Fever in acute myelogenous leukemia

Twenty patients with acute myelocytic leukemia were observed over a period of 16.5 patient years in an attempt to identify any relationship between fever, granulocytopenia (<1000 gran ulocytes/μl), infection, and disease status. An infectious origin for fever in association with gran ulocytopenia could be established in the majority of instances during the induction of remission and during relapse. This finding differs from what has been previously noted in children with the more common form of leukemia, acute lymphocytic leukemia.

Preleukemic states in children with acute lymphoblastic leukemia

Two cases are reported of childhood acute lymphoblastic leukemia presenting with preleukemic states and 13 other cases in the literature are reviewed. Hypoplastic anemias, which transiently resolved spontaneously or with steroid therapy, were seen most commonly. Acquired hypoplastic anemias, even when associated with spontaneous resolution, may at times represent a preleukemic state.

Transfusion nomogram: an application of physiology to clinical decisions regarding the use of blood

A nomogram has been prepared that depicts relationships between cardiac output (Q), oxygen consumption (Vo2), hemoglobin concentration (Hb), the position of the oxygen-hemoglobin dissociation curve, the oxygen saturation of arterial blood (SaO2), and the partial pressure of oxygen in the mixed venous blood (PVO2). Examples are provided to illustrate how this nomogram may be employed to facilitate decisions regarding the need for blood transfusions in patients in whom oxygen delivery may be impaired.

HLA antigens and childhood acute lymphocytic leukaemia

HLA-A and -B antigens were determined for 94 children with acute lymphocytic leukaemia (ALL) and for 376 normal controls. Sixty-four of these 94 patients were typed for lymphocyte surface markers and 59 were defined as 'null cell' ALL. There was no difference in the distribution of the HLA-A or -B locus antigens between the control group and the entire group of patients with ALL or the 'null cell' subgroup. Patients with HLA-A9 determinants had a significant increase in early, first remission duration compared to patients without HLA-A9. This was particularly evident in the 'null cell' ALL subgroup. In addition, HLA-A9 appeared to be an independent factor affecting the length of first remission since there was no correlation between known prognostic factors such as patient age, sex or WBC and the presence or absence of the HLA-A9 antigen. Survival for the first 12-18 months was also greater in the HLA-A9 group than in the non-HLA-A9 population. Thus, the presence of HLA-A9 appears to be associated with some protective effect among patients with ALL.

Red cell transfusion in the newborn. Indications and unique blood banking needs

The nursery presents unique problems for the physician caring for ill newborn infants. The indications for transfusion and the blood banking techniques to provide for these needs have changed significantly in recent years. The decision to transfuse must be based on an understanding of what is known to normally occur with respect to the postnatal decline in hemoglobin and the adaptive mechanisms which exist at this age. Exchange transfusion by increasing oxygen availability at any hemoglobin level may result in a greater than expected decline in hemoglobin. Several blood banking procedures have been developed to provide for the transfusion requirements of the neonate. The walking donor system remains controversial and has created opposition by the American Association of Blood Banks. The use of triple, quadruple, and "cow' pack systems has allowed a greater versatility and better utilization. The concept of frozen red cell transfusions has been extended to the nursery setting with the introduction of "pedi-paks.' These techniques have clearly diminished the risks of transfusion in the neonatal period.

RBC values in low-birth-weight infants during the first seven weeks of life

Hemoglobin, RBC mean corpuscular volume (MCV), and other RBC indices were studied in a group of 40 infants, each with a birth weight of less than 1,500 g. Results indicated that the hemoglobin level fell from 18.2 +/- 2.7 g/dL at birth to a low of 9.5 +/- 1.5 g/dL at 6 weeks of age. During this time, the MCV declined from 115 +/- fentoliters (fL) to 97 +/- 5 fL and did not again rise as the hemoglobin stabilized. Although the decline in MCV may simply reflect an aging RBC population, these data raise the possibility that RBC size may in part be determined by postnatal factors independent of time from conception.

Anemia due to inadequate iron sources or poor iron utilization

Anemias due to dietary iron deficiency and poor iron utilization have some features in common. In both, the anemia is hypochromic and microcytic. Also in both, the levels of free erythrocyte protoporphyrin are increased, even though many of the causes of ineffective iron utilization are actually associated with normal or increased iron stores. Appropriate use of currently available assays, including a determination of the level of serum ferritin, can distinguish between many of these disorders. Above all, a logical approach with attention to the clinical response to treatment with iron medications will help achieve a rapid diagnosis.

Unilateral optic neuropathy following vincristine chemotherapy

Two subjects with acute lymphatic leukemia have been observed to have unilateral optic neuropathy five to seven days following administration of Vincristine (2.0 mg/sq m) during maintenance chemotherapy. Both subjects were in mission at the time their ocular problems developed. After discontinuance of Vincristine therapy, marked vision improvement in the affected eye occurred over the ensuing months. It is presumed that Vincristine therapy was the cause of toxic optic neuropathy in these patients.

A prospective randomized study to determine the efficacy of steroids in treatment of croup

We evaluated the use of dexamethasone in the management of acute laryngotracheobronchitis (croup). Thirty patients, ranging in age from eight to 60 months, were evaluated in a prospective, double-blind study. Patients received dexamethasone, 0.3 mg/kg at the time of admission and a similar dose 2 hours later, and were compared with a placebo group receiving saline. Sixteen patients received dexamethasone and 14 patients received the placebo. Severity of each group was scored by a standardized system. Patients receiving dexamethasone had a mean admission score of 8.46 points; patients receiving placebo, 8.14. Twenty-four hours after admission the patients in the treatment group had a mean score of 1.19 as contrasted with a score of 5.58 for the placebo group (P less than 0.01). We concluded that dexamethasone when administered in adequate dosage by an intramuscular route hastens the recovery of infants and children with acute uncomplicated croup.

