Results of liver transplantation for nodular regenerative hyperplasia

Liver transplantation has been performed in individuals with a pretransplant clinical diagnosis of cirrhosis but with nodular regenerative hyperplasia histologically. The purpose of this report is to investigate the results of liver transplantation in patients proven to have nodular regenerative hyperplasia post-transplant. A retrospective review was undertaken of four patients who underwent liver transplantation with a histologic diagnosis of nodular regenerative hyperplasia. All were felt to be cirrhotic on clinical grounds. Final histology of the explanted liver was confirmed by a single pathologist. Their ages ranged from 39 to 54 years, and three of the four were male. Three had pretransplant needle liver biopsies, two percutaneous and one transjugular. All revealed nonspecific reactive changes. Ultrasound and MRI were interpreted as consistent with cirrhosis in four of four and three of four cases, respectively. Portal vein flow was hepatopedal in three and absent in one. Pretransplant clinical characteristics and frequency were as follows: bleeding varices two, clinical ascites three, encephalopathy three, and impaired hepatic synthetic function two. All four patients underwent successful liver transplantation. There were no episodes of acute rejection. All are alive and well with normal graft function 2 to 4 years post-transplant. We conclude the following. 1) Patients with clinical end-stage liver disease due to underlying nodular regenerative hyperplasia can successfully undergo transplantation. 2) Nodular regenerative hyperplasia can present with signs and symptoms of liver failure, is difficult to diagnose by needle biopsy, and can be difficult to discriminate clinically from cirrhosis. 3) Although each case must be individually evaluated transplantation may be the optimal therapy in patients presenting with complications of liver failure.

FLT3 internal tandem duplication mutations in adult acute myeloid leukaemia define a high-risk group

Genomic DNA from 106 cases of adult de novo acute myeloid leukaemia (AML) was screened by polymerase chain reaction (PCR) and gel electrophoresis for FLT3 internal tandem duplication (ITD) mutations within the juxtamembrane (JM) domain. FLT3 mutations were detected in 14 cases (13.2%) and occurred in FAB types M1 (4 out of 14 cases), M3 (1 out of 10 cases), M4 (5 out of 37 cases) and M5 (4 out of 11 cases). Sequence analysis of four cases with abnormal PCR electrophoretic patterns revealed in frame duplications in the region of exon 11 of between 27 and 111 base pairs. Three are predicted to result in the tandem duplication of adjacent amino acid residues and one to result in a tandem duplication plus insertion of a novel amino acid motif. Statistical analysis showed the FLT3 mutations to be a strong prognostic factor, with patients lacking the mutation surviving significantly longer from diagnosis (mean 29.1 months) than those with an ITD (mean 12.8 months; P = 0.0002). Thirteen of the 14 patients with FLT3 mutations died within 18 months of diagnosis. FLT3 mutations were of prognostic significance in good risk disease (P = 0.04), as well as in patients with standard risk disease (P = 0.0096). This study demonstrates that the FLT3 ITD mutation occurs in a significant percentage of adult AML cases and is an important adverse prognostic factor that appears independent of conventional karyotypic findings.

Preoperative evaluation of living renal donors: comparison of CT angiography and MR angiography

PURPOSE

To compare computed tomographic (CT) angiography and magnetic resonance (MR) angiography for preoperative evaluation of living renal donors.

MATERIALS AND METHODS

Thirty-five living renal donors underwent preoperative contrast material-enhanced CT angiography and gadolinium-enhanced MR angiography. Each study was interpreted by two independent radiologists blinded to all other studies and to interpretations provided by other reviewers. Eighteen kidneys had surgical correlation.

RESULTS

CT demonstrated 33 supernumerary arteries in 19 patients, bilateral solitary arteries in 16 patients, and 18 proximal arterial branches in 16 patients. MR demonstrated 26 supernumerary arteries in 15 patients, bilateral solitary renal arteries in 20 patients, and 21 proximal arterial branches in 16 patients. Interobserver agreements for MR (kappa = 0. 74) and CT (kappa = 0.73) were similar to the agreement between MR and CT (kappa = 0.74). Among the kidneys chosen for nephrectomy, one small accessory artery and one proximal arterial branch were missed with CT and MR. Two of the accessory arteries suggested at CT were not found at nephrectomy. By averaging data for both modalities, supernumerary arteries were present in 49% of kidney donors and were bilateral in approximately 17%. Proximal arterial branches were present in 46% of kidney donors.

