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Mills KI, Albert BD, Bechard LJ, Chu S, Duggan CP, Kaza A, Rakoff-Nahoum S, Sleeper LA, Newburger JW, Priebe GP, Mehta NM. Stress Ulcer Prophylaxis Versus Placebo-A Blinded Pilot Randomized Controlled Trial to Evaluate the Safety of Two Strategies in Critically Ill Infants With Congenital Heart Disease. Pediatr Crit Care Med 2024; 25:118-127. [PMID: 38240536 PMCID: PMC10829532 DOI: 10.1097/pcc.0000000000003384] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
OBJECTIVES The routine use of stress ulcer prophylaxis (SUP) in infants with congenital heart disease (CHD) in the cardiac ICU (CICU) is controversial. We aimed to conduct a pilot study to explore the feasibility of performing a subsequent larger trial to assess the safety and efficacy of withholding SUP in this population (NCT03667703). DESIGN, SETTING, PATIENTS Single-center, prospective, double-blinded, parallel group (SUP vs. placebo), pilot randomized controlled pilot trial (RCT) in infants with CHD admitted to the CICU and anticipated to require respiratory support for greater than 24 hours. INTERVENTIONS Patients were randomized 1:1 (stratified by age and admission type) to receive a histamine-2 receptor antagonist or placebo until respiratory support was discontinued, up to 14 days, or transfer from the CICU, if earlier. MEASUREMENTS AND MAIN RESULTS Feasibility was defined a priori by thresholds of screening rate, consent rate, timely drug allocation, and protocol adherence. The safety outcome was the rate of clinically significant upper gastrointestinal (UGI) bleeding. We screened 1,426 patients from February 2019 to March 2022; of 132 eligible patients, we gained informed consent in 70 (53%). Two patients did not require CICU admission after obtaining consent, and the remaining 68 patients were randomized to SUP (n = 34) or placebo (n = 34). Ten patients were withdrawn early, because of a change in eligibility (n = 3) or open-label SUP use (n = 7, 10%). Study procedures were completed in 58 patients (89% protocol adherence). All feasibility criteria were met. There were no clinically significant episodes of UGI bleeding during the pilot RCT. The percentage of patients with other nonserious adverse events did not differ between groups. CONCLUSIONS Withholding of SUP in infants with CHD admitted to the CICU was feasible. A larger multicenter RCT designed to confirm the safety of this intervention and its impact on incidence of UGI bleeding, gastrointestinal microbiome, and other clinical outcomes is warranted.
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Affiliation(s)
- Kimberly I. Mills
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Ben D. Albert
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Perioperative and Critical Care Center for Outcomes (PC-CORE), Boston Children’s Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Lori J. Bechard
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Perioperative and Critical Care Center for Outcomes (PC-CORE), Boston Children’s Hospital, Boston, MA
| | - Stephen Chu
- Department of Pharmacy, Boston Children’s Hospital, Boston, MA
| | - Christopher P. Duggan
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Aditya Kaza
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
| | - Seth Rakoff-Nahoum
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Gregory P. Priebe
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Nilesh M. Mehta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA
- Perioperative and Critical Care Center for Outcomes (PC-CORE), Boston Children’s Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
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Deitch AM, Moynihan K, Przybylski R, Gauvreau K, Braudis NJ, Farr B, Modi B, Mills KI, Nathan M, Levy PT. Risk Factors for Adverse Outcomes in Term Infants with CHD and Definitive Necrotising Enterocolitis. Cardiol Young 2024; 34:92-100. [PMID: 37226515 DOI: 10.1017/s104795112300121x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVES To define the incidence of definitive necrotising enterocolitis in term infants with CHD and identify risk factors for morbidity/mortality. METHODS We performed a 20-year (2000-2020) single-institution retrospective cohort study of term infants with CHD admitted to the Boston Children's Hospital cardiac ICU with necrotising enterocolitis (Bell's stage ≥ II). The primary outcome was a composite of in-hospital mortality and post-necrotising enterocolitis morbidity (need for extracorporeal membrane oxygenation, multisystem organ failure based on the paediatric sequential organ failure assessment score, and/or need for acute gastrointestinal intervention). Predictors included patient characteristics, cardiac diagnosis/interventions, feeding regimen, and severity measures. RESULTS Of 3933 term infants with CHD, 2.1% (n = 82) developed necrotising enterocolitis, with 67% diagnosed post-cardiac intervention. Thirty (37%) met criteria for the primary outcome. In-hospital mortality occurred in 14 infants (17%), of which nine (11%) deaths were attributable to necrotising enterocolitis. Independent predictors of the primary outcome included moderate to severe systolic ventricular dysfunction (odds ratio 13.4,confidence intervals 1.13-159) and central line infections pre-necrotising enterocolitis diagnosis (odds ratio 17.7, confidence intervals 3.21-97.0) and mechanical ventilation post-necrotising enterocolitis diagnosis (odds ratio 13.5, confidence intervals 3.34-54.4). Single ventricle, ductal dependency, and feeding related factors were not independently associated with the primary outcome. CONCLUSIONS The incidence of necrotising enterocolitis was 2.1% in term infants with CHD. Adverse outcomes occurred in greater than 30% of patients. Presence of systolic dysfunction and central line infections prior to diagnosis and need for mechanical ventilation after diagnosis of necrotising enterocolitis can inform risk triage and prognostic counseling for families.
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Affiliation(s)
- Anna M Deitch
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Cardiology, Lucile Packard Children's Hospital, Stanford, CA, USA
| | - Katie Moynihan
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert Przybylski
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nancy J Braudis
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bethany Farr
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Biren Modi
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kimberly I Mills
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Philip T Levy
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Newborn Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Kerstein JS, Klepper CM, Finnan EG, Mills KI. Nutrition for critically ill children with congenital heart disease. Nutr Clin Pract 2023; 38 Suppl 2:S158-S173. [PMID: 37721463 DOI: 10.1002/ncp.11046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/28/2023] [Accepted: 07/04/2023] [Indexed: 09/19/2023] Open
Abstract
Children with congenital heart disease often require admission to the cardiac intensive care unit at some point in their lives, either after elective surgical or catheter-based procedures or during times of acute critical illness. Meeting both the macronutrient and micronutrient needs of children in the cardiac intensive care unit requires complex decision-making when considering gastrointestinal perfusion, vasoactive support, and fluid balance goals. Although nutrition guidelines exist for critically ill children, these cannot always be extrapolated to children with congenital heart disease. Children with congenital heart disease may also suffer unique circumstances, such as chylothoraces, heart failure, and the need for mechanical circulatory support, which greatly impact nutrition delivery. Guidelines for neonates and children with heart disease continue to be developed. We provide a synthesized narrative review of current literature and considerations for nutrition evaluation and management of critically ill children with congenital heart disease.
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Affiliation(s)
- Jason S Kerstein
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusettes, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusettes, USA
| | - Corie M Klepper
- Department of Pediatrics, Harvard Medical School, Boston, Massachusettes, USA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusettes, USA
| | - Emily G Finnan
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusettes, USA
| | - Kimberly I Mills
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusettes, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusettes, USA
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Lappin MJ, Dellett M, Mills KI, Lundy FT, Irwin CR. The neutralising and stimulatory effects of antimicrobial peptide LL-37 in human gingival fibroblasts. Arch Oral Biol 2023; 148:105634. [PMID: 36773560 DOI: 10.1016/j.archoralbio.2023.105634] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/01/2023]
Abstract
OBJECTIVES To investigate the effects of LL-37, a broad spectrum antimicrobial peptide expressed in periodontal tissues, on human gingival fibroblast responsiveness to microbial challenge and to explore the direct effects of LL-37 on human gingival fibroblasts. DESIGN The effect of LL-37 on bacterial lipopolysaccharide-induced expression of Interleukin (IL-6) and chemokine C-X-C motif ligand (CXCL) 8 was determined by enzyme linked immunosorbent assay (ELISA). LL-37's influence on bacterial lipopolysaccharide-induced IκBα degradation was investigated by western blot. DNA microarray analysis initially determined the direct effects of LL-37 on gene expression, these findings were subsequently confirmed by quantitative polymerase chain reaction and ELISA analysis of selected genes. RESULTS Bacterial lipopolysaccharide-induced IL-6 and CXCL8 production by human gingival fibroblasts was significantly reduced in the presence of LL-37 at concentrations in the range of 1-10 µg/ml. LL-37 led to a reduction in lipopolysaccharide-induced IκBα degradation by Escherichia coli lipopolysaccharide and Porphyromonas gingivalis lipopolysaccharide (10 µg/ml). LL-37 (50 µg/ml) significantly altered the gene expression of 367 genes in human gingival fibroblasts by at least 2-fold. CXCL1, CXCL2, CXCL3, Interleukin-24 (IL-24), CXCL8, Chemokine (C-C motif) Ligand 2, and Suppressor of Cytokine Signalling 3 mRNA were significantly upregulated by LL-37. LL-37 also significantly stimulated expression of CXCL8, hepatocyte growth factor and CXCL1 at the protein level. CONCLUSION LL-37 plays an important regulatory role in the immunomodulatory activity of gingival fibroblasts by inhibiting lipopolysaccharide -induced expression of inflammatory cytokines and directly stimulating the expression of an array of bioactive molecules involved in inflammation and repair.
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Affiliation(s)
| | - M Dellett
- Patrick G Johnston Centre for Cancer Research, UK
| | - K I Mills
- Patrick G Johnston Centre for Cancer Research, UK
| | - F T Lundy
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, UK
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Milligan C, Mills KI, Ge S, Michalowski A, Braudis N, Mansfield L, Nathan M, Sleeper LA, Teele SA. Cardiovascular intensive care unit variables inform need for feeding tube utilization in infants with hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2023; 165:1248-1256. [PMID: 35691711 DOI: 10.1016/j.jtcvs.2022.04.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 03/24/2022] [Accepted: 04/28/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Feeding strategies in infants with hypoplastic left heart syndrome (HLHS) following stage 1 palliation (S1P) include feeding tube utilization (FTU). Timely identification of infants who will fail oral feeding could mitigate morbidity in this vulnerable population. We aimed to develop a novel clinical risk prediction score for FTU. METHODS This was a retrospective study of infants with HLHS admitted to the Boston Children's Hospital cardiovascular intensive care unit for S1P from 2009 to 2019. Infants discharged with feeding tubes were compared with those on full oral feeds. Variables from early (birth to surgery), mid (postsurgery to cardiovascular intensive care unit transfer), and late (inpatient transfer to discharge) hospitalization were analyzed in univariate and multivariable models. RESULTS Of 180 infants, 66 (36.7%) discharged with a feeding tube. In univariate analyses, presence of a genetic disorder (early variable, odds ratio, 3.25; P = .014) and nearly all mid and late variables were associated with FTU. In the mid multivariable model, abnormal head imaging, ventilation duration, and vocal cord dysfunction were independent predictors of FTU (c-statistic 0.87). Addition of late variables minimally improved the model (c-statistic 0.91). A risk score (the HV2 score) for FTU was developed based on the mid multivariable model with high specificity (93%). CONCLUSIONS Abnormal head imaging, duration of ventilation, and presence of vocal cord dysfunction were associated with FTU in infants with HLHS following S1P. The predictive HV2 risk score supports routine perioperative head imaging and vocal cord evaluation. Future application of the HV2 score may improve nutritional morbidity and hospital length of stay in this population.
