilities is totally unacceptable to the United Kingdom.

There was a certain inevitability about the British government's decision shut down the Iranian Embassy in London. Now that the British mission in Tehran finds it impossible to function and all of its staff have been withdrawn, it would have been impossible to allow Iranian diplomats to carry on as normal over here.

But the nuances of all this are important. William Hague was at pains to point out that Britain is not breaking off all diplomatic relations with Iran. Instead, bilateral ties are being reduced to the bare minimum, but not severed altogether. This is designed to give the Iranians a bridge back to respectability.

Britain will support an embargo on Iranian oil imports following the deterioration of relations between the two countries, a diplomatic source told Reuters on Wednesday, in an apparent reversal of its former position.

"Now that the UK has downgraded diplomatic relations with Iran, it will support increased sanctions...and would likely go ahead with those sanctions unilaterally or with France and Germany," said a diplomatic source, referring to the ban on Iranian crude oil imports.

Italy will also discuss with its European allies and the US the option of an oil embargo against Iran. Italy is also considering closing its embassy in Tehran, Reuters reports. In light of yesterday's events in Tehran, Foreign Minister Guido Westerwelle decided that the German ambassador in Iran should be recalled to Berlin for consultations.

All UK based staff have now left Tehran, Hague announces.

French president, Nicolas Sarkozy, is the latest world leader to condemn the attacks. During a cabinet session, "the president firmly condemned the scandalous attack on the embassy of Great Britain" in the Iranian capital, the French government spokeswoman said. Mr Sarkozy said the attacks "confirmed" the decision to impose new sanctions on Iran, the spokeswoman, Budget Minister Valerie Pecresse, told journalists. UN Security Council President Jose Filipe Moraes Cabral condemns the attacks. Norway said it had temporarily closed its embassy but its diplomats continued to work from elsewhere in Tehran

Will this spread beyond Iran? In this little noticed report I notice that Khamenei has been speaking in Saudi Arabia, supposedly bitterly opposed to Iran:

Iran – Supreme leader calls for "Islamic power-bloc"

In a message to more than 2.5 million Hajj pilgrims in Saudi Arabia on 5 November, Iran’s supreme leader called on the world’s Muslim-majority nations to form an “international Islamic power-bloc”, laying down an ominous challenge to Western powers. Ayatollah Seyyed Ali Khamenei said that Islamic countries should “make the most of [the] opportunity” created by the Arab Spring, as well as the anti-capitalist movement across the world.

According to the Ayatollah, Islam has become the guiding principle of the Arab uprisings despite the efforts of secular rulers to curtail the influence of religion in their countries. Pointing to the victory of the Islamist Ennahda Party in Tunisia’s recent elections, he predicted similar outcomes elsewhere, saying, “Without doubt, free elections in any Islamic country will hardly result in anything except what happened in Tunisia.”

Heralding a global power shift and issuing an ominous challenge to Western powers, the Ayatollah said that “the West, the United States and Zionism are weaker than ever before”. He urged the entire umma (Islamic nation) and especially the revolutionary nations to continue to be vigilant “against the plots of arrogant international powers”.

The Hajj is a strange thing. Muslims should be committed to visit Mecca once in their lifetimes. I know many Muslims for whom this is a holy and life-changing experience, but many Muslims leave it very late in their lives and actually die on the visit. Charter airlines arrange cheap flights with poor conditions and there is an 8 mile walk at the other end in searing heat. Although there are rickshaws to carry them for this journey many demur and insist on walking. Those who die are often propped upright in their airplane seat and leak body fluids on the way home to European destinations. For the other passengers it is not a pleasant experience.

The kinetics of MRD

The German CLL8 trial has been the most important study in CLL thus far reported. But there are a lot of scientific data that derive from this trial that are yetto be reported. The value of minimal residual disease measurements is an important investigation that will be reported at ASH. Here is the German abstract:

1777 Minimal Residual Disease (MRD) Re-Growth Kinetics Are An Independent Predictor for Progression Free Survival (PFS) in Chronic Lymphocytic Leukemia (CLL) and Are Related to Biologically Defined CLL-Subgroups – Results From the CLL8 Trial of the German CLL Study Group (GCLLSG)
Sebastian Boettcher, Matthias Ritgen, Kirsten Fischer,, Stephan Stilgenbauer, Raymonde Busch, Gunter R. Fingerle-Rowson, Anna-Maria Fink, Andreas Buehler, Dirk Winkler, Michael K. Wenger, Myriam Mendila, Clemens Wendtner, Barbara Eichhorst, Hartmut Döhner, Michael Hallek, and Michael Kneba.

MRD single time point assessments during therapy and at the end of treatment have been identified as independent predictors of PFS and overall survival in CLL patients (pts) by our group and others. However, it is currently unknown whether MRD kinetics during follow-up (FU) also have prognostic significance and whether kinetics show associations with CLL risk features. We therefore investigated MRD during treatment-free FU within the CLL8 trial of the GCLLSG.

MRD kinetics were analyzed in 256 pts who had not progressed 1 year after completion of therapy and for whom at least 2 peripheral blood MRD assessments during the subsequent year were available. The slope of the common logarithm of MRD / time was calculated for 193 patients with at least 2 positive MRD measurements. Median MRD increase was 6.3fold during the observation period for the whole group (i.e. 0.80 log MRD unit increase / year). We compared groups of pts who (1) were always MRD negative (25% of all 256 pts), (2) had measurable disease with a slope below median (slow re-growth, 37% of pts), and (3) had measurable disease with a slope above median (fast re-growth, 39 %).

The medians of the first measurable MRD levels during observation did not differ significantly between groups 2 (4.3 x 10-3) and 3 (1.7 x 10-3, p=.16). Pts with faster MRD re-growth kinetics (group 3) experienced a shorter median PFS (40 months) than pts with slower re-growth (group 2, 66 months), whereas median PFS has not been reached in pts who were always MRD negative (group 1, log-rank p= 3 x 10-14). Compared to group 1, group 2 and 3 pts carried increasingly higher risks of progression (HR 3.1 and 7.7, resp.). Pts showing a slow re-growth pattern (group 2) had a 2.5fold lower risk of clinical progression than pts with a greater MRD slope (group 3, p=5 x 10-6).

The prognostic significance of MRD kinetics for PFS was also tested in Cox regression analysis together with clinical response, deletion 17p, IGHV mutational status, number of treatment cycles, treatment arm, thymidine kinase, beta2-microglobulin, pre-therapeutic WBC and MRD levels 1 year after completion of therapy. MRD kinetics (p=4x10-9), MRD levels (7x10-14), cycle number (8x10-5) and IGHV mutational status (1x10-3) remained independently significant for PFS in this multivariate analysis.

We next correlated MRD slopes during the second year of FU and prognostic features in 204 pts (groups 2 and 3 plus 11 pts with early clinical relapse but measurable MRD slope during second FU year). Pts who required treatment within 2 years from diagnosis experienced a faster re-growth after therapy (.92/a) than pts with a longer treatment-free interval (.68, p=.04). The slope was significantly lower in pts with Binet A disease prior to therapy (.43/a) than in Binet B (.77/a, p =.03) and Binet C (.88/a, p=.02) pts. Pts carrying a chromosomal deletion (del) 13q as single abnormality had a significantly slower MRD re-growth pattern (.58/a) than those with del(11q) (1.0/a, p=.0004) or without cytogenetic abnormalities (1.1/a, p=.001), while the difference to pts with 12q+ (.71/a) was not significant. Pts with a mutated IGHV gene progressed slower (.54/a) than those with unmutated IGHV (.96/a, p=.0002). A thymidine kinase of at least 10 U/L was associated with a steeper MRD slope (.82/a) than lower levels (.61/a, p=.03). MRD slopes were not significantly associated with gender, WBC prior to therapy, beta2-microglobuline levels, presence of B-symptoms, or treatment arm.

We demonstrate for the first time the independent prognostic significance of MRD kinetics during FU in CLL. MRD kinetics improve the prediction of PFS even when single time point MRD assessments during FU and other major risk features in CLL are additionally considered. MRD kinetics classify known CLL risk factors into two groups. IGHV, cytogenetics, thymidine kinase, stage, and time to treatment distinguish CLL subgroups with different re-growth kinetics, likely characterizing the relationship of proliferation to spontaneous apoptosis of the CLL clone itself. Other risk features did not show an association with kinetics in spite of proven significance in the CLL8 trial. Those features likely identify differences in responsiveness to therapy. We hypothesize that maintenance strategies will chance the course of the disease most effectively in patients who are responsive to therapy but relapse early due to fast CLL re-growth.

What this paper is saying is that the prognostic factors already identified determine how rapidly MRD relapses. MRD negativity is not a cure; it just lowers the bulk of disease to a greater amount and from here the disease starts reaccumulating at the same rate as it had been before. There is no 'immune reaction' that wipes out tiny bits of CLL.

Maintenance R after FMCR

Another topic that has been insufficiently addressed is the whole question of maintenance rituximab. This Spanish abstract deals with the question after the use of FMCR which is a particularly intensive, but effective induction regime.

293 Rituximab Maintenance In Patients with Chronic Lymphocytic Leukemia (CLL) After Upfront Treatment with Rituximab Plus Fludarabine, Cyclophosphamide, and Mitoxantrone (R-FCM): Final Results of a Multicenter Phase II Trial On Behalf of the Spanish CLL Study Group (GELLC)Francesc Bosch, Pau Abrisqueta, Neus Villamor, María José Terol, Eva González-Barca, Marcos González, Christelle Ferrà, Eugenia Abella, Julio Delgado, Jose A. Garcia-Marco, Yolanda Gonzalez11, Felix Carbonell, Secundino Ferrer1, Encarna Monzo, Isidro Jarque, Ana Muntanola, Mireia Constants, Lourdes Escoda and Emili Montserrat.

The effectiveness of rituximab, fludarabine, cyclophosphamide, and mitoxantrone (R-FCM) followed by rituximab maintenance in the treatment of CLL has been investigated in a phase II clinical trial that includes two treatment parts. First, patients were given induction therapy with R-FCM up to 6 cycles, achieving an overall response (OR) rate of 93% and a CR rate of 82% (46% MRD-negative CR).

Note: this is the maintenance part of their study. The induction part of the study was published in 2009 in JCO (JCO gets the clinical parts; Blood the scientific parts of studies, but JCO tends to have a bigger Impact Factor)

Patients achieving CR or PR with the initial part of the treatment received rituximab maintenance. Here we present the final results of the treatment maintenance part, initiated three months after concluding R-FCM, and consisting of rituximab 375 mg/m2 every three months for two years (up to 8 cycles). Sixty-four patients (median age 60 years, 70% male) receiving > 4 cycles of maintenance therapy were evaluated for response, including bone marrow (BM) examination and MRD assessment by four-color flow cytometry of peripheral blood and BM. Patients in whom rituximab maintenance was prematurely interrupted (≤ 4 cycles) due to toxicity were considered as failures.

