Risk scores for Kawasaki disease, a management tool developed by the KAWA-RACE cohort

INTRODUCTION/OBJECTIVES

Asian scores developed to predict unresponsiveness to intravenous immunoglobulin (IVIG) or development of coronary artery aneurysms (CAA) in patients with Kawasaki disease (KD) are not appropriate in Western populations. The purpose of this study is to develop 2 scores, to predict unresponsiveness to IVIG and development of CAA, appropriate for Spanish population.

METHOD

Data of 625 Spanish children with KD collected retrospectively (2011-2016) were used to identify variables to develop the 2 scores of interest: unresponsiveness to IVIG and development of CAA. A statistical model selected best variables to create the scores, and scores were validated with data from 98 patients collected prospectively.

RESULTS

From 625 patients of the retrospective cohort, final analysis was performed in 439 subjects: 37 developed CAA, and 212 were unresponsive to IVIG. For the score to predict CAA, a cutoff ≥ 8 was considered for high risk, considering a score system with a different weight for each of the eight variables. External validation showed a sensitivity of 22% and a specificity of 75%. The score to predict unresponsiveness to IVIG established a cutoff ≥ 8 for high risk, considering a score system with a different weight for each of the nine variables. External validation showed a sensitivity of 78% and a specificity of 50%.

CONCLUSIONS

Two risk scores for KD were developed from Spanish population, to predict development of CAA and unresponsiveness to IVIG; validation in other cohorts could help to implement these tools in the management of KD in other Western populations.

Kawasaki disease in children younger than 6 months of age: characteristics of a Spanish cohort

A retrospective study that compared children younger than 6 months versus older children of a Spanish cohort of patients diagnosed with Kawasaki disease between 2011 and 2016 (Kawa-Race study). From the 598 patients recruited, 42 patients were younger than 6 months (7%) and presented more frequently with an incomplete diagnosis of Kawasaki disease (52.4 vs 27.9%, p = 0.001). Cardiac abnormalities detected by echocardiography were more common in younger patients (52.4 vs 30%, p = 0.002). These younger patients presented with a higher proportion of coronary aneurysms as well (19 vs 8.6%, p < 0.001). Shock at diagnosis (9.5 vs 1.9%, p = 0.016) and admission to intensive care units (17.7 vs 4.1%, p = 0.003) were more frequent in patients younger than 6 months. There were no statistically significant differences in relation to infections, non-response to IVIG, or mid- or long-term outcomes.Conclusion: Data of the Spanish cohort are consistent with other American and Asian studies, although Spanish children younger than 6 months had a lower rate of non-response to IVIG and better clinical outcomes. A high index of suspicion should be considered for this population due to a higher risk of coronary abnormalities, presentation of shock, and admission to the intensive care unit. What is Known: •Children below 6 months of age with Kawasaki disease (KD) have different features compared to older. •Younger patients usually have an incomplete form of KD and coronary artery abnormalities. What is New: •Younger than 6 months with KD presented with shock and required admission to PICU more frequently compared to older. •Infections play a similar role in KD despite the age of the patients.

Arthroscopic Matrix-Encapsulated Autologous Chondrocyte Implantation: A Pilot Multicenter Investigation in Latin America

Objective. To evaluate minimum biosecurity parameters (MBP) for arthroscopic matrix-encapsulated autologous chondrocyte implantation (AMECI) based on patients' clinical outcomes, magnetic resonance imaging (MRI) T2-mapping, Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score, and International Cartilage Repair Society (ICRS) second-look arthroscopic evaluation, laying the basis for a future multicenter study. Design. Pilot clinical study. We analyzed the logistics to perform AMECI to treat focal chondral lesions in different hospitals following strict biosecurity parameters related to tissue and construct transportation, chondrocyte isolation, and cell expansion. Patient progress was analyzed with patient-reported outcome measures, MRI T2-mapping, MOCART, and ICRS arthroscopic second-look evaluation. Results. Thirty-five lesions in 30 patients treated in 7 different hospitals were evaluated. Cell viability before implantation was >90%. Cell viability in construct remnants was 87% ± 11% at 24 hours, 75% ± 17.1% at 48 hours, and 60% ± 8% at 72 hours after implantation. Mean final follow-up was 37 months (12-72 months). Patients showed statistically significant improvement in all clinical scores and MOCART evaluations. MRI T2-mapping evaluation showed significant decrease in relaxation time from 61.2 ± 14.3 to 42.9 ± 7.2 ms (P < 0.05). Arthroscopic second-look evaluation showed grade II "near normal" tissue in 83% of patients. Two treatment failures were documented. Conclusions. It was feasible to perform AMECI in 7 different institutions in a large metropolitan area following our biosecurity measures without any implant-related complication. Treated patients showed improvement in clinical, MRI T2-mapping, and MOCART scores, as well as a low failure rate and a favorable ICRS arthroscopic evaluation at a mid-term follow-up. Level of Evidence. 2b.

