CTLA-4, position 49 A/G polymorphism associated with coronary artery lesions in Kawasaki disease

OBJECTIVE

Kawasaki disease (KD) is a systemic vasculitis of unknown etiology and primarily affects children less than 5 years of age. Cytotoxic T lymphocyte-associated antigen-4 (CTLA-4) has been suggested as a candidate gene for conferring susceptibility to autoimmunity. This study examined the correlation of CTLA-4 gene polymorphisms in KD with and without coronary artery lesions (CAL).

MATERIALS AND METHODS

A total of 233 KD patients and 644 controls were subjected to determination of CTLA-4 polymorphisms at (-318) C/T and (+49) A/G positions by restriction fragment length polymorphism. Susceptibility, CAL, and intravenous immunoglobulin treatment response of KD were then analyzed with genetic variants.

RESULTS

Polymorphisms of CTLA-4 (+49 A/G) and (-318 C/T) were not significantly different between normal children and patients with KD. The CTLA-4 (+49) A allele (AA+AG genotype), however, was significantly associated with CAL formation, especially in female patients.

CONCLUSIONS

This study provides the first evidence supporting the association of CTLA-4 (+49) A/G polymorphism with the CAL formation of KD particularly in female patients.

Revisiting human IL-12Rβ1 deficiency: a survey of 141 patients from 30 countries

Interleukin-12 receptor β1 (IL-12Rβ1) deficiency is the most common form of Mendelian susceptibility to mycobacterial disease (MSMD). We undertook an international survey of 141 patients from 102 kindreds in 30 countries. Among 102 probands, the first infection occurred at a mean age of 2.4 years. In 78 patients, this infection was caused by Bacille Calmette-Guérin (BCG; n = 65), environmental mycobacteria (EM; also known as atypical or nontuberculous mycobacteria) (n = 9) or Mycobacterium tuberculosis (n = 4). Twenty-two of the remaining 24 probands initially presented with nontyphoidal, extraintestinal salmonellosis. Twenty of the 29 genetically affected sibs displayed clinical signs (69%); however 8 remained asymptomatic (27%). Nine nongenotyped sibs with symptoms died. Recurrent BCG infection was diagnosed in 15 cases, recurrent EM in 3 cases, recurrent salmonellosis in 22 patients. Ninety of the 132 symptomatic patients had infections with a single microorganism. Multiple infections were diagnosed in 40 cases, with combined mycobacteriosis and salmonellosis in 36 individuals. BCG disease strongly protected against subsequent EM disease (p = 0.00008). Various other infectious diseases occurred, albeit each rarely, yet candidiasis was reported in 33 of the patients (23%). Ninety-nine patients (70%) survived, with a mean age at last follow-up visit of 12.7 years ± 9.8 years (range, 0.5-46.4 yr). IL-12Rβ1 deficiency is characterized by childhood-onset mycobacteriosis and salmonellosis, rare recurrences of mycobacterial disease, and more frequent recurrence of salmonellosis. The condition has higher clinical penetrance, broader susceptibility to infections, and less favorable outcome than previously thought.

Partial protein-hydrolyzed infant formula decreased food sensitization but not allergic diseases in a prospective birth cohort study

BACKGROUND

Exposure to cow's milk protein in early infancy could lead to increased rates of allergic diseases later in life. We investigated whether feeding a protein-hydrolyzed formula (HF) in the first 6 months of life decreased allergic diseases up to 36 months later.

METHODS

Newborns who had at least 1 first-degree family member with a history of atopy and could not breast-feed were enrolled. They were fed with HF or cow's milk infant formula (CM) for at least 6 months via an open-label protocol and were monitored prospectively at 6, 18 and 36 months of age to assess allergy sensitization and allergic diseases.

RESULTS

A total of 1,002 infants were enrolled and 679 infants were consistently fed the same formula for the first 6 months of life (345 HF and 334 CM). The percentage of food sensitization (especially to milk protein) was significantly lower in the HF group than in the CM group at 36 months (12.7 vs. 23.4%, p = 0.048). There was no significant difference in the prevalence of aeroallergen sensitization between the groups. Occurrence of allergic diseases during the first 3 years of life was significantly correlated with aeroallergen sensitization, but not to food allergen sensitization, parental atopy or feeding types.

CONCLUSIONS

Infants fed with HF during the first 6 months of life had a significantly lower percentage of sensitization to milk protein allergens, but not allergic diseases during the first 3 years of life. Avoidance of cow's milk protein alone in infancy is not enough to decrease rates of allergic diseases.

Comparison of the Global Initiative for Asthma guideline-based Asthma Control Measure and the Childhood Asthma Control Test in evaluating asthma control in children

BACKGROUND

Reliable assessment of asthma control is essential for effective treatment. While several validated tools for assessing asthma control in children are currently available, few studies have evaluated the correlations between different asthma control measures in children. This study aimed to determine the correlations between the Childhood Asthma Control Test (C-ACT) and the Global Initiative for Asthma (GINA) guideline-based asthma control measure (ACM) with lung function parameters in children with asthma.

METHODS

Sixty-three children aged 6-11 years with mild-intermittent to severe-persistent asthma were evaluated. They completed the C-ACT, the GINA guideline-based assessment and lung function tests with the help of their caregivers.

RESULTS

C-ACT scores and GINA guideline-based ACM were positively correlated. The average C-ACT scores for children with controlled, partly controlled and uncontrolled asthma according to the GINA guidelines were 24.4±0.3, 22.8±0.6 and 21.3±1.0 (mean±SE), respectively. High C-ACT scores were also noted in children with uncontrolled asthma based on the GINA guidelines. The GINA guideline-based ACM was correlated with spot spirometry parameters (forced vital capacity, forced expiratory volume in 1 second, and maximal mid-expiratory flow). Conversely, the C-ACT score was not correlated with these spirometry parameters.

CONCLUSIONS

The C-ACT may overestimate asthma control in certain circumstances. For children with poorly controlled asthma or poor symptom perception, more frequent visits and serial pulmonary function tests are recommended.

Serum albumin level predicts initial intravenous immunoglobulin treatment failure in Kawasaki disease

OBJECTIVES

Kawasaki disease (KD) is a systemic vasculitis primarily affecting children who are <5 years old. Intravenous immunoglobulin (IVIG) is the standard therapy for KD. However, many patients with KD still show poor response to initial IVIG treatment. This study was conducted to investigate the risk factors for initial IVIG treatment failure in KD.

METHODS

Children who met KD diagnosis criteria and were admitted for IVIG treatment were retrospectively enrolled for analysis. Patients were divided into IVIG-responsive and IVIG-resistant groups. Initial laboratory data before IVIG treatment were collected for analysis.

RESULTS

A total of 131 patients were enrolled during the study period. At 48 h after completion of initial IVIG treatment, 20 patients (15.3%) had an elevated body temperature. Univariate analysis showed that patients who had initial findings of high neutrophil count, abnormal liver function, low serum albumin level (≤2.9 g/dL) and pericardial effusion were at risk for IVIG treatment failure. Multivariate analysis with a logistic regression procedure showed that serum albumin level was considered the independent predicting factor of IVIG resistance in patients with KD (p = 0.006, OR = 40, 95% CI: 52.8-562). There was no significant correlation between age, gender, fever duration before IVIG treatment, haemoglobin level, total leucocyte and platelet counts, C-reactive protein level, or sterile pyuria and initial IVIG treatment failure. The specificity and sensitivity for prediction of IVIG treatment failure in this study were 96% and 34%, respectively.

