[Are "behaviorally disordered" migrant children of "noncompliant" parents treatable? Interdisciplinary cooperation between system-oriented school psychology and psychoanalytically oriented therapy]

This case presentation describes the cooperation between experts of different basic training and theoretical provenance. A system oriented school psychologist takes on the 'case' of a massively behaviourally abnormal, aggressive, and marginalized girl of working migrants from the lower stratum, prepares the way for psychotherapy and transfers the treatment to a psychoanalyst. In this case the role of the school psychologist consists of receiving a crisis situation which is slipping out of hand and redefining the problems with all parties involved. By expanding the perspective to the context of school-family-immigration society contradictions and breaks become evident. The culture shock of the first migration phase was reinacted by the parents in the difficult confrontation with the Swiss institutions. In contrast to psychosocial sees the contradictions as being logical-congruent and tries to build bridges and activate change. The transformation of rigid reality constructs is furthered and psychotherapeutic treatment is mediated, explained and accompanied during the process. The role of the psychoanalyst consists of taking up the relationship to the girl and establishing a serviceable working relationship with the parents. She has to recognize the girl's inner and unconscious conflicts which are actualized in transference and countertransference in the therapeutic process. After empathetic interpretative work she offers new forms of dealing with conflicts which take the girl's outer reality (family, school, migrant situation, cultural reality) into consideration. Accompanying the parents intensively at the same time broadens their competence in raising their daughter. In this case the neurotic developmental disorder is strongly connected with the migration problem.

Autologous bone marrow transplantation for acute myeloid leukaemia in children using total body irradiation and melphalan as conditioning regimen

We conducted a phase II study on 19 children with AML in first (10 patients) or second (nine patients) complete remission (CR) treated with ABMT, evaluating the combination of total body irradiation (TBI, 12 Gy in six divided fractions) and high-dose melphalan (140 mg/m2 in single dose) in an attempt to improve antitumour efficacy of conditioning regimen. All patients received cryopreserved and in vitro purged (mafosfamide at a dose of 100 micrograms/ml) bone marrow. The median time from first CR to ABMT was 5 months compared with a median time of 3 months for patients in second remission. One of the 19 patients, transplanted in second CR, died of transplant-related complication 10 days after transplant and another second CR patient relapsed on day +28, before engraftment. Three further patients in second CR relapsed at 6, 6 and 18 months after marrow transplant, respectively, and this determined a relapse rate of 43% in children given ABMT in second CR and 0% for patients transplanted in first remission (P < 0.05). Seventy-two per cent of all patients are projected to be alive and disease-free at 6 years, whereas the event-free survival of patients in first and in second CR is 100 and 44%, respectively (P < 0.05). Although the number of patients does not allow us to draw any firm conclusion, our results are encouraging and suggest that the association of TBI and high-dose melphalan appears to be safe and valuable.

Sympathetic activation in obese normotensive subjects

Human obesity is characterized by profound alterations in the hemodynamic and metabolic states. Whether these alterations involve sympathetic drive is controversial. In 10 young obese subjects (body mass index, 40.5 +/- 1.2 kg/m2, mean +/- SEM) with normal blood pressure and 8 age-matched lean normotensive control subjects, we measured beat-to-beat arterial blood pressure (Finapres technique), heart rate (electrocardiogram), postganglionic muscle sympathetic nerve activity (microneurography at the peroneal nerve), and venous plasma norepinephrine (high-performance liquid chromatography). The measurements were performed in baseline conditions and, with the exception of plasma norepinephrine, during baroreceptor stimulation and deactivation caused by increases and reductions of blood pressure via intravenous infusions of phenylephrine and nitroprusside. Baseline blood pressure and heart rate were similar in obese and control subjects. Plasma norepinephrine was also similar in the two groups. Muscle sympathetic nerve activity, however, was 38.6 +/- 5.1 bursts per minute in obese subjects and less than half that level in control subjects (18.7 +/- 1.3 bursts per minute), the difference being highly statistically significant (P < .02). Muscle sympathetic nerve activity and heart rate were reduced during phenylephrine infusion and increased during nitroprusside infusion, but the changes were about half as great in obese subjects as in control subjects. Thus, even in the absence of any blood pressure alteration, human obesity is characterized by a marked sympathetic activation, possibly because of an impairment of reflex sympathetic restraint. This may be involved in the high rate of hypertension and cardiovascular complications seen in obesity.

