Prevalence of post-thrombotic syndrome following asymptomatic thrombosis in survivors of acute lymphoblastic leukemia

BACKGROUND

Deep vein thrombosis (DVT) is a complication of treatment of acute lymphoblastic leukemia (ALL) in children but little is known about the long-term outcomes of these DVT.

OBJECTIVE

To determine the incidence of post-thrombotic syndrome (PTS) in (i) children with ALL diagnosed with asymptomatic DVT using radiographic testing and (ii) an unselected group of ALL survivors.

METHODS

Cross-sectional study in two populations. Group I comprised children in the Prophylactic Antithrombin Replacement in Kids with ALL treated with L-Asparaginase (PARKAA) study diagnosed with DVT by radiographic tests. Group II consisted of non-selected childhood ALL survivors <21 years. PTS was assessed using a standardized scoring sheet.

RESULTS

Group I: 13 PARKAA patients (median age 12 years) were assessed, and 7 had PTS (54%; 95% CI, 25-81). All patients had collaterals, three also had increased arm circumference. Group II: 41 patients (median age 13 years) with a history of ALL were enrolled, and 10 had PTS (24%; 95% CI, 11-38). All patients had collaterals; five also had increased arm circumference.

CONCLUSION

There is a high incidence of PTS in survivors of childhood ALL with radiographically diagnosed asymptomatic DVT. A significant proportion of ALL survivors develop PTS, indicating previously undiagnosed DVT.

Prothrombotic conditions in an unselected cohort of children with venous thromboembolic disease

Venous thromboembolic events (VTEs) in children are usually associated with underlying clinical conditions. The added contribution of prothrombotic conditions to the occurrence of VTEs in children is not clear. This study reports the prevalence of prothrombotic conditions in 171 consecutive children with VTE followed in the Hospital for Sick Children Thrombosis Outpatient Clinic. The median age of the children at the time of VTE was 2.3 months (range 1 day to 16.5 years). An underlying medical condition and a central venous line (CVL) were present in 156 (91%) and 132 (77%) of 171 children, respectively. A positive family history was present in 8% of children. The prevalence of factor V Leiden was 4.7%, prothrombin G20210A polymorphism was 2.3%, protein S deficiency was 1.2%, protein C deficiency was 0.6% and increased plasma lipoprotein (a) concentration (>30 mg dL-1) was 7.5% (tested in 107 children). The overall frequency of inherited prothrombotic coagulation proteins was 13% (95% confidence interval 7 to 19%) and the frequency was not significantly different between neonates and older children with VTE. Inherited prothrombotic coagulation proteins were not associated with gender, CVL-related VTE, a positive family history of thrombosis or spontaneous VTE in neonates. Increased frequency of inherited prothrombotic coagulation proteins was, however, found in older children with spontaneous VTE (60%) compared with older children with VTEs secondary to an underlying medical condition (10%) (P = 0.02). In conclusion, this study indicates that inherited prothrombotic coagulation proteins do not contribute significantly to the pathogenesis of VTEs in neonates and children, in whom the most significant etiological factors are the presence of a CVL and/or other medical conditions.

Nicotinic receptor abnormalities in the cerebellar cortex in autism

Autism is a common developmental disorder associated with structural and inferred neurochemical abnormalities of the brain. Cerebellar abnormalities frequently have been identified, based on neuroimaging or neuropathology. Recently, the cholinergic neurotransmitter system has been implicated on the basis of nicotinic receptor loss in the cerebral cortex. Cerebellar cholinergic activities were therefore investigated in autopsy tissue from a series of autistic individuals. The presynaptic cholinergic enzyme, choline acetyltransferase, together with nicotinic and muscarinic receptor subtypes were compared in the cerebellum from age-matched mentally retarded autistic (eight), normal control (10) and non-autistic mentally retarded individuals (11). The nicotinic receptor binding the agonist epibatidine (the high affinity receptor subtype, consisting primarily of alpha3 and alpha4, together with beta2 receptor subunits) was significantly reduced by 40-50% in the granule cell, Purkinje and molecular layers in the autistic compared with the normal group (P < 0.05). There was an opposite increase (3-fold) in the nicotinic receptor binding alpha-bungarotoxin (to the alpha7 subunit) which reached significance in the granule cell layer (P < 0.05). These receptor changes were paralleled by a significant reduction (P < 0.05) and non-significant increase, respectively, of alpha4 and alpha7 receptor subunit immunoreactivity measured using western blotting. Immunohistochemically loss of alpha(4 )reactivity was apparent from Purkinje and the other cell layers, with increased alpha7 reactivity in the granule cell layer. There were no significant changes in choline acetyltransferase activity, or in muscarinic M1 and M2 receptor subtypes in autism. In the non-autistic mentally retarded group, the only significant abnormality was a reduction in epibatidine binding in the granule cell and Purkinje layers. In two autistic cases examined histologically, Purkinje cell loss was observed in multiple lobules throughout the vermis and hemispheres. This was more severe in one case with epilepsy, which also showed vermis folial malformation. The case with less severe Purkinje cell loss also showed cerebellar white matter thinning and demyelination. These findings indicate a loss of the cerebellar nicotinic alpha4 receptor subunit in autism which may relate to the loss of Purkinje cells, and a compensatory increase in the alpha7 subunit. It remains to be determined how these receptor abnormalities are involved in neurodevelopment in autism and what is the relationship to mental function. Since nicotinic receptor agonists enhance attentional function and also induce an elevation in the high affinity receptor, nicotinic therapy in autism may be worth considering.