Note: the lymphoma dose of rituximab rather than the CLL dose was used.

Median number of cycles of maintenance administered was 8 (range, 1 to 8) and 76% of patients completed the entire planned treatment. Treatment was delayed due to insufficient hematological recovery in 9 cycles (2%) and to non-hematological toxicity in 4 cycles (0.8%). Neutropenia was observed in 31.3% of cycles (grade 3&4 in 8.5%), thrombocytopenia in 4.6%, and anemia in 1.2%.

Note: presumably because of toxicity, it was not possible to administer the planned dose of maintenance treatment.

At the end of the maintenance therapy, 45% of patients had low IgA serum levels, 37% low IgG, and 66% low IgM. Sixteen patients experienced grade 3&4 infectious episodes, including 9 pneumonia, 2 febrile neutropenia, 1 appendicitis, 1 myositis, 1 herpes zoster, and 1 cerebral abscess. Two patients died, one due to multifocal leukoencephalopathy and the other due to hemophagocytic syndrome. Infectious episodes grade 3&4 were observed in 19.5% of cycles with neutropenia 3&4, but in only 3% of cycles with neutropenia inferior to grade 3 (p=0.001). In contrast, no relationship was observed between infectious events and the presence of low levels of immunoglobulins or diminished CD4+ T lymphocyte counts.

Note: an extra toxicity from maintenance rituximab will be hypogammaglobulinaemia but in this case they weren't able statistically to link infectious complications to the rituximab. However, I sould be very worried about about the cerebral abscess and the two patients who died, one due to multifocal leukoencephalopathy and the other due to hemophagocytic syndrome. These are not usual post-chemotherapy complications.

After rituximab maintenance, 40.6% of patients were in MRD-negative CR, 40.6% in CR, 7.9% in PR, and 10.9% failed to treatment. Failures were due to disease progression (two patients), severe neutropenia (three patients), infectious toxicity (one patient) and death (one patient). Among 35 patients in MRD-negative CR after R-FCM induction, 22 maintained the MRD-negative status at the end of maintenance treatment, 9 (25.7%) switched from MRD-negative to MRD-positive, and 4 failed to treatment. Median time to conversion from negative to positive MRD was 45.4 months, significantly longer than that observed in patients treated with FCM only (45.4 vs. 16.4 months; p=0.011) (Bosch et al. Clin Can Res 14:155-161,2008). Moreover, among 21 patients that achieved MRD-positive CR with the initial R-FCM treatment, 2 (9.5%) became MRD-negative upon rituximab maintenance, 17(81%) continued in MRD-positive CR, 2 achieved PR, and 2 failed to maintenance therapy. Among the 8 patients in PR, 4 patients achieved CR (2 MRD-negative and 2 MRD-positive), 3 patients continued in PR, and one patient progressed. Three-year progression-free survival was 94% (95% CI 88-100%). Compared to the FCM series, maintenance with rituximab significantly prolonged the time to next treatment in patients that after the initial treatment with R-FCM were in MRD-positive CR (44.1 vs. 54.5 months, p=0.049) or PR (6.5 vs. 54.4 months, p=0.001).

Note: so it is not the whole answer. We await overall survival rates in a randomized phase 3.

In conclusion, treatment maintenance with rituximab after R-FCM in patients with CLL is feasible and might improve patients' outcome, particularly those who do not attain a MRD-negative CR after the initial, upfront therapy. However, its toxicity is not negligible. Further, ongoing studies should help to clarify the role of maintenance therapy with rituximab in the management of patients with CLL.

Moorlands College

Moorlands College is one of the Charities that I support. My former Pastor, Steve Brady, whose book I recently reviewed, is the Principle there. It is an Evangelical Bible College administered under the University of Cheltenham and Gloucester.

My son-in-law, Tim Johnson, is an air-traffic controller. He may one day become a lecturer at the College of Air Traffic Control. I have just had this press release from Moorlands:

Moorlands is very grateful to the Bournemouth College of Air Traffic Control for the donation of furniture made this month. God’s timing is always perfect and as we continue to grow and develop as a College there are various needs that arise. The need for furniture is always high as we have new staff, more students and more advanced technology. So when the nearby College of Air Traffic Control closed down to move to a different site, the offer came to Moorlands to inherit some of their furniture.

We are so grateful to them for thinking of us and we look forward to putting some of their teaching equipment, desks and filing cabinets to good use. So a massive thank you goes to Bournemouth College of Air Traffic Control, to Paul Craddock for making this possible and of course to God for His continued provision for us!

CHOP-R in refractory patients

Chris was kind enough to publish a link to the ASH abstracts for this year and I have just started looking at them. The first one from the German group tickles all the boxes that I have been concerned about:

2860 Cyclophosphamide, Adriamycin, Vincristine and Prednisone Plus Rituximab (CHOP-R) in Fludarabine (F) Refractory Chronic Lymphocytic Leukemia (CLL) or CLL with Autoimmune Cytopenia (AIC) or Richter’s Transformation (RT): Final Analysis of a Phase II Study of the German CLL Study Group Petra Jenke1, Barbara Eichhorst, Raymonde Busch, Nadine Anheier, Ulrich Duehrsen, Jan Duerig, Martin H. Dreyling, Manuela Bergmann, Maria Elisabeth Goebeler, Hans Juergen Hurtz, Martina Beate Stauch, Stephan Stilgenbauer, Hartmut Doehner, Prof. Dr. med., Anna-Maria Fink, Kirsten Fischer, Clemens-Martin Wendtner, and Michael Hallek,

Introduction: In the last decade, important progress has been achieved in the treatment of CLL through the use of purine analog-based chemoimmunotherapies. Several conditions remain a challenge, often with a poor outcome. Amongst these therapeutic problems are Richter’s transformation (RT), refractoriness to F-based therapies (Fref), and the occurrence of AIC, which are sometimes induced by F. Fref and RT pts have a very poor prognosis with an estimated overall survival (OS) of only 10 and 8 months (mos), respectively. Therefore, therapeutic alternatives are urgently warranted. CHOP-R has improved the outcome of pts with aggressive non-Hodgkin’s lymphoma. To test the efficacy and tolerability of the CHOP-R regimen in CLL patients with RT, Fref, or AIC, the GCLLSG initiated a prospective phase II trial.

With the usual German efficiency, rather than rely on anecdotes this is a formal phase 2 (reasonably sized) clinical trial. Of course being a phase 2 it is primarily looking at response rate, but since we have ample historical controls over what usually happens in this group of patients, we probably won't need a phase 3 to determine outcome unless this trial should prove to be a stupendous outlier.

Material and Methods: 62 patients were included in the study. Due to protocol violations, 2 patients were excluded. Within the group of Fref pts, the medical review detected 11 patients who had received pre-treatment with F (Fpret), but were not refractory according to the updated 2008 guidelines. Thus, 26 pts were classified as Fref/pret, 19 pts as AIC and 15 pts as RT. All patients received CHOP every 3 weeks (cyclophosphamide 750mg/m², adriamycin 50mg/m² and vincristine 1,4mg/m² d1; prednisone 100mg/m² d1-5). Rituximab was added starting with the 2nd cycle (375mg/m² on each d0, and 21 days after the last CHOP-R). RT pts received up to 8, Fref/pret and AIC up to 6 courses of CHOP-R. In case of PD after 3 cycles, pts went off-study. The primary endpoints were remission rate, quality and duration of response.

Note: this was the lymphoma dose of R, not the CLL dose.

Results: 79%, 73%, and 40% of AIC, Fref/pret, and RT pts were male, respectively. The median age was 65 years (y) for Fref/pret-pts, 66y in the AIC and 69y in the RT group. Binet stages for Fref/pret pts were: A: 8%; B: 27% C: 65 %. All but 3 AIC pts were at Binet stage C. Initial RT stages according to Ann Arbor were: II: 13%, III: 13%, IV 73%. The median number of previous therapies were 3 for Fref/pret, 2 for AIC and 2 for RT.

Note: these were younger patients, but most had advanced disease and were a poor risk lot with many previous types of treatment.

A total of 314 cycles were administered, with a median number of 3 cycles for AIC and Fref pts and a median number of 4 cycles for the RT group. Due to toxicity 73% of cycles in the Fref/pret group, 66% in the AIC and 87% in the RT group were dose-reduced. 69% of Fref/pret-pts and 58% of AIC-pts received full 6 cycles of therapy and only 40% of RT-pts completed 8 cycles of therapy. Treatment was stopped in 6 pts because of PD. Due to treatment related toxicity treatment was stopped in 16 pts (27%). Treatment related mortality was 3% (2 pts). Treatment toxicity was reported according to NCI common toxicity criteria (CTC) version 2.0. Adverse events grade 3 or 4 for anemia, neutropenia and thrombocytopenia were documented in 75%, 55% and 65% of patients, respectively. Infections were the most common non-hematologic toxicity and occurred in 67%; severe infections CTC grade 3 or 4 occurred in 28%.

Treatment was not administered with the dose intensity that was planned for. This was because of toxicity - as would be expected with so many stage C patients in the mix.

All 26 Fref/pret-pts were available for response evaluation. CHOP-R achieved 54% PR, 35% SD and 12% PD. The median progression-free survival (PFS) and median treatment-free survival (TFS) were 11 and 14 mos. OS was 27 mos with a significant difference concerning F-ref (n=15) and F-pret (n=11) pts (17 vs. 35m; p=0.05). We evaluated the response of all 15 RT-pts with 60% PR, 7% CR, 13% SD and 20% PD. The PFS was 15 mos, TFS was 17 mos and OS 27 mos. 17 AIC pts were available for response evaluation with 82% PR, 6% SD and 12% PD. The PFS and TFS were only 14 and 16 mos. The OS was 50 mos.

Note: although the PR rate was respectable, it is artificially high because only some of the pret patients would have been refractory to fludarabine and the difference between overall survival for Fref and pret was more than double and statistically significant. If patients lived long enough they could benefit from other treatment including lenolidemide, alemtuzumab and transplant.