Arthroscopic Matrix-Assisted Autologous Chondrocyte Transplantation Versus Microfracture: A 6-Year Follow-up of a Prospective Randomized Trial

BACKGROUND

Few randomized controlled trials with a midterm follow-up have compared matrix-assisted autologous chondrocyte transplantation (MACT) with microfracture (MFx) for knee cartilage lesions.

PURPOSE

To compare the structural, clinical, and safety outcomes at midterm follow-up of MACT versus MFx for treating symptomatic knee cartilage lesions.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 48 patients aged between 18 and 50 years, with 1- to 4-cm² International Cartilage Repair Society (ICRS) grade III to IV knee chondral lesions, were randomized in a 1:1 ratio to the MACT and MFx treatment groups. A sequential prospective evaluation was performed using magnetic resonance imaging (MRI) T2 mapping, the MOCART (magnetic resonance observation of cartilage repair tissue) score, second-look arthroscopic surgery, patient-reported outcome measures, the responder rate (based on achieving the minimal clinically important difference for the Knee injury and Osteoarthritis Outcome Score [KOOS] pain and KOOS Sport/Recreation), adverse events, and treatment failure (defined as a reoperation because of symptoms caused by the primary defect and the detachment or absence of >50% of the repaired tissue during revision surgery).

RESULTS

Overall, 35 patients (18 MACT and 17 MFx) with a mean chondral lesion size of 1.8 ± 0.8 cm² (range, 1-4 cm²) were followed up to a mean of 6 years postoperatively (range, 4-9 years). MACT demonstrated significantly better structural outcomes than MFx at 1 to 6 years postoperatively. At final follow-up, the MRI T2 mapping values of the repaired tissue were 37.7 ± 8.5 ms for MACT versus 46.4 ± 8.5 ms for MFx (P = .003), while the MOCART scores were 59.4 ± 17.3 and 42.4 ± 16.3, respectively (P = .006). More than 50% defect filling was seen in 95% of patients at 2 years and 82% at 6 years in the MACT group and in 67% at 2 years and 53% at 6 years in the MFx group. The second-look ICRS scores at 1 year were 10.7 ± 1.3 for MACT and 9.0 ± 1.8 for MFx (P = .001). Both groups showed significant clinical improvements at 6 years postoperatively compared with their preoperative status. Significant differences favoring the MACT group were observed at 2 years on the KOOS Activities of Daily Living (P = .043), at 4 years on all KOOS subscales (except Symptoms; P < .05) and the Tegner scale (P = .008), and at 6 years on the Tegner scale (P = .010). The responder rates at 6 years were 53% and 77% for MFx and MACT, respectively. There were no reported treatment failures after MACT; the failure rate was 8.3% in the MFx group. Neither group had serious adverse events related to treatment.

CONCLUSION

Patients who underwent MACT had better structural outcomes than those who underwent MFx at 1 to 6 years postoperatively. Both groups of patients showed significant clinical improvements at final follow-up compared with their preoperative status. MACT showed superiority at 4 years for the majority of the KOOS subscales and for the Tegner scale at 4 to 6 years. The MACT group also had a higher responder rate and lower failure rate at final follow-up.

REGISTRATION

NCT01947374 (ClinicalTrials.gov identifier).

[Clinical spectrum and risk factors for complicated disease course in children admitted with SARS-CoV-2 infection]

INTRODUCTION

At this time there are still major questions about the characteristics of disease caused by the new coronavirus (COVID-19) in children as well as factors associated with the development of severe forms of the disease.

