Cataracts after bone marrow transplantation: long-term follow-up of adults treated with fractionated total body irradiation

PURPOSE

To determine the risk of, and risk factors for, developing cataracts after bone marrow transplantation.

METHODS AND MATERIALS

Four hundred and ninety-two adults who underwent bone marrow transplantation in Seattle were followed for 2 to 18 (median, 6) years. Before transplantation, patients received a preparative regimen of chemotherapy plus total body irradiation (TBI) (n = 407) or chemotherapy alone, without TBI (n = 85). TBI was administered in a single dose of 10 Gy (n = 74) or in fractionated doses totaling 12-15.75 Gy (n = 333). The risk of cataracts was determined for groups of patients with respect to the type of preparative regimen received and other pretransplant and posttransplant variables.

RESULTS

One hundred and fifty-nine patients (32%) developed cataracts between 0.5 to 11 (median, 2.3) years after transplantation. The probability of cataracts at 11 years after transplantation was 85%, 50%, 34%, and 19% for patients receiving 10 Gy of single-dose TBI, > 12 Gy fractionated TBI, 12 Gy fractionated TBI, and no TBI, respectively (p < 0.0001). Among those developing cataracts, the severity was greater in patients after single-dose TBI (59% probability of surgical extraction) than after > 12 Gy fractionated TBI, 12 Gy fractionated TBI, or no TBI (33%, 22% and 23%, respectively). Patients given corticosteroids after transplant had a higher probability of cataracts (45%) than those without steroids (38%) (p < 0.0001). In a proportional hazards regression model, the variables that were correlated with an increased probability of cataracts were single-dose TBI (relative risk (RR) = 2.46) and steroid therapy (RR = 2.34), while a decreased probability of cataracts was correlated with a nonTBI preparative regimen (RR = 0.41). The yearly hazard of developing cataracts in recipients of single-dose TBI was highest during the third year after transplantation, while in recipients of fractionated TBI, the hazard was distributed among years one through seven. The probability of cataracts in all groups reached a plateau at 7 years after transplantation, after which the development of cataracts was extremely unlikely.

CONCLUSION

TBI is the major risk factor for developing cataracts after BMT. Single-dose TBI results in the highest risk of cataracts. However, the risk of cataracts in recipients of fractionated-TBI is significantly higher than in patients who receive no TBI. In addition to TBI, steroid therapy is an independent risk factor for cataracts after BMT.

Structure of leadership among preschool children

The purpose of the present study was to examine the structure of leadership among preschool children. Leadership behaviors of 18 five-year-old Japanese children were observed during free play and scored on the basis of a 15-item leadership scale. A factor analysis of the items indicated two factors: facilitation of play and consideration-evaluation of playmates. Children who had a central role in group play showed more leadership behaviors on the consideration-evaluation of playmates dimension than those on the periphery. For the dimension of facilitation of play, however, no significant difference was seen between the two groups.

CONTRIBUTION OF THE PENTOSE PHOSPHATE SHUNT TO THE FORMATION OF CO2 IN SWIMBLADDER TISSUE OF THE EEL

The contribution of the pentose phosphate shunt to glucose metabolism in the swimbladder tissue of the American eel Anguilla rostrata has been evaluated by comparing the rate of 14CO2 and [14C]lactate production from [1-14C]glucose and [6-14C]glucose. In blood-perfused swimbladder preparations, 0.18&plusmn;0.07 nmol min-1 of [6-14C]glucose and 3.19&plusmn;0.57 nmol min-1 of [1-14C]glucose were converted to CO2. The rate of [14C]glucose conversion to [14C]lactate was about the same in preparations perfused with [6-14C]glucose and with [1-14C]glucose. This may indicate that the C5 skeleton formed in the pentose phosphate shunt is not returned to glycolysis and converted to lactate. Although gas deposition was usually not measurable in these blood-perfused swimbladder preparations, 14CO2 was detected in the eel swimbladder gas of preparations perfused with [1-14C]glucose, but not in preparations perfused with [6-14C]glucose. The results confirm the hypothesis that, in the eel swimbladder epithelium, some of the glucose taken up from the blood is metabolized in the pentose phosphate shunt. This results in the formation of CO2, which is released into the swimbladder as well as into the bloodstream.

