Near haploid childhood acute lymphoblastic leukemia masked by hyperdiploid line: detection by fluorescence in situ hybridization

Near-haploid (<30 chromosomes) acute lymphoblastic leukemia (ALL) is a rare and unique subgroup of childhood common ALL associated with a very poor outcome. It may be underdiagnosed when masked by a co-existing hyperdiploid line, which has to be distinguished from the common good-prognostic hyperdiploid (>50 chromosomes) ALL. We present three children in whom, by conventional cytogenetics, near-haploid ALL was detected on relapse. Using interphase FISH probes of chromosomes X, Y, 4, 12, and 21, we were able, in two cases, to trace the hidden near-haploid lines of approximately 5% and 20% of the cells, masked by hyperdiploid cells of approximately 80% and 70%, respectively; at relapse, the proportion was reversed, with predominant near-haploid lines of over 80% and residual hyperdiploidy of less than 10%. The near-haploid lines consisted of 24 and 27 chromosomes, and always retained the second copy of chromosome 21 or its derivative, as detected in one of our patients by SKY. The hyperdiploid clones were the exact duplicates of the near-haploid ones and contained four and two copies of the chromosomes represented in two and one copies in the near-haploid stem line, respectively. Unlike the common hyperdiploid ALL, no trisomies were observed. The patients were all aged >10 years, with WBC 0.7-30 x 10(9)/L, and a common ALL phenotype. They were treated with the ALL-BFM-95 protocol, medium risk group, and responded well to 8 days of steroid therapy, but relapsed early, within 11 months, and died a few months later. Interphase FISH technique is recommended for the detection of cryptic near-haploid clones in the diagnostic survey of ALL. To assess the prognostic value of near-haploidy in the context of the ALL-BFM protocols, a larger cohort of patients is required.

Effects of atropine and propranolol on retinal vessel diameters during isometric exercise

PURPOSE

There is controversy regarding the nervous control of retinal blood vessels in humans. Most in vitro studies indicate that the intraocular part of the central retinal artery lacks autonomic innervation. We investigated the response of retinal vessels to isometric exercise during blockade of beta-receptors (propranolol) or muscarinic receptors (atropine).

METHODS

Twelve healthy subjects performed squatting for 6 min during infusion of either propranolol atropine or placebo. Blood pressure and pulse rate were measured non-invasively. Retinal vessel diameters were measured continuously using the Zeiss Retinal Vessel Analyser.

RESULTS

Squatting induced a significant increase in blood pressure and pulse rate, which was paralleled by a decrease in retinal vein and artery diameters. Atropine did not change the retinal vessel response to isometric exercise. Propranolol significantly blunted the exercise-induced vasoconstriction in retinal arteries.

CONCLUSION

This result likely indicates propranolol-evoked vasoconstriction in the extraocular parts of the central retinal artery during isometric exercise.

Long-term follow-up of twenty patients with adenocarcinoma of the pancreas: resection following combined modality therapy

Long-term follow-up of 5 or more years in 20 patients with initially unresectable cancer of the pancreas that responded to chemoradiation therapy is detailed in this article. All patients underwent resection. Seven or 18 surgical survivors are alive 50 or more months.

Distribution of the neurotrophin receptors p75 and trkB in peripheral mechanoreceptors; observations on changes after injury

The neurotrophin family mediates effects of growth, cell differentiation and cell death through low- and high-affinity transmembrane receptors. The Pacinian corpuscle (PC) is the largest peripheral mechanoreceptor in mammals and was studied by immuno-histochemistry and immuno-electron microscopy with regard to the distribution of neurotrophin receptors, p75; p140 trkA, p145 trkB and 145 trkC. TrkA- and trkC-like immunoreactivity (IR) was not expressed in rat and cat PCs. Developing and adult animals expressed p75 and trkB in lamellar cells of the PC. The inner core cells, thought to be specialised Schwann cells, demonstrated an injury-induced increased immuno-labelling for trk B. Perineurial-derived outer core cells were reactive to p75 after injury similar to the perineurium of distal nerve stumps. Inner core cells of PCs behaved as leptomeningeal cells with regard to trkB. Outer core lamellar cells of PCs behaved as perineurial cells with regard to p75. A role for brain-derived neurotrophic factor is proposed in the development and nerve regeneration of PCs via an anterograde messenger transfer through p75 and trkB.

