The impact of glomerular filtration rate estimation on cardiovascular events in elderly patients undergoing coronary angiography

Objectives

Estimation of kidney function by glomerular filtration rate (eGFR) is affected by age and is important for decision making regarding treatment and prognosis of patients with cardiovascular disease. We aimed to investigate the impact of eGFR on long-term cardiovascular outcomes in an elderly population undergoing coronary angiography for evaluation or treatment of coronary artery disease.

Methods

GFR was estimated according to Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation in 3,690 elderly patients (aged 70–100 years) undergoing coronary angiography. Patients receiving maintenance dialysis were excluded. The association between eGFR and long-term major adverse cardiovascular events (MACE) including myocardial infarction, ischemic stroke or death, was investigated. GFR was further calculated according to Modification of Diet in Renal Disease (MDRD) and the Cockroft-Gault equations, and compatibility between estimations was analyzed.

Results

Cardiovascular comorbidities were more prevalent with the reduction in kidney function as was the proportion of patients presenting with acute coronary syndromes. The adjusted hazard ratio (95% confidence interval) for MACE during a mean follow-up of 5 years was 0.98 (0.80–1.19), 1.05 (0.85–1.30), 1.45 (1.15–1.82), 2.20 (1.64–2.95) and 3.87 (2.28–6.58) in patients with eGFR 60–89, 45–59, 30–44, 15–29 and <15 ml/min/1.73m2, respectively, compared to eGFR >90 ml/min/1.73m2. Reclassification of eGFR stages by MDRD (upward 23.8%, downward 0.4%) and Cockroft-Gault (upward 4.3%, downward 28.1%) compared to CKD-EPI estimation, was noted. However, the association between eGFR stages and MACE was similar between equations.

Conclusions

Kidney function, as manifested by eGFR, has a graded inverse association with the burden of cardiovascular comorbidities and long-term adverse events in elderly patients undergoing coronary angiography.

Funding Acknowledgement

Type of funding sources: None.

Lymphopenia and risk for long-term mortality among patients undergoing coronary angiography

Background

Lymphopenia has been shown to be associated with adverse prognosis in chronic disease states that are related to immune dysregulation.

Purpose

We aimed to determine the association between lymphopenia and all-cause mortality in patients presenting to coronary angiography with or without acute coronary syndromes (ACS). We also investigated whether elevated red blood cell distribution width (RDW), an established cardiovascular prognostic marker, further refines risk stratification and improves predictive accuracy beyond lymphocytes count.

Methods

Retrospective cohort analysis of patients undergoing coronary angiography for evaluation or treatment of coronary artery disease between 2003 and 2018. Long-term mortality risk associated with relative (1000–1500 /μL) or severe (<1000 /μL) lymphopenia was analyzed using Cox proportional hazards regression models, adjusting for comorbidities, ACS and RDW.

Results

Overall, 15179 patients underwent coronary angiography, at a mean age of 65±12 years. On cross-sectional analysis, lymphopenia was associated with kidney disease, cancer, heart failure and presentation with ACS, but lower rates of smoking and obesity. During a median follow-up of 7 (IQR 3.5–11.5) years, 4253 patients died. Compared to normal lymphocytes count (1500–5000 /μL), the multivariable adjusted hazard ratio (HR) (95% confidence interval) for mortality was 1.31 (1.21–1.41) and 1.97 (1.75–2.22) for relative and severe lymphopenia, respectively. The increase in mortality associated with severe lymphopenia was significant in patients presenting with non-ACS [HR 2.18 (1.74–2.73)], ST-segment elevation myocardial infarction (STEMI) [HR 1.59 (1.15–2.21)], or unstable angina/non-STEMI [HR 2.00 (1.70–2.34)]; p-for-interaction 0.626. The association of lymphopenia with mortality remained significant after additional adjustment to RDW. High RDW (>14.5%) was associated with increased mortality risk in each of the lymphocytes count groups, and improved the predictive accuracy with AUC increase from 0.609 (0.601–0.616) to 0.646 (0.639–0.654) (p<0.001).

Conclusions

Lymphopenia is associated with increased risk for long-term mortality in patients undergoing coronary angiography, regardless of coronary presentation. High RDW may enhance the predictive ability of lymphopenia.

Lymphocyte count and mortality risk

Funding Acknowledgement

Type of funding source: None

BRAF V600E mutation in Juvenile Xanthogranuloma family neoplasms of the central nervous system (CNS-JXG): a revised diagnostic algorithm to include pediatric Erdheim-Chester disease

The family of juvenile xanthogranuloma family neoplasms (JXG) with ERK-pathway mutations are now classified within the "L" (Langerhans) group, which includes Langerhans cell histiocytosis (LCH) and Erdheim Chester disease (ECD). Although the BRAF V600E mutation constitutes the majority of molecular alterations in ECD and LCH, only three reported JXG neoplasms, all in male pediatric patients with localized central nervous system (CNS) involvement, are known to harbor the BRAF mutation. This retrospective case series seeks to redefine the clinicopathologic spectrum of pediatric CNS-JXG family neoplasms in the post-BRAF era, with a revised diagnostic algorithm to include pediatric ECD. Twenty-two CNS-JXG family lesions were retrieved from consult files with 64% (n = 14) having informative BRAF V600E mutational testing (molecular and/or VE1 immunohistochemistry). Of these, 71% (n = 10) were pediatric cases (≤18 years) and half (n = 5) harbored the BRAF V600E mutation. As compared to the BRAF wild-type cohort (WT), the BRAF V600E cohort had a similar mean age at diagnosis [BRAF V600E: 7 years (3-12 y), vs. WT: 7.6 years (1-18 y)] but demonstrated a stronger male/female ratio (BRAF V600E: 4 vs WT: 0.67), and had both more multifocal CNS disease ( BRAFV600E: 80% vs WT: 20%) and systemic disease (BRAF V600E: 40% vs WT: none). Radiographic features of CNS-JXG varied but typically included enhancing CNS mass lesion(s) with associated white matter changes in a subset of BRAF V600E neoplasms. After clinical-radiographic correlation, pediatric ECD was diagnosed in the BRAF V600E cohort. Treatment options varied, including surgical resection, chemotherapy, and targeted therapy with BRAF-inhibitor dabrafenib in one mutated case. BRAF V600E CNS-JXG neoplasms appear associated with male gender and aggressive disease presentation including pediatric ECD. We propose a revised diagnostic algorithm for CNS-JXG that includes an initial morphologic diagnosis with a final integrated diagnosis after clinical-radiographic and molecular correlation, in order to identify cases of pediatric ECD. Future studies with long-term follow-up are required to determine if pediatric BRAF V600E positive CNS-JXG neoplasms are a distinct entity in the L-group histiocytosis category or represent an expanded pediatric spectrum of ECD.

