Focal lymphoblastic transformation of chronic myelogenous leukemia develops into erythroid leukemia:A case report

BACKGROUND We present a case of focal lymphoblastic transformation to erythroid leukemia following acute myeloblastic transformation in a patient with chronic myelogenous leukemia(CML)and discuss its mechanism of occurrence and development.CASE SUMMARY The presence of the Philadelphia(Ph)chromosome was identified through karyotype analysis,while the BCR-ABL fusion gene was detected using quantitative real-time polymerase chain reaction of the peripheral blood sample.Fluorescence in situ hybridization was used to detect the expression of the BCRABL gene in the lymphoma.Antigen expression and gene mutations in the primitive cells were detected by flow cytometry.The analysis confirmed the presence of CML along with focal lymphoblastic transformation to erythroid leukemia.Additionally,the patient was found to have secondary erythroid leukemia,along with multiple new gene mutations and abnormalities in complex karyotypes of chromosomes.CONCLUSION Our findings suggest a possible molecular basis for the focal lymphoblastic transformation secondary to myeloblastic transformation in patients with CML.

Redistribution of Platelet Membrane Glycoprotein IV and Release of Intracellular α-granule Thrombospondin in Patients with Chronic Myelogenous Leukemia

The redistribution of platelet membrane glycoprotein IV (GPIV) and the release of intracellular Q-granule thrombospondin (TSP) were examined and the inhibition of 5-thromboglobulin (&TG) and platelet factor 4 (PF4) in patients with chronic myelogenous leukemia (CML) was observed and quantitation of β-TG and PF4 in sera was conducted. GPIV in inactive platelet from CML was 36080±17010 molecules/platelet as compared with 13190±4810 from the controls (P<0,01), No abnormality was found in the distribution of platelet membrane GPIb and GPIIb/III.(P>0. 05). The GPIV redistribution on active platelet membrane induced thrombin (1U/ml) from CML and healthy donors was 44320132310 and 228001 12700 molecules/platelet respectively (P<0. 01 ). The difference in the release of intracellular Q-granule TSP between CML and the control group was not found (P>0.05). There was no direct correlation between GPIV expression and TSP binding after platelet activation. The high leveIs of β-TG and PF4 in sera inhibited release of intracellular a-granule TSP in vitro. These results indicate that the abnormality of platelet membrane GPIV is a common marker in CML, therefore the specific increase of platelet GPIV in patients with CML may be a useful tool for the diagnosis and monitoring of the platelet dysfunction. The release of interna1 TSP pools is hindered by either β-TG or PF4 in sera.

HIM_(1) AND HIM4, TWO MONOCLONAL ANTIBODIES POTENTIALLY USEFUL FOR AUTOLOGOUS BONE MARROW TRANSPLANTATION IN CHRONIC MYELOGENOUS LEUKEMIA

We developed two complement-fixing MoAbsHIMand HIM(murine)that were specifically reac-tive with chronic myelogenous leukemia (CML) cells.They were capable of fixing human or rabbit com-plement and suitable for CML cells purging of re-mission marrow from CML patients.HIMreactedwith majority leukemic cells form 7 out of 10 CMLpatients by complement-mediated cytotoxicity(C’MC)assay(positive cells 80%—90%),HIMreacted withmajority CML cells from 4 out of 5 CML by C’MCassay(positive cells 80%—90%).Treatment withHIMor HIMand human C’was capable of lysing97% of K562,U937,HL-60 and CML cells in a 20fold excess of unrelated cells by indirect FITC+EBstain.Using limited dilution culture,incubation withHIMand C’produced 1.5 logs inhibition of growthin K562 cells,and 1.9 logs in U937 cells,and withHIMand C’produced 2.9 logs inhibition in HL-60cells and 3.0 logs in U937 cells.Both MoAbs cocktailwas shown 1.8 logs in K562 cells and 3.2 logs in U937cells.They were no suppression on the growth o

Investigation on Marking Method for Phenomenon on Regrowth Drug Resistance in Relapsed Acute Myelogenous Leukemia