Cerebellar involvement in Langerhans' cell histiocytosis: a progressive neuropsychiatric disease

We describe a 21-year-old patient who was being followed since the age of 3(1/2) years for Langerhans' cell histiocytosis. Although previously a bright and gifted student, the patient presented at age 16(1/2) with new-onset cerebellar neurologic signs, obsessive-compulsive disorder, and dementia. Findings on magnetic resonance imaging study of the brain were normal, but brain single photon emission computed tomography with technetium 99m ethylene cysteinate dimer showed markedly decreased cerebellar perfusion. This case is unique for the wide extent of the central nervous system involvement in Langerhans' cell histiocytosis, which has not been reported previously. Although obsessive-compulsive disorder has also been associated with several other cerebellar disorders, it is still unknown whether the cerebellum plays a role in its development. We suggest that in some cases, brain single photon emission computed tomography may be superior to magnetic resonance imaging for demonstrating cerebellar disorder in Langerhans' cell histiocytosis.

Methotrexate treatment protocols and the central nervous system: significant cure with significant neurotoxicity

Methotrexate can influence the central nervous system through several metabolic toxic pathways. These effects can be categorized as immediate, acute to subacute, or chronic neurologic syndromes. The acute to subacute syndrome occurs frequently in acute lymphoblastic leukemia treatment protocols, generally manifesting with focal neurologic signs and changes seen on magnetic resonance imaging and single photon emission computed tomography. While in some patients the neurotoxicity is transient and benign and allows for continuation of chemotherapy, in others it can be quite severe and debilitating, leading to permanent neurologic deficits. The need to modify the treatment protocols when neurotoxicity appears is not fully established. It is also unknown whether the use of sufficient amounts of leucovorin can overcome the toxic effects of the drug.

Apparently unrelated clones shown by spectral karyotyping to represent clonal evolution of cryptic t(10;11)(p13;q23) in a patient with acute monoblastic leukemia

The accurate genetic classification of acute leukemia is of the utmost clinical importance for treatment stratification. In the present study, we report on a young girl with aggressive acute monoblastic leukemia (AML) (M5b) with skin, lymph node, and bone marrow involvement, in whom cytogenetic analysis revealed three clones with different secondary chromosomal changes. Two clones had the secondary +8 and del(9q) aberrations, with the der(11)t(1;11) in the second one; the third clone was apparently unrelated to the others, and had add(7)(p?21),-13,+22. Using the spectral karyotyping (SKY) technique, we found that all three clones originated from a common clone that harbored the hidden primary t(10;11)(p13;q23) or its derivatives, suggesting clonal evolution. The first clone had the balanced t(10;11), the second had its derivative, der(10)t(10;11), and the third had the other derivative, der(11)t(10;11). On fluorescence in situ hybridization (FISH), MLL gene splitting, with translocation of its centromeric portion to 10p, and deletion of its telomeric portion, was demonstrated. In conclusion, the detection of the very poor prognostic t(10;11) aberration in AML, was possible by complementing the traditional cytogenetic analysis with SKY and FISH.

Improved outcome in childhood B-cell lymphoma with the intensified French LMB protocol

BACKGROUND

During the last 20 years, 120 children with B cell lymphoma were treated at the National Pediatric Hematology/Oncology Center of Israel. Until 1986, 63 patients received an institutional protocol (BMC), and thereafter 57 patients received a modified French LMB protocol. We report the results of a retrospective analysis comparing the results of these two protocols.