P1253Long-term risk stratification of patients undergoing coronary angiography according to the TIMI risk score for secondary prevention

Background

A risk score for secondary prevention after myocardial infarction (TRS2P) was recently developed from the TRA2°P-TIMI50 trial based on 9 established clinical factors [age≥75, hypertension, diabetes, smoking, kidney dysfunction, peripheral artery disease, heart failure, prior stroke and prior coronary artery-bypass surgery (CABG)], classifying the risk for major adverse cardiovascular events (MACE). We aimed to evaluate the performance of TRS2P for predicting long-term outcomes in real-world patients presenting for coronary angiography.

Methods

Retrospective analysis of 13,593 patients that were referred to angiography for the assessment or treatment of coronary artery disease between 2000–2015 in a single center. Risk stratification for 10-year MACE (myocardial infarction, ischemic stroke or all-cause death) was performed using the TRS2P score, divided into 6 categories (0 to ≥5 points), and in relation to the presenting coronary syndrome.

Results

All clinical variables, except of prior CABG, were independent risk predictors. The annualized incidence rate of MACE increased in a graded manner with increasing TRS2P score, ranging from 1.65 to 16.6 per 100 person-years (ptrend<0.001). The pattern was similar for 10-year cumulative incidence of MACE. Compared to the lowest-risk group (risk indicators=0), the hazard-ratios (95% confidence interval) for MACE were 1.60 (1.36–1.89), 2.58 (2.21–3.02), 4.31 (3.69–5.05), 6.43 (5.47–7.56) and 10.03 (8.52–11.81), in those with 1,2,3,4 and ≥5 risk indicators, respectively. Risk gradation was consistent across the individual clinical endpoints. TRS2P score showed reasonable discrimination with c-statistics of 0.704 for MACE and 0.735 for mortality. The graded relationship between the risk score and event rates was observed in both patients presenting with acute and non-acute coronary syndromes.

Cumulative 10-year incidence of MACE

Conclusions

The use of TRS2P, a simple risk score based on routinely collected variables, enables risk stratification in patients undergoing coronary angiography. Its predictive value was demonstrated in real-world setting with long-term follow-up, and irrespective of the acuity of coronary presentation.

Acknowledgement/Funding

None

Enhanced B Cell Alloantigen Presentation and Its Epigenetic Dysregulation in Liver Transplant Rejection

T cell suppression prevents acute cellular rejection but causes life-threatening infections and malignancies. Previously, liver transplant (LTx) rejection in children was associated with the single-nucleotide polymorphism (SNP) rs9296068 upstream of the HLA-DOA gene. HLA-DOA inhibits B cell presentation of antigen, a potentially novel antirejection drug target. Using archived samples from 122 white pediatric LTx patients (including 77 described previously), we confirmed the association between rs9296068 and LTx rejection (p = 0.001, odds ratio [OR] 2.55). Next-generation sequencing revealed that the putative transcription factor (CCCTC binding factor [CTCF]) binding SNP locus rs2395304, in linkage disequilibrium with rs9296068 (D' 0.578, r(2) = 0.4), is also associated with LTx rejection (p = 0.008, OR 2.34). Furthermore, LTx rejection is associated with enhanced B cell presentation of donor antigen relative to HLA-nonidentical antigen in a novel cell-based assay and with a downregulated HLA-DOA gene in a subset of these children. In lymphoblastoid B (Raji) cells, rs2395304 coimmunoprecipitates with CTCF, and CTCF knockdown with morpholino antisense oligonucleotides enhances alloantigen presentation and downregulates the HLA-DOA gene, reproducing observations made with HLA-DOA knockdown and clinical rejection. Alloantigen presentation is suppressed by inhibitors of methylation and histone deacetylation, reproducing observations made during resolution of rejection. Enhanced donor antigen presentation by B cells and its epigenetic dysregulation via the HLA-DOA gene represent novel opportunities for surveillance and treatment of transplant rejection.

Allospecific CD154+ T cells associate with rejection risk after pediatric liver transplantation

Antigen-specific T cells, which express CD154 rapidly, but remain untested in alloimmunity, were measured with flow cytometry in 16-h MLR of 58 identically-immunosuppressed children with liver transplantation (LTx), to identify Rejectors (who had experienced biopsy-proven rejection within 60 days posttransplantation). Thirty-one children were sampled once, cross-sectionally. Twenty-seven children were sampled longitudinally, pre-LTx, and at 1-60 and 61-200 days after LTx. Results were correlated with proliferative alloresponses measured by CFSE-dye dilution (n = 23), and CTLA4, a negative T-cell costimulator, which antagonizes CD154-mediated effects (n = 31). In cross-sectional observations, logistic regression and leave-one-out cross-validation identified donor-specific, CD154 + T-cytotoxic (Tc)-memory cells as best associated with rejection outcomes. In the longitudinal cohort, (1) the association between CD154 + Tc-memory cells and rejection outcomes was replicated with sensitivity/specificity 92.3%/84.6% for observations at 1-60 days, and (2) elevated pre-LTx CD154 + Tc-memory cell responses were associated with significantly increased incidence (p = 0.02) and hazard (HR = 7.355) of rejection in survival/proportional hazard analysis. CD154 expression correlated with proliferative alloresponses (r = 0.835, p = 7.1e-07), and inversely with CTLA4 expression of allospecific CD154 + Tc-memory cells (r =-0.706, p = 3.0e-05). Allospecific CD154 + T-helper-memory cells, not CD154 + Tc-memory, were inhibited by increasing Tacrolimus concentrations (p = 0.026). Collectively, allospecific CD154 + T cells provide an estimate of rejection risk in children with LTx.