The population had a high incidence of unfavourable genetic markers: deletion of chromosome 17p [del(17p)] was detected in 24%, del(11q) in 34% and unmutated IGHV in 70%. 85% had high levels of serum thymidine kinase (sTK > 10 U/l), and 49% had high levels of ß2-microglobulin (ß2M > 3.5 mg/l). Patients with del(17p) had an unfavourable response rate and achieved significant less a PR or CR (36% vs. 76%; p=0.03). Multivariate analyses showed that del(17p) and ECOG performance status had a negative prognostic impact on OS (p = 0.0001). Moreover the presence of a del(17p) predicted a short PFS (6 vs. 16.9 mos; p=0.001).

Note: This is of course old news, but we are now discerning other factors involved in Richter Syndrome and fludarabine refractoriness.


CHOP-R achieves promising response rates in CLL patients with Fref and RT and very good response rates in patients with AIC. However, the progression-free survival and overall survival remain unsatisfactory. Therefore, CHOP-R might be used as induction therapy prior to allogeneic stem cell transplantation in physically fit patients.

Or the agents that interfere with BCR stimulation, or alemtuzumab, or lenalidemide especially early in the disease. Even Bendamustine-R (or Ofatumumab) has not been evaluated in this scenario. Still CHOP-R for AIC might be promising.

John 8:20-22. The sovereignty of God

He spoke these words while teaching in the temple courts near the place where the offerings were put. Yet no one seized him, because his hour had not yet come. Once more Jesus said to them, “I am going away, and you will look for me, and you will die in your sin. Where I go, you cannot come.” This made the Jews ask, “Will he kill himself? Is that why he says, ‘Where I go, you cannot come’?”

The attitude of the Jews is what today's secular world would display. With no concept of the supernatural world, they would not detect the Sovereignty of God in these happenings. But we can, can't we?

More female doctors; a good thing?

An article in the Student Edition of the BMJ has prompted this article in today's Independent

Female doctors who have laid siege to the male bastion of the medical profession are poised to overtake their male counterparts in what a medical journal describes as a "giant leap for womankind". Women have outnumbered men in medical schools for a decade and are set to become a majority of the medical workforce by 2017. They already dominate in people-friendly areas such as general practice, paediatrics and palliative care, while still struggling in the chauvinistic disciplines of cardiology and surgery.

But the progressive feminisation of medicine carries dangers, experts warn. There is a still a gender pay gap and a reluctance by women to put in the time and effort needed to attain the most senior posts and maintain medicine's influence in the corridors of power. Maham Khan, from Imperial College, London, writing in the student edition of British Medical Journal, says more women doctors could lead to safer practice. Women are less likely to be hauled before the General Medical Council on disciplinary charges or investigated for failures in performance. Over eight years 490 male doctors were banned from seeing patients following performance reviews by the National Clinical Assessment Service, compared with 79 women.

Problems remain, however. Women are under-represented at the top of the profession, according to Professor Jane Dacre, medical school director of University College London, because they are "not investing in the time and effort it takes to get the top jobs". Parveen Kumar, president of the Royal Society of Medicine, told the BMJ: "Women don't like to be seen as putting themselves forward." In 2004, Dame Carol Black, then president of the Royal College of Physicians, triggered a debate about the influence of women in an interview with The Independent in which she warned that the growing numbers could reduce the influence of the medical profession at the highest level. This was not about women's capacity to perform, but about their willingness to devote the time and effort, beyond their medical responsibilities, to furthering the interests of the profession. Men were happy to give up their evenings, sit on committees and eat dinners for a chance to walk the corridors of power. It was not clear, Lady Black suggested, whether women would have the same appetite for networking.

A report by the Royal College of Physicians warned in 2009 that the gender balance of the profession was changing so fast it threatened the care of patients. Women were more likely to work part time and to break their careers to have families, and competition for less female-friendly disciplines such as surgery would be reduced.

Despite the challenges, medicine is ahead of other professions in terms of gender equality, Maham Khan writes. Women will take 55 years to reach equality with men amongst senior judges and 73 years amongst directors of FTSE 100 companies. "In terms of numbers, female doctors have made giant leaps," she says.

Men fare better than women in almost all areas of life – except when it comes to their health. They are twice as likely as women to die before 65. Now a doctors' study is calling for policies to tackle problems caused by men's macho attitude to health – rejecting advice and not seeing GPs soon enough. Alan White, professor of men's health at Leeds Metropolitan University – who led the study published in the British Medical Journal – said intervention should start in schools to give boys "skills to make healthier decisions throughout their lives". Bosses should collaborate with unions to promote men's health in the workplace, while pubs, clubs and sports centres should also be targeted, the study urges.

I got into trouble for predicting this in 1984. Here is my comment today:

More female doctors means more part-time posts, more juggling between home and work commitments, more hand-overs that are not completed, more overlapping double shifts that are paid for twice, less continuity, more patients falling through the cracks, less working late to paper over the cracks.

Worst off will be those unmarried female doctors, especially those without children who will be expected to work extra long hours (unpaid) to compensate for their sisters who 'must get off to see to the kids'.

Take a look at what is actually happening on the ground rather than in some idealized image of how the 'equalities industry' would like it to be.

Tuesday, November 29, 2011

John 8:19. Among atheists

Then they asked him, “Where is your father?” “You do not know me or my Father,” Jesus replied. “If you knew me, you would know my Father also.”

They are still unaware. They are a Godless lot!

How do you argue with those who do not believe in God? It is not our responsibility to convert people, merely to witness, and to witness means to tell our own story, not become a theologian

String of disasters

I am still waiting for news about the monoclonal antibody. I am told that we should hear today.

Meanwhile it has been an eventful week. First, our dishwasher broke. Normally this would be something we would do together, but I am not well enough to9 go shopping so my wife went to Currys and bought a replacement which will be installed tomorrow. Then via the MacMillan Unit I had some aromatherapy. While I am sure this does not affect the cancer, it is very relaxing having sandalwood oil rubbed into my feet and legs. These are getting very puffy and despite elastic stockings I have to keep them raised. Then a large amalgam filling fell out of my back teeth. No I don't blame the aromatherapy.

Today as I was dozing in the armchair I heard a clattering from the chimney. My wife was sure that a pigeon had fallen down the chimney and trapped itself there. We phoned Prokill, the pest controller, and she was right. In about 20 minutes they had rescued the bird and released it. Best of all they made no charge for it. What nice people!

University applications fall

Universities face a record 15.1 per cent slump in UK applicants after the tripling of tuition fees, official statistics show. Rising numbers of British students are being deterred as charges of up to £9,000 a year are introduced next autumn. The UCAS statistics suggest a looming meltdown in higher education after years of unbridled expansion. Vice chancellors are likely to become reliant on lucrative overseas students who pay the full cost of courses – as much as £26,000 a year – to help boost their coffers.

The figures show that 133,357 home students have applied for 2012 degree courses at UK institutions so far, a drop of 23,759 compared with the same point last year. Applications from other EU students have fallen 13.1 per cent to 9,034. However, the number of applicants from outside the EU has risen by 11.8 per cent – from 14,306 to 15,996 – amid extensive overseas recruitment drives. There has been a 31.8 per cent rise in applications from Hong Kong alone – up to 2,248 – as British institutions target this market.

Overall applications – including British, other EU and non-EU students – to UK universities by November 21 have dropped by 12.9 per cent to 158,387. At the same point last year, overall applications for courses starting in autumn 2011 had soared by 11.7 per cent to 181,814. Students cancelled gap years in the rush to get places ahead of next year’s increase in fees.

Last night Professor Alan Smithers, director of the Centre for Education and Employment Research at Buckingham University, said: ‘I think this is the highest drop outside of the two World Wars, when some universities almost became bankrupt due to falling applications. They were rescued by State support. ‘In the 1980s, when the number of 18-year-olds dropped by a third, the shortfall in applications was made good by mature students and part-time students.’ He added: ‘It will be the less popular universities that will struggle. ‘Students will be questioning whether they would be getting sufficient value from £9,000-a-year from those universities.’ The largest fall in applications (17.1 per cent) is among Scottish students, even though they get free tuition in Scotland. This is believed to be due to a fall in the birth rate, together with a 19.1 per cent fall in their applications to English universities. Applications are down among English students by 15.2 per cent, Welsh by 10.3 per cent and Northern Irish by 16.9 per cent. Areas of the UK with the largest falls in applications include the North East (-21.4 per cent) and the East Midlands (-20.1 per cent).

Sally Hunt, general secretary of the University and College Union, said the figures were worrying, adding: ‘Putting financial barriers in front of young people who have been told their entire lives to aim for university is nothing more than a policy of penalising ambition.’ UCAS chief executive Mary Curnock Cook said: ‘We expect some depression of demand due to a decline in the young population, but it is much too early to predict any effects from changes in fees.’

Mr Willetts said: ‘Most new students will not pay up front and there will be more financial support for those from poorer families.’ Students have until January 15 to apply for 2012 courses. Research suggests they will face an average total bill of £48,503 for three years’ study at a Russell Group university, including the higher fees and living costs.

When higher fees were introduced, part of the reason was to embarrass those 'universities' that gave poor value for money. It is almost universally accepted that the expansion of Universities allowed some to provide very poor value with too many courses in 'Media Studies' and the like attracting students who would be better off in apprenticeships learning to be craftsmen or mechanics or secretaries. Tony Blair's "Education, education, education." warcry was misdirected.

The polls

Peter Kellner is a left-leaning pollster and journalist. Here is what his blog is saying about the state of the parties just before the Chancello's Autumn statement:

Here's the bad news.

By a two-to-one majority (60-31%), voters think the coalition is managing the economy badly. Five times as many people (57%) think their family's financial situation will get worse rather than better (11%) over the next 12 months. Only 27% think the government is managing the public spending cuts fairly; 57% think they are being done unfairly. More people think the cuts are too deep (43%) than too shallow (10%) or about right (27%).

Faced with these figures, most chancellors and prime ministers would be twitching uncomfortably. However, other YouGov data suggest reasons for surprising equanimity.

One major reason is that the figures quoted above have changed little in recent months. The past month or two has seen some stinking economic news, as spending cuts take effect and the ripples from the eurozone crisis lap at the shores of Britain's economy. Unemployment is up. Growth is anaemic. Expectations for next year are sharply down. One might have expected a marked rise in public disenchantment with the government.

It hasn't happened. The main indicators have been weak for much of this year, but have not weakened further this autumn. Why not? Here are some figures that help to explain what has, or rather has not, happened.

By two-to-one (56-27%) voters think the public spending cuts are necessary. The proportion saying 'necessary' has remained stable since February. The only change since then is that slightly FEWER people say the cuts are 'unnecessary', while slightly more don't know. The opponents of cuts have made no headway for the past nine months. More people still blame Labour (38%) rather than the coalition (22%) for the current spending cuts. If anything, the coalition's position has slightly improved since the summer, when blame for the coalition reached 26% on a number of occasions. In short, the Conservatives continue to win the argument that they are cleaning up a mess they inherited. Last autumn, I believed that Labour was losing this debate because it had spent the summer months engaged in its leadership contest; inevitably, it was talking to itself rather than the wider electorate.

