Renal transplantation in children; the Auckland experience 1980-96

AIM

To review the experience and outcome of renal transplantation in children who received a renal allograft at the Auckland Children's Hospital between January 1980 and June 1996.

METHODS

Retrospective review of patient records and access to data collected through the ANZDATA Registry. Forty one renal transplants were undertaken in 39 children. Prednisone and Azathioprine were the mainstay of the immunosuppressive regimen from 1980 to 1985, then cyclosporin A was introduced in 1986. Median age of first graft was 11 years (range 1.6-14 years). There were 34 living related and 7 cadaveric grafts and 17 males and 22 females. Thirteen children (33%) had a primary glomerular disorder as the cause of renal failure. Another 9 (28%) had reflux nephropathy and a further 8 (18%) had congenital renal dysplasia/hypoplasia either as primary cause or secondary to lower urinary obstruction.

RESULTS

Survival analysis showed that 93% of grafts were functioning at 12 months and 73% were still functioning at 5 years. Longest surviving transplant is 16 years. Ten primary grafts were lost with the most common cause being chronic rejection, accounting for 50% of all transplants lost. Recurrence of primary disease was the second most common (4 of 13) cause of graft failure. There was one malignancy in this series with a child developing a Kaposi's sarcoma.

CONCLUSIONS

Renal transplantation is a successful treatment of endstage renal failure in children. Chronic rejection remains a major cause of graft loss and better immunosuppressive strategies are required to deal with this problem.

Results of a phase I clinical trial of a T-cell receptor peptide vaccine in patients with multiple sclerosis. I. Analysis of T-cell receptor utilization in CSF cell populations

To identify a panel of multiple sclerosis patients (MS) for a phase I clinical trial of a T-cell receptor (TCR) peptide vaccine we characterized the T-cell populations present in the cerebrospinal fluids (CSF) of a large group of patients with respect to surface phenotype and state of activation, TCR beta chain utilization, features of the CDR3 junctional region, the extent of clonality and persistence of selected clonotypes over time. These CSF cell populations consist of approximately 60% CD4+ T-cells, half of which bear IL-2 receptors, indicating these activated T-cells may be part of the pathogenic process in MS. When these activated CD4+ T-cells were selectively expanded in IL-2/IL-4 supplemented cultures, an over-representation of several TCRV beta families was noted in 39/47 patients, the most frequent being V beta 6.5, V beta 6.7, V beta 2, V beta 5 and V beta 4. Biased expression of various members of the V beta 6 family was seen in 21 of this group of 39 patients. Clonal analysis of TCR beta 6 CDR3 sequences, revealed two notable features: clonal dominance and clonal persistence. CSF cells from two-thirds of MS patients contained a dominant clone comprising 50% or more of sequences and the same patient-specific clone could be shown to persist for up to 18 months. This clonal prevalence and over representation of V beta 6+TCR raises the possibility that immunization with a V beta 6 peptide vaccine may produce a regulatory immune response leading to a clinical benefit.

Docetaxel in combination with fluorouracil: study design and preliminary results

The relatively recent introduction of a new class of chemotherapeutic agents--the taxoids--has raised hope of improved survival for patients with advanced or metastatic cancer. Following encouraging preclinical results of taxoid combinations, this phase I, nonrandomized trial was designed to evaluate a 1-hour intravenous infusion of docetaxel (Taxotere) on day 1 combined with fluorouracil (5-FU) as a daily intravenous bolus for 5 consecutive days. To date, 27 patients with advanced solid neoplasms have received 86 courses of docetaxel/5-FU at the following dose levels: 25/100, 35/150, 50/200, 60/200, and 60/300 mg/m2. Preliminary results showed no unexpected toxicities, and the principal toxicity was neutropenia of short duration. A treatment regimen of 60 mg/m2 docetaxel on day 1 and 300 mg/m2 of 5-FU given for 5 days, with a single course length of 28 days, is projected as the maximum tolerated dose.

A literature review of adolescence and cancer

Cancer is a relatively rare phenomenon in adolescents and a traumatic experience which arouses feelings of anger, anxiety, fear and sadness. For the adolescent with cancer, there are missed opportunities, not only in daily life but also through lost social events such as dances or football games with friends. Adolescent cancer patients may understand the implications of the diagnosis of cancer but lack the personal resources or life event experience which could equip them to cope and make sense of the many potential problems which may accompany cancer. This paper reviews and explores the literature associated with the adolescent with cancer.

