Evaluation of low-to-moderate arsenic exposure, metabolism and skin lesions in a Turkish rural population exposed through drinking water

BACKGROUND

There is no human data regarding the exposure, metabolism and potential health effects of arsenic (As) contamination in drinking water in the Central Anatolian region of Turkey.

METHODS

Residents in ten villages with drinking water of total As (T-As) level >50 μg L^-1 and 10-50 μg L^-1 were selected as an exposed group (n = 420) and <10 μg L^-1 as an unexposed group (n = 185). Time-weighted average-As (TWA-As) intake was calculated from T-As analysis of drinking water samples. Concentrations of T-As in urine and hair samples, urinary As species [i.e., As(III), As(V), MMA(V) and DMA(V], and some micronutrients in serum samples of residents of the study area were determined. Primary and secondary methylation indices (PMI and SMI, respectively) were assessed from urinary As species concentrations and the presence of skin lesion was examined.

RESULTS

TWA-As intake was found as 75 μg L^-1 in the exposed group. Urinary and hair T-As and urinary As species concentrations were significantly higher in the exposed group (P < 0.05). The PMI and SMI values revealed that methylation capacities of the residents were efficient and that there was no saturation in As metabolism. No significant increase was observed in the frequency of skin lesions (hyperpigmentation, hypopigmentation, keratosis) of the exposed group (P > 0.05). Only frequency of keratosis either at the hand or foot was higher in individuals with hair As concentration >1 μg g^-1 (P < 0.05).

CONCLUSIONS

Individuals living in the study area were chronically exposed to low-to-moderate As due to geological contamination in drinking water. No significant increase was observed in the frequency of skin lesions. Because of the controversy surrounding the health risks of low-to-moderate As exposure, it is critical to initiate long-term follow-up studies on health effects in this region.

Accumulation of heavy metals with water quality parameters in Kızılırmak River Basin (Delice River) in Turkey

Kızılırmak River has been used as Ankara's drinking water source for approximately 1.5 years. Therefore, this region's water, sediment, and fish samples are measured for detecting the heavy metals. This is important for the current situation as well as the future in terms of potential impact. The amount of heavy metals in drinking water should be within the limited values; otherwise, the accumulation of heavy metals will cause many problems to living organisms. Especially high levels of arsenic, cadmium, nickel, mercury, etc. are very dangerous to freshwater ecosystems as for human if the water is being use as drinking water. In this study, water, sediment samples, muscle, and gills of three fish species (Capoeta tinca, Capoeta capoeta, Leuciscus cephalus) were analyzed for the presence of heavy metals such as (Al, Fe, As, Cd, Ni, Mn, Se, Si) to determine present accumulation levels and possible toxic effect. The accumulation pattern of heavy metals in the water, sediment, and fish tissue follows the sequence: Si>Fe>Al>Mn>As>Ni>Se>Cd, Fe>Al>Mn>Ni>As>Se>Cd, and Fe>Al>Mn>As>Ni>Si>Cd. In addition, the detected concentrations of heavy metals in the Kızılırmak and Delice Rivers are compared with other heavy metal studies in the other main rivers and lakes in Turkey.

Excessive naked megakaryocyte nuclei in myelodysplastic syndrome mimicking idiopathic thrombocytopenic purpura: a complicated pre- and post-transplantation course

A boy 3 years 7 months old with thrombocytopenia and history of intracranial hemorrhage who underwent bone marrow transplantation is presented. He was refractory to steroids, immunoglobulin G, vincristine, azathioprine, cyclosporine A, interleukin-11, chemotherapy, and splenectomy. Idiopathic thrombocytopenic purpura was excluded by light /electron microscopic and flow cytometric findings; the diagnosis of refractory cytopenia, a subgroup of pediatric myelodysplastic syndrome, was made. Naked megakaryocyte nuclei were 55.38 +/- 28.2% vs. 31.67 +/- 23.22% of all megakaryocytes in the patient and the control group of 9 patients with idiopathic thrombocytopenic purpura, respectively (p = .016). The posttransplatation course was complicated by delayed platelet engraftment, bronchiolitis obliterans associated with pneumocystis carinii pneumonia, which resolved completely.

Successful treatment with gemtuzumab ozogamicin monotherapy in a pediatric patient with resistant relapse of acute myeloid leukemia

There are few therapeutic options in relapsed or refractory acute myeloid leukemia patients. CD33 antigen is expressed on approximately 90% of myeloblasts, and gemtuzumab ozogamicin, as a monoclonal antibody directed against the CD33 surface antigen, may be a good target for these patients. Herein, we present a 15-year-old acute myeloid leukemia patient who was resistant at relapse and could achieve remission with gemtuzumab ozogamicin at a total dose of 9 mg/m2, divided into three doses and delivered to hematopoietic stem-cell transplantation; however, the patient relapsed in a short time without application of transplantation.