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Affiliation(s)
- Caitlin Milligan
- Department of Cardiology, Boston Children's Hospital, Boston, Mass.
| | - Kimberly I Mills
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Shirley Ge
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Anna Michalowski
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Nancy Braudis
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Laura Mansfield
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Sarah A Teele
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
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Mills KI, Kim JH, Fogg K, Goldshtrom N, Graham EM, Kataria-Hale J, Osborne SW, Figueroa M. Nutritional Considerations for the Neonate With Congenital Heart Disease. Pediatrics 2022; 150:189883. [PMID: 36317972 DOI: 10.1542/peds.2022-056415g] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 02/25/2023] Open
Abstract
The importance of nutrition in managing critically ill infants with congenital heart disease (CHD) is foundational to optimizing short- and long-term health outcomes. Growth failure and malnutrition are common in infants with CHD. The etiology of growth failure in this population is often multifactorial and may be related to altered metabolic demands, compromised blood flow to the intestine leading to nutrient malabsorption, cellular hypoxia, inadequate energy intake, and poor oral-motor skills. A dearth of high-quality studies and gaps in previously published guidelines have led to wide variability in nutrition practices that are locally driven. This review provides recommendations from the nutrition subgroup of the Neonatal Cardiac Care Collaborative for best evidence-based practices in the provision of nutritional support in infants with CHD. The review of evidence and recommendations focused on 6 predefined areas of clinical care for a target population of infants <6 months with CHD admitted to the ICU or inpatient ward. These areas include energy needs, nutrient requirements, enteral nutrition, feeding practice, parenteral nutrition, and outcomes. Future progress will be directed at quality improvement efforts to optimize perioperative nutrition management with an increasing emphasis on individualized care based on nutritional status, cardiorespiratory physiology, state of illness, and other vulnerabilities.
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Affiliation(s)
- Kimberly I Mills
- Division of Cardiovascular Critical Care, Department of Cardiology, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts.,Contributed equally as co-first authors
| | - Jae H Kim
- Division of Neonatology, Perinatal Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, Ohio.,Contributed equally as co-first authors
| | - Kristi Fogg
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Nimrod Goldshtrom
- Division of Neonatology, Department of Pediatrics, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York
| | - Eric M Graham
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Jasmeet Kataria-Hale
- Division of Neonatology, Department of Pediatrics, Mission Children's Hospital, Asheville, North Carolina
| | - Scott W Osborne
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Mayte Figueroa
- Division of Cardiology and Critical Care, Department of Pediatrics, St Louis Children's Hospital, Washington University School of Medicine, St Louis, Missouri
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Hames DL, Sleeper LA, Bullock KJ, Feins EN, Mills KI, Laussen PC, Salvin JW. Associations With Extubation Failure and Predictive Value of Risk Analytics Algorithms With Extubation Readiness Tests Following Congenital Cardiac Surgery. Pediatr Crit Care Med 2022; 23:e208-e218. [PMID: 35184097 PMCID: PMC9058191 DOI: 10.1097/pcc.0000000000002912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Extubation failure is associated with morbidity and mortality in children following cardiac surgery. Current extubation readiness tests (ERT) do not consider the nonrespiratory support provided by mechanical ventilation (MV) for children with congenital heart disease. We aimed to identify factors associated with extubation failure in children following cardiac surgery and assess the performance of two risk analytics algorithms for patients undergoing an ERT. DESIGN Retrospective cohort study. SETTING CICU at a tertiary-care children's hospital. PATIENTS Children receiving MV greater than 48 hours following cardiac surgery between January 1, 2017, and December 31, 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Six hundred fifty encounters were analyzed with 49 occurrences (8%) of reintubation. Extubation failure occurred most frequently within 6 hours of extubation. On multivariable analysis, younger age (per each 3-mo decrease: odds ratio [OR], 1.06; 95% CI, 1.001-1.12), male sex (OR, 2.02; 95% CI, 1.03-3.97), Society of Thoracic Surgery-European Association for Cardiothoracic Surgery category 5 procedure (p equals to 0.005), and preoperative respiratory support (OR, 2.08; 95% CI, 1.09-3.95) were independently associated with unplanned reintubation. Our institutional ERT had low sensitivity to identify patients at risk for reintubation (23.8%; 95% CI, 9.7-47.6%). The addition of the inadequate delivery of oxygen (IDO2) index to the ERT increased the sensitivity by 19.0% (95% CI, -2.5 to 40.7%; p = 0.05), but the sensitivity remained low and the accuracy of the test dropped by 8.9% (95% CI, 4.7-13.1%; p < 0.01). CONCLUSIONS Preoperative respiratory support, younger age, and more complex operations are associated with postoperative extubation failure. IDO2 and IVCO2 provide unique cardiorespiratory monitoring parameters during ERTs but require further investigation before being used in clinical evaluation for extubation failure.
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Affiliation(s)
- Daniel L. Hames
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kevin J. Bullock
- Department of Respiratory Care, Boston Children’s Hospital, Boston, MA
| | - Eric N. Feins
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
| | - Kimberly I. Mills
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Peter C. Laussen
- Department of Anesthesia, Boston Children’s Hospital, Boston, MA
- Department of Anesthesia, Harvard Medical School, Boston, MA
| | - Joshua W. Salvin
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital
- Department of Pediatrics, Harvard Medical School, Boston, MA
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Hames DL, Sleeper LA, Ferguson MA, Mehta NM, Salvin JW, Mills KI. Fluid Restriction Contributes to Poor Nutritional Adequacy in Patients With Congenital Heart Disease Receiving Renal Replacement Therapy. J Ren Nutr 2022; 32:78-86. [PMID: 34625332 PMCID: PMC8991421 DOI: 10.1053/j.jrn.2021.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 06/24/2021] [Accepted: 08/10/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES Critically ill patients receiving renal replacement therapy (RRT) in the pediatric cardiac intensive care unit (CICU) are at high risk for inadequate nutrition delivery. The objective of this study is to evaluate barriers to adequate energy and protein delivery in critically ill patients with congenital heart disease receiving RRT. METHODS This is a single-center retrospective cohort study of patients receiving RRT in the CICU from 2011 to 2019. Energy and protein adequacy was recorded over the first 7 days of RRT. Adequacy was defined as delivery of >80% of the energy and protein targets during this time period. Patients who achieved adequacy were compared to those who did not. Multivariable logistic regression models were constructed to determine factors independently associated with energy and protein adequacy while receiving RRT. RESULTS Sixty patients were included for analysis. Fifty-five patients (92%) achieved energy adequacy and 37 patients (62%) achieved protein adequacy. A higher weight-for-age z-score (WAZ) on admission to the CICU was the only independent predictor of inadequate energy intake (odds ratio 0.07, 95% confidence interval 0.01-0.58, P = .014); median WAZ was -1.17 versus +1.24 for those with adequate versus inadequate energy intake, respectively. Fluid restriction to <80% of maintenance fluid at the time of RRT initiation was more likely in patients with higher WAZ. Fluid restriction was the only independent predictor of inadequate protein intake (odds ratio 0.13, 95% confidence interval 0.02-0.7, P = .018); 5% versus 30% were fluid restricted in those with adequate versus inadequate protein intake, respectively. Azotemia was not associated with inadequate protein intake. Initiation of RRT did not allow for liberalization of fluid intake over the time period evaluated. CONCLUSIONS Protein delivery was inadequate in 38% of children undergoing RRT in the CICU. Fluid restriction was associated with inadequate protein intake and higher WAZ was associated with inadequate energy intake.
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Affiliation(s)
- Daniel L. Hames
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Michael A. Ferguson
- Division of Nephrology, Department of Medicine, Boston Children’s Hospital,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Nilesh M. Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital
| | - Joshua W. Salvin
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kimberly I. Mills
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital,Department of Pediatrics, Harvard Medical School, Boston, MA
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Hames DL, Mills KI, Teele SA. Surgical Strategy for Truncus Arteriosus Repair and ECMO: Reply. Ann Thorac Surg 2020; 111:1412. [PMID: 33096071 DOI: 10.1016/j.athoracsur.2020.07.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/16/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Daniel L Hames
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115.
