[Clinical outcomes of reverse shoulder arthroplasty for the treatment of failed fixation of proximal humeral fracrtures in the elderly patients]

OBJECTIVE

To evaluate the clinical outcomes of reverse total shoulder arthroplasty as a revision procedure for the failed fixation of proximal humeral fractures in the elderly patients.

METHODS

A retrospective analysis was performed on 8 patients with failed internal fixation of proximal humeral fractures from May 2014 to March 2020, including 3 males and 5 females, aged from 65 to 75 years old. All 8 patients underwent reverse total shoulder arthroplasty, and the mean time between initial fixation and reverse total shoulder arthroplasty ranged from 8 to 16 months. Range of motion(ROM), University of California at Los Angeles(UCLA) shoulder score, visual analogue scale (VAS), self-rating anxiety scale(SAS), and Constant-Murley score of shoulder function were assessed pre-operatively and at the last follow-up. Complications relating to the surgery were recorded.

RESULTS

All 8 patients successfully followed up. The mean follow-up after reverse total shoulder arhroplasty ranged from 16 to 28 months. The range of motion (forward flexion, external rotation, abduction and internal rotation) of the affected shoulder was significantly improved after surgery, and the post-operative VAS, SAS and UCLA scores were also significantly improved. For the Constant-Murley score of shoulder joint function, the total scores and the subscores of pain, daily activities, range of motion and strength test at the last follow-up were all significantly improved. Scapular glenoid notch was observed in patient, which was evaluated as grade 1 on imaging. All the other patients did not develop specific or non-specific complications.

CONCLUSION

Reverse total shoulder arhroplasty is an appropriate treatment as a revision surgery for failed fixation of proximal humeral fractures. It has shown satisfactory clinical outcomes, accelerating the rehabilitation of shoulder function and improving the quality of life.

[High strength wire under arthroscopy combined with outside anchor nail in treating Meyers McKeever II, III avulsion fracture of anterior cruciate ligament tibial check point]

OBJECTIVE

To explore clinical effect of high strength wire under arthroscopy combined with outside anchor nail in treating Meyers McKeever II, III anterior cruciate ligament tibial check point.

METHODS

From March 2014 to June 2016, 21 patients with Meyers McKeever II, III avulsion fracture of anterior cruciate ligament tibial check point were treated by high strength wire under arthroscopy combined outside anchor nail. There were 13 males and 8 females aged from 18 to 48 years old with an average of (26.40±5.42) years old. There were 9 cases injured on the left side, and 12 cases on the right side. The courses of disease included sports injuries of 12 cases, falling down injuries of 6 cases, and accident injuries of 3 cases. According to Meyers-McKeever classification, 16 patients were type II and 5 patients were type III. All fractures were fresh, closed and simple injury. The time from injury to operation ranged from 2 to 15 days with an average of (6.20±2.63) d. Lysholm score, IKDC score and the changes of knee mobility were observed and compared before operation and 6 months after operation.

RESULTS

Twenty-one patients were followed up for 12 to 24 months with an average of (14.30±3.01) months. Operation time ranged from 40 to 65 min with an average of (45.10±4.82) min, Blood loss ranged from 5 to 15 ml with an average of (10.05±2.75) ml. Lysholm score was improved from 50.29±6.67 before operation to 92.48±2.18 at 6 months after operation. IKDC scores was increased from 47.19±4.57 before operation to 90.71±2.22 at 6 months after operation. Knee joint activity was respectively (83.05±5.33)° and (132.05±7.15)° before operation and 6 months after operation.

CONCLUSIONS

High strength wire under arthroscopy combined outside anchor nail in treating Meyers McKeever II, III ACL tibial check point has the advantages of less trauma, firm fixation, and satisfactory clinical effect.

Abstract P6-09-17: Evaluation of a risk score based on biologic factors to enhance prognostic stratification by the American Joint Committee on Cancer (AJCC) Staging System

Background: The 7th edition AJCC staging system provides prognostic information based on the anatomic extent of disease determined by the tumor size (T), lymph node status (N), and presence or absence of metastatic disease (M). Tumor biology, including grade, estrogen receptor (ER) status and HER2 status, which are known to have prognostic and predictive value, are not incorporated. This study was undertaken to evaluate a risk score that takes into account the tumor grade and other biomarkers that can be added to the current anatomic TNM staging system to improve stratification of patients with respect to disease specific survival (DSS) and overall survival (OS).

Methods: A prospectively maintained database was used to identify 3,327 patients with non-metastatic invasive breast cancer who underwent surgery as a first intervention from January 2007 through December 2013. Clinicopathologic data were recorded including: age, grade, ER status, HER2 status, and pathologic stage. Pathologic stage was determined according to the 7th edition of the AJCC staging guidelines. ER status was recorded as the percentage of cells staining positive by immunohistochemistry (IHC). Prior to 2010, tumors were classified as ER positive if there was >10% staining. A cut-off of 1% was used for patients treated after 2010, consistent with the change in American Society of Clinical Oncology (ASCO) guidelines. HER2 status was defined as positive if 3+ on immunohistochemistry or gene amplification was shown on fluorescence in situ hybridization. A risk score was calculated by assigning one point for each of the following tumor characteristics: ER-negative status, HER2 negative status and grade 3. Univariate survival analyses according to AJCC stage (I, IIA, IIB, IIIA and IIIC) and risk score (0-3) were performed for DSS and OS using the Kaplan Meier method.

Results: Median follow-up time was 5.0 years (range, 0.1 to 8.8). Five year DSS for the entire cohort was 97.9% (95% CI: 97.3%-98.4%). The distribution in risk score in the entire cohort was: risk score 0=81 (2.4%), 1=2289 (68.8%), 2=683 (20.5%), and 3= (8.3%). As shown in the table, for all AJCC stages, the 5-yr DSS and 5-yr OS varied according to risk score (p<.01).

StageRisk Scoren5-yr DSS (%)95% CI5-yr OS (%)95% CII (IA and IB)036100 9780.4-99.6 1117399.498.7-99.796.795.4-97.6 227498.896.4-00.694.691.0-06.8 311996.691.1-98.793.887.5-97.0IIA031100 96.879.2-99.5 163499.497.5-99.897.194.7-98.4 223697.593.2-99.194.188.7-97.0 39891.081.8-95.788.278.5-93.8IIB011100 100  130996.992.6-98.894.689.6-97.2 210792.983.6-97.189.380.1-94.4 34091.575.6-97.291.575.6-97.2IIIA03100 100  113498.388.2-99.891.582.6-96.0 25092.277.2-97.590.375.7-96.3 3768.621.3-91.268.621.3-91.2IIIC00     13992.272.1-98.084.463.7-93.9 21680.851.4-93.480.851.4-93.4 31033.36.3-64.633.36.2-64.6

Conclusion: The current study demonstrates that incorporating the risk score with current AJCC staging significantly improves the ability to stratify breast cancer patients with respect to DSS and OS. We recommend that the risk score be incorporated into the forthcoming revision of the AJCC staging system.

Citation Format: Mittendorf EA, Vila J, Yi M, Chavez-MacGregor M, Chen RL, Giordano SH, Hunt KK. Evaluation of a risk score based on biologic factors to enhance prognostic stratification by the American Joint Committee on Cancer (AJCC) Staging System [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-09-17.