A method for evaluating the regrowth drug resistance in relapsed acute myelogenous leukemia (AML) was developed. Drug sensitivity and proliferation of leukemic cells in vitro were determined using leukemic cell colony forming unit (CUF L), MTT drug sensitive test, percentage of S phase cells in cell cycle (S %), fluorescent index (FI) and drug resistant index (DRI) by detecting intracellular daunorubicin, expression of P 170 glycoprotein by APAAP assay, and abundance of Bcl XL mRNA by semiquantitative reverse transcription polymerase chain reaction (RT PCR) methods. First, the correlation between scoring criteria and cell drug resistance and cell proliferation was investigated in newly untreated AML patients. Second, 20 patients with relapsed AML were marked. According to each tested result, its point (s) was scored. The results showed that among the 20 cases of replased AML, 9 were diagnosed as having regrowth drug resistance. It was concluded that the scoring method for regrowth drug resistance was first developed in AML. There was regrowth drug resistance in relapsed AML; clinically circumventing it would be of extreme significance for establishment of new approaches to the treatment in AML.

Research on Marketing Strategies of Product D—a Chronic Myelogenous Leukemia Drug for Pharmaceutical Company A

Objective To put forward some suggestions on the marketing strategies for chronic myelogenous leukemia in a pharmaceutical enterprise.Methods Based on the development status of the pharmaceutical industry and the SWOT analysis of a company’s product,the marketing strategies were formulated to provide theoretical basis for pharmaceutical enterprise to adapt to the new medical reform.Results and Conclusion Nowadays,due to fierce competition,in order to expand the new market,enterprises should implement the strategies of new products,centralized management and professional training.Meanwhile,the effective marketing strategies should be formulated and strictly carried out according to the conditions of the pharmaceutical company.

Cytotoxic effect of Spirulina platensis extracts on human acute leukemia Kasumi-1 and chronic myelogenous leukemia K-562 cell lines

Objective: To evaluate the cytotoxic effects of Spirulina platensis extracts on acute leukemia Kasumi-1 and chronic leukemia K-562 cancer cell lines.Methods: Various concentrations of Spirulina platensis extracts(0.25–50.00 mg/m L)obtained with different solvents were used to treat cell lines for 72 h. For cytotoxic effect studies, cell viability test with trypan blue solution, MTT assay and microscopic cytomorphological assessment were done.Results: Spirulina extract obtained with 70% ethanol showed significant cytotoxicity in K562 and Kasumi-1 cell lines. With trypan blue solution, IC_(50) values were found to be4.64 mg/m L for K-562 and 3.68 mg/m L for Kusumi-1 cell lines. Spirulina aqueous extract also showed cytotoxicity with trypan blue method, at a slightly higher dose; where IC_(50) values were 12.68 mg/m L for K-562 and 2.13 mg/m L for Kusumi-1 cell lines. The IC_(50) values were found 0.40 mg/m L for K-562 and 0.31 mg/m L for Kusumi-1 cell lines for the 70% ethanol extract according to the MTT assay. Spirulina extract obtained with water also showed cytotoxicity but the dose was a little higher where IC_(50) values were15.77 mg/m L for K-562 and 9.44 mg/m L for Kusumi-1 cell lines. The effect of cytotoxicity with ethanol extract is quite comparable with that observed for cyclophosphamide, which is a chemical used as anticancer agent.Conclusions: The cytotoxicity exhibited by Spirulina extract to cancer cell lines might be due to the presence of phytopigments(carotenoids, chlorophyll, phycocyanin) as well as polysaccharides that were reported previously as constituents of the extract. So crude extracts of Spirulina can be used as a source to develop anticancer drugs.

Haploidentical vs cord blood transplantation for adults with acute myelogenous leukemia

Hematopoeitic cell transplantation is established as a curative treatment for patients w acute myelogenous leukemia. Haploidentical family donor and umbilical cord blood(UCB) are alternative sources of stem cells for patients lacking a matched sibling or unrelated do-nor. The early challenges of transplant complications related to poor engraftment and graft-vs-host disease have been overcome with new strategies such as using 2 units and increased cell dose in UCB and T-cell deple-tion and post transplantation cyclophosphamide in hap-loidentical transplantation. The outcomes of alternative transplantation for acute leukemia were compared to other traditional graft sources. For patients lacking a matched sibling or unrelated donor, either strategy is a suitable option. The choice should rely mostly on the urgency of the transplantation and the available cell dose as well as the expertise available at the trans-plant center. This manuscript reviews the options of alternative donor transplantation and highlights recent advances in each of these promising transplantation options.

