The establishment and validation of a prediction model for traumatic intracranial injury patients: a reliable nomogram

Objective

Traumatic brain injury (TBI) leads to death and disability. This study developed an effective prognostic nomogram for assessing the risk factors for TBI mortality.

Method

Data were extracted from an online database called "Multiparameter Intelligent Monitoring in Intensive Care IV" (MIMIC IV). The ICD code obtained data from 2,551 TBI persons (first ICU stay, >18 years old) from this database. R divided samples into 7:3 training and testing cohorts. The univariate analysis determined whether the two cohorts differed statistically in baseline data. This research used forward stepwise logistic regression after independent prognostic factors for these TBI patients. The optimal variables were selected for the model by the optimal subset method. The optimal feature subsets in pattern recognition improved the model prediction, and the minimum BIC forest of the high-dimensional mixed graph model achieved a better prediction effect. A nomogram-labeled TBI-IHM model containing these risk factors was made by nomology in State software. Least Squares OLS was used to build linear models, and then the Receiver Operating Characteristic (ROC) curve was plotted. The TBI-IHM nomogram model's validity was determined by receiver operating characteristic curves (AUCs), correction curve, Hosmer-Lemeshow test, integrated discrimination improvement (IDI), net reclassification improvement (NRI), and decision-curve analysis (DCA).

Result

The eight features with a minimal BIC model were mannitol use, mechanical ventilation, vasopressor use, international normalized ratio, urea nitrogen, respiratory rate, and cerebrovascular disease. The proposed nomogram (TBI-IHM model) was the best mortality prediction model, with better discrimination and superior model fitting for severely ill TBI patients staying in ICU. The model's receiver operating characteristic curve (ROC) was the best compared to the seven other models. It might be clinically helpful for doctors to make clinical decisions.

Conclusion

The proposed nomogram (TBI-IHM model) has significant potential as a clinical utility in predicting mortality in TBI patients.

Increased Vδ1γδT cells predominantly contributed to IL-17 production in the development of adult human post-infectious irritable bowel syndrome

Background

γδT cells play an important role in the mucosa inflammation and immunity-associated disorders. Our previous study reported that γδ T cells producing IL-17 were involved in the pathogenesis of post-infectious irritable bowel syndrome (PI-IBS). However, their subset characteristic profile in this kind of disease remains unclear. Thus the current study’s aim is to investigate the functionally predominant subset and its role in PI-IBS.

Methods

The total T cells were collected from the peripheral blood of patients with PI-IBS. The peripheral proportion of Vδ1 and Vδ2 subset was detected by FACS after stained with anti δ1-PE and anti δ2-APC. The local colonic proportion of this two subsets were measured under laser confocal fluorescence microscope. Vδ1 γδ T cells were enriched from the total peripheral T cells by minoantibody-immuno-microbeads (MACS) method and cultured, functionally evaluated by CCK-8 assay (proliferation), CD69/CD62L molecules expression assay (activation) and ELISA (IL-17 production) respectively.

Results

1. Vδ1 γδ T cells significantly increased while Vδ2 γδ T cells remained unchanged in both the peripheral blood and local colonic tissue from PI-IBS patients (p < 0.05). 2. When cultured in vitro, the Vδ1 γδ T cells remarkably proliferated, activated and produced IL-17 (p < 0.05).

Conclusions

Our results suggest that Vδ1 γδ T cells was the predominant γδ T cells subset in both peripheral and intestinal tissue, and was the major IL-17 producing γδ T cells in PI-IBS.

[Clinical study on the effects of global end-diastolic volume index-directed fluid resuscitation on the prognosis of chronic heart failure patients with septic shock]

Objective: To investigate the effect of global end-diastolic volume index (GEDI)-guided fluid resuscitation on the prognosis of patients with chronic heart failure and septic shock. Methods: This study was a prospective randomized controlled study. Consecutive eligible patients were divided into 2 groups according to the random number table method: control group (n=21) and experimental group (n=20). On the basis of routine treatment, patients in the control group received early goal-directed therapy until the central venous pressure (CVP) reaching 8-12 mmHg (1 mmHg=0.133 kPa), mean arterial pressure reaching over 65 mmHg, urine volume reaching over 0.5 ml·kg(-1)·h(-1), and central venous oxygen saturation reaching more than 70%. On the basis of routine treatment, patients in the experimental group were monitored continuously on cardiac output with pulse indication and fluid resuscitation guided by volume index GEDI. The GEDI should be maintained on the range of 680-800 ml/m(2). The remaining resuscitation goals were the same as control group. General clinical data of the two groups were collected at admission. Negative fluid balance onset time, duration of mechanical ventilation, ICU mortality and 28-day mortality were compared between the two groups. The outcomes were recorded as listed: start time of negative fluid balance, duration of mechanical ventilation, mortality in ICU and 28-day mortality. Results: There was no significant difference in age, sex, weight, APACHE Ⅱ score, SOFA score and NYHA functional class score between the two groups (all P>0.05). The negative liquid balance onset time in the control group was 3.5 (2.5, 4.0) days, which was significantly longer than that in the experimental group (2.6 (2.0, 3.0) days,U=115.0, P=0.012). The duration of mechanical ventilation was 355 (118, 552) hours in the control group, which was significantly longer than that in the experimental group (132 (36.75, 233.3) hours, U=130, P=0.038). The ICU mortality was 38.1% (8/21) in the control group, tended to be higher than that in the experimental group (20.0%(4/20), χ(2)=1.620, P=0.203). The 28-day mortality was 42.9% (9/21) in the control group, similar as in the experimental group (25.0%(5/20), χ(2)=1.482,P=0.477). Conclusion: Fluid resuscitation guided by volume index (GEDI) may improve the prognosis of patients with chronic heart failure complicated with septic shock.

Serotonin transporter gene promoter region polymorphisms and serotonin transporter expression in the colonic mucosa of irritable bowel syndrome patients

BACKGROUND

The role of serotonin transporter (SERT) gene polymorphism in irritable bowel syndrome (IBS) has been demonstrated. However, the expression of SERT mRNA and proteins in the colonic mucosa with different 5-HTT gene-linked polymorphic region (5-HTTLPR) genotypes remains unknown. We examined SERT mRNA and protein levels in colon biopsies from patients with different 5-HTTLPR genotypes and evaluated the links between the polymorphism and the expression levels.

METHODS

Two hundred and fifty-four patients with IBS and 120 healthy subjects were studied. DNA samples were extracted from peripheral blood and genotyped by polymerase chain reaction (PCR). SERT mRNA and protein levels were evaluated by quantitative real time PCR and western blotting. The promoter efficiency of the serotonin transporter promoter (SERT-P) was evaluated with luciferase reporter system.

KEY RESULTS

The frequency of the L/L genotype in C-IBS group was significantly higher than that in the control and D-IBS. However, the S/S genotype in D-IBS was significantly higher than that in C-IBS. The transcriptional efficiency of the L/L genotype was significantly higher than that in the L/S and S/S genotype. Patients with the L/L genotype demonstrated increased production of the SERT protein when compared with L/S and S/S patients. The l variant increased SERT promoter activity by 2.43-fold when compared with the s variant.

CONCLUSIONS & INFERENCES

Polymorphism in the promoter region of the SERT gene can influence the expression of SERT mRNA and the levels of the SERT protein in the colonic mucosa, thereby playing a key role in motility-related symptoms of IBS patients.