STUDY DESIGN

Retrospective study including patients under 18 years of age admitted with SARS-CoV-2 infection from March 1 to April 30, 2020. Infection was confirmed by realtime reverse transcriptase-polymerase chain reaction (RT-PCR) or antibody testing. We describe the epidemiological and clinical data, laboratory and imaging findings, as well as treatment and outcome in these patients. In light of these findings, patients were classified into two severity groups and then compared.

RESULTS

Thirty-nine children were included, with a median age of 9 years (range 12 days-16 years); 23 were boys. Cases with uncomplicated disease course (24) mostly presented to the emergency department (ED) with fever and/or respiratory symptoms without significant alterations in laboratory findings. Of the 15 children with a complicated course, 12 developed shock. In addition to fever, they frequently presented altered appearance, extreme tachycardia, abdominal pain, vomiting, diarrhea, rash, and/or conjunctival hyperemia. They also showed greater lymphopenia (p = 0.001), elevated neutrophil/lymphocyte ratio (p = 0.001), C-reactive protein (p < 0.001), procalcitonin (p = 0.001), D-dimer (p < 0.001), and ferritin (p < 0.001).

CONCLUSIONS

SARS-CoV-2 infection in admitted children presents with great clinical variability. When provided supportive care, patients with predominant respiratory symptoms without altered laboratory-test results generally have an uncomplicated course. Patients with complicated disease present mainly with fever and abdominal and/or mucocutaneous symptoms. Most develop shock. Elevation of inflammatory markers may allow for early detection and the final outcome is good.

Clinical spectrum and risk factors for complicated disease course in children admitted with SARS-CoV-2 infection

INTRODUCTION

At this time there are still major questions about the characteristics of disease caused by the new coronavirus (COVID-19) in children as well as factors associated with the development of severe forms of the disease.

STUDY DESIGN

Retrospective study including patients under 18 years of age admitted with SARS-CoV-2 infection from March 1 to April 30, 2020. Infection was confirmed by real-time reverse transcriptase polymerase chain reaction (RT-PCR) or antibody testing. We describe the epidemiological and clinical data, laboratory and imaging findings, as well as treatment and outcome in these patients. In light of these findings, patients were classified into two severity groups and then compared.

RESULTS

Thirty-nine children were included, with a median age of 9 years (range 12 days-16 years); 23 were boys. Cases with uncomplicated disease course (24) mostly presented to the emergency department (ED) with fever and/or respiratory symptoms without significant alterations in laboratory findings. Of the 15 children with a complicated course, 12 developed shock. In addition to fever, they frequently presented altered appearance, extreme tachycardia, abdominal pain, vomiting, diarrhea, rash, and/or conjunctival hyperemia. They also showed greater lymphopenia (p = 0.001), elevated neutrophil/lymphocyte ratio (p = 0.001), C-reactive protein (p < 0.001), procalcitonin (p = 0.001), D-dimer (p < 0.001), and ferritin (p < 0.001).

CONCLUSIONS

SARS-CoV-2 infection in admitted children presents with great clinical variability. When provided supportive care, patients with predominant respiratory symptoms without altered laboratory-test results generally have an uncomplicated course. Patients with complicated disease present mainly with fever and abdominal and/or mucocutaneous symptoms. Most develop shock. Elevation of inflammatory markers may allow for early detection and the final outcome is good.

Diagnostic Accuracy of QuantiFERON-TB Gold Plus Assays in Children and Adolescents with Tuberculosis Disease

In 2016, a new interferon-gamma release assay, QuantiFERON-TB Gold Plus, was introduced. We conducted a cross-sectional multicenter study, involving 158 children and adolescents with tuberculosis disease. The overall sensitivity of the assay was 82.9% (IQR 77.0%-88.8%), indicating that in children this test does not have higher sensitivity than previous generation interferon-gamma release assays.