Monoclonal expansion of large granular lymphocytes with a CD4+ CD8dim+/- phenotype associated with hairy cell leukemia

Peripheral blood lymphoid cell expansions with an unusual CD3+, CD4+, CD8dim+/-, CD11b+, CD57+ immunophenotype have recently been reported. They frequently have the morphology of large granular lymphocytes (LGL) and can be either monoclonal or polyclonal. Their significance is still unclear and no association with hematological neoplasms has been described. We report the case of a patient with a monoclonal expansion of LGL associated with a B-cell-derived hairy cell leukemia. The two lymphoid clones were not physically associated since T-LGL were found in the peripheral blood and hairy cells were detected in the bone marrow and kidney.

Hypertension--when is the clinical problem solved? When patients are rendered normotensive

Hypertension is usually symptomless and associated with little or no alterations in well-being. However, conclusive evidence demonstrates that hypertension is a major risk factor for cardiovascular disease. A reduction of the elevated blood pressure with antihypertensive medication can reduce this risk, but not to that of a normotensive patient. Furthermore, antihypertensive treatment is more effective against stroke and congestive heart failure than against coronary heart disease. Antihypertensive treatment is costly due to its extensive use and life-long indication. Future progress in this area will aim to identify those hypertensive patients at greatest risk of cardiovascular disease, in order to limit treatment to those patients who may benefit most. This paper will consider the effects of blood pressure reduction on cardiovascular morbidity and mortality, the differing effects of antihypertensive treatment on the complications of hypertension, and how antihypertensive therapy can be optimized.

[Arterial hypertension and myocardial infarction]

Several epidemiological and clinical studies, carried over the past 30 years, have unequivocally shown that high blood pressure is an important risk factor for development of myocardial infarction. The risk level, which has been documented for an increase both in systolic and diastolic blood pressure values, further increases when hypertension is accompanied with other conditions (e.g. hyperlipidemia, diabetes, cigarette smoking) well-known to adversely affect the cardiovascular system. Antihypertensive treatment significantly decreases, although without normalizing, the incidence of coronary events in the hypertensive patient, the reasons for this only partial cardioprotection being so far largely unknown. More complex and less documented are the relationships between hypertension and myocardial reinfarction. Although there is no doubt that high blood pressure levels increase the incidence of reinfarction, it should be emphasized that no study so far has been undertaken to clarify the effectiveness of antihypertensive treatment in reducing the risk of myocardial infarction and in improving the prognosis of the disease.

Application of molecular analysis to genetic counseling in the Wiskott-Aldrich syndrome (WAS)

The Wiskott-Aldrich syndrome (WAS) is a severe X-linked, recessive disorder, with a high mortality rate at early age due to hemorrhages, infections, and lymphoid malignancies. The molecular pathogenesis of the disease is unknown. Carrier females of WAS are clinically and immunologically normal, thus precluding carrier detection by simple laboratory tests. Major advances in molecular genetics have allowed mapping of the WAS gene to the pericentromeric short arm of the X chromosome, and have made carrier detection and prenatal diagnosis feasible by segregation analysis with closely linked polymorphic DNA markers. Furthermore, the observation that carriers of WAS exhibit a unilateral inactivation of the X chromosome in hematopoietic cells has provided a new tool for carrier detection. However, critical interpretation of molecular analysis data is essential to provide accurate genetic counseling to WAS families.

["...at least in my village, it is the custom...". From stagnation to transformation of familial reality constructs in immigrants]

The overrepresentation of immigrant children in special-education facilities and their underrepresentation in the stationary and ambulatory child and adolescent psychiatric services is becoming more and more alarming. It is inadequate to understand the reality of immigrant families by focusing on the concept of the "back and forth" between two cultures. It is more adequate to understand the reality of immigrant families by making use of the concept of the "construct of transitional realities". This newer and more relevant concept of understanding the reality or situation of immigrant families is based on the method of ethnobiographic case reconstruction and case comparison. Through this new approach, it is possible to discern the ways and means by which some families living in a foreign culture achieve a more or less autonomous mode of living and how they succeed in overcoming difficulties when going from one frame of reference to another or from one phase of life to another. This report presents excerpts from a study of southern Italian families living in Switzerland. As drawn from the collected material, these families can be typified as: traditional-progressive, traditional-sclerotic, traditional-regressive. In analyzing these individual family biographies and the various constructs of problem solving, the general societal background is always taken into consideration by the author. Therefore, the three types of families are neither singular nor particular but rather universal.