The absence of peripheral blood blasts at diagnosis may predict CNS involvement or CNS relapse in pediatric acute lymphoblastic leukemia patients

A high tumor burden at the time of diagnosis of childhood acute lymphoblastic leukemia has an unfavorable outcome. Peripheral white blood cell count is commonly used to reflect the leukemic burden and is used as one of the most important factors during determination of the risk-based treatment. However, peripheral blood blast count may not always reflect the tumor burden if leukocytes are not in blast nature. In the present study, we observed no central nervous system involvement at the time of diagnosis in patients with no peripheral blood blasts at the beginning, and furthermore, none of the patients with no peripheral blasts at the diagnosis had central nervous system relapse.

The prognostic impact of myeloid antigen expression in pediatric acute lymphoblastic leukemia patients

The incidence of mixed-lineage leukemias in the pediatric age group was previously reported as 13.8% for myeloid antigen-positive ALL and 11.1% for lymphoid antigen-positive acute myeloid leukemia (AML). Recent studies showed that extensive chemotherapy protocols overcome the risk of myeloid lineage. Our study also supports most of the previous data and we postulate that myeloid antigen expression in pediatric ALL cases has insignificant effect on clinical presentation, relapse rates and survival. Importantly, 54% of myeloid antigen-expressing ALL patients received high-risk treatment protocols for some other reasons and this may also have contributed to similar outcome in these patients to that observed in myeloid antigen-negative ALL patients.

The neurologic complications in pediatric acute lymphoblastic leukemia patients excluding leukemic infiltration

This study presents retrospective analyses of 20 acute lymphoblastic leukemia (ALL) patients who developed neurologic complications (except leukemic infiltration). These subjects represent 9.9% of 203 ALL patients aged 16 years or younger followed in our hospital between March 1991 and January 2003. Fourteen male and six female patients, whose ages ranged between 6 and 168 months, developed 24 episodes of neurologic complications after the diagnosis of ALL. The most common complication was meningitis, which developed in six (25%) episodes, and two thirds of the patients who had meningitis were evaluated to be iatrogenic. Cerebral infarct and venous thrombosis were detected in five (21%) of the episodes. In two (8%) episodes progressive cerebral dysfunction developed after radiotherapy. The remaining 11 (45%) episodes are due to varying types of complications. Interestingly, one patient had abundant histiocytes exhibiting hemophagocytosis in the cerebrospinal fluid (CSF) examination and this patient was subsequently diagnosed with fungal meningoencephalitis, by further investigation. Six (30%) patients died; epilepsia developed in five (25%) patients in the follow-up period and the remaining nine (45%) are healthy. By close follow-up and effective treatment of thrombosis and, especially, of infections including iatrogenic meningitis in developing countries, the morbidities and mortalities of these complications can be decreased.

Acute lymphoblastic leukemia in infants

Between January 1978 and August 1999, 29 infants with newly diagnosed acute lymphoblastic leukemia (ALL) were treated on three consecutive protocols. Eighteen patients with infant ALL diagnosed between 1978-1991 were included in Group 1. In this group, treatment comprised a two- or three-drug induction with prednisolone, vincristine and L-asparaginase, and maintenance therapy consisted of weekly oral administration of mercaptopurine and methotrexate for three years. Group 2: Between 1991 and 1999, 11 infants with ALL were treated by St. Jude Total Therapy XI (n=4) and XIII (n=7) protocols with minor modification. Three years' event-free survival (+/-SE) was 14 +/- 9% in group 1. In group 2, this rate was 25 +/- 22% in Total XI and 57 +/- 19% in Total XIII. Outcome for infants on protocols Total Therapy XI and XIII improved compared with that of group 1.

Children with acute myeloblastic leukemia presenting with extramedullary infiltration: the effects of high-dose steroid treatment

To evaluate whether children with acute myeloblastic leukemia (AML) presenting with extramedullary infiltration (EMI) have different clinical, morphologic features and prognosis from children without EMI, a 127 consecutive previously untreated children with AML were entered in this study. Fifty-one children (40%) had EMI at diagnosis and 27% of these showed multiple site involvement. Twenty-seven of 127 children (21%) presented myeloid tumors. No age related differences in the incidence of EMI was noted. However, analysis of clinical and biological features at diagnosis showed that WBC count > or =50 x 10(9) l(-1), hepatosplenomegaly >5 cm, FAB AML-M4 and AML-M5 subtypes and CD13, CD14 expression of bone marrow (BM) leukemic cells (>20%) were more frequent in children with EMI. Two consecutive treatment protocols were used. In both protocols remission was achieved with combined high-dose methylprednisolone (HDMP) as a differentiating and apoptosis inducing agent with mild cytotoxic chemotherapy (low-dose cytosine arabinoside (LD Ara-C), weekly mitoxantrone and Ara-C or 6-thioguanine). Administration of short-course (4-7 days) HDMP (20-30 mg/kg per day) alone resulted in a remarkable decrease in peripheral blood, BM blasts and in the size of EMI in responding patients. In both protocols, remission rate in patients with EMI was 71 and 80%, which was lower than that of the patients without EMI (87 and 89%). This may be attributed to the higher frequency of unfavorable features in children with EMI. However, in patients who presented with myeloblastoma and treated with a more intensive post-remission therapy (AML-94), the 4-year disease-free survival (DFS) and event-free survival (EFS) rates were not found to be significantly different from children who had no EMI (P>0.05). Whereas, the outcome of children who presented with gingival infiltration did not improve. In further studies, the prognostic significance of different localisation of EMI and the effect of addition of HDMP to cytotoxic chemotherapy should be explored in larger series.