[Effect of elongated-needle penetration intervention on spinal apoptosis and cell signal transduction in acute spinal cord injury rabbits]

OBJECTIVE

To observe the effect of elongated-needle penetration (ENP) stimulation of "Zhibian" (BL 54), "Shuidao" (ST 28), "Qihai" (CV 6) and "Zhongji" (CV 3) on spinal nerve cell apoptosis and cellular signal transduction in spinal cord injury rabbits, so as to reveal its mechanism underlying improvement of spinal injury.

METHODS

A total of 80 adult Newzealand rabbits were randomized to control, model, ENP, ENP + LY 294002 (PI3K antagonist), ENP + PD 98059 (MEK antagonist) groups, with 16 rabbits in each group. The spinal cord injury model was established by using modified Allen's method (Gravity-drop device). Elongated-needle penetration was applied to bilateral BL 54, ST 28, CV 3 and CV 6, once daily for 3 times. For rabbits of the ENP+ LY 294002 and ENP+ PD 98059 groups, LY 294002 (10 microg, 20 microL), PD 98059 (3 microg, 20 microL) were separately given by intrathecal injection. Pathomorphological changes of the injured spinal cord (T13-L1) were observed after H.E. stain. Spinal cell apoptosis was detected by TUNEL,and phosphorylated (p)-Akt and p-ERK1/2 immunoactivity was detected by immunohistochemistry, and the expression levels of p-Akt, p-ERK1/2, cytochrome C (Cyt C) and Caspase-3 proteins were determined by Western blot (WB), and serum TNF-alpha content was assayed by ELISA.

RESULTS

H. E. staining showed apparent structural changes as hemmorrhage, inflammatory cell infiltration, cellular edema and necrosis, and formation of vacuolation in the spinal cord in the model group, which was marked milder in the ENP group. TUNEL assay showed that the rate of apoptotic cells was notably increased in the model group than in the control group (P < 0.05), obviously decreased in the ENP group when compared with the model group (P < 0.05). Immunohistochemistry, WB and ELISA results showed that compared with the control group, spinal p-Akt and p-ERK1/2 protein expression levels in the model group were significantly decreased (P < 0.05), and Cyt C and Caspase-3 expression levels and serum TNF-a content were significantly increased in the model group (P < 0.05). Compared with the model group, the expression levels of p-Akt, p-ERK1/2 were significantly increased in the ENP group (P < 0.05), while Cyt C and Caspase-3 expression levels and TNF-alpha content were significantly down-regulated in the ENP group (P < 0.05). After intrathecal injection of PI3K and MEK antagonists, the effects of ENP were significantly weakened in reducing apoptosis rate, upregulating p-Akt and p-ERK1/2 expression and in down-regulating Cyt C and Caspase-3 expression and TNF-alpha content (P < 0.05), suggesting important roles of ERK1/2 mediated extracellular and PI3K/Akt mediated intracellular apoptotic signal transduction pathways in ENP induced repair of the traumatic tissues.

CONCLUSION

ENP stimulation can decrease spinal injury and cell apoptosis in spinal injury rabbits, which may be closely related to its effects in up-regulating p-Akt and p-ERK1/2 and down-regulating Cyt C and Caspase-3 expression levels in the spinal cord and serum TNF-alpha content.

[Case-control study on minimally invasive percutaneous plate osteosynthesis for the treatment of distal tibial comminuted fractures at different operation times]

OBJECTIVE

To compare clinical outcomes of minimally invasive percutaneous plate osteosynthesis (MIPPO) in treating distal tibial comminuted fractures at early and delayed stage.

METHODS

From January 2006 to January 2012,66 patients with distal tibial comminuted fractures were treated by MIPPO. All patients were divided into primary group and delayed group according to operation time. There were 31 patients in primary group, including 18 males and 13 females aged 21 to 57 years old with an average of (39.0 +/- 17.8), treated by MIPPO at primary stage,according to Tscherne soft tissue injury, 18 cases were grade I ,12 cases were grade II and 1 case were grade III. Thirty-five patients were treated by MIPPO at delayed stage, including 16 males and 19 females aged 24 to 55 years old with an average of (39.5 +/- 15.2), according to Tscherne soft tissue injury, 6 cases were grade I, 26 cases were grade II and 3 cases were grade III. Operation time, blood loss, hospital stay, fracture healing time and complications of two groups were recorded and observed, Lowa scoring of ankle joint were used to evaluated therapeutic effects at final following and AP and lateral X-rays were used to evaluated fracture reduction and alignment.

RESULTS

All patients were followed up, the time of following-up of primary group was (13.5 +/- 3.5) months, (15.2 +/- 3.8) months in delayed group, there was no significant meaning between two groups (t = 1.882, P = 0.064). There was no significant differences between two groups in operation time and blood loss (P > 0.05), but hospital stay in primary group was shorter than that of delayed group(P<0.05). There was no significant meaning between primary group (5.5 +/- 2.8) and delayed group (6.2 +/- 3.1) in fracture healing time (t = 0.958, P = 0.342); there was no significant meaning between primary group (87.6 +/- 6.8) and delayed group (89.6 +/- 5.2) in Lowa scores at final following-up (t = 1.351, P = 0.182). Two cases occurred postoperative superficial inflammatory reaction around fibular incision in primary group, 1 case occurred postoperative superficial inflammatory reaction around fibular incision and 1 case occurred delayed deep incision infection in delayed group at four months after operation. There was no significant differences in incidence of postoperative soft tissue complications between primary group (6.5%) and delayed group (5.7%) (t = 0.016, P = 0.900).

CONCLUSION

For distal tibial comminuted fractures with grade I and II of Tscherne soft tissue injury, MIPPO at primary stage can not increase incidence of soft tissue complications, also can obtain the same clinical outcomes just like delayed MIPPO.

Stroke syndromes and clinical management

The knowledge of brain syndromes is essential for stroke physicians and neurologists, particularly those that can be extremely difficult and challenging to diagnose due to the great variability of symptom presentation and yet of clinical significance in terms of potential devastating effect with poor outcome. The diagnosis and understanding of stroke syndromes has improved dramatically over the years with the advent of modern imaging, while the management is similar to general care as recommended by various guidelines in addition to care of such patients on specialized units with facilities for continuous monitoring of vital signs and dedicated stroke therapy. Such critical care can be provided either in the acute stroke unit, the medical intensive care unit or the neurological intensive care unit. There may be no definitive treatment at reversing stroke syndromes, but it is important to identify the signs and symptoms for an early diagnosis to prompt quick treatment, which can prevent further devastating complications following stroke. The aim of this article is to discuss some of the important clinical stroke syndromes encountered in clinical practice and discuss their management.

[The role of the expression of PPAR-gamma gene in the adipogenesis in hemangioma evolution]

OBJECTIVE

To investigate the role of the expression of PPAR-gamma gene in the adipogenesis in hemangioma evolution.

METHODS

Routine immunohistochemistry staining of Perilipin A, the marker antigen of adipocytes, was performed to observe the adipogenesis in hemangioma. Immunofluorescence staining of PPAR-gamma, the important transcription factor in promoting adipogenesis, was carried out to observe its location in hemangioma tissue, with the co-staining of alpha-SMA and CD31. And RT-PCR was used to examine the expression of PPAR-gamma gene in hemangioma in different stages.