Results of a phase I clinical trial of a T-cell receptor vaccine in patients with multiple sclerosis. II. Comparative analysis of TCR utilization in CSF T-cell populations before and after vaccination with a TCRV beta 6 CDR2 peptide

We report here the results of a phase I trial of a T-cell receptor (TCR) V beta 6 CDR2 region peptide vaccine in 10 patients with multiple sclerosis who showed biased over-representations of V beta 6 mRNA among T-cells in their cerebrospinal fluids (CSF). One group of 5 patients was immunized twice during a four week period with 100 micrograms of the TCRV beta 6 peptide 39-LGQGPEF LTYFQNEAQLEKS-58 emulsified in incomplete Freund's adjuvant (IFA); the second group of 5 MS patients received 300 micrograms of the same peptide in IFA over a similar time period. Patients were monitored for adverse events, immunogenicity of the peptide and changes in their CSF T-cell populations. The results indicate that this peptide was immunogenic (T-cell proliferation assays and recall DTH responses) in some of the patients, although none of the immunized patients produced detectable anti-peptide antibodies. More importantly, we show that the 5 patients treated with higher doses of the vaccine displayed a slight decrease in CSF cellularity, a lack of growth of CSF cells in cytokine supplemented expansion cultures that implies a significant absence of a subset of activated CD4 T-cells and a marked diminution in V beta 6 mRNA levels among T-cells in these cultures. By comparison, in 5 patients receiving the lower dosage of the vaccine, CSF cellularity was the same or slightly increased over pre-vaccination levels, CSF cells from 1 patient failed to grow in expansion cultures and cultured CSF cells from 2 patients underwent a change from an oligoclonal V beta 6 pattern to one that was more polyclonal. These results justify a more through exploration of the use of TCR peptide vaccines as a possible therapeutic treatment for MS.

ERP assessment of visual and auditory language processing in schizophrenia

Language disturbance in schizophrenia has been recently attributed to disturbed priming mechanisms. In the present study, event-related potentials (ERPs), were recorded to final words in sentences presented to 13 chronic patients with schizophrenia and 12 normal controls. Half of the final words fit a sentence context and another half did not. The N400 (the ERP sensitive to language) latency was prolonged, and its amplitude was more negative to both correct and incorrect sentence endings in the group with schizophrenia relative to the group of normal controls. The early ERP components, N100 and P200, were similar in both groups. These results suggest that language abnormalities in schizophrenia are related to a dysfunction in the language system and not to a general cognitive dysfunction, and may be related to poor use of context in patients with schizophrenia.

Aberrant semantic activation in schizophrenia: a neurophysiological study

OBJECTIVE

Schizophrenia has long been thought to be characterized by a fundamental disturbance in semantic associations, which has often been presumed to be of neurobiological origin. The authors examined the neurophysiological characteristics of semantic processing in schizophrenic patients.

METHOD

During EEG recording, 15 schizophrenic patients and 15 age-matched comparison subjects read sentences that had either sensible or nonsensical endings. The authors recorded the N400 component, a specific negative event-related brain potential occurring approximately 400 msec after the final word in the sentence. N400 is highly, if not uniquely, sensitive to semantic expectancy and context, and larger, more negative N400 amplitude is associated with increased semantic unexpectancy.

RESULTS

In relation to the normal comparison subjects, the schizophrenic patients demonstrated prolonged N400 latency after nonsensical sentence endings and also showed enhanced N400 negativity, regardless of the sense of the sentence ending.

CONCLUSIONS

These findings suggest slower and more diffuse semantic activation in patients with schizophrenia, perhaps reflective of a disease-related failure to maintain and to use semantic context.

Critical thinking, health policy, and the Hmong culture group, Part I

The author discusses the historical connection between the Hmong and the U.S. military operations in South Eastern Asia; gives an overview of Hmong culture health traditions, such as efficacious, neutral and harmful; socioeconomic data; immigration and the local community; and health problems specific to the Hmong.

Factors associated with elective Norplant removal in black and white women

Premature removal of contraceptive implants (Norplant [levonorgestrel implants], Wyeth-Ayerst Laboratories, Philadelphia, Pennsylvania) is a cause of a sizable national medical expenditure in the United States. Understanding the factors that influence the decision to remove the implants and being able to predict which users are likely to elect discontinuation prematurely could provide useful information for counseling patients as they are considering contraceptive implants so that potentially enormous long-term savings could be achieved. This study surveyed 98 women who had Norplant inserted and removed between January 1991 and December 1994. Data were collected from chart review, and when necessary, a questionnaire was used to extract information not found in the chart. The chi-squared statistic and t-test were used to compare demographic variables. All but one subject received comprehensive pre-implant counseling. The main reason given for electively removing the Norplant prematurely was irregular menstrual bleeding (60%). Pre-implant counseling did not influence the decision for removal. These results indicate the importance of clarifying patients' doubts regarding menstrual bleeding irregularities during follow-up visits rather than relying on the information patients received during preimplant counseling.