| | - Kimberly I Mills
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115
| | - Sarah A Teele
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115
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Mills KI, Albert BD, Bechard LJ, Duggan CP, Kaza A, Rakoff-Nahoum S, Vlamakis H, Sleeper LA, Newburger JW, Priebe GP, Mehta NM. Stress ulcer prophylaxis versus placebo-a blinded randomized control trial to evaluate the safety of two strategies in critically ill infants with congenital heart disease (SUPPRESS-CHD). Trials 2020; 21:590. [PMID: 32600393 PMCID: PMC7322718 DOI: 10.1186/s13063-020-04513-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 06/15/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Critically ill infants with congenital heart disease (CHD) are often prescribed stress ulcer prophylaxis (SUP) to prevent upper gastrointestinal bleeding, despite the low incidence of stress ulcers and limited data on the safety and efficacy of SUP in infants. Recently, SUP has been associated with an increased incidence of hospital-acquired infections, community-acquired pneumonia, and necrotizing enterocolitis. The objective of this pilot study is to investigate the feasibility of performing a randomized controlled trial to assess the safety and efficacy of withholding SUP in infants with congenital heart disease admitted to the cardiac intensive care unit. METHODS A single center, prospective, double-blinded, randomized placebo-controlled pilot feasibility trial will be performed in infants with CHD admitted to the cardiac intensive care unit and anticipated to require respiratory support for > 24 h. Patients will be randomized to receive a histamine-2 receptor antagonist (H2RA) or placebo until they are discontinued from respiratory support. Randomization will be performed within 2 strata defined by admission type (medical or surgical) and age (neonate, age < 30 days, or infant, 1 month to 1 year). Allocation will be a 1:1 ratio using permuted blocks to ensure balanced allocations across the two treatment groups within each stratum. The primary outcomes include feasibility of screening, consent, timely allocation of study drug, and protocol adherence. The primary safety outcome is the rate of clinically significant upper gastrointestinal bleeding. The secondary outcomes are the difference in the relative and absolute abundance of the gut microbiota and functional microbial profiles between the two study groups. We plan to enroll 100 patients in this pilot study. DISCUSSION Routine use of SUP to prevent upper gastrointestinal bleeding in infants is controversial due to a low incidence of bleeding events and concern for adverse effects. The role of SUP in infants with CHD has not been examined, and there is equipoise on the risks and benefits of withholding this therapy. In addition, this therapy has been discontinued in other neonatal populations due to the concern for hospital-acquired infections and necrotizing enterocolitis. Furthermore, exploring changes to the microbiome after exposure to SUP may highlight the mechanisms by which SUP impacts potential microbial dysbiosis of the gut and its association with hospital-acquired infections. Assessment of the feasibility of a trial of withholding SUP in critically ill infants with CHD will facilitate planning of a larger multicenter trial of safety and efficacy of SUP in this vulnerable population. TRIAL REGISTRATION ClinicalTrials.gov , NCT03667703. Registered 12 September 2018, https://clinicaltrials.gov/ct2/show/NCT03667703?term=SUPPRESS+CHD&draw=2&rank=1 . All WHO Trial Registration Data Set Criteria are met in this manuscript.
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Affiliation(s)
- Kimberly I. Mills
- grid.2515.30000 0004 0378 8438Department of Cardiology, Boston Children’s Hospital, Boston, MA USA ,grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA
| | - Ben D. Albert
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,grid.2515.30000 0004 0378 8438Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA USA
| | - Lori J. Bechard
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,grid.2515.30000 0004 0378 8438Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA USA
| | - Christopher P. Duggan
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,grid.2515.30000 0004 0378 8438Center for Nutrition, Boston Children’s Hospital, Boston, MA USA
| | - Aditya Kaza
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,grid.2515.30000 0004 0378 8438Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA USA
| | - Seth Rakoff-Nahoum
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,grid.2515.30000 0004 0378 8438Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
| | - Hera Vlamakis
- grid.66859.34Broad Institute of MIT and Harvard, Boston, MA USA
| | - Lynn A. Sleeper
- grid.2515.30000 0004 0378 8438Department of Cardiology, Boston Children’s Hospital, Boston, MA USA ,grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA
| | - Jane W. Newburger
- grid.2515.30000 0004 0378 8438Department of Cardiology, Boston Children’s Hospital, Boston, MA USA ,grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA
| | - Gregory P. Priebe
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,grid.2515.30000 0004 0378 8438Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA USA
| | - Nilesh M. Mehta
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA ,grid.2515.30000 0004 0378 8438Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA USA ,grid.2515.30000 0004 0378 8438Center for Nutrition, Boston Children’s Hospital, Boston, MA USA
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Hames DL, Mills KI, Thiagarajan RR, Teele SA. Extracorporeal Membrane Oxygenation in Infants Undergoing Truncus Arteriosus Repair. Ann Thorac Surg 2020; 111:176-183. [PMID: 32335016 DOI: 10.1016/j.athoracsur.2020.03.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 03/12/2020] [Accepted: 03/17/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Infants undergoing truncus arteriosus (TA) repair suffer one of the highest mortality rates of all congenital heart defects. Extracorporeal membrane oxygenation (ECMO) can support patients undergoing TA repair, but little is known about factors contributing to mortality in this cohort. The objective of this study was to identify risk factors for mortality in infants with TA requiring perioperative ECMO. METHODS Data from the Extracorporeal Life Support Organization from 2002 to 2017 for infants less than 60 days old undergoing TA repair were analyzed. Demographics, clinical characteristics, and ECMO characteristics and complications were compared between survivors and nonsurvivors. Multivariable logistic regression was used to evaluate independent risk factors for mortality. RESULTS Of 245 patients analyzed, 92 (37.6%) survived to discharge. Nonsurvivors had a lower weight and a longer ECMO duration. A higher proportion of nonsurvivors suffered complications on ECMO, including mechanical complications, circuit thrombus, bleeding, and need for renal replacement therapy. In multivariable analysis lower weight (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.33-0.95), duration of ECMO (OR, 1.1; 95% CI, 1.02-1.18), need for renal replacement therapy (OR, 3.23; 95% CI, 1.68-6.2), cardiopulmonary resuscitation on ECMO (OR, 11.52; 95% CI, 1.3-102.33), and infection on ECMO (OR, 4.47; 95% CI, 1.2-16.64) were independently associated with mortality. CONCLUSIONS Many factors associated with mortality for infants requiring perioperative ECMO with TA repair are related to complications suffered on ECMO. Thoughtful patient selection and meticulous ECMO management to prevent complications are essential in improving outcomes for these infants.
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Affiliation(s)
- Daniel L Hames
- Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Kimberly I Mills
- Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ravi R Thiagarajan
- Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sarah A Teele
- Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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12
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Mills KI, Kaza AK, Walsh BK, Bond HC, Ford M, Wypij D, Thiagarajan RR, Almodovar MC, Quinonez LG, Baird CW, Emani SE, Pigula FA, DiNardo JA, Kheir JN. Phosphodiesterase Inhibitor-Based Vasodilation Improves Oxygen Delivery and Clinical Outcomes Following Stage 1 Palliation. J Am Heart Assoc 2016; 5:JAHA.116.003554. [PMID: 27806964 PMCID: PMC5210357 DOI: 10.1161/jaha.116.003554] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Systemic vasodilation using α-receptor blockade has been shown to decrease the incidence of postoperative cardiac arrest following stage 1 palliation (S1P), primarily when utilizing the modified Blalock-Taussig shunt. We studied the effects of a protocol in which milrinone was primarily used to lower systemic vascular resistance (SVR) following S1P using the right ventricular to pulmonary artery shunt, measuring its effects on oxygen delivery (DO2) profiles and clinical outcomes. We also correlated Fick-based assessments of DO2 with commonly used surrogate measures. METHODS AND RESULTS Neonates undergoing S1P were treated according to best clinical judgment prior to (n=32) and following (n=24) implementation of a protocol that guided operative, anesthetic, and postoperative management, particularly as it related to SVR. A majority of the subjects (n=51) received a modified right ventricular to pulmonary artery shunt. In a subset of these patients (n=21), oxygen consumption (VO2) was measured and used to calculate SVR, DO2, and oxygen debt. Neonates treated with the protocol had significantly lower SVR (P=0.02), serum lactate (P<0.001), and Sa-vO2 difference (P<0.001) and a lower incidence of CPR requiring extracorporeal membrane oxygenation (E-CPR, P=0.02) within the first 72 postoperative hours. DO2 was closely associated with SVR (r2=0.78) but correlated poorly with arterial (SaO2) and venous (SvO2) oxyhemoglobin concentrations, the Sa-vO2 difference, and blood pressure. CONCLUSIONS A vasodilator protocol utilizing milrinone following S1P effectively decreased SVR, improved serum lactate, and decreased postoperative cardiac arrest. DO2 correlated more closely with SVR than with Sa-vO2 difference, highlighting the importance of measuring VO2 in this population. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02184169.
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Affiliation(s)
- Kimberly I Mills
- Department of Cardiology, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Aditya K Kaza
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA.,Department of Surgery, Harvard Medical School, Boston, MA
| | - Brian K Walsh
- Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Hilary C Bond
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Mackenzie Ford
- Department of Cardiology, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Ravi R Thiagarajan
- Department of Cardiology, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Melvin C Almodovar
- Department of Cardiology, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Luis G Quinonez
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA.,Department of Surgery, Harvard Medical School, Boston, MA
| | - Christopher W Baird
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA.,Department of Surgery, Harvard Medical School, Boston, MA
| | - Sitaram E Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA.,Department of Surgery, Harvard Medical School, Boston, MA
| | - Frank A Pigula
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA.,Department of Surgery, Harvard Medical School, Boston, MA
| | - James A DiNardo
- Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - John N Kheir
- Department of Cardiology, Boston Children's Hospital, Boston, MA .,Department of Pediatrics, Harvard Medical School, Boston, MA
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13
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Mills KI, Vincent JA, Zuckerman WA, Hoffman TM, Canter CE, Marshall AC, Blume ED, Bergersen L, Daly KP. Is Endomyocardial Biopsy a Safe and Useful Procedure in Children with Suspected Cardiomyopathy? Pediatr Cardiol 2016; 37:1200-10. [PMID: 27272694 DOI: 10.1007/s00246-016-1416-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 05/20/2016] [Indexed: 10/21/2022]
Abstract
Endomyocardial biopsy (EMB) is a common procedure used to aid in the diagnosis, prognosis and treatment of suspected pediatric cardiomyopathy. In suspected cardiomyopathy, no multicenter experience has previously reported on the safety and utility of EMBs. Retrospectively, adverse event (AE) and patient and procedural characteristics were obtained at seven institutions participating in the Congenital Cardiac Catheterization Outcomes Project for both a cardiomyopathy (n = 158) and a post-transplant surveillance (n = 2665) cohort. Descriptive information regarding biopsy indication, pathology and clinical management based on EMB findings were retrospectively obtained. High-severity AEs were more common in the cardiomyopathy cohort when compared to the post-transplant surveillance cohort. The cardiomyopathy cohort was younger, more hemodynamically vulnerable and required more cardiorespiratory support during the procedure. The eight high-severity AEs in the cardiomyopathy group included one myocardial perforation, two ECMO cannulations and three deaths following the EMB. Factors associated with high-severity AEs included performing another catheter-based intervention during the EMB and longer fluoroscopy time. Notably, an increased number of biopsy attempts did not increase the risk of an AE. Suspected myocarditis was the most common indication. Diagnostic EMB pathology and thus alteration to clinical management based on pathology occurred more frequently in patients with suspected myocarditis. In conclusion, there is an increased incidence of high-severity AEs in patients undergoing EMB for suspected cardiomyopathy. EMB may be more clinically useful in the management of suspected myocarditis. The increased risk of high-severity AEs when additional interventions are performed highlights the hemodynamic vulnerability in patients with suspected cardiomyopathy.