CONCLUSION

Pre-IVIG treatment serum albumin levels are a useful predictor of IVIG resistance in patients with KD.

MicroRNA-21 expression in neonatal blood associated with antenatal immunoglobulin E production and development of allergic rhinitis

BACKGROUND

The prevalence of allergic diseases has increased in the past decades. It is unknown whether expression of certain microRNAs (miRNAs) in neonatal leucocytes is correlated to IgE production and/or allergic diseases.

OBJECTIVE

This study investigated the association of miRNA expression in neonatal leucocytes with cord blood IgE (CBIgE) elevation and development of allergic disease.

METHODS

We screened for the expression of a panel of 157 miRNAs in mononuclear leucocytes from human umbilical cord blood (CB) samples with elevated CBIgE and tracked the association of down-regulated miRNA expression to the miRNA-targeted gene expression and to children with allergic rhinitis (AR).

RESULTS

Among the initial screen of 10 CB samples with elevated CBIgE, expression of eight of the 157 miRNAs was low. Of these eight down-expressed miRNAs, three remained down-regulation in a validation with other 20 CB samples, and two of the three miRNAs, miR-21 and miR-126, were significantly lower in monocytes from AR children. Further analysis of mRNA expression of the miR-21-targeted genes identified that TGFBR2 expression on monocytes was significantly up-regulated in CB with elevated CBIgE, and in AR patients. Transfection of miR-21 precursor into monocytes from patients with AR increased miR-21 expression and decreased TGFBR2 expression.

CONCLUSION

This study demonstrated the first in the literature that lower miR-21 expression in CB and increased TGFBR2 expression is associated with antenatal IgE production and development of AR.

Correlation of pandemic (H1N1) 2009 viral load with disease severity and prolonged viral shedding in children

Pandemic (H1N1) 2009 virus causes severe illness, including pneumonia, which leads to hospitalization and even death. To characterize the kinetic changes in viral load and identify factors of influence, we analyzed variables that could potentially influence the viral shedding time in a hospital-based cohort of 1,052 patients. Viral load was inversely correlated with number of days after the onset of fever and was maintained at a high level over the first 3 days. Patients with pneumonia had higher viral loads than those with bronchitis or upper respiratory tract infection. Median viral shedding time after the onset of symptoms was 9 days. Patients <13 years of age had a longer median viral shedding time than those >or=13 years of age (11 days vs. 7 days). These results suggest that younger children may require a longer isolation period and that patients with pneumonia may require treatment that is more aggressive than standard therapy for pandemic (H1N1) 2009 virus.

Gene-gene and gene-environment interactions on IgE production in prenatal stage

BACKGROUND

Prevalence of allergic diseases in children has increased worldwide over the past decades. Allergy sensitization may occur in fetal life. This study investigated whether gene-gene and gene-environment interactions affected cord blood IgE (CBIgE) levels.

METHODS

A total of 575 cord blood DNA samples were subjected to a multiplex microarray for 384 single nucleotide polymorphisms (SNPs) in 159 allergy candidate genes. Genetic association was initially assessed by univariate and multivariate analyses. Multifactor dimensionality reduction (MDR) was used to identify gene-gene and gene-environment interactions. Environmental factors for analysis included maternal atopy, paternal atopy, parental smoking, gender, and prematurity.

RESULTS

Twenty-one SNPs in 14 genes were associated with CBIgE elevation (>or =0.5 KU/l) in univariate analysis. Multivariate analysis identified eleven genes (IL13, IL17A, IL2RA, CCL17, CXCL1, PDGFRA, FGF1, HAVCR1, GNAQ, C11orf72, and ADAM33) which were significantly associated with CBIgE elevation. MDR analyses of gene-gene interactions identified IL13 interacted with IL17A and/or redox genes on CBIgE elevation with the prediction accuracy of 62.52%. Analyses of gene-environment interactions identified that maternal atopy combined with IL13, rs1800925 and CCL22, rs170359 SNPs had the highest prediction accuracy of 67.15%. All the high and low risk classifications on gene-gene and gene-environment interactions by MDR analyses could be validated by Chi-square test.

CONCLUSIONS

Gene-gene (e.g. immune and redox genes) and gene-environment (e.g. maternal atopy and FGF1or redox genes) interactions on IgE production begin in prenatal stage, suggesting that prevention of IgE-mediated diseases may be made possible by control of maternal atopy and redox responses in prenatal stage.

miR-146b is highly expressed in adult papillary thyroid carcinomas with high risk features including extrathyroidal invasion and the BRAF(V600E) mutation

BACKGROUND

Papillary thyroid carcinoma (PTC) are clinicopathogenetically heterogeneous. Micro-RNAs (miRNAs) are involved in the pathogenesis of diverse human cancers, including PTC. Information regarding associations between clinicopathological features of PTC with the expression of specific miRNAs, however, is sparse. In this study, we compared expression of deregulated miRNAs in PTCs to assess this was associated with selected clinicopathogenetic features.

METHODS

We analyzed the expression levels of three reported deregulated miRNAs (miR-221, miR-222, and miR-146b) using quantitative real-time polymerase chain reaction in 100 cases of PTCs with distinct clinicopathogenetic characteristics and 16 paired normal controls. The tumor samples were categorized into low- and high-risk groups on the basis of the tumor-node-metastasis staging system.

RESULTS

The expression levels of miR-221, miR-222, and miR-146b were significantly associated with extrathyroidal invasion (p = 0.013, 0.05, and 0.003, respectively). The expression levels of miR-221 and miR-146b were significantly higher in the high-risk PTC group (p = 0.01 and 0.042, respectively). The miR-146b expression levels in PTCs with BRAF mutation were significantly higher than those without this mutation (p < 0.0001). There were no other associations between the expression of these miRNAs and other clinicopathological parameters.

CONCLUSIONS

Our results show the potential importance of miR-221, miR-222, and miR-146b in determining the aggressive properties of PTCs and highlight the need to identify the gene targets of these miRNAs.

Extracorporeal shockwave for hip necrosis in systemic lupus erythematosus

Patients with systemic lupus erythematosus (SLE) frequently received corticosteroid therapy, resulting in osteonecrosis of the femoral head (ONFH). Prior studies demonstrated the effectiveness of extracorporeal shockwave treatment (ESWT) for ONFH.. This study evaluated the effectiveness of ESWT for ONFH in patients with SLE. We studied 39 patients, including 15 patients with SLE (26 hips) and 24 controls (29 hips). To each affected hip we applied ESWT (6000 impulses at 28 kV in a single session). Patients were ambulated with partial weight bearing for 4-6 weeks. The primary endpoint was the need for hip replacement. The secondary endpoints were improvement in hip pain and function and image changes on X-ray and MRI. Patients received total hip replacement in 12% of patients with SLE and in 14% of controls (P = 0.802). There was no statistically significant difference in pain scores (0.86 vs. 0.89; P = 0.467) and function scores (89% vs. 91%; P = 0.194) between patients with SLE and controls. SLE response to ESWT for ONFH is comparable with ONFH in patients without SLE.