Impact of conceptus mass on glucose disposal rate in pregnant women

The impact of an increasing fetal and placental mass on maternal glucose disposal rate (GDR) was studied in 17 pregnant women. Eleven pregnancies were singleton pregnancies, five were twin and one was a triplet pregnancy. Both the maternal fasting glucose concentration [Glc] and the total fetal and placental weight (W) were significantly correlated with an increased maternal GDR. Glucose concentration and conceptus weight were interdependent. The multiple linear regression of glucose disposal rate on glucose concentration and total weight is given by GDR = -1.573 + 0.176W + 0.932[Glc] +/- 0.24, r2 = 0.52, P < 0.01. These data are utilized to estimate the glucose utilization rate of the human conceptus at a fasting glucose concentration of 3.9 mM with a range of 10-15 mg.kg-1.min-1. Maternal GDR increases with increasing glucose concentration at a rate similar to that reported for newborn infants, consistent with a high glucose utilization by the uterus.

Diagnostic value of blood sampling in fetuses with growth retardation

BACKGROUND

Fetuses with intrauterine growth retardation are delivered if they have evidence of distress, as manifested by abnormalities in the fetal heart rate and umbilical-artery blood flow. We studied whether umbilical-blood sampling might provide further information useful for management.

METHODS

We measured hemoglobin and lactate concentrations, oxygen content, pH, blood gas levels, and base deficit in umbilical-vein blood and correlated these measurements with the heart rate and umbilical-artery wave forms recorded by Doppler velocimetry in 56 fetuses with growth retardation. Twenty-one fetuses had normal heart rates and normal results of velocimetry, 24 had normal heart rates and abnormal results of velocimetry (indicative of decreased diastolic flow), and 11 had abnormal heart rates and abnormal results of velocimetry.

RESULTS

None of the 21 fetuses with normal heart rates and velocimetry had hypoxia or acidemia. Of the 24 fetuses with normal heart rates and abnormal velocimetry, 4 (17 percent) had moderate lactic acidosis, 1 (4 percent) had a low pH value, and 3 (12 percent) had hypoxia. Of the 11 fetuses with abnormal heart rates and velocimetry, 7 (64 percent) had lactic acidosis, low blood oxygen content, and low pH values. The absence of end-diastolic flow increased the risk of hypoxia and acidemia. The proportion of fetuses with elevated hemoglobin concentrations was similar among the three groups.

CONCLUSIONS

Assessment of fetal oxygenation and acid-base balance is not indicated in fetuses with growth retardation if their heart rates and the results of velocimetry are normal. If the results of velocimetry are abnormal, fetal-blood sampling can distinguish fetuses that have growth retardation alone from those that also have hypoxia and acidosis, and thus may aid in determining the optimal time of delivery.

Successful bone marrow transplantation in children with severe aplastic anemia using HLA-partially matched family donors

Bone marrow transplantation (BMT) using HLA-partially matched family donors has produced disappointing results (25-30% of long-term survivors) in patients with severe aplastic anemia. We describe two children affected by severe aplastic anemia, not responsive to immunosuppressive therapy, who underwent allogeneic bone marrow transplantation using a HLA-partially matched family donor. Both cases presented 2 first class HLA-antigens (A and B) disparity between donor and recipient. The pretransplant conditioning regimen consisted of cyclophosphamide, thoracoabdominal irradiation, cytosine-arabinoside, and antilymphocyte globulin. As graft versus host disease (GVHD) prophylaxis, Cyclosporine-A was administered at usual dosages for 6 months. A full marrow engraftment was observed in both cases. Only grade I acute GVHD, promptly responsive to corticosteroid therapy, developed with no chronic GVHD. Five months after transplant, both children progressively developed hypertension, renal function impairment, thrombocytopenia, and severe normochromic anemia, with erythropoietin serum levels lower than expected for the haematocrit. After antihypertension treatment and supportive therapy, the clinical picture progressively improved, while treatment with recombinant human erythropoietin completely corrected the long-lasting anemia. The two children are alive and well 28 months after the transplant, with a Karnofsky score of 100% and a normal peripheral blood count. The authors suggest that, once immunosuppressive therapy has failed, BMT from donors other than HLA-identical sibling is a feasible approach in children affected by severe aplastic anemia, not having an HLA-identical donor.