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Affiliation(s)
- Kimberly I Mills
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA.
| | - Julie A Vincent
- Department of Pediatrics, Morgan Stanley Children's Hospital of New York Presbyterian - Columbia University Medical Center, New York, NY, USA
| | - Warren A Zuckerman
- Department of Pediatrics, Morgan Stanley Children's Hospital of New York Presbyterian - Columbia University Medical Center, New York, NY, USA
| | - Timothy M Hoffman
- Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Charles E Canter
- Department of Pediatrics, St. Louis Children's Hospital and Washington University in St. Louis, St. Louis, MO, USA
| | - Audrey C Marshall
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Lisa Bergersen
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Kevin P Daly
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
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14
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Mills KI, Costello JM, Almodovar MC. A Review of Systemic Vasodilators in Low Cardiac Output Syndrome Following Pediatric Cardiac Surgery. Curr Vasc Pharmacol 2016; 14:29-36. [PMID: 26463987 DOI: 10.2174/1570161113666151014124459] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 04/08/2015] [Accepted: 10/11/2015] [Indexed: 11/22/2022]
Abstract
Following surgery for congenital heart disease, patients develop a predictable and progressive decline in cardiac output known as low cardiac output syndrome. During low cardiac output states, a compensatory response to increase systemic perfusion occurs both innately and as part of the postoperative pharmacologic support strategies intended to increase or sustain adequate oxygen delivery. The result typically involves a rise in systemic vascular resistance and heart rate. These and other responses may actually limit the ability of the recently operated heart to provide sufficient cardiac output to meet the oxygen demands of the body. In order to improve systemic oxygen delivery, clinicians have increasingly employed systemic vasodilator therapy to reduce afterload and improve ventriculoarterial coupling. This review will summarize currently utilized pharmacologic agents that promote systemic vasodilation and improve cardiac output through afterload reduction. This article addresses the fourth of eight topics comprising the special issue entitled "Pharmacologic strategies with afterload reduction in low cardiac output syndrome after pediatric cardiac surgery".
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Affiliation(s)
- Kimberly I Mills
- Department of Cardiology, Boston Children`s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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15
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Mills KI, Anderson J, Levy PT, Cole FS, Silva JNA, Kulkarni S, Shinawi M. Duplication of 20p12.3 associated with familial Wolff-Parkinson-White syndrome. Am J Med Genet A 2012; 161A:137-44. [PMID: 23239491 DOI: 10.1002/ajmg.a.35701] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Accepted: 09/01/2012] [Indexed: 01/19/2023]
Abstract
Wolff-Parkinson-White (WPW) syndrome is caused by preexcitation of the ventricular myocardium via an accessory pathway which increases the risk for paroxysmal supraventricular tachycardia. The condition is often sporadic and of unknown etiology in the majority of cases. Autosomal dominant inheritance and association with congenital heart defects or ventricular hypertrophy were described. Microdeletions of 20p12.3 have been associated with WPW syndrome with either cognitive dysfunction or Alagille syndrome. Here, we describe the association of 20p12.3 duplication with WPW syndrome in a patient who presented with non-immune hydrops. Her paternal uncle carries the duplication and has attention-deficit hyperactivity disorder and electrocardiographic findings consistent with WPW. The 769 kb duplication was detected by the Affymetrix Whole Genome-Human SNP Array 6.0 and encompasses two genes and the first two exons of a third gene. We discuss the potential role of the genes in the duplicated region in the pathogenesis of WPW and possible neurobehavioral abnormalities. Our data provide additional support for a significant role of 20p12.3 chromosomal rearrangements in the etiology of WPW syndrome.
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Affiliation(s)
- Kimberly I Mills
- Edward Mallinckrodt Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
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16
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del Rey M, O'Hagan K, Dellett M, Aibar S, Colyer HAA, Alonso ME, Díez-Campelo M, Armstrong RN, Sharpe DJ, Gutiérrez NC, García JL, De Las Rivas J, Mills KI, Hernández-Rivas JM. Genome-wide profiling of methylation identifies novel targets with aberrant hypermethylation and reduced expression in low-risk myelodysplastic syndromes. Leukemia 2012; 27:610-8. [PMID: 22936014 DOI: 10.1038/leu.2012.253] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Gene expression profiling signatures may be used to classify the subtypes of Myelodysplastic syndrome (MDS) patients. However, there are few reports on the global methylation status in MDS. The integration of genome-wide epigenetic regulatory marks with gene expression levels would provide additional information regarding the biological differences between MDS and healthy controls. Gene expression and methylation status were measured using high-density microarrays. A total of 552 differentially methylated CpG loci were identified as being present in low-risk MDS; hypermethylated genes were more frequent than hypomethylated genes. In addition, mRNA expression profiling identified 1005 genes that significantly differed between low-risk MDS and the control group. Integrative analysis of the epigenetic and expression profiles revealed that 66.7% of the hypermethylated genes were underexpressed in low-risk MDS cases. Gene network analysis revealed molecular mechanisms associated with the low-risk MDS group, including altered apoptosis pathways. The two key apoptotic genes BCL2 and ETS1 were identified as silenced genes. In addition, the immune response and micro RNA biogenesis were affected by the hypermethylation and underexpression of IL27RA and DICER1. Our integrative analysis revealed that aberrant epigenetic regulation is a hallmark of low-risk MDS patients and could have a central role in these diseases.
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Affiliation(s)
- M del Rey
- Centro de Investigación del Cáncer, Universidad de Salamanca-CSIC, Salamanca, Spain
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Tonks A, Pearn L, Musson M, Gilkes A, Mills KI, Burnett AK, Darley RL. Transcriptional dysregulation mediated by RUNX1-RUNX1T1 in normal human progenitor cells and in acute myeloid leukaemia. Leukemia 2007; 21:2495-505. [PMID: 17898786 DOI: 10.1038/sj.leu.2404961] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The t(8;21)(q22;q22) occurs frequently in acute myelogenous leukaemia and gives rise to the transcription factor fusion protein, RUNX1-RUNX1T1 (also known as AML1-ETO). To identify the genes dysregulated by the aberrant transcriptional activity of RUNX1-RUNX1T1, we used microarrays to determine the effect of this mutation on gene expression in human progenitor cells and during subsequent development. Gene signatures of these developmental subsets were very dissimilar indicating that effects of RUNX1-RUNX1T1 are highly context dependent. We focused on gene changes associated with the granulocytic lineage and identified a clinically relevant subset of these by comparison with 235 leukaemia patient transcriptional signatures. We confirmed the overexpression of a number of significant genes (Sox4, IL-17BR, CD200 and gamma-catenin). Further, we show that overexpression of CD200 and gamma-catenin is also associated with the inv(16) abnormality which like RUNX1-RUNX1T1 disrupts core binding factor activity. We investigated the functional significance of CD200 and gamma-catenin overexpression in normal human progenitor cells. The effect of IL17 on growth was also assessed. Individually, none of these changes were sufficient to recapitulate the effects of RUNX1-RUNX1T1 on normal development. These data provide the most comprehensive and pertinent assessment of the effect of RUNX1-RUNX1T1 on gene expression and demonstrate the highly context-dependent effects of this fusion gene.
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MESH Headings
- Antigens, CD/biosynthesis
- Antigens, CD/genetics
- Cell Line, Tumor/metabolism
- Cell Lineage
- Cells, Cultured/metabolism
- Chromosomes, Human, Pair 21/genetics
- Chromosomes, Human, Pair 21/ultrastructure
- Chromosomes, Human, Pair 8/genetics
- Chromosomes, Human, Pair 8/ultrastructure
- Core Binding Factor Alpha 2 Subunit/physiology
- Desmoplakins/genetics
- Desmoplakins/physiology
- Gene Expression Profiling
- Gene Expression Regulation, Leukemic/genetics
- Hematopoietic Stem Cells/metabolism
- Hematopoietic Stem Cells/pathology
- High Mobility Group Proteins/biosynthesis
- High Mobility Group Proteins/genetics
- Humans
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/pathology
- Neoplasm Proteins/biosynthesis
- Neoplasm Proteins/genetics
- Oncogene Proteins, Fusion/physiology
- RNA, Messenger/biosynthesis
- RNA, Messenger/genetics
- RNA, Neoplasm/biosynthesis
- RNA, Neoplasm/genetics
- RUNX1 Translocation Partner 1 Protein
- Receptors, Interleukin-17/biosynthesis
- Receptors, Interleukin-17/genetics
- Recombinant Fusion Proteins/physiology
- SOXC Transcription Factors
- Trans-Activators/biosynthesis
- Trans-Activators/genetics
- Transcription, Genetic/genetics
- Translocation, Genetic
- gamma Catenin/genetics
- gamma Catenin/physiology
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Affiliation(s)
- A Tonks
- Department of Haematology, School of Medicine, Cardiff University, Cardiff, UK.