Iron absorption in the thalassemia syndromes and its inhibition by tea

To determine the hemoglobin concentration at which iron absorption is minimal, five subjects with thalassemia major and one with thalassemia intermedia underwent a series of iron-absorption studies. The effect of tea as an inhibitor of non-heme iron absorption was also tested. Iron absorption increased as the hemoglobin concentration decreased, although iron absorption was much higher at any given hemoglobin level in the subject with thalassemia intermedia. In the subjects with thalassemia major, iron absorption averaged 10 per cent at hemoglobin concentrations between 9 and 10 and 2.7 per cent between 11 and 13 g per deciliter. The percentage of iron absorbed could be accurately predicted from the nucleated red-cell count (r = 0.91, P less than 0.001). Tea produced a 41 to 95 per cent inhibition of iron absorption. Since patients with thalassemia intermedia may absorb a large percentage of dietary iron, inhibitors of iron absorption, such as tea, may be useful in their management.

Consumptive coagulopathy. A complication of therapy of solid tumors in childhood

The association of consumptive coagulopathy and malignancy is thought to be rare in pediatrics. In one patient with Ewing's sarcoma and in two with rhabdomyosarcoma consumptive coagulopathy developed in the presence of either diffuse metastatic disease or an extensive primary tumor. The coagulopathy was a major clinical problem, developing within five days of the onset of chemotherapy. Resolution coincided with the clinical response of the tumor.

Aspirin-induced hemolysis: the role of concomitant oxidant (H2O2) challenge

Studies were conducted in an attempt to determine the hemolytic potential of acetylsalicylic acid (ASA) on normal intact red blood cells (RBCs). ASA (25 mg/100 ml) did not impair RBC G-6-PD, glutathione peroxidase or catalase activity, glutathione stability, or hexose monophosphate shunt activity. Hemolysis was not observed after incubation with ASA alone but was quickly noted after exposure to ASA (25 mg/100 ml) and H2O2 (1.2%). Hemolysis did not occur with H2O2 alone but was directly proportional to the ASA concentration. Hemolysis was preceded by peroxidation of membrane lipid and was inhibited by the presence of the antioxidant, thymol. With ASA and H2O2 a marked reduction in membrane phosphatidyl ethanolamine occurred with oxidation of 20:4 and 22:6 fatty acids. No effect on phospholipids or fatty acids occurred with either ASA or H2O2 alone. Salicylic acid, singly or with H2O2, does not exhibit these effects.

L-Asparaginase-induced coagulopathy during therapy of acute lymphocytic leukemia

L-Asparaginase-induced coagulation abnormalities were observed in all patients receivng this drug. All patients studied demonstrated low factor IX and fibrinogen levels and most (75%) had low levels of factor XI. Disturbances in other factors were much less frequent. Despite the presence of markedly abnormal coagulation studies, clinical bleeding was not observed.

The anemia of prematurity. Factors governing the erythropoietin response

We performed sequential studies in 45 premature infants (birth weights less than 1500 g) from 7 to 120 days of age to determine factors governing the erythropoietin response to a declining hemoglobin concentration. The hemoglobin level and the plasma erythropoietin showed a significant inverse correlation (r = 0.50, P less than 0.001), as did, even more strikingly, the plasma erythropoietin response and the infants' oxygen-unloading capacity (r = 0.55, P less than 0.001). In infants with "right-shifted" oxygen-hemoglobin dissociation curves (hemoglobin F less than 30 per cent) hemoglobin levels fell 2 to 3 g per deciliter lower than those in infants with "left-shifted" curves (hemoglobin F greater than 60 per cent) before comparable erythropoietin responses occurred. It appears that premature infants respond appropriately to alterations in oxygen unloading capacity and that the position of the oxygen-hemoglobin dissociation curve and not the hemoglobin concentration alone has a major role in modulated erythropoiesis.

Neutropenia, fever, and infection in children with acute lymphocytic leukemia

In an attempt to determine the relationship between neutropenia (absolute granulocyte count less than 1,000/cu mm), infection, and disease status, 20 patients with acute lymphoblastic leukemia were observed for a total of 34 patient-years. Febrile episodes occurred with much greater frequency in patients during the course of treatment induction (0.9/mo), or while in relapse (2.46/mo) than while in remission (0.19/mo). A cause for fever was identified much more frequently in patients in remission, both when neutropenic and nonneutropenic. When absolute granulocyte counts fell below 200/cu mm, a cause for fever was generally identified regardless of disease status. We propose that the majority of febrile episodes in patients at the time of induction of treatment or in relapse with neutrophil counts of more than 200/cu mm are caused by the disease process rather than secondary to a diagnosable infection.

Rapid correction of anemia with partial exchange transfusion

Six pediatric patients have recently undergone eight partial exchange transfusions for anemias complicated by other clinical conditions. The procedure was well tolerated, and those patients who were in congestive heart failure exhibited good clinical improvement. This technique is particularly useful in situations where the patient is unable to tolerate the increased blood volume produced by other methods of RBC-transfusion therapy. We present a formula for estimation of partial exchange transfusion volume and suggest indications for partial exchange transfusion.