Prevalence and Clinical Characteristics of SARS-CoV-2 Confirmed and Negative Kawasaki Disease Patients During the Pandemic in Spain

Introduction: COVID-19 has a less severe course in children. In April 2020, some children presented with signs of multisystem inflammation with clinical signs overlapping with Kawasaki disease (KD), most of them requiring admission to the pediatric intensive care unit (PICU). This study aimed to describe the prevalence and clinical characteristics of KD SARS-CoV-2 confirmed and negative patients during the pandemic in Spain. Material and Methods: Medical data of KD patients from January 1, 2018 until May 30, 2020 was collected from the KAWA-RACE study group. We compared the KD cases diagnosed during the COVID-19 period (March 1-May 30, 2020) that were either SARS-CoV-2 confirmed (CoV+) or negative (CoV-) to those from the same period during 2018 and 2019 (PreCoV). Results: One hundred and twenty-four cases were collected. There was a significant increase in cases and PICU admissions in 2020 (P-trend = 0.001 and 0.0004, respectively). CoV+ patients were significantly older (7.5 vs. 2.5 yr) and mainly non-Caucasian (64 vs. 29%), had incomplete KD presentation (73 vs. 32%), lower leucocyte (9.5 vs. 15.5 × 10⁹) and platelet count (174 vs. 423 × 10⁹/L), higher inflammatory markers (C-Reactive Protein 18.5vs. 10.9 mg/dl) and terminal segment of the natriuretic atrial peptide (4,766 vs. 505 pg/ml), less aneurysm development (3.8 vs. 11.1%), and more myocardial dysfunction (30.8 vs. 1.6%) than PreCoV patients. Respiratory symptoms were not increased during the COVID-19 period. Conclusion: The KD CoV+ patients mostly meet pediatric inflammatory multisystem syndrome temporally associated with COVID-19/multisystem inflammatory syndrome in children criteria. Whether this is a novel entity or the same disease on different ends of the spectrum is yet to be clarified.

Spanish Version of the National Institutes of Health Stroke Scale: Awareness and Use in United States. A Survey Study

OBJECTIVE

To investigate the awareness and the use of Spanish version of National Institutes of Health Stroke Scale (NIHSS) throughout the United States (US) by regions using a web-based survey.

METHODS

A survey targeting physicians from two specialties that regularly manage acute stroke patients was conducted from February to August of 2015. Academic centers from the Accreditation Council for Graduate Medical Education online directory belonging to emergency medicine (EM) and neurology residency programs were identified. The questionnaire was composed of ten questions separated into three different groups. The responses received from the programs were separated by specialty and grouped into different regions in the US for comparison.

RESULTS

Out of 230 residency-invited programs, we received a total of 73 responses, 35 from EM and 26 responses from neurology residency programs. In addition, 12 respondents were categorized as unknown recipients. The South region had the highest response rate with 30.3%. There was no significant difference in the responses by region if Puerto Rico was not analyzed. Interviewees reported a substantial percentage of Spanish-speaking patients reported across the regions and more than 75% of the programs report lack of knowledge of the Spanish version of the NIHSS and/or the use of it.

CONCLUSION

There may be a need to increase awareness and to promote the use of the Spanish version of the NIHSS. Spanish-speaking population in the US may be inaccurately assessed for acute stroke and could impact the outcomes. Larger population studies should be conducted to confirm our findings.

AUTHOR CONTRIBUTIONS

Dr. Villalobos and Dr. Barnes are involved in formulating the study concept and design; Dr. Rodriguez and Dr. Maud are involved in manuscript writing; Dr. Qureshi is involved in statistical analysis of the data; Dr. Cruz-Flores is involved in critical revision of the manuscript.

DISCLOSURES

Dr. Villalobos reports no disclosure; Dr. Barnes reports no disclosure; Dr. Qureshi reports no disclosure; Dr. Cruz-Flores reports no disclosure; Dr. Maud reports no disclosure; Dr. Rodriguez reports no disclosure.

Follow-up of a new arthroscopic technique for implantation of matrix-encapsulated autologous chondrocytes in the knee

PURPOSE

The purpose of this study was to evaluate the clinical and sequential imaging follow-up results at a mean of 36 months after an arthroscopic technique for implantation of matrix-encapsulated autologous chondrocytes for the treatment of articular cartilage lesions on the femoral condyles.