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Tonks A, Pearn L, Mills KI, Burnett AK, Darley RL. The sensitivity of human cells expressing RUNX1-RUNX1T1 to chemotherapeutic agents. Leukemia 2006; 20:1883-5. [PMID: 16932340 DOI: 10.1038/sj.leu.2404364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Mills KI, Walsh V, Gilkes AF, Agrawal SG, Knapper S. Novel observation of three FLT3 codons mutated in tandem in an elderly acute myeloid leukaemia patient. Br J Haematol 2006; 132:116-7. [PMID: 16371029 DOI: 10.1111/j.1365-2141.2005.05836.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Dorak MT, Lawson T, Machulla HKG, Mills KI, Burnett AK. Increased heterozygosity for MHC class II lineages in newborn males. Genes Immun 2002; 3:263-9. [PMID: 12140744 DOI: 10.1038/sj.gene.6363862] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2001] [Revised: 01/14/2002] [Accepted: 02/01/2002] [Indexed: 11/09/2022]
Abstract
In plants, fungi and marine invertebrates, there are genetic compatibility systems to ensure diversity in the offspring. The importance of genetic compatibility in gametic union and selective abortion in vertebrate animals has also been appreciated recently. There have been suggestions that the major histocompatibility complex (HLA in humans) may be a compatibility system in vertebrates. HLA class II haplotypes often contain a second expressed DRB locus which can be either DRB3, DRB4 or DRB5. These encode the supertypical specificities and mark the ancestral lineages. The members of each lineage have related DNA sequences at the main class II locus HLA-DRB1. We analysed 415 newborns at all expressed DRB loci by PCR analysis to seek evidence for sex-specific prenatal selection events. While there was no significant change in heterozygosity rates between males and females at DRB1, the proportion of males carrying two DRB1 specificities from different ancestral lineages was significantly increased (53.7% in males vs 39.3% in females, P = 0.003). The genotypes consisting of phylogenetically most distinct ones, namely the DRB3 and DRB4 haplotypes, showed the most striking difference between sexes (P = 0.007). These results suggested a more favourable outcome for male concepti heterozygous for supertypical haplotypes. Heterozygosity for most divergent haplotypical families ensures the highest degree of functional heterozygosity at the main HLA class II locus DRB1 while increasing the likelihood of heterozygosity also at other MHC loci. Our observations agree with the previously reported heterozygote excess in male newborn rats and mice. Correlations between MHC class II heterozygosity and advertised male quality in deer and pheasant as well as increased reproductive success in MHC class II heterozygous male macaques are examples of postnatal benefits of heterozygosity in males that may be behind the development of prenatal selection mechanisms. The MHC-mediated prenatal selection of males may also be one of the selective events suggested by the very high primary (male-to-female) sex ratio at fertilization reaching close to unity at birth in humans. These results provide an appealing working hypothesis for further studies in humans and other vertebrates.
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Affiliation(s)
- M T Dorak
- Department of Haematology, University of Wales College of Medicine, Cardiff CF14 4XN, UK.
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Keeshan K, Mills KI, Cotter TG, McKenna SL. Elevated Bcr-Abl expression levels are sufficient for a haematopoietic cell line to acquire a drug-resistant phenotype. Leukemia 2001; 15:1823-33. [PMID: 11753601 DOI: 10.1038/sj.leu.2402309] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2001] [Accepted: 08/09/2001] [Indexed: 11/08/2022]
Abstract
A characteristic feature of chronic myeloid leukaemia (CML) is the inevitable advancement from a treatable chronic phase to a fatal, drug-resistant stage referred to as blast crisis. The molecular mechanisms responsible for this disease transition remain unknown. As increased expression of Bcr-Abl has been associated with blast crisis CML, we have established transfectants in 32D cells that express low and high levels of Bcr-Abl, and assessed their drug sensitivity. Cells with high Bcr-Abl expression levels are resistant to conventional cytotoxic drugs, and also require higher levels of STI571 (an inhibitor of Bcr-Abl), to induce cell death. Co-treatment with cytotoxic drugs and STI571 increased the sensitivity of the drug-resistant cells. Despite the drug-resistant phenotype, high Bcr-Abl levels concomitantly increased the expression of p53, p21, Bax and down-regulated Bcl-2. These cells maintain a survival advantage irrespective of a reduced proportion of cycling cells and the pro-apoptotic shift in gene expression. In addition, the level of Bcr-Abl expression (high or low) does not alter the growth factor independence and elevated Bcl-xL expression observed. Our study indicates that drug resistance can be primarily attained by increased Bcr-Abl expression, and highlights the potential of therapy which combines STI571 with conventional cytotoxic drugs.
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Affiliation(s)
- K Keeshan
- Department of Biochemistry, University College Cork, Ireland
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23
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Abstract
Different subgroups of acute myeloid leukemia (AML) can be defined by the specific non-random chromosomal translocation that is present within the abnormal cell types. In one type of AML, acute promyelocytic leukemia (APL), the block in the normal process of differentiation can be circumvented by the addition of a chemical inducer, in this case retinoic acid. This is due to the defect in APL affecting the retinoic acid receptor gene. This type of therapy has become known as differentiation therapy. However, most types of leukemia do not respond to the retinoic acid, and therefore methods of differentiation therapy need to be developed by targeting other genes involved in the leukemia process. This requires the molecular characterizations of the genes that are expressed during differentiation and in particular those genes that show a differential expression in inducer sensitive cells and those resistant to induced differentiation. Therefore, therapeutic agents could be developed to specifically target these genes. This article describes how the technique of differential display, as one of several possible methods of molecular screening, may allow the identification of genes which can be targeted to induce differentiation.
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Affiliation(s)
- K I Mills
- Department of Haematology, University of Wales College of Medicine, Cardiff, Wales, UK.
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24
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Tennant GB, Walsh V, Truran LN, Edwards P, Mills KI, Burnett AK. Abnormalities of adherent layers grown from bone marrow of patients with myelodysplasia. Br J Haematol 2000; 111:853-62. [PMID: 11122147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Myelodysplastic syndromes (MDS) are characterized by a clonal disorder of haemopoiesis with defective growth in vitro. The long-term culture system was used to examine aspects of stromal function in MDS patients. Primary long-term cultures of MDS bone marrow showed poor myelopoiesis with progenitors being detected for a median 3.5 weeks (n = 12) compared with 18 weeks in cultures of normal marrow (n = 10; P < 0.0001). The haemopoietic function of adherent layers was assessed in secondary co-cultures seeded with 5 x 10(6) cord blood mononuclear cells on irradiated normal (n = 27; aged 38-82 years) or MDS (n = 32; aged 41-86 years) adherent layers (> 60% confluent). The median myeloid progenitor number/cord blood co-culture was 135 in 5-week-old cultures with normal adherent layers and 22 in those with MDS layers (P < 0.0001). Myeloid colonies were detectable for a median 11 weeks with normal adherent layers and 6 weeks with MDS adherent layers (P < 0.0001); erythroid colonies were detectable for 7 weeks (normal) compared with 5 weeks (MDS) (P < 0.01). The differences in granulocyte-macrophage colony forming unit (CFU-GM) generation were not related to patient age. Cells from adherent layers of at least half of the primary normal (n = 48) and MDS (n = 26) long-term cultures expressed cytokines [interleukin (IL)-3, IL-1 beta, thrombopoietin (Tpo) and erythropoietin (Epo)] and receptors for retinoic acid (RAR alpha) [IL-2, IL-3, macrophage colony stimulating factor (M-CSF) (Fms) and Tpo (Mpl)]. Only IL-1 beta expression was reduced in week-5 MDS cultures compared with those from normal marrows (P < 0.05). There was also a highly significant decline in IL-1 beta expression in normal (but not MDS) adherent layers between week 5 and week 10. Thus, the adherent layers in cultures grown from MDS patients were haemopoietically defective and showed abnormal IL-1 beta expression.
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Affiliation(s)
- G B Tennant
- Department of Haematology, University of Wales College of Medicine, Cardiff, UK.
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25
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Guinn BA, Evely RS, Walsh V, Gilkes AF, Burnett AK, Mills KI. An in vivo and in vitro comparison of the effects of b2-a2 and b3-a2 p210BCR-ABL splice variants on murine 32D cells. Leuk Lymphoma 2000; 37:393-404. [PMID: 10752991 DOI: 10.3109/10428190009089440] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The Philadelphia (Ph) chromosome, a characteristic cytogenetic marker of chronic myeloid leukaemia (CML), is caused by a reciprocal translocation juxtaposing the 3' region of the ABL gene onto the 5' region of the BCR gene. Due to conservation of the reading frame, but depending on the site of the breakpoint in the BCR gene, two alternatively spliced variants of the p210BCR-ABL mRNA (known as b2-a2 and b3-a2) are produced. To investigate whether there are any biological differences between these splice variants we have transfected the b3-a2 or b2-a2 cDNA into a murine myeloid cell line, 32D. We have also included the previously prepared 32Dp210 cell line (which expresses the b3-a2 transcript) in all of our comparisons. RT-PCR analysis indicated that transcription levels were comparable between the variants. Morphological examination of the cells expressing either of the BCR-ABL transcripts indicated that these cells were more mature with increased cytoplasm:nuclear ratios compared to the 32D parental and 32Dneo vector control cells. However, the 32Dp210 cells had a very different appearance from the other panel members and flow karyotyping indicated a clonal evolution and cytogenetic instability in these cells alone. At 10(6) and 10(7) cell doses all 32D cells expressing BCR-ABL caused ill health and tissue infiltration in SCID mice with such rapidity that statistical analysis was not informative. However, at the 10(5) and 10(4) dosage levels there were similar survival rates between mice injected with 32Db2-a2 or 32Db3-a2 while mice injected with 32Dp210 had a significantly shorter survival time. The study of this 32D cell line panel indicated that there were no overt differences in the biological properties conferred by the b3-a2 or b2-a2 transcripts to the 32D cells although these transcripts were able to confer in vitro and in vivo biological effects. This panel of BCR-ABL expressing 32D cells provides a useful model for CML disease progression studies.
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Affiliation(s)
- B A Guinn
- Department of Haematology, University of Wales College of Medicine, Cardiff, United Kingdom.
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26
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Abstract
Retinoic acid has the ability to induce differentiation in some myeloid leukaemia cell lines and has been used to induce remission in acute promyelocytic leukaemia patients. We have analysed changes in gene expression, by differential display, in HL60 cells exposed to all-trans retinoic acid (ATRA) for only 1 h. Only about 0.4% of the genes examined by this technique showed changes in expression level, and all four of the gene fragments identified were downregulated during the short 1 h exposure. Two of the fragments were novel, a third was MYC and the fourth was the FUS proto-oncogene. Northern analysis showed that FUS was downregulated within 1 h only during induced neutrophil differentiation but not at all during induced monocyte differentiation. Unlike the sensitive cell lines, ATRA-resistant cell lines did not show a downregulation of FUS over a 24 h period of exposure to ATRA. Using a semiquantitative PCR analysis, no difference in FUS levels was observed between ATRA-sensitive and -resistant cell lines. A similar analysis was carried out on primary acute myeloid leukaemia (AML), peripheral stem cell harvests (PBSC) and cord blood samples. The PBSC and cord blood samples had FUS levels that were similar or generally less than the cell lines. However, much higher levels were seen in 63% of the AML samples examined. The data presented are consistent with previous reports for a role for FUS in the promotion and maintenance of cellular proliferation.
