Time of Emergence and Large Ensemble Intercomparison for Ocean Biogeochemical Trends

Anthropogenically forced changes in ocean biogeochemistry are underway and critical for the ocean carbon sink and marine habitat. Detecting such changes in ocean biogeochemistry will require quantification of the magnitude of the change (anthropogenic signal) and the natural variability inherent to the climate system (noise). Here we use Large Ensemble (LE) experiments from four Earth system models (ESMs) with multiple emissions scenarios to estimate Time of Emergence (ToE) and partition projection uncertainty for anthropogenic signals in five biogeochemically important upper-ocean variables. We find ToEs are robust across ESMs for sea surface temperature and the invasion of anthropogenic carbon; emergence time scales are 20-30 yr. For the biological carbon pump, and sea surface chlorophyll and salinity, emergence time scales are longer (50+ yr), less robust across the ESMs, and more sensitive to the forcing scenario considered. We find internal variability uncertainty, and model differences in the internal variability uncertainty, can be consequential sources of uncertainty for projecting regional changes in ocean biogeochemistry over the coming decades. In combining structural, scenario, and internal variability uncertainty, this study represents the most comprehensive characterization of biogeochemical emergence time scales and uncertainty to date. Our findings delineate critical spatial and duration requirements for marine observing systems to robustly detect anthropogenic change.

Emergence of Anthropogenic Signals in the Ocean Carbon Cycle

Attribution of anthropogenically-forced trends in the climate system requires understanding when and how such signals will emerge from natural variability. We apply time-of-emergence diagnostics to a Large Ensemble of an Earth System Model, providing both a conceptual framework for interpreting the detectability of anthropogenic impacts in the ocean carbon cycle and observational sampling strategies required to achieve detection. We find emergence timescales ranging from under a decade to over a century, a consequence of the time-lag between chemical and radiative impacts of rising atmospheric CO₂ on the ocean. Processes sensitive to carbonate-chemical changes emerge rapidly, such as impacts of acidification on the calcium-carbonate pump (10 years for the globally-integrated signal, 9-18 years regionally-integrated), and the invasion flux of anthropogenic CO₂ into the ocean (14 globally, 13-26 regionally). Processes sensitive to the ocean's physical state, such as the soft-tissue pump, which depends on nutrients supplied through circulation, emerge decades later (23 globally, 27-85 regionally).

Predictors of radiation exposure to providers during percutaneous nephrolithotomy

Background:

Limited studies have reported on radiation risks of increased ionizing radiation exposure to medical personnel in the urologic community. Fluoroscopy is readily used in many urologic surgical procedures. The aim of this study was to determine radiation exposure to all operating room personnel during percutaneous nephrolithotomy (PNL), commonly performed for large renal or complex stones.

Materials and Methods:

We prospectively collected personnel exposure data for all PNL cases at two academic institutions. This was collected using the Instadose™ dosimeter and reported both continuously and categorically as high and low dose using a 10 mrem dose threshold, the approximate amount of radiation received from one single chest X-ray. Predictors of increased radiation exposure were determined using multivariate analysis.

Results:

A total of 91 PNL cases in 66 patients were reviewed. Median surgery duration and fluoroscopy time were 142 (38–368) min and 263 (19–1809) sec, respectively. Median attending urologist, urology resident, anesthesia, and nurse radiation exposure per case was 4 (0–111), 4 (0–21), 0 (0–5), and 0 (0–5) mrem, respectively. On univariate analysis, stone area, partial or staghorn calculi, surgery duration, and fluoroscopy time were associated with high attending urologist and resident radiation exposure. Preexisting access that was utilized was negatively associated with resident radiation exposure. However, on multivariate analysis, only fluoroscopy duration remained significant for attending urologist radiation exposure.

Conclusion:

Increased stone burden, partial or staghorn calculi, surgery and fluoroscopy duration, and absence of preexisting access were associated with high provider radiation exposure. Radiation safety awareness is essential to minimize exposure and to protect the patient and all providers from potential radiation injury.