Improved treatment results for childhood acute myeloid leukemia in Taiwan

To improve treatment results for children with de novo acute myeloid leukemia (AML), we introduced a novel protocol, Taiwan Pediatric Oncology Group-AML-97A, for AML other than acute promyelocytic leukemia (APL), for which modified conventional protocols were used. From January 1, 1997, to December 31, 2002, 141 children younger than 17 years old with de novo AML were enrolled. In total, 117 patients with non-APL AML were treated with induction therapy of idarubicin and cytarabine (Ara-C), postremission therapy with high-dose Ara-C - containing regimens for four monthly courses, and moderate-dose therapy with idarubicin and Ara-C for four monthly courses. The first 19 patients with APL were treated with all-trans retinoic acid, idarubicin and Ara-C, with the remaining five patients receiving all-trans retinoic acid and idarubicin, followed by maintenance therapy for 2 years. Stem cell transplantation was performed in 29 patients in first remission with a similar outcome as chemotherapy alone. The remission rate in the AML-97A study was 90%, the 5-year survival 51 +/- 5.3% (s.e.) and the 5-year event-free survival 50 +/- 4.8%; for APL, these were 100%, 86 +/- 7.0, and 75 +/- 9.8%. For the whole group, the 5-year survival was 57 +/- 4.7% and the 5-year event-free survival 54 +/- 4.4%. The AML-97A regimen was well tolerated.

Structure of monomeric porcine DesB1-B2 despentapeptide (B26-B30) insulin at 1.65 A resolution

Insulin has a concentration of 10(-8)-10(-11) M in the blood which ensures that it circulates and exerts its physiological functions in vivo as a monomer. The crystal structure of monomeric porcine desB1-B2 despentapeptide (B26-B30) insulin (DesB1-2 DPI) with M(r) = 4934 Da has been determined at 1.65 A resolution using the molecular replacement method. A structural comparison between DesB1-2 DPI and 2Zn insulin reveals that the conformation of DesB1-2 DPI is more similar to molecule I than molecule II of 2Zn insulin. The remarkable conformational difference between B25-Phe in DesB1-2 DPI and B25-Phe in despentapeptide (B26-B30) insulin (DPI) indicates that the residue B25-Phe possesses great flexibility and mobility.

Structural genomics efforts at the Chinese Academy of Sciences and Peking University

Structural genomics efforts at the Chinese Academy of Sciences and Peking University are reported in this article. The major targets for the structural genomics project are targeted proteins expressed in human hematopoietic stem/progenitor cells, proteins related to blood diseases and other human proteins. Up to now 328 target genes have been constructed in expression vectors. Among them, more than 50% genes have been expressed in Escherichia coli, approximately 25% of the resulting proteins are soluble, and 35 proteins have been purified. Crystallization, data collection and structure determination are continuing. Experiences accumulated during this initial stage are useful for designing and applying high-throughput approaches in structural genomics.

Overexpression, purification, crystallization and preliminary crystallographic studies on a thermostable beta-glycosidase from Thermus nonproteolyticus HG102

A thermostable beta-glycosidase (Tn-gly) from Thermus nonproteolyticus HG102 has been cloned and overexpressed in Escherichia coli. The recombinant enzyme, with a molecular mass of 48.9 kDa, was purified to homogeneity. It can hydrolyze a wide range of oligosaccharides and perform transglycosylation. Crystals of the recombinant enzyme were grown by the hanging-drop vapour-diffusion technique with MPD and NaCl as precipitants. They belong to the orthorhombic space group P2(1)2(1)2(1), with unit-cell parameters a = 66.7, b = 94.6, c = 176.5 A.

The synergistic effect of thrombopoietin in erythropoiesis with erythropoietin and/or IL-3 and myelopoiesis with G-CSF or IL-3 from umbilical cord blood cells of full-term neonates

The authors sought to determine whether recombinant human thrombopoietin (TPO) acts synergistically with other cytokines on burst-forming unit-erythroid (BFU-E)-derived and colony-forming unit-granulocyte/macrophage (CFU-GM)-derived colony formations from cord blood. Cord blood nonadherent mononuclear cells (MNC) from normal full-term neonates were cultured in a methylcellulose system. When cultured with 5 x 10(4) MNC/mL, erythropoietin (EPO) 2 U/mL, interleukin-3 (IL-3) 50 ng/mL, and/or TPO 400 ng/mL (experiment 1), the addition of TPO to EPO gave rise to more BFU-E-derived colonies (p = .002). The addition of TPO to EPO + IL-3 gave rise to more BFU-E-derived colonies (p = .006) also. TPO synergizes erythropoiesis from cord blood. When cultured with IL-3 50 ng/mL, granulocyte colony-stimulating factor (G-CSF) 25 ng/mL, and/or TPO 400 ng/mL, the addition of TPO to IL-3 gave rise to more CFU-GM-derived colonies (p = .002). The addition of TPO to G-CSF gave rise to more CFU-GM-derived colonies (p = .002) also. TPO synergizes myelopoiesis from cord blood. Thus, TPO has synergistic effects on both erythropoiesis and myelopoiesis from cord blood. In the identical conditions of culture, cord blood had significantly greater BFU-E-derived or CFU-GM-derived colony formation than bone marrow (in a previous report by the authors) did. When cultured under conditions similar to those of experiment 1, but with 1 x 10(4) cord blood MNC/mL and TPO 100 ng/mL (experiment 2), results similar to those in the experiment 1 also revealed that TPO has synergistic effects on erythropoiesis and myelopoiesis from cord blood. In every individual assay, the numbers of BFU-E-derived or CFU-GM-derived colonies in experiment 1 were significantly higher than those in experiment 2.

Crystal structure of R-phycocyanin and possible energy transfer pathways in the phycobilisome

The crystal structure of R-phycocyanin from Polysiphonia urceolata (R-PC-PU) at 2.4 A is reported. The R-PC-PU crystal belongs to space group P4(3)2(1)2 with cell parameters a = 135.1 A, c = 210.0 A, and alpha = beta = gamma = 90 degrees. The structure was determined by molecular replacement. The crystallographic R-factor of the refined model is 0.189 (R(free) = 0.239). Comparison of the microenvironment of chromophore beta 155 in R-PC-PU and in C-PC from Fremyolla diphosiphon (C-PC-FD) reveals that their spectral differences may be caused by their different alpha 28 residues. In the R-PC-PU crystal structure, two (alpha beta)(3) trimers assemble face to face to form a hexamer, and two such hexamers assemble in two novel side-to-side arrangements. Possible models for the energy transfer from phycoerythrin to phycocyanin and from phycocyanin to allophycocyanin are proposed based on several phycobiliprotein crystal structures.

Structure of C-phycocyanin fromSpirulina platensisat 2.2 Å resolution: a novel monoclinic crystal form for phycobiliproteins in phycobilisomes

The crystal structure of C-phycocyanin from the cyanobacterium S. platensis has been determined at 2.2 A resolution. The crystals belong to the monoclinic crystal form, which has not been previously reported for phycobiliprotein structures. The structure was solved using the molecular-replacement method with a final R value of 18.9% (R(free) = 23.7%) after model building and refinement. In the crystals used for the study, the C-phycocyanin hexamers formed by face-to-face association of two trimers are arranged in layers rather than in columns. Three different kinds of packing between adjacent hexamers in the layer were compared. The tight packing of two adjacent hexamers formed by four trimers in the asymmetric unit brings beta155 PCB chromophores close together, so it is possible that lateral energy transfer takes place through the beta155-beta155 route.