PROCEDURE

Patient characteristics were similar in both groups except for stage of disease and lactate dehydrogenase (LDH) levels. Significantly more patients in the LMB group had higher stage disease, and the LDH levels also were higher (<600 microg/ml).

RESULTS

Fifty-four of fifty-seven children on the modified LMB protocol are alive, disease-free, with an overall event-free survival of 94% (median follow-up of 73 months). Event-free survival for stages I, II, and III patients is 100%, and for stage IV 77%, whereas the overall event-free survival was 58% among 63 children treated previously, and for stage IV patients only 10%. Severe marrow suppression and neutropenic enterocolitis were the major complications of this intensive protocol.

CONCLUSIONS

Intensive chemotherapy with a modified LMB protocol and modern supportive care result in a high cure rate of childhood B cell lymphoma even in patients with advanced disease.

Decreased insulin-like growth factor-I receptor sites on circulating mononuclear cells from children with acute leukemia

Insulin-like growth factor-I (IGF-I) is a known mitogen for various cell types, including those of the hematopoietic cell system. To study the role of IGF-I in the neoplastic process of leukemia in children, the authors have determined the number of IGF-I binding sites on circulating mononuclear cells of children with acute leukemia as compared to normal children, using binding assays. The IGF-I binding sites per cell on peripheral mononuclear cells of children with leukemia decreased compared to those of the control group (411 +/- 73 and 1334 +/- 227, respectively, p < .001), while their affinity increased (Kd = 0.14 +/- 0.04 and 0.43 +/- 0.16, respectively, p = .05). Furthermore, in the patients, the number of the IGF-I binding sites was significantly lower in the subgroup of the peripheral mononuclear cells, which included lymphocytes and monocytes, as compared to their number in the peripheral blast cells (254 +/- 43.6 and 536 +/- 98.6, respectively, p = .02). A significant reduction was found in serum GHBP levels in the patients as compared to the controls (28.21 +/- 1.93 and 35.83 +/- 2.90, respectively, p = .02), while serum IGF-I and growth hormone levels were similar in patient and control groups. These results suggest a possible involvement of IGF-I in childhood acute leukemia, but further studies are needed to establish whether IGF-I plays a role in this disease.

Developmental and lesion-induced changes in the distribution of the glucose transporter Glut-1 in the central and peripheral nervous system

The active transport of D-glucose from the vascular to the neural compartment requires the presence of a carrier molecule at the blood-brain and the blood-nerve barrier. The glucose transporter 1 (Glut-1) seems to be the main carrier in blood-tissue barriers of endothelial and perineurial type. The distribution of Glut-1 was assessed in the normal central and peripheral nervous system of young and adult animals and compared with changes after nerve injury. Immuno-histochemistry, in situ hybridization, and perfusions with Evans Blue were carried out. Glut- I was not expressed in the perineurium of peripheral nerves at birth, but appeared in the perineurium of peripheral nerves, spinal roots, in the capsule of dorsal-root ganglia, and in the pia mater of adult animals. The perineurium of peripheral nerves subjected to Wallerian degeneration presented a faint Glut-1 immunoreaction, which was restored after regeneration. Glut-1 was expressed in capillaries of the gray substance of the spinal cord. Perineurial-derived lamellar cells of Pacinian corpuscles exhibited a strong Glut-1-like immunoreactivity in response to denervation and during development. Merkel cells and Meissner corpuscles were found to be Glut-1 negative. Glut-1 seems to reflect the quality of an adult, mature perineurial and blood-nerve barrier.

Combined intraoperative laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography: lessons from 29 cases

BACKGROUND

The role and timing of endoscopic retrograde cholangiopancreatography (ERCP) in patients with suspected choledocholethiasis remains a controversial subject. There have been few studies exploring the role of intraoperative ERCP. Therefore, we set out to perform a retrospective review of 29 patients who underwent combined laparoscopic cholecystectomy (LC) and intraoperative ERCP (LC/ERCP). Our objective was to assess the feasibility of a one-stage approach using intraoperative ERCP.