RESULTS

In the evolution of hemangioma, the number of adipocytes increased continuously. And the tumor was replaced by fibrofatty tissue finally. PPAR-gamma was located in the nuclei of perivascular cell in hemangioma tissue. The expression of PPAR-gamma gene in hemangioma increased in the evolution of hemangioma, but still was lower than that in normal fat tissue from children.

CONCLUSION

The expression of PPAR-gamma in the perivascular cells suggests that they may contribute to the adipogenesis in hemangioma involution.

[Awn needle therapy on the impact of urinary retention after spinal cord injury]

OBJECTIVE

To investigate the therapeutic mechanism of point 8L54-through-point ST2S acupuncture with elongate needles in treating urinary retention after spinal cord injury.

METHODS

Thirty-five healthy Japanese rabbits (weight 2.5 +/- 0.25 kg, 3 months old, male or female), used as experimental subjects, were divided into 4 groups involving blank group, model group, acupuncture group, elongate needles group (5 rabbits in blank group, 10 rabbits in each of the other group 10). Modified Allen's method was used to cause spinal cord injury model for the model group, the acupuncture group and the elongate needles group, the blank group was only sham surgery. Immediately after spinal cord injury model,the elongated needle group was given the bilateral acupoints of the elongated needle penetration needling and electric stimulation, electrical stimulation 15 mm stimulation frequency of 20 to 40 times/mm, intensity 1.5 to 3 V the acupuncture group immediately was given ordinary electric needle acupuncture, given other disposals as the elongated needle group; model group was not given electric needle acupuncture, waiting 15 minutes, started to detect and record the observed indicator as the elongated needle group; the blank group was only sham surgery. The following indicators including the Tarlov score ,urinary bladder pressure point, the threshold urination, voided volume, were observed in the first day and the fifth day after surgery.

RESULTS

Three groups of animals which modeled were urinary retention after operation. Compared to 1 d, Tarlov score of model group, acupuncture group and elongate needles group significantly improved at postoperative 5 d (P < 0.05). Compared with acupuncture group, the Tarlov score of elongate needles group had no significant difference at postoperative 5 d (P > 0.05). Compared with model group, values of urinary bladder pressure point decreased with varying degrees in the acupuncture group and elongate needles group at postoperative 5 d (P < 0.05); relative to the acupuncture group, the point of the bladder voiding pressure in the elongate needles group decreased more significantly at postoperative 5 d (P < 0.05); compared with model group, micturition threshold of acupuncture group and elongate needles group had been significantly improved at the fifth day after surgery (P < 0.05); relative to the acupuncture group, the improvement is more obvious in the elongate needles group. Compared with model group, voided volume of acupuncture group and elongate needles group had increased significantly at the fifth day after surgery (P < 0.05); relative to the acupuncture group, the increment is more evident in the elongate needles group (P < 0.05).

CONCLUSION

To treat urinary retention after spinal cord injury, the method, which was point-through-point acupuncture with elongate needles in the "Zhibian" and "Shuidao", was better than general acupuncture method. The therapeutic mechanism may be related to stimulate peripheral nerve of bladder, and to rectify the dysfunction between detrusor and sphincter.

Mesenchymal stem cells in infantile hemangioma reside in the perivascular region

Infantile hemangioma grows quickly in the first year of life and regresses slowly to fibrofatty tissue during childhood; mesenchymal stem cells (MSCs) have been reported to contribute to this adipogenesis. Recent studies have shown the perivascular origin of MSCs in multiple organs. We hypothesized that MSCs in hemangioma might also reside in the perivascular region. We isolated MSCs from proliferating hemangioma by their selective adhesion to plastic culture dishes. Mesenchymal stem cells from bone marrow (BM-MSCs) and foreskin-derived fibroblasts were used as controls. Flow cytometry and immunofluorescence staining were used to examine their antigen profiles; in vitro induction of multi-lineage differentiation was performed to test their pluripotency. Platelet-derived growth factor R-β (PDGFR-β), CD133, and peroxisome-proliferator-activated receptor gamma (PPAR-γ) were selected as the markers to observe MSCs in hemangioma by immunohistochemistry staining, with costaining of CD31 and alpha-smooth muscle actin (α-SMA). Hemangioma-derived MSCs (Hem-MSCs) had fibroblast-like morphology; they expressed the MSC markers CD105, CD90, CD29, and vimentin and did not express the hematopoietic/endothelial markers CD45, CD34, CD31, and flt-1; Hem-MSCs also expressed CD133 and PPAR-γ. Most Hem-MSCs expressed PDGFR-β and α-SMA; in contrast, the expression of PDGFR-β and α-SMA in BM-MSCs was very weak. The Hem-MSCs differentiated into adipocytes, osteoblasts, and chondroblasts in vitro. This confirmed their pluripotency. Immunohistochemistry showed the colocalization of PDGFR-β/α-SMA, CD133/α-SMA, and PPAR-γ/α-SMA in the perivascular region. MSCs were successfully obtained from proliferating hemangioma, revealing the perivascular origin of MSCs in hemangioma.

Electroacoustic analysis of an electret loudspeaker using combined finite-element and lumped-parameter models

An unconventional type of electrostatic loudspeaker is presented in this paper. The loudspeaker made of thin, light, and flexible electret material lends itself well to the space-concerned applications. Electrical impedance measurement reveals that the coupling between the electrical system and the mechanical system is weak, which renders conventional parameter identification based on electrical impedance measurement impractical. A different approach is thus employed to model the electret loudspeaker. To predict the loudspeaker's dynamic response, finite-element analysis (FEA) is conducted on the basis of a simple model and a full model. In the simple model, FEA is applied to model the electret membrane, leaving the rest of system as rigid parts. In the full model, FEA is applied to model the entire membrane-spacer-back plate assembly. Velocity response of the membrane subject to a uniformly distributed force is calculated using FEA harmonic analysis. Mechanical impedance is then calculated with the velocity response. The acoustical impedance due to the back cavity, pores, and the radiation loading at the front side is calculated by theoretical formulas. The volume velocity of the membrane and the resulting on-axis sound pressure level are predicted with electrical-mechanical-acoustical analogous circuits. The response data predicted by the simulation compare very well with experimental measurements.

Age-related changes in choroid plexus and blood-cerebrospinal fluid barrier function in the sheep

Dysfunction of the choroid plexuses (CPs) and the blood-cerebrospinal fluid barrier (BCSFB) might contribute to age-related cognitive decline and neurodegenerative disease. We used the CPs from young (1-2 years), middle-aged (3-6 years) and old (7-10 years) sheep to explore effects of aging on various aspects of CP and BCSFB functions. Total protein in the cerebrospinal fluid (CSF) was significantly higher in old compared to young sheep and CSF secretion by the CP perfused in situ was significantly lower in both old and middle-aged when compared to young sheep, which correlated with reduced (22)Na(+) uptake and efflux by the CP. Steady-state extractions of a low and medium size molecular weight extracellular space marker, (14)C-mannitol and (3)H-polyethylene glycol, respectively, were significantly higher in CPs from old compared to young animals; however, there was no significant difference in steady-state extraction of a high molecular weight marker, (125)I-bovine serum albumin. This indicates increased passive BCSFB permeability for small and medium sized molecules in old sheep. CP redox activity was significantly lower in the old animals as assessed by the MTT assay, however, there was no significant difference in ATP content and energy charge of the CP with age suggesting adequate baseline energy reserve capacity. These data indicate that normal aging processes alter protein content in the CSF, CSF secretion, integrity of the BCSFB and Na(+) flux in the epithelial layer, which could impact on CSF homeostasis and turnover.