Biotransformation of 17-alkylsteroids in the equine: gas chromatographic-mass spectral identification of ten intermediate metabolites of methyltestosterone

The metabolism of the orally active anabolic steroid methyltestosterone in the equine was investigated by administration of the drug along with a tritiated radiolabel tracer. In this study some of the metabolites were identified and a radio immunoassay screen and immunoaffinity chromatography gel for methyltestosterone were also evaluated. Pathway intermediates, in particular the 17-methylandrostanediols, were studied to gain an insight into the most likely stereochemistry of the major metabolites. The predominant phase I biotransformations involve reduction of the A ring 3-oxo and 4-ene groups to yield predominantly 3 beta-hydroxy-5 alpha-androstane products and hydroxylation of the steroid nucleus at several positions. Epimerisation of the 17 alpha-methyl group also occurred. Ten steroids could be positively identified by comparison with authentic reference materials and many other triol, tetrol and pentols were also observed. Phase II metabolites and sulphate conjugates in particular, were common.

Bryostatin 1 and phorbol ester down-modulate protein kinase C-alpha and -epsilon via the ubiquitin/proteasome pathway in human fibroblasts

We evaluated the possibility that distinct proteolytic pathways contribute to the down-regulation of a novel (epsilon) or conventional (alpha) isoform of protein kinase C (PKC) in nonimmortalized human fibroblasts. Inhibitors of calpains and other cysteine proteinases, vesicle trafficking, or lysosomal proteolysis did not affect the down-regulation of PKC-alpha or -epsilon produced by bryostatin 1 (Bryo). Lactacystin (Lacta) and certain terminal aldehyde tripeptides or tetrapeptides, which selectively inhibit the proteasome, preserved substantial PKC-alpha and -epsilon protein from down-regulation by Bryo or phorbol-12-myristate-13-acetate. Lacta preserved active kinase in vivo, as shown by the retention of Bryo-induced autophosphorylated PKC-alpha. Concomitant with down-regulation, Bryo produced PKC-alpha and -epsilon species that were larger than the native proteins (80 and 90 kDa, respectively). Western blot analysis showed that the larger PKC-alpha species were ubiquitinylated. Treatment with Bryo plus Lacta synergistically increased multiubiquitinylated PKC-alpha, as expected if Bryo induces ubiquitinylation of PKC-alpha and Lacta blocks its degradation. Bryo also produced a 76-kDa, nonphosphorylated form of PKC-alpha and an 86-kDa form of PKC-epsilon. Phosphatase inhibitors decreased production of 76- and 86-kDa PKC-alpha and -epsilon by Bryo and preserved 80- and 90-kDa PKC-alpha and -epsilon, respectively. Our results suggest that the down-modulation of PKC-alpha and -epsilon occurs principally via the ubiquitin/ proteasome pathway. Dephosphorylation seems to predispose PKC to ubiquitinylation.

Sclerosing encapsulating peritonitis associated with continuous ambulatory peritoneal dialysis: surgical management

Sclerosis of the peritoneum with encapsulation of the small intestine is one of the most serious complications of continuous ambulatory peritoneal dialysis (CAPD) and is associated with a high mortality rate. Its presence should be suspected in patients treated by CAPD who develop small bowel dysfunction with associated abdominal pain and progressive loss of ultrafiltration. In its severest form, it leads to complete high small intestinal obstruction and requirement for total parenteral nutrition. We report the successful surgical management of two young, severely emaciated patients who had this complication of CAPD. Each had entrapment of their bowel by a thick, fibrosed, and calcified membrane. Both were treated by surgically peeling the membrane away from the intestines.

ERP assessment of visual and auditory language processing in schizophrenia

Language disturbance in schizophrenia has been recently attributed to disturbed priming mechanisms. In the present study, event-related potentials (ERPs), were recorded to final words in sentences presented to 13 chronic patients with schizophrenia and 12 normal controls. Half of the final words fit a sentence context and another half did not. The N400 (the ERP sensitive to language) latency was prolonged, and its amplitude was more negative to both correct and incorrect sentence endings in the group with schizophrenia relative to the group of normal controls. The early ERP components, N100 and P200, were similar in both groups. These results suggest that language abnormalities in schizophrenia are related to a dysfunction in the language system and not to a general cognitive dysfunction, and may be related to poor use of context in patients with schizophrenia.

Comparing costs of monitoring glaucoma patients: hospital ophthalmologists versus community optometrists

OBJECTIVES

To compare the costs of monitoring stable glaucoma patients by community optometrists and hospital ophthalmologists.

METHODS

A cost analysis was conducted alongside a randomised controlled trial which compared the accuracy and acceptability of measurement in each form of care. The viewpoints of the health service and of patients were considered. Costs were assessed using a number of different methods. Sensitivity analysis was conducted for key variables.