Characteristics of Clostridium difficile infection in patients hospitalized with myelodysplastic syndrome or acute myelogenous leukemia

AIM To evaluate factors associated with Clostridium difficile infection (CDI) and outcomes of CDI in the myelodysplastic syndrome(MDS) and acute myeloid leukemia (AML) population.METHODS After IRB approval,all MDS/AML patients hospitalized at the University of Maryland Greenebaum Comprehensive Cancer Center between August 2011 and December 2013 were identified.Medical charts were reviewed for demographics,clinical information,development of CDI,complications of CDI,and mortality.Patients with CDI,defined as having a positive stool PCR done for clinical suspicion of CDI,were compared to those without CDI in order to identify predictors of disease.A t-test was used for comparison of continuous variables and chisquare or Fisher's exact tests were used for categorical variables,as appropriate.RESULTS Two hundred and twenty-three patients (60.1% male,mean age 61.3 years,13% MDS,87% AML) had 594 unique hospitalizations during the study period.Thirtyfour patients (15.2%) were diagnosed with CDI.Factors significantly associated with CDI included lower albumin at time of hospitalization (P < 0.0001),prior diagnosis of CDI (P < 0.0001),receipt of cytarabine-based chemotherapy (P = 0.015),total days of neutropenia (P = 0.014),and total days of hospitalization (P = 0.005).Gender (P = 0.10),age (P = 0.77),proton-pump inhibitor use (P = 0.73),receipt of antibiotics (P = 0.66),and receipt of DNA hypomethylating agent-based chemotherapy (P = 0.92) were not significantly associated with CDI.CONCLUSION CDI is common in the MDS/AML population.Factors significantly associated with CDI in this population include low albumin,prior CDI,use of cytarabine-based chemotherapy,and prolonged neutropenia.In this study,we have identified a subset of patients in which prophylaxis studies could be targeted.

Acute myelogenous leukemia and acute leukemic appendicitis:A case report

Acute myelogenous leukemia(AML)can involve the gastrointestinal tract but rarely involves the appendix. We report a male patient who had 1 year partial remission from AML and who presented with apparent acute appendicitis as the initial manifestation of leu-kemia relapse.Pathological findings of the appendix revealed transmural infiltrates of myeloblasts,which indicated a diagnosis of leukemia.Unfortunately,the patient died from progression of the disease on the 19th d after admission.Although leukemic cell infiltration of the appendix is uncommon,patients with leu-kemia relapse can present with symptoms mimicking acute appendicitis.

Correlation of Aurora family and TRPV family gene expression in acute myelogenous leukemia with disease progression

Objective:To study the correlation of Aurora family and TRPV family gene expression in acute myelogenous leukemia with disease progression.Methods: Patients who were diagnosed with acute myelogenous leukemia in Kashgar Prefecture First People's Hospital between January 2014 and September 2017 were selected as the leukemia group of the research, and patients who underwent bone marrow puncture and were without myelogram anomaly in Kashgar Prefecture First People's Hospital during the same time were selected as the control group. The bone marrow tissue was collected to determine the mRNA expression of Aurora family and TRPV family genes, apoptosis genes and metastasis genes.Results: Aurora-A, Aurora-B, Aurora-C, TRPV-5, TRPV-6, GFI-1, Bcl-2, CXCR3, C3AR1,β-arrestin1, MMP2 and MMP9 mRNA expression in bone marrow tissue of leukemia group were significantly higher than those of control group whereas CD40L, Bax, Caspase-9 and Caspase-3 mRNA expression were significantly lower than those of control group. Aurora-A, Aurora-B, Aurora-C, TRPV-5 and TRPV-6 mRNA expression in bone marrow tissue of leukemia group were positively correlated with GFI-1, Bcl-2, CXCR3, C3AR1,β-arrestin1, MMP2 and MMP9 mRNA expression, and negatively correlated with CD40L, Bax, Caspase-9 and Caspase-3 mRNA expression.Conclusion: The high expression of Aurora family and TRPV family genes in acute myelogenous leukemia can promote the proliferation and metastasis of tumor cells during disease progression.