Evaluation of coagulation in pediatric bone marrow transplantation patients

A hypercoagulable state is frequently described in adult patients undergoing bone marrow transplantation (BMT). In this study, the coagulation profile of 29 children was prospectively investigated in the pre- and post-transplant period. A significant rise in the activated partial thromboplastin time (aPTT) values was detected on days 7 and 14 after transplantation. Moreover, an increase in the d-dimer level was also notable, regardless of the clinical condition of the patients. The other coagulation parameters investigated (i.e. protein S, protein C, anti-thrombin III, factor VIII, von Willebrand factor, and prothrombin time) remained essentially unchanged. However, hyper-fibrinogenemia was observed in all patients with chronic myeloid leukemia (CML) (n=5) before and after transplantation. In summary, in the present study pediatric bone marrow transplantation patients did not show a hyper-coagulable state after marrow infusion. However, a significant rise in PTT and d-dimer values were noted.

Allogeneic bone marrow transplantation for children with myelodysplastic syndrome

Six children with myelodysplastic syndrome underwent allogeneic bone marrow transplantation (BMT) from their HLA-identical siblings. Ages ranged from six to 16 years. French-American British (FAB) diagnosis was refractory anemia with excess blasts (RAEB) in three, RAEB in transformation (RAEB-t) in one and chronic myelomonocytic leukemia (CMML) in two cases. Two patients had progressed to leukemia before BMT. All patients received busulfan and cyclophosphamide as a conditioning regimen. Antithymocyte globulin (ATG) was administered to two of them due to the multiple transfusion history. Graft versus host disease (GvHD) prophylaxis consisted of cyclosporine-methotrexate. Engraftment was documented in all patients except one who underwent a second infusion of bone marrow cells. She died in the early post-transplant period with pancytopenia and veno-occlusive disease of the liver. Two patients died from disease recurrence. Three patients are alive > 12 months post-transplant, two are in remission and one just relapsed at +16 months and is now being prepared for a second bone marrow transplant. The only significant factor for favorable outcome was short duration between diagnosis to transplant in the two patients in remission.

Multimedia and children in Turkey

Multimedia will be regarded as essential tools for children to create their new world. The effects of television on young children's life have been well studied. Television differs, however, from other media, including the movies, in its pervasive impact on children. Children spend more time watching television than any other activity except sleeping. Overall 31% of children spent at least 4 hours a day watching television during weekday and 71.7% during weekend in Turkey. Television's influence on children is a function of the length of time they spend watching and the cumulative effect of what they see. Television may be a cause as well as a solution for many serious childhood problems. Excessive viewing of television has also been linked to aggressive behavior, violence, childhood obesity. On the other hand, television may act as a socializing agent and as a learning tool if the recommendations of American Academy of Pediatrics is learned by pediatricians, parents and broadcasters. The use of home personal computers in urban residence increased from 3.2% in 1993 to 6.5% by January 1998 in Turkey. Around 20% of computer households reported owing a modem. Internet has been using only for 5 years in Turkey. Nearly 40% of computer households also used CD-ROM equipment. The percentage of schools that have a computer laboratory is only 2.64%. On the other hand, multimedia allows students to move away from a uniform education for everyone to assert individual identity, liberalize education and management. It seems likely that, within the next few years, most of the countries with substantial internet infrastructure will use the internet as the major medium for disseminating information, including information on children. To prepare students for such a world demands that educational systems make the best possible use of all knowledge and technologies currently available.

CD34/CD117 co-expression in childhood acute leukemia

CD117 protein is expressed by the primitive CD34 positive haemopoietic stem cells and also demonstrated on the blasts of 30-100% of AML cases, but rarely on lymphoblasts. Therefore several investigators have used CD117 expression to exclude lymphoblastic origin of blasts. However, conflicting results exist in the literature. We investigated CD34 and CD117 status at initial presentation of 232 children with acute leukemia. CD34 was commonly expressed in all types of acute leukemias, whereas CD117 molecule seemed to be a more specific marker for leukemia of myeloid origin being demonstrated on > 5% of blasts in 60 out of 73 cases of AML patients, but rarely detected in ALL (9/140 patients). Moreover, co-expression of CD34/CD117 was extremely rare on lymphoblasts with only 3/140 ALL patients demonstrating > 5% co-expression of CD34 and CD117, and therefore we suggest that it should be used in the exclusion of ALL.