Optimal design of resonant piezoelectric buzzer from a perspective of vibration-absorber theory

In this paper, an optimization technique is presented for the design of piezoelectric buzzers. This design technique aims at finding the optimal configuration of the coupled cavity and diaphragm structure to maximize the sound pressure output. Instead of measuring the material constants of the piezoelectric ceramic and the metal diaphragm, an "added-mass method" is developed to estimate the equivalent electromechanical parameters of the system on which an analogous circuit can be established. The electrical impedance and on-axis sound pressure level of the piezoelectric buzzer can be simulated by solving the loop equations of the electromechanoacoustical analogous circuit. An interesting finding of this research is that the nature of the piezoelectric buzzer bears remarkable resemblance to that in the dynamic vibration absorber theory. Much physical insight can be gained by exploiting this resemblance in search of the optimal configuration. According to the system characteristic equation, a design chart was devised to "lock" the critical frequency at which the system delivers the maximal output. On the basis of the analogous circuit and the vibration absorber theory, an optimal design was found with constrained optimization formalism. Experiments were conducted to justify the optimal design. The results showed that the performance was significantly improved using the optimal design over the original design. Design guidelines for the piezoelectric buzzers are summarized.

Dose-dependent transthyretin inhibition of T4 uptake from cerebrospinal fluid in sheep

Transthyretin (TTR), synthesized by the choroid plexuses (CP) has an important role in transporting thyroxine from blood to cerebrospinal fluid (CSF). However, the role of TTR on thyroxine transport from CSF to either blood or brain is not clear. By using the incubated isolated ovine brain tissues technique, we found the CP accumulated most 125I-T4 compared to ventricular ependymal, frontal cortex or cerebellum. The accumulation was higher in the young CP than the old. There was dose-dependent inhibition by TTR on 125I-T4 accumulation in the brain tissues, and kinetics of T4 accumulation in presence of TTR was obtained by plotting a double reciprocal of B (bound) versus TTR concentration curve. The KD of 125I-T4 binding to TTR was higher in the CP compared to other tissues, suggesting that CP competes with TTR for T4 binding to a greater extent than the other tissues. Using the isolated perfused CP preparation, TTR significantly inhibited 125I-T4 efflux across CP from the CSF to blood side. Bovine serum albumin (BSA) was also able to inhibit 125I-T4 accumulation in the incubated tissues, but required higher concentrations to reach the level of inhibition seen with TTR. In conclusion, this study found a significant role for CSF TTR in preventing T4 loss to blood across the CP, and TTR inhibited both CP and selected brain tissue uptake in a dose-dependent manner. The physiological relevance of TTR may relate to preventing T4 loss from CSF and encouraging redistribution of hormone around the brain in CSF.

Improved treatment results for childhood acute myeloid leukemia in Taiwan

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

The effect of hyperbaric oxygen on human oral cancer cells

Discoveries of the beneficial cellular and biochemical effects have strengthened the rationale for the administration of hyperbaric oxygen therapy (HBO2) as an adjunctive therapy for the treatment of osteoradionecrosis (ORN). Malignancies, however, are considered a contraindication for HBO2 because of the possible tumor-promoting effects. The aim of this study was to examine the effects of HBO2 therapy on tumor weight, and to measure the progression of apoptosis and tumor cell proliferating activity in a cultured human oral cancer cell line. Twenty 5-week-old male NODscid mice underwent daily HBO2 of 2.5 atm abs, 90 minutes for 20 treatments. The control group, n = 20, did not undergo HBO2 and tumor weight, apoptosis index, and proliferating activity parameters were compared between the two groups. The results showed no significant differences (p < 0.05) in the whole-body weights, tumor weights, apoptotic index or proliferating activity index between the two groups. By using the apoptosis and proliferating activity assays which were better indicators of tumor cell growth than tumor weight alone, our results suggest that the clinical application of HBO2 does not promote the growth or proliferation of human oral cancer cells.

Characterization of an important enzymatic component in collagenase that is essential for the effective digestion of the human and porcine pancreas

Recent clinical results from Edmonton have demonstrated the feasibility of achieving normoglycemia in type I diabetic patients by islet transplantation. One of the key issues in obtaining this success was transplanting sufficient numbers of islets by sequential transplants. Although the development of semipurified endotoxin-free Clostridium histolyticum-derived collagenase (Liberase) has improved islet yields from the human pancreas, batch-to-batch variation and loss of activity with time still hampers progress in obtaining consistent islet preparations. In order to define key components of crude collagenase, a panel of monoclonal antibodies (McAbs) was raised against crude collagenase. Monoclonal antibodies were generated by fusions between splenocytes of BALB/c mice immunized with Boheringer P collagenase and the myeloma cell line NS-0. These monoclonal antibodies were used as probes to study molecular differences between effective and ineffective collagenase batches using Western blotting. Two monoclonal antibodies (LDS71 and LDS81) were raised and characterized as recognizing separate epitopes on a 125-kDa component. Western blotting indicated that the 125-kDa band was rapidly broken down by storage or by dialysis in the presence of dithiothreitol. However, this breakdown could be prevented by the addition of leupeptin (a protease inhibitor) to the dialysis buffer. On testing fractions at 5-min intervals from the "Ricordi" digestion circuit during porcine and human pancreas digestion, the 125-kDa component was rapidly broken down in relatively ineffective collagenase batches but in effective batches was present throughout the digestion process. The correlation between the presence of the 125-kDa band and effectiveness of pancreas digestion suggests that this may be a key component in the formulation of C. histolyticum collagenase.

Cell surface glypicans are low-affinity endostatin receptors

Endostatin, a collagen XVIII fragment, is a potent anti-angiogenic protein. We sought to identify its endothelial cell surface receptor(s). Alkaline phosphatase- tagged endostatin bound endothelial cells revealing two binding affinities. Expression cloning identified glypican, a cell surface proteoglycan as the lower-affinity receptor. Biochemical and genetic studies indicated that glypicans' heparan sulfate glycosaminoglycans were critical for endostatin binding. Furthermore, endostatin selected a specific octasulfated hexasaccharide from a sequence in heparin. We have also demonstrated a role for endostatin in renal tubular cell branching morphogenesis and show that glypicans serve as low-affinity receptors for endostatin in these cells, as in endothelial cells. Finally, antisense experiments suggest the critical importance of glypicans in mediating endostatin activities.

Assays for angiotensin converting enzyme inhibitory activity

A colorimetric method and a capillary electrophoresis procedure were developed for quantifying histidyl-leucine and hippurate, respectively. The colorimetric method is sensitive (extinction coefficient = 7.5 mM(-1) cm(-1)) and reproducible (CV = 1.7%, n = 5), which is based on a selective chromogenic reaction for histidyl-leucine (lambda(max) = 390 nm) using o-phthalaldehyde. For samples containing unusually high levels of histidine and/or histidyl peptides, the separation-based approach is preferable. The capillary electrophoresis method makes use of an in-capillary microextraction technique; complicated samples can be measured in less than 4 min without pretreatment. Protocols using both methods to measure angiotensin converting enzyme inhibitory activity were proposed.