Ataxia telangiectasia: report of two cases

Ataxia telangiectasia (A-T) is a rare autosomal recessive multisystem disease. The diagnosis of A-T is based on the typical clinical picture: ataxia and telangiectasia. However, an increase in (alpha-fetoprotein (AFP) level and the identification of the A-T mutated gene (ATM) assist in an early diagnosis. Here we report two cases of A-T diagnosed in our hospital (case 1: a 7-year-old boy; case 2: an 8-year-old girl). Both of these patients had typical clinical pictures of ataxia and telangiectasia, AFP was also increased (case 1:471.2 ng/dL; case 2: 196 ng/dL). T-cell dysfunction was noted in both patients. Case 1 had IgG2 deficiency and case 2 had IgA, IgG2 and IgG3 deficiency. Case 2 developed malignant lymphoma at 9 years of age and died of pneumonia with respiratory failure at 10 years of age. Because of rhe rarity of A-T in Taiwan, we report two cases to help pediatricians make an early diagnosis of A-T if they have a patient with progressive ataxia and oculocutaneous telangiectasia.

Hepatitis B vaccination and hepatocellular carcinoma rates in boys and girls

CONTEXT

Hepatocellular carcinoma (HCC) has a male predominance and is closely related to hepatitis B virus (HBV) infection. Hepatitis B virus vaccination was launched in 1984 in Taiwan for neonates of mothers carrying hepatitis B e antigen, resulting in a decreased incidence of HCC in children. The effect on boys vs girls is not known.

OBJECTIVE

To evaluate the association between a HBV vaccination program with incidence of childhood HCC by sex.

DESIGN AND SETTING

Analysis of data collected from Taiwan's National Cancer Registry System and the Taiwan Childhood Hepatoma Study Group between 1981 and 1996.

PARTICIPANTS

Children aged 6 to 14 years who were diagnosed as having HCC (201 boys and 70 girls).

MAIN OUTCOME MEASURE

Incidence of HCC in boys and girls before and after implementation of the vaccination program.

RESULTS

The boy-girl incidence ratio decreased steadily from 4.5 in 1981-1984 (before the program's introduction) to 1.9 in 1990-1996 (6-12 years after the vaccination program was launched). The incidence of HCC in boys born after 1984 was significantly reduced in comparison with those born before 1978 (relative risk [RR], 0.72; P =.002). No significant decrease in HCC incidence was observed in girls born in the same periods (RR, 0.77; P =.20). The incidence of HCC in boys remained stable with increasing age, while an increase of HCC incidence with age in girls was observed. These age and sex effects remained the same regardless of birth before or after the vaccination program.

CONCLUSION

Our results suggest that boys may benefit more from HBV vaccination than girls in the prevention of HCC.

Granulocyte-macrophage colony-forming-unit assay and liquid suspension culture of bone marrow and peripheral blood in newly diagnosed childhood acute lymphoblastic leukemia

Granulocyte-macrophage colony-forming-unit (CFU-GM)-assays and/or liquid suspension cultures of bone marrow (BM) and peripheral blood (PB), using human placental conditioned medium as a source of colony-stimulating activity, were performed in 125 children with newly diagnosed acute lymphoblastic leukemia (ALL). Unlike the previous small series which invariably showed poor BM granulocyte-macrophage colony and cluster formations, we found 3 growth patterns. A poor-growth pattern was seen in 101 patients. A low-growth pattern with BM colony and cluster formations in the lower range of the normal limits was observed in 6 patients. All 6 patients had low-risk ALL, and the in vitro growth may reflect the residual normal CFU-GM in BM. Thirdly an over-growth pattern was noted in one patient with refractory ALL. In 49 cases where liquid suspension cultures of BM were performed, 4 had a normal-growth pattern and 42 had apoptotic cells and/or few residual granulocytic/monocytic cells after 7 days of culture. However, in both B cell ALL cases and in 1 refractory T cell ALL case with hyperleukocytosis, repetitive liquid suspension cultures of BM and PB consistently revealed an extensive growth of lymphoblasts. Thus, an over-growth pattern in either the BM CFU-GM assay or liquid suspension culture of BM or PB in children with ALL at diagnosis may indicate a refractory or aggressive disease. A low-growth pattern in the BM CFU-GM assay in children with ALL at diagnosis probably predicts a favorable outcome.

Hereditary cyclic neutropenia in the male members of a Chinese family with inverted Y chromosome

We describe four male members of a Chinese family, including the father and three sons, with hereditary cyclic neutropenia. These patients had all developed cyclic neutropenia in childhood with a cycle of around 21 d. Recurrent mucosa and skin infections with fever had occurred frequently, but gradually decreased in severity on reaching adulthood. Monocytosis was found during the neutrophil nadirs in all four patients. Mildly increased serum immunoglobulin (Ig)A and IgG levels, low levels of serum stem cell factor, as well as decreased sperm count and motility were demonstrated in the two elder sons. Chromosomal analysis showed a pericentric inversion of Y chromosome [46,X, inv(Y)(p11.2;q11.23)] in all of the men. These findings may suggest an association between cyclic neutropenia with oligospermia and inv(Y)(p11.2;q11.23) in this particular family.

Treatment results of the TPOG-NHL92 protocols for childhood non-Hodgkin's lymphomas in Taiwan: a report from the Taiwan Pediatric Oncology Group (TPOG)

A nation-wide chemotherapeutic trial for childhood non-Hodgkin's lymphoma (NHL) was conducted by the Taiwan Pediatric Oncology Group (TPOG). Four TPOG-NHL92 protocols based on stage and histology were activated in 1992: TPOG-92LD (treatment duration: 8 months) was used for localized (stages I/II) NHL with any histology, 92LB (2 years), 92SNC (5 months), and 92LC (1 year) for advanced (stages III/IV) lymphoblastic (LB), small non-cleaved cell (SNC), and large cell (LC) lymphoma, respectively. From January 1992 through June 1998, 200 children with newly diagnosed NHL from 13 member hospitals of TPOG were enrolled. There were 140 boys and 60 girls. Their ages at diagnosis ranged from 2.4 months to 18.3 years with a median of 8.2 years. There were 54 (27.3%) patients with LB, 94 (47.5%) with SNC including B-cell acute lymphoblastic leukemia (B-ALL), and 50 (25.2%) with LC. Stages I, II, III, and IV (including B-ALL) of the disease comprised 5%, 10%, 43%, and 42% of cases, respectively. There were 176 patients eligible for evaluation of treatment results. The remission rate of induction was 82.4%, induction failed in 22 (12.5%) patients, and nine patients died during induction. As of August 31, 1999, 26 patients relapsed, six died during remission, one patient developed secondary acute myelomonocytic leukemia, and 105 patients remained in continuous remission with a median remission duration of 49 months. The event-free survival (EFS) at 7 years was 63.5%, 61.5% and 65% for LB, SNC, and LC groups (P = 0.8298). The 7-year EFS for stages I/II, III, and IV of the disease was 73%, 68.9%, and 50.3% (P = 0.0212), respectively. We concluded that following the strategy of stratification of therapy, only disease stages had prognostic significance in this study. More efforts are needed to improve our treatment results.

