Improved prognosis for acquired aplastic anaemia

This study compared the prognosis of patients treated for aplastic anaemia at Great Ormond Street Hospital for Children from 1973-88 (group A; n = 38) with a more recent cohort from 1989-96 (group B; n = 37). The two groups were similar in terms of clinical history, age, and severity of aplasia. The main treatment differences included the use of androgen treatment in group A (21 of 38 patients) but not in group B, and the addition of cyclosporin A to immunosuppressive treatment for 14 patients in group B. Actuarial survival at eight years' follow up was significantly better for group B (84%; 95% CI, 68% to 93%) than for group A (45%; 95% CI, 30% to 60%), because of improved outcome for both immunosuppressive treatment (86% v 39%) and bone marrow transplantation (93% v 56%). There was no evidence for late clonal disorders or secondary malignancies in survivors in either group. The prognosis for aplastic anaemia has improved greatly in recent years so that over 80% of children are long term survivors.

Psychological disturbance in children with haemophilia

OBJECTIVE

To assess the need for formal psychotherapeutic intervention in children attending a children's haemophilia clinic after some of them had been diagnosed as positive for HIV.

DESIGN

Comparison of haemophiliac children with matched control groups of diabetic and healthy children.

SETTING

The West of Scotland Children's Haemophilia Centre, Glasgow.

PATIENTS

43 Children aged 3 to 16 years with mild, moderate, and severe clotting disorders were matched with control groups of 46 diabetic children and 42 physically healthy children.

INTERVENTIONS

Parents of children aged 3-5 years were interviewed with the behaviour screening questionnaire. Children aged 6 to 16 were assessed by parental and teacher report using standardised questionnaires and self report using a computerised depression inventory. All were scored numerically according to the presence of symptoms of emotional and behavioural problems.

MAIN OUTCOME MEASURES

The groups were compared for mean scores on each rating device and for number of children achieving scores within the pathological range.

RESULTS

In the 6-16 age group five haemophiliac children, five diabetic children, and three healthy children scored in the pathological range on the parent questionnaire, as did two, three, and five respectively on the teacher questionnaire and four, four, and eight on the depression inventory. There was no significant difference across the three groups. Analysis of mean scores similarly showed no significant difference across groups. In contrast, the single measure used for younger children showed an increase in behavioural difficulties among the diabetic children.

CONCLUSION

Haemophiliac children attending the West of Scotland Centre were no more disturbed than their diabetic or healthy peers despite the identification of HIV infection within the clinic and the widespread adverse publicity associated with AIDS and HIV infection.

Recurrent thrombocytopenic purpura associated with accessory spleen

In the case of a boy with a relapsed thrombocytopenic purpura removal of a splenunculus, shown by radioisotope scanning, resulted in a partial remission. The significance of the association of relapse in ITP and the presence of splenunculi remains unknown: investigation of similar cases would clarify the matter.

The c-ets-1 proto-oncogene is rearranged in some cases of acute lymphoblastic leukaemia

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Visceral leishmaniasis: rapid response to AmBisome treatment

There appears to be an increase in imported cases of visceral leishmaniasis in Northern Europe; many are children infected on holiday in the Mediterranean. Making the diagnosis in young children can be difficult especially when an adequate travel history is not obtained at presentation. Two infants with visceral leishmaniasis are presented who were initially felt to have alternative diagnoses and who subsequently responded dramatically to a short course of liposomal amphotericin B (AmBisome).

Relevance of circulating immune complexes in childhood acute lymphoblastic leukaemia

Circulating immune complexes have been measured using the (125I)C1q binding test in 216 sera from 135 children with acute lymphoblastic leukaemia. Increased circulating immune complexes were detectable in 10.7% of the sera and 10.4% of the children. There was no correlation between the presence of circulating immune complexes and prognosis, but a strong correlation with a history of recent infection.

Late functioning adrenocortical carcinoma in a 5-year-old girl

A 5-year-old with adrenocortical carcinoma presented with acute paraplegia. The tumour was initially nonfunctioning but finally showed rapid dissemination and the patient then developed Cushingoid features and virilisation.