But that contest ended 14 months ago. Labour has a settled duo at its helm: Ed Miliband and Ed Balls. They have not been short of opportunities to attack the government and proclaim their own alternative. Bluntly, they have failed to make an impact. This is why Labour's voting-intention lead averages just 5%. At this stage in a parliament's life, as we approach its mid-term, an economy as weak as Britain's would normally expect to be accompanied by a double-digit lead for the opposition.

Even worse for Labour, they actually lag behind on our 'forced choice' question: If you had to choose, which would you prefer to see after the next election, a Conservative government led by David Cameron or a Labour government led by Ed Miliband? Our latest figures show Conservatives/Cameron on 40% and Labour/Miliband on 35%. This 5% lead is similar to what we found in the spring. Actually, Miliband caught up with Cameron, and briefly overtook him, in the summer, when the news was dominated by phone-hacking and, then, August's urban riots; but normality resumed when the news returned to the state of the economy.

As with financial investments, past performance offers no guarantee of future behaviour. This week's autumn statement and public sector strikes may cause many voters to revise their view of the government's competence. And, as time passes, if the economy stays weak, it is possible that more people will blame the Conservatives and fewer will blame Labour. The next election is more than three years away: only a fool would say its outcome is a foregone conclusion. But for the moment, the Conservatives seem to have the Teflon factor on their side, for they have managed to stop the autumn's bad economic news from sticking to them and messing up their reputation.

I have been watching the Labour lead in the Daily Telegraph each day. It varies from 2% to 9% which seems to bear out Kellner's assertions. There is hope yet.

Monday, November 28, 2011

Rules for citizenship

In today's Times Libby Purves has written an article about testing for British Citizenship. Many countries have introduced such a test for immigrants.

The French are planning a new citizenship test that candidates for naturalisation must pass. President Sarkozy places importance on cultural assimilation and understanding of the philosophical basis of French equality, liberty and fraternity. The Interior Ministry adds that there must be basic knowledge of his country’s artistic history, great painters, writers and philosophers, as well as its contemporary culture. The British test has some basic stuff about Parliament and elections, but is mainly a cautious mish-mash of stuff about MoT tests, benefits, and the Council of Europe. It demands that you know the exact number of days per year when schools are legally required to open and is dusted with some dottily detailed questions about population statistics, a ridiculous inquiry as to which “issues” young people in the UK most worried about in a survey made eight long years ago, and a multiple-choice question about whether married women got the right to divorce husbands in 1837, 1857, 1875 or 1882.

Canada’s is detailed and proud, asking for the six main responsibilities of citizenship, the meaning of the Remembrance poppy, major rivers and natural resources, and whether the national symbol is a moose, hawk, beaver or bear. The Dutch are proud, too, at least of their social attitudes. They demand knowledge that nude sunbathing is legal, and preface the test with a film of two men kissing, and a prostitute. (There has been some fuss about whether all this is covertly Islamophobic , and one indignant message-boarder says: “Basically you must be a degenerate to obtain Dutch nationality.”) The German test asks, equally contentiously some say, whether the candidate believes that Israel has the right to exist. Again, one learned paper in a European think-tank attacks that as being anti-Muslim thought-policing.

Libby has made up her own list:

• Who stands on that pillar in Trafalgar Square and why?

• Do we have theatre censorship?

• Why is sea trade important to Britain?

• Who should you complain to about a TV programme that offends you?

• Write 30 words on either the British attitude to pigs or Winnie the Pooh or Alan Bennett or David Beckham or Bob Geldof.

• Who is Dame Vera Lynn? or What is another meaning of the word dame, especially around Christmas?

• Name a Shakespeare play or three songs by Lennon and McCartney.

• What did William Wilberforce achieve?

• What was Dunkirk or D-Day?

• Is Coronation Street (a) a television show or (b) the Queen’s address?

• If you wanted to know about toad-in-the-hole, would you be more likely to ask (a) Sir David Attenborough (b) Delia Smith (c) Alan Titchmarsh?

• Are you allowed to swear at a policeman?

• What is the National Trust? A zebra crossing? The Premier League?

One commentator has answered these :

1. Lord Nelson – naval hero and won a number of battles.
2. Not since the 1960s but the matter is still under discussion
3. We are an island doh! Sea trade is our lifeline.
4. Ofcom
5. Pigs are highly intelligent animals and provide wonderful meat, bacon, ham and sausages. Traditionally, they were fed on household scraps, waste milk products and so were environmentally friendly. So there!
6. Dame Vera Lynn is a singer and performer who performed all over the world in wartime to raise morale. Love her to bits
7. King Lear – appropriate for these difficult times.
8. He abolished slavery
9. D-Day was when our troops landed in Europe, including my father.
10. Corry – TV show
11. Toad in the hole – Delia Smith but I bet DA would have something to say on the matter too.
12. No – not AT a policeman. The recent case was about a man who swore IN FRONT of a policeman as he was so ignorant, the “F” word was part of his normal vocab.
13. The National Trust takes over and runs, for public enjoyment, large houses and estates which are part of our historical heritage.

I don't think that these answers are strictly accurate but they are close enough to pass, but to my mind they are the wrong sort of questions. Another comments thus:

What do any of these questions have to do with true citizenship? Since when did knowing a load of facts and having a good guess at the rest matter? What counts is being able to earn a living, speaking English, good manners etc. and a lot to be said for loving thy neighbour.

I tend to agree.

What we need is not a test but a pledge, and this should apply not only to those applying for citizenship, but to all those entering the country. Those breaking their word on this pledge should be immediately expelled. The pledge would go something like this: Do you agree while living in the UK to respect freedom of speech, freedom of religion, including witnessing for your faith, the right to own property, the right of free assembly, and do you agree to abstain from violence, intolerance of the behaviour of others, insulting behaviour and to obey the criminal law on pain of expulsion from the country without appeal?

Danger at night and weekends

The annual hospital guide published by Dr Foster Intelligence using official figures shows that one in eight trusts has higher than expected death rates on Saturdays and Sundays, suggesting they are only working to a five-day week. Many hospitals have far fewer senior consultants on site outside of normal office hours, the data show, and rely on junior doctors and nurses to treat critically ill patients.

In a handful of trusts, the mortality rate rises by 20 per cent or more between weekdays and weekends. Low staffing levels in A&E have been identified as one of the long-standing problems at Stafford Hospital, where hundreds of patients died after receiving “appalling” care, and the unit will close overnight for three months starting this week.

Although I do not take much notice of Dr Foster reports, since they use crude data which is often modified when the CQC produces a more comprehensive view. (Stafford was only one of 6 Trusts identified by Dr Foster - the other 5 were exonerated). Nevertheless, out of hours care has been one of the problems identified by the NHS as one of its deficiencies. As a result there have been major changes to the provision of care. Vascular surgery has been confined to small groups of expert vascular surgeons, who are ready with their teams to appear where the problem is. No junior doctor ever gets to lead on emergency vascular surgery. It is true of almost all elective surgery, which is now conducted between 9 and 5.

When I was young it was quite commonplace for major colorectal surgery to take place in the evening for an elective list arranged by the Senior Registrar from 7pm to 11pm. But we had different types of junior doctors then.

When I was a resident in Bristol there were 6 Senior Registrars in Surgery, aged between 38 and 44. These were very senior and experienced doctors who were just waiting consultant jobs. One of those was John Trapnell, whose obituary I posted recently. Among the others I remember were Colin Davidson, Roger Celestin and Harry Espiner. All have long since retired with great success in their careers. Today, Senior Registrars have all gone and instead we have registrars. These young men have many fewer hours of experience and their training is arranged so that they will get fewer yet. At the age of 35 they expect to get consultant jobs, but although they may get expert in microspecialties (just doing breasts or stomachs or pancreases) they will never become the General Surgeons that their predecessors were.

Physicians were always younger than surgeons when they became consultants, and I was particularly young at the age of 30, but 33-35 would be average. I was always on an on-call rota of at least 1 in 3 throughout my whole career, but we trained a mixed junior doctor/ senior nurse cadre who were competent to deal with the medical emergencies that we would have to deal with urgently (mainly neutropenic sepsis) and more complicated problems (mainly transfusion and coagulation difficulties) could be dealt with from the confines of a warm bed.

General Physicians have largely disappeared from the NHS. Elective work is done in daytime by Gastroenterologists, Chest Physicians, Neurologists, Endocinologists, Cardiologists, Rheumatologists, and Rehabilitation Specialists. We and others have set up Acute Medical Units, attached to Accident and Emergency Units where an on-call Senior Doctor is responsible for the first 24-48 hours of an admission only, although referral to an intensive cardiac unit or stroke unit may be required earlier. Expert endoscopy, CT scanning, MRI and ultrasonography is also available within the first 24 hours.

Changes in junior doctor training have forced more senior involvement at nights and at weekends and have in the best hospitals rethinking on how things should be done. There is one major deficiency that I have identified, though. The European Union forced through its European Working Time Directive, with the consent of the last Labour Government and against protests of the British Medical Establishment. This meant that not only were junior doctors not allowed to work for more than 48 hours a week, but included in that time would be on-call time, when the doctors would be sleeping, not working. This has meant a total revision of doctors' rotas that has neither helped the service they provide nor their training. Now even the Germans think it was a mistake and have conceded that this may be one of the things that the UK can have back to its own control if there have to be renegotiation of the EU charter because of fiscal rearrangements.

SF3B1 in sideroblastic anemia

This is the abstract of the paper from the NEJM that I was taling about in the last posting. It comes from the UK (including my old unit in Southampton), Italy, Houston, Boston, the Karolinska and Cologne.

Somatic SF3B1 Mutation in Myelodysplasia with Ring Sideroblasts

Myelodysplastic syndromes are a diverse and common group of chronic hematologic cancers. The identification of new genetic lesions could facilitate new diagnostic and therapeutic strategies. The suthors used massively parallel sequencing technology to identify somatically acquired point mutations across all protein-coding exons in the genome in 9 patients with low-grade myelodysplasia. Targeted resequencing of the gene encoding RNA splicing factor 3B, subunit 1 (SF3B1), was also performed in a cohort of 2087 patients with myeloid or other cancers. They identified 64 point mutations in the 9 patients. Recurrent somatically acquired mutations were identified in SF3B1. Follow-up revealed SF3B1 mutations in 72 of 354 patients (20%) with myelodysplastic syndromes, with particularly high frequency among patients whose disease was characterized by ring sideroblasts (53 of 82 [65%]). The gene was also mutated in 1 to 5% of patients with a variety of other tumor types. The observed mutations were less deleterious than was expected on the basis of chance, suggesting that the mutated protein retains structural integrity with altered function. SF3B1 mutations were associated with down-regulation of key gene networks, including core mitochondrial pathways. Clinically, patients with SF3B1 mutations had fewer cytopenias and longer event-free survival than patients without SF3B1 mutations. Mutations in SF3B1 implicate abnormalities of messenger RNA splicing in the pathogenesis of myelodysplastic syndromes.