Mechanisms underlying preferential assembly of heparan sulfate on glypican-1

Glypicans are major cell surface heparan sulfate proteoglycans, the structures of which are characterized by the presence of a cysteine-rich globular domain, a short glycosaminoglycan (GAG) attachment region, and a glycosylphosphatidylinositol membrane anchor. Despite strong evolutionary conservation of the globular domains of glypicans, no function has yet been attributed to them. By using a novel quantitative approach for assessing proteoglycan glycosylation, we show here that removal of the globular domain from rat glypican-1 converts the proteoglycan from one that bears approximately 90% heparan sulfate (HS) to one that bears approximately 90% chondroitin sulfate. Mutational analysis shows that sequences at least 70 amino acids away from the glypican-1 GAG attachment site are required for preferential HS assembly, although more nearby sequences also play a role. The effects of the glypican-1 globular domain on HS assembly could also be demonstrated by fusing this domain to sequences representing the GAG attachment sites of other proteoglycans or, surprisingly, simply by expressing the isolated globular domain in cells and analyzing effects either on an exogenously expressed glypican-1 GAG attachment domain or on endogenous proteoglycans. Quantitative analysis of the effect of the globular domain on GAG addition to proteoglycan core proteins suggested that preferential HS assembly is achieved, at least in part, through the inhibition of chondroitin sulfate assembly. These data identify the glypican-1 globular domain as a structural motif that potently influences GAG class determination and suggest that an important role of glypican globular domains is to ensure a high level of HS substitution of these proteoglycans.

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

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

Probing for the threshold energy for visual transduction: red-shifted visual pigment analogs from 3-methoxy-3-dehydroretinal and related compounds

While azulenic retinal analogs failed to yield a red-shifted visual pigment analog, the 9-cis isomers of the push-pull polyenals 3-methoxy-3-dehydroretinal and 14F-3-methoxy-3-dehydroretinal yielded iodopsin pigment analogs with absorption maxima at, respectively, 663 and 720 nm. The former gave a relatively stable batho product (700 nm) and was able to activate transducin. A lower activity was observed for the latter. One possible explanation for the combined results is that the excitation energies of these red-shifted pigments are approaching the threshold energy for visual transduction (although at this time we cannot rigorously exclude a role of the added F-atom in reducing the transducin activity).

Niemann-Pick disease type C (a cellular cholesterol lipidosis) treated by bone marrow transplantation

Bone marrow transplantation (BMT) has been used for a wide variety of lysosomal storage diseases with encouraging results. We report a 3-year 5-month-old girl with Niemann-Pick type C disease (NPC) who received an allogeneic BMT. The patient presented with repeated lower respiratory tract infections, hepatosplenomegaly, failure to thrive, and developmental delay. Chest computed tomography (CT) revealed diffuse interstitial lung infiltration. Bone marrow and liver biopsies revealed abundant lipid-filled foamy macrophages. Skin fibroblast sphingomyelinase assay revealed partial deficiency. The ability of her skin fibroblasts to esterify cholesterol was very low, and the cells stained brightly for free cholesterol. She received BMT from a healthy HLA-identical male sibling donor at the age of 2 year 6 months. Full engraftment was evidenced by repeated bone marrow sex chromosome studies. Regression of the hepatosplenomegaly, markedly reduced foamy macrophage infiltration in bone marrow, and decreased interstitial lung infiltration was noted 6 months after BMT. Her neurological status, however, deteriorated. Follow-up magnetic resonance image (MRI) revealed progressive, diffuse brain atrophy. We conclude that resolution occurred in the liver, spleen, bone marrow and lung following successful engraftment. Such a response is remarkable since the underlying problem involves a membrane receptor for cholesterol. This positive response might be due to replacement of the monocyte-phagocytic system or it may imply the existence of cross-correction in the NPC membrane receptor defect by BMT approach. Since BMT did not halt the neurological deterioration, it is unlikely to be an adequate treatment for NPC.

Longitudinal observation and outcome of nonfamilial childhood haemophagocytic syndrome receiving etoposide-containing regimens

The long-term outcome of 22 children treated with etoposide-containing regimens for haemophagocytic syndrome (HS) were longitudinally studied; none of them had a family history of the disease. All patients received etoposide-containing (150 mg/m2/d) regimens, combined, in 16 cases, with intravenous immunoglobulin (IVIG) and prednisolone. Complete remission (CR) was achieved in 12 patients, partial remission in seven, and early mortality occurred in three. Of the 12 CR patients, only four remain alive and disease-free, with a median follow-up of 47.4 months; one CR patient died due to infection and the remaining seven had relapsed diseases. Three patients with a partial response or with relapsed disease progressed to T-cell lymphoma, characterized, in the two cases tested, by clonal chromosomal abnormalities. Epstein-Barr virus (EBV) infection was implicated in disease pathogenesis in 15/22 patients. The overall survival was 45.5%, 40.9% and 40.9% at 1, 3 and 5 years, respectively, and disease-free survival for CR patients at these same times was 45.5%, 36.4% and 36.4%. The etoposide-containing regimen would appear to be an effective initial therapeutic option for childhood HS. However, in view of the frequency of partial remissions and relapsed disease, a more intensive chemotherapy or bone marrow transplantation should be applied. The progression to EBV-containing T-cell lymphoma in three patients is consistent with the previous observation that EBV-associated HS is a potentially malignant disease.

Can severe neonatal jaundice be prevented by neonatal screening for glucose-6-phosphate dehydrogenase deficiency?--a review of evidence

An evidence-based approach is used to evaluate the neonatal screening program for glucose-6-phosphate dehydrogenase (G-6-PD) deficiency. The primary consideration to include G-6-PD deficiency (G-6-PDD) in neonatal screening program was the public health burden of G-6-PDD-associated neonatal jaundice (G-6-PDDANJ) in the target population. However, the prevalence of G-6-PDD per se cannot be the sole index of the public health burden of G-6-PDDANJ. In more developed areas, G-6-PDDANJ is no longer a major public health problem. Further, most cases with G-6-PDDANJ in more developed areas are not precipitated by any identifiable icterogenic agents, and therefore not preventable by avoidance education. In less developed areas, however, G-6-PDDANJ is still a big public health burden and requires intervention. In this study, the effectiveness of neonatal screening programs for G-6-PDD to prevent severe neonatal jaundice(NJ) has been shown based on historical comparison, but the results may be confounded by other temporal factors. G-6-PDDANJ usually occurs in the first week after birth. Prompt need for G-6-PD screening results precludes it from incorporation into other existent neonatal screening programs (i.e., for PKU), and from centralization of laboratory work. The efficacy, adverse effects and cost-effectiveness of this mass screening program need further study.

Paroxysmal nocturnal hemoglobinuria presenting as moyamoya syndrome

We report an 11-year-old girl who has paroxysmal nocturnal hemoglobinuria (PNH) and was admitted because of recurrent cerebrovascular accidents (CVA) and intermittent hemoglobinuria. Internal carotid angiography revealed bilateral typical moyamoya patterns. Although CVA due to arterial thrombosis may occur in PNH, the basal moyamoya vessels were never mentioned in case reports yet. The moyamoya syndrome has been reported in a variety of diseases and represents the nonspecific response to an impairment of arterial flow at specific sites in the brain. Our case discloses that PNH may present as moyamoya syndrome.