CONCLUSION

Preoperative CT and MR angiography of the renal arteries in renal donors demonstrate substantial agreement. Interobserver disagreement in the interpretation of CT and MR angiograms is related to 1-2-mm-diameter vessels.

Risperidone in the treatment of two very young children with autism

This report describes the use of risperidone in the treatment of two very young children with autistic disorder, a 29-month-old boy and a 23-month-old boy, respectively. These children presented with severe and persistent symptoms of aggression and irritability that had not responded to previous treatment. In both cases, risperidone significantly reduced aggression and improved social relatedness. One patient's treatment with risperidone was complicated by persistent tachycardia and QTc interval prolongation that was dose-related. Consideration should be given to the appropriate use of medication in the treatment of very young children with autism when other interventions do not prove helpful.

Genetic variation within and relatedness among wood and plains bison populations

There are two recognized subspecies of bison, wood (Bison bison athabascae) and plains (Bison bison bison) bison. The establishment of most bison populations from a small number of individuals has raised concerns about their genetic variation. To this end, 11 bison populations were surveyed with 11 microsatellite loci in order to calculate genetic variation and genetic distances. Mean number of alleles ranged between 3.18 at Antelope Island State Park (Utah) and 6.55 at Wood Buffalo National Park (Alberta and Northwest Territories). Mean heterozygosity ranged from 0.295 at Antelope Island State Park to 0.669 at Custer State Park (South Dakota). The amount of genetic variability present in the bison populations as measured by mean number of alleles and overall probability of identity was found to correlate with the number of founders for all sampled populations. The G-test for heterogeneity revealed some evidence for the existence of subpopulations at Wood Buffalo National Park, however very small genetic distances between these subpopulations suggest that nuclear material from the plains bison introduced into Wood Buffalo National Park has diffused throughout the park. Genetic distances between the sampled populations were generally larger between than within the two bison subspecies.

Genetic variation within and relatedness among wood and plains bison populations

There are two recognized subspecies of bison, wood (Bison bison athabascae) and plains (Bison bison bison) bison. The establishment of most bison populations from a small number of individuals has raised concerns about their genetic variation. To this end, 11 bison populations were surveyed with 11 microsatellite loci in order to calculate genetic variation and genetic distances. Mean number of alleles ranged between 3.18 at Antelope Island State Park (Utah) and 6.55 at Wood Buffalo National Park (Alberta and Northwest Territories). Mean heterozygosity ranged from 0.295 at Antelope Island State Park to 0.669 at Custer State Park (South Dakota). The amount of genetic variability present in the bison populations as measured by mean number of alleles and overall probability of identity was found to correlate with the number of founders for all sampled populations. The G-test for heterogeneity revealed some evidence for the existence of subpopulations at Wood Buffalo National Park, however very small genetic distances between these subpopulations suggest that nuclear material from the plains bison introduced into Wood Buffalo National Park has diffused throughout the park. Genetic distances between the sampled populations were generally larger between than within the two bison subspecies.Key words: Bison bison bison, Bison bison athabascae, DNA microsatellites, genetic variation, genetic relatedness.

Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation

Specific data on pregnancies following transplantation continue to accrue in the National Transplantation Pregnancy Registry (NTPR) in each type of organ recipient, with the following conclusions: 1. While the majority of kidney recipients appear to tolerate pregnancy well, a small percentage develops rejection, graft dysfunction and/or graft deterioration. Overall, there is a slight increase in the mean postpartum creatinine level when compared with the prepregnancy level, which has been noted in previous investigations by the NTPR. One neonatal death attributed to thrombotic cardiomyopathy was noted in a set of twins of a tacrolimus-based kidney recipient, but no other death has been noted in any of the additional reports among the recipients given newer immunosuppression regimens. Follow-up of offspring of these recipients is ongoing. 2. No structural malformations have been noted among offspring exposed to mycophenolate mofetil, but exposures are limited. (5 mothers, 29 fathers). 3. Female liver recipients with biopsy-proven acute rejection during pregnancy appear to be at greater risk for both poorer newborn outcomes and recurrent rejection episodes. In the setting of acute rejection diagnosed during pregnancy, close attention is warranted, anticipating that birthweight may be lower and that a substantial percentage of these female recipients may have recurrent rejection episodes. 4. Pancreas-kidney grafts can maintain normoglycemia throughout pregnancy. A high incidence of maternal hypertension, prematurity and low birthweight have been noted, so, as in other recipient groups, these are high-risk pregnancies. Maternal pancreas and kidney function must be closely monitored. 5. No specific prepregnancy predictors of adverse outcomes have yet been identified among heart or lung recipients although none of the deaths among heart recipients in the NTPR database occurred within 2 years of delivery. When compared with other solid organ recipients, female lung recipients may face higher risks, particularly related to rejection. Whether prepregnancy factors can help to predict either heart or lung recipients at risk requires continued study. 6. No structural malformations or significant learning disabilities have been noted in follow-up of the offspring of CsA-treated females, the largest group of offspring followed to date with a mean age of 4-5 years. Continued surveillance of children will be essential to determine if effects become apparent as age-related developmental delays or other problems in immune function or fertility later in life. 7. Newer regimens as well as new combinations of agents will continue to be studied. It is essential that non-viable as well as viable pregnancy outcomes be reported to the registry (i.e., recipients with pregnancies that result in spontaneous abortion or termination should be included for study). True estimates of non-viable outcomes have been difficult to assess. Additionally, inclusion of reports of pathologic evaluations at delivery hospitals will be helpful to determine whether spontaneous abortions are a result of lethal malformations related to immunosuppressive or other medication exposure. Safety of pregnancy for parent and child remain the primary goals of the NTPR.

Determination of leucocyte antibody binding capacity (ABC): the need for standardization

The flow cytometric determination of antigen density, or cellular antibody binding capacity, is now an accepted technique for the characterization of cells in health and disease. In HIV infection, for example, antigen density changes in CD38 expression may be an important indicator of disease progression. Our experience of using one such method, Quantum Simply Cellular, which measures antibody binding capacity (ABC), has highlighted several technical factors which can affect the results. We report the influence of pH, incubation temperature and time, antibody fluorochrome and titre, as well as lysing reagent (FACS Lysing Solution v. Ortho-mune Lysing Reagent) on the ABC of anti-CD3, CD4 and CD8 of normal lymphocytes. In addition, the effect of single, double or triple-staining was assessed. The results indicate that the ABC values are influenced by all the variables studied. The pH range tested (6.0-9.0) demonstrated that pH 7.4 gave maximal binding. Furthermore, temperature also influenced the pH of the two lysing solutions, and thus potentially the ABC. Antibody concentration, fluorochrome and staining technique are also important factors with an observed difference of up to 458,855 ABC between the various fluorochromes. In addition a maximal difference of 130,119 ABC was observed between single and triple staining techniques. In conclusion, if antigen quantification is to be used in the clinical setting, an internationally standardized method is required to ensure the reproducibility of results from centre to centre. Our data suggests that single staining, using fluorescein isothiocynate (FITC) conjugated antibodies with all reagents at pH 7.4 + 0.1, with incubation and lysing carried out at 20 + 1 degrees C, could be used as a 'benchmark' method for ABC determination using the QSC system.

Fragile X syndrome

Fragile X syndrome is the most common form of inherited mental retardation. It is seen in people of all nationalities and in all areas of the world. Fragile X syndrome can be a devastating condition, as many boys are severely retarded and require multiple services. Treatment involves behaviour management techniques, appropriate school placement, community support for the family, and careful medical follow-up often including psychopharmacology. The genetics of fragile X syndrome is now understood, prenatal testing is available, and the disorder is preventable through appropriate genetic counselling. This review focuses on the neurobiology of fragile X syndrome, its clinical features and treatment.

Validation of three paediatric pain scores for use by parents

Twenty children undergoing general surgery and 20 children undergoing otorhinolaryngological surgery were simultaneously assessed on two occasions by a doctor and a parent using three pain scoring systems. The pain scoring systems used were the Objective Pain Score, a four point numerical score and a 100 mm visual analogue scale. There was a high correlation between the scores given by the doctor and by the parents for all three scoring systems with parents consistently giving slightly higher scores than the doctor. The correlation coefficients for parental and medical pain scores in recovery were 0.77 for the Objective Pain Score, 0.70 for the four point numerical score and 0.69 for the visual analogue scale (p < 0.01). At 1 h after leaving the recovery area the correlation coefficients were 0.81, 0.80 and 0.73 respectively (p < 0.01). These results suggest that parental scoring of pain in children will be useful in future audit and research of analgesic regimens, particularly in day-case surgery.