The spliceosome: a new factor in bad risk CLL

I mentioned some weeks ago that the spliceosome is going to be important in CLL. The spliceosome is an epigenetic mechanism which is involved in splicing together the separated introns of a gene identified on DNA. It had already been identified as a factor in determining the various subtypes of MDS, but it has now been recognized as an important mechanism underlying fludarabine refractoriness in CLL and also in some cases of Richter syndrome.

I have quoted from this paper from Italy in a recent BLOOD

Mutations of the SF3B1 splicing factor in chronic lymphocytic leukemia:association with progression and fludarabine-refractoriness

The clinical course of chronic lymphocytic leukemia (CLL) ranges from a very indolent
disorder with a normal lifespan, to a rapidly progressive disease leading to death. Occasionally, CLL undergoes transformation to Richter syndrome (RS). The variable clinical course of CLL is driven, at least in part, by the disease immunogenetic and molecular heterogeneity.

Despite recent advances, the genetic lesions identified to date do not entirely explain the development of severe complications, such as chemorefractoriness, which still represent unmet clinical needs. Fludarabine-refractoriness is due to TP53 disruption in ~40% of refractory cases, but in a sizeable fraction of patients the
molecular basis of this aggressive phenotype remains unclear. Recently, two independent studies of the CLL coding genome investigated at disease presentation have revealed a restricted number of mutated genes, including NOTCH1. These
studies have provided a proof of concept that, similar to other malignancies, genome-wide mutational analysis might identify novel lesions of biological and clinical relevance in CLL.

On these grounds, the authors have embarked on the investigation of the coding genome of fludarabine refractory CLL in order to identify genetic lesions associated with chemorefractoriness. The initial phases of this analysis have revealed recurrent mutations of SF3B1, a critical component of the cell spliceosome, pointing to the potential involvement of splicing regulation in CLL pathogenesis and chemo-refractoriness.

The study population comprised 3 cohorts representative of different disease phases: i) fludarabine-refractory CLL (n=59), including cases (n=11) subjected to whole exome sequencing; ii) a consecutive series of newly diagnosed and previously untreated CLL (n=301); and iii) clonally related RS (n=33; all diffuse large B cell lymphomas).

Diagnosis of CLL and of fludarabine-refractoriness were based on IWCLL-NCI criteria; RS was based on histological criteria. Peripheral blood tumor samples were obtained as follows: i) for fludarabine-refractory CLL, immediately before starting treatment to which the patient failed to respond because of stable/progressive disease; ii) for newly diagnosed and previously untreated CLL, at disease presentation. All RS studies were performed on RS diagnostic biopsies. Normal DNAs from the same patients were obtained from saliva or from purified granulocytes and confirmed to be tumor-free by PCR of tumor-specific IGHV-D-J rearrangements. Patients provided informed consent in accordance with local IRB requirements and Declaration of Helsinki. The study was approved by the Local Ethical Committee (Protocol Code 59/CE; Study Number
CE 8/11).

Mutation analysis of SF3B1 (exons 1-25, including splice sites; RefSeq NM_012433.2) was performed on PCR amplimers obtained from genomic DNA by a combination of Sanger sequencing and targeted next generation sequencing. FISH karyotype, mutation analysis of IGHV, TP53 and NOTCH1, copy number analysis, and gene expression profile analysis FISH analysis was performed using probes LSI13 and LSID13S319, CEP12, LSIp53, and LSIATM. IGHV sequences were aligned to ImMunoGeneTics directory and considered mutated if identity to corresponding germline genes was less than 98%.3, TP53 and NOTCH1 mutations were analysed by Sanger sequencing.3,7 Genome-wide DNA profiles were obtained using Affymetrix Genome-Wide Human SNP Array 6.0. Gene expression profile analysis was performed using Affymetrix HG-U133_plus2 arrays.

Statistical analysis

Overall survival was measured from date of diagnosis to date of death (event) or last followup (censoring). Treatment free survival was measured from date of diagnosis to date of progression to symptomatic disease requiring treatment according to IWCLL-NCI guidelines (event), death, or last follow up (censoring).

Results and Discussion

Following the initial observation of recurrent SF3B1 mutations in 3/11 fludarabine refractory CLL analyzed by whole exome sequencing, we performed targeted re-sequencing of the SF3B1 coding sequence and splice sites in 48 additional cases of progressive and fludarabinerefractory CLL (total number of cases analyzed: 59). SF3B1 was altered in 10/59 (17%) fludarabine-refractory CLL by missense mutations (n=9) or in-frame deletions (n=1) clustering in the HEAT3, HEAT4 and HEAT5 repeats of the SF3B1 protein. Two sites that are highly conserved inter-species (codon 662 and codon 700) were recurrently mutated in 3 and 5 cases, respectively. SF3B1 mutations were monoallelic, and were predicted to be functionally significant according to the PolyPhen-2 algorithm. These data document that mutations of SF3B1, a splicing factor that is a critical component of the spliceosome, recurrently associate with fludarabine-refractory CLL.

The biological characteristics of fludarabine-refractory CLL harboring SF3B1 mutations are in summary that mutations occurred irrespective of the IGHV mutation status, CD38 expression and ZAP70 expression. At the time of fludarabine-refractoriness, SF3B1 mutations were enriched in cases harboring a normal FISH karyotype (p=.008). Also, SF3B1 mutations distributed in a mutually exclusive fashion compared to TP53 disruption tested by deletion and/or mutation (mutual information I =0.0609; p=.046). By combining SF3B1 mutations with other genetic lesions enriched in chemorefractory cases (TP53 disruption, NOTCH1 mutations, ATM deletion), fludarabine-refractory CLL appeared to be characterized by multiple molecular alterations that, to some extent, are mutually exclusive.

To investigate whether SF3B1 mutations are restricted to chemorefractory cases, we then compared the prevalence of mutations observed at the time of fludarabine-refractoriness to the prevalence of mutations observed in other disease phases. In a consecutive series evaluated at CLL diagnosis, SF3B1 mutations were rare (17/301; 5%)and occurred irrespective of other molecular and immunogenetic features. Remarkably, 5/17 (29%) CLL mutated at diagnosis were primary fludarabine-refractory patients. In these 5 cases, TP53 disruption and NOTCH1 mutations occurred in 1 cases each. None of the 12 remaining cases harbored TP53 disruption or NOTCH1 mutations.

By univariate analysis, SF3B1 mutations showed a crude association with short treatment free survival (p<.001) and overall survival (p=.011). By multivariate analysis, the increased risk of death predicted by SF3B1 mutations was independent (HR: 3.02; 95% CI: 1.24-7.35; p=.015) of confounding clinical and biological variables. Confirmation within the frame of prospective clinical trials will be helpful to fully assess the generalization of SF3B1 mutations as a CLL prognostic marker. In CLL investigated at diagnosis, the hotspot distribution and molecular spectrum of SF3B1 mutations, as well as their mutual relationship with other genetic lesions, were similar to those observed in fludarabine-refractory CLL. SF3B1 mutations were only found in 2/33 (6.0%) clonally-related RS. Across the different disease phases investigated, mutations were confirmed to be somatically acquired in all cases (n=18) for which germline DNA was available. Among the three SF3B1 mutated cases for which serial samples were analyzed, SF3B1 mutations were acquired in 2 cases. One fludarabine-refractory CLL acquired the c.2044A>G p.K666E mutation at the time of refractoriness, and one RS acquired the c.2146A>G p.K700E mutation at the time of transformation. In the remaining case, the SF3B1 mutation was present in all disease phases. Although the relative expression of SF3B1 in CLL was higher compared to normal B-cell subsets, extensive investigation by SNP array analysis ruled out focal copy number abnormalities of SF3B1 in this leukemia (n=0/323). SF3B1 mutations were consistently absent among mature B-cell neoplasms (n=136) other than CLL. These data document that SF3B1 mutations: i) are specific for CLL among mature B-cell neoplasms; ii) occur at a low rate at CLL presentation, whereas they are enriched in fludarabine-refractory cases; iii) play a minor role in RS transformation, corroborating the notion that CLL histologic shift is molecularly distinct from chemorefractory progression without RS transformation.

The identification of SF3B1 mutations in CLL, and the recent discovery of SF3B1 mutations in myelodysplasia, points to the involvement of splicing regulation as a novel pathogenetic mechanism in hematologic malignancies. SF3B1 is a critical component of both major (U2-like) and minor (U12-like) spliceosomes, which enact the precise excision of introns from premRNA. The precise biological role of SF3B1 mutations in CLL is currently elusive, and will require dedicated studies. The pathogenicity of SF3B1 mutations in CLL is strongly supported by the clustering of these mutations in evolutionarily conserved hotspots localized within HEAT domains, which are tandemly arranged curlicue-like structures serving as flexible scaffolding on which other components can assemble. Also, the observation that SF3B1 regulates the alternative splicing program of genes controlling cell cycle progression and apoptosis points to a potential contribution of SF3B1 mutations in modulating tumor cell proliferation and survival. In addition to pathogenetic implications, SF3B1 mutations might also provide a therapeutic target for SF3B1 inhibitors, which are currently under pre-clinical development as anti-cancer

John 8:17-18. Is there a God?

"In your own Law it is written that the testimony of two witnesses is true. I am one who testifies for myself; my other witness is the Father, who sent me.”

Note: another "I AM". Jesus is playing with them. He cites their own law back at them. The irony is that the Saducees among them do not believe in the supernatural so "God" is just a cipher for them; they do not actually believe in God as we know him. That is why it is futile to argue with the Church hierarchy; they also do not believe in a personal God.

Sunday, November 27, 2011

Gary Speed

Very sad today to read of the apparent suicide of Gary Speed, the team manager of the Wales soccer team. I remember his playing days at Leeds and Everton. With the selection of younger players he had managed to raise Wales in the FIFA rankings. He seemed to have everything to live for. I don't really want to know what underlies this.