Lung cancer mortality update and prevalence of smoking among copper miners and smelters

OBJECTIVES

The aim of this investigation was to study the cancer mortality of Chinese copper miners and smelters further, with particular reference to that from lung cancer, and smoking prevalence.

METHODS

From an earlier follow-up (1970-1985) of the mortality of the two cohorts, all new death cases registered since 1985 were recorded, and the mortality analysis was extended through 1992. A questionnaire survey of smoking habits was carried out in three samples, randomly chosen from the copper miners (N = 1125), smelters (N = 603), and local residents (N = 1517) of Tongling city.

RESULTS

Lung cancer was significantly increased among the copper miners [standardized mortality ratio (SMR) 152, 95% confidence interval (95% CI) 123-187], but not among the copper smelters (SMR 102, 95% CI 53-178). Smoking was more prevalent among copper miners than among local male residents (71.7 versus 64.3%, P < 0.001), whereas among the smelters it was significantly less prevalent (57.4 versus 64.3%, P < 0.005). Similar patterns were found for the average number of cigarettes smoked daily among the miners (21.6 +/- 7.2), smelters (15 +/- 7.1), and local male residents (19.2 +/- 7.3).

CONCLUSIONS

In addition to occupational exposures, cigarette smoking may partly play a role in influencing mortality from lung cancer among Chinese copper miners and smelters.

Hemophagocytic syndrome in Epstein-Barr virus-associated T-lymphoproliferative disorders: disease spectrum, pathogenesis, and management

The Epstein-Barr virus (EBV) has been shown to infect T lymphocytes and is associated with two recently recognized human T-lymphoproliferative disorders: childhood EBV-associated hemophagocytic syndrome (VAHS) representing a primary or active EBV infection of T cells in young children, and the EBV-containing T cell lymphoma in adults predominantly affecting the nose, skin and gastrointestinal tract. In both diseases, hemophagocytic syndrome (HS) accounts for the major cause of mortality. The patients developing HS share common clinicopathologic features such as fever, skin lesions, lung infiltrates, hepatosplenomegaly with jaundice, cytopenias, and coagulopathy. The liver, spleen, lymph nodes, and bone marrow usually show florid histiocytic proliferation with hemophagocytosis in addition to the proliferation of atypical T lymphocytes or immunoblasts. The HS in T cell lymphoma may develop simultaneously with initial lymphoma presentation, at tumor relapse, or even during remission. The cytokines, in particular tumor necrosis factor-alpha, released from the EBV-infected T lymphocytes are presumed to cause the histiocytic activation and the subsequent hemophagocytic process. Chemotherapy or antiviral agents fail to arrest the hemophagocytic process in both diseases. Immunomodulatory treatment incorporating etoposide and intravenous immunoglobulin, however, has been effective in the control of the progression of the hemophagocytic process in a substantial number of VAHS patients. Preliminary data suggest that bone marrow transplantation may be a promising way for eliminating both the virus and the proliferating T cells. Further investigations are mandatory for combating this aggressive hemophagocytic process in EBV-associated T lymphoproliferative disorders.

Recombinant alpha-interferon treatment of intracranial hemangioma and Kasabach-Merritt syndrome in an infant with cytomegalovirus

A 2-month-old girl presented with enlarged head girth, generalized petechiae, anemia, coagulopathy and hepatosplenomegaly. Imaging studies showed a huge, dumbbell-shaped intracranial hemangioma located between the falx, and involving the supra- and infra-tentorium, extending through the posterior fontanel to involve the subgaleal area. A urine culture grew cytomegalovirus. Severe thrombocytopenia was refractory to a massive platelet transfusion, intravenous immunoglobulin and corticosteroid therapy. Hypertension, pulmonary hemorrhage and sepsis complicated the course. After establishing a diagnosis of Kasabach-Merritt syndrome, subcutaneous injections of alpha-interferon were given with an initial dose of 1 x 10(6) IU/m2 followed by 3 x 10(6) IU/m2 per day for 12.5 mo. Her platelet count rose gradually and became stable after 1.5 mo of interferon treatment. The intracranial hemangioma regressed remarkably and the hepatosplenomegaly was also resolved. The infant showed good growth and development, without obvious side-effects during the 23-month follow-up period. The treatment with recombinant alpha-interferon appeared to be effective in reversing thrombocytopenia associated with the patient's massive intracranial hemangioma.

Immunomodulation treatment for childhood virus-associated haemophagocytic lymphohistiocytosis

The Epstein-Barr virus (EBV), or human herpesvirus-6 (HHV-6) associated haemophagocytic lymphohistiocytosis, has been found prevalent in Taiwan; it affects previously healthy children and is always fatal when treated only supportively. Recognition of the underlying pathogenesis for this disease prompted adoption of an immunomodulatory regimen of intravenous immunoglobulin (IVIG) and/or etoposide on 17 such patients treated between 1990 and 1993. Remarkable improvement in patients' prognoses was demonstrated. Eight patients are still alive with a median follow-up of 1 year and 2 months post-treatment. Both IVIG and etoposide had positive immunomodulation effects such as alleviation of fever and normalization of haematological and hepatic parameters. Sustained complete response was obtained in two of nine cases of EBV-associated diseases treated with IVIG only. EBV transcripts became undetectable after etoposide and/or IVIG treatment without antiviral agents. Etoposide given by split-doses schedule appeared to be superior to conventional three-consecutive-days schedule for both remission induction and disease-free survival. Our preliminary trial apparently provides a promising improvement in the treatment of this previously fatal disease. IVIG or etoposide is effective in reversing the process of lymphohistiocytic dysregulation resulting from virus infection of immune cells in this syndrome and probably helps hosts to control active virus replication in certain cases, through immunomodulation.

Allogeneic bone marrow transplantation for children with acute lymphoblastic leukemia in second remission or relapse

Most children with acute lymphoblastic leukemia (ALL) are successfully treated by chemotherapy. For those patients, who relapse on therapy, bone marrow transplantation (BMT) is considered most appropriate after a subsequent remission is achieved. Three boys with ALL aged from 9 to 13 years met these criteria and received BMT from their HLA-compatible sisters after marrow ablation with total body irradiation 12 Gy plus high dose cytosine arabinoside 3 gm/m2/12h x 12 doses and graft-versus-host disease (GVHD) prophylaxis with cyclosporine plus short course methotrexate from March 10, 1989 to May 23, 1992. Filgrastim (rhG-CSF) was used to hasten the recovery of granulocyte in one patient. All three patients got full engraftment and two had grade 1 acute GVHD. None of them developed chronic GVHD. Two patients have disease-free survival over 51 and 12 months respectively post BMT without further chemotherapy. One patient died of recurrent refractory leukemia 5 months after BMT. The toxicity of this conditioning regimen included photophobia, conjunctivitis and erythematous skin rashes. One patient who received filgrastim from day 1 to 21 developed severe bone pain. However, this patient had faster recovery of granulocyte count than the other two patients. The preliminary results of this work favors BMT for children with recurrent ALL whose ultimate survival is usually poor when treated with chemotherapy. Further efforts are necessary to investigate new methods for reducing leukemic relapse in ALL patients undergoing BMT.