Cocktail therapy for femoral head necrosis of the hip

INTRODUCTION

Cocktail therapy consists of extracorporeal shock wave treatment (ESWT), hyperbaric oxygen therapy (HBO) and alendronate. We hypothesized that this combined therapy may produce better results than ESWT alone when treating hip necrosis.

METHODS

This prospective, randomized study evaluated the effectiveness of cocktail therapy in early hip necrosis, and then compared it to shock wave treatment alone. Sixty-three patients (98 hips) were randomly divided into two groups. Group A consisted of 28 patients (50 hips) who received cocktail therapy, and group B consisted of 35 patients (48 hips) who received only ESWT. Each affected hip was treated with 6,000 shocks of ESWT at 28 kV (equivalent to 0.62 mJ/mm2) in a single session. Cocktail patients also received HBO therapy performed in a multi-place chamber daily for 20 treatments, and they were administered 70 mg of alendronate orally per week for 1 year. The evaluations included clinical assessment, radiograph and MRI.

RESULTS

After a minimum of 2-years of follow-up, the overall results showed 74% improved, 16% unchanged and 10% worsened in group A; and 79.2% improved, 10.4% unchanged and 10.4% worsened in group B (P = 0.717). Total hip replacement (THR) was performed for 10% of group A and 10.4% of group B (P = 0.946). MRI showed significant reduction in bone marrow edema and a trend of decrease in the size of the lesions in both groups, however, no difference was noted between the two groups. Cocktail therapy is effective for early hip necrosis, but the results are comparable to ESWT in short-term follow up. The joint effects of HBO and alendronate over EWST were not observed.

CONCLUSION

Long-term results are needed to determine whether or not the synergistic effects of ESWT, HBO and alendronate over ESWT alone exist in early hip necrosis.

Prolonged acquired neutropenia in children

BACKGROUND

Acquired neutropenia is not uncommon in childhood. This study investigated the risk factors associated with developing prolonged acquired neutropenia.

PROCEDURE

We reviewed 66,062 hospital admission medical records from the 5-year period January 1, 2002 to December 31, 2006 to identify neutropenic patients, with and without follow-up of their neutropenic course until December 31, 2007. After excluding patients with malignancy, collagen disease, bone marrow failure, prematurity, hereditary disease, congenital neutropenia, immunodeficiency, or status post-liver transplantation, 735 admissions with acquired neutropenia were included in our study.

RESULTS

A total of 474 patients with 735 admissions had moderate or severe neutropenia during the 5-year period. Among the 252 acquired neutropenia patients who had follow-up for at least 1 month, 226 patients recovered within 3 months, while 26 patients remained neutropenic after 3 months. Of these 26 patients, 14 recovered after 1 year. An absolute neutrophil count of <500/mm(3) (odds ratio [OR]: 13.66, 95% confidence interval [CI]: 2.90-64.41), thrombocytosis (OR: 5.76, 95% CI: 1.78-18.58), and age <1 year (OR: 4.93, 95% CI: 1.03-23.54) were associated with prolonged acquired neutropenia, as shown by multivariate logistic regression. Kaplan-Meier analysis showed that neutropenia associated with cytomegalovirus (CMV) was more prolonged than neutropenia associated with influenza or Epstein-Barr virus infection.

CONCLUSIONS

Prolonged acquired neutropenia was associated with younger age, thrombocytosis, and CMV infection. Neutropenic infants with CMV infection may require antiviral therapy to prevent prolonged acquired neutropenia.

Increased complement factor H with decreased factor B determined by proteomic differential displays as a biomarker of tai chi chuan exercise

BACKGROUND

Exhaustive exercise can be associated with short-term immune suppression, but moderate exercise such as tai chi chuan (TCC) has been shown to have beneficial effects on immunity. The mechanisms for the health benefits of exercise remain to be determined, and no potential biomarkers for these beneficial health effects have been identified. This study investigated serum proteomic markers in individuals participating in TCC exercise.

METHODS

Two-dimensional fluorescence difference gel electrophoresis was used to compare proteomic markers in 3 individuals before and after 12 weeks of TCC exercise. The different protein spots were identified by mass spectrometry and validated in an additional 20 individuals by western blot analysis.

RESULTS

We identified 39 protein spots for 18 proteins with a noticeable increase or decrease after TCC exercise. Validation of the differentially displayed proteins with 20 paired pre- and postexercise samples revealed a significant increase in complement factor H (P = 0.0034) associated with decreases in C1 esterase inhibitor (P = 0.0038) and complement factor B (P = 0.0029).

CONCLUSIONS

In this first study of proteomic biomarkers of TCC exercise, we found an increase in complement factor H associated with a decrease in complement factor B. Complement factor H is involved in protection from microangiopathy and macular degeneration and may represent a useful marker of the health effects of exercise.

A unique plasma proteomic profiling with imbalanced fibrinogen cascade in patients with Kawasaki disease

Kawasaki disease (KD) is the leading cause of acquired heart disease during childhood in the developed countries. The mechanism and biomarkers of KD remain to be determined. In this study, we sought to elucidate potential plasma proteomic markers in KD patients in comparison to that in febrile controls. Plasma samples from KD patients and febrile controls were subjected to two-dimensional polyacrylamide gel electrophoresis analysis. Differential protein displays between KD patients and febrile controls were determined. Fibrinogen beta and gamma chains, alpha-1-antitrypsin (A1AT), CD5 antigen-like precursor (CD5L), and clusterin were increased in KD patients, whereas immunoglobulin free light chains were decreased, as compared with controls. The differential protein displays were validated with enzyme-linked immunosorbent assay tests. We found higher fibrinogen-related proteins (fibrinogen, A1AT, clusterin, and CD5L), along with a lower level of the immunoglobulin free light chains that involve fibrin degradation in KD. Results from this study showing a unique proteomic profiling with abnormal fibrinogen cascade may afford a good biomarker of KD and a better strategy to prevent cardiovascular complications of KD by correcting abnormal fibrin deposition or degradation.

Association of acute urticaria with Mycoplasma pneumoniae infection in hospitalized children

BACKGROUND

Acute urticaria is a common and disturbing disorder in children and has a versatile etiology.

OBJECTIVE

To investigate the association of acute urticaria with Mycoplasma pneumoniae infection in hospitalized children.

METHODS

Hospitalized children with acute urticaria from Taiwan who did not respond to antihistamine treatment and avoidance of food allergens were studied from February 1, 2006, to July 31, 2007. These patients with urticaria were compared with those who had other respiratory tract diseases and were classified into 2 groups: urticaria patients with and without M pneumoniae infection. The presence of M pneumoniae infection was determined by positive serologic findings.

RESULTS

Sixty-five patients with acute urticaria and 49 patients with other respiratory tract diseases were enrolled in this study. Patients with urticaria had significantly less febrile duration but significantly higher platelet and lymphocyte counts than those with other respiratory tract diseases. Of the 65 patients with urticaria, 21 (32%) showed serologic evidence of M pneumoniae infection. Patients with M pneumoniae-associated urticaria received azithromycin treatment and needed a shorter time for improvement (P = .01) and complete resolution (P = .04). The total IgE levels and the results of specific IgE tests were not significantly different between urticaria patients with and without M pneumoniae infection.