Cord-blood disappointment

One of the supposed advantages of cord-blood transplantation is the suggestion that intensive matching is not required. Advocates of this view will be disappointed by this comment in Lancet Oncology

After years of research and debate, findings after umbilical-cord blood transplantation have mirrored those of other sources for haemopoietic stem-cell transplantation—ie, matching of the HLA loci between donor and recipient does matter. Thus cord-blood transplantation now faces the same hurdles as bone-marrow or peripheral-blood stem-cell transplantation. In The Lancet Oncology, in a clear and convincing analysis, Mary Eapen and colleagues1 show that additional matching of donor and recipient for HLA C improved the outcome of patients with a cord-blood transplant. This improvement was identified independently of other known risk factors for outcome after haemopoietic stem-cell transplantation, such as the patient's age or disease stage. Results were based on a homogeneous group of more than 800 patients with leukaemia or myelodysplastic syndrome and with sufficient information for the class I HLA antigens HLA A, B, and C and the class II antigen DRB1 in donors and recipients. Pairs with or without matching for HLA C could be compared with pairs with no, single, or multiple mismatches at HLA loci other than HLA C. Effects of matching for HLA C were greatest when no HLA antigen or only one other HLA antigen differed between the donor and recipient.

The importance of matching for HLA in general was underlined by two additional findings: results were better with full matching than with a single, double, or multiple mismatch at any of the class I or class II antigens; and, in the case of a single mismatch for one class I antigen, results were better when the class II antigens DRB1 were identical.

These findings accord with results from unrelated-donor transplants and are reassuring to immunologists (it was difficult to understand why cord blood should behave differently to other sources). These findings might be disappointing for some who thought minimal matching sufficient, but they have clear consequences. The degree of matching between donor and recipient, including HLA C, needs to be integrated into the algorithm used to select for or against transplantation. The risk of disease should be balanced against the transplant risk, so that overall a better outcome with regard to survival, quality of life, and cost, compared with a non-transplant strategy, is achieved. If cord-blood transplants are to be used in early disease, such as for patients with high-risk acute myeloid leukaemia in first complete remission, the search strategy should aim for the best match and should now include HLA C. The value of high-degree matching in unrelated-donor transplants was recently shown to be specifically important for patients with early disease and low-risk characteristics. Hence, an optimally matched transplant product might tip the balance in favour of immediate transplantation in first remission, whereas a suboptimal product would favour a watch and wait or non-transplant strategy. To allow sufficient time for the selection process, any donor search for an unrelated-living or cord-blood donor needs to be started at diagnosis.

The findings of Eapen and colleagues further support the role of standardised reporting of transplant data, as recently stipulated by the WHO's guiding principles on organ and cell transplantation. Only by such cooperation can results be yielded. Furthermore, other antigens such as HLA DQ, HLA DP, or minor histocompatibility antigens are likely to be important in cord-blood transplants because they are present in unrelated-volunteer donor transplants. Typing for HLA C should now become mandatory, accompanied with storage of samples for later analysis. Cord-blood banks will have to provide this service. The additional costs will be recouped through improved transplant outcomes. Quality management systems such as the Foundation for the Accreditation of Cellular Therapy, the Joint Accreditation Committee: European Group for Blood and Marrow Transplantation and the International Society for Cellular Therapy, or Netcord should implement full typing for class I and II antigens into their standards. These steps will help to further improve the procedure and define those selected patients who will clearly benefit from a cord-blood transplant.

Non-hemic autoimmunity in CLL

One of the things I have been complaining about is the idea that there is a high degree of autoimmunity in CLL patients. It is absolutely true that autoimmune hemolytic anemia and ITP are more common in CLL and there may perhaps be a higher incidence of a few non-hemic autoimmunities like paraneoplastic pemphigus and nephrotic syndrome among CLL patients, but most autoimmune diseases are not commoner.

This is an interesting case report in which a patient with CLL developed severe celiac disease. The story of the celiac disease is particularly well told.

A 70-year-old gentleman chronic lymphocytic leukemia presented with a four-day history of weakness and profuse, watery diarrhea. He reported 7-8 bowel movements per day, all of which were large volume, watery and greenish-brown in color. The diarrhea was usually associated with crampy abdominal pain and bloating, which was partially relieved with defecation. He also noted occasional red-tinged toilet paper, although he denied any visible blood in the stool or melenotic stools. He complained of occasional "chills" although he denied any fevers or any nausea and vomiting. He reported a 20-30 lb. weight loss over the past month and complained of overwhelming fatigue, weakness and decreased work tolerance during the week prior to admission.

He was admitted for similar symptoms approximately four weeks prior to this admission. At that time a flexible sigmoidoscopy was essentially negative, and an EGD showed gastric and duodenal inflammation, but the ensuing gastric biopsy was negative. During that admission, the patient received treatment of his CLL with cytoxan and was placed on a lactose free diet. The diarrhea decreased to 1-2 bowel movements per day following these interventions and the patient was discharged home on a lactose free diet.

He was readmitted approximately one week prior to this admission, when he developed a new right foot drop. A diagnosis of idiopathic peripheral neuropathy was made with an MRI showing long-standing spinal stenosis. His diarrhea was present but not severe during this hospitalization. His lower extremity weakness improved during the course of stay, and he was discharged home, still on a lactose free diet, in good condition. However, immediately after discharge the patient's diarrhea returned in a severe form, culminating in the most recent admission.

His past medical history was significant for the aforementioned CLL, diagnosed in 1993. His disease had been well controlled until 1997 when new lymphadenopathy and increasing lymphocyte counts prompted treatment with two courses of fludaribine, after which the patient developed esophageal dysmotility. More recently, the disease was again found to be progressing and treatment with cytoxan and prednisone was instituted. The patient also has a history of hypertension, osteoarthritis, hypercholesterolemia, spinal stenosis and he is known to have had a goiter The patient has had a laminectomy in 1990, a supraclavicular lymph node biopsy in 9/00 (consistent with CLL), port-a-cath placement in fall of 2000 and past bilateral cataract surgeries.

His mother had a history of "thyroid disease" and died at age 90. His father died at age 84 with gastric cancer. He had a sister who died at birth and a has brother with coronary artery disease and coronary artery bypass grafting. His son is alive and healthy.

He is a retired printer with no smoking or alcohol history. He is married. His medications on admission were Cardura and Epogen 20,000 units SQ qd.

On examination, the patient was a pleasant 70-year-old male, NAD, alert and oriented to time, person and place. He was somewhat pale and fatigued appearing. His vitals were within normal limits. HEENT exam was unremarkable, and his oral mucosa was moist. He had shoddy cervical adenopathy bilaterally. His lungs were clear to auscultation bilaterally with no significant chest findings. His cardiac exam was notable for a 1/6 SEM heard best at the base. He had a mildly distended abdomen with a palpable spleen 3-4 fingerbreadths below the left costal margin. The liver edge was palpable at the right costal margin. His extremities were intact without cyanosis, clubbing or edema. There were 2 palpable, non-tender freely movable axillary nodes noted, both 1.5 cm, one in each axilla. The neurological exam was significant only for slightly decreased strength (4/5) with plantar flexion of the right ankle.

Lab tests at the time of admission showed a WBC of 36.9 with 92% lymphocytes, 5% monocytes and 0% segmented neutrophils. The hemoglobin was 9.8 and platelets were 145. His sodium was 138, potassium was 3.7, chloride was 114, bicarbonate was 14 and creatinine was 1.3. The BUN and glucose were normal. CXR on admission showed areas of atelectasis. The patient was admitted with a diagnosis of diarrhea, dehydration and known CLL.

At the time of admission, GI felt the most likely causes for this patient's diarrhea were: 1. Infiltration of CLL into the small bowel wall; 2. opportunistic infections (either micro or cryptosporidium) or; 3. bacterial overgrowth syndrome. Stool gram stains returned showing normal flora and the C. Difficile toxin assay was negative. He was placed on a clear liquid diet, but still had significant diarrhea. Fluid losses were replaced with IV hydration.

A colonoscopy was initially interpreted as normal, but the pathology report the following day was showed lymphocytic colitis, not related to colonic infiltration by CLL. The patient was placed on prednisone for the colitis.

An abdominal CT showed decreased adenopathy as compared to previous films and no obvious infiltration of disease into the bowel. The colon was noted to be moderately distended. The patient underwent an EGD four days post admission where biopsies of stomach and duodenum were obtained. There was no gross pathology noted.

Based on the CT results, it was clear that the patient responded to his last treatment with cytoxan and prednisone. A second dose was given on day 5 post admission and the patient was also started on allopurinol to prevent tumor lysis symptoms. EGD biopsy results were still pending at this time. As the patient was having 7-8 BM's per day of increasing volume and increasing abdominal distention, he was started on metronidazole as the diarrhea had not responded to steroids

On hospital day 6 a regular diet was again resumed and Imodium was started. The patient also began to c/o some vomiting episodes, which were attributed to the metronidazole. Sandostatin 100 mcg was begun in an attempt to reduce the fecal output. The patient was also switched from Imodium to Lomotil at this time, as the diarrhea continued to be severe. A 24-hour stool collection was yielded approximately 10 liters of stool were made during this collection.

On hospital day nine the duodenal biopsy results returned consistent with celiac sprue. The patient was immediately placed on a gluten free diet and antiendomysial and antigliadin antibodies tests were drawn.

Unfortunately, the diarrhea only increased in volume and by day 10, the patient began to have rigors and fever spikes. His blood and urine were cultured but no antibiotics were begun at this time. An abdominal US revealed no significant pathology. TPN was begun as an apparent 50lb weight loss was recognized over the past 6 weeks.

During the admission the patient had been consistently acidotic, with low HCO3 readings but increased Cl causing a non-anion gap acidosis, almost undoubtedly from the chronic diarrhea. This was becoming more severe and correction with bicarbonate in the IV fluids and acetate in the TPN was required. The sandostatin dosage was increased to 100 mcg tid. On day 11, the blood cultures were positive for gram positive cocci and the patient was placed Ceftriaxone and vancomycin. TPN was halted because of concerns over TPN use in a bacteremic patient, but was renewed after a discussion with ID. Antiendomysial and antigliadin antibody test results returned and both IgA and IgG antigliadin were positive. Interestingly, antiendomysial IgA was found to be negative.

In the early evening of day 11, the patient was somewhat more dyspneic and an EKG was ordered. This showed new onset atrial fibrillation with occasional PAC's. As the patient looked acutely ill, was extremely weak and still having massive diarrhea, it was decided to transfer the patient to the MICU for aggressive fluid resuscitation and more continuous monitoring.