Evaluation of a novel stable whole blood quality control material for lymphocyte subset analysis: results from the UK NEQAS immune monitoring scheme

The UK NEQAS immune Monitoring Scheme (UK NEQAS) evaluates the performance of laboratories routinely performing T-lymphocyte subset analysis on HIV-infected individuals. The scheme originally issued fresh whole blood, but a significant problem was that of analyte stability, especially 36 h postphlebotomy. To circumvent this problem, we have developed a novel stabilisation procedure that ensures retention of leucocyte light scatter and immunological staining characteristics for up to 300 days. In addition, the stabilised whole blood preparation is fully compatible with flow cytometer technology, incorporating either whole blood lysis or "no wash, no lyse" techniques. The ranges of interlaboratory coefficient of variation for the stabilised material are now tighter than those previously obtained with fresh whole blood. Development of this novel material has enabled overseas laboratories to participate in the UK NEQAS immune Monitoring Scheme and could in the future lead to the production of reference and/or calibration reagents for leucocyte immunophenotyping.

Impact of serum lipids on long-term graft and patient survival after renal transplantation

The results after primary cadaveric renal transplantation in 665 consecutive patients were reviewed with respect to posttransplant serum lipids. Data were available for 182 of 665 patients on serum total cholesterol and triglycerides at 1 year posttransplant. Hypercholesterolemia (cholesterol > 200 mg/dl) developed in 141 of 182 patients (77%) and hypertriglyceridemia developed in 73 of 166 patients (44%). At 1 year posttransplant, hypercholesterolemia and hypertriglyceridemia both correlated with age at transplant (P = 0.0001, P = 0.01). Hypercholesterolemia and hypertriglyceridemia were also correlated with obesity as determined by body mass index (kg/m2) (P = 0.006, P = 0.01). Hypertriglyceridemia at 1 year posttransplant correlated with pretransplant triglyceride level (P = 0.006), but hypercholesterolemia did not correlate with pretransplant cholesterol level (P = 0.53). Hyperlipidemia was not correlated with cyclosporine (CsA) or prednisone dose (mg/kg), CsA trough levels, number of rejection episodes, or serum creatinine at 1 year. Despite significant differences in serum cholesterol and triglycerides, actuarial graft and patient survival were similar between the normolipidemic and hyperlipidemic groups.

Obesity as a risk factor after combined pancreas/kidney transplantation

The impact of pretransplant overweight/obesity was analyzed in a group of 268 consecutive primary pancreas renal transplant recipients. Obesity was defined as body mass index (BMI) greater than 27 kg/m2. BMI was available for 240 of the 268 patients. A total of 88% (212/240) of the patients had a BMI < or = 27 and 28/240 (12%) had BMI > 27. There were no significant differences in age, sex, or race between obese and nonobese patients. The incidence and degree of posttransplant hypertension, weight gain, increase in BMI, and hyperlipidemia did not differ on the basis of pretransplant BMI. Serum creatinine at one year posttransplant was slightly increased in obese patients, but the increase was not statistically significant. Cumulative prednisone dose (mg/kg) as well as cyclosporine (CsA) dose (mg/kg) at one year was not significantly different between obese and nonobese patients. However, there was a marginally significant negative correlation between BMI and one-year cumulative (mg/kg) prednisone dose (P = .06). Types and frequency of posttransplant complications were similar between obese and nonobese patients, although there was a slightly higher incidence of wound related complications in obese patients (11% vs. 6.8%) (P = NS). There was no difference in the frequency of acute rejection episodes in obese and nonobese patients. Actuarial patient survival was comparable between patients with BMI < or = 27 versus those with BMI > 27 (P = .10). However, actuarial graft survival, both pancreas and renal, were significantly decreased in patients with BMI > 27 (P = .029). The decrease in pancreas and kidney graft survival in obese patients could not be attributed to decreased "early" patient survival, increased incidence of perioperative or postoperative complications, differences in hypertension, acute rejection episodes, serum lipids, or immunosuppression dosage. The most common causes of graft loss were rejection and patient death in both obese and nonobese patients. After three years posttransplant, the decreased pancreas and renal graft survival in obese patients corresponded to decreased patient survival. The most common cause of patient death was cardiovascular complications in both obese and nonobese PKT recipients.