Myeloid sarcoma presenting as a colon polyp and harbinger of chronic myelogenous leukemia

Myeloid sarcoma, also known as granulocytic sarcoma or chloroma is an unusual accumulation of malignant myeloid precursor cells in an extramedullary site, which disrupts the normal architecture of the involved tissue. It is known to occur more commonly in patients with acute myelogenous leukemia and less commonly in those with myelodysplastic syndrome and myeloproliferative neoplasm, such as chronic myelogenous leukemia. The most common sites of involvement include bone, skin and lymph nodes. However, rare cases have been reported in the gastrointestinal tract, genitourinary tract, or breast. Most commonly, a neoplastic extramedullary proliferation of myeloid precursors in a patient would have systemic involvement of a myeloid neoplasm, including in the bone marrow and peripheral blood. Infrequently, extramedullary disease may be the only site of involvement. It may also occur as a localized antecedent to more generalized disease or as a site of recurrence. Herein, we present the first case in the English literature of a patient presenting with an isolated site of myeloid sarcoma arising in the form of a colonic polyp which, after subsequent bone marrow biopsy, was found to be a harbinger of chronic myelogenous leukemia.

Induction of Myelogenous Leukemia Cells with Histone Deacetylase Inhibitors through Down-regulating the Daxx Protein Expression

The effects of two different histone deacetylase （HDAC） inhibitors, sodium butyrate （NAB） and trichostatin A （TSA）,on apoptosis of human leukemic cells in vitro and the molecular mechanisms were investigated. The experiments were divided up 5 groups： control group, NaB group, TSA group, NaB＋Z-VAD-FMK group and TSA＋Z-VAD-FMK group. The apoptosis rate was determined by mor- phological analysis and flow cytomytry. The expression of Daxx, Bcl-2, and Bcl-xl proteins was detected by Western blot. NaB and TSA could induce the apoptosis of HL-60 and K562 cells, and Z-VAD-FMK caused a marked decrease in apoptosis induced by HDAC inhibitors. HDAC inhibitors could down-regulate the expression of Daxx protein, but had no significant influence on the expression of Bcl-2 and Bcl-xl proteins. The results suggested that NaB and TSA induce distinct caspase-dependent apoptosis of human leukemic cells through down-regulating the expression of Daxx protein in vitro.

Overexpression of P-glycoprotein induces acquired resistance to imatinib in chronic myelogenous leukemia cells

Imatinib,a breakpoint cluster region(BCR)-Abelson murine leukemia(ABL) tyrosine kinase inhibitor(TKI),has revolutionized the treatment of chronic myelogenous leukemia(CML).However,development of multidrug resistance(MDR) limits the use of imatinib.In the present study,we aimed to investigate the mechanisms of cellular resistance to imatinib in CML.Therefore,we established an imatinib-resistant human CML cell line(K562-imatinib) through a stepwise selection process.While characterizing the phenotype of these cells,we found that K562-imatinib cells were 124.6-fold more resistant to imatinib than parental K562 cells.In addition,these cells were cross-resistant to second-and third-generation BCR-ABL TKIs.Western blot analysis and reverse transcription-polymerase chain reaction(RT-PCR) demonstrated that P-glycoprotein(P-gp) and MDR1 mRNA levels were increased in K562-imatinib cells.In addition,accumulation of [14C]6-mercaptopurine(6-MP) was decreased,whereas the ATP-dependent efflux of [14C]6-MP and [3H]methotrexate transport were increased in K562-imatinib cells.These data suggest that the overexpression of P-gp may play a crucial role in acquired resistance to imatinib in CML K562-imatinib cells.

Preliminary Research on the p53 Gene Rearrangements in the Evolution of Chronic Myelogenous Leukemia to Blast Crisis

DNA from 36 patients with chronic myelogenous leukemia (CML) at various clinical stages and 6 cases of acute leukemia was investigated for alterations of the p53 gene by Southern blot analysis.Rearrangements of the p53 gene were seen in 3 of 12 (25.00%) cases of blast crisis and accelerated phase (AP) of CML and in only one of 18 chronic phrase (CP),just as has been reported previously. Meanwhile,by restriction fragment length polymorphism (RFLP) analysis the Bgl II site polymorphism in the p53 gene was also found. The frequency in Chinese people detected here was 0.392,which was strikingly higher than that in some other countries(P<0. 001).These results suggested that the alterations of the p53 gene, for example,p53 rearrangements,were probably responsible for the progression of BC in some CML patients, and that the frequency of Bgl II polymorphism in the p53 gene might be related to the population distribution.