Laparoscopically assisted repair of an acute traumatic diaphragmatic hernia

A 60-year-old man with chronic obstructive pulmonary disease and a heavy smoker and drinker presented to the emergency department with left-sided thoracoabdominal pain after falling down the stairs. Initial clinical findings were left-sided chest tenderness with no clinical evidence of subcutaneous emphysema. Twenty-four hours later the patient's respiratory distress increased-repeat chest X-ray showed a left gastrothorax indicative of a ruptured left hemi diaphragm. Diagnostic laparoscopy in the supine position via an umbilical port confirmed the presence of the stomach, spleen and splenic flexure of the colon in the left chest. Laparoscopic reduction of the stomach and colon was performed, but a small upper midline incision was required to reduce the spleen without injury. The diaphragmatic tear was repaired by direct open suture. The patient required a brief period of postoperative ventilation via a tracheostomy. The patient remained well at a 3-month follow-up visit.

Electrophysiological measurements and analysis of nociception in human infants

Pain is an unpleasant sensory and emotional experience. Since infants cannot verbally report their experiences, current methods of pain assessment are based on behavioural and physiological body reactions, such as crying, body movements or changes in facial expression. While these measures demonstrate that infants mount a response following noxious stimulation, they are limited: they are based on activation of subcortical somatic and autonomic motor pathways that may not be reliably linked to central sensory processing in the brain. Knowledge of how the central nervous system responds to noxious events could provide an insight to how nociceptive information and pain is processed in newborns.

The heel lancing procedure used to extract blood from hospitalised infants offers a unique opportunity to study pain in infancy. In this video we describe how electroencephalography (EEG) and electromyography (EMG) time-locked to this procedure can be used to investigate nociceptive activity in the brain and spinal cord.

This integrative approach to the measurement of infant pain has the potential to pave the way for an effective and sensitive clinical measurement tool.

The vermiform appendix presenting in a laparoscopic port site hernia

Laparoscopic port site hernias (PSHs) are uncommon but present a potential source of morbidity due to incarceration of the hernial contents which is usually omental fat or small bowel. We report only the third case of the vermiform appendix presenting in a symptomatic PSH; we discuss the appropriate management of this condition as well as ways in which the incidence of PSHs may be reduced.

Biliary complications after orthotopic liver transplantation from donors after cardiac death: broad spectrum of disease

BACKGROUND

Donation-after-death liver transplantation (DCD-LT) carries higher complication rates compared with donation-after-brain death liver transplantation (DBD-LT). In this report we describe our experience with biliary complications in DCD-LT with emphasis on anatomical patterns and outcomes.

MATERIALS AND METHODS

We performed retrospective review of patients' medical records from August 2004 to December 2008, during which time total of 26 DCD-LTs were performed. Mean follow-up was 29 months (range 3 to 51 months).

RESULTS

Biliary complications occurred in 12 patients (46%), of whom 9 were related to DCD (35%). Four patients had more than 1 biliary complication, and 4 had concomitant arterial problems (stricture/thrombosis). Treatment of complications included: ERCP (n = 5, 3 resolved), conversion to roux (n = 5, 2 resolved), revision of roux (n = 1), percutaneous transhepatic cholangiography (n = 1), artery revision (n = 3). Three patients with casts had operative extraction of casts depicting a mummified biliary tree; histology showed casts and fibrosis and anastomotic suture material. Six patients underwent retransplantation (23%). Among retransplanted patients, 2 deaths occurred (7.7%).

CONCLUSION

Our experience with DCD-LT reveals a high prevalence of biliary complications with a new and wide spectrum of clinicopathologic findings. Better strategies for prevention of these unique biliary complications are needed to better justify the added risks and costs for performance of DCD-LT.

Colonic carcinoma presenting as strangulated inguinal hernia: report of two cases and review of the literature

Inguinal hernia and colonic carcinoma are common surgical conditions, yet carcinoma of the colon occurring within an inguinal hernia sac is rare. Of 25 reported cases, only one was a perforated sigmoid colon carcinoma in an inguinal hernia. We report two cases of sigmoid colon carcinoma, one of which had locally perforated. Each presented within a strangulated inguinal hernia. Oncologically correct surgery in these patients presents a technical challenge.

Nicorandil and idiopathic anal ulceration

PURPOSE

Several reports have implicated nicorandil as a reversible cause of anal ulceration. We have recently commenced a specialist clinic for patients presenting with severe anal ulceration to assess treatment in this difficult group. Recognition of this association may avoid unnecessary surgery.