Effects of G-CSF and high-dose methylprednisolone on peripheral stem cells, serum IL-3 levels and hematological parameters in acute lymphoblastic leukemia patients with neutropenia: a pilot study

Several agents, used either alone or in combination, have been shown to boost absolute numbers of PMLs and CD34+ stem cells in PB. In this study, we compared the effects of three different treatments, G-CSF, HDMP, and G-CSF + HDMP, for neutropenic patients (absolute PML count < 0.5 x 10(9)/l) who were on maintenance therapy for ALL with a control group who received no treatment. Hematological parameters, PB-CD34+33- and -CD34+ HLA-DR- stem cell numbers, and serum IL-3 levels were measured prior to, and a week after, the first day of treatment. WBC and absolute PML counts were significantly increased compared to pretreatment values in all treatment groups. However, peripheral CD34+ 33- and CD34+ HLA-DR stem cell numbers and serum IL-3 levels were increased significantly only in the G-CSF group. There was also a significant increase in serun IL-3 levels in the G-CSF + HDMP group. This study suggests that G-CSF may induce an increase in peripheral stem cell numbers, and that it supports hemopoietic recovery by increasing IL-3 in patients with chemotherapy-induced neutropenia.

Relationship between high leukocyte count and cell size in childhood acute myeloblastic leukemia

In order to determine the significance of cell size together with high leukocyte count (>30x10(9)/L) in acute myeloblastic leukemia (AML), we evaluated the percentages of small, medium and large cells in 33 children with AML. All of the 10 patients with a high leukocyte count and 14 of the 23 patients with a low leukocyte count (<30x10(9)/L) died or experienced a relapse within the first year. The mean small cell percentage of patients with high leukocyte counts was significantly lower than that of patients with low leukocyte counts (p<0.05). The percentages of small, medium and large cells of patients with high leukocyte counts and of patients with low leukocyte counts who died or experienced a relapse within the first year were similar. The percentage of medium cells of patients with high leukocyte counts was significantly higher than that of surviving patients with low leukocyte counts (p<0.05). The mean percentages of small, medium and large cells were similar in patients who died or experienced a relapse and surviving patients with low leukocyte count. We conclude that cell size has prognostic significance when the leukocyte count at admission is over 30x10(9)/L, although confirmation seems necessary with a larger population of patients.

The importance of cell size and surface marker analysis in childhood acute myeloblastic leukemia

In order to evaluate the prognostic significance of cell size and surface marker expression, we evaluated 33 children with newly diagnosed acute myeloblastic leukemia by flow cytometry. We determined: the percentage of small, middle and large cells; large to small cell ratios (LS); large plus middle to small cell ratios (LMS); the percentage of surface markers expressed by each group of cell; the ratios of surface marker percentages expressed by the large blasts to that expressed by small blasts (LS for surface markers); and large plus middle blasts to that by small blasts (LMS for surface markers). For 'early prognosis', patients who could and could not achieve remission (n = 23 and 10) and for late prognosis, the patients who deceased or relapsed within the first 12 months of the treatment (n = 24) and who survived for more than 12 months (n = 9) were compared, in two classifications. CD3 percentages of the small cells of alive patients were significantly higher than that of dead or relapsed patients. LMS for CD3 and CD20 and LS for CD20 were higher in dead relapsed patients than that of alive patients. The total percentage of CD14 was significantly higher in dead relapsed patients than it was in the alive patients and CD3 was significantly higher in the group of patients who achieved remission than that of the patients who could not achieve remission. It was striking that, expression of CD3, CD7, CD22, CD33, CD14, CD15, CD34 increased or decreased as to cell size, whatever the prognosis. CD10, CD20 and CD13 were expressed on the large cells of the patients who could not achieve remission or died relapsed. We showed that, the blast cell size, individually does not have any prognostic significance in childhood AML and the prognostic significance of surface markers not only depends on their presence or absence but also on their relative configuration of expression by the blasts with different size.

Biphenotypic characteristics, cell size and prognosis in childhood acute myeloblastic leukemia

In order to determine the prognostic significance of cell size together with expression of biphenotypic markers in childhood acute myeloblastic leukemia (AML), we evaluated the cell size of children with AML, 12 with and 21 without biphenotypic markers. The patients were followed up for at least 12 months. The cells which were stained with FITC conjugated surface marker antibodies were divided into small, middle or large cell groups according to their mean channel number of forward scatter by flow cytometry. Nine of 12 biphenotypic and 15 of 21 non-biphenotypic children either died or relapsed within the first 12 months. The percentages of the small, middle and large cells were similar in children and in deceased patients, regardless of whether or not they expressed biphenotypic markers. We believe that biphenotypic marker expression is a poor prognostic factor regardless of cell size.

Transferrin receptor on peripheral blood lymphocytes in iron deficiency anaemia

The effect of iron deficiency anaemia (IDA) on CD71 expression by peripheral blood lymphocytes was studied in 43 children with iron deficiency anaemia. 18 healthy age-matched children were selected as the control group. 11 children with beta-thalassaemia trait were also studied. Lymphocytes bearing CD71 were enumerated by flow cytometric analysis of peripheral blood. At diagnosis, CD71+ peripheral lymphocytes (mean+/-SE) was 5.90+/-0-76% in patients with IDA and 12.60+/-0.98% in healthy controls (P=0.000). In beta-thalassaemia trait patients the peripheral blood CD71+ lymphocytes were 7.80+/-1.20%. In IDA patients there was a statistically significant correlation between the levels of CD71+ peripheral lymphocytes and haemoglobin value (P = 0.000). In 19 patients studied at days 0 and 30 of oral iron therapy, the number of peripheral blood CD71+ lymphocytes was shown to be increased from 5.90+/-0.76% to 12.11+/-1.21%. In severe IDA presence of a limited number of CD71+ peripheral blood lymphocytes indicated that severe IDA should be borne in mind when considering conditions responsible for the suppression of lymphocyte proliferation.