Correlated Flow Cytometric Analysis of H－ras p21 and DNA Ploidy in Acute Myelogenous Leukemia

The flow cytometric immunoassay was used to study the correlation between the H-ras oncogene product p21 and the DNA ploidy in 30 de novo cases of acute myelogenous leukemia (AML). The results showed that 17 cases were negative for p21 expression and 13 positive for p21. The patients with positive p21 had higher percentage of bone marrow and peripheral blasts and lower peripheral leukocyte count. The expression of p21 had no influence on the therapeutic effect. Before treatment,DNA diploidy occurred in 18 cases including 13 p21 negative ones,and DNA aneuploidy was revealed in 12 cases including 8 p21 positive ones. Patients with positive p21 or having aneuploidy in complete remission were at risk for early relapse. Our results suggest that p21 may be involved in the process of leukemogenesis and progression in AML.

Carrimycin in the treatment of acute promyelocytic leukemia combined with pulmonary tuberculosis: A case report

BACKGROUND Pulmonary tuberculosis(PTB)is prevalent in immunocompromised populations,including patients with hematologic malignancies,human immunodeficiency virus infections,and chronic diseases.Effective treatment for acute promyelocytic leukemia(APL)combined with PTB is lacking.These patients show an extremely poor prognosis.Therefore,studies should establish efficient treatment options to improve patient survival and prognosis.CASE SUMMARY A 60-year-old male with pain in the right side of his chest and a fever for 4 d visited the outpatient department of our hospital.Peripheral blood smear revealed 54%blasts.Following bone marrow examinations,variant APL with TNRC18-RARA fusion gene was diagnosed.Chest computed tomography scan showed bilateral pneumonitis with bilateral pleural effusions,partial atelectasis in the lower lobes of both lungs,and the bronchoalveolar lavage fluid gene X-Pert test was positive,indicative of PTB.Carrimycin,ethambutol(EMB),and isoniazid(INH)were administered since he could not receive chemotherapy as the WBC count decreased continuously.After one week of treatment with carrimycin,the patient recovered from fever and received chemotherapy.Chemotherapy was very effective and his white blood cells counts got back to normal.After being given five months with rifampin,EMB and INH and chemotherapy,the patient showed complete remission from pneumonia and APL.CONCLUSION We report a case of PTB treated successfully with carrimycin with APL that requires chemotherapy.

Impact of comorbid subthreshold depressive symptoms on cancerrelated fatigue and complications in adults with leukemia

BACKGROUND Patients not only experience symptoms caused by cancer but also suffer from the accompanying psychological pain.Therefore,these patients do not have high quality of life.According to the World Health Organization,the incidence of leukemia in China in 2020 was 5.1/100000,the mortality rate was 3.3/100000,and the prevalence rate was 16.7/100000.Therefore,it is important to examine the influence of comorbid subthreshold depressive symptoms on leukemia patients.AIM To determine the impact of comorbid subthreshold depressive symptoms on cancer-related fatigue and complications in leukemia patients,thereby providing a basis for early diagnosis and treatment in clinical practice.METHODS A questionnaire survey was conducted among leukemia patients admitted to a tertiary hospital in Xi'an,Shaanxi Province,China,from August 2022 to December 2023.Patients with a score>16 on the Chinese Classification of Mental Disorders(CCMD-3)and a Hamilton Depression Rating Scale score of 8-17 were classified as the subthreshold depressive group(n=95),while 100 leukemia patients admitted during the same period were classified as the control group.Data were collected using Epidata 3.1 software,and comparisons were made between the two groups regarding general clinical data,the Piper Fatigue Scale(PFS),the Pittsburgh Sleep Quality Index(PSQI),the Numeric Rating Scale for pain assessment,laboratory indicators,and the occurrence of complications.RESULTS In this survey,120 leukemia patients with depression were preliminarily screened,95 patients with subthreshold depression were ultimately selected as the subthreshold depression group,and 100 leukemia patients admitted during the same period were enrolled as the normal group.Comparison of basic clinical data between the two groups revealed no significant differences in age,sex,body mass index,cognitive function,or comorbidity with other chronic diseases.However,there were statistically significant differences in the use of radiotherapy and regular exercise between the two groups(P<0.05).Comparisons of scales and laboratory indicators revealed no significant differences in albumin or PSQI scores between the two groups,but there were statistically significant differences in pain scores,PSQI scores,PFS scores,hemoglobin levels,and C-reactive protein levels(P<0.05).Spearman’s correlation analysis indicated that cancer-related fatigue was correlated with age,hemoglobin levels,C-reactive protein levels,pain,and regular exercise among leukemia patients with subthreshold depression.Multivariate regression analysis revealed that advanced age,combined radiotherapy,pain,and low hemoglobin levels were risk factors for cancer-related fatigue in leukemia patients with comorbid subthreshold depression,while regular exercise was a protective factor against cancer-related fatigue.Follow-up comparisons revealed a significantly lower overall incidence of complications in the control group(4%)than in the depressive group(24.21%;P<0.001).CONCLUSION Leukemia patients with comorbid subthreshold depressive symptoms experience more severe cancer-related fatigue and a higher incidence of complications.These findings may be related to advanced age,combined radiotherapy,pain,and low hemoglobin levels,while regular exercise may effectively alleviate symptoms.