Hodgkin-like posttransplant lymphoproliferative disorder in children: does it differ from posttransplant Hodgkin lymphoma?

Epstein-Barr virus (EBV)-mediated lymphoid proliferations occur in patients who are immunocompromised and are reported following bone marrow or solid organ transplantation. Most post-transplant lymphoproliferative disorders (PTLD) are polymorphic in appearance; some are monomorphic and can resemble conventional malignant lymphomas. PTLD that resembles Hodgkin lymphoma has been reported infrequently. We herein report seven cases of PTLD that have large numbers of Reed-Sternberg-like (RS-like) cells and highlight differences in the phenotype of these cases that may distinguish Hodgkin-like PTLD (HL-PTLD) from true Hodgkin lymphoma/disease (HD). All patients were in the second decade of life and were 8 months to 13 years following transplant. HL-PTLD involves lymph nodes that contain a mixed population of small to intermediate-sized lymphocytes with large mononuclear and occasionally binucleate RS-like cells. The large cells of HL-PTLD are pleomorphic B cells that react strongly for CD20 and/or CD79a, express CD30, but are usually negative for CD15 and have few mitoses. They are positive for EBV early RNA (EBER) using an EBER-1 probe, as are some of the background small lymphocytes. A single case of true Hodgkin lymphoma has highly atypical RS-like cells that contain numerous mitoses, does not have CD20 or CD79a reactivity, has CD15 and CD30 staining, and the EBER-1 probe is confined to the large cells only. All patients were managed by withdrawal of immunosuppression and variably treated with either antiviral or anti-CD20 monoclonal antibody, or with chemotherapy. A unique instance of evolution from a HL-PTLD to true HD is also illustrated. In conclusion, HL-PTLD and HD appear to be two related but immunophenotypically and biologically distinct forms of lymphoproliferation in post-transplant patients and may require different protocols for their management.

Primary cerebral non-Langerhans cell histiocytosis: MRI and differential diagnosis

We report a young woman with primary cerebral non-Langerhans cell histiocytosis of the juvenile xanthogranuloma family. The clinical course was complicated by extensive infiltration of cranial nerves and meninges and epi- and intramedullary spinal dissemination. Whereas the cutaneous form of juvenile xanthogranuloma is usually benign and self-limited, central nervous system involvement is associated with high morbidity and mortality and might therefore be considered a separate clinical entity.

Primary tacrolimus (FK506) therapy and the long-term risk of post-transplant lymphoproliferative disease in pediatric liver transplant recipients

While the overall incidence of post-transplant lymphoproliferative disease (PTLD) in pediatric liver transplant recipients has been reported to be 4-11%, the long-term risk of PTLD associated with primary tacrolimus therapy is unknown. Therefore, in order to determine the incidence and long-term risk of PTLD, the present study examined 131 pediatric recipients who underwent liver transplantation (LTx) between October 1989 and December 1991 and received primary tacrolimus therapy. This cohort of children was evaluated over an extended time-period (until December 31 1996) with a mean follow-up of 6.3 yr. Actuarial Kaplan-Meier analysis was utilized to determine the risk of PTLD over time. The overall incidence of PTLD was 13% (17/131) with an average age of 4.3 +/- 0.75 yr at diagnosis. Pretransplant Epstein-Barr virus (EBV) serologies were negative in 82%, positive in 12%, and not available in 6% of the patients. The median time to diagnosis of PTLD post-Tx was 11.9 months (mean 16.4 +/- 3.9, range 1.7-63.0 months). Mean tacrolimus dose and plasma trough level (as evaluated by enzyme-linked immunosorbent assay [ELISA]) at the time of diagnosis was 0.32 +/- 0.06 mg/kg/day and 1.3 +/- 0.3 ng/mL, respectively. The cumulative long-term risk of PTLD was found to increase over time: 3% at 6 months, 8% at 1 yr, 12% at 2 yr, 14% at 3 yr, and 15% at 4 and 5 yr. Mortality from PTLD was 12% (two of 17 patients). Primary tacrolimus use in pediatric LTx has a long-term risk of PTLD approaching 15%, with the majority of episodes (78%) occurring in the first 2 yr, suggesting that intense EBV surveillance should occur early post-transplantation.

The role of genetic abnormalities of PTEN and the phosphatidylinositol 3-kinase pathway in breast and ovarian tumorigenesis, prognosis, and therapy

Breast and ovarian cancers exhibit similar epidemiologic, genotypic, and phenotypic characteristics. Phosphatidylinositol 3-kinase (PI3K) and the PTEN tumor suppressor gene product phosphorylate and dephosphorylate the same 3' site in the inositol ring of membrane phosphatidylinositols. Germ-line mutations in the PTEN tumor suppressor gene are causative of Cowden's breast cancer predisposition syndrome, and PTEN is frequently mutated in sporadic breast cancers. In contrast, amplification of multiple components of the PI3K pathway is a hallmark of serous epithelial ovarian cancers. The resultant activation of the PI3K pathway in both breast and ovarian cancers contributes to cell-cycle progression, decreased apoptosis, and increased metastatic capabilities. Strikingly, both ovarian and breast cancer cells are selectively sensitive to pharmacologic and genetic manipulation of the PI3K pathway, making molecular therapeutics targeting this pathway particularly attractive approaches for these cancers.