Pulmonary sequelae after electron spinal irradiation

We measured pulmonary function in 21 patients, after craniospinal irradiation with a posterior spinal electron beam. The median age at treatment was 7.5 years. Nine patients (43%) demonstrated abnormal pulmonary function tests, five with restrictive changes, one with isolated diminished diffusion capacity, and three with obstructive disease. These changes were mild and predominantly asymptomatic.

Natural zeolite clinoptilolite increases the concentrations of sphingoid bases in the yeast Yarrowia lipolytica

In the present paper, we studied the effect of natural zeolite clinoptilolite on sphingolipid metabolism in the yeast Yarrowia lipolytica. We also investigated if zeolite addition had any impact on cell shape and size, as well as on the pH alterations during the culture growth. High performance liquid chromatography analysis of sphingoid bases obtained by acid hydrolysis of complex sphingolipids from Y. lipolytica showed that their concentrations markedly rose upon the zeolite addition. The largest increase among the identified molecular species of sphingoid bases was seen in C18 phytosphingosine, whose levels rose 6.2-fold and 22.3-fold after culturing cells for 24 and 36 hours respectively in the presence of finely ground zeolite. pH measurements of the culture medium showed a similarity between pH profiles of control and zeolite-supplemented cells, suggesting that ion-exchange capacity was not probably responsible for the observed change in sphingolipid metabolism. Scanning electron microscopy revealed that zeolite affected cell size and shape. Y. lipolytica cells grown in the absence of zeolite were oval-shaped with an average cell size of 0.7-2.7 microns, whereas when cultured with zeolite, they were round-shaped and larger, having an average cell size of 1.3-2.9 microns.

High-performance liquid chromatographic determination of sphinganine and sphingosine in serum and urine of subjects from an endemic nephropathy area in Croatia

Endemic nephropathy (EN) is a chronic renal disease present as an endemic in Brodska Posavina, Croatia. The aim of the study was to assess the possible role of fumonisins, i.e., mycotoxins produced by Fusarium moniliforme, as causative agents for EN. Fumonisins inhibit ceramide synthase, the enzyme of de novo synthesis of sphingolipids, which leads to an increase in the sphinganine/sphingosine ratio. In the present study, a modified method has been used for the determination of the sphinganine/sphingosine ratio in human serum and urine of healthy subjects and EN patients from the endemic area. Free sphingoid bases, sphinganine and sphingosine, were obtained by base hydrolysis. Afterwards, precolumn ortho-phthaldialdehyde derivatisation, HPLC separation and quantification by fluorescence detection were performed. The results thus obtained pointed to a sphingolipid metabolism impairment, which may have been induced by fumonisins or fumonisin-like mycotoxins. As statistically significant differences were recorded in the subjects not yet affected with EN, an impairment in the metabolism of sphingolipids might be considered as an early indicator of EN.

Peripheral arterial responses to treadmill exercise among healthy subjects and atherosclerotic patients

BACKGROUND-Peripheral cutaneous vascular beds, such as the fingertips, contain a high concentration of arteriovenous anastomoses, richly innervated by a-adrenergic nerve fibers, to control heat regulation. Nevertheless, for a variety of technical reasons, finger blood flow responses to exercise have not been well studied in health and disease. Hence, we compared finger pulse-wave amplitude (PWA) responses to exercise among 50 normal volunteers and 57 patients with atherosclerotic coronary artery disease (CAD) using a robust, modified form of volume plethysmography.