Effect of high-dose methylprednisolone and G-CSF treatments on lymphocyte subtypes in neutropenic children with acute lymphoblastic leukemia: a pilot study

Treatment of neutropenia with corticosteroids and hemopoietic growth factors may cause alterations in the immune system. This study investigated and compared the effects of various regimens (HDMP, G-CSF, and G-CSF + HDMP) on total lymphocyte counts and subtypes in neutropenic patients with acute lymphoblastic leukemia. Lymphocyte subtypes were studied just prior to treatment and 1 week later. In the HDMP group, total lymphocyte counts and the numbers of CD3+, CD4+, CD8+, and CD19+ lymphocytes and monocytes increased, while the helper/suppressor lymphocyte ratio decreased. No significant changes were seen in lymphocyte subtypes in the G-CSF and G-CSF + HDMP groups, apart from an increase in total lymphocyte numbers. In the control group there was an increase in the number of CD3+ and CD8+ lymphocytes and a decrease in the helper/suppressor lymphocyte ratio. These results suggest that HDMP has an inducing, rather than a suppressive effect on all lymphocyte subtypes studied.

Necrotizing otitis externa, otitis media, peripheral facial paralysis, and brain abscess in a thalassemic child after allogeneic BMT

Severe infection is one of the major complications in the early and late post-bone marrow transplantation period. The authors report a thalassemic child who developed necrotizing otitis externa and otitis media, a very rare complication after bone marrow transplantation, and then peripheral facial nerve paralysis and brain abscess in the early period of bone marrow transplantation despite antibacterial and antifungal prophylaxis. Necrotizing otitis media is characterized by necrosis and sloughing of considerable areas in the middle ear and adjacent tissues and is an unusual disorder because of today's antibiotics. Granulocytopenia and background ear tissue exposed to previous repeated otitis media attacks may be the predisposing factors in this case. The authors conclude that the children with previous histories of recurrent otitis media should be prepared and monitored very carefully during bone marrow transplantation because of the risk of necrotizing otitis media, especially in the granulocytopenic period.

A comparison of the effect of high-dose methylprednisolone with conventional-dose prednisolone in acute lymphoblastic leukemia patients with randomization

In this preliminary study the efficacy of high-dose methylprednisolone (HDMP) during remission-induction chemotherapy was evaluated on 166 children with acute lymphoblastic leukemia (ALL). The St. Jude Total Therapy Study XI protocol with minor modifications was used in this trial. Patients were randomized into two groups. Group A received conventional-dose (2 mg/kg/day orally) prednisolone, and group B received high-dose methylprednisolone (HDMP, Prednol-L, 900-600 mg/m2 orally) during remission-induction chemotherapy. Complete remission was achieved in 97% of the children. For the 80 patients who were followed up for 3 years, median follow-up was 44 (range 5-60) months and the 3-year event-free survival (EFS) rate was 68.5%) overall, 58.6% in group A and 78.4% in group B. The EFS among patients in group B was significantly higher than in group A (p=0.05). When we compared the 3-year EFS of groups A and B in the high-risk groups and high-risk subgroups with white blood cell (WBC) counts > or = 50 x 10(9)/l and age > or = 10 years, the survival rates were 45% versus 77.2%, 33% versus 78% and 45% versus 89%, respectively. During the follow-up of 162 patients, relapses were significantly higher in group A. Bone marrow relapses in 162 patients, and also in a subgroup of patients > or = 10 years of age were significantly higher in group A. These results suggest that HDMP during remission-induction chemotherapy improves long-term EFS, particularly for high-risk patients.

Dramatic resolution of pleural effusion in children with chronic myelomonocytic leukemia following short-course high-dose methylprednisolone

High-dose methylprednisolone (HDMP) which can induce--differentiation and -apoptosis of myeloid leukemic cells has been shown to be very effective in the treatment of extramedullary infiltration (EMI) of children with acute myeloblastic leukemia (AML). In the present study 2 children with chronic myelomonocytic leukemia (CMML) who had pleural effusions were given a single daily dose of oral methylprednisolone (20 mg/kg or 30 mg/kg). In addition to dramatic improvement of respiratory symptoms, pleural effusions disappeared in four days in both patients possibly due to apoptotic cell death induced by HDMP treatment. Further studies are needed to determine whether high-dose corticosteroids are also effective on the resolution of pleural effusions associated with other malignant disease.