Echovirus hepatic failure in infancy: report of four cases with speculation on the pathogenesis

Disseminated echovirus infection with fulminant hepatic failure occurs almost exclusively in newborns. Although a relatively uncommon condition, it is on occasion associated with neonatal death accompanied by diffuse and extensive hemorrhagic necrosis of the liver and adrenals as the defining finding. We report four cases of severe systemic neonatal echovirus infection and present histologic and clinical evidence to demonstrate the two histologic patterns of liver involvement; intravascular coagulation in the early clinical course and a veno-occlusive component in later stages of the disease. Viral damage to vascular endothelium and hepatic venous endothelium by a "hit-and-run" process in the early viremic phase rather than direct hepatocyte injury is postulated to be a mechanism.

Interaction between Hg(II) and natural dissolved organic matter: a fluorescence spectroscopy based study

Interaction between Hg(II) and dissolved organic matter (DOM) collected from surface water samples of the Florida Everglades was studied using different fluorescence spectroscopic methods. Complexation between Hg(II) and DOM leached from mangrove leaves, sawgrass, and periphyton was investigated. Both fluorescence emission and synchronous fluorescence spectra showed that these dissolved organic materials, whether they are highly degraded or are freshly leached, can "complex" Hg(II) since fluorescence intensity was quenched upon addition of Hg(II) to the DOM samples. Synchronous fluorescence spectra disclosed structural information on the DOM sample, regarding possible binding sites for Hg(II). Chemical parameters on the complexation of Hg(II), including the conditional stability constants and the percentage of fluorophores participating in the complexation, were estimated by the modified Stern-Volmer equation. A detailed investigation under different experimental conditions showed that the complexation of the DOM samples collected from the Everglades was influenced by pH, Cl-(aq) anion, and cations such as Ca2+ and Mg2+. Experimental results suggest that DOM-Hg(II) complexes can be removed from the water column through adsorption on biogenically precipitated CaCO3(s).

Enteric adenovirus infection in pediatric small bowel transplant recipients

Three of 70 small bowel transplant recipients were diagnosed with adenovirus enteritis. The biopsies were performed for surveillance in one patient at 2.7 years after transplantation and in two symptomatic children 1.5 years and 4.5 months after transplantation. In all three patients the characteristic epithelial changes were not noted by the primary observers. Two biopsies had been called "suggestive of acute rejection" and both patients had been so treated. One biopsy had been diagnosed as "regenerative". Once the epithelial changes were recognized as being viral, confirmation was possible by stool culture in one patient, immunohistochemistry in two patients, or by lift technique of the H&E sections for electron microscopy. The immune suppression was reduced and none of the patients developed disseminated infection. As in other transplanted organs, such as lung and liver, adenovirus infection may be limited largely to the allograft but can be destructive. Early recognition of the characteristic changes that are illustrated can lead to confirmation of the virus and appropriate reduction of immune suppression. A mistaken diagnosis of rejection and augmentation of immune suppression can lead to viral dissemination and potential fatality.

Three-dimensional ultrasonography in early pregnancy

Three-dimensional ultrasound was introduced into clinical use over a decade ago. Early attempts on three-dimensional ultrasound were primitive and limited to experimental use only. Recently, it was used as a powerful tool to display three-dimensional fetal appearance and assess normal and pathological conditions. Because of the improvement in image resolution and reconstruction speed, three-dimensional ultrasound is now more and more popular in many centers, and used commonly as an adjunct in prenatal diagnosis. Indeed, a skillful sonographer may usually make the correct diagnosis of fetal anomaly with simply two-dimensional ultrasound. Nonetheless, the situation is gradually changing, because some anomalies have been diagnosed only based on the findings of three-dimensional ultrasound. In spite of that, the application of three-dimensional ultrasound is still less discussed in early pregnancy. In this article, the authors clarify the capability of three-dimensional ultrasound in different anatomic areas, and catalog its clinical merits in the early pregnancy to date. We also present the safety guidelines for its use in the first trimester.

Development of early uteroplacental circulation

A crucial event in human development is trophoblast invasion, a process that will enable chorionic and maternal circulations to develop in a synchronized fashion. Early embryo and trophoblast are very sensitive to the conditions in which they grow, and progressive development of placental circulations is essential for normal pregnancy development. It has been demonstrated that inadequate trophoblast invasion is a major finding in many clinical deleterious conditions facing the obstetrician. Pathologic studies of placentas of pregnancies complicated by intrauterine growth restriction or preeclampsia demonstrate shallow trophoblast invasion of the spiral arteries. This has also been seen in early spontaneous miscarriages. In our study, we used color Doppler sonography to assess the uteroplacental circulation and predict outcome of first-trimester gestations. One hundred women with viable pregnancies of 7 to 12 weeks gestational age were prospectively evaluated. Color Doppler imaging was used to identify the location of blood flow within the uteroplacental circulation, and spectral Doppler imaging was used to analyze waveforms obtained from the decidual spiral arteries. Abnormal color Doppler findings were associated with a significantly higher prevalence of complicated pregnancies. Among women with abnormal Doppler findings, 12 (43%) of 28 pregnancies ended in miscarriage, whereas among women with normal findings only one (1.4%) of 72 women miscarried (p<.055). This study indicates that abnormal flow patterns of the early uteroplacental circulation due most likely to abnormal trophoblast invasion are associated with an increased prevalence of pregnancy complications. What causes inadequate invasion remains a mystery. Abnormal nitric oxide synthesis, due to possible endothelial cell dysfunction, has been demonstrated in some of these complicated pregnancies but, whether this is cause of effect, is not known. Every step of embryonal-maternal interaction from fertilization and onward has major implications on subsequent development of embryo, fetus, neonate and adult human being. Trophoblast invasions and transformation of the spiral arteries are possibly the most significant interactions and will have the most profound effect on pregnancy development.