CONCLUSION

This study found that in Taiwan one-third of acute childhood urticaria leading to patient hospitalization was related to M pneumoniae infection. Therefore, children with urticaria who are not responding to antihistamine treatment and abstinence from food allergens should be encouraged to undergo serologic examinations for M pneumoniae to diagnose this antibiotic-responsive disorder.

Sialylated glycans as receptor and inhibitor of enterovirus 71 infection to DLD-1 intestinal cells

Background

Many viruses recognize specific sugar residues, particularly sulfated or sialylated glycans, as the infection receptors. A change of sialic acid (2-6)-linked galactose (SA-α2,6Gal) to SA-α2,3Gal determines the receptor for avian flu infection. The receptor for enterovirus 71 (EV71) infection that frequently causes fatal encephalitis in Asian children remains unclear. Currently, there is no effective vaccine or anti-virus agent for EV71 infection. Using DLD-1 intestinal cells, this study investigated whether SA-linked glycan on DLD-1 intestinal cells was a receptor for EV71, and whether natural SA-linked sugars from human milk could block EV71 infection.

Results

EV71 specifically infected DLD-1 intestinal cells but not K562 myeloid cells. Depletion of O-linked glycans or glycolipids, but not N-linked glycans, significantly decreased EV71 infection of DLD-1 cells. Pretreatment of DLD-1 cells with sialidase (10 mU, 2 hours) significantly reduced 20-fold EV71 replication (p < 0.01). Taken together, these results suggest that SA-linked O-glycans and glycolipids, but not N-glycans, on DLD-1 cells were responsible for EV71 infection. Purified SA-α2,3Gal and SA-α2,6Gal from human milk significantly inhibited EV71 infection of DLD-1 cells, indicating terminal SA-linked glycans could be receptors and inhibitors of EV71 infection.

Conclusion

This is the first in the literature to demonstrate that EV71 uses SA-linked glycans as receptors for infection, and natural SA-linked glycans from human milk can protect intestinal cells from EV71 infection. Further studies will test how a SA-containing glycan can prevent EV71 in the future.

Extracorporeal shock wave treatment modulates skin fibroblast recruitment and leukocyte infiltration for enhancing extended skin-flap survival

Extracorporeal shock wave (ESW) treatment has a positive effect of rescuing ischemic skin flaps. This study assessed whether ESW treatment rescues the compromised flap tissue by suppressing the apoptosis of ischemic tissue and recruiting tissue remodeling. We used a random-pattern extended dorsal-skin-flap (10 x 3 cm) rodent model. Thirty-six male Sprague-Dawley rats were divided into three groups. Group I, the control group, received no treatment. Group II received one session of ESW treatment (500 impulses at 0.15 mJ/mm(2)) immediately after surgery. Group III received two sessions of ESW treatment, immediately and the day after the surgery. Results indicated that the necrotic area in the flaps in group II was significantly smaller than that of the flaps in group I (p<0.01). Transferase dUTP-nick end labeling (TUNEL) analysis revealed a significant decrease in the number of apoptotic cells in group II. Hydrogen peroxide (H(2)O(2)) expression in circulation blood was significantly decreased in group II on the day after ESW treatment. Immunohistochemical staining indicated that compared with no treatment, ESW treatment could substantially increase proliferating cell nuclear antigen (PCNA), endothelial nitric oxide synthase, and prolyl 4-hydroxylase (rPH) expression, reduce CD45 expression, and suppress 8-hydroxyguanosine (8-OG) expression in the ischemic zone of the flap tissue. In conclusion, ESW treatment administered at an optimal dosage exerts a positive effect of rescuing ischemic extended skin flaps. The mechanisms of action of ESWs involve modulation of oxygen radicals, attenuation of leukocyte infiltration, decrease in tissue apoptosis, and recruitment of skin fibroblasts, which results in increased flap tissue survival.

Association of lower eosinophil-related T helper 2 (Th2) cytokines with coronary artery lesions in Kawasaki disease

Kawasaki disease (KD) is a systemic febrile vasculitis particular coronary artery involvement. Eosinophilia has been found in our and other studies in KD. This study further investigates whether eosinophil-related T helper 2 (Th2) cytokines or the activation marker (eosinophil cationic protein - ECP) is involved in KD with coronary artery lesions (CAL). A total of 95 KD patients were enrolled for this study. Plasma samples were subjected to the measurement of interleukin (IL)-4, IL-5, and eotaxin by Luminex-Bedalyte multiplex beadmates system and to the measurement of ECP by fluoroimmunoassay. Patients with KD had higher eosinophils than controls. Eosinophil-related mediators: IL-4, IL-5, eotaxin, and ECP levels were also higher in KD patients than controls before intravenous immunoglobulin (IVIG) treatment. After IVIG treatment, ECP decreased but IL-4, IL-5, and eotaxin increased significantly. The higher the IL-5 and eosinophil levels after IVIG treatment, the lower rate of CAL was found. Changes of eosinophils after IVIG treatment were positively correlated to changes of IL-5 levels but not ECP levels. An increase of eosinophils and IL-5, but not ECP levels after IVIG treatment, was inversely correlated with CAL formation in KD.

Non-Langerhans cell histiocytosis in a child with Kawasaki disease

Polymorphous skin rashes are one of the major presentations in children with Kawasaki disease. This report describes an unusual presentation of a skin rash (non-Langerhans cell histiocytosis) in a 4-month-old baby with resistance to intravenous immunoglobulin (IVIG) treatment and coronary artery dilatation. Though refractory to repeat dosages of IVIG treatment, the patient had a favourable response to methylprednisolone pulse therapy.

Aminoguanidine alleviates radiation-induced small-bowel damage through its antioxidant effect

PURPOSE

To evaluate the effect and its mechanism of aminoguanidine (AG) on small-bowel protection after whole-abdominal irradiation (WAI) in rats.

METHODS AND MATERIALS

Male Sprague-Dawley rats (300-400 g) subjected to 12 Gy WAI were used for the study. Aminoguanidine at a dose of 50-800 mg/kg was administered by the gavage route 2 h before WAI. Mucosal damage of small bowel was evaluated by the grade of diarrhea and crypt survival; oxidative stress was determined by the level of 8-hydroxy 2'-deoxyguanosine (8-OHdG) with immunohistochemistry (IHC). Nitrosative stress was evaluated by the expression of inducible nitric oxide synthase (iNOS) and 3-nitrotyrosine (3-NT) with IHC, and systemic and portal vein NOx (nitrite + nitrate) levels were measured and compared with and without AG treatment after WAI.

RESULTS

Aminoguanidine showed a dose-dependent effect against WAI-induced diarrhea. Aminoguanidine at a dose of 400 mg/kg had the best protective effect, from 92% to 17% (p = 0.002). Aminoguanidine increased crypt survival from 23% to 46% (p = 0.003). It also significantly attenuated 8-OHdG expression but not 3-NT and iNOS expression at both 4 and 8 h after 12-Gy WAI. Aminoguanidine did not alter the portal vein NOx levels 4 and 8 h after 12-Gy WAI.

CONCLUSION

Aminoguanidine has a radioprotective effect against radiation-induced small-bowel damage due to its antioxidant effect but not inhibition of nitric oxide production. Dietary AG may have a potentially protective effect on the small intestine of patients subjected to pelvic and abdominal radiotherapies.