Retrospective analysis of 78 children with chronic idiopathic thrombocytopenic purpura: follow-up from 1976 to 1996

In this retrospective study of 20 years, 78 children with chronic idiopathic thrombocytopenic purpura (ITP) were analyzed. Patients were followed for 1-17 years (median 2.7 years). Every application that required therapy was accepted as an "attack." Seventy-eight patients received therapy in 236 attacks. Immediate platelet responses to high-dose methylprednisolone (HDMP), prednisone, and splenectomy were 69.3% (in 53 patients), 48.3% (in 35 patients), and 84.6% (in 29 patients) of attacks, respectively. Because 31 patients were lost to follow-up, the rate of remission was calculated on the basis of 47 patients. The remission rates for patients who underwent remission spontaneously, after steroid therapy, and after splenectomy were 29.78, 6.38, and 14.89%, respectively. Of 78 adolescent patients, 11.5% had intracranial hemorrhage (ICH), being after splenectomy. One patient died because of ICH. These data indicate that chronic ITP is still a serious problem during adolescence and splenectomy still seems to be a current choice of therapy.

Effect of short-course high-dose methylprednisolone treatment on serum IL-2 levels in children with myelodysplastic syndromes: a pilot study

Promising results in children with myelodysplastic syndromes (MDS) have been reported with high-dose methylprednisolone (HDMP) as a differentiation inducer, combined with cytotoxic chemotherapy. HDMP treatment has been shown to stimulate some cytokines in patients with acute leukemia. In the present study the effect of HDMP treatment on serum levels of interleukin 2 (IL-2) was evaluated in five children with MDS. Remarkable increases in serum IL-2 levels were observed 3 and 7 days after HDMP (30 mg/kg per day) treatment in three patients with chronic myelomonocytic leukemia (CMML). There was no correlation between the peripheral blood absolute lymphocyte counts and serum IL-2 levels. The results of this preliminary study indicate that the use of short-course HDMP treatment might be beneficial to increase the serum IL-2 level in patients with CMML.

The effect of short-course high-dose corticosteroid therapy on peripheral blood CD34+ progenitor cells in children with acute leukemia

High-dose methylprednisolone (HDMP) treatment has been shown to induce the differentiation of myeloid leukemic cells to mature granulocytes in patients with acute promyelocytic leukemia and other subtypes of acute myeloblastic leukemia (AML). HDMP administration has also been shown to accelerate the recovery of leukocytes and increase bone marrow hematopoietic CD34+ progenitor cells in patients with acute lymphoblastic leukemia (ALL). In the present study, we evaluated the effect of short-course (4-day) HDMP treatment on peripheral blood (PB) CD34+ cells in patients with acute leukemia (AL). Fourteen children with AL who were receiving maintenance therapy were enrolled in this study. Methyl-prednisolone was given orally as a single daily dose of 30 mg/kg for only 4 days to nine children (three AML, six ALL) in whom chemotherapy-induced leukopenia (< 2 x 10(9)/L) was observed. Circulating CD34+ progenitor cells were determined by flow cytometry before (day 0) and 4 and 7 days after HDMP treatment. On days 4 and 7 after initiation of HDMP treatment, the number of PB CD34+ cells increased significantly (p < 0.05). Hematopoietic CD34+ progenitor cells were also determined in five patients with AL (two AML, three ALL) and chemotherapy-induced leukopenia who did not receive HDMP. The number of CD34+ cells was found to be significantly (p < 0.05) higher in the patients who received HDMP than in those who did not. Along with PB CD34+ progenitor cells, white blood cells (WBC), polymorphonuclear cells (PMN), and monocytes also increased significantly (p < 0.05) in patients treated with short-course HDMP. In conclusion, short-course HDMP treatment can be used to shorten the chemotherapy-induced leukopenic period in patients with AL, possibly by increasing the number of hematopoietic progenitor cells. Further studies are needed to evaluate the effect of this treatment on leukopenic patients with other malignancies.

Morphologic evidence of apoptosis in childhood acute myeloblastic leukemia treated with high-dose methylprednisolone

We have previously demonstrated that various subtypes of AML children respond to high-dose methylprednisolone (HDMP; 20-30 mg/kg/day) which could induce in vivo differentiation of myeloid leukemic cells to mature granulocytes. In this study we have evaluated whether apoptosis occurs in AML cells of patients treated by HDMP using morphological criteria. For light and electron microscopic examination bone marrow aspirates were obtained four days and two weeks after methylprednisolone (30 mg/kg/day) treatment from two children with newly diagnosed AML (AML-M3 and AML-M4). In both patients maturation of leukemic cells has previously been reported four days (in patient with AML-M3) and two weeks (in patient with AML-M4) after HDMP treatment. Electron microscopy revealed the characteristic ultrastructural changes of various stages of apoptosis four days after HDMP treatment in a case with AML-M3. Morphologic evidence of apoptosis induced by HDMP were also detected on Wright-stained and toluidine blue stained semithin sections of BM preparations in a patient with AML-M4 and AML-M3 respectively. These findings suggest that HDMP which could induce in vivo terminal differentiation in myeloid leukemic cells is also able to induce apoptosis in patients with AML. The possibility of HDMP-induced apoptosis should be evaluated in a larger series of patients with AML and other types of malignant tumors.

Spontaneous complete remission in a child with acute lymphoblastic leukemia

A five-year-old girl was admitted to the hospital with fever and tender lymphadenopathy. She was diagnosed with acute lymphoblastic leukemia (ALL-L3). Because of infection she was given antibiotics and a blood transfusion. Her bone marrow was in remission after 15 days without chemotherapy. This case emphases the role of transfusion and/ or infection in obtaining complete remission without chemotherapy.