Application of three intragenic DNA polymorphisms for carrier detection in haemophilia B

In the west of Scotland use of a single intragenic restriction fragment length polymorphism (F9(VIII)/TaqI) allowed definitive genetic counselling for 45% of females at risk of being carriers for haemophilia B. Two further intragenic RFLPs, F9(VIII)/XmnI) and F9(VIII)/DdeI, have been applied to this population and by using all three polymorphisms the carrier status could be determined in 68% of females at risk. Linkage disequilibrium was apparent between these three RFLPs, and in the west of Scotland the single most clinically useful polymorphism was F9(VIII)/TaqI followed by F9(VIII)/DdeI and then F9(VIII)/XmnI. Overall, prenatal diagnosis by DNA analysis could be offered to 31 of 37 (84%) carriers (obligate and detected) in these families.

Application of an intragenic genomic probe to genetic counselling for haemophilia B in the west of Scotland

Total ascertainment revealed 28 families with haemophilia B in the west of Scotland (prevalence 1/26 870 males). In 12 of these families more than one person was affected and 26 living obligate carriers were identified and tested. Of these, 42% were heterozygous for a DNA polymorphism recognised by a factor IX genomic probe. No recombination was observed in 11 phase known and four phase unknown informative meioses. Definitive genetic counselling was possible for 14 of 42 females at risk, 11 could not be traced, in 10 the probe was not informative, and in seven paternal absence prevented interpretation. Linkage disequilibrium was apparent for this restriction fragment length polymorphism and haemophilia B in the west of Scotland.

The clinical significance of blast cell morphology in childhood lymphoblastic leukaemia

The morphological classification of ALL based on the FAB co-operative group's criteria is capable of identifying 10-15% of children with L2 disease who, given similar treatment, will fare less well than the 85-90% with the L1 variant. The significant features defining L2 morphology are a low cellular nuclear: cytoplasmic ratio and the presence of nucleoli. Children with L2 disease do not have higher leucocyte counts but are older, have "common" ALL less frequently, and more often have well-preserved marrow function at diagnosis. Their poor outlook is manifest not only by their higher relapse rate but also by a higher proportion failing to remit in the first instance. L2 morphology does not necessarily "breed true" and can arise in a small proportion of patients with previous L1 disease at the time of relapse. Other striking morphological features of lymphoblasts, including azurophil granules, vacuoles and "hand mirror" cells, have yet to have their significance defined, though the latter feature may be an unfavourable finding.

Carcinoid syndrome: an unusual cause of diarrhoea

A 9 year old girl underwent laparotomy because of intermittent diarrhoea, present since infancy. Histology of a mass at the head of pancreas and multiple hepatic nodules suggested an apudoma. Plasma serotonin and urinary excretion of 5 hydroxy indole acetic acid were raised. The child is asymptomatic four years after diagnosis.

Bone marrow necrosis in acute lymphoblastic leukaemia

Bone marrow necrosis, an uncommon finding in acute lymphoblastic leukaemia, has previously been regarded as a poor prognostic feature. It has been associated with difficulty in establishing the diagnosis, a low rate of remission as well as short remission duration. We report a case of bone marrow necrosis in a girl with acute lymphoblastic leukaemia and good prognostic features who attained complete remission uneventfully and will discuss previous reports of this association in the literature.

Haemoglobin and prognosis in childhood acute lymphoblastic leukaemia

Two hundred and nine children presenting consecutively with acute lymphoblastic leukaemia to a regional paediatric oncology unit were investigated to determine the prognostic significance of various factors at diagnosis. There was a strong positive correlation between the pretreatment haemoglobin level and the percentage of bone marrow blast cells in S phase of the cell cycle as assessed by flow cytometry. Patients with T- and B-cell leukaemia had significantly higher haemoglobin levels than non-B non-T patients. In patients with total white cell counts less than 20 X 10(9)/l, aged less than 13 years, and no mediastinal mass, there was no association of haemoglobin with length of first remission. However, among those with white blood counts greater than 20 +/- 10(9)/l there was a strong positive trend towards shorter remission with higher haemoglobin levels. Children with high white blood counts at diagnosis and low haemoglobin levels may have a better prognosis than predicted by the white blood count alone.