METHODS

Ten patients underwent arthroscopic implantation of autologous chondrocytes seeded onto a bioabsorbable scaffold. The patients were evaluated clinically using a visual analog scale (VAS) for pain and International Knee Documentation Committee (IKDC), Lysholm, and Tegner scores. Magnetic resonance imaging (MRI) T2-mapping and magnetic resonance observation of cartilage repair tissue (MOCART) evaluations were also performed. Second-look arthroscopic evaluation using the International Cartilage Repair Society (ICRS) grading classification was performed at 12 months.

RESULTS

Compared with their preoperative values, at 36 months mean values ± standard deviation for the VAS scale for pain were 6.0 ± 1.5 to 0.3 ± 0.4. Improvement in clinical scores between preoperative values and 36-month follow-up values in subjective IKDC scores was 46.9 ± 18.5 to 77.2 ± 12.8; in Lysholm scores, it was 51.8 ± 25.1 to 87.9 ± 6.5, and in the Tegner activity scale it was 2.9 ± 1.7 to 5.9 ± 1.9. Mean T2 mapping and MOCART scores improved over time to 38.1 ± 4.4 ms and 72.5 ± 10, respectively. Mean ICRS score by second-look arthroscopy at 1 year was 10.4 ± 0.1.

CONCLUSIONS

All clinical scores improved over time compared with the preoperative values. Clinical results are comparable with MRI T2 mapping and ICRS evaluations, suggesting that this arthroscopic technique for cell-based cartilage repair is efficacious and reproducible at a mean of 36 months of follow-up.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Effect of angiogenesis-related cytokines on rotator cuff disease: the search for sensitive biomarkers of early tendon degeneration

BACKGROUND

Hallmarks of the pathogenesis of rotator cuff disease (RCD) include an abnormal immune response, angiogenesis, and altered variables of vascularity. Degenerative changes enhance production of pro-inflammatory, anti-inflammatory, and vascular angiogenesis-related cytokines (ARC) that play a pivotal role in the immune response to arthroscopic surgery and participate in the pathogenesis of RCD. The purpose of this study was to evaluate the ARC profile, ie, interleukin (IL): IL-1β, IL-6, IL-8, IL-10, vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), and angiogenin (ANG), in human peripheral blood serum and correlate this with early degenerative changes in patients with RCD.

METHODS

Blood specimens were obtained from 200 patients with RCD and 200 patients seen in the orthopedic clinic for nonrotator cuff disorders. Angiogenesis imaging assays was performed using power Doppler ultrasound to evaluate variables of vascularity in the rotator cuff tendons. Expression of ARC was measured by commercial Bio-Plex Precision Pro Human Cytokine Assays.

RESULTS

Baseline concentrations of IL-1β, IL-8, and VEGF was significantly higher in RCD patients than in controls. Significantly higher serum VEGF levels were found in 85% of patients with RCD, and correlated with advanced stage of disease (r = 0.75; P < 0.0005), average microvascular density (r = 0.68, P < 0.005), and visual analog score (r = 0.75, P < 0.0002) in RCD patients. ANG and IL-10 levels were significantly lower in RCD patients versus controls. IL-1β and ANG levels were significantly correlated with degenerative tendon grade in RCD patients. No difference in IL-6 and bFGF levels was observed between RCD patients and controls. Patients with degenerative changes had markedly lower ANG levels compared with controls. Power Doppler ultrasound showed high blood vessel density in patients with tendon rupture.

CONCLUSION

The pathogenesis of RCD is associated with an imbalance between pro-inflammatory, anti-inflammatory, and vascular ARC.

Characterisation of Zea mays L. plastidial transglutaminase: interactions with thylakoid membrane proteins