The patient continued on TPN in the MICU and was also started on Neupogen for a low WBC count presumably secondary to the cytoxan treatment. He was given nothing by mouth and by Day 13 stool output had begun to decrease. The bacteremia was found to be S. pneumoniae that was sensitive to vancomycin but intermediately resistant to ceftriaxone. The patient's diarrhea continued to improve over the next two days. His TPN was discontinued on day 15 and he was placed back on a gluten free diet. The vancomycin was discontinued and the patient remained on ceftriaxone. He had been afebrile since day 2 of antibiotics. At this time he was place on fluconazole for esophageal candidiasis with odynophagia. He continued to improve and was transferred back to the floor on day 17 and discharged home on day 21 with no diarrhea, a good appetite and increased energy and strength subjectively. He was to continue with a gluten free diet at home.


Celiac disease, often called celiac sprue, is an acquired sensitivity to the protein gluten. Exposure to the gliadin moiety of gluten is responsible for the characteristic histopathologic changes and the resulting clinical picture. The classic pathologic changes consist of flattening of the intestinal mucosa, hyperplasia of intestinal crypts and complete absence of normal villi. Remaining absorptive cells are cuboidal rather than columnar and the brush border is greatly reduced. Furthermore, tight junction abnormalities are present, causing an enhanced permeability of the mucosal barrier.

Interestingly, the length of the celiac lesion (ie: the amount of small bowel effected) varies greatly from patient to patient, and has a direct correlation with the severity of clinical disease. Consequently, there is a large spectrum of disease presentations ranging from asymptomatic to life-threatening "celiac crisis." The intestinal lesion may also range from involvement of only the proximal duodenum to complete small bowel involvement. If the lesion does not involve the entire small bowel, the proximal intestine is the most severely effected and the lesion decreases in severity distally.

Appropriate treatment (gluten-free diet) results in a return of normal intestinal architecture. The cytologic appearance of the surface absorptive cells improves first, often within a few days. Cells again become columnar and well developed brush borders began to appear. Later, villi began to lengthen and the crypts revert back to their usual size. The length of time required for complete restoration of gut mucosa is variable, with some patients still having biopsy proven changes years after gluten withdrawal.

Gluten is found in certain cereal grains including wheat, barley, and rye. It is not found in rice or corn, and oat flour is usually safe for celiac patients, although this is somewhat controversial. The gliadin moiety, a complex mixture of glutamine and proline rich polypeptides, seems to be the factor causing the mucosal damage. How gliadin causes the typical celiac mucosal alterations is not precisely known, but it is clear that both genetic and environmental factors are involved. Celiac disease is found in 10% of first order relatives of known celiac patients. Furthermore, a 70% concordance rate is noted in HLA identical twins. Genetic markers for celiac sprue have recently been elucidated. Approximately 95% of affected individuals inherit the DQA1*0501 and DQB1*0201 alleles, mapping on the HLA region of chromosome 6. These code for the HLA-DQ molecule DQ2. No known structural abnormalities in these DQ alleles have been found in celiac patients, and the majority of individuals who have these HLA haplotypes remain healthy. It is likely that these individuals are genetically susceptible to celiac development, but an immunologic or environmental trigger may be necessary for development of disease.

Immune mechanisms clearly play a role in sprue pathogenesis. Antigliadin antibodies are usually found in celiac sprue patients, in both serum and intestinal luminal secretions. These antibodies may participate in cell-mediated cytotoxic destruction of absorptive cells, or cause immune complex formation, which bind complement and cause local destruction. T- cell activation may also play a role, as many cells in the lamina propria of untreated patients are activated. This activation may cause the release of TNF and interferon, resulting in inflammation and epithelial cell damage. Interestingly, mucosal damage in graft-versus-host disease resembles that in celiac sprue, further suggesting that T-cell activation may play a role.

The environmental trigger causing immunologic activation has yet to be determined, but human type 12 adenovirus has an amino acid segment with high sequence homology to alpha-gliadin. Molecular mimicry of the viral segment by gliadin peptides may be the underlying trigger. The gliadin sequences are presented by the specific HLA heterodimers to gliadin specific T-cells. T-cell activation causes cytokine release and B-cell activation. B-cells produce antibodies that may cause antibody dependent cell-mediated cytotoxicity or complement mediated cytotoxicity. The end result is mucosal damage.

Celiac disease is found in about 1 in 1000 people in Europe, South America and North Africa. It effects the sexes equally and the initial presentation may be in any age group, although it is more common in children. The United States was thought to have a much lower incidence, but recent studies show antiendomysial antibodies present in about 8 of 2000 people. If this can be considered a diagnostic test, then the prevalence of celiac in the US is similar to other populations.

The clinical presentation of celiac disease can vary tremendously from patient to patient. The patient in this case presented with the most severe form of this disease, the so-called "celiac crisis," where pan-malabsorption lead to a life threatening nutritional deficit and non-anion gap acidosis. Initial presentation of celiac crisis in adulthood is rare, with most patients being children under two years.

The most common presenting signs and symptoms include diarrhea, weight loss, fatigue, bloating and flatulence. This patient had all of these including diarrhea of approximately 10 liters per 24 hours. Diarrhea is caused by increased stool volume and osmotic load delivered to the colon (secondary to malabsorption). Water and electrolytes are secreted into the small intestine rather than absorbed and if the ileum is involved, absorption of bile salts is impaired. Weight loss in sprue is variable as some patients may compensate by increasing their appetite tremendously, however some, like our patient, actually develop anorexia, predisposing them to marked weight loss.

Celiac disease can manifest in extraintestinal disease as well. Anemia is a very common adult presentation of sprue. It is usually caused by impaired iron of folate absorption in the duodenum, but may be related to vitamin B12 deficiency if the terminal ileum is involved. Mucosal and GI bleeding may also contribute to anemia. This bleeding is the result of impaired coagulability secondary to poor vitamin K absorption. Hyposplenism and thrombocytosis occurs in 50% of adults; the etiology of this is unknown. Osteopenic bone disease is common, resulting from poor calcium and vitamin D absorption. Secondary hyperparathyroidism may result, further increasing the destruction of bone matrix. Interestingly, patients with severe disease may sometimes have neurologic symptomatology. Lesions of either the central or peripheral nervous system have been found, resulting in muscle weakness, paresthesias and ataxia. Our patient was known to have a recent episode of idiopathic peripheral neuropathy causing right foot drop. It is possible this finding was directly related to his as of yet undiagnosed celiac disease.

Diagnosis of celiac disease has clinical, pathologic and serologic components. Clinically, in any patient presenting with intractable diarrhea and weight loss a diagnosis of celiac disease must be considered. The patient should also experience full clinical remission after the removal of gluten from the diet. The typical pathologic findings of flattened villi, hypertrophic crypts and absence of the brush border, should also be biopsy proven. Serologic testing has also become helpful in making the diagnosis. IgA and IgG antiendomysial and antigliadin antibodies are usually present in patients with true celiac sprue. Antiendomysial IgA is the most sensitive and specific test but may be falsely negative (along with antigliadin IgA) when the patient has IgA deficiency, a common associated disorder of celiac disease. This patient was both IgG and IgA antigliadin +, but IgA antiendomysial negative. IgG antiendomysial testing was not ordered. The finding of a negative IgA antiendomysial antibody should not cast doubt on this patient’s diagnosis, as tissue biopsy is still the gold standard.

At first glance, the treatment of celiac disease seems simple, complete removal of gluten from the diet. In reality however, a diet free of gluten is exceedingly difficult to achieve and maintain, especially here in the US where gluten is ubiquitous. Wheat, barley and rye must be completely avoided and oats should be avoided initially as their consumption may or may not exacerbate sprue. Wheat is often hidden in processed foods. It is sometimes found in ice cream, salad dressing, canned vegetables and soups, coffee, ketchup, mustard and candy bars. Therefore a skilled nutritionist is often required to help patients achieve and maintain a completely gluten free diet. Patients generally tolerate rice, soybean, corn, millet, buckwheat, sorghum and tapioca. Furthermore, patients often require replacement therapy in addition to gluten removal. Anemic patients may need iron, folate or vitamin B12 replacement. Electrolyte imbalances must be aggressively treated. In this patient, replacement of bicarbonate was necessary as he developed a significant non-anion gap metabolic acidosis. Serum calcium levels must be strictly monitored and almost all celiac patients should receive both calcium and vitamin D supplementation in an effort to stave off osteopenic changes.

Complications of celiac disease generally fall into three categories, malignancy, stricture and ulceration, and refractory sprue. Malignancy accompanying celiac disease was found in 11-13% of patients. The most common of these was T-cell lymphomas, followed by squamous cell carcinomas of the esophagus and small intestinal adenocarcinomas, the latter showing a full 80 fold increase over the expected population incidence. This patient had a previous diagnosis of CLL, but I was unable to find any studies linking this (or any other leukemia) with celiac sprue. Ulceration and stricture is a rare complication of sprue, but well documented. These patients often present with abdominal pain, intestinal bleeding and obstruction. Peritonitis can develop if not treated early and aggressively with surgical intervention. Finally, some patients may develop celiac disease, which is unresponsive to gluten withdrawal. These patients usually respond to removal of gluten initially, but will later experience relapses even with strict gluten avoidance. Some of these patients will respond to corticosteroid or immunosuppressive medications, but usually not permanently. Refractory sprue can often lead to death even with aggressive fluid and electrolyte management.

Prognosis of celiac patients is generally quite favorable as long as the condition is recognized and appropriate therapy is instituted. Of course, untreated sprue can often lead to life-threatening malnutrition and electrolyte abnormalities. Moreover, patients who develop one of the complications mentioned above will certainly have a much poorer prognosis. In general, patients with gluten responsive sprue and no complications have an only slightly elevated mortality rate as compared with controls, and most die of causes unrelated to their celiac disease.

Before assays for antiendomysial and antigliadin antibodies became available, we had to rely on Type II anti-reticulin antibodies as an indication that celiac disease might be present. In 1986 I published a paper demonstrating that such antibodies were no commoner in CLL patients than in age-matched individuals. Like the authors of this case report I am convinced that the celiac disease and CLL in this patients are unrelated. This goes to point out that treating the CLL in the hope that the autoimmunity might remit is dangerous and futile.

Another trap to avoid falling into is to think that if small lymphocytes are found in strange places, such as the bowel wall, that they must be pathological. In CLL, small lymphocytes are found everywhere.

Scotland wants to go it alone ... again.

Alex Salmond, the First Minister of Scotland, has promised a referendum to the people of Scotland to repeal the Act of Union whereby Scotland joined England and Wales to become the United Kingdom in 1707. Since the current financial crisis in the UK was precipitated by the government having to take the Royal Bank of Scotland and the Bank of Scotland into partial private ownership, a lot of English people would be pleased to say "Good riddance". What a lot of people don't know is why the Scots signed up to the Act of Union in the first place.