Functional outcome comparison of semiconstrained and unconstrained total elbow arthroplasties

Twenty-six patients, each of whom had undergone either a semiconstrained (linked) or an unconstrained (unlinked) total elbow arthroplasty, were examined specifically to evaluate the restoration of function with respect to activities of daily living. The functional outcomes of these 2 groups were then compared to identify any significant differences. All of the unlinked/unconstrained prostheses were Ewald total elbow arthroplasties; the linked/semiconstrained prostheses, all of which were performed by a single surgeon, were Mayo-Coonrad prostheses. Follow-up radiographs, taken to rule out loosening or failure of the prosthesis as a cause for functional deficits, were available for review for 25 elbows. There were 14 elbows in 13 patients who had semiconstrained prostheses and 12 elbows in 10 patients who had unconstrained total prostheses. Average age at the time of elbow replacement surgery was 62.8 years (range, 47-75 years) for the semiconstrained group and 63.1 years (range, 54-74 years) for the unconstrained group. The semiconstrained group consisted of 8 female and 6 male elbows; the unconstrained group consisted of 10 female and 2 male elbows. Follow-up averaged 35.5 months (range, 24-73 months) in the semiconstrained group and 73 months (range, 27-110 months) in the unconstrained group. Twenty-two operations were performed for rheumatoid arthritis, 3 for posttraumatic humeral nonunion, and 1 for posttraumatic degenerative arthritis. Two elbows required revision, one (in the semiconstrained group) for aseptic loosening and the other (in the unconstrained group) for metal synovitis and pain from a chronically dislocated prosthesis; both of these elbows were considered failures and excluded from the functional comparison. No significant differences in functional performance were found, and no elbows demonstrated progressive radiolucencies suggestive of loosening. With the exception of 1 patient (in addition to the patients who had revisions) with a dislocated unconstrained prosthesis, all patients were satisfied with the procedure. It appears that when it is properly performed, total elbow arthroplasty with either type of prosthesis yields satisfactory functional results.

Liver transplantation and chemotherapy for hepatoblastoma and hepatocellular cancer in childhood and adolescence

OBJECTIVE

To describe our experience with total hepatectomy and liver transplantation as treatment for primary hepatoblastoma (HBL) and hepatocellular carcinoma (HCC) in children.

STUDY DESIGN

A retrospective analysis of the perioperative course of 31 children with unresectable primary HBL (n = 12) and HCC (n = 19) who underwent transplantation between May 1989 and December 1998. Systemic (n = 18) and intraarterial (n = 7) neoadjuvant chemotherapy were administered; follow-up ranged from 1 to 185 months.

RESULTS

For HBL, 1-year, 3-year, and 5-year posttransplantation survival rates were 92%, 92%, and 83%, respectively. Intravenous invasion, positive hilar lymph nodes, and contiguous spread did not have a significant adverse effect on outcome; distant metastasis was responsible for 2 deaths. Intraarterial chemotherapy was effective in all patients treated. For HCC, the overall 1-year, 3-year, and 5-year disease-free survival rates were 79%, 68%, and 63%, respectively. Vascular invasion, distant metastases, lymph node involvement, tumor size, and gender were significant risk factors for recurrence. Intraarterial chemotherapy was effective in 1 of 3 patients. Six patients died of recurrent HCC, and 3 deaths were unrelated to recurrent tumor.

CONCLUSION

Liver transplantation for unresectable HBL and HCC can be curative. Risk factors for recurrence were significant only for HCC, with more advanced stages amenable to cure in the HBL group.

Atopic dermatitis

Atopic dermatitis is a chronic skin disorder. It affects up to 15% of the childhood population in the United States and more than half of these patients into adulthood. A clinical diagnosis is made based on the superficial, inflammatory, erythematous and puritic eruptions. Control of symptoms involves patient and parent education with regard to skin care and avoidance of triggers. Treatment includes corticosteroids, with newer strategies emerging.

Multiple cardiac rhabdomyomas detected in utero

Prenatal fetal echocardiography studies detected large multiple cardiac rhabdomyomas and led to the diagnosis of tuberous sclerosis. Despite episodes of bradyarrhythmias and severe lung compression in utero, the neonate did well and was discharged home on day 20 of life. On day 30 of life, the infant expired at home from cardiac arrest secondary to arrhythmia.

Cryptosporidial infections after solid organ transplantation in children

The diagnosis and treatment of moderate-to-severe diarrhea in solid organ transplant recipients is often a challenge because of the variety of infectious and non-infectious causes. The morbidity associated with this clinical condition is of particular significance in the pediatric population where malnutrition may lead to poor growth and development. Rarely, Cryptosporidium has been identified as the cause of clinically significant diarrhea in pediatric solid organ transplant patients. A retrospective review identified cases of cryptosporidiosis among the 1160 non-renal, abdominal organ transplant recipients cared for at the Children's Hospital of Pittsburgh between 1981 and June 1998. Four cases of clinically significant diarrhea were identified in three liver transplant recipients and one small bowel transplant recipient. Endoscopy and biopsy with histologic confirmation diagnosed three cases; ova and parasitic examination of stool specimens identified the fourth case. Therapy varied among the patients depending on when they had been diagnosed as, over the years, different and newer agents have been indicated for the treatment of cryptosporidiosis. All four patients resolved their infections. Hence, endoscopy and biopsy is recommended for pediatric transplant patients who present with chronic diarrhea of unknown etiology. The patients who may be at a higher risk for cryptosporidial infections include those with an increased immunosuppressive state (i.e. pre-existing immunodeficiency, malignancy, re-transplantation, and those receiving higher doses of immunosuppressive therapy). While cryptosporidiosis is a non-lethal complication, it allows the clinician to gain further insight into the degree of immunosuppression of their patient.