Chloroplast transglutaminase (chlTGase) activity is considered to play a significant role in response to a light stimulus and photo-adaptation of plants, but its precise function in the chloroplast is unclear. The characterisation, at the proteomic level, of the chlTGase interaction with thylakoid proteins and demonstration of its association with photosystem II (PSII) protein complexes was accomplished with experiments using maize thylakoid protein extracts. By means of a specific antibody designed against the C-terminal sequence of the maize TGase gene product, different chlTGase forms were immunodetected in thylakoid membrane extracts from three different stages of maize chloroplast differentiation. These bands co-localised with those of lhcb 1, 2 and 3 antenna proteins. The most significant, a 58 kDa form present in mature chloroplasts, was characterised using biochemical and proteomic approaches. Sequential fractionation of thylakoid proteins from light-induced mature chloroplasts showed that the 58 kDa form was associated with the thylakoid membrane, behaving as a soluble or peripheral membrane protein. Two-dimensional gel electrophoresis discriminated, for the first time, the 58-kDa band in two different forms, probably corresponding to the two different TGase cDNAs previously cloned. Electrophoretic separation of thylakoid proteins in native gels, followed by LC-MS mass spectrometry identification of protein complexes indicated that maize chlTGase forms part of a specific PSII protein complex, which includes LHCII, ATPase and pSbS proteins. The results are discussed in relation to the interaction between these proteins and the suggested role of the enzyme in thylakoid membrane organisation and photoprotection.

[Leaf micrografic anatomy of the Neotropical palm Bactris gasipaes (Arecaceae)]

The economic importance of the palm Bactris gasipaes is growing in the Neotropoical region. We collected leaflets from plants under a chemical fertilization regime and a population of 5000 plants per hectare, in Costa Rica. The variety, Diamantes 10, has an ascendency fom the upper Amazon basin. We used Harries hematoxiline, eocine and standard light microscopy techniques. The presence of raphids and buliform cells was confirmed for the abaxial surface of the leaflets and for the hypodermic tissue on both sides. The absence of the Krantz anatomy was confirmed in consistence with former observations about the C3 photosynthesis in other species of Palmaceae. The average stomatal density on the abaxial surface was 96.87 +/- 16.31 stomata.mm(-2) and 14.20 +/- 4.05 in the adaxial surface.

Anatomía micrográfica del folíolo de la palma neotropical Bactris gasipaes (Arecaceae)

Se estudiaron hojas de plantas jóvenes cultivadas para producción de palmito de la variedad Diamantes 10 de ascendencia del Alto Amazonas. Se estudió la anatomía micrográfica foliar y la frecuencia de estomas en la superficie adaxial y abaxial de los foliolos de Bactris gasipaes provenientes de una plantación experimental en un régimen de fertilización química y una densidad de población de 5000 plantas por hectárea, en Guápiles, Costa Rica. Se confirmó la presencia de rafidios y células buliformes en la superficie abaxial de las láminas foliares y del tejido hipodermico en ambos lados. Confirmamos la ausencia de la anatomía Krantz en esta especie, reafirmando la fotosíntesis C3 como mecanismo metabólico en la familia Palmaceae. La densidad promedio de estomas en la superficie abaxial fue de 96,87±16,31 estomas.mm-2 y en la superficie adaxial fue de 14,20±4,05 estomas.mm-2.

Purification and in vitro refolding of maize chloroplast transglutaminase over-expressed in Escherichia coli

In contrast to mammalian transglutaminases (TGs), plant members of the superfamily are poorly characterized. In order to produce pure and active TG for its functional and structural studies, variants of maize chloroplast transglutaminase (TGZ, Patent WWO03102128) were sub-cloned into a pET28 vector and overexpressed in Escherichia coli BL21 (DE3) cells. The recombinant proteins were present mainly as insoluble inclusion bodies. The TGZ4p variant with four B-type repeats (M(r) approximately 55 kDa), was affinity purified from urea-solubilized inclusion bodies. TGZ4p was refolded by rapid dilution in a Ca(2+)- and guanidine-containing buffer. Active TGZ4p shows the general catalytic characteristics described for other TGs.

Immunogold localization of trehalose-6-phosphate synthase in leaf segments of wild-type and transgenic tobacco plants expressing the AtTPS1 gene from Arabidopsis thaliana

Following the establishment of a transgenic line of tobacco (B5H) expressing the trehalose-6-phosphate synthase (TPS) gene from Arabidopsis thaliana, a preliminary immunolocalization study was conducted using leaves of adequately watered B5H and wild-type plants. Immunocytochemical staining, followed by electron microscopy showed that the enzyme could be detected in both B5H and wild-type plants at two different levels. Quantification showed the signal to be two to three times higher in transgenic plants than in the wild type. This enzyme was markedly present in the vacuoles and the cell wall, and to a lesser extent in the cytosol. Moreover, a high profusion of gold particles was detected in adjacent cells and in the sieve elements. Occasional spots were also detected in chloroplasts and the nucleus, especially in the transgenic B5H line. No labeling signal was detected in mitochondria. Protein localization seems to confirm the important role of TPS in sugar metabolism and transport through the plant, which could explain its role in plant stress tolerance. Finally, it can be expected that TPS from tobacco has a relatively high similarity to the TPS of Arabidopsis thaliana.