Mandibular osteomyelitis caused by Blastoschizomyces capitatus in a child with acute myelogenous leukemia

A 6-year-old girl with acute myelogenous leukemia (AML) developed fungal mandibular osteomyelitis during chemotherapy. Blastoschizomyces capitatus was recognized histologically by its yeast-like morphology and formation of annelloconidia, and was confirmed by culture. The fungal osteomyelitis of the mandible was treated successfully with prolonged antifungal medication, extensive surgical debridement and an oral care program, without interrupting leukemia chemotherapy. B. capitatus osteomyelitis of the mandible may occur during chemotherapy in AML patients with poor dental condition. Successful treatment can be achieved by careful management without interruption of antineoplastic chemotherapy.

Purification, crystallization and preliminary crystallographic studies on the N-terminal fragment of human protein disulfide isomerase

A fragment of human protein disulfide isomerase composed of the thioredoxin-like a and b domains (ab) has been expressed in Escherichia coli as a fusion protein with glutathione-S-transferase and purified after thrombin cleavage. Two forms of ab crystal were obtained with polyethylene glycol as precipitant and different additives at pH 7.5. The space group of form I is P4(1)2(1)2 or P4(3)2(1)2, with unit-cell dimensions a = 81.5, c = 259.7 A. The space group of form II is P4(1)22 or P4(3)22, with unit-cell dimensions a = 82.7, c = 86.5 A.

Pancreatic tumors in children: report of three cases

From 1981 to 1996, we experienced 3 cases of pancreatic tumors in children--two pancreatoblastomas (PB) and one solid and cystic tumor (SCT). The ages were 1 month, 4 years, and 13 years of age respectively. The two cases of pancreatoblastoma initially presented as chronic diarrhea with failure to thrive, the other case presented with abdominal mass. All of them were studied by laboratory examination, ultrasonography, computed tomography and pathology. Increasing alpha- fetoprotein (AFP) levels were found in the 2 pancreatoblastoma cases, however, the level in the SCT case was normal. Abdominal sonography showed pancreatic masses with or without calcification, and the echogenicity may be solid and/or cystic. All patients underwent total excision of the tumors. We have reviewed the literature and find no pancreatoblastoma with chronic diarrhea was reported in young children, especially in neonate. Therefore, we suggest that young children presenting with an abdominal mass and/or weight loss should undergo imaging studies for the possibility of pancreatic tumors.

Crystal structure of allophycocyanin from red algae Porphyra yezoensis at 2.2-A resolution

The crystal structure of allophycocyanin from red algae Porphyra yezoensis (APC-PY) at 2.2-A resolution has been determined by the molecular replacement method. The crystal belongs to space group R32 with cell parameters a = b = 105.3 A, c = 189.4 A, alpha = beta = 90 degrees, gamma = 120 degrees. After several cycles of refinement using program X-PLOR and model building based on the electron density map, the crystallographic R-factor converged to 19.3% (R-free factor is 26.9%) in the range of 10.0 to 2.2 A. The r.m.s. deviations of bond length and angles are 0.015 A and 2.9 degrees, respectively. In the crystal, two APC-PY trimers associate face to face into a hexamer. The assembly of two trimers within the hexamer is similar to that of C-phycocyanin (C-PC) and R-phycoerythrin (R-PE) hexamers, but the assembly tightness of the two trimers to the hexamer is not so high as that in C-PC and R-PE hexamers. The chromophore-protein interactions and possible pathway of energy transfer were discussed. Phycocyanobilin 1alpha84 of APC-PY forms 5 hydrogen bonds with 3 residues in subunit 2beta of another monomer. In R-PE and C-PC, chromophore 1alpha84 only forms 1 hydrogen bond with 2beta77 residue in subunit 2beta. This result may support and explain great spectrum difference exists between APC trimer and monomer.

Unexpected mortality from the use of E. coli L-asparaginase during remission induction therapy for childhood acute lymphoblastic leukemia: a report from the Taiwan Pediatric Oncology Group

The relative efficacy and toxicity of E. coli L-asparaginase and epidoxorubicin used in remission induction therapy for childhood acute lymphoblastic leukemia (ALL) were assessed in a randomized trial conducted in Taiwan. All patients had standard-risk ALL, defined as a leukocyte count <10 x 10(9)/l and were aged between 1 and 2 or 7 and 10 years, or a leukocyte count <50 x 10(9)/l and were aged between 2 and 7 years, without evidence of a T cell or mature B cell immunophenotype, central nervous system leukemia or expression of two or more myeloid-associated antigens. Ninety-three patients were randomized to receive E. coli L-asparaginase at 10,000 IU/m2 thrice weekly for nine doses and 108 to receive epidoxorubicin at 20 mg/m2 weekly for two doses during remission induction with daily prednisolone, weekly vincristine and, on day 22, a dose of etoposide plus cytarabine. Patients treated with L-asparaginase had a significantly higher rate of fatal infection with or without hemorrhage than did those who received epidoxorubicin during remission induction (six of 93 vs none of 108, P = 0.009), resulting in a lower rate of complete remission in the former group (93.6 vs 99.1%, P = 0.05). In addition, patients treated with L-asparaginase had a higher frequency of hyperglycemia and hypoalbuminemia. The overall rate of event-free survival was lower in patients treated with L-asparaginase than in other patients (P = 0.06); estimated 3-year rates were 72% (95% confidence interval, 55-89%) and 87.2% (78-96%), respectively. We conclude that L-asparaginase (Leunase) given at 10,000 IU/m2 for nine doses was poorly tolerated and resulted in excessive toxicity, both through its effects as a single agent and possibly through potentiation of etoposide.

Detection of PAX3-FKHR and PAX7-FKHR fusion transcripts in rhabdomyosarcoma by reverse transcriptase-polymerase chain reaction using paraffin-embedded tissue

BACKGROUND

Alveolar rhabdomyosarcoma (RMS) is associated with a characteristic chromosomal translocation t(2;13)(q35;q14). The genes involved in this translocation are paired box (PAX)3 on chromosome 2 and forkhead in RMS (FKHR) on chromosome 13. An occasional variant translocation t(1;13)(p36;q14) affecting PAX7 and FKHR on chromosomes 1 and 13, respectively, has also been described. Chromosomal translocations in RMS are detected using conventional cytogenetic analysis, fluorescence in situ hybridization (FISH) or reverse transcriptase-polymerase chain reaction (RT-PCR) on fresh or frozen tissue samples. We describe the results of RT-PCR analysis of PAX3-FKHR and PAX7-FKHR chimeric messages in formalin-fixed, paraffin-embedded tissue samples from 17 RMS cases.

METHODS

RNA was extracted from formalin-fixed, paraffin-embedded RMS tissue. Oligonucleotide primers corresponding to the regions of PAX3, PAX7 and FKHR were used for the detection of PAX3-FKHR and PAX7-FKHR chimeric messages. A seminested PCR of the PCR products was used to increase the sensitivity of detection. The amplified fragments were purified and directly sequenced to confirm the specificity of the methods.

RESULTS

The PAX3-FKHR chimeric message was detected in all three cases of alveolar RMS but not in any of the 12 embryonal and two pleomorphic RMS cases. The PAX7-FKHR fusion transcript was detected in one case of embryonal RMS.

CONCLUSIONS

The results indicate that the RT-PCR assay is a reliable method for the detection of the PAX3-FKHR fusion transcript of alveolar RMS in formalin-fixed, paraffin-embedded tissue. This simple method enables pathologists to identify chromosomal rearrangements in RMS as a diagnostic aid in cases where fresh or frozen tissue is not available.