The Darién scheme was an unsuccessful attempt by the Kingdom of Scotland to become a world trading nation by establishing a colony called "New Caledonia" on the Isthmus of Panama in the late 1690s. In practice the undertaking was marked by poor planning and leadership, lack of demand for trade goods, devastating epidemics of disease, and increasing shortage of food; it was finally abandoned after a siege by Spanish forces in April of 1700. As the Darien company was backed by about a quarter of the money circulating in Scotland, its failure left the nobles and landowners – who had suffered a run of bad harvests – almost completely ruined and was an important factor in weakening their resistance to the Act of Union (finally consummated in 1707).

The late 17th century was a difficult period for Scotland. The country's economy was relatively small, its range of exports very limited and it was in a weak position in relation to England, its powerful neighbour (with which it was in personal union, through James I (VI in Scotland) but not yet in political union). In an era of economic rivalry in Europe, Scotland was incapable of protecting itself from the effects of English competition and legislation. The kingdom had no reciprocal export trade and its once thriving industries such as shipbuilding were in deep decline. Goods which were in demand had to be bought from England for Sterling, the Navigation Acts further increased economic dependence on England by limiting Scots shipping and the navy was tiny. Several ruinous civil wars in the late 17th century had squandered the country's human and other resources, the 1690s also saw several years of widescale crop failure, which brought famine. This period was referred to as the "ill years." The deteriorating economic position of Scotland led to calls for a favorable political union, or at least a customs union, with England. However the stronger feeling among Scots - which played to their pride - was that the country should become a mercantile and colonial great power like England.

In response, a number of remedies were enacted by the Parliament of Scotland: in 1695 the Bank of Scotland was established; the Act for the Settling of Schools established a parish-based system of public education throughout Scotland; and the Company of Scotland was chartered with capital to be raised by public subscription to trade with "Africa and the Indies". The Company of Scotland easily raised subscriptions in Amsterdam, Hamburg and London for the scheme. The English Government of King William III, however, was opposed to the idea. It was at war with France and hence did not want to offend Spain which claimed the territory as part of New Granada. It was also under pressure from the English East India Company, who were keen to maintain their monopoly over English foreign trade. It therefore forced the English and Dutch investors to withdraw. Next, the East India Company threatened legal action on the grounds that the Scots had no authority from the king to raise funds outside the English realm, and obliged the promoters to refund subscriptions to the Hamburg investors. This left no source of finance but Scotland itself.

Returning to Edinburgh, the Company raised 400,000 pounds sterling in a few weeks (equivalent to roughly £40 million in 2007, with investments from every level of society, and totalling roughly a fifth of the wealth of Scotland. The Company of Scotland for Trading to Africa was able to raise what was, for Scotland, a massive amount of capital. Scots born trader and financier William Paterson had long been promoting a plan for a colony on the Isthmus of Panama to be used as a gateway between the Atlantic and Pacific — the same principle which, much later, would lead to the construction of the Panama Canal. Patterson, who had a huge capacity for hard work was instrumental in getting the Company off the ground in London. He had failed to interest several European countries in his scheme but in the aftermath of the English reaction to the Company he was able to get a respectful hearing for his ideas. The Scots' original aim of emulating the East India Company by breaking into the lucrative trading areas of the Indies and Africa was forgotten and the highly ambitious Darien scheme was adopted by the company. Paterson fell from grace when a subordinate embezzled from the Company. The Company took back Patterson's stock and expelled him from the Court of Directors; he was to have little real influence on events after this point.

There were a large number of former officers and soldiers who joined happily as they had little hope of any other employment, many were acquainted from serving in the army and several – the best known being Thomas Drummond – were notorious for involvement in the Massacre of Glencoe, in some eyes they appeared to be a clique and this was to cause much suspicion among other members of the expedition.

The first expedition of five ships (Saint Andrew, Caledonia, Unicorn, Dolphin, and Endeavour) set sail from the east coast port of Leith to avoid observation by English warships in July 1698, with around 1,200 people on board. The journey round Scotland while kept below deck was so traumatic that some colonists thought it comparable to the worst parts of the whole Darien experience. Their orders were to proceed to the Bay of Darien, and make the Isle called the Golden Island … some few leagues to the leeward of the mouth of the great River of Darien … and there make a settlement on the mainland. After calling at Madeira and the West Indies, the fleet made landfall off the coast of Darien on 2 November. The settlers christened their new home "New Caledonia".

With Drummond in charge they cut a ditch through the neck of land that divided one side of the harbour in Caledonia Bay from the ocean, and constructed Fort St Andrew, equipped with 50 cannon, on the peninsula behind the canal; the fort did not have a source of fresh water. On a mountain, at the opposite side of the harbour, they built a watchhouse. Close to the fort they began to erect the huts of the main settlement, New Edinburgh, and to clear land for growing yams and maize. Letters sent home by the expedition created the misleading impression that everything was going according to plan. This seems to have been by agreement as certain optimistic phrases kept recurring, but it meant the Scottish public would be completely unprepared for the coming disaster.

Agriculture proved difficult and the local Indian tribes, although hostile to Spain, were unwilling to buy the combs and other trinkets offered by the colonists. Most serious was the almost total failure to sell any goods to the few passing traders that put in to the bay. With the onset of summer the following year the stifling atmosphere, along with other causes, led to a large number of deaths in the colony. Eventually the mortality rate rose to ten settlers a day. Although local Indians brought gifts of fruit and plantains these were appropriated by the leaders and sailors who largely remained onboard ship. The only luck the settlers had was in giant turtle hunting but fewer and fewer men were fit enough for such strenuous work. The situation was exacerbated by the lack of food mainly due to a high rate of spoilage caused by improper stowing, at the same time King William had instructed the Dutch and English colonies in America not to supply the Scots' settlement so as not to incur the wrath of the Spanish Empire. The only reward the council had to give was alcohol, and drunkenness became common, even though it speeded the deaths of many men weakened by dysentery, fever and the rotting, worm infested food. After eight months the colony was abandoned in July 1699 apart from six men who were too weak to move. Deaths continued on the ships, and those who managed to survive the journey and returned home found themselves regarded as a disgrace to their country and even disowned by their families.

Only 300 of the 1,200 settlers survived and only one ship managed to return to Scotland. A desperate ship from the colony that called at the Jamaican city of Port Royal was refused assistance on the orders of the English government, which feared antagonising the Spanish.

Word of the first expedition did not reach Scotland in time to prevent a second voyage of more than 1,000 people. The second expedition arrived on November 30, 1699 and found two sloops there; one with Thomas Drummond from the original expedition. Some men were sent ashore to rebuild huts, which caused others to complain that they had come to join a settlement, not build one. Morale was low and little progress was made. Drummond insisted that there could be no discussion, the fort must be rebuilt as the Spanish attack would surely come soon, but he clashed with the merchant James Byres who maintained the Counsellors of the first expedition had now lost that status, and consequently had Drummond arrested. Initially bellicose, Byres began to send away all those he suspected of being offensively minded – or of being allegiant to Drummond. He outraged a Kirk Minister by claiming it would be unlawful to resist the Spanish by force of arms, as all war was unchristian. He then showed his real concern was for his own personal safety by deserting the colony in a sloop. The colonists sank into apathy until the arrival of Alexander Campbell of Fonab, sent by the company to organize a defence. He provided the resolute leadership which had been lacking and took the initiative from the Spanish by driving them from their stockade at Toubacanti in January 1700. However, Fonab was wounded in this daring frontal attack and became incapacitated with a fever. The Spanish force – who were also suffering serious losses from fever – closed in on Fort St Andrew and besieged it for a month, although disease was still the main cause of death during this time. The Spanish commander called for the Scots to surrender and avoid a final assault, warning that if they did not no quarter would be given. After negotiations the Scots were allowed to leave with their guns, and the colony was abandoned for the last time. Only a handful of those from the second expedition returned to Scotland. Of the total 2,500 settlers that set off, just a few hundred survived.

The failure of the scheme provoked tremendous discontent throughout Lowland Scotland where almost every family had been affected. Many held the English responsible while believing that they could and should assist in yet another effort at making the scheme work. The company petitioned the King to affirm their right to the colony however he declined replying that, though he was sorry that the company had incurred such huge loses, to claim Darien would mean war with Spain. The continuing futile debate on the issue served to further increase bitter feeling.

Hoping to recoup some capital by a more conventional venture, the company sent two ships from the Clyde, the Speedy Return and the Continent, to the Guinea coast laden with trade goods. Sea captain Robert Drummond was the master of the Speedy Return, his brother Thomas, who had played such a part in the second expedition, was supercargo on the vessel. Neither ship was seen in Scotland again. Instead of seeking to sell for gold as the company's directors intended the Drummonds exchanged the goods for slaves which they sold in Madagascar. Carousing with the buccaneers for whom the island was a refuge, the Drummonds fell in with the pirate John Bowen of Bermuda who offered loot if they lent the Scots ships to him for a raid on homeward bound Indiamen. Robert Drummond was initially persuaded but backed out of the agreement, only for Bowen to appropriate the ships while he was ashore. The Continent was lost to fire on the Malabar coast and Bowen scuttled the Speedy Return after transferring to a merchant ship he had taken. The Drummonds decided against returning to Scotland to explain the loss of the ships they had been entrusted with and no more was ever heard of the tough-minded brothers.

The company sent out another ship but it was lost at sea. Not being able to afford the cost of fitting out yet another ship the Annandale was hired in London with the intention of trading in the Spice Islands, but the East India Company had it seized on the grounds that the venture was a contravention of their charter. This provoked uproar in Scotland, greatly aided by the inflammatory rhetoric of the company's secretary, and relentless enemy of the English, Roderick MacKenzie. Fury at the country's impotence led to what followed: the scapegoating and hanging of three innocent English sailors.

The failure of the Darien scheme has been cited as one of the motivations for the 1707 Acts of Union. According to this argument, the Scottish establishment realised that it could never be a major power on its own and that if it wanted to share the benefits of England's international trade and the growth of the English Empire, then its future would have to lie in unity with England. More so, Scotland's nobles were almost bankrupted by the "Darien Fiasco". Some Scots nobility petitioned Westminster to wipe out the Scottish national debt and stabilise the currency. The first request was not met though the second was and a Scottish Pound was given the fixed value of a shilling. Personal Scottish financial interests were also involved. Scottish Commissioners had invested heavily in the Darien Scheme and they believed that they would receive compensation for their losses. The 1707 Acts of Union, Article 14, granted £398,085 10s sterling to Scotland to offset future liability towards the English national debt.