Involvement of Escherichia coli DNA polymerase II in response to oxidative damage and adaptive mutation

DNA polymerase II (Pol II) is regulated as part of the SOS response to DNA damage in Escherichia coli. We examined the participation of Pol II in the response to oxidative damage, adaptive mutation, and recombination. Cells lacking Pol II activity (polB delta 1 mutants) exhibited 5- to 10-fold-greater sensitivity to mode 1 killing by H2O2 compared with isogenic polB+ cells. Survival decreased by about 15-fold when polB mutants containing defective superoxide dismutase genes, sodA and sodB, were compared with polB+ sodA sodB mutants. Resistance to peroxide killing was restored following P1 transduction of polB cells to polB+ or by conjugation of polB cells with an F' plasmid carrying a copy of polB+. The rate at which Lac+ mutations arose in Lac- cells subjected to selection for lactose utilization, a phenomenon known as adaptive mutation, was increased threefold in polB backgrounds and returned to wild-type rates when polB cells were transduced to polB+. Following multiple passages of polB cells or prolonged starvation, a progressive loss of sensitivity to killing by peroxide was observed, suggesting that second-site suppressor mutations may be occurring with relatively high frequencies. The presence of suppressor mutations may account for the apparent lack of a mutant phenotype in earlier studies. A well-established polB strain, a dinA Mu d(Apr lac) fusion (GW1010), exhibited wild-type (Pol II+) sensitivity to killing by peroxide, consistent with the accumulation of second-site suppressor mutations. A high titer anti-Pol II polyclonal antibody was used to screen for the presence of Pol II in other bacteria and in the yeast Saccharomyces cerevisiae. Cross-reacting material was found in all gram-negative strains tested but was not detected in gram-positive strains or in S. cerevisiae. Induction of Pol II by nalidixic acid was observed in E. coli K-12, B, and C, in Shigella flexneri, and in Salmonella typhimurium.

A program to address the special needs of drug-exposed children

The Ravenswood-Stanford Coalition for At-Risk Children promotes school success by intervening with K-3 students identified as drug-exposed, either prenatally or environmentally, enabling them to remain in regular classrooms rather than diverted to special education. This goal was accomplished through professional partnerships, home involvement, individual intervention plans, special school-based services, and mentorships. Results from the project indicate these children are not significantly different from their peers; home involvement promotes better school linkages and reinforces positive behavior change; appropriate short-term, school-based services can increase academic and behavioral performance; dedicated volunteers working individually with students accelerate change processes; and these special at-risk students must be assigned to caring, supportive, and predictable classrooms.

VAGAL REGULATION OF INTRACARDIAC SHUNTING IN THE TURTLE PSEUDEMYS SCRIPTA

Two principal hypotheses account for intracardiac shunting in reptiles. The ‘pressure shunting’ hypothesis proposes that there is no fuctional separation between the ventricular cava during systole. The ‘washout shunting’ hypothesis suggests that the cavum pulmonale is functionally separated from the rest of the ventricle during systole. The purpose of this study was to test the two principal hypotheses in a turtle, Pseudemys scripta, after inducing a right-to-left shunt by electrical stimulation of the vagus nerve. Animals were anaesthetized with sodium pentobarbital (30–40 mg kg-1), tracheotomized and mechanically ventilated. Two experimental groups were used. Both groups had the right and left cervical vagi exposed and sectioned and silver bipolar electrodes were attached for electrical stimulation. In addition, cardiac function was evaluated by determining the pulmonary blood flow, pulmonary arterial pressure, peak systolic pressure in the cavum pulmonale, central arterial pressure, pulmonary vascular resistance and heart rate. In group I, hydrogen electrodes were inserted into the right aorta, the left aorta and the pulmonary artery. Hydrogen, dissolved in saline, was infused into the left atrium, jugular vein and cavum pulmonale. Blood flow from these sites was deduced from detection of a H2 signal in the right and left aortae and the pulmonary artery. In group II, catheters were inserted in the left and right atria and aortae for the measurement of blood gases. For both groups, the protocol consisted of control periods and periods of electrical stimulation of the efferent and afferent ends of the vagus nerve. During the control periods, infusion of a H2 solution into either the left atrium or the jugular vein resulted in the detection of H2 in the right and left aortae and the pulmonary artery. This suggested that both right-to-left and left-to-right intracardiac shunts were present. H2 infused into the cavum pulmonale was always detected in the pulmonary artery but never in the left or right aortae. During stimulation of the right vagal efferents, a bradycardia developed (heart rate declined by 65 %), pulmonary blood flow was reduced by 73 % and pulmonary vascular resistance increased by 158 %. This was accompanied by a reduction in the PO2 of both the right and left aortae, although the PO2 of the left and right atria remained constant. Under these conditions, H2 infused into the jugular vein and the left atrium was detected in the right and left aortae and the pulmonary artery of all animals studied. Infusion of H2 into the cavum pulmonale was detected in the right and left aortae in only two animals. The results supported the washout mechanism for right-to-left intracardiac shunting.