Technetium-99m-HmPAO brain SPECT in infantile Gaucher's disease

The authors report serial technetium-99m hexamethylpropylene-amine-oxime brain single photon emission computed tomography (SPECT) findings in two infants with Gaucher's disease type 2. Detailed neurologic and laboratory examinations, including bone marrow biopsies and enzymatic assays, were described. Serial brain magnetic resonance imaging studies in one patient illustrated the progressive cerebral atrophy in the frontal and temporal lobes. The SPECT in both cases demonstrated positive findings of initial scattered hypoperfusion, with extending to hypoperfusion of the entire cerebrum after 4 months of clinical deterioration. These changes in the SPECT findings may reflect progressive degeneration of the cerebrum in Gaucher's disease type 2. Brain SPECT may provide useful information on cerebral flow and metabolic distribution corresponding to the neurologic deficits of neuronopathic Gaucher's disease.

High-grade endometrial stromal sarcoma in a 10-year-old girl: case report

Endometrial stromal sarcomas occur primarily in perimenopausal women and are quite uncommon in children. We report a case of high-grade endometrial stromal sarcoma in a 10-year-old girl, who initially experienced lower abdominal pain on voiding. After a series of examinations, surgical treatment was performed, including an extended total hysterectomy with bilateral salpingo-oophorectomy, bilateral pelvic lymph node sampling, and partial omentectomy. Adjuvant radiotherapy and hormonal therapy followed, however, the abdominal tumor recurred 9 months later. Invasion of the right lobe of the liver with compression of the inferior vena cava and pleural effusion was noted. The patient then received prolonged oral etoposide therapy. The treatment stabilized the tumor size and relieved her symptoms for 4 months. She finally succumbed to the disease as a result of distant metastasis.

Crystallization and preliminary X-ray studies of allophycocyanin from red alga Porphyra yezoensis

Allophycocyanin from red alga Porphyra yezoensis has been crystallized in three crystal forms. Form 1 crystals with space group P4132 or P4332 and cell parameters a = 286 A, alpha = 90 degrees were obtained by using isopropanol as precipitant. These crystals did not diffract beyond 5.8 A and could not be used in structure analysis. Form 2 crystals were obtained when crystallization conditions were slightly changed by adding 0.2 M magnesium chloride. The space group of form 2 was not determined because it was difficult to get large single crystals. Form 3 crystals were obtained by using ammonium sulfate as precipitant. The space group of form 3 is R32 with cell dimensions a = b = 105.3, c = 189.4 A and one alpha beta unit in the asymmetric unit. These crystals diffract up to 2.06 A resolution and are suitable for structure determination by molecular-replacement methods.

Effects of thrombopoietin on megakaryocyte colony formation from leukemic cells at diagnosis and from marrow cells after induction chemotherapy for acute leukemias

We have studied the effects of recombinant human thrombopoietin (TPO, mpl ligand) on the megakaryocyte colony formation from control human bone marrow cells, human leukemia cells at diagnosis, and human bone marrow cells after induction chemotherapy for acute leukemias. In the control human bone marrow cells from four adults and nine children who had localized malignancy and histologically normal-looking marrow. TPO alone effectively stimulated megakaryocyte colony formation, and interleukin-3 (IL-3) synergized this. In 17 patients (13 adults and four children) with acute myeloid leukemia (AML) at diagnosis, TPO stimulated leukemic colony formation in only one patient with FAB M7 subtype. In 11 children with acute lymphoblastic leukemia (ALL) at diagnosis, TPO did not enhance leukemic colony formation. After 17 courses of induction chemotherapy, nine for AML and eight for ALL, TPO stimulated megakaryocyte colony formation to a level of 51%, of that in the control human bone marrow cells. This may suggest that the administration of TPO to patients with M7 subtype warrants caution, whereas it is probably safe to give TPO at any time to patients with ALL. The administration of TPO to patients with acute leukemias after induction chemotherapy could stimulate megakaryocytopoiesis.

High-dose cytarabine-containing chemotherapy with or without granulocyte colony-stimulating factor for children with acute leukemia

We sought to determine the role of granulocyte colony-stimulating factor (G-CSF) as an adjunct therapy in high-dose cytarabine-containing chemotherapy (HD C/T) for children with acute leukemia. Seventeen patients, aged 9 months to 18 years old, 8 ALL and 9 AML, were treated with cytarabine (Ara-C) 1 g/m2 q12h for 8 doses with mitoxantrone, idarubicin, VP-16, or asparaginase. A total of 71 courses of HD C/T was given. G-CSF was not used in 14 courses (Group A). Prophylactic G-CSF was given in 57 courses (Group B) as 200 microg/m2/d SC started one day after the completion of HD C/T and continued until the neutrophil recovery was maintained. The incidences of sepsis per course in Group A and Group B were 35.7% (5/14) and 40.4% (23/57), respectively. While 2 patients in Group A died of sepsis or pneumonia, none in Group B died. The mortality and delay in chemotherapy were fewer in Group B (P = 0.037 and 0.0006, respectively, Fisher exact test). There was a shorter average number of days of neutrophil <500/cumm, antibiotic usage, fever, and hospital stay in Group B (11, 8, 5, 17 days in Group B vs. 21, 17, 10, 37 days in Group A; P = 0.0001, log-rank test; 0.0006, 0.0023, 0.0001, Wilcoxon rank sum test, respectively). The incidence of neutropenic fever was lower in Group B, but the difference did not reach statistical significance (P = 0.06, Fisher exact test). We conclude that G-CSF as an adjunct therapy in HD C/T is effective in reducing mortality, days of neutropenia, antibiotic usage, fever, hospital stay, and frequency of delay in chemotherapy. The efficacy of this treatment approach requires further testing in a randomized, controlled trial.

The stage I yolk sac tumor of testis in children younger than 2 years, chemotherapy or not?

Yolk sac tumor is the most frequent germ cell tumor of testis in children. For stage I yolk sac tumor of testis in children younger than 2 years, high inguinal orchiectomy alone has been the standard treatment, with a cure rate of at least 75%. Here, we compare the treatment results of receiving chemotherapy or no chemotherapy after orchiectomy, to analyze the role of chemotherapy. From February 1987 to January 1997, 22 children younger than 2 years, with stage I yolk sac tumor of testis, were included in the study. All patients had high inguinal orchiectomy without retroperitoneal lymphadenectomy. Initial diagnostic imaging studies included computed tomographic scan of abdomen, chest radiography, and long bone survey. Clinical stage I was defined as a tumor completely resected with no evidence of local regional lymph node involvement or distant metastases. Serum alpha-fetoprotein (AFP) was assessed at diagnosis. After orchiectomy, diagnosis, and staging, patients were stratified into two treatment groups, with or without chemotherapy, according to the decision of the parents. Ten children received chemotherapy consisting of cisplatin, vinblastine, and bleomycin (PVB, modified "Einhorn regimen") for 12 weeks. The remaining 12 patients were followed up according to a "wait and see" policy. Determination of AFP was performed monthly during the first postoperative year, every other month during the second year, every 3 months during the third year, every 6 months during the fourth year, and yearly until the fifth postoperative year at least. The duration of follow-up ranged from 3 months to 119 months (median, 53 months). The Kaplan-Meier plot estimated an overall survival rate of 91.6% at 7 years after diagnosis. Among the 12 patients without chemotherapy, 2 children had relapses at 4 and 6 months after diagnosis, respectively. One was cured with PVB chemotherapy. The other patient died with refractory lung metastasis, in spite of intensive multimodality salvage therapy. The Kaplan-Meier plot showed a survival rate of 80% at 7 years and a relapse-free survival rate of 81.8% at 5 years after diagnosis. All children receiving chemotherapy were alive and free from relapse. There was no significant treatment-related toxicity. Our results may suggest that PVB chemotherapy after orchiectomy is an affective and safe regimen for stage I yolk sac tumor of testis in children younger than 2 years. Instead of four courses of PVB as used here, two or three courses could be enough. To elucidate the necessity for chemotherapy and to determine the number of courses of PVB needed (if chemotherapy is given), a randomized study of more cases is warranted.