METHODS AND RESULTS

PWA was quantified for each minute of exercise as a ratio relative to baseline. Exercise PWA responses were compared with clinical, hemodynamic, ECG, and myocardial single photon emission computed tomography parameters. Among normal subjects, 38 (76%) manifested vasodilation throughout exercise and 12 (24%) manifested initial vasodilation followed by vasoconstriction at high heart rate thresholds. None manifested vasoconstriction throughout exercise. By contrast, 20 CAD patients (35%) manifested progressive vasoconstriction from the onset of exercise, and 10 others (18%) manifested vasoconstriction at low heart rate thresholds (P < 0.001 versus normals) after initial vasodilation with exercise. Patients exhibiting vasodilation versus vasoconstriction during exercise had similar clinical and exercise profiles, except for a greater use of ACE inhibitors and a greater level of achieved metabolic equivalents among the former (P<0.05 for both).

CONCLUSIONS

Half of our CAD patients manifested diminution in PWA that was consistent with peripheral arterial vasoconstriction during the early phases of treadmill exercise. Such paradoxical vasoconstrictive responses were not observed in normal subjects and, therefore, they may represent generalized vascular pathology secondary to atherosclerosis.

Reproducibility of broth microdilution and disk diffusion susceptibility tests of nine antimicrobial agents against Streptococcus pneumoniae ATCC 49619

Collaborative studies documented the reproducibility of broth microdilution susceptibility tests of Streptococcus pneumoniae against nine antimicrobial agents and of disk diffusion tests with six of those drugs. Replicate tests of Streptococcus pneumoniae ATCC 49619 in five different laboratories led to the following provisional quality control limits: cefdinir--0.03 to 0.25 microgram/ml and 26 to 31 mm; cefetamet--0.5 to 2 micrograms/ml and 20 to 25 mm; ciprofloxacin--0.25 to 1 microgram/ml and 20 to 26 mm; clinafloxacin--0.03 to 0.125 microgram/ml and 28 to 34 mm; grepafloxacin--0.06 to 0.5 microgram/ml and 21 to 28 mm; PD131628--0.125 to 0.5 microgram/ml and 24 to 29 mm; clindamycin--0.03 to 0.12 microgram/ml; cefpodoxime--0.03 to 0.12 microgram/ml; and trospectomycin--1 to 4 microgram/ml (disk tests were not evaluate for the latter three drugs).

Differences in bovine lymphocyte antigen associations between immune responsiveness and risk of disease following intramammary infection with Staphylococcus aureus

This study evaluated the relationships between immune response, disease resistance, and bovine leukocyte antigens, BoLA, in Holstein cows following intramammary challenge with Staphylococcus aureus. This investigation was to determine whether immune responsiveness differed between these cows and whether differences were related to expression of class I BoLA antigens, which might explain the increased resistance or susceptibility to S. aureus mastitis. Antibody responses to S. aureus in milk and serum, total IgG1 in milk, and blastogenic responses with and without concanavalin A were evaluated. The CA42 allele, previously associated with increased risk of infection, was relatively uninformative for the immune response parameters examined. Other alleles, such as W3, were associated with higher milk antibody responses to S. aureus and higher milk IgG1 postchallenge. Alleles W7, W4, and W26 were associated with lower milk IgG1 and lower antibody titers in serum postchallenge. The association reported between allele CA42 and increased risk of S. aureus mastitis did not relate to lower antibody or blastogenic responses by these cows; however, indicators of innate resistance were not examined. In addition, the different associations detected between milk and serum emphasize the importance of considering mucosal immunity and unique immunological compartments when searching for relevant genetic markers of disease resistance.

Necrotizing funisitis and herpes simplex infection of placental and decidual tissues: study of four cases

Necrotizing funisitis (NF) is a macroscopically and microscopically distinctive pattern of umbilical cord inflammation recently heralded as presumptive of congenital syphilis. Four nonsyphilitic cases are presented in which herpes simplex virus (HSV) 2 antigen was demonstrated in the placenta by immunohistochemistry. The clinicopathologic findings in one case, including HSV 2 antigen in amniotic epithelium, subamniotic chorion, and Wharton jelly, indicate that NF was caused by chronic ascending primary HSV 2 infection, whereas those of the other three cases with HSV 2 Ag confined to decidual cell clusters suggest that NF was caused by chronic ascending bacterial infection and that latent endometrial HSV 2 infection was fortuitous. We conclude that (1) NF is caused by protracted inflammation of a structure whose normal anatomy precludes removal of inflammatory debris; (2) no single pathogen causes NF; and (3) NF is strongly associated with latent endometrial HSV 2 infection, which should be sought in all instances. Although latent HSV 2 endometrial infection may be more prevalent than currently recognized, we speculate that its strong association with NF may be more than causal; whereas the usual ascending bacterial infection leads to labor before NF has had sufficient time to develop, latent endometrial HSV 2 infection may alter local paracrine factors and delay parturition for the time sufficient to permit NF, a morphological hallmark of chronicity, to become apparent.