Serum TNF-alpha, gamma-INF, G-CSF and GM-CSF levels in neutropenic children with acute leukemia treated with short-course, high-dose methylprednisolone

High-dose methylprednisolone (HDMP, 20-30 mg/kg/day po) treatment has been shown to increase the number of bone marrow and peripheral blood CD34 positive progenitors and serum granulocyte-macrophage colony-stimulating factor (GM-CSF) levels in patients with ALL and AML. To investigate the effect of HDMP on some other hematopoietic regulatory cytokines, tumor necrosis factor-alpha (TNF-alpha), gamma-interferon (gamma-INF), granulocyte colony-stimulating factor (G-CSF) and interleukin-6 (IL-6) were studied by microplate ELISA technique in 15 chemotherapy-induced neutropenic episodes of 14 children with acute leukemia (eight with ALL and six with AML) in whom HDMP was given alone (30 mg/kg/day po) for 4 days. The absolute neutrophil counts increased significantly in all neutropenic episodes on the fourth day of HDMP treatment. The TNF-alpha was 93.5 +/- 161 pg/ml in ALL and 78.3 +/- 61.4 pg/ml in AML before treatment and 76.1 +/- 160 pg/ml in ALL and 19.1 +/- 39.8 pg/ml in AML after treatment. The gamma-INF was 204.1 +/- 210.3 pg/ml in ALL and 130.8 +/- 138.3 pg/ml in AML before treatment and 28.6 +/- 50.5 pg/ml in ALL and 23.3 +/- 20.4 pg/ml in AML after treatment (P<0.05). Serum G-CSF and GM-CSF levels increased in all episodes (100%). The GM-CSF levels increased from 12.2 +/- 10.9 pg/ml to 36 +/- 24.7 pg/ml after treatment in ALL (P<0.05) and from 13.3 +/- 4 pg/ml to 45 +/- 48.1 pg/ml in AML (P<0.05). Serum G-CSF levels increased from 13.3 +/- 11.7 pg/ml to 83.3 +/- 86.8 pg/ml after treatment in ALL (P<0.05) and from 6.6 +/- 12.1 pg/ml to 28.3 +/- 11.3 pg/ml in AML (P<0.05). However, IL-6 levels were undetectable in all patients before and after therapy. These preliminary data suggest that short-course HDMP treatment could decrease serum TNF-alpha and gamma-INF and increase G-CSF and GM-CSF levels.

The effect of high-dose methylprednisolone on CD34-positive bone marrow cells in the children with acute myeloblastic leukemia

The expression of CD34 antigen on the surface of bone marrow (BM) cells during remission induction was studied in 20 patients with CD34-negative acute myeloblastic leukemia (AML). The patients were given high-dose methylprednisolone (HDMP) alone for one week, after which time mitoxantrone and low-dose Ara-C were added. BM cells from all patients were studied one, two and four weeks after initiation of treatment to evaluate CD34 antigen expression using a three-step peroxidase antiperoxidase staining technique. The mean percentage of CD34-positive BM cells was 5.3% at presentation, increasing to 15.6% in the first week, 12.9% in the second week and 21.7% in the fourth week of therapy. During the same period the mean percentages of the initial BM blasts decreased from 64% to 22%, 7% and 2% in the first, second and fourth weeks of therapy, respectively. The increase in the CD34-positive BM cells one week after HDMP treatment alone suggests that HDMP directly or indirectly stimulates CD34-positive hematopoietic progenitor cells while decreasing BM blasts in patients with AML.

Secondary acute myeloblastic leukemia in a child with acute lymphoblastic leukemia treated with epipodophyllotoxins

Etoposide is a semi-synthetic, topoisomerase active podophyllotoxin derivative which frequently causes deletions and rearrangements on chromosomes 11q23 and 11q22. It can cause therapy-related, acute myeloblastic leukemia in patients receiving the drug in a schedule-dependent manner. Here we present a case with acute lymphoblastic leukemia who developed secondary acute myeloblastic leukemia 28 months after the beginning of therapy which contained etoposide on an every-other-week schedule.

The effect of high-dose methylprednisolone combined chemotherapy on CD34-positive cells in acute lymphoblastic leukemia