Granulopoiesis in newly diagnosed childhood solid tumors

Granulopoiesis at the diagnosis of solid tumors has not been previously reported. The purpose of this study is to detect the changes of granulopoiesis of patients with solid tumors in different clinical stages. Granulocyte-macrophage colony-forming unit (CFU-GM) assays and liquid suspension cultures of bone marrow and peripheral blood were studied in 90 children with newly diagnosed solid tumors, including 5 benign tumors and 85 malignant tumors. The malignant tumors were categorized into nonadvanced, advanced, or marrow-invaded ones. Bone marrow from children with immune thrombocytopenic purpura and peripheral blood from adult volunteers were used as controls. Granulocyte-macrophage colony formation from bone marrow in benign or nonadvanced malignant tumor was not significantly different from that of controls. However, granulocyte macrophage colony formation from bone marrow in advanced or marrow-invaded malignant tumor was significantly less than that of controls or nonadvanced malignant tumor. Furthermore, the bone marrow of patients with advanced malignant tumor occasionally had a defective proliferation pattern and the bone marrow of those with marrow-invaded malignant tumor often had a defective proliferation pattern. Peripheral blood in marrow-invaded malignant tumor had colony and cluster formations in very wide ranges. As a malignant tumor progresses into advanced stages, irrespective of marrow infiltration, bone marrow CFU-GM levels may decline and defective granulopoiesis may occur.

Universal hepatitis B vaccination in Taiwan and the incidence of hepatocellular carcinoma in children. Taiwan Childhood Hepatoma Study Group

BACKGROUND

A nationwide hepatitis B vaccination program was implemented in Taiwan in July 1984. To assess the effect of the program on the development of hepatocellular carcinoma, we studied the incidence of this cancer in children in Taiwan from 1981 to 1994.

METHODS

We collected data on liver cancer in children from Taiwan's National Cancer Registry, which receives reports from each of the country's 142 hospitals with more than 50 beds. Data on childhood liver cancer were also obtained from Taiwan's 17 major medical centers. To prevent the inclusion of cases of hepatoblastoma, the primary analysis was confined to liver cancers in children six years of age or older. Data were also obtained on mortality from liver cancer among children.

RESULTS

The average annual incidence of hepatocellular carcinoma in children 6 to 14 years of age declined from 0.70 per 100,000 children between 1981 and 1986 to 0.57 between 1986 and 1990, and to 0.36 between 1990 and 1994 (P<0.01). The corresponding rates of mortality from hepatocellular carcinoma also decreased. The incidence of hepatocellular carcinoma in children 6 to 9 years of age declined from 0.52 for those born between 1974 and 1984 to 0.13 for those born between 1984 and 1986 (P<0.001).

CONCLUSIONS

Since the institution of Taiwan's program of universal hepatitis B vaccination, the incidence of hepatocellular carcinoma in children has declined.

Crystal structure of desheptapeptide(B24-B30)insulin at 1.6 A resolution: implications for receptor binding

The crystal structure of desheptapeptide (B24-B30) insulin (DHPI), a virtually inactive analog of insulin, was determined at 1.6 A resolution. In the refined structure model, DHPI retains three alpha-helices (A1-A8, A12-A18, and B9-B19) as its structural framework, while great conformational changes occur in the N and C termini of B-chain. The beta-turn, which lies in B20-B30 in insulin and insulin analogs with high potency, no longer exists in DHPI. Relative motion is observed among the three alpha-helices, each as a rigid functional group. In contrast, a region covering B5-B6 and A6-A11 exhibits a relatively stable conformation. We interpret our results as identifying: (i) the importance of beta-turn in determining the receptor-binding potency of insulin and (ii) a leading role of PheB24 in maintaining the beta-turn structure.

Clinicopathologic, cytogenetic, and molecular studies of 13 Chinese Patients with Ki-1 anaplastic large cell lymphoma. Special emphasis on the tumor response to 13-cis retinoic acid

BACKGROUND

The clinicopathologic and molecular features of the newly characterized Ki-1 lymphoma, although well studied in Western countries, are less well described in Asia.

METHODS

Pathology material of lymphoma cases, consecutively diagnosed at our institution between 1986 and 1994, was reviewed. The cases fulfilling the diagnostic criteria of Ki-1 lymphoma were selected, and their clinicopathologic features were studied. Immunohistochemistry and cytogenetic studies of the lymphoma tissues, and molecular analysis for nucleophosmin (NPM) gene translocation were performed.

RESULTS

A total of 13 cases (2.3%) of Ki-1 large cell lymphoma were identified from a total of 572 cases of non-Hodgkin's lymphoma diagnosed during this period of time. There were 10 men and 3 women with a median age of 43 years (range, 18 to 61 years). The initial presenting sites included the skin alone in five cases, lymph node alone in one case, both skin and lymph node in five cases, and the stomach in one case. All cases had large cell morphology, with the majority of the neoplastic cells expressing Ki-1 antigen (CD30). Except for the case with gastric involvement, all other cases were T-cell lymphomas. One of seven cases examined had chromosomal abnormality of t (2;5). Rearrangement of the NPM gene at chromosome 5 was detected by Southern blot analysis in three of nine cases. Two of seven cases tested by reverse-transcriptase polymerase chain reaction showed fusion of the NPM gene and anaplastic lymphoma kinase gene. Seven (78%) of 9 patients who had received systemic chemotherapy with a standard cyclophosphamide, doxorubicin, vincristine, and prednisolone regimen obtained a complete remission (CR). The median duration of remission was 33 months. Three (60%) of 5 patients, of whom 4 recurred from previous intensive chemotherapy, achieved a prolonged CR with treatment with 13-cis retinoic acid (RA). The median survival of the whole group has not yet been reached at a median follow-up of 40 months.

CONCLUSIONS

The clinicopathologic and molecular features of Ki-1 lymphoma of Chinese patients are comparable to those reported from Western countries. 13-cis RA appears to be an effective treatment of Ki-1 lymphoma.

Crystal structure of R-phycoerythrin from Polysiphonia urceolata at 2.8 A resolution

The structure of R-phycoerythrin (R-PE) from Polysiphonia urceolata was determined at 2.8 A resolution. The crystals belong to space group R3 with unit cell dimensions of a = b = 189.8 A, c = 60.1 A. The subunit composition of R-PE is (alpha 2 beta 2)3 gamma. The three-dimensional structure of R-PE was solved by the multiple isomorphous replacement method. After several cycles of model building and refinement, the crystallographic R-factor of the final model is 18.0% with data from 10.0 to 2.8 A resolution. The four phycoerythrobilin chromophores alpha 84, alpha 140a, beta 84 and beta 155 in an (alpha beta) unit are each covalently bound to a cysteine residue through ring A. The phycourobilin chromophore is bound to cysteine beta 50 by ring A and bound to cysteine beta 61 by ring D. The ring A and ring D of phycourobilin deviate from the conjugate plane formed by ring B and ring C and the four rings form a boat-shaped structure. R-PE contains a 34 kDa gamma subunit that is assumed to lie in the central channel of the molecular disc (alpha 2 beta 2)3. The energy transfer and relationship between cysteine residues and chromophores are discussed.