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Affiliation(s)
- K I Mills
- LRF Differentiation Programme, Department of Haematology, University of Wales College of Medicine, Heath Park, Cardiff, UK
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27
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Mills KI, Woodgate LJ, Gilkes AF, Walsh V, Sweeney MC, Brown G, Burnett AK. Inhibition of mitochondrial function in HL60 cells is associated with an increased apoptosis and expression of CD14. Biochem Biophys Res Commun 1999; 263:294-300. [PMID: 10491287 DOI: 10.1006/bbrc.1999.1356] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The myelomonocytic cell line HL60 can be induced by a variety of chemical agents to differentiation to either neutrophils or monocytes. Examination of gene expression, by differential display, in cells induced to monocytes with 1alpha,25-dihydroxyvitamin D(3) or neutrophils with all-trans retinoic acid (ATRA) identified a number of clones with altered patterns of expression over the period of differentiation. One of these clones was the mitochondrial gene NADH dehydrogenase subunit 4 (ND4) which showed a differential pattern of expression between the neutrophil and monocyte lineages. The potential of mitochondrial inhibitors to induce differentiation was investigated by treating the HL60 cells with either the NADH dehydrogenase inhibitor, Rotenone, the complex III inhibitor, Antimycin A, or the highly specific mitochondrial ATP-synthase inhibitor, Oligomycin. Although functional assays of differentiation did not produce any positive results, all the inhibitors resulted in a dramatic increase in CD14 expression at day 1, with CD38 markers not observed until day 3. The increased expression of CD14 was accompanied by a decrease in viability and all CD14 positive cells were also positive for Annexin V, a marker of apoptosis. These results suggest that inhibition of the components of the mitochondrial pathways may lead to the marking of some cells, via CD14, for cell death, whilst allowing commitment to differentiation to occur in the surviving population.
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Affiliation(s)
- K I Mills
- Department of Haematology, University of Wales College of Medicine, Cardiff, Heath Park, United Kingdom.
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Dorak MT, Lawson T, Machulla HK, Darke C, Mills KI, Burnett AK. Unravelling an HLA-DR association in childhood acute lymphoblastic leukemia. Blood 1999; 94:694-700. [PMID: 10397736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023] Open
Abstract
Genetic and environmental factors play an interactive role in the development of childhood acute lymphoblastic leukemia (ALL). Since the demonstration of a major histocompatibility complex (MHC) influence on mouse leukemia in 1964, an HLA association has been considered as a possible genetic risk factor. Despite extensive efforts, however, no strong evidence comparable to the H-2(k) influence on mouse leukemia has been shown. The number of negative serological studies resulted in a loss of interest and consequently, no molecular HLA-DR association study has been published to date. We reconsidered the HLA-DR association in childhood ALL in 114 patients from a single center and 325 local newborn controls by polymerase chain reaction (PCR) analysis of the HLA-DRB1/3/4/5 loci. With conventional analysis, there was a moderate allelic association with the most common allele in the HLA-DR53 group, HLA-DRB1*04, in the whole group that was stronger in males (P =.0005, odds ratio = 2.9). When the other expressed HLA-DRB loci were examined, homozygosity for HLA-DRB4*01, encoding the HLA-DR53 specificity, was increased in patients (21.1% v 8.3%; odds ratio = 2.9, P =.0005). Consideration of gender showed that all of these associations were reflections of a male-specific increase in homozygosity for HLA-DRB4*01 (32.8% v 4. 0%; odds ratio = 11.7, 95% confidence interval [CI] = 4.9 to 28.0; P = 3 x 10(-8)). This highly significant result provided the long-suspected evidence for the HLA-DR influence on the development of childhood ALL while confirming the recessive nature of the MHC influence on human leukemogenesis as in experimental models. The cross-reactivity between HLA-DR53 and H-2Ek, extensive mimicry of the immunodominant epitope of HLA-DR53 by several carcinogenic viruses, and the extra amount of DNA in the vicinity of the HLA-DRB4 gene argue for the case that HLA-DRB4*01 may be one of the genetic risk factors for childhood ALL.
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Affiliation(s)
- M T Dorak
- Department of Haematology, University of Wales College of Medicine, Cardiff, Wales, UK.
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29
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Mills KI, Gilkes AF, Sweeney M, Choudhry MA, Woodgate LJ, Bunce CM, Brown G, Burnett AK. Identification of a retinoic acid responsive aldoketoreductase expressed in HL60 leukaemic cells. FEBS Lett 1998; 440:158-62. [PMID: 9862446 DOI: 10.1016/s0014-5793(98)01435-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Neutrophil and monocyte differentiation can be induced in HL60 leukaemia cells by all-trans-retinoic acid (ATRA) and 1alpha,25-dihydroxyvitamin D3 (D3), respectively, whose differentiating effects can be enhanced by exposure to 'anti-inflammatory agents' and steroids. We have provided evidence that this potentiation is via inhibition of the activity of an enzyme of the aldoketoreductase (AKR) family, but had failed to identify expression of known AKRs in HL60 cells. In this study, we have identified a previously unclassified aldoketoreductase family member (termed HAKR e) that is expressed in HL60 cells. HAKR e is dramatically and transiently up-regulated in HL60 cells within 24 h of exposure to ATRA, further supporting the proposition that a member(s) of this family of enzymes play(s) a role in controlling cell growth and/or differentiation.
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Affiliation(s)
- K I Mills
- Department of Haematology, University of Wales College of Medicine, Cardiff, UK.
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30
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Mills KI, Walsh V, Gilkes AF, Woodgate LJ, Brown G, Burnett AK. Identification of transcription factors expressed during ATRA-induced neutrophil differentiation of HL60 cells. Br J Haematol 1998; 103:87-92. [PMID: 9792294 DOI: 10.1046/j.1365-2141.1998.00947.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A recent clinical therapeutic initiative has been the use of chemical agents which induce the leukaemic cells to overcome their block in differentiation. In order to understand this block the cascade of molecular events needs to be characterized. Haemopoietic differentiation is ultimately controlled at the level of gene transcription which is mediated by an array of transcription factors. Many transcription factors contain similar structural protein sequences, and we have used an RT-PCR-based approach to isolate sequences, from transcription factor gene families which share similar domains. Degenerate primers corresponding to the TFIIIA zinc-finger consensus amino acid sequences and to the POU-homeodomain and POU-specific domain were used to amplify genes on the basis that they contained similarities in structural motifs shared within these families of transcription factors. A serum-independent HL60 cell line was induced towards the neutrophil lineage by treatment with all-trans retinoic acid (ATRA) for 24 h. CD38+ cells committed towards this lineage were enriched and a population of these cells treated with dihydroxyvitamin D3 to induce neutrophil maturation. RNA extracted from uninduced, ATRA-induced CD38+ cells, and vitamin D3 treated maturing cell cultures were amplified using the degenerate primers. PCR fragments were cloned, sequenced, clustered into homologous groups, and the group sequences searched on the GenBank database. The Oct 1 transcription factor, and a very close homologue, KIAA0144, was identified using the POU family primers. The zinc-finger primers identified three zinc-finger genes. The pattern of gene expression was suggested from the number of clones in each group at neutrophil commitment and maturation. The differential expression of the genes in the zinc finger and POU families will lead to a better understanding of the cascade of gene expression which occurs following ATRA-induced differentiation.
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Affiliation(s)
- K I Mills
- Department of Haematology, University of Wales College of Medicine, Cardiff
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Abstract
The biological progression of chronic myeloid leukaemia is often associated with secondary cytogenetic abnormalities but the molecular mechanisms underlying this progression are poorly understood. This study explores the association of c-myc gene amplification with the progression of chronic myeloid leukaemia in fourteen individuals. Three of these cases showed amplification of c-myc during the course of their disease. Cytogenetic and molecular analysis of serial samples from some patients suggested the successive expansion of distinct clones of malignant cells. Our findings also suggest that trisomy 8 and locus amplification could represent alternative mechanisms for increasing c-myc gene dosage.
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Affiliation(s)
- B A Jennings
- Molecular Genetics, Norfolk and Norwich Hospital, Norwich, UK
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32
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Abstract
In chronic myeloid leukaemia (CML), as with other tumour types, mutations of the p53 gene are associated with disease progression. Changes in regional methylation of DNA with CML tumour development have also been demonstrated. Methylation is one mechanism by which gene expression is controlled and the CpG sites, which are the targets of DNA methylation, are also the sites of a number of the mutations found in the p53 gene. Cells harbouring mutant p53 have been shown to accumulate further genomic and genetic aberrations and methylation which alters the conformation of DNA is also believed to play a role in genomic stability. There appears to be an interplay between p53 deregulation and changing methylation patterns with the progression of CML. The cause and effect of changes in both of these critical gene regulating, DNA repair and genomic stability factors and their deviation during the progression of CML will be discussed.
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MESH Headings
- Animals
- DNA Methylation
- DNA, Neoplasm/genetics
- DNA, Neoplasm/metabolism
- Disease Progression
- Genes, p53
- Genome
- Genome, Human
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/metabolism
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Mutation
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Affiliation(s)
- B A Guinn
- Oncology Research Program, Toronto General Hospital, Ontario, Canada.
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34
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Abstract
The modification of DNA by cytosine methylation is crucial for normal development. DNA methylation patterns are distinctive between tissues and are maintained with high fidelity during cell division. DNA methylation probably exerts its effects through alterations in chromatin structure, with a resultant effect on genetic transcription. 5-methylcytosine is also prone to spontaneous hydrolytic deamination to thymine. Whilst most G:T mismatches so produced are repaired, failure of mismatch repair leads to established mutation. Indeed, mutations that are the result of 5-methylcytosine transitions account for a disproportionate number of genetic mutations described in malignant and non-malignant disease. There is also evidence for substantial deregulation of DNA methylation in malignancy. Whether this deregulation is crucial for the transformation process, or simply an epiphenomenon associated with it, is still not established.