Clinical characteristics, risk factors, and outcomes in adults experiencing dengue hemorrhagic fever complicated with acute renal failure

In a retrospective study, acute renal failure (ARF) was found in 10 (3.3%) among 304 hospitalized adults with dengue hemorrhagic fever (DHF), and 6 (60%) of the 10 patients with ARF died, whereas all 294 patients without ARF (controls) survived (P < 0.001). Compared with the controls, DHF patients with ARF were found to be significantly older (P = 0.002) and male predominant (P < 0.001) and to have higher frequency of previous stroke (P = 0.005), chronic renal insufficiency (P = 0.046), dengue shock syndrome (DSS; P < 0.001), gastrointestinal bleeding (P < 0.001), and concurrent bacteremia (P = 0.009), lower hemoglobin (P = 0.003) and serum albumin levels (P = 0.003), and higher incidences of prolonged prothrombin time (P < 0.001), elevated aspartate aminotransferase (P < 0.001), and alanine aminotransferase levels (P < 0.001). Multivariate analysis showed DSS (odd ratio = 220.0; P < 0.001) was an independent risk factor for development of ARF in DHF patients. The high fatality rate in DHF patients complicated with ARF in our series underscore the importance of clinicians' alertness to this potentially fatal complication so that initiation of timely appropriate treatment is possible.

Combination of CTLA-4 and TGFbeta1 gene polymorphisms associated with dengue hemorrhagic fever and virus load in a dengue-2 outbreak

The pathogenesis of dengue hemorrhagic fever (DHF) has been considered to be massive immune activation of T cells. Abnormal expression of the immune regulatory molecules, CTLA-4 and TGFbeta1, leads to disturbances of regulatory T cell immune response. We investigate the contribution of CTLA-4 and TGFbeta1 in DHF by analyzing them for association with virus load in blood and polymorphisms of CTLA-4 +49A/G, and TGFbeta1 -509C/T in a DEN-2 outbreak. The increased frequency of the TGFbeta1 -509 CC genotype in patients with DHF was compared to those with dengue fever (OR=1.9, p=0.034). Moreover, the presence of the CTLA-4 +49 G allele and TGFbeta1 -509 CC genotype increased the susceptibility to risk of DHF (OR=2.1, p=0.028) and significantly higher virus load (p=0.013). This finding suggests that a combination of CTLA-4 and TGFbeta1 polymorphisms is associated with the susceptibility of DHF and higher virus load.

Seroprevalence of SARS Coronavirus Among Residents Near a Hospital with a Nosocomial Outbreak

Background/Purpose

An epidemic of severe acute respiratory syndrome (SARS) occurred in Taiwan from April to July 2003. A nosocomial outbreak of SARS occurred at Kaohsiung Chang Gung Memorial Hospital (CGMH) in May 2003. The purpose of our study was to survey the prevalence of the SARS coronavirus (CoV) in a community adjacent to Kaohsiung CGMH and collect demographic data, including basic information about health status, household, and possible risk factors for SARS-CoV infection.

Methods

We randomly recruited 1030 persons living in three precincts adjacent to Kaohsiung CGMH. For all subjects, we collected demographic data and measured the seroprevalence of the SARS-CoV with an enzyme-linked immunosorbent assay (ELISA) and an immunofluorescence assay (IFA).

Results

The ELISA was seropositive for 124 of 1030 participants (12%). The more sensitive and specific IFA confirmed SARS in only two cases (0.19%). Both confirmed cases were under 19 years of age and had no known SARS-related risk factors.

Conclusion

There was low post-epidemic seroprevalence of SARS-CoV in a community adjacent to a hospital which had a nosocomial SARS outbreak. The SARS outbreak in Taiwan was primarily limited to hospital settings.

Treatment of osteonecrosis of the hip: comparison of extracorporeal shockwave with shockwave and alendronate

BACKGROUND AND PURPOSE

Extracorporeal shockwave therapy (ESWT) and alendronate are reported effective in early osteonecrosis of the femoral head (ONFH). We hypothesized that joint effects of ESWT and alendronate may produce superior results. This prospective study compared the results of ESWT and alendronate with that of ESWT without alendronate in early ONFH.

PATIENTS AND METHODS

Forty-eight patients with 60 hips were randomly divided into tow groups. There were 25 patients with 30 hips in group A and 23 patients with 30 hips in group B. Both groups showed similar demographic characteristics. All patients were treated with 6,000 impulses of ESWT at 28 KV (equivalent to 0.62 mJ/mm(2)) to the affected hip as a single session. Patients in group B also received alendronate 70 mg per week for 1 year, whereas patients in group A did not. The evaluations included clinical assessment, radiograph and MR image of the affected hip. Both groups were compared statistically using paired t, Mann-Whitney and Chi square tests with statistical significance at P < 0.05. The primary end point is the need for total hip arthroplasty (THA). The secondary end point is the improvement in pain and function of the hip. The third end point is the progression or regression of the lesion on image study.

RESULTS

The overall clinical outcomes were improved in 83%, unchanged in 7% and worsened in 10% for group A; and improved in 77%, unchanged in 13% and worsened in 10% for group B. THA was performed in 10% of group A and 10% of group B (P = 1.000). Significant improvements in pain and function of the hip were noted in both groups (P < 0.001), however, the differences between the two groups were not significant (P = 0.400, 0.313). On MR images, the lesions showed progression in 10%, regression in 47% and unchanged in 43% in group A, and progression in 7%, regression in 53% and unchanged in 40% in group B (P = 0.830).

CONCLUSION

ESWT and alendronate produced comparable result as compared with ESWT without alendronate in early ONFH. It appears that ESWT is effective with or without the concurrent use of alendronate. The joint effects of alendronate over ESWT in early ONFH are not realized in short-term.

Clinical and laboratory characteristics and risk factors for fatality in elderly patients with dengue hemorrhagic fever

To better understand the clinical and laboratory characteristics and to identify risk factor(s) for fatality in elderly patients with dengue hemorrhagic fever (DHF), 66 elderly (age > or = 65 years) and 241 non-elderly adults (age, 19-64 years) with DHF were retrospectively analyzed. Compared with non-elderly adults, elderly individuals had significantly lower incidences of fever (P = 0.002), abdominal pain (P = 0.003), bone pain (P < 0.001), and skin rashes (P = 0.002); higher frequencies of concurrent bacteremia (P = 0.049), gastrointestinal bleeding (P = 0.044), acute renal failure (P = 0.001), and pleural effusion (P < 0.010); higher incidence of prolonged prothrombin time (P = 0.025); lower mean hemoglobin level (P < 0.001); longer hospitalization (P = 0.049); and a higher fatality rate (P = 0.006). Five elderly patients with DHF died. When compared with non-fatal elderly patients with DHF, a significant higher frequency in men (P = 0.019), those with chronic obstructive pulmonary disease (P = 0.008), those with dengue shock syndrome (DSS; P < 0.001), and those with acute renal failure (P < 0.001) was found in the elderly counterparts that died. Multivariate analysis showed that only DSS (odd ratio = 77.33, P = 0.001) was an independent risk factor for fatality in elderly patients.