Ocular nonnephropathic cystinosis: clinical, biochemical, and molecular correlations

Ocular nonnephropathic cystinosis, a variant of the classic nephropathic type of cystinosis, is an autosomal recessive lysosomal storage disorder characterized by photophobia due to corneal cystine crystals but absence of renal disease. We determined the molecular basis for ocular cystinosis in four individuals. All had mutations in the cystinosis gene CTNS, indicating that ocular cystinosis is allelic with classic nephropathic cystinosis. The ocular cystinosis patients each had one severe mutation and one mild mutation, the latter consisting of either a 928 G-->A (G197R) mutation or an IVS10-3 C-->G splicing mutation resulting in the insertion of 182 bp of IVS10 into the CTNS mRNA. The mild mutations appear to allow for residual CTNS mRNA production, significant amounts of lysosomal cystine transport, and lower levels of cellular cystine compared with those in nephropathic cystinosis. The lack of kidney involvement in ocular cystinosis may be explained by two different mechanisms. On the one hand (e.g. the G197R mutation), significant residual cystinosin activity may be present in every tissue. On the other hand (e.g. the IVS 10-3 C-->G mutation), substantial cystinosin activity may exist in the kidney because of that tissue's specific expression of factors that promote splicing of a normal CTNS transcript. Each of these mechanisms could result in minimally reduced lysosomal cystine transport in the kidneys.

Significance of echogenic foci in the left ventricle of the fetal heart in a low-risk population

OBJECTIVE

To determine if there exists a significant association between prenatally detected left ventricular echogenic foci and chromosomal abnormalities.

METHODS

Over a 10-month period the presence of intracardiac echogenic foci was recorded on all low-risk patients referred for anatomical assessment. The study group consisted of 113 singleton fetuses and was compared to a control group with no foci.

RESULTS

Among the study group with echogenic foci, 5 chromosomal abnormalities (three trisomies) were detected. In the control group only one chromosomal abnormality was diagnosed.

CONCLUSION

An association exists between the finding of intracardiac echogenic foci in the fetus and the presence of chromosomal abnormalities.

Diagnosis of hirschsprung disease using the rectal biopsy: multi-institutional survey

Diagnostic pathologists remain uncomfortable with the diagnosis of Hirschsprung disease (HD) via rectal (mucosal/submucosal) biopsy and with performance and interpretation of the associated acetylcholinesterase (AChE) assay. This report details the different diagnostic approaches taken by four major pediatric institutions-Children's Hospital, Columbus, OH; Children's Hospital Medical Center, Cincinnati, OH; Children's Hospital, Pittsburgh, PA; Children's Hospital, Los Angeles, CA-in confirming or excluding the presence of HD. The Columbus approach emphasizes serial morphologic examination of rectal biopsies, while Cincinnati emphasizes the primary diagnostic utility of the AChE stain. Pittsburgh and Los Angeles emphasize a detailed gross and microscopic analysis of rectal biopsies to detect both conventional HD and its more rare subtypes. The diagnostic approaches of these four institutions can be used on a complementary basis to the advantage of the general diagnostic pathologist, especially in HD cases with subtle clinical presentations. The need for careful and continual communication between the clinician and pathologist in diagnosing or excluding the presence of HD is imperative.

Epstein-Barr virus-related disorders in children undergoing renal transplantation with tacrolimus-based immunosuppression

In children undergoing renal transplantation, Epstein-Barr virus- (EBV) related disorders, including posttransplant lymphoproliferative disorder, constitute a major complication associated with tacrolimus-based immunosuppression. In this study, we reviewed the EBV complications in 81 children, all of whom had EBV serological studies before renal transplantation. We also highlight the data in a subgroup of 30 children transplanted more recently who were monitored sequentially for EBV symptoms and signs and with immunological studies, and in whom the donor EBV serology was also determined. During a mean follow-up time of 3.9+/-2.3 years, 19 children developed symptomatic Epstein-Barr virus (EBV*) infection. This consisted of the clinical syndrome of infectious mononucleosis in 7 children; in addition, 10 children developed posttransplant lymphoproliferative disorder (PTLD), which was histologically confirmed in 8, and 2 others developed malignant lymphoma. Recipient seronegativity (EBV-) and donor EBV seropositivity (EBV+) predicted a high probability for seroconversion (P=0.0072) and for developing PTLD or malignancy (P<0.01). In the subgroup of 30 children studied prospectively, seroconversion occurred in 15 of 19 seronegative recipients of EBV seropositive grafts at 6.6+/-2.6 months (mean+/-SD) after transplantation. Seven children developed symptomatic EBV infection (including three with PTLD) in association with seroconversion and a rise in EBV viral load in the peripheral blood, demonstrated by an EBV-specific polymerase chain reaction (EBV-PCR). Of 15 seroconverters, 7 who developed symptomatic infection had received EBV+ grafts; 8 others with EBV+ grafts seroconverted but did not become symptomatic. These two subgroups did not differ in age, rejection rate, antiviral prophylaxis, or level of immunosuppression. In the overall group of 81 children, only the two with malignant lymphoma who were managed with chemotherapy had substantial morbidity. The 10 individuals with PTLD received a regimen combining i.v. ganciclovir and CytoGam, and stopping or reducing the tacrolimus. Four children with associated marked tonsilar growth underwent tonsillectomy. All 19 individuals with EBV disorders resolved their symptoms and signs, and all have maintained good allograft function during a follow-up time of 3.0+/-2.5 years (mean+/-SD) after the development of symptomatic EBV infection, PTLD, or malignancy. We conclude that seronegative recipients of EBV+ grafts are at high risk for developing EBV-related disorders after renal transplantation under tacrolimus-based immunosuppression, although the ultimate clinical outcomes have been remarkably good. These data form the basis for formulating strategies for early identification of children at risk for EBV complications, and for instituting preventive and treatment strategies that permit these children to realize the substantial benefits offered by tacrolimus-based immunosuppression.