The expression of CD34 antigen on the surface of bone marrow cells during remission induction was studied in 27 selected acute lymphoblastic leukemia (ALL) patients who were CD34 negative at presentation and were stratified to receive high-dose methylprednisolone (30 mg/kg/day po) or conventional-dose prednisolone (2 mg/kg/day po). Patients received either induction with L-Asparaginase, vincristine (VCR), and high-dose methylprednisolone [HDMP, 30 mg/kg/day po for 1 week, 20 mg/kg/day po for 1 week, and 20 mg/kg/day po every other day for 2 more weeks (20 patients)], or identical induction in which HDMP was replaced by prednisolone 2 mg/kg/day by mouth for 4 weeks (8 patients). Bone marrow cells from all patients were studied 1,2, and 4 weeks after initiation of treatment for expression of the CD34 antigen using a three-step indirect immunoperoxidase staining technique. In the 20 patients with ALL who received HDMP the percentage of normal bone marrow cells expressing CD34 was significantly higher (p < 0.05) than in the 8 patients who did not receive HDMP. The mean percentage of CD34-positive bone marrow cells during the fourth week was 17.2% in patients with ALL who received HDMP, whereas patients who received 2 mg/kg prednisolone per day had only 6.1% CD34 cells in the marrow. Absolute polymorphonuclear leukocyte (pmnl) count was also significantly higher in the patients who received HDMP in the second and third week of therapy [(absolute pmnl count was 2197.7/mm3 in the second week and 4091.8/mm3 in the fourth week in the patients who received HDMP compared to 974.4/mm3 and 1556.5/mm3 in the patients who did not receive HDMP) (p < 0.05)].(ABSTRACT TRUNCATED AT 250 WORDS)

Acute lymphoblastic leukemia following optic glioma treated by radiotherapy and surgery

A 14-year-old girl was diagnosed as having acute lymphoblastic leukemia following 5000 cGy cranial radiotherapy for treatment of optic glioma. In the absence of underlying predisposing factors, development of acute leukemia was attributed to the oncogenic effect of radiation.

The effect of high-dose methylprednisolone treatment on GM-CSF level in children with acute leukemia: a pilot study

High-dose methylprednisolone therapy (HDMP) induces acceleration of leukocyte recovery in acute lymphoblastic leukemia (ALL) and the differentiation of myeloblasts to mature granulocytes in acute myeloblastic leukemia (AML). These effects of corticosteroids have been shown to be due to the enhanced colony-stimulating activity (CSA) and responses to corticosteroids in some patients with aplastic anemia and myelodysplastic syndromes (MDS) have been related to increased CSA activity. We measured the serum (granulocyte-macrophage colony-stimulating factor (GM-CSF) levels by a sandwich linked immunoabsorbent assay (ELISA) in patients with ALL and AML at presentation and following high-dose methylprednisolone (HDMP) therapy. Serum GM-CSF levels at presentation in the ten cases studied ranged between 160 and 700 pg/ml (mean 418.5 +/- 252.5). One week following HDMP therapy GM-CSF levels increased to between 260 and 950 pg/ml (733.5 +/- 203.2). Four weeks after therapy the GM-CSF levels increased to between 470 and 1350 pg/ml (911 +/- 278.7). GM-CSF levels were markedly elevated one week after HDMP in the patients with ALL, suggesting that in addition to the lymphotoxic effects on leukemic blasts, the acceleration in neutrophil recovery may be due to release of GM-CSF induced by HDMP and its effects on myeloid progenitors.

High remission rate in acute myeloblastic leukemia in children treated with high-dose methylprednisolone

Since the differentiating effect of high-dose methylprednisolone (HDMP) on myeloid leukemic cells has been shown in one of our patients with acute myeloblastic leukemia (AML-M4), 27 previously untreated children with AML were given HDMP (20-30 mg/kg per day) combined with cytosine arabinoside (Ara-C; 3 mg/kg) for the first 2 weeks of induction therapy. Marked clinical improvement was observed in all patients with the exception of one who died within 24 hours of the treatment. Enlarged liver and spleen (greater than 5 cm) became nonpalpable in 3 (37%) out of 8 and 5 (100%) out of 5 patients, respectively, and bone marrow blasts decreased below 5% in 7 patients (27%) within 2 wk of HDMP and Ara-C treatment. Adriamycin (1 mg/kg) was added 2 wk after initiation of induction therapy. Twenty-two (84.6%) of the 26 patients achieved complete remission, 3 (11.5%) had partial remission and no response was obtained in one. Treatment was well tolerated. The addition of HDMP as a differentiating and/or cytolytic agent to conventional anti-leukemic chemotherapy increased the complete remission rate and prolonged the duration of remission of our AML patients.

Detection of p53 oncogene in acute-leukemia cells by immunoperoxidase technique

Expression of p53 oncogene in blast cells may have prognostic importance in acute leukemia. Simple and reliable methods which could detect enhanced p53 expression in leukemia cells would be important for follow-up studies of leukemia patients in remission. We used immunoperoxidase (IP) technique with an anti-p53 monoclonal antibody PAb421 to study the expression of p53 in leukemia cells. The expression of p53 was studied in 9 cell lines and 17 de novo acute leukemia (9 acute myeloid leukemia [AML], 8 acute lymphoblastic leukemia [ALL]) patients. The expression of p53 was demonstrated in non-T non-B cells and Burkitt's lymphoma cell lines, but neither in two myeloid leukemia cell lines nor in normal lymphoid cells after mitogenic stimulation. p53 expression was demonstrated in 7 cases (2 AML, 5 ALL) but only in ALL cases the percentage of positive of cells was over 20%. Bone marrow cells from patients were studied also after short-term culture (AML patients); in 1 case the number of PAb421-positive cells rose significantly after culture. These data suggest that IP staining with PAb421 can be used to demonstrate high p53 expression in B cell leukemias.