Alloantigen-pulsed host dendritic cells induce T-cell regulation and prolong allograft survival in a rat model of hindlimb allotransplantation

BACKGROUND

Composite tissue allotransplantation is restricted due to the risks presented by long-term therapeutic immunosuppression. This study is conducted to investigate whether treatment with recipient immature dendritic cells (DCs) pulsed with donor alloantigens can prolong allograft survival and induce T-cell regulation in a rodent model.

MATERIALS AND METHODS

Orthotopic hindlimb transplants from Brown-Norway (RT1(n)) to Lewis (RT1(1)) rats were performed (day 0). DCs were propagated from the recipient bone marrow and pulsed with the donor alloantigen lysate. Group 1 (control group) did not receive any treatment. Groups 2 and 3 received cyclosporine A (CsA) at a concentration of 10 and 16 mg.kg(-1).day(-1), respectively, on days 0-20 following composite tissue allotransplantation. Group 4 received antilymphocyte serum (i.p. administered 4 d before and 1 d after transplantation) therapy. Group 5 received combined treatment with CsA (10 mg.kg(-1).day(-1), days 0-20) and donor alloantigen-pulsed recipient DCs (i.v. administered on days 7, 14, and 21). Group 6 received combined treatment with CsA (10 mg.kg(-1).day(-1) on days 0-20), antilymphocyte serum (administered i.p. 4 d before and 1 d after transplantation), and DCs (administered i.v. on days 7, 14, and 21). Graft rejection was defined as epidermolysis/desquamation of the donor skin. The mixed lymphocyte reaction was performed to determine the donor T-cell reactivity. Tissue samples were biopsied to analyze the histological changes, and flow cytometry was performed to quantify the donor T-cells.

RESULTS

Allograft survival was significantly prolonged (>200 d) in Group 6 when compared with the other groups (P < 0.001). The mixed lymphocyte reaction performed for Group 6 revealed hyporesponsiveness of the T-cells to donor alloantigens. Flow cytometric analysis in Group 6 revealed a significant increase in the percentage of CD4(+)/CD25(+) and CD4(+)/foxP3(+) T-cells expression, and significant increase in the percentage of donor cells (RT1(n)) in the recipient peripheral blood. Immunohistochemical staining of allo-skin revealed a significant increase in the proportion of CD25(+) cells in the subcutaneous and dermis layers in Group 6, as compared to other groups.

CONCLUSION

Treatment with donor alloantigen-pulsed recipient immature DCs in combination with transient immunosuppression prolongs allograft survival and induced tolerance by inducing T-cell hyporesponsiveness to donor alloantigens and increasing the CD4(+)/CD25(+) T-cell population.

Regular Tai Chi Chuan exercise improves T cell helper function of patients with type 2 diabetes mellitus with an increase in T-bet transcription factor and IL-12 production

BACKGROUND

Exercise has been shown to be beneficial in the treatment of type 2 diabetes mellitus (DM); its benefit to immune function, however, remains to be determined.

OBJECTIVE

This study investigated the effect of a 12-week course of Tai Chi Chuan (TCC) exercise on T cell helper (Th) reaction in patients with type 2 DM.

METHODS

A case-control study was performed in 30 pairs of patients with type 2 DM and normal age-matched adults. Fasting blood glucose, HbA1c, mediators (interleukin (IL)-12, IL-4 and transforming growth factor (TGF)beta) and transcription factors (T-bet, GATA-3 and FoxP3) of Th1/Th2/T regulatory (Treg) reaction were measured before and after a 12-week TCC exercise programme.

RESULTS

Fasting glucose and HbA1c levels in the patients with type 2 DM were significantly higher than in age-matched controls before exercise. After TCC exercise, HbA1c levels in patients with type 2 DM significantly decreased (7.59 (0.32)% vs 7.16 (0.22)%; p = 0.047) and blood levels of IL-12 increased significantly (5.96 (1.10) vs 12.96 (3.07); p = 0.035). To study the molecular Th1/Th2/Treg reaction, patients with type 2 DM were found to have lower T-bet but not GATA-3 or FoxP3 expression than normal controls before TCC exercise. After the 12-week TCC exercise T-bet expression significantly increased in patients with type 2 DM.

CONCLUSIONS

A 12-week TCC exercise programme decreases HbA1c levels along with an increase in the Th1 reaction. A combination of TCC with medication may provide an even better improvement in both metabolism and immunity of patients with type 2 DM.

Macrophage activation syndrome as initial presentation of systemic lupus erythematosus

Macrophage activation syndrome (MAS) is known to be a severe and potentially life-threatening complication of rheumatic disorder, especially systemic juvenille rheumatoid arthritis. It is very rare for MAS to be an initial presentation of systemic lupus erythematosus (SLE). Here, we report a 14-year-old girl in whom MAS developed as an initial presentation of SLE. With early diagnosis and administration of cyclosporine A, she had a fair outcome. Further testing showed positive anti-dsDNA about 8 months later.

Suppression of plasma matrix metalloproteinase-9 following montelukast treatment in childhood asthma

BACKGROUND

Montelukast and ketotifen are commonly prescribed anti-inflammatory medications used in the treatment of childhood asthma.

METHODS

To investigate the modulation effect of montelukast and ketotifen, the levels of exhaled nitric oxide (eNO) and plasma matrix metalloproteinase-9 (MMP-9) were analyzed in a group of 30 children with mild persistent asthma.

RESULTS

Patients on montelukast therapy for 8 weeks had significantly decreased levels of eNO and plasma MMP-9, which were associated with improved symptoms and enhanced peak expiratory flow but not significantly associated with increased level of tissue inhibitor metalloproteinase-1 (TIMP-1). In contrast, treatment with ketotifen produced no significant changes in these parameters until 4-6 weeks into the therapy and no effect on plasma MMP-9.

CONCLUSION

Leukotriene antagonists, such as montelukast, may be better non-steroidal anti-inflammatory drugs for preventing airway inflammation in mild childhood asthma.

Different clinical and laboratory manifestations between dengue haemorrhagic fever and dengue fever with bleeding tendency

The incidence of dengue fever (DF) is estimated to have increased 30-fold in the past 50 years. The incidence of dengue haemorrhagic fever (DHF), a life-threatening complication of DF, is also increasing. The need for better classification of the severity of dengue infections has been proposed in order to clarify different entities of dengue infections. We defined a class of patients with DF with bleeding tendency (DF w/B) to differentiate further the varying pathogenesis among DF, DF w/B and DHF. In a hospital-based study in Taiwan, we compared clinical features, biochemistry and immune mediators among patients with DHF, DF w/B and DF. Results showed that DF w/B patients, similar to DHF patients, had a higher rate of secondary dengue infection (P<0.001) as well as higher IL-10 (P=0.023) and lower IFNgamma (P=0.009) levels than DF patients. In contrast, DHF patients had significantly higher soluble vascular cell adhesion molecule 1 levels than DF w/B patients (P=0.038) and DF patients (P<0.001). This study provides new insight into the different immune mechanisms of DF, DF w/B and DHF. DF involves a Th1 reaction and DF w/B involves an altered Th2 reaction, whereas DHF involves an altered Th2 reaction and augmented vascular insult.