Identification of cell surface markers for acute myeloid leukemia prognosis based on multi-model analysis

Given the extremely high inter-patient heterogeneity of acute myeloid leukemia(AML),the identification of biomarkers for prognostic assessment and therapeutic guidance is critical.Cell surface markers(CSMs)have been shown to play an important role in AML leukemogenesis and progression.In the current study,we evaluated the prognostic potential of all human CSMs in 130 AML patients from The Cancer Genome Atlas(TCGA)based on differential gene expression analysis and univariable Cox proportional hazards regression analysis.By using multi-model analysis,including Adaptive LASSO regression,LASSO regression,and Elastic Net,we constructed a 9-CSMs prognostic model for risk stratification of the AML patients.The predictive value of the 9-CSMs risk score was further validated at the transcriptome and proteome levels.Multivariable Cox regression analysis showed that the risk score was an independent prognostic factor for the AML patients.The AML patients with high 9-CSMs risk scores had a shorter overall and event-free survival time than those with low scores.Notably,single-cell RNA-sequencing analysis indicated that patients with high 9-CSMs risk scores exhibited chemotherapy resistance.Furthermore,PI3K inhibitors were identified as potential treatments for these high-risk patients.In conclusion,we constructed a 9-CSMs prognostic model that served as an independent prognostic factor for the survival of AML patients and held the potential for guiding drug therapy.

RNF6 promotes chronic myelogenous leukemia cell proliferation and migration by stabilizing vimentin via multiple atypical ubiquitinations

Chronic myelogenous leukemia(CML)is a malignancy from bone marrow myeloid stem cells mainly driven by the fusion gene BCR-ABL.In addition to BCR-ABL,other genes including RNF6 are also dysregulated in CML cells.1 RNF6,a ubiquitin ligase of the RING family,promotes various cancer cell proliferation,chemoresistance,and tumor growth in vivo by targeting various proteins for ubiquitination and degradation,including SHP1,TLE3,FOXA1,and MAD1.^(2) However,its specific mechanism in CML is not known.

Overview of novel nanobiosensors for electrochemical and optical diagnosis of leukemia:Challenge and opportunity

Leukemia is one of the ten types of cancer that causes the biggest death in the world.Compared to other types of cancer,leukemia has a low life expectancy,so an early diagnosis of the cancer is necessary.A new strategy has been developed to identify various leukemia biomarkers by making blood cancer biosensors,especially by developing nanomaterial applications so that they can improve the performance of the biosensor.Although many biosensors have been developed,the detection of leukemia by using nanomaterials with electrochemical and optical methods is still less carried out compare to other types of cancer biosensors.Even the acoustic and calorimetric testing methods for the detection of leukemia by utilizing nanomaterials have not yet been carried out.Most of the reviewed works reported the use of gold nanoparticles and electrochemical characterization methods for leukemia detection with the object of study being conventional cancer cells.In order to be used clinically by the community,future research must be carried out with a lot of patient blood objects,develop non-invasive leukemia detection,and be able to detect all types of blood cancer specifically with one biosensor.This can lead to a fast and accurate diagnosis thus allowing for early treatment and easy periodic condition monitoring for various types of leukemia based on its biomarker and future design controlable via internet of things(IoT)so that why would be monitoring real times.