Purification and crystal growth of F1-ATPase from pig heart mitochondria

A method has been evolved toward the aim of getting suitable crystals for high resolution of structural analysis of F1-ATPase by X-ray crystallography. The different conditions for crystal growth of ATPase that were isolated and purified by different methods from pig heart mitochondrial ATP synthase had been compared and screened. A simple method for purification of F1-ATPase was adopted. The F1-ATPase is released with chloroform from submitochondrial particles. Then it was treated with fractional precipitation of (NH4)2SO4 and finally was further purified by employing the sephadex G 200 column. The crystals of F1-ATPase were usually obtained after a few months. They appeared to have uniform morphology of tetrahedron. They diffracted to a resolution of 7A. The diffraction data were collected on the XRD-100 Siemens Area Detector. According to a total of 240 frames, the cell parameters obtained are a = b = 147 A, c = 208 A, alpha = beta = gamma = 90 alpha, the probable space group is P4 or its antipode. The reproducibility of this method for crystallization of F1-ATPase is good.

Lack of TEL-AML1 fusion transcript resulting from a cryptic t(12;21) in adult B lineage acute lymphoblastic leukemia in Taiwan

Cryptic t(12;21)(p12-13;q22) leading to TEL-AML1 fusion has recently been recognized as the most frequent genetic rearrangement in childhood acute lymphoblastic leukemia (ALL) in Western countries. More recently, we found a similar frequency of this abnormality in Chinese children with ALL in Taiwan. In this study, we assessed further the frequency of TEL-AML1 fusion as well as that of BCR-ABL in Chinese adults with ALL, using reverse transcriptase-polymerase chain reaction assays. Among the 81 cases with newly diagnosed B lineage ALL studied, none had the TEL-AML1 fusion whereas 30 had the BCR-ABL fusion. The lack of cases with the TEL-AML1 fusion together with the high frequency of BCR-ABL fusion could largely account for the poorer outcome of adult ALL as compared with childhood ALL.

High incidence of TEL/AML1 fusion resulting from a cryptic t(12;21) in childhood B-lineage acute lymphoblastic leukemia in Taiwan

Despite its rarity by routine karyotypic analysis, cryptic t(12;21)(p12-13;q22) translocation leading to TEL/AML1 fusion has been recognized as the most frequent genetic rearrangement in childhood acute lymphoblastic leukemia (ALL) in two recent studies, one from France and the other from the United States. To estimate the frequency of this abnormality in the Chinese population, we studied 41 children with ALL and 17 with acute myeloid leukemia (AML) in two medical centers in Taiwan, using the reverse transcriptase polymerase chain reaction (RT-PCR) assay. Results of this analysis demonstrated a 17% frequency of this translocation in the ALL population overall and 19% in patients with B-lineage ALL, similar to previous findings in Caucasian children. None of the patients with AML had TEL/AML1 fusion transcripts. In addition to its association with the B-lineage immunophenotype, TEL/AML1 was also correlated with a low presenting leukocyte count and favorable age (1-10 years). These findings, combined with earlier reports, indicate that TEL/AML1 fusion is the most frequent genetic abnormality in childhood ALL, regardless of race. Molecular diagnosis of t(12;21)-positive ALL may identify a subgroup of patients who do not require intensive treatment for cure.

Pancreatitis in children--experience with 43 cases

Pancreatitis in children is not common and can be associated with severe morbidity and mortality. We encountered 43 children, ranging in age from 2 to 18 years, with pancreatitis over the past 10 years. The diagnosis of pancreatitis was made in those patients who showed: (1) significant intra-operative pathology or; (2) clinical findings of pancreatic inflammation and laboratory confirmation. More than one third (16 cases) of the cases were due to trauma, other causes included systemic disease (10), structural disease (8), and toxins or drugs (4). Five cases were classified as idiopathic. Most of the patients presented with abdominal pain (95%) and vomiting (56%). Jaundice was found in 7 patients and an abdominal mass in 2. Morbidity included pseudocyst (10), relapse (4), hyperglycaemia (4) and miscellaneous problems. Eight (50%) of the patients with trauma and 6 (86%) of the patients with structural diseases required surgery. Other patients were managed conservatively with bowel rest, gastric decompression, intravenous fluid and total parenteral nutrition. One case had a fatal outcome. All the survivors did well in long term follow up. Relevant literature has been reviewed and the sensitivity of various diagnostic modalities compared and discussed. A lesser known association between pancreatitis and structural anomalies such as choledochal cyst is discussed. To our knowledge, the present review is the first on pancreatitis in Chinese children.

CONCLUSION

Pancreatitis can occur from a wide variety of causes and may result in severe complications. Early diagnosis, close monitoring and aggressive intervention are mandatory to reduce morbidity and mortality.

Intelligence quotient in childhood acute lymphoblastic leukemia after prophylactic treatment in central nervous system with 18 Gy cranial irradiation and intrathecal methotrexate

The purpose of this study is to evaluate whether central nervous system prophylactic treatment (CNSP) with cranial irradiation therapy (CrRT) 18 Gy and intrathecal methotrexate would decline the intelligence quotient (IQ) scores of children with acute lymphoblastic leukemia (ALL). In protocol TCL 842, children with ALL received CrRT 18 Gy in 12 fractions, and 5 concomitant doses of intrathecal methotrexate 15 mg/m2/dose with 15 mg as the maximum, for CNSP after remission achieved. The first IQ test was performed immediately after CNSP. Those who had no CNS relapse for more than 5 years after CNSP had a second IQ test. For children between 3 and 6 years old, the Stanford-Binet (S-B) IV test was used, and for older children, the Wechsler Intelligence Scale for Children-Revised (WISC-R) was used. Fourteen consecutive children at our hospital were enrolled. There were 7 boys and 7 girls. The age at diagnosis ranged from 3 to 9 years old. Two of them were in the high-risk group, eight in the intermediate-risk group, and four in the standard-risk group. The IQ scores of all patients fell within the average range. In the first IQ tests, the mean IQ score was 104.29 (range 83-124, S.D. 14.55). In the second IQ tests, the mean IQ score was 100.93 (range 85-128, S.D. 11.57). Statistically, there was no significant difference between the first and second IQ scores (paired t-test, two-tailed P = 0.4232; one-tailed P = 0.2116). Our findings suggested that CNSP used in protocol TCL 842 did not reduce IQ scores of children with ALL 5 years after CNSP.

Neonatal alloimmune thrombocytopenia in Taiwan due to an antibody against a labile component of HPA-3a (Baka)

We report on two siblings who developed severe neonatal alloimmune thrombocytopenia (NAIT) due to an alloantibody against a labile component or components of the HPA-3a (Baka) antigen. The antibody reacted only with fresh, unfixed platelets by the solid-phase red cell adherence test, immunofluorescence test and mixed passive haemagglutination test. In the latter method, weakly fixed platelets also gave a weak positive reaction. Monoclonal-antibody-specific immobilization of platelet antigens and immunoblotting tests gave negative results. Our findings may possibly help to explain why in some cases of NAIT no platelet-specific antibody is demonstrable in tests with fixed or solubilized platelets.