Hemophagocytic syndrome presenting as acute hepatic failure in two infants: clinical overlap with neonatal hemochromatosis

Two patients with hemophagocytic lymphohistiocytosis who presented with acute liver failure are reported. Both presented with fever, hepatosplenomegaly, markedly elevated liver function tests, abnormal coagulation profiles, and an increase in serum ferritin. Both infants were diagnosed with neonatal hemochromatosis based on a clinical picture of hepatic insufficiency with hyperferritinemia and were referred for liver transplantation. The first patient died of liver failure and septicemia before transplantation. Review of autopsy material revealed a hepatitis-like pattern and extensive infiltration of liver and other organs including bone marrow by histiocytes, some of which were hemophagocytic. The second patient underwent liver transplantation but died 44 days thereafter from progressive hemophagocytic lymphohistiocytosis. Examination of the resected liver demonstrated a hepatitis-like pattern, proliferation of histiocytes, and hemophagocytosis, and the bone marrow revealed hemophagocytic histiocytosis. Hemophagocytosis recurred in the allograft. Hepatic manifestations are common in hemophagocytic lymphohistiocytosis and overt hepatic failure may occur, but initial presentation as fulminant hepatic failure is not well recognized. Elevated serum ferritin can make the distinction from neonatal hemochromatosis and other forms of neonatal liver failure difficult. Hemophagocytic lymphohistiocytosis should be considered in the differential diagnosis of neonatal liver disease, especially when it is accompanied by cytopenias.

The histiocytoses

The histiocytoses, systemic disorders of the dendritic or macrophage lines, are an enigmatic group of disorders. It is hoped that by better understanding and identification of the responsible cells in each of the various conditions, their biological nature will become apparent. Because they are unusual, only multi-institutional groups, such as the Histiocyte Society, will be able to collect enough examples and bring a standardized approach to their evaluation. Those interested in joining the Histiocyte Society are invited to apply by contacting the Histiocyte Society, 302 N Broadway, Pitman, NJ 08071.

Onychomycosis: recognition, diagnosis, and management

About 20% of the US population between the ages of 40 and 60 years have fungal nail disease, or onychomycosis. The incidence of this infection is increasing worldwide. Most cases of onychomycosis in the United States are caused by dermatophytes, but nondermatophyte fungi (molds or yeasts) may also be causative agents. To confirm the diagnosis of onychomycosis, a potassium hydroxide examination should be performed. A culture is necessary to determine the fungal pathogen and to aid in selecting appropriate therapy. Worldwide, fluconazole (not yet approved in the United States for onychomycosis), itraconazole, and oral terbinafine have superseded griseofulvin and ketoconazole as the agents of choice in treating onychomycosis. These newer systemic compounds have higher cure rates and cause fewer side effects than traditional agents. Intermittent dosing with itraconazole (3 or 4 one-week pulses of 200 or 400 mg daily) is the latest advance in the treatment of onychomycosis. This regimen has been found to be at least as safe and effective as short-term continuous therapy, yet more flexible, convenient, and economical.

Management of posttransplant lymphoproliferative disease in pediatric liver transplant recipients receiving primary tacrolimus (FK506) therapy

BACKGROUND

Posttransplant lymphoproliferative disease (PTLD) after pediatric liver transplantation has been associated with high mortality rates.

METHODS

The present study examined 282 consecutive pediatric liver transplant recipients from October 1989 to June 1996 who received primary tacrolimus immunosuppression. The aim was to determine the incidence of PTLD, management strategies, and patient outcome.

RESULTS

The incidence of PTLD was 13% (361282) with a mean age of 5.5+/-0.7 years (range 0.6 to 15) at diagnosis. The average time from transplantation to PTLD was 10.1+/-2.1 months. Initial treatment of PTLD consisted of reduction (3 patients) or discontinuation (33 patients) of tacrolimus and initiation of antiviral therapy (intravenous ganciclovir, 14 patients; intravenous acyclovir, 22 patients; or both, 5 patients). Alpha-interferon was used in four patients (two successfully). One patient also received gamma-interferon, chemotherapy, and radiation for a central nervous system lesion. Chemotherapy was also used in one patient with Burkitt's, whereas one patient with a pulmonary lesion received additional radiation therapy. Three patients received supportive surgery for gastrointestinal involvement, and one patient had a splenectomy for hemolysis. Overall mortality was 22% (8/36) with 5 (14%) PTLD-related deaths (disseminated disease, 4 patients; bowel perforation, 1 patient). Of 31 survivors, 23 had acute rejection at a median time of 24 days after PTLD, with 2 patients developing chronic rejection. One patient required retransplantation. Present immunosuppression consists of tacrolimus monotherapy in 14 patients, tacrolimus/prednisone in 8 patients, and none in 6 patients.

CONCLUSION

In summary, PTLD can be successfully treated with reduction of immunosuppression and administration of antiviral agents in most patients. The management of rejection after PTLD requires reassessment of disease status and judicious reintroduction of immunosuppression therapy.

First trimester utero-placental circulation: maternal-fetal interaction

Progressive development of embryonal and maternal circulations is essential for normal pregnancy outcome. The early embryo and trophoblast are very sensitive to the conditions under which they grow and differentiate. The most crucial event in human ontogeny is trophoblast invasion, a process that will enable chorionic and maternal circulations to develop in a synchronized fashion, balancing the metabolic needs with the capability to defend against oxidative stress. Trophoblast invasion transforms the spiral arteries into low resistance vessels, a change necessary for establishment of continuous forward blood flow once the villi are anchored and have obtained defense mechanisms against oxidative insult. Based on a review of current knowledge of human trophoblast and embryonic growth and development of embryonic and maternal placental circulations it seems that human ontogeny occurs in a low oxygen environment during the initial stages of pregnancy. This is similar to the environment in which the first single cell organisms appeared and it remains to be seen if the development process of the primitive single cell organisms, and its energy generating processes, is an appropriate model for studying early human ontogeny.