Molecular cloning and characterization of a maize transglutaminase complementary DNA

Two related complementary DNA clones, TGZ15 and TGZ21, encoding active maize transglutaminase (TGase) have been isolated for the first time in plants by molecular cloning (Patent Pending PCT/ES03/00247). Southern and northern blot analyses indicate that the two cDNAs probably corresponded to two different single-copy genes in the maize genome. Northern blot analyses revealed that the transcript is expressed preferentially in young leaves and differentiated embryogenic maize callus. This expression is dependent on light exposure time. TGase activity of the proteins encoded by clones TGZ15 and TGZ21 was detected in bacterial extracts overexpressing them, using two enzymatic assays. TGase activity was significantly higher than that of the empty-phagemid bacterial extracts. As in other TGases, this activity was inhibited by monodansyl cadaverine (MDC), GTP and the absence of exogenous Ca(2+). Likewise, light-stimulated Ca(2+)-dependent TGase activity was detected in thylakoids and grana of maize chloroplast, which was inhibited by MDC, GTP, DIECA and Diuron.

Immunogold localization of a transglutaminase related to grana development in different maize cell types

A comparative study of the subcellular localization of a plant transglutaminase (TGase; EC 2.3.2.13) in various in vivo and in vitro maize cell types was carried out with a polyclonal antibody raised against a 58 kDa TGase purified from Helianthus tuberosus leaves. Immunocytochemical staining, followed by electron microscopy, showed that this enzyme was markedly present in the grana-appressed thylakoids of mature chloroplasts of the light-exposed cells. Moreover, during embryogenic callus chloroplast differentiation, the abundance of TGase in the grana-appressed thylakoids depended on the degree of grana development and was greater than in mature leaf chloroplasts. In addition to the 58 kDa form, two other forms of the protein (of 77 and 34 kDa) were obtained by Western blot. The 77 kDa form might correspond to the inactive form and was immunodetected in dense vesicles observed in dark-grown embryogenic callus cells. In adult leaves, the enzyme was also markedly present in the grana-appressed thylakoids of the mesophyll cell chloroplasts, though very scarce and dispersed in the bundle-sheath cell chloroplasts (which do not contain grana). The concordance of these localizations with those described for the light-harvesting antenna proteins of the photosystem II suggests that it is possible that this TGase has a functional role in photosynthesis, perhaps modulating the photosynthetic efficiency and the absorption of excess light by means of polyamine conjugation to the antenna proteins.

[Acute myocardial infarct and coronary artery aneurysm during pregnancy]

We present the first published case in Spain on a gestant woman with acute myocardial infarction. She was angiographically studied showing a coronary artery aneurysm with inner thrombus. This is also the first time that such a lesion is described in vivo in a gestant woman.

[Acute lymphoblastic leukemias off therapy: course of 80 cases after treatment cessation]

PURPOSE

To retrospectively analyse all the patients diagnosed and treated in the same hospital for acute lymphoblastic leukaemia (ALL) in whom therapy was suppressed after sustained complete remission (CR) for a variable period.

PATIENTS AND METHODS

Eighty cases of ALL treated at the Jiménez Díaz Foundation between 1968 and 1991 were revised. Treatment had been suppressed after 60 months of maintained CR (1968-1974) or after 28 months (1986-1991), with a median follow-up after suppression of 6 years. All the patients had been treated with several protocols (FJD-68, FJD/BFM, APO, BFM-83, BFM-86 and BFM-90). Maintained CR, relapses and course after therapy cessation were analysed. Actuarial curves of RC duration and survival were drawn according to the Cutler and Ederer life tables.