Infant frequent wheezing correlated to Clara cell protein 10 (CC10) polymorphism and concentration, but not allergy sensitization, in a perinatal cohort study

BACKGROUND

Wheezing episodes are common in young infants. However, the molecular mechanism of wheezing is unclear, and very few therapeutic regimens are effective.

OBJECTIVE

This study investigated the genetic and environmental factors predisposing to infant wheezing in a birth cohort study.

METHODS

A cohort of 1211 pregnant women was recruited for this study. Infant wheezing episodes during the first 18 months of life were correlated to parental atopic history, parental smoking, prematurity, CB IgE levels, and the sequence variant (G+38A) of the Clara cell protein 10 (CC10) gene encoding a secretary anti-inflammatory CC10 protein.

RESULTS

Nine hundred eighty-three infants completed umbilical cord blood collection, and 813 infants completed the 18-month postnatal follow-up. Twenty-two percent of the infants experienced at least 1 wheezing episode, and 6.6% of the infants experienced frequent wheezing (> or =3 episodes). Multivariate logistic regression showed that male sex and the CC10 G+38A polymorphism, but not prematurity, CB IgE level, passive smoking, or parental atopy, were predictors of frequent wheezing. Further studies found that infant frequent wheezing was significantly associated with the CC10 +38AA genotype and lower plasma CC10 levels at 18 months of age (P = .046), and infants with acute wheezing episodes had significantly lower CC10 levels than those without (P = .023). No association of wheezing episodes with allergic sensitization was observed in this cohort population.

CONCLUSION

Infant frequent wheezing is associated with the CC10 G+38A polymorphism and lower CC10 levels but not infant atopy.

CLINICAL IMPLICATIONS

Lower CC10 expression, but not allergy sensitization, is involved in the pathogenesis of infant frequent wheezing.

Persistent monocytosis after intravenous immunoglobulin therapy correlated with the development of coronary artery lesions in patients with Kawasaki disease

BACKGROUND AND PURPOSE

This study was conducted to investigate whether changes in the complete blood count (CBC)/differential count (DC) and C-reactive protein (CRP) were correlated to Kawasaki disease (KD) with coronary artery lesions (CALs).

METHODS

A retrospective analysis was performed of all children with KD at Chang Gung Memorial Hospital at Kaohsiung from 2001 to 2006. KD patients were divided into those with and without CALs for testing of correlations with changes in CBC/DC and CRP levels.

RESULTS

A total of 147 patients were enrolled for this analysis. Serial CBC/DC and CRP measurements and echocardiographic data for determination of CAL formation were obtained before and after intravenous immunoglobulin (IVIG) treatment. There were 44 (29%) KD patients having CAL formation (>3 mm in diameter of internal lumen). There was no significant difference in terms of age distribution and major diagnostic criteria between KD patients with and without CALs. Male KD patients, however, had a significantly higher rate of CAL formation (p=0.009). In multivariate logistical regression analysis, persistent monocytosis after IVIG treatment was the only factor significantly correlated to CAL formation (p=0.003).

CONCLUSIONS

Of the febrile routine measurements of CBC/DC and CRP in KD, persistent monocytosis after IVIG treatment was correlated to CAL formation. Further studies to clarify the mechanism of monocytosis may help prevent the CALs of KD.

Implications of dynamic changes among tumor necrosis factor-alpha (TNF-alpha), membrane TNF receptor, and soluble TNF receptor levels in regard to the severity of dengue infection

Tumor necrosis factor-alpha (TNF-alpha) and soluble TNF receptors (sTNFR1 and sTNFR2) have been implicated in infectious diseases. We investigated dynamic changes among TNF-alpha, membrane TNF receptors (mTNFR1 and mTNFR2), and sTNFR1 and sTNFR2 levels for patients with dengue hemorrhagic fever (DHF) and those not infected during a DEN-2 outbreak in southern Taiwan in 2002-2003. Patients with DHF showed the lowest levels of mTNFR1 and mTNFR2 expression. Multivariate analysis showed that a decrease in levels of mTNFR1 expression was the only factor significantly different between patients with DHF and those with dengue fever. Moreover, lower mTNFR1 expression was significantly correlated with higher plasma TNF-alpha levels, but not with sTNFR1 levels in patients with DHF. This finding suggests that a lower level of mTNFR1 expression in response to a higher plasma TNF-alpha level may be a pathogenic marker for early detection of DHF.

Outcomes of continuing education in the care of children with asthma for pediatric healthcare providers

In this study, the authors assessed the knowledge of healthcare providers regarding asthma care, examined the outcomes of continuing education for asthma care, and explored the relationships among demographic characteristics of the healthcare providers and the improvement in asthma care knowledge. Thirty-one pediatricians and 38 nurses in the pediatric units of a medical center completed a questionnaire before and after an asthma care program. Pediatricians and pediatric nurses provided correct answers to asthma care questions 84.45% and 61.97% of the time, respectively, before the program and 93.06% and 88.03% of the time, respectively, after the program, which was a significant improvement (p < .001). No significant correlations or differences were found between the changes in asthma care knowledge and the demographic characteristics of healthcare providers. Results from this study suggest that continuing education can improve the knowledge of asthma care among pediatric healthcare providers.

Montelukast decreased exhaled nitric oxide in children with perennial allergic rhinitis

BACKGROUND

Measurement of exhaled nitric oxide (eNO) is a simple and noninvasive method for assessment of inflammatory airway diseases. eNO is elevated in adolescent patients with perennial allergic rhinitis and related to bronchial hyperresponsiveness. The aim of this study was to investigate whether oral loratadine, montelukast, nasal budesonide or nasal sodium cromoglycate could reduce airway inflammation as indicated by decrease of eNO in children with perennial allergic rhinitis as demonstrated by eNO levels.

METHODS

A randomized and investigator-blinded study was conducted in a hospital-based outpatient clinic. Children with perennial allergic rhinitis were divided into four groups and treated by loratadine, loratadine with nasal sodium cromoglycate, loratadine with oral montelukast, and loratadine with nasal budesonide, respectively. Allergic rhinitis scores, eNO and peak expiratory flow were measured before and 2, 4, 6 and 8 weeks after treatment.

RESULTS

Results showed that eNO in children with perennial allergic rhinitis was reduced by nasal budesonide and oral montelukast within 2 weeks (24.56 +/- 14.42 vs 18.42 +/- 12.48, P < 0.001, in budesonide group; 27.81 +/- 13.4 vs 19.09 +/- 10.45, P < 0.001, in montelukast group), but not in the loratadine and cromoglycate groups. In contrast, loratadine or sodium cromoglycate also did not decrease eNO levels although they could decrease the symptom scores.

CONCLUSIONS

It was concluded that four common treatment modalities could effectively release symptom scores, but decrease of airway inflammation as determined by decrease of eNO might be only achieved by nasal budesonide and montelukast, but not nasal sodium cromoglycate and loratadine. Children with perennial allergic rhinitis with high eNO levels may require oral montelukast or nasal budesonide treatment to prevent airway hyperresponsiveness.

Childhood macrophage activation syndrome differs from infection-associated hemophagocytosis syndrome in etiology and outcome in Taiwan

BACKGROUND AND PURPOSE

Hemophagocytic lymphohistiocytosis (HLH) is a syndrome composed of macrophage activation syndrome (MAS), infection-associated hemophagocytosis syndrome (IAHS), malignancy-associated HLH and genetic HLH. Differentiation of MAS from IAHS and other HLH is important for early appropriate treatment.