Expression of CD45R0 antigen on the surface of resting and activated neonatal T lymphocyte subsets

Expression of CD45R0 antigen has been evaluated on the surface of T lymphocyte subsets obtained from cord blood and on peripheral blood lymphocytes (PBL) from both term and preterm neonates. In some experiments, expression of the same antigen has also been evaluated after in vitro activation of cord blood lymphocytes (CBL) with phytohemagglutinin (PHA) or in mixed lymphocyte culture. The CD45R0 molecule was found to be present on a significantly lower percentage of CD3+, CD4+ and CD8+ CBL as compared with the same subsets evaluated in adult individuals. Moreover, at variance with adult PBL, the great majority of CBL displayed a low level of fluorescence when stained with UCHL1 (CD45R0-specific monoclonal antibody), and both PHA and allogeneic stimuli were able to strongly increase the expression of the CD45R0 molecule on CBL. The percentage of CD45R0+ PBL obtained from both term and preterm neonates on the 1st day of life was comparable to that of CBL, however the expression of this molecule increases remarkably within a few days in the majority of term neonates, while it seems to take more time for the antigen to be fully expressed in preterm infants.

Fetal amino acids in normal pregnancies and in pregnancies complicated by intrauterine growth retardation

Plasma amino acid concentrations were measured in normal (AGA) and intrauterine growth retarded (IUGR) percutaneous umbilical blood sampling (PUBS) performed for prenatal diagnosis or at elective cesarean section. IUGR fetuses present significantly lower concentrations of most amino acids, with a significant reduction of the umbilical veno-arterial difference for total alpha-amino nitrogen. These findings are present early in growth retarded fetuses and may be potentially responsible for the growth retardation.

Functional depletion of T cells by vincristine and methylprednisolone as an in vitro model for the prevention of graft versus host disease

BACKGROUND AND METHODS. The outcome of mismatched bone marrow transplantation is still severely hampered by graft versus host disease (GVHD) and graft rejection. Procedures for the recognition and selective elimination of T cells are still unsatisfactory due to the increased incidence of graft failure and late rejection. Lymphocyte proliferation and generation of cytotoxic T cells (CTL) in response to allogeneic cells are considered good in vitro correlates of GVHD and have been used in the present study to asses the capacity of two drugs (vincristine, VCR, and methylprednisolone, MP) to affect the T cells involved in these reactions. RESULTS AND CONCLUSION. Treatment in vitro with VCR and MP has been shown to inhibit the functional capacity of peripheral blood lymphocytes to proliferate (mean reduction 95.8%) and to generate CTL in response to haploidentical stimulator cells. Responsiveness to antigens and mitogens was affected to a minor extent (mean reduction 40% and 65.5%, respectively), and the method allowed recovery of hemopoietic precursors. The results suggest that treatment of donor bone marrow with VCR and MP is worth studying as a new approach to the prevention of GVHD in haploidentical bone marrow transplantation.

Analysis of X-chromosome inactivation and presumptive expression of the Wiskott-Aldrich syndrome (WAS) gene in hematopoietic cell lineages of a thrombocytopenic carrier female of WAS

We report on a thrombocytopenic female belonging to a pedigree with the Wiskott-Aldrich syndrome (WAS). Restriction fragment length polymorphism (RFLP) analysis with probe M27 beta, closely linked to the WAS gene, demonstrated that she is a carrier of WAS. Both small-sized and normal-sized platelets were present, suggesting that, unlike the vast majority of WAS carriers, she does not manifest nonrandom X-chromosome inactivation in the thrombopoietic cell lineage. Study of X-chromosome inactivation by means of RFLP and methylation analysis demonstrated that the pattern of X-chromosome inactivation was nonrandom in T lymphocytes, but random in granulocytes. While this is the first complete report on the occurrence of thrombocytopenia in a carrier female of WAS as the result of atypical lyonization, it also suggests that expression of the WAS gene occurs at (or extends up to) a later stage than the multipotent stem cell along the hematopoietic differentiation pathway.

Kaposi's sarcoma in a child after autologous bone marrow transplantation for non-Hodgkin's lymphoma

A case of Kaposi's sarcoma in a child with no serologic evidence of human immunodeficiency virus (HIV) infection is reported. A 7-year-old boy with Stage IV non-Hodgkin's lymphoma, after conventional chemotherapy, underwent autologous bone marrow transplantation (ABMT). Five months later he presented with supraclavicular mass and mediastinal enlargement. A bone marrow biopsy showed hypoplasia with no signs of the underlying disease, whereas the excised mass revealed a typical histologic pattern of Kaposi's sarcoma. The child is currently being treated with recombinant alpha-interferon (alpha-IFN) and regression of the disease has been achieved.