Treatment of platelet alloimmunization with intravenous immunoglobulin in a child with aplastic anemia

A 9-year-old girl with severe refractory aplastic anemia had become refractory to platelet transfusion due to platelet alloimmunization. As a result, a huge right parieto-temporo-occipital cerebral hematoma and a subarachnoid hemorrhage subsequently occurred. Intravenous immunoglobulin (IVIG) (Green Cross, Taiwan) at a dose of 0.4 g/kg/day for 5 days, followed by another 3 doses during the following 5 days, and combined with large-dose platelet transfusions effectively controlled the bleeding by elevating the platelet count to above 100 x 10(3)/mm3. The patient soon recovered with only a mild sequela. Two months later, because of multiple caries and a periodontal abscess, dental extraction needed to be performed. IVIG (0.4 g/kg/day x 6 days) enabled surgery to proceed by elevating the platelet count to above 55 x 10(3)/mm3, and no bleeding complications occurred during or after the procedure. The potential benefit of high-dose IVIG in modulating platelet alloimmunization is a result of increasing the survival of transfused platelets. Thus, this therapy is recommended when patients with platelet alloimmunization have critical bleeding episodes or undergo surgical procedures.

Role of granulocyte colony-stimulating factor as adjunct therapy for septicemia in children with acute leukemia

The granulocyte colony-stimulating factor (G-CSF) has been shown to accelerate recovery from severe neutropenia and to decrease the incidence of documented infections after intensive chemotherapy in cancer patients. However, the routine prophylactic use of G-CSF is expensive. This study was conducted to determine the role of G-CSF as adjunct therapy for septicemia following neutropenia caused by chemotherapy in children with acute leukemia. Fifty consecutive episodes of septicemia were studied involving 34 episodes of Gram-negative, 7 episodes of Gram-positive, 5 episodes of polymicrobial bacterial septicemia, one episode of fungemia, and 3 episodes of disseminated fungal infection. In the first 25 episodes, G-CSF was not used (group A). For the next 16 episodes, G-CSF 200 micrograms per square meter per day subcutaneously was given immediately after the septicemia was documented until the absolute neutrophil count was maintained at more than 1,500 per cubic millimeter (group B). Thereafter, G-CSF at the same dose as that of group B was prophylactically used in all the children who received high-dose cytosine arabinoside-containing regimens. Nine episodes of septicemia occurred (group C). The incidences of mortality per episode of septicemia in groups A, B, and C were 12.0% (3/25), 12.5% (2/16) and 0% (0/9), respectively. Statistically, there was no difference between the three groups overall and in pair-wise comparisons (all P > 0.5). The durations of G-CSF administration in group B ranged from 6 to 26 days with a median of 12 days and the durations of G-CSF administration in group C ranged from 10 to 23 days with a median of 19 days. With or without G-CSF, there may be no significant difference in the mortality of septicemia following neutropenia caused by chemotherapy in children with acute leukemia.

The Le(a) antigen and neonatal hyperbilirubinemia in Taiwan

Neonatal jaundice is known to be more severe in Taiwanese infants than in Caucasian infants. Although ABO fetomaternal incompatibility and glucose-6-phosphate dehydrogenase deficiency have been shown to play a role in the etiology of neonatal jaundice in some Taiwanese infants, the etiology in the majority of cases is unknown. In this study we found that in Taiwanese newborn infants, the red cell Le(a) antigen appeared later in infants who were jaundiced (peak serum bilirubin levels of > 12 mg/dl during the first week of life) than in infants who were not. However, the Leb antigen, and hence the transferase encoded by the Se and Se(w) genes, did not appear to be similarly involved in the etiology of physiological jaundice. Thus it would appear that the Le gene-specified transferase is less active or has a delayed function, in jaundiced infants. The relationship between the Le gene-specified transferase and bilirubin has yet to be established.

A clinicopathological study of Langerhans cell histiocytosis

BACKGROUND

Langerhans cell histiocytosis encompasses a wide clinical spectrum, from a benign localized disease to acute generalized disease with fatal outcome. Here the histological features and clinical data for thirteen patients are reviewed and compared. The antigenic phenotype of the proliferating cells in Langerhans cell histiocytosis was also studied.

METHODS

The antibodies used included S-100 protein, vimentin, peanut agglutinin, HLA-DR, leukocyte common antigen, UCHL-1, CD 20, lysozyme, alpha 1-antitrypsin and epithelial membrane antigen.

RESULTS

Six patients had localized lesions affecting a bone or its surrounding soft tissue. Four patients had multifocal disease without organ dysfunction. All patients of these two categories survived, except for one adult who died of hypertensive cerebral hemorrhage. Three patients had multifocal disease with liver, lung or bone marrow dysfunction. One died and two were lost to follow up.

CONCLUSIONS

There was no significant difference in pathological findings between localized disease and multifocal disease. Immunohistochemical examinations using a panel of antibodies, including S-100 protein, peanut agglutinin, HLA-DR and vimentin, were very helpful for diagnosis of Langerhans cell histiocytosis.

Epstein-Barr virus pneumonia associated with hemophagocytic syndrome: report of one case

An 8-year-old girl was admitted because of high fever and cough for seven days. The physical examination on admission revealed diffuse moist rales over the left lung field. Her high fever persisted, and she subsequently developed hepatosplenomegaly, lymphadenopathy, skin rashes, subconjunctival hemorrhage, diffuse pulmonary infiltrates, abnormal liver function, anemia, thrombocytopenia, leukocytosis, and hypoalbuminemia. A bone marrow study revealed increased numbers of macrophages with apparent hemophagocytosis. She developed respiratory failure and required artificial ventilation, but finally died despite resuscitative efforts. Serology for EB virus initially revealed negative findings, but on the 24th day after admission, showed IgG antibody to viral capsid antigen 320x (+), and IgM antibody to viral capsid antigen (+). This is a very unusual case of fatal EB virus pneumonia associated with hemophagocytic syndrome.

A proposed interaction model of the insulin molecule with its receptor

Based on the extensive structural comparisons among the determined structures of the different species and crystal forms of insulin and its derivatives in our laboratory, it was suggested that the binding interaction with the receptor molecule should take place mainly on an amphipathic surface of the insulin molecule. In the middle of this amphipathis surface, there was a hydrophobic surface with an area of about 150 A2, while the polar and charged groups distributing around the hydrophobic surface constructed a hydrophilic zone. The hydrophobic surface was usually covered by the extended B-chain C-terminal peptides with great mobility. The angle between the proposed binding interaction surface and the surface of dimerization was about 20 degrees. The results from studies on structures of A1-(L-Trp) insulin and A1-(D-Trp) insulin confirmed the interaction mechanism model we proposed.

Computed tomography of spontaneous intracranial haemorrhage due to haemostatic disorders in children

Intracranial haemorrhage is a serious problem in haemostatic disorders in children. Intracranial bleeding is sometimes more marked than suspected clinically. Computed tomography (CT) permits accurate, sensitive diagnosis of intracranial haemorrhage. We report 13 patients; 3 patients with hypoprothrombinaemia, 4 patients with thrombocytopenia or platelet dysfunction and 6 with haemophilia A, B or Von-Willebrand's disease. One patient with hypoprothrombinaemia had a subarachnoid hemorrhage (SAH), one a subdural haematoma (SDH) and the third a combination of SAH, SDH and intracerebral haematoma (ICH). One patient with thrombocytopenia or platelet dysfunction had a SDH, while the others had ICH. In the six patients with haemophilia A, B or Von-Willebrand's disease, there were four examples of ICH, five of SAH and six of SDH. A neurosurgical procedure was performed in only one patient. Three children died of serious intracranial complications with uncal herniation.