METHODS

We identified 29 patients in whom LC/ERCP was attempted between January 1996 and November 1998 at a university-affiliated hospital with a large private faculty. Parameters reviewed included preoperative diagnosis, liver function tests (LFT), finding on transcystic cholangiogram (TCC), ERCP, stone retrieval, failure of ERCP, length of stay, morbidity, and mortality.

RESULTS

Twenty-eight of 29 patients (97%) underwent successful combined LC/ERCP. Successful TCC followed by ERCP was performed in 21 of 26 patients (81%). Five TCC were technically unsuccessful; in these patients, ERCP was performed on the basis of preoperative criteria. In three patients, TCC was not attempted. Stones were successfully retrieved from 20 of 21 patients (95%) with abnormal finding on TCC, one of five patients (20%) with failed TCC, and two of three patients (67%) with ERCP but without TCC. Overall morbidity was 14%, comprising two patients with postoperative hyperamylasemia and two with cystic duct leaks. There were no deaths in the group. The mean time for the combined procedure was 173 min (range, 50-290). Mean length of hospitalization was 3.4 days, and mean postoperative stay was 2.2 days.

CONCLUSIONS

LC/ERCP can be performed safely. The advantages of the combined procedures include one-stage treatment of cholelithiasis and choledocholithiasis, avoidance of unnecessary preoperative ERCP and their concomitant complications, and elimination of potential return to the operating room when postoperative ERCP is technically impossible.

Effective preventive central nervous system therapy with extended triple intrathecal therapy and the modified ALL-BFM 86 chemotherapy program in an enlarged non-high risk group of children and adolescents with non-B-cell acute lymphoblastic leukemia: the Israel National Study report

BACKGROUND

Preventive cranial radiotherapy (CRT) in childhood acute lymphoblastic leukemia (ALL), although effective, may be associated with neurologic sequelae and second malignancies. Attempts to replace CRT with intensified intrathecal therapy (IT) have shown promise in lower risk subgroups. In the Israel National Study (INS) 89 trial, the efficacy of extended triple IT (TIT) alone for cranial prophylaxis in an enlarged non-high risk group (Non-HRG) was assessed in the context of a modified ALL-Berlin-Frankfurt-Munster (BFM) systemic chemotherapy program.

METHODS

Non-HRG patients included the standard-risk group (SRG) and the risk group (RG), as defined in ALL-BFM 86. In the INS 89 protocol, all Non-HRG patients were treated with extended TIT x 18 times and systemic therapy based on the BFM 86 protocol, with the addition of etoposide x 4 times. The HRG patients, classified according to BFM 86 criteria, were treated with the BFM 90 HRG protocol including CRT.

RESULTS

A total of 250 patients were enrolled. At a median follow-up of 58 months (range, 2-8.5 years), the overall 5-year event free survival (EFS) was 73.5% +/- 3% (standard error ¿SE), and the cumulative central nervous system (CNS) recurrence rate was 4.3% +/- 1.4% (SE) (isolated, 2.3%; combined, 2%). Of the 220 eligible children, 189 (86%) were in the Non-HRG group, and their 5-year EFS was 77.8% +/- 3% (SE). The cumulative CNS recurrence rate for patients without CNS disease at presentation was 3.1% +/- 1% (SE) (isolated, 1.7%; combined, 1.4%). Within the risk subsets defined by the BFM 86 of the Non-HRG, the 5-year EFS rates of the RG (148 patients) and the SRG (41 patients) were 74.8% +/- 4% (SE) and 89.5% +/- 5% (SE), respectively, and the rates of CNS recurrence (isolated and combined) were 4% and 0%, respectively. For the HRG (31 patients), the 5-year EFS and CNS recurrence rates were 47.9% +/- 9% (SE) and 8. 5% +/- 6% (SE), respectively.