[Cellular and molecular therapy in severe combined immunodeficiencies]

Severe combined immunodeficiencies are usually fatal diseases unless affected children are admitted to protective isolation unit or unless the underlying immunological defect is treated by transplanting bone marrow from an healthy donor. The patients present, with early onset, life-threatening infections from fungal, viral or bacterial agents. Since only a minority of patients has an HLA-identical donor, recently other strategies have been devised including bone marrow transplantation from donors other than HLA-identical within the family or from HLA-non identical family members or from HLA-matched unrelated donors included in the International Bone Marrow Volunteers' Registry. In these cases, in order to realize this approach the "purging" of T-cells of the HLA-non identical donor bone marrow is necessary. Overall survival after HLA-identical BMT is 76%, when all BMT of the European multicenter analysis are considered, while in BMT from non-identical donors is 56%. Recently particular cases of SCID caused by enzyme deficiency, such as adenosine-deaminase (ADA), have been treated by molecular therapy with administration of polyethylene glycol (PEG) conjugated ADA: PEG protects from degradation and inhibits clearance of the enzyme. This approach, already realized in 15 children, allows reconstitution of cellular and humoral immunity, as demonstrated by one case treated by our group.

[Bone marrow transplantation in congenital defects of immunity]

BMT can cure several congenital immunological defects: if in these disease the engrafting is easier, the GVH reactions are more frequent and severe. The possibility to deplete from T lymphocyte the marrow before infusion, has overcame this difficulty. From 1968 183 BMT have been performed in Europe on patients with SCID (70 from HLA-identical donor, 113 from HLA-nonidentical donor). The survival after 2 years is 76% in the first group, and 56% in the second group (100 marrows have been T-depleted with different techniques). Strict isolation procedures before the transplant are very important to achieve good results. The possibility to treat different immunodeficiency With BMT are also discussed.

Successful lectin-separated bone marrow transplantation in adenosine deaminase deficiency-related severe immunodeficiency

Severe combined immunodeficiency disease (SCID) with adenosine deaminase (ADA) deficiency is a genetic autosomic recessive disorder with profound impairment of T-cell function, invariably complicated by fatal infections. The absence of ADA-enzyme and the accumulation of deoxy-ATP, with toxic effects on the T-lymphocytes is the common feature of this disease. As a consequence, lymphoid precursors failure to develop into mature T-cells, resulting in absolute lymphopenia and atrophy of the thymus. Bone marrow transplantation from an HLA-identical donor is considered the treatment of choice for this disease. We describe the case of a 1-month-old child with ADA deficiency SCID who underwent bone marrow transplantation (BMT) using paternal haploidentical, lectin-separated marrow, as a source of hemopoietic stem cells.

Influence of long-term diabetes on liver glycogen metabolism in the rat

Diabetes acutely impairs the ability of the liver to synthesize glycogen. However, the effect of chronic diabetes on the glycogenic function of the liver is not known. We measured hepatic glycogen contents in streptozotocin (STZ)-diabetic rats 3 weeks or 9 months after the induction of diabetes, in the fed state and following a 24-hour fast. In the fed state, liver glycogen levels were markedly decreased in short-term diabetic animals (5.8 +/- 2.0 v 33.9 +/- 2.3 mg/g, P less than .001), but not in long-term diabetic rats (18.3 +/- 4.4 v 20.7 +/- 1.3 mg/g, P = NS) as compared with age-matched nondiabetic animals, despite comparable hyperglycemia (portal plasma glucose levels of 424 +/- 21 and 449 +/- 24 mg/100 mL, short- and long-term diabetics, respectively). In the fasted state, on the other hand, liver glycogen was depleted in acute diabetes (4.5 +/- 2.2 mg/g v 1.9 +/- 0.5 of control rats), but significantly increased in chronic diabetes (10.1 +/- 3.1 v 0.2 +/- 0.03 mg/g, P less than .001). The latter finding was confirmed by electron-microscopical examination of liver cells. Furthermore, the percentage of hepatic glycogen synthase in the active form (synthase a) was lower than normal in short-term diabetic rats and in old nondiabetic rats. In long-term diabetic animals, on the other hand, synthase a was significantly higher than in old controls (P less than .01).(ABSTRACT TRUNCATED AT 250 WORDS)