Prognostic significance of cell surface markers in childhood acute lymphoblastic leukaemia

Examination of surface markers on leukaemic blasts from 51 children with ALL revealed that ALL is a heterogeneous disease. The majority (68%) of patients with ALL lack surface markers (null leukaemia); 28% could be classed as T cell as they form rosettes with sheep RBC and 4% have been shown to possess surface immunoglobulins and hence are classed as B cells. The children with null cell leukaemia have a better prognosis than T and B cell types.

Acquired aplastic anaemia: still a serious disease

Over 15 years, 42 children aged 2-14 years were diagnosed as having acquired aplastic anaemia. Adequate clinical details were available for 38 children who were categorised as very severe (n = 13), severe (n = 16), or nonsevere (n = 9) by the modified Camitta criteria. Treatment varied over the study period. Seven children received a bone marrow allograft from a full match family donor and three a matched unrelated donor transplant after failed treatment with antilymphocyte globulin. The remainder were treated with antilymphocyte globulin (n = 11), antilymphocyte globulin and oxymetholone (n = 4), oxymetholone with or without prednisolone (n = 12), or supportive treatment alone (n = 1). With a minimum follow up of one year since treatment, the five year survival was 70% for bone marrow transplantation with a family donor, 30% for antilymphocyte globulin, and 25% for oxymetholone. All three children with a matched unrelated donor transplant died. The prognosis of acquired aplastic anaemia remains poor for most children and new approaches to treatment are urgently required.

Prophylactic studies against herpes infections in severely immunocompromised patients with acyclovir

A total of 59 patients, including 20 undergoing bone marrow transplantation (BMT) and 39 who were receiving cytotoxic chemotherapy (CT), were included in a placebo-controlled trial of intravenous acyclovir as a prophylactic against herpes simplex virus infections. Fifty per cent of the patients (both BMT and CT) receiving placebo developed herpes simplex virus infections; in those receiving acyclovir, none of the BMT group and 10 per cent of the CT group became infected with herpes simplex. Prevention of herpes infections in the immunosuppressed is clearly both desirable and, in the case of herpes simplex virus, attainable.

Paediatric myelodysplasia

Myelodysplastic syndromes (MDS) in childhood comprise a heterogeneous group of disorders, many of which respond poorly to intensive chemotherapy; the only curative treatment for these is bone marrow transplant (BMT). There are, however, some types of paediatric MDS with a slower, more indolent course, and it is important to differentiate these and tailor treatment accordingly. The prognosis for children with MDS who have a matched sibling BMT is improving and, as experience of unrelated donor BMT is gained, this treatment modality is likely to become available for the majority of the remainder.

The effect on human neuroblastoma spheroids of fractionated radiation regimes calculated to be equivalent for damage to late responding normal tissues

Multicellular tumour spheroids (MTS) are a useful in vitro model of human cancer. An experiment was designed to assess the likely therapeutic advantage of hyperfractionation--a proposed strategy in radiotherapy. A cell line (NB1-G) derived from human neuroblastoma was grown as MTS. This MTS line is radiosensitive with low capacity for repair of sublethal radiation damage. These properties make NB1-G a suitable line to test the theoretical advantage of hyperfractionation. MTS were irradiated using alternative fractionated regimens, with fraction sizes varying from 0.5 to 4 Gy. In each experiment, the total dose was chosen to make the regimens theoretically isoeffective for damage to late-responding normal tissues (calculated using the linear-quadratic mathematical model with alpha/beta = 3 Gy). The radiation responses of MTS were evaluated using the end-points of regrowth delay and "proportion cured". Regimens using smaller doses per fraction were found to be markedly more effective in causing damage to neuroblastoma MTS, as assessed by either end-point. These experimental findings support the proposal that hyperfractionation should be a therapeutically advantageous strategy in the treatment of tumours whose radiobiological properties are similar to those of the MTS neuroblastoma line NB1-G.