CONCLUSIONS

Early extended TIT therapy in the context of modified BFM 86 systemic chemotherapy was found to provide adequate CNS protection and systemic leukemia control in patients with non-high risk ALL. However, no benefit for etoposide could be proven in this study.

Clustering of Pacinian corpuscle afferent fibres in the human median nerve

To further study the functional organisation of human peripheral nerves, the intrafascicular arrangement of afferent fibres supplying Pacinian corpuscles (PCs) was explored by percutaneous microneurography using thin-calibre, concentric needle electrodes. In normal adults, 20 PC afferents were identified in 13 recording sites. Low-amplitude (less than 30 microm) vibratory stimuli to the skin were applied with tuning forks oscillating at 128 Hz or 256 Hz and response patterns of individual PC units were studied. In many recording sites, two, sometimes even three, PC afferents with adjacent or overlapping receptive fields in the hand were clustered in the nerve. The observed incidence in the records containing a certain number of PC units was compared with the expected probability calculated according to the hypothesis that all nerve fibres are randomly organised in peripheral nerves. The results suggested that PC afferents are partially segregated in the nerve. In addition, PC afferents were neighbouring on slowly adapting type II (SAII) units and skin sympathetic activity in individual fascicles. SAII units often innervated the same skin area as PC units, but did not respond to vibration. The data provided additional information regarding the functional organisation of the human peripheral nerve and the mechanisms underlying the sense of vibration in man with special regard to population behaviour of neighbouring PC mechanoreceptors.

Continuing Education Outcomes Related to Pain Management Practice

BACKGROUND

Nursing practice outcomes of continuing education need to be measured and reported as one indicator of the value of nursing continuing education. This article makes the case that knowledge gain, the traditional measure of continuing education effectiveness, is not necessarily sufficient to assess changes in nursing practice.

METHOD

A pretest/posttest design was used to measure nursing practice outcomes of a continuing education program about pain management. A total of 50 attendees returned both the pretests and posttests and 68 attendees returned the follow-up evaluation.

RESULTS

Ninety-four percent of the respondents had improved scores on the posttest. Ninety-one percent of the follow-up evaluation respondents stated they had an opportunity to use the new information and 98% stated the use of this information has improved patient care.

CONCLUSION

This study found that a continuing education program triggered practice changes. The results of this study correlate with previous research that supports the need for practice outcome measurements.

Putting a lid on injury costs: the economic impact of the California motorcycle helmet law

BACKGROUND

This study analyzed the effect of California's motorcycle helmet law on injury costs.

METHODS

An economic evaluation was performed using state hospital discharge data, county-level cost data, and statewide crash reports to estimate the costs, charges, and lost productivity from motorcycle injuries. Total and per person costs and changes in these costs were estimated.

RESULTS

Total medical care costs were $35 million less in 1993 than in 1991, a reduction of 35%. Costs decreased for all payer categories, and 73% of the reduced hospitalization costs were attributable to reduced costs for patients with head injuries. Initial hospital costs for patients with head injuries were $18,527 compared with $10,350 for patients without head injuries.

CONCLUSION

During the first 2 years of implementation of California's helmet law, there were reduced costs for injuries and fatalities and large dollar savings to the state and other payers compared with the previous year.