Changes in uterine artery doppler velocimetry in pregnant patients undergoing glucose tolerance test may predict adverse outcome in later pregnancy: a preliminary study

OBJECTIVE

Previous studies have demonstrated that high glucose levels often cause increased placental resistance to blood flow. The present study was undertaken to assess whether any changes in placental vascular resistance would occur following a standard glucose tolerance test.

METHODS

Doppler velocimetry of uterine, intraplacental and umbilical vessels was performed before and after administration of glucose tolerance test.

RESULTS

The uterine circulation demonstrated abnormal indices in patients that later developed placental insufficiency.

CONCLUSION

This preliminary study demonstrated that following a glucose tolerance test significant changes seem to occur in the uteroplacental but not in the fetoplacental circulation of pregnancies destined to develop preeclampsia or intrauterine growth restriction.

Continuous passive motion after repair of the rotator cuff. A prospective outcome study

Despite the apparent success of continuous passive motion after soft-tissue procedures or joint replacements, its effect after repair of the rotator cuff is still unknown. The purpose of this prospective, randomized outcome study was to compare the results of continuous passive motion with those of manual passive range-of-motion exercises after repair of the rotator cuff. Thirty-one patients (thirty-two rotator cuffs) were randomly assigned to one of two types of postoperative management: continuous passive motion (seventeen patients) or manual passive range-of-motion exercises (fifteen patients). There were seventeen women and fourteen men, and the mean age was sixty-three years (range, thirty to eighty years). The patients were followed for a mean of twenty-two months (range, six to forty-five months). Five tears of the rotator cuff were small, eighteen were medium, and nine were large. All of the operations were performed by one surgeon. The patients who were managed with continuous passive motion used the device for the first four weeks postoperatively. The patients who were managed with manual passive range-of-motion exercises were assisted by a trained relative, friend, or home-care nurse. After the four-week period, the two groups were managed similarly for two to five months. According to the Shoulder Pain and Disability Index, a valid and reliable self-administered questionnaire, the treatment was extremely successful in both groups. The overall score was excellent for twenty-seven shoulders (84 per cent), good for two (6 per cent), fair for two (7 per cent), and poor for one (3 per cent). With the numbers available, we could detect no significant differences (p > 0.05) between the two groups with respect to the score according to the Index, pain (according to a visual-analog scale), range of motion, or isometric strength. Manual passive range-of-motion exercises were more cost-effective than continuous passive motion. The limited number of physical-therapy visits associated with the manual passive range-of-motion exercises in the present study appeared to be more cost-effective than a traditional physical-therapy schedule of three visits per week. Postoperative therapy with continuous passive motion or manual passive range-of-motion exercises appears to yield favorable results after repair of a small, medium, or large tear of the rotator cuff.

Fascin and the differential diagnosis of childhood histiocytic lesions

This is a descriptive screening of 46 examples of childhood histiocytic lesions and some of their look-alikes using a monoclonal antibody, p55, to fascin. Fascin, an actin-bundling protein, identifies dendritic cells in the blood and in tissues. Our aim was to test the diagnostic utility of the antibody in various lesions at different sites and to see whether the staining patterns give insight into the cell types involved. Fascin intensely stained the cells of juvenile xanthogranulomas (JXG), Rosai-Dorfman lesions, and soft tissue dendrocytomas. Normal Langerhans' cells and the cells of Langerhans' cell histiocytosis were unreactive. Their lack of fascin staining may be relevant to fascin being maturation as well as lineage related. Epithelioid and palisading granulomas were unstained, though an example of Kikuchi lymphadenitis had large numbers of dendritic-type cells that stained strongly. A reticulohistiocytoma of the skin was also unstained and look-alike lesions, Spitz nevi, and mast cell lesions did not stain. Two of three large-cell lymphomas (both CD30+) also had fascin reactivity. Even though fascin is not specific to dendritic cells, staining other cell types as well (false positive), and not entirely sensitive, dendritic cells such as tissue Langerhans' cells are unstained (false negative), there seems to be a consistency of staining in childhood histiocytic lesions. This may be of diagnostic use when read in the context of the tissue differential diagnosis. Whether fascin can serve as a marker for the dendritic cell lineage, or at least for some phases of dendritic cell lifecycle, is not answered by this survey.

Expression of acute otitis media after receptor blockade of platelet activating factor, thromboxane, and leukotrienes in the chinchilla

To determine the role of inflammatory products of phospholipid metabolism in acute otitis media (AOM), we infected 128 chinchillas with Streptococcus pneumoniae and randomly assigned them to one of four equal-sized treatment groups receiving intramuscular ampicillin sodium (control) or intramuscular ampicillin plus receptor blockers of platelet activating factor (WEB 2086, 5 mg/d orally), of leukotriene (MK 571, 0.5 mg/d orally), or of thromboxaneA2 (GR 32191B, 5 mg/d orally). All treatments were begun on day 2 postinoculation and continued for 10 days. On days 3, 6, 9, and 12, 8 animals from each group were sacrificed. Effusions were recovered for biochemical assay, and the right middle ears were prepared for histologic study. Differences among groups in the number of ears with effusion or in effusion volume were not statistically significant. In comparison to the control group, mucosal thickness and the number of ears with histopathologic signs of inflammation were significantly less in the GR and WEB treatment groups, but not the MK group. Also, effusion concentrations of free fatty acids, protease, and hydrolytic enzymes were significantly less in those groups. These results show that the addition of a receptor blocker for either platelet activating factor and/or thromboxane to ampicillin in the treatment of AOM reduces mucosal inflammation and decreases the production of other inflammatory chemicals. The failure of a receptor blocker of leukotrienes to moderate disease expression suggests either a less important role for these chemicals in AOM or an insufficient bioavailability of the specific MK 571 inhibitor. These results confirm that platelet activating factor and thromboxane are active mediators of inflammation in AOM.