Primary hepatic B-cell lymphoma in a child

Lymphoma arising in the liver is uncommon in adults and rare in children. A 12-year-old boy with hepatomegaly and jaundice had a calcified intrahepatic large-cell lymphoma of B-cell origin that expressed bcl-2 protein and had near-tetraploid chromosome number with a t(8;14) (q24;q32) and a homogeneously staining region (HSR). This tumor, only the fourth example of primary hepatic lymphoma in a child, has the rare finding of an HSR before treatment and is the first human lymphoma with t(8;14) that expresses bcl-2 protein. In addition, the demonstration of extensive calcification in the tumor by computed tomography scan is highly unusual for lymphoma. Lymphoma must be considered in the differential diagnosis of primary liver tumors in children and adults, especially if the serum alpha-fetoprotein level is normal.

Nalmefene enhances LH secretion in a proportion of oligo-amenorrheic athletes

The influence upon LH secretion of doses of nalmefene, an orally effective congener of naloxone, and a placebo was compared in nine oligo-amenorrheic athletes with that in five regularly menstruating non-athletic women as a test for periodic elevations in hypothalamic opioid tone. After a 360-min control period, LH levels were followed for an additional 360 min following ingestion of the medications in random order approximately six weeks apart, 10-min blood sampling being employed throughout. The mean amplitude post-nalmefene in the athletes was significantly greater than pre (p < 0.05), although there were no differences in the frequency of LH pulses after placebo or nalmefene ingestion. Subjects were labelled as "responders" if their peak AUC after treatment exceeded their pretreatment AUC for LH by more than 1.96 SD (p < 0.05). There were no placebo responders, but 5/9 of the athletes and 1/5 of the menstruating controls were classified as nalmefene responders (p < 0.05). In addition, a variable proportion of the athletes (but none of the controls) experienced symptoms suggestive of narcotic withdrawal 1-4 h after ingesting nalmefene and again 12-18 h later. It appears that demonstrable increases in opioid tone occur at least transiently in a proportion of oligo-amenorrheic athletes.

A prototype beam delivery system for the proton medical accelerator at Loma Linda

A variable energy proton accelerator was commissioned at Fermi National Accelerator Laboratory for use in cancer treatment at the Loma Linda University Medical Center. The advantages of precise dose localization by proton therapy, while sparing nearby healthy tissue, are well documented [R. R. Wilson, Radiology 47, 487 (1946); M. Wagner, Med. Phys. 9, 749 (1982); M. Goitein and F. Chen, Med. Phys. 10, 831 (1983)]. One of the components of the proton therapy facility is a beam delivery system capable of delivering precise dose distributions to the target volume in the patient. To this end, a prototype beam delivery system was tested during the accelerator's commissioning period. The beam delivery system consisted of a beam spreading device to produce a large, uniform field, a range modulator to generate a spread out Bragg peak (SOBP), and various beam detectors to measure intensity, beam centering, and dose distributions. The beam delivery system provided a uniform proton dose distribution in a cylindrical volume of 20-cm-diam area and 9-cm depth. The dose variations throughout the target volume were found to be less than +/- 5%. Modifications in the range modulator should reduce this considerably. The central axis dose rate in the region of the SOBP was found to be 0.4 cGy/spill with an incident beam intensity of 6.7 x 10(9) protons/spill. With an accelerator repetition rate of 30 spills/min and expected intensity of 2.5 x 10(10) protons/spill for patient treatment, this system can provide 50 cGy/min for a 20-cm-diam field and 9-cm range modulation.(ABSTRACT TRUNCATED AT 250 WORDS)

Histoanatomic observations of the brain in early infantile autism

Early infantile autism is a behaviorally defined syndrome that is often associated with abnormalities on neurologic examination and seizures. We report on the brain of a 29-year-old autistic man as compared with that of an age- and sex-matched normal control, using gapless sections of whole brain. Abnormalities were found in the hippocampus, subiculum, entorhinal cortex, septal nuclei, mamillary body, selected nuclei of the amygdala, neocerebellar cortex, roof nuclei of the cerebellum, and inferior olivary nucleus.