Bone marrow transplantation for childhood acute myelogenous leukemia

Six consecutive patients with acute myelogenous leukemia (AML) underwent 7 allogeneic bone marrow transplants at National Taiwan University Hospital. Marrow ablation for 4 patients consisted of busulfan 16 mg/kg and cyclophosphamide 120 mg/kg (BUCY 2). Two patients had busulfan 16 mg/kg and cyclophosphamide 200 mg/kg (BUCY 4) as marrow ablation. One had a second transplant following cytosine arabinoside 3 gm/m2/dose x 10 doses plus total body irradiation 12 Gy. Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine and short course methotrexate. Four patients received marrow from their HLA compatible siblings and two from their HLA-haplotype-matched fathers. Four transplants were performed during first remission and the other three during subsequent remission or relapse. All patients except one engrafted and achieved a complete remission (CR). Three of 4 patients transplanted in first CR are alive for over 10, 20 and 59 months respectively after transplant. One of the two patients who each received marrow from their fathers during 2nd CR and relapse, developed relapse 5 months later and the other developed aplasia 3 months later. Acute GVHD occurred in two of six patients. Localized chronic GVHD occurred in one of these two patients. Toxicities of BUCY 2 were minimal except veno-occlusive disease. One patient who received BUCY 4 developed hemorrhagic cystitis. There were no treatment related deaths except one patient who received 2nd transplant. These results demonstrate that BUCY 2 should be considered as a preparative regimen for allogeneic bone marrow transplantation for patients with AML in first remission.(ABSTRACT TRUNCATED AT 250 WORDS)

Epstein-Barr virus (EBV) infects T lymphocytes in childhood EBV-associated hemophagocytic syndrome in Taiwan

We have reported the prevalence of a fulminant hemophagocytic syndrome (HS) in previously healthy young children in Taiwan, most of which probably represent a lethal form of primary or active Epstein-Barr virus (EBV) infection. To further confirm their EBV association, in situ EBV hybridization (ISH) was performed on tissue biopsies from 15 pediatric HS patients (median age, 3 years and 4 months) using digoxigenin-labeled RNA probes EBER1. Double labeling immunostaining and ISH was then performed to define the immunophenotype of the lymphoid cells containing the EBV transcripts. Among the 13 patients who had serological evidence of acute or active EBV infection, 9 had demonstrable EBER1 transcripts in bone marrow, liver, and/or skin biopsies. EBER1-specific signal was not detectable in the two specimens from EBV-seronegative patients. The distribution of EBV-containing cells could be extensive or scattered. To our surprise, the EBER1 transcripts existed exclusively in T lymphoid cells in all nine cases examined rather than in B cells as previously believed in infectious mononucleosis. Considering the young affected age of the HS patients and the serological response to EBV, we suggest that EBV can infect T cells in primary EBV infection and the proliferation of these EBV-infected T cells may be responsible for the ominous outcome in childhood HS patients in Taiwan.

Cytomegalovirus-induced persistent mononucleosis in an infant

Chronic mononucleosis has recently gained much attention in the literature. Almost all cases of this new syndrome have been ascribed to persistent Epstein-Barr virus infection. However, a case presented with infantile chronic mononucleosis syndrome caused by persistent cytomegalovirus infection. Transient clonal chromosomal change was noted during follow-up.

L-asparaginase-related pancreatic pseudocyst: report of a case

Pancreatitis following the administration of L-asparaginase (L-asp) has been well documented. However, the progression of such pancreatitis to pseudocyst formation in some patients has been rarely reported. The few reported cases have been teenagers, with the exception of one adult. All pseudocysts required surgical management. This report documents a pancreatic pseudocyst in a seven-year-old girl with acute lymphoblastic leukemia whose treatment regimen included L-asp. The pseudocyst was managed medically with nasogastric decompression, intravenous hyperalimentation, and antibiotics. The pseudocyst resolved spontaneously in one month without complication.

Epstein-Barr virus-associated lymphoproliferative disorder of granular lymphocytes presenting initially as cutaneous vasculitis

Lymphoproliferative disorders of granular lymphocytes (LDGL) represent a family of diseases characterized by persistent granular lymphocytosis with variable prognosis. The Epstein-Barr virus (EBV) has been occasionally linked with the development of LDGL. However, cutaneous manifestations of LDGL have rarely been reported. One patient had cutaneous vasculitis for 10 years before a definite diagnosis of LDGL was made. Chronic EBV infection was documented serologically and EBV DNA was detected in the peripheral blood lymphocytes. EBV RNA was detected in the nuclei of infiltrating lymphoid cells expressing CD43 in a skin biopsy specimen. A cytogenetic study showed clonal chromosomal abnormalities. This is the first report of EBV-associated LDGL of natural killer cells with cutaneous manifestations.

Peripheral T-cell lymphoma in childhood: a report of five cases in Taiwan

We encountered five children with peripheral T-cell lymphoma (PTL) at National Taiwan University Hospital (NTUH) from 1985-1989. The patients were four boys and one girl, aged between 5 and 13 years. The duration of prediagnostic symptoms varied from 1 month to 5 years. All had pyrexia and lymphadenopathy; one had a prolonged history of granulomatosis with repeated infection. Four had hepatosplenomegaly. One patient presented with diffuse pulmonary infiltration and impending respiratory failure. All patients were negative for human T-cell leukemia virus (HTLV)-I antibody, and positive for HBsAg. Four patients who had EBV-viral capsid antigen (VCA) IgG and who were IgM tested were positive for EBV-VCA IgG, but only two had evidence of active EBV infection. Tumor cell markers were examined and showed the following phenotypes: all patients were CD2, CD3, and CD7 positive but CD19 and CD20 negative; three patients were CD4 positive and CD8 negative; the other two patients were CD4 negative and CD8 positive. Four patients died 2-7 months after diagnosis. The remaining patient received allogeneic bone marrow transplantation and has survived free of disease for more than 22 months after transplant. Our five cases reconfirm the high frequency of diagnostic delay, the heterogenous immunophenotypes, high mortality, and poor responsiveness to conventional therapy for PTL. Bone marrow transplantation in the early stage might be a possible cure of this disease.

Cytogenetic characterization of Epstein-Barr virus-associated T-cell malignancies

Recently, Epstein-Barr virus (EBV) infection has been found not only to be associated with Burkitt lymphoma and nasopharyngeal carcinoma but also with some T-cell malignancies. Cytogenetic studies were performed on four Chinese patients with EBV-associated T-cell neoplasms: three peripheral T-cell lymphomas and one large granular lymphocyte leukemia with coexpression of T-cell antigen. Clonal chromosomal abnormalities were detected in all four patients. Rearrangements of chromosome 7 were observed in three patients: one at 7p22, one at 7q35 or 36, and the remaining one at both sites. The last patient also had a chromosomal abnormality involving 14q11. Trisomy of part of the 1q segment was detected in two patients. The results revealed that the chromosomal abnormalities in these patients were similar to those observed in other T-cell lymphomas. Further studies on more patients are necessary to find out whether there are specific chromosomal aberrations in EBV-associated T-cell neoplasms.

Congenital factor VII deficiency complicated with hemoperitoneum and intracranial hemorrhage: report of a case

Hypoproconvertinemia, or factor VII deficiency, is a rare congenital coagulopathy. We report on a female infant with congenital factor VII deficiency complicated by hemoperitoneum and intracranial hemorrhage. Most reports indicate that the bleeding of victims tends to be mild and confined to the superficial mucosa area. However, other reports and our experience with this patient suggest that it can result in fatal cerebral hemorrhage and necessitate early diagnosis, effective treatment and careful genetic counseling.