Quantitative effects of physical therapy on muscular and functional performance in subjects with osteoarthritis of the knees

Osteoarthritis (OA) of the knees is a functionally limiting disability. Physical therapy (PT) is considered a useful treatment for OA, although evidence is qualitative. The purpose of this study was to quantitatively measure the effects of a 3-month PT program (n = 40; 20 men and 20 women) with knee OA. Muscle function and functional assessment parameters were measured. All data were analyzed by repeated measures analysis of variance (p < 0.05). There were no significant changes in handgrip strength and endurance, limb volume, or angular velocity after PT. Maximal muscle length was significantly increased. Muscle strength significantly increased for the hamstrings (9% and 19%) and quadriceps (8% and 24%) for the men and women, respectively. Endurance improved for the quadriceps (26% and 39%) and hamstrings (18% and 28%) for men and women, respectively. Functionally, there were significant improvements in the ability to climb stairs, rise from a chair, and walk. Walking time (50 ft) and the difficulty and pain of performing various activities decreased. Most improvements had occurred after 1 month of PT. For the first time, the effects of a PT program have been quantitatively measured for patients with knee OA.

The treatment of inclusion body myositis: a retrospective review and a randomized, prospective trial of immunosuppressive therapy

We have sought to examine the response to immunosuppressive therapeutic intervention in inclusion body myositis (IBM) in a retrospective review of prior responses to therapy and in an open, randomized crossover trial. We collected information on the response to prior therapy on 25 patients, and for prospective therapy on 11 of these patients. All met criteria for a definite idiopathic inflammatory myopathy and had biopsy-proven IBM. Clinical and laboratory results were assessed by interviews of patients and by chart review in the retrospective trial. Manual muscle strength was assessed by a single trained observer; the patients' activities of daily living were assessed by questionnaire; and serum tests of muscle-associated enzymes were measured in the prospective trial. In the retrospective review, prednisone appeared to have been of some, albeit modest, clinical benefit in 10 of 25 (40%) patients. Other therapies, primarily azathioprine and methotrexate, also appeared to have halted the progression of weakness in 8 of 35 trials (23%). In the prospective study, combination therapy of oral azathioprine and methotrexate and a biweekly infusion of high-dose intravenous methotrexate with leucovorin rescue were given for 3 to 6 months in an open, crossover design. Both the oral and the intravenous regimens were clinically effective in some patients. There was clinical improvement in 3 trials, stabilization in 11 trials, and worsening in 5 trials, out of a total of 19 completed (22 intended) trials. The presence of active inflammation at entry into the prospective therapeutic protocol, either directly observed on muscle biopsy or indirectly indicated by serum creatine kinase level, may have been associated with clinical improvement. A complete laboratory response with normalization of creatine kinase and other muscle-associated enzymes did not, however, significantly predict clinical responsiveness in the prospective trial. In this first report, to our knowledge, of a prospective trial of immunosuppressive therapy for this disease, stabilization and even slight improvement of strength and functional abilities appeared to be achieved in some patients. We believe that prednisone and other immunosuppressive therapies were of modest benefit in about half of patients with inclusion body myositis, especially those with some evidence of active inflammation. Stabilization of an otherwise inexorably deteriorating course appears, therefore, to be an attainable goal in some patients with IBM.

The outcome of pregnancy in women with lupus nephritis

We analysed the outcome of pregnancy in patients with pre-existing lupus nephritis, seen in a tertiary referral centre for nephrology. Fifty-three pregnancies in 25 patients who already had clinical and histological evidence of lupus nephritis were recorded between January 1970 and June 1989, and data were analysed retrospectively. All 53 pregnancies occurred in patients with more or less stable disease, while three pregnancies during which lupus first presented were excluded. Six pregnancies were ended by therapeutic abortions (four for social reasons), and in eight spontaneous abortion occurred. Thus, 39 deliveries occurred, 28 at 36 weeks or more, while 11 were delivered prematurely, of which one was a stillbirth. After allowance was made for therapeutic abortions, the fetal loss rate (9/47) was 19%. Seventeen Caesarian sections were performed in the 39 completed pregnancies (44%), 11 as emergencies. Although the overall fetal loss, incidence of premature births and Caesarian section rate were all higher than expected for a population of normal women, neither initial histology, treated hypertension, the presence of proteinuria or a nephrotic syndrome showed statistically significant relationships with the outcome of completed pregnancies. In no case was maternal renal function affected irreversibly, although proteinuria increased substantially during pregnancy in six patients, and creatinine clearance fell during pregnancy, also in six patients. No 'flares' in systemic disease were seen, but all patients save five were treated with a brief period of high-dose oral corticosteroids or intravenous methylprednisolone in the postpartum period. No case of neonatal lupus or congenital heart block was observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Significance of anti-phospholipid antibodies in patients with lupus nephritis