RESULTS

The baseline analysis reflected heavily the different length of time between follow-up in the two arms of the trial (10 months (average) for hospital, 6 months for optometrists). It showed annual cost per patient for hospital ophthalmologists varied from 14.50 pounds to 59.95 pounds, and community optometrist costs varied from 68.98 pounds to 108.98 pounds. Assuming a 6-month follow-up interval for the hospital ophthalmologists, costs varied from 24.16 pounds to 99.92 pounds.

CONCLUSIONS

Recommendations about the least costly form of follow-up must depend on the context in which the decision is being taken and the scale of change envisaged. If the aim is to recoup resources from hospitals in order to pay for monitoring in the community, community monitoring is unlikely to be the least costly option.

Caval thrombectomy for severe staphylococcal osteomyelitis

Two children are presented in whom thrombosis of the inferior vena cava developed in association with an acute staphylococcal osteomyelitis. One case involved the left femur and the other the left ileum. Both children had diffuse bilateral staphylococcal pneumonia from presumed septic embolization. There were close similarities between their illness and management, except that the child who survived underwent a caval thrombectomy in the acute phase of her illness. It is hypothesized that the thrombectomy played an important role in her recovery.

Novel nuclear magnetic resonance spectroscopy methods demonstrate preferential carbon source utilization by Acinetobacter calcoaceticus

Novel nuclear magnetic resonance spectroscopy techniques, designated metabolic observation, were used to study aromatic compound degradation by the soil bacterium Acinetobacter calcoaceticus. Bacteria which had been rendered spectroscopically invisible by growth with deuterated (2H) medium were used to inoculate cultures in which natural-abundance 1H hydrogen isotopes were provided solely by aromatic carbon sources in an otherwise 2H medium. Samples taken during the incubation of these cultures were analyzed by proton nuclear magnetic resonance spectroscopy, and proton signals were correlated with the corresponding aromatic compounds or their metabolic descendants. This approach allowed the identification and quantitation of metabolites which accumulated during growth. This in vivo metabolic monitoring facilitated studies of catabolism in the presence of multiple carbon sources, a topic about which relatively little is known. A. calcoaceticus initiates aromatic compound dissimilation by forming catechol or protocatechuate from a variety of substrates. Degradation proceeds via the beta-ketoadipate pathway, comprising two discrete branches that convert catechol or protocatechuate to tricarboxylic acid cycle intermediates. As shown below, when provided with several carbon sources simultaneously, all degraded via the beta-ketoadipate pathway, A. calcoaceticus preferentially degraded specific compounds. For example, benzoate, degraded via the catechol branch, was consumed in preference to p-hydroxybenzoate, degraded via the protocatechuate branch, when both compounds were present. To determine if this preference were governed by metabolites unique to catechol degradation, pathway mutants were constructed. Studies of these mutants indicated that the product of catechol ring cleavage, cis,cis-muconate, inhibited the utilization of p-hydroxybenzoate in the presence of benzoate. The accumulation of high levels of cis,cis-muconate also appeared to be toxic to the cells.

Introducing change to the post-anaesthetic care unit

Parental presence in the post-operative care unit (PACU) is an under-reported and under-researched area of paediatric care. This article explores the importance and value of parents being present with their child post-operatively. It reports on the audit findings following a practice development project which encouraged parents to be with their child in the PACU.

Glycosaminoglycans can modulate extracellular localization of the wingless protein and promote signal transduction

Wingless, the Drosophila homologue of the proto-oncogene Wnt-1, encodes a secreted glycoprotein that regulates differentiation and proliferation of nearby cells. Here we report on the biochemical mechanism(s) by which the wingless signal is transmitted from cell to cell. When expressed in S2 cells, the majority (approximately 83%) of secreted wingless protein (WG) is bound to the cell surface and extracellular matrix through specific, noncovalent interactions. The tethered WG can be released by addition of exogenous heparan sulfate and chondroitin sulfate glycosaminoglycans. WG also binds directly to heparin agarose beads with high affinity. These data suggest that WG can bind to the cell surface via naturally occurring sulfated proteoglycans. Two lines of evidence indicate that extracellular glycosaminoglycans on the receiving cells also play a functional role in WG signaling. First, treatment of WG-responsive cells with glycosaminoglycan lyases reduced WG activity by 50%. Second, when WG-responsive cells were preincubated with 1 mM chlorate, which blocks sulfation, WG activity was inhibited to near-basal levels. Addition of exogenous heparin to the chlorate-treated cells was able to restore WG activity. Based on these results, we propose that WG belongs to the group of growth factor ligands whose actions are mediated by extracellular proteoglycan molecules.

Acquisition of identity in the developing leaf

Leaves are produced repeatedly from the shoot apical meristem of plants. Molecular and cellular evidence show that identity of the leaf and its parts is acquired progressively and that the underlying process changes as the leaf matures. The relative importance of cell lineage compared with a position-dependent model for specifying cell fates is discussed.