DNA fingerprinting in the Chinese with an oligonucleotide probe (GTG)5

DNA fingerprinting is a very powerful tool that enables specific identification of individuals. In order to study fingerprinting patterns in the Chinese, the oligonucleotide probe designed by Epplen et al was used. Peripheral blood leukocyte DNA was digested with restriction enzyme Hinf I and probed by (GTG)5. Normal females and males were tested; all revealed very different DNA fingerprints. Most of the discernible bands in the gel were polymorphic; there was no specific association between any polymorphic band and the sex of the individual tested. In situ gel-hybridization was used with the oligonucleotide probe, and after electrophoresis, all procedures could be completed within one working day. Three patients who had received bone marrow transplants from their respective siblings had the same fingerprints as their donors. The inheritance of all bands from either the father or mother proved parents' authenticity. DNA fingerprinting with a oligonucleotide probe is obviously a useful technique. Clinical application may include engraftment monitoring, zygosity determination and paternity testing.

Long-term observation of pediatric aplastic anemia

Fifty-nine verified cases of acquired aplastic anemia (AA), diagnosed at the Pediatric Department of the National Taiwan University Hospital from 1977 to 1987, were reviewed and analyzed. The demographic features showed a high relative incidence (acute myelogenous leukemia/AA ratio, 2.2/1), a high percentage of non-severe AA (39%) and a high association with hepatitis (20.8%). No evidence of hepatitis A, B or C virus infection was found in five cases of hepatitis-associated AA. No sex preponderance was noted in this pediatric series. The 10-year projected survival rate of the total series approached 55%. The crude two-year-survival and two-year-transfusion-free-survival rates were 59% and 44%, respectively, in the conservative therapy group treated with androgens and steroids; 36% and 32%, respectively, in patients with severe AA in the conservative therapy group; and 73% and 64%, respectively, in the aggressive therapy group treated with cyclosporin, anti-lymphocyte globulin or bone marrow transplant. The major causes of death were hemorrhage (44%) and infection (56%) in the conservative therapy group; but in the aggressive therapy group, two out of three deaths were related to therapeutic complications. Multivariate analysis of prognostic factors revealed that severity and treatment modality were independent risk factors. Only two out of 31 patients who survived more than two years (long-term survivors) experienced late mortalities. At two, five, seven and 10 years after diagnosis, 61%, 55%, 41% and 40% of the long-term survivors had inadequate hematopoietic recovery.

Infantile osteopetrosis: report of two cases

Two cases of infantile osteopetrosis are reported. Both were males aged four and eight months at presentation. They presented with osteosclerotic change of the bone, leukoerythroblastic anemia, optic atrophy, hepatosplenomegaly and frequent infection. The histology of the bone showed thickened bone trabeculae with little osteoclastic activity, although in one patient the number of osteoclasts increased, while in the other they did not. One received a bone marrow transplant (BMT) but died from disseminated cytomegaloviral infection, pulmonary hemorrhage and sepsis. The post-transplant marrow histology showed evidence of engraftment and osteoclastic activity. The other only received a course of prednisolone, which was of little help. His condition has followed a natural course with progressive visual impairment and marrow failure. Our cases suggest that infantile osteopetrosis should be taken into consideration in dealing with infants who present with early marrow failure and that patients of infantile osteopetrosis should receive BMT. BMTs appear to be the only cure. They should be given as early as possible to avoid major consequences and severe infection.

Congenital intractable diarrhea with possible defective crypt regeneration: report of a case

A male infant, born uneventfully from a consanguinous marriage, presented with intractable watery diarrhea from his third day of life, with subsequent malnutrition and failure to thrive. He received central parenteral nutrition beginning at three months of age after a poor response to a semielemental diet and peripheral parenteral nutrition. He was totally dependent on central parenteral nutrition thereafter. Although diarrhea disappeared with strict bowel rest, intolerance to minimal enteral feedings persisted throughout his 2 years 4 months of life. Investigations including stool examinations and repeated cultures, immune function studies, radiologic studies of the small bowel and screening for galactosemia and cystic fibrosis could not demonstrate a specific cause for the diarrhea. Repeated small intestinal biopsies at 1 month, 4 months and 1 year 5 months of age showed persistent villous atrophy with crypt hypoplasia and a low crypt mitotic index. Electron microscopic examination revealed normal-appearing microvilli. This child may have had a congenital enteropathy due to an inborn crypt regeneration defect causing lifelong intolerance to enteral feedings.

A pathologic study of childhood lymphoma in Taiwan with special reference to peripheral T-cell lymphoma and the association with Epstein-Barr viral infection

The authors retrospectively reviewed the clinicopathologic and immunologic features of 65 consecutive cases of childhood lymphoma reported between 1980 and 1989. Southern blot hybridization was also performed in 23 cases to study their association with Epstein-Barr virus (EBV) and human T-cell leukemia virus type 1 (HTLV-1). The 65 cases included 56 non-Hodgkin's lymphoma (NHL) (86%) and 9 Hodgkin's disease (HD) (14%). The NHL could be classified into the following groups: Group I, small noncleaved cell lymphoma (20 cases); Group II, lymphoblastic lymphoma (17 cases); Group III, large cell lymphoma (17 cases); and miscellaneous (2 cases). There was no follicular lymphoma case. Immunohistochemical study on paraffin sections and/or frozen specimens in 47 cases of NHL showed that all the Group I cases belonged to B-cell neoplasm (17 of 17 cases); most of the Group II cases belonged to T-cell neoplasm (9 of 14 cases); and most of the Group III cases were peripheral T-cell lymphoma (PTL) (8 of 16 cases), including 2 cases of Ki-1 lymphoma. The majority of childhood NHL belonged to high-grade malignancy with an aggressive clinical course (median survival time, 8 months). The EBV DNA could be detected from the tumor tissues in 4 of 6 PTL, but in none of the remaining 19 cases of NHL including 6 Burkitt's type lymphomas. HTLV-1 proviral genome was not detected in all specimens examined. The authors concluded that the distribution pattern and clinicopathologic feature of childhood lymphoma in Taiwan are comparable to that in Japan and western countries. The frequent association of EBV with aggressive PTL was unique and deserves additional investigation.

Hemorrhagic pericardial effusion in beta-thalassemia major: report of a case

Although sterile pericardial effusion occurs in about half of the patients with massive iron overload, hemorrhagic pericardial effusion is rarely seen in beta-thalassemia major patients. A 10-year-old girl with beta-thalassemia major who was diagnosed in her early infancy developed a massive hemorrhagic pericardial effusion. She was receiving blood transfusions every 4-6 weeks without chelating therapy with an average hemoglobin (Hb) level of 6-9 g/dL. Progressive hepatospenomegaly was noted during the course. She had complained of orthopnea with palpitation and bilateral leg edema before admission. After evaluation, a massive pericardial effusion was found and pericardiocentesis was performed twice, which revealed a bloody and uncoagulable effusion. Finally a pericardial window was performed to eliminate the bloody effusion. Negative etiological evaluations of blood and pericardial effusion were reported. Pathological examination of the pericardial biopsy revealed hemosiderosis with a few lymphocytic infiltrates. We report this case for its rarity and its necessity for urgent treatment.