METHODS

A retrospective analysis was used to differentiate childhood MAS from IAHS and other HLH in Chang Gung Memorial Hospital (CGMH), Kaohsiung. All relevant clinical features, laboratory data, treatments and outcomes were analysed.

RESULTS

Seventeen patients with childhood HLH were found at CGMH, Kaohsiung in the past decade, and could be classified into 3 categories: IAHS (9 patients), MAS (5 patients), and HLH of unknown etiology (3 patients). The diagnosis of MAS first appeared in this hospital in 2001. Patients with IAHS tended to be younger than those with MAS. Boys were more frequently found in the IAHS group whereas girls (with systemic lupus erythematosus or juvenile idiopathic arthritis) were more frequently found in the MAS group. The majority of mortality cases were noted in the IAHS group (44%, 4/9). All patients with MAS survived with early cyclosporine A treatment.

CONCLUSIONS

Childhood MAS is different from IAHS in terms of age, gender, etiology and mortality. Early administration of cyclosporine A for MAS results in a lower mortality. Further prospective studies are required to confirm these findings.

The relationship of eosinophilia to intravenous immunoglobulin treatment failure in Kawasaki disease

To investigate the role of eosinophils in Kawasaki disease (KD) and the relationship to initial intravenous immunoglobulin (IVIG) treatment failure. A retrospective analysis of all children who were admitted and met the criteria of KD between 1999 and 2005. The patients were divided into IVIG-responsive and IVIG-resistant groups. A total of 185 patients were enrolled during the study period. A series of blood eosinophils and biochemistry studies were correlated to the effectiveness of IVIG. The neutrophils percentage before IVIG treatment (pre-IVIG), leukocyte counts within 3 days after IVIG treatment (post-IVIG), liver enzyme, albumin levels, and post-IVIG eosinophils percentage were all significantly different between the two groups in univariate analysis. Under multivariate analysis with logistic regression, post-IVIG eosinophilia [peripheral blood (PB) eosinophils >or=4%] had an inverse correlation to KD patients with IVIG-resistance (p = 0.003). Also, pre-IVIG hypoalbuminemia (albumin <or=3.0 g/dl) was positively correlated to IVIG-resistance (p = 0.018). Further analysis showed that the PB eosinophils was markedly increased in the acute stage and returned to normal 3 weeks after IVIG treatment (p < 0.001). Eosinophil levels are highly elevated in the acute stage of KD both before and after the IVIG treatment. Post-IVIG treatment eosinophilia has an inverse correlation to KD patients with IVIG-resistance and may indicate IVIG-responsive. This may be a valuable factor to survey for the necessity of a second dose IVIG treatment.

The different volume effects of small-bowel toxicity during pelvic irradiation between gynecologic patients with and without abdominal surgery: a prospective study with computed tomography-based dosimetry

PURPOSE

To evaluate the effect of abdominal surgery on the volume effects of small-bowel toxicity during whole-pelvic irradiation in patients with gynecologic malignancies.

METHODS AND MATERIALS

From May 2003 through November 2006, 80 gynecologic patients without (Group I) or with (Group II) prior abdominal surgery were analyzed. We used a computed tomography (CT) planning system to measure the small-bowel volume and dosimetry. We acquired the range of small-bowel volume in 10% (V10) to 100% (V100) of dose, at 10% intervals. The onset and grade of diarrhea during whole-pelvic irradiation were recorded as small-bowel toxicity up to 39.6 Gy in 22 fractions.

RESULTS

The volume effect of Grade 2-3 diarrhea existed from V10 to V100 in Group I patients and from V60 to V100 in Group II patients on univariate analyses. The V40 of Group I and the V100 of Group II achieved most statistical significance. The mean V40 was 281 +/- 27 cm(3) and 489 +/- 34 cm(3) (p < 0.001) in Group I patients with Grade 0-1 and Grade 2-3 diarrhea, respectively. The corresponding mean V100 of Group II patients was 56 +/- 14 cm(3) and 132 +/- 19 cm(3) (p = 0.003). Multivariate analyses revealed that V40 (p = 0.001) and V100 (p = 0.027) were independent factors for the development of Grade 2-3 diarrhea in Groups I and II, respectively.

CONCLUSIONS

Gynecologic patients without and with abdominal surgery have different volume effects on small-bowel toxicity during whole-pelvic irradiation. Low-dose volume can be used as a predictive index of Grade 2 or greater diarrhea in patients without abdominal surgery. Full-dose volume is more important than low-dose volume for Grade 2 or greater diarrhea in patients with abdominal surgery.

Interaction of maternal atopy, CTLA-4 gene polymorphism and gender on antenatal immunoglobulin E production

BACKGROUND

Genetic heritability and maternal atopy have been correlated to antenatal IgE production, but very few studies have studied gene-maternal atopy interaction on antenatal IgE production. This study investigated the interaction of CTLA-4 polymorphism with prenatal factors on the elevation of cord blood IgE (CBIgE).

METHODS

Pregnant women were antenatally recruited for collection of prenatal environmental factors by a questionnaire. Umbilical cord blood samples were collected for CBIgE detection by fluorescence-linked enzyme assay and CTLA-4 polymorphism measurement by restriction fragment length polymorphism.

RESULTS

A total of 1104 pregnant women initially participated in this cohort study, and 898 of them completed cord blood collection. 21.4% of the newborns had elevation of CBIgE (>or=0.5 kU/L). The CTLA-4+49A allele (P=0.021), maternal atopy (P<0.001) and gender (P=0.034), but not the CTLA-4+49G allele, -318C allele, -318T allele, parental smoking or paternal atopy, were significantly correlated with the CBIgE elevation in multivariate analysis. A dichotomous analysis of gene-maternal atopy interactions identified maternal atopy and CTLA-4+49A allele had an additive effect on the CBIgE elevation, especially prominent in male newborns; and in the absence of maternal atopy, CTLA-4+49GG genotype had a protective effect on CBIgE elevation in female newborns.

CONCLUSIONS

Maternal but not paternal atopy has significant impacts on CBIgE elevation depending on gender and CTLA-4+49A/G polymorphism of newborns. Control of maternal atopy and modulation of CTLA-4 expression in the prenatal stage may be a target for the early prevention of perinatal allergy sensitization.

Implications of previous subclinical dengue infection but not virus load in dengue hemorrhagic fever

In a study comparing the virus load and immune reaction between patients with primary and secondary dengue-2 (DEN-2) infections in a hospital-based analysis, we found that 40.7% (55/135) of the 135 patients had secondary DEN-2 infection following a DEN-2 outbreak in southern Taiwan. Most of the secondary infections had subclinical primary dengue infections (78.2%; 43/55). Patients with secondary DEN-2 infections had lower platelet counts, and blood interferon-alpha and virus load, but significantly higher interleukin-10 (P=0.030) and anti-DEN-1 neutralization titers (P=0.013) than those with primary infection. Patients with secondary DEN-2 infection also had a higher rate of dengue hemorrhagic fever (DHF) (61.7% vs. 36.3%). A previous subclinical dengue infection is involved in the secondary DEN-2 infection associated with altered immune reaction and higher DHF rate, but lower blood virus load.