Results after resection of intraoral cancer and reconstruction with the free radial forearm flap

Between 1989 and 1996, 47 patients with an intraoral squamous cell carcinoma underwent tumor resection and reconstruction with a free volar forearm flap. Tumor resection and neck dissection were performed by a head and neck surgeon and the free tissue transfer by a plastic surgeon. Preoperative radiation therapy was given to 44 of 47 patients and postoperative radiation therapy to 2. One other patient was not irradiated. There were 15 females and 32 males, with a mean age of 61 years. The primary site of the cancer was the tongue in 15 cases, the floor of the mouth in 15, the tonsil in 10, the bucca in 3 and the retromolar trigone in 4 cases. The flap was harvested from the left forearm in 34 and from the right in 13 patients. The mean operation time was 10 h (range 6-20) and the mean intraoperative bleeding was 486 ml (250-2,500). Forty-four of 46 flaps healed completely. Twelve revisions on 9 free flaps were performed between 6 h and 6 days postoperatively. Overall revisional surgery was done in 9 of 47 cases (19%). Two flaps could not be saved (4%). Infections/fistulas in the neck occurred in 11 of 46 cases (24%). Complete healing of the donor site occurred at a mean of 2.5 months (1-5). Nine patients developed complications at the donor site, 3 hematomas and 6 superficial infections (19%). Twenty-seven of 47 patients are still alive (57%). The mean survival time was 49 months (16-71).

Distribution of human Pacinian corpuscles in the hand. A cadaver study

The subcutaneous distribution and number of Pacinian corpuscles were studied in ten fresh cadaver hands. They were found to cluster close to nerves and vessels at the metacarpophalangeal joints and the proximal phalanx. The total mean number in the hand was 300 (192-424). The percentage of the total was 44 to 60% in the fingers, 23 to 48% in the metacarpophalangeal area and 8 to 18% in the thenar and hypothenar regions. Corpuscles in palmar skin overlying the distal phalanx were smaller than receptors in the metacarpophalangeal area. The lowest density of corpuscles was along the nerves and vessels of the middle phalanx.

The free radical forearm flap: a reliable method for reconstruction of the laryngohypopharynx after in-continuity resection

Between 1992 and 1996 14 patients with a squamous cell carcinoma of the laryngohypopharynx underwent tumour resection and primary reconstruction with the free volar forearm flap. Tumour resection was performed by a head and neck surgeon and reconstruction by a plastic surgeon. Preoperative radiotherapy was given to 13 patients and postoperative radiation to one patient. Thirteen patients were male and one patient was female, with a mean age of 66 years (range 53-79 years). The flap was harvested from the left forearm in 12 cases and from the right in two. The mean operation time was 12 h (range 11-20 h), and the mean intraoperative bleeding volume was 700 ml (range 400-1,000 ml). Twelve of 14 flaps survived. One flap was totally lost 3 weeks postoperatively and another was partially lost 2 weeks after surgery. Overall revisional surgery was carried out in six patients. Infections and fistulae at the neck occurred in six of the 14 patients. Six of the 14 patients were alive at follow-up. One patient died of an acute haemorrhage from an oesophageal ulcer 2 months after surgery, one patient died of a second primary oesophageal cancer and six patients developed recurrences. The mean survival time was 26 months (range 2-43 months).

Molecular analysis of childhood acute lymphoblastic leukemia in Israel

Ninety-two Israeli children with acute lymphoblastic leukemia (ALL) (67 B-lineage and 25 T-lineage) were analyzed for the immunological antigen receptor gene configuration. Thirty-nine of the patients (27 B-lineage and 12 T-lineage) relapsed. The incidence of the identified rearrangements within the immunoglobulin heavy chain (IgH) and T-cell receptor (TCR)beta, gamma and delta genes, at diagnosis, was in accordance with previous studies from other countries. Furthermore, the clinical relevance of bi/oligoclonal status, at diagnosis, and clonal selection was determined in this long-term follow-up study (median 112 months). A similar relapse rate was observed among the B-lineage patients with bi/oligoclonal and monoclonal patterns indicated by IgH gene rearrangement. Based on our results, we suggest that bi/oligoclonality has no prognostic significance (P=0.8533). Clonal variations between diagnosis and subsequent relapses were detected in 60% (12/20) of the patients; 64% (7/11) B-lineage and 55% (5/9) T-lineage. Clonal selection significantly correlated with shorter duration of remission and earlier recurrence (P=0.0025).