Anti-phospholipid antibodies (APA) as markers or mediators of thrombosis in lupus could be of pathogenetic significance in nephritis, since glomerular capillary thrombi are an indicator of subsequent renal dysfunction. Isotype specific APA antibodies were measured, using cardiolipin as the antigen, in 76 patients with lupus nephritis. Twenty-nine percent of the patients had elevated IgG APA. Overall, 43% of patients showed raised levels of at least one isotype. In general, APA had specificity for anionic phospholipids. In vitro lupus anticoagulant activity was associated with all three isotypes of APA, but only the IgM isotype correlated with the biological false positive test for syphilis. APA were not associated with thromboses or neurological involvement, and only the IgA isotype correlated with thrombocytopenia. We confirmed an association between the presence of intraglomerular thrombi and serum IgG APA. However, we found no association between APA and renal histological pattern, or long-term renal function. Our data, therefore, do not support a major pathogenetic role for APA in the nephritis of lupus in treated patients.

Kinesin heavy chain is essential for viability and neuromuscular functions in Drosophila, but mutants show no defects in mitosis

The in vivo function of the microtubule motor protein kinesin was examined in Drosophila using genetics and immunolocalization. Kinesin heavy chain mutations (khc) cause abnormal behavior and lethality. Mutant larvae exhibit loss of mobility and tactile responsiveness in the most posterior segments, followed by general paralysis and death during larval or pupal development. Adults homozygous for a temperature-sensitive allele also exhibit a loss in mobility and sensory responses. The data indicate that kinesin function is essential and suggest that kinesin has an important role in the neuromuscular system, perhaps as a motor for axonal transport. The possibility of more general cellular functions remains open, but observation of embryogenesis and morphogenesis in khc mutants suggests that mitosis and the cell cycle can proceed in spite of impaired kinesin function. Immunolocalization suggests that kinesin may have some general cellular functions but that it is not a major component of mitotic spindles.

The effect of HCO3- on anion-stimulated ATPase from rat parotid granules

ATPase from isolated secretory granules was stimulated in a concentration-dependent manner by HCO3- above 0.9 mM. Maximal stimulation was found at about 16 mM HCO3- and was about half of that with sulphite (SO3(2-)). The activation site(s) appeared to be similar to at least one class of SO3(2-) sites, HCO3(-)-stimulate ATPase was inhibited by SITS. Furthermore, maximal stimulation with SO3(2-) was not enhanced with HCO3-. At low Mg2+ concentrations, Ca2+ stimulated granule ATPase. At higher concentrations of Mg2+ (0.5 mM and above), Ca2+ at 0.1 mM or less had little effect on HCO3(-)-ATPase, and Ca2+ at 4 mM inhibited HCO3(-)-ATPase. At concentrations of Ca2+ above 0.44 mM, the enzyme was partially stimulated in the absence of Mg2+ and presence of HCO3-. Mitochondrial contamination did not account for the presence of ATPase in the isolated granule fraction. The granule ATPase may be regulated by HCO3- and calcium and this could be related to changes in the granule environment during exocytosis.

Switching of Candida albicans during successive episodes of recurrent vaginitis

Strain relatedness and switching were monitored in Candida albicans strains isolated from different body locations through three episodes of recurrent vulvovaginal candidiasis separated by two treatment-latency periods in a single patient. Strain relatedness was assessed by comparing Southern blot hybridization patterns with the relatively immobile mid-repeat sequence Ca3. The following conclusions are demonstrated. (i) Three different strains of C. albicans colonized the mouth, the area under the breasts, and the vulvovaginal, anal, and rectal regions, respectively, at the time of the first infection. (ii) The same strain of C. albicans was responsible for the three vaginal infections. (iii) Switching of colony phenotype occurred with each new vaginal infection. (iv) Enrichment of drug-resistant switch phenotypes (assessed in vitro) was unlikely the basis for the changes in the switch phenotypes of the strain found in the vulvovaginal, anal, and rectal areas after treatment of the first infection with clotrimazole. (v) The same strain of C. albicans was responsible for the recurrent increases in mouth colonization and was distinct from the recurrent vaginal strain. The results of this case study demonstrate the need for further detailed analyses of full-body mycofloras, strain relatedness, switching repertoires, and changes in drug susceptibility during successive episodes of recurrent vulvovaginal candidiasis.