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Affiliation(s)
- B H Ramsahoye
- Department of Haematology, University of Wales College of Medicine, Health Park, Cardiff, UK
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35
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Boultwood J, Fidler C, Mills KI, Frodsham PM, Kusec R, Gaiger A, Gale RE, Linch DC, Littlewood TJ, Moss PA, Wainscoat JS. Amplification of mitochondrial DNA in acute myeloid leukaemia. Br J Haematol 1996; 95:426-31. [PMID: 8904904 DOI: 10.1046/j.1365-2141.1996.d01-1922.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
There is a long-standing interest in the possible role of mitochondria in malignancy. We sought to discover whether amplification of mitochondrial DNA (mtDNA) occurred in leukaemia, and found it was often remarkably amplified in the blast cells of acute myeloid leukaemia (AML). We used gene dosage experiments to quantify the amount of mtDNA relative to nuclear DNA. DNA extracted from peripheral blood leucocytes or bone marrow of healthy individuals or patients was simultaneously hybridized with a probe for the mitochondrial genome and a control probe for the renin gene on human chromosome 1. Comparative densitometric ratios of approximately 1 were obtained between the two signals in 20 normal control peripheral blood samples. In contrast, comparative ratios in the range of 2-50 were observed in 25 AML samples and 13 of these showed 8-fold or greater amplification of mtDNA relative to normal peripheral blood controls. An additional four cases of AML were investigated at both presentation and remission and showed 3-10-fold amplification of mtDNA at presentation, but no amplification when in clinical remission. 18 cases of chronic granulocytic leukaemia (CGL) were also studied in chronic phase and showed mtDNA dosage levels equivalent to normal peripheral blood controls. However, 8/9 CGL patients showed mtDNA amplification during transformation from chronic phase. We conclude that amplification of mtDNA is an invariable feature of acute myeloid leukaemia and that it may be a useful marker for detecting transformation of CGL.
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Affiliation(s)
- J Boultwood
- Department of Haematology, John Radcliffe Hospital, Oxford, U.K
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36
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Stephens M, Talary MS, Pethig R, Burnett AK, Mills KI. The dielectrophoresis enrichment of CD34+ cells from peripheral blood stem cell harvests. Bone Marrow Transplant 1996; 18:777-82. [PMID: 8899194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
There is considerable interest in isolating the CD34+ cell population from leukaemic patients undergoing peripheral blood stem cell harvests. The techniques currently available make use of antibodies specific to the CD34+ surface markers. However, all of these techniques involve disturbance of the cell surface, are time-consuming and relatively expensive. In this study, we have used dielectrophoresis, which does not rely on the presence of cell-specific markers, to separate CD34+ cells from peripheral blood stem cell harvest samples containing an untreated natural mixed cell population. The separation is achieved by exploiting differences in the inherent dielectric properties of the various cell types. Samples obtained from peripheral blood stem cell harvests were resuspended in medium with a conductivity of less than 50 microS/cm and introduced into the dielectrophoretic separation chamber. Alternating field frequencies, from 500 kHz to 5 kHz, were used to collect cell fractions which were analysed by FACS, using a CD34-specific antibody, to quantify the CD34+ population within the fractions. On average a nearly five-fold increase in the frequency of the CD34+ cell population was observed in the fractions collected within the 50-10 kHz range. For this dielectrophoretic separation technique to be suitable in harvesting CD34+ cells for transplantation, it is important to demonstrate that the cells remain viable after the separation process. Cells obtained from each fraction grew when plated in colony assay cultures, GM-CFU and BFU-E, demonstrating that the cells remain normal, viable and capable of colony formation when cultured for 2 weeks. The number of colonies formed correlated with the percentage of CD34+ cells in each fraction. The dielectrophoretic separation technique is simple to operate, the separation is fast, the procedure non-invasive and although not tested has the potential to be incorporated as a batch-wise online facility with the standard harvesting equipment to increase the yield and speed of CD34+ cells in the PBSC harvest.
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Affiliation(s)
- M Stephens
- Department of Haematology, University of Wales College of Medicine, Cardiff, UK
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37
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Dorak MT, Mills KI, Poynton CH, Burnett AK. HLA and Hodgkin's disease. Leukemia 1996; 10:1671-2. [PMID: 8847906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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38
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Abstract
In chronic myeloid leukaemia (CML), disease progression from the initial chronic phase to the acute phase or blast crisis has previously been shown to be correlated with progressive increases in hyper-methylation of the calcitonin gene, located at chromosome 11p15. However, sequential studies of individual patients were not performed in these investigations. We have analysed 44 samples from nine patients with typical Philadelphia chromosome positive CML throughout their disease progression to determine the methylation state of the calcitonin gene at these time points. Densitometry was used to quantitate the ratio of the normal 2.0 kb Hpa II fragments, indicating normal methylation status of the gene, compared to the intensity of the abnormal, hyper-methylated, 2.6-3.1 kb Hpa II fragments. We found a gradual increase in the ratio of methylated:unmethylated calcitonin gene during chronic phase with a dramatic rise at blast crisis. Further, the ratio of the abnormal hypermethylated 3.1 kb fragments to the methylated 2.6 kb fragment resulted in the identification of a clonal expansion of abnormally methylated cells. This expansion of cells with hypermethylation of the calcitonin gene during chronic phase was shown to coincide with the presence of a mutation in the p53 gene. The data presented in this study would suggest that an increased methylation status of the calcitonin gene during disease progression may indicate the expansion of abnormal blast cell populations and subsequent progression to blast crisis.
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Affiliation(s)
- K I Mills
- Department of Haematology, University of Wales College of Medicine, Cardiff, U.K.
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39
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Affiliation(s)
- H A James
- School of Biological Sciences, University of East Anglia, Norwich, Norfolk, UK
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40
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Abstract
The major histocompatibility complex is one of the interactive factors in the multifactorial model of carcinogenesis. Its main influence in experimental models is on the age at onset of malignancies. We have previously shown a similar effect of homozygosity for HLA-DR53 in CML. In the present study, we investigated 79 patients with CLL and 329 local controls from Germany. In addition to full serotyping, all patients and 116 of controls were also typed by HLA-DRB PCR analysis. The homozygosity rates for DR53 in patients under and over the median age (60 years) were 18.6% and 2.9%, respectively (p = 0.03). Eight of the 9 homozygous patients were under the median age. The sex ratio in the DR53 homozygous group was reversed in favour of females. The homozygosity rates for DR53 were different in the overall groups of patients and controls, yielding a relative risk (RR) of 2.4 (p = 0.03). This association was stronger in the early-onset group compared to age-matched controls (RR = 4.4; p = 0.008) and for females with an early onset compared to age- and sex-matched controls (RR = 17.9; p = 0.0008). The simultaneous occurrence of the alleles of the haplotype A2B62DR4 showed a strong association with CLL (RR = 4.1; p = 0.002). This was probably the reason behind the association with HLA-DRB1*0401 (RR = 2.4; p = 0.009). Compared to the accelerating effect of HLA-DR53, HLA-DR52 showed a significant delaying effect on the onset of CLL. These findings confirmed the influence of the HLA complex on the development of another leukaemia.
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Affiliation(s)
- M T Dorak
- Department of Haematology, University of Wales College of Medicine, Cardiff, UK
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41
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Dorak MT, Owen G, Galbraith I, Henderson N, Webb D, Mills KI, Darke C, Burnett AK. Nature of HLA-associated predisposition to childhood acute lymphoblastic leukemia. Leukemia 1995; 9:875-8. [PMID: 7769851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
A molecular analysis was carried out in 63 sequentially diagnosed childhood acute lymphoblastic leukemia (ALL) patients and 1011 controls to investigate the homozygosity rate for HLA-DR53. HLA-DR53 is associated with acute myeloblastic leukemia at the protein level, and our previous study has shown its association with early-onset chronic myeloid leukemia only in homozygous form at the DNA level. In the present study, the homozygosity rates for DR53 were 17.5 and 13.6% in patients and controls, respectively. Ten of the 11 homozygous patients were boys. In the common ALL group (n = 40), all seven DR53 homozygous patients were boys, and among 19 girls this genotype was not observed (P = 0.006). For males, homozygosity for DR53 revealed a relative risk (RR) of 3.29 (P = 0.008) for common ALL. Five of the 11 relapsed patients were homozygous for DR53. Heterozygous frequencies for HLA-DR53 were not different between patients and controls. Homozygosity for DR53 was associated with a very high relapse rate (45.5 vs 7.7%, P = 0.002, RR = 9.1). These results extended our findings in chronic myeloid leukemia and showed the recessive nature and the male predominance of the interactive HLA influence on the development of childhood leukemia. Molecular mimicry of an HLA-DR53 epitope by oncogenic (retro)viruses or putative susceptibility genes in linkage disequilibrium with HLA-DR53 may be responsible for this association.
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Affiliation(s)
- M T Dorak
- Department of Haematology, University of Wales College of Medicine, Cardiff, UK
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Talary MS, Mills KI, Hoy T, Burnett AK, Pethig R. Dielectrophoretic separation and enrichment of CD34+ cell subpopulation from bone marrow and peripheral blood stem cells. Med Biol Eng Comput 1995; 33:235-7. [PMID: 7543968 DOI: 10.1007/bf02523050] [Citation(s) in RCA: 92] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Dielectrophoresis has been used to enrich selected cell subpopulations in a mixed cell population by exploiting differential dielectric properties. Six-fold enrichment of stem cells expressing the CD34+ antigen has been achieved for bone marrow samples and peripheral blood, without the requirement for initial chemical treatment associated with immunoadsorption techniques.
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Affiliation(s)
- M S Talary
- Institute of Molecular and Biomolecular Electronics, University of Wales, Gwynedd, UK
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Mills KI. [The BCR/ABL gene in chronic myeloleukemia]. Gematol Transfuziol 1994; 39:21-4. [PMID: 7758903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Silly H, Chase A, Mills KI, Apfelbeck U, Sormann S, Goldman JM, Cross NC. No evidence for microsatellite instability or consistent loss of heterozygosity at selected loci in chronic myeloid leukaemia blast crisis. Leukemia 1994; 8:1923-8. [PMID: 7967738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The aim of the present study was to investigate loss of heterozygosity (LOH) or microsatellite instability in chronic myeloid leukaemia (CML) blast crisis at genomic locations which are known or postulated to harbour tumour suppressor genes. We studied 48 patients in blast crisis of myeloid (n = 31), lymphoid (n = 15), megakaryocytic (n = 1), or mixed lineage (n = 1) phenotype by comparing constitutional DNA extracted from buccal epithelial cells or chronic phase leucocytes with DNA obtained from blast crisis leucocytes. Twelve variable number tandem repeat loci from six different chromosomes were amplified by polymerase chain reaction using labelled primers, and fractionated on polyacrylamide gels. After autoradiography, length as well as intensity of the amplified products were compared between constitutional and blast crisis samples. LOH was scored as complete, partial or none in informative patients. Complete LOH was found in one patient at 8p22 and another at 13q14; partial LOH was detected in three patients at 11p13 and/or 11p15. No LOH was found at 6q27, 8p21, 18q21, 22q11-12 and 22q13 in any patient. Furthermore, no consistent difference in allelic length was observed in 517 paired amplifications indicating no microsatellite instability. We conclude that the Rb gene at 13q14, the Wilms tumour gene at 11p13, the DCC gene at 18q21, the neurofibromatosis 2 gene at 22q11-13 and uncloned tumour suppressor genes at 6q27, 8p21-22 and 11p15, as well as genes responsible for microsatellite instability, are unlikely to be involved in the progression of CML to blast crisis in the majority of patients.