RESULTS

The age at diagnosis ranged from 1.5 to 68 years. Childhood (< 15 years) ALL presented in 49 cases; 25 were young adults (15-30 years), and 6 others were over 30 years of age. Two of the 80 patients (2.5%) died in CR (astrocytoma and demyelinating leukoencephalopathy). Fifty-eight patients (72.5%) are living in maintained CR; 20 others relapsed (25%), 14 of them (70%) attaining a second CR. Allogenic BMT was carried out in 4 such cases. Four patients are out of any treatment after the second CR. The actuarial curves of CR duration after suppression of therapy gave a stable plateau at 73% for children, at 75% for young adults and at 22% for patients over 30 years. The survival after suppression of therapy showed a plateau at 75% for children and at 86% for young adults.

CONCLUSIONS

1) Relapse was seen in 25% of the patients after cessation of therapy. 2) Relapse occurred in the first two years after therapy cessation in 75% of the instances. 3) At this writing, 78.7% of the patients keep up the CR. 4) Adults over 30 years of age comprise the poorest prognosis. 5) The course of young adults in this series after cessation of therapy is as good as that of children.

[Possibilities of remission of acute lymphoblastic leukemia in adults: retrospective study of 51 patients subjected to a "total therapy" protocol in the period 1969-1983]

Between 1969 and 1983, 51 (35 men and 16 women) new cases of acute lymphoblastic leukemia (ALL) were diagnosed in patients aged 15 to 85 years (mean 21 yrs.). All patients received a "total therapy" which included: 1st induction (PRD, VCR, DBR, and/or L-ASN); 2nd, Central Nervous System profilaxis (craneal TCT and/or intrathecal MTx); 3rd, maintenance (6MP and MTx) and 4th, reinductions every 3 months (PRD, VCR, and DRB). This treatment lasted for at least 3 years. Complete Remission (CR) was achieved in 45 patients (88.2%): 3 of these patients were referred to other centers to continue treatment, 1 patient developed an early "metamorphosis" to hemophagocytic hystiocytosis and another patient developed a late chronic granulocytic leukemia (Ph +) dying a few months later after an acute myeloblastic worsening. During treatment 16 patients relapsed (9 in bone marrow and 7 in Central Nervous System). Treatment was discontinued in 24 patients with complete remission of which 5 relapsed in bone marrow 17 to 61 months after treatment). In one of the latter (ALL Ph +) an allogenic bone marrow transplant was performed and CR was achieved and maintained 46 months later. The post diagnosis acutarial curve of the 51 patients gave a mean survival of 6 years with a plateau at 43% of the patients after 11 years. The duration of the first uninterrupted CR was of 6.5 years and a plateau was reached at 46% of the patients after 10.5 years. At the present time, 20 patients are in CR (46 to 129 months) without treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute lymphoblastic leukaemia in adults: results of a 'total-therapy' programme in 47 patients over 15 years old

For the last 13 years, 47 patients with ALL over 15 years old (range 15-72; median 21) entered a 'total-therapy' programme. All cases received a 6-8 week induction course of PRD, VCR, DRB and/or L-ASN. Prophylaxis of CNS was done by cranial radiotherapy plus i.t. MTX in 32/45 patients who attained complete remission (CR). After CR, subsequent therapy involved a programme of maintenance with 6MP and MTX at full doses. Pulses of intermittent reinforcement (PRD, VCR and DRB) were done for 2 weeks, every 3 months, for at least 3 years. CR was achieved in 42/47 patients (89.3%). The median relapse-free survival of the patients who attained CR was 57 months, with an 8-year estimated disease-free survival rate of 43% for those cases. If actuarial assumptions were to be sustained, it would indicate an encouraging cure rate of 38% of all our adult ALL patients (mainly in those cases between 15 and 30 years old).

[Spontaneous internal biliary fistula. Review of the literature]

The literature concerning internal biliary fistula is reviewed. Its frequency in autopsy ranges from 0.4 to 5%, and in biliary tract operations from 0.4 to 7%. A general approach has to be established in order to obtain a diagnosis, and an individually oriented treatment provided. Emphasis is placed on certain measures of treatment and complications. The most severe complications are cholangitis (7.5%) and gall stone ileus (2% to 6%).