a/Alpha-specific repression by MAT alpha 2

The product of the MAT alpha 2 gene is a DNA-binding protein that acts as a repressor of two different sets of cell type-specific genes. In alpha cells, the alpha 2 protein represses the transcription of several a-specific genes. In a/alpha cells, the alpha 2 protein acts together with the product of the MATa1 gene, the a1 protein, to repress several genes used by haploids in the mating process. In addition to the mat alpha 2 mutations that result in defects in both types of regulation, other mat alpha 2 alleles have been described that result in defects in the repression of a-specific genes but that do not affect the ability of the alpha 2 and a1 proteins to interact to repress the haploid-specific genes. We report here the isolation of a new class of mat alpha 2 mutations that do not affect the ability of the alpha 2 protein to repress a-specific genes, but that interfere with the ability of the alpha 2 protein to interact with the a1 protein to repress the haploid-specific genes and establish the a/alpha cell type. These mutations may help determine the means by which the a1 protein interacts with alpha 2 to expand the set of genes under its control.

Multiple Candida strains in the course of a single systemic infection

Species and strain variabilities have been monitored during the history of a prolonged Candida infection in a single compromised bone marrow transplant patient by analyzing sugar assimilation patterns, high-frequency switching repertoires, and Southern blot hybridization patterns with two cloned mid-repeat sequences (Ca3 and Ca7) which are species specific for Candida albicans and one cloned mid-repeat sequence (Ct13-8) which is species specific for Candida tropicalis. Evidence is presented that during the course of this infection (i) two strains of C. albicans and three strains of C. tropicalis were distinguished by their switching repertoires, Southern blot hybridization patterns, and sugar assimilation patterns; (ii) the three C. tropicalis strains were in a high-frequency mode of switching; (iii) two C. tropicalis strains coexisted in the blood and three C. tropicalis strains coexisted in the throat at different times during the history of the infection; (iv) amphotericin B treatment selectively removed one of two C. tropicalis strains coexisting in the blood and this strain exhibited greater susceptibility to amphotericin B in vitro (the remaining strain was subsequently removed from the blood by flucytosine treatment); and (v) both the strain removed from the blood by amphotericin B and the strain removed from the blood by flucytosine reappeared several days later at another site of infection. It is demonstrated for the first time that C. tropicalis is capable of high-frequency switching of colony morphology just as C. albicans is, that there is more than one strain-specific switching repertoire in C. tropicalis, and that a C. tropicalis mid-repeat sequence can be used for discriminating species and assessing strain relatedness, as previously demonstrated for C. albicans mid-repeat sequences.

High-frequency switching in Candida strains isolated from vaginitis patients

High-frequency switching and strain variability at the site of infection was assessed in 11 patients with acute Candida albicans vaginitis. By cloning cells directly from the site of infection, it was demonstrated that 4 of the 11 isolates contained multiple-switch phenotypes at the site of infection and that 9 of the 11 isolates were in a high-frequency mode of switching (10(-2) to 10(-3)). Isolates could be separated into four general categories of switching repertoires. To demonstrate that multiple phenotypes at the site of a single infection represented the same strain, EcoRI digests of total cell DNA were separated on agarose gels, and Southern hybridization patterns with two cloned midrepeat sequences were compared.

Urinary cannabinoids in monitoring abstinence in a drug abuse treatment program

Urine specimens from 162 adolescents entering a drug treatment program were tested for cannabinoids using a photometric immunoassay (EMITst) and thin-layer chromatography (TLC). The EMITst has a cutoff point of detection 25 ng/mL or less of 9-carboxy-tetrahydrocannabinol. When reported as positive, both tests appeared to be reliable. There were two false-positive EMITst results and three false-positive TLC results in the 67 urine specimens that did not contain cannabinoids. When reported as negative, however, the EMITst with its 100 ng/mL cutoff failed to detect almost 40% of all cannabinoid-positive specimens. Of the 65 chronic marijuana smokers in the present study who stated that they had smoked within two days of their admission into the treatment facility, 17 (26%) went undetected by the 100 ng/mL cutoff used by the EMITst method. In clinical settings such as drug treatment programs, tests for urinary cannabinoids should use a detection threshold at 20 ng/mL or less.