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MESH Headings
- Blast Crisis/genetics
- Blast Crisis/pathology
- Chromosomes, Human, Pair 11
- Chromosomes, Human, Pair 8
- DNA, Neoplasm/genetics
- Genes, Retinoblastoma
- Genes, Tumor Suppressor
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Polymorphism, Genetic
- Repetitive Sequences, Nucleic Acid
- Sequence Deletion
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Affiliation(s)
- H Silly
- LRF Centre for Adult Leukaemia, Royal Postgraduate Medical School, London, UK
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Smith MA, Mills KI, Smith JG. Long-term culture and molecular biological studies highlight differences in relative BCR-ABL expression levels in the peripheral blood and bone marrow of a patient with chronic granulocytic leukaemia. Br J Haematol 1994; 88:406-8. [PMID: 7803292 DOI: 10.1111/j.1365-2141.1994.tb05041.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
A patient with accelerating Ph+ve chronic granulocytic leukaemia (CGL) was considered for autologous BMT using marrow 'purged' by 4 weeks long-term culture (LTC). Efficacy of purging was determined using reverse transcriptase PCR for BCR-ABL mRNA transcripts b2a2 and b3a2. Peripheral blood and bone marrow were compared. Three observations emerged: (i) the initial b2a2:b3a2 ratios for unmanipulated blood and marrow were different with values of 9:1 and 2:1 respectively; (ii) both transcripts were successfully 'purged' with LTC of blood but not marrow; and (iii) LTC of marrow caused a transient increase in relative levels of b3a2 mRNA and a corresponding reduction in the b2a2 signal. This is the first case where such differences have been demonstrated in association with LTC.
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MESH Headings
- Bone Marrow/metabolism
- Bone Marrow Purging/methods
- Cells, Cultured
- Fusion Proteins, bcr-abl/biosynthesis
- Fusion Proteins, bcr-abl/blood
- Gene Expression
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/blood
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/metabolism
- Leukemia, Myeloid, Chronic-Phase/blood
- Leukemia, Myeloid, Chronic-Phase/genetics
- Leukemia, Myeloid, Chronic-Phase/metabolism
- Polymerase Chain Reaction
- RNA, Messenger/genetics
- Time Factors
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Affiliation(s)
- M A Smith
- Department of Haematology, Royal United Hospital Trust, Bath
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Abstract
To investigate the relevance of the major histocompatibility complex (MHC) in longevity, we carried out a molecular analysis of the MHC in 432 unrelated healthy individuals. The comparison of individuals < or = 25 years and > 25 years showed that the 5.8-kb DQA1 allele, which corresponds to HLA-DR53, was negatively associated with longevity (p = 0.0035) resulting mainly from decreased homozygosity with age for that allele (p = 0.008), and restricted to males (p = 0.008). The difference was more striking for the 5.8 kb DQA1: 9.0 kb HSP70 haplotype again only in males (26.3 vs. 6.2%; p = 0.017, OR = 5.4, 95% CI = 1.5 - 19.5). The oldest male subject homozygous for this DQA1: HSP70 haplotype was 54 years (p = 0.005). Comparing leukemic patients and healthy individuals with the same ethnic and geographical origin, homozygosity for these genotypes was more frequent in the young leukemic group. The results suggested the existence of recessive deleterious genes in a segment of HLA-DR53 haplotypes.
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Affiliation(s)
- M T Dorak
- Department of Haematology, University of Wales College of Medicine, Cardiff, UK
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Dorak MT, Chalmers EA, Gaffney D, Wilson DW, Galbraith I, Henderson N, Worwood M, Mills KI, Burnett AK. Human major histocompatibility complex contains several leukemia susceptibility genes. Leuk Lymphoma 1994; 12:211-22. [PMID: 7909466 DOI: 10.3109/10428199409059592] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
In mice, homozygosity for the Mhc haplotype H-2k is associated with increased susceptibility to spontaneous and virus-induced leukemia, lymphoma and other neoplasms in the predisposed host. The influence of the Mhc on malignant development in these models is to shorten the latency after virus inoculation. Here, we present evidence that a similar phenomenon results in early-onset of human leukemia. A molecular analysis of the MHC in 112 CML patients showed that those who developed the disease when aged less than 35 years (early-onset group) had higher homozygosity rates for the DOA1, HSP70 and C4 alleles of the DR53 group of ancestral haplotypes, for a subtype of HLA-A3, and a higher allele frequency of BfFb compared to the late-onset group. The oldest patient (n = 13) homozygous for DR53 was 52-years-old (p = 0.004), and all HLA-A3 homozygous patients (n = 4) were in the early-onset group (p = 0.01). The relative risk for early-onset CML yielded by HLA-A3 homozygosity was 17.6. The well-known serological HLA-Cw4 association was not confirmed at the DNA level and thought to be due to linkage disequilibrium with BfFb. The factor B association was sex-limited. The DR52 group haplotypes appeared to be protective. The HLA-identical sibling frequency was increased only in the early-onset group (p < 0.01). Our findings agree with the concept of an MHC influence on the development of malignancies. The similarity in the location of the susceptibility loci and the serological cross-reaction between H-2Ek and DR53 raise the possibility that the mouse and human MHC share the same leukemia susceptibility genes.
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MESH Headings
- Acute Disease
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Alleles
- Cell Line
- Child
- Child, Preschool
- Disease Susceptibility/immunology
- Genetic Predisposition to Disease
- H-2 Antigens/genetics
- HLA-A Antigens/genetics
- HLA-B Antigens/genetics
- HLA-D Antigens/genetics
- Humans
- Leukemia/genetics
- Leukemia/immunology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/immunology
- Leukemia, Myeloid/genetics
- Leukemia, Myeloid/immunology
- Lymphoma/genetics
- Lymphoma/immunology
- Major Histocompatibility Complex
- Middle Aged
- Neoplasms/genetics
- Neoplasms/immunology
- Nuclear Family
- Polymorphism, Restriction Fragment Length
- Restriction Mapping
- Tumor Cells, Cultured
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Affiliation(s)
- M T Dorak
- Department of Haematology, University of Wales College of Medicine, Cardiff, UK
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Mills KI, Sproul AM, Burnett AK. Methylation of the major breakpoint cluster region (M-bcr) in Philadelphia-positive CML. Leukemia 1993; 7:707-11. [PMID: 7683349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
It has previously been shown that a cluster of HpaII sites with the potential to be methylated exist around exon b3 of the M-bcr region involved in the formation of the Philadelphia chromosome in chronic myeloid leukemia (CML). The degree of hypermethylation of these sites can be directly correlated with the percentage of immature cells, whilst progressive hypomethylation occurs during the maturation of the granulocyte lineage. We have examined samples obtained from CML patients at diagnosis, during chronic phase, and blast crisis to examine the degree of methylation of this region in the non-rearranged BCR gene and the rearranged BCR-ABL gene. A low degree of methylation of the non-rearranged gene, similar to that observed in normal individuals, was observed in diagnosis and chronic phase samples. Increased methylation was observed during blast crisis indicative of the presence of immature cells in the samples. In contrast, a significantly lower degree of methylation was observed in the rearranged BCR-ABL gene at the onset of blast crisis. Division of the samples into those patients who had lost exon b3 during the formation of the BCR/ABL gene and those that had retained exon b3 produced differing patterns of methylation during disease progression. The former group, who also expressed a b2-a2 mRNA, showed an increase in methylation of the non-rearranged BCR gene prior to and during blast crisis, with a inverse decrease in the methylation of the BCR/ABL gene. Those patients who had retained exon b3, and expressed a b3-a2 mRNA, showed no change in the extent of methylation of the BCR/ABL gene but did exhibit an increase in methylation of the BCR gene during blast crisis. The consequence of the differing degree of methylation during disease progression could affect, to some extent, the specificity of protein binding or RNA expression.
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Affiliation(s)
- K I Mills
- Department of Haematology, Glasgow Royal Infirmary, UK
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Mills KI. [The BCR/ABL gene in chronic myeloleukemia]. Gematol Transfuziol 1993; 38:3-7. [PMID: 8020733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Dorak MT, Chalmers EA, Sproul AM, Mills KI, Wilson DW, Galbraith I, Henderson N, Gibson BE, Burnett AK. MHC class III polymorphisms in selection of donors for BMT. Bone Marrow Transplant 1993; 11:37-41. [PMID: 8094307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Current practice for the selection of unrelated donors involves serological typing of HLA-A, -B and -DR antigens, DNA analysis of the class II region and the MLR. However, even after matching for the class II loci at the DNA level, a significant proportion of matched unrelated pairs remain MLR reactive. Ideal matching for BMT would be a match for the whole MHC haplotype rather than individual HLA loci. In the present study, we have evaluated the complementary role of class III typing in determining MHC identity. A group of 86 donor/recipient pairs, of which 14 were unrelated, was investigated using C4, Bf, HSP70 and TNF DNA probes. Phenotypically HLA-matched siblings were always identical at the C4 locus which is the most polymorphic of all the loci examined. Nine of the 14 HLA serologically matched MLR non-reactive (RRI < 20%) unrelated pairs had class III mismatching. Four of these pairs with class III mismatching were matched at the DRB and DQB loci by RFLP analysis. These results demonstrate that serological identity, DRB/DQB RFLP-matching and a negative MLR do not always match the whole haplotype in unrelated pairs. It can be concluded that the linkage of the class III loci to both HLA regions makes this region a reliable marker of the whole MHC haplotype.
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Affiliation(s)
- M T Dorak
- Department of Haematology, Glasgow Royal Infirmary, UK
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