Circulating CD20dim T-lymphocytes increase with age: evidence for a memory cytotoxic phenotype

The CD20 antigen has been regarded as a B lineage specific, 35 kDa, non-glycosylated membrane phosphoprotein, which functions as either a Ca2+ ion channel or as a regulatory protein of such a channel. Weak expression of CD20 (CD20dim), however, has recently been reported on a sub-population of T lymphocytes. We present results which confirm the existence of a CD20dim T lymphocyte population and show that such cells have a reduced antibody-binding capacity, when compared to CD20bright B-cells (10337 +/- 642 and 346311 +/- 24264 respectively). In addition, CD20dim cell counts vary with age, with the highest levels occurring in octogenarians: cord blood 0.3 +/- 0.1% (n = 13), 20-60 year-old group 2.1 +/- 1.1% (n = 18) and individuals > or = 61 years of age 6.9 +/- 3.2% (n = 10) (P < 0.001). Further characterization of CD20dim T cells, using three colour flow cytometry, demonstrated a predominantly memory cytotoxic phenotype, in that the cells were CD8+CD28+CD45RO+T-CR alpha beta +CD38-HLA-DR-.

Typing and subtyping of influenza viruses in clinical samples by PCR

Type A and B influenza viruses can cause a wide spectrum of illness, and these viruses are responsible for considerable mortality and morbidity. Rapid typing of isolates is desirable when amantadine treatment or prophylaxis of contacts of type A influenza virus carriers is considered, but the available rapid techniques lack sensitivity and standard diagnostic methods require expansion of virus in tissue culture or embryonated hens' eggs. We developed a series of oligonucleotide primers able to detect, type, and subtype type A influenza viruses in a single reverse transcription-PCR. RNA was isolated from clinical specimens, and cDNA was generated with random primers. PCR was carried out with a mixture of primers specific for influenza viruses of types B, A/H1 and A/H3, and subtyping of the neuraminidase was carried out on the same cDNA template under identical conditions. Amplified products were detected by ethidium bromide staining of amplified products after agarose gel electrophoresis. When it was used to test 98 clinical specimens, this method was comparable to standard culture techniques in the detection, typing, and subtyping of influenza viruses.

Heterodyne detection of swept-carrier frequency-selective optical memory signals

Swept-carrier time-domain optical memories [Opt. Lett. 17, 535 (1992)] are unique in that memory output signals occur cotemporally with the excitation field (read field) responsible for their generation. We demonstrate that this fact provides for the convenient detection of memory signals through their heterodyne interference with the cotemporal read field. Memory implementation is dramatically simplified.

Experimental demonstration of swept-carrier time-domain optical memory

Swept-carrier time-domain optical memory [Opt. Lett. 17, 535 (1992)] has been proposed as a means of storing optical data streams in inhomogeneously broadened spectral recording materials. The process provides for full utilization of the material storage bandwidth regardless of the data rate and permits storage of data sequences with durations exceeding the material dephasing time. We report what we believe is the first experimental demonstration of this storage process. Our experiments, implemented with frequency-swept diode lasers and Tm(3+):YAG storage material, demonstrate single-event storage of 98-bit data streams whose duration is an order of magnitude longer than the material dephasing time.

Proteolytic processing of reovirus is required for adherence to intestinal M cells

Reovirus adheres specifically to apical membranes of mouse intestinal M cells and exploits M-cell transepithelial transport activity to enter Peyer's patch mucosa, where replication occurs. Proteolytic conversion of native reovirus to intermediate subviral particles (ISVPs) occurs in the intestine, but it is not known whether conversion is essential for interaction of virus with M cells. We tested the capacity of native virions, ISVPs, and cores (that lack outer capsid proteins) to bind to intestinal epithelial cells in vivo and found that only ISVPs adhered to M cells. Thus, intraluminal conversion of native reovirus to ISVPs is a prerequisite for M-cell adherence, and outer capsid proteins unique to ISVPs (either sigma 1 or products of mu 1) mediate interaction of virus with M-cell apical membranes.