METHODS

Twenty-six patients treated with nicorandil had severe painful anal ulceration. Examination under anesthesia was required to biopsy the lesions to exclude neoplasia or inflammatory bowel disease. In total, three patients had proximal diverting stomas without subsequent ulcer resolution, two had perineal debridement with one requiring subsequent skin grafting, and one had an abdominoperineal excision for unremitting pain.

RESULTS

The association of perianal ulceration with nicorandil became apparent only in the latter part of this series. Ten ulcers successfully re-epithelialized when nicorandil was stopped. Nine patients reported anal pain relief and partial healing on clinical examination at two months but failed to show subsequent complete resolution. One patient agreed to nicorandil cessation and reported symptomatic anal pain relief at two weeks but subsequently developed unstable angina requiring hospital admission. Nicorandil was recommenced with anal pain relapse.

CONCLUSIONS

Failure to recognize nicorandil as an etiologic factor in the development of anal ulceration, when other potential underlying well-recognized inflammatory or neoplastic processes have been excluded, may lead to unnecessary surgical intervention in a group of high-risk patients. One of our patients had a potentially avoidable abdominoperineal resection. Pharmaceutical manipulation with alternative antiangina medication may induce healing. Pharmacologic manipulation should be coordinated with a physician to minimize precipitation of unstable angina.

Translocation t(2;3)(p15-23;q26-27) in myeloid malignancies: report of 21 new cases, clinical, cytogenetic and molecular genetic features

Chromosomal rearrangements involving 3q26 either due to inversion or translocation with various partner chromosomes are a recurrent finding in malignant myeloid disorders. Typically, these chromosome aberrations contribute to ectopic expression of or to the formation of fusion genes involving the EVI1 proto-oncogene. Chromosomal translocations involving the short arm of chromosome 2 (p15-p23) and the distal part of the long arm of chromosome 3 (q26-q27) are a rare but recurrent finding in patients with myeloid malignancies, and are assumed to be part of this spectrum of disorders. Thus far, however, these translocations have been poorly studied. Here, we present 21 new cases with myelodysplasia, acute myeloid leukemia or CML in blast crisis, which upon karyotyping showed the presence of a t(2;3). Furthermore, an extensive literature review disclosed 29 additional cases. Morphological, clinical and cytogenetic assessment revealed the typical hallmarks of 3q26/EVI1 rearrangements, that is, trilineage dysplasia and dysmegakaryopoiesis, poor prognosis and additional monosomy 7. Molecular cytogenetic analysis and PCR in selected samples indicated that in most cases the translocation indeed targets the EVI1 locus. Mapping of the chromosome 2 breakpoints confirmed the initially suspected cytogenetic breakpoint heterogeneity at the 2p arm.

Patient communication during cataract surgery

PURPOSE

Most cataract surgery is now performed under local anaesthesia on a day-case basis. As patients are fully conscious during the procedure, it is important that they remain still. There are a variety of reasons why patients may need to move, and it is important that the surgeon is made aware that this may happen. Some centres offer a nurse's hand as a means of perioperative patient communication. We sought to study the safety and efficacy of using an electronic patient-controlled alert device.

METHOD

We compared hand-holding with the use of a patient alert device, and with both communication methods at the same time, on 150 subjects undergoing cataract surgery under local anaesthesia. Assessment of pre- and postoperative state anxiety was undertaken and patients' satisfaction with the communication strategies was assessed.

RESULTS

There was a significant difference between pre- and postoperative state anxiety for each group (P<0.001) but no significant differences in pre-, peri-, or postoperative state anxiety between groups. There were no significant differences in confidence, pain, understanding, satisfaction, memory, and reassurance between the three groups. A total of 46% of all patients reported experiencing one or more of the potential problems enquired about, during the operation. Significant correlations were also identified between some of the psychological variables investigated.

CONCLUSIONS

An electronic patient alert device is as effective a means of perioperative patient communication as holding a nurse's hand, during cataract surgery under local anaesthesia. It is safe, reassuring and it allows patients to communicate directly with the surgeon.

Detecting diminutive colorectal lesions at colonoscopy: a randomised controlled trial of pan-colonic versus targeted chromoscopy

BACKGROUND

Diminutive and flat colorectal lesions can be difficult to detect using conventional colonoscopic techniques. Previous data have suggested that pan-chromoscopy may improve detection rates. No randomised control trial has been performed examining detection rates of such lesions while controlling for extubation time and lavage effect.

AIM

We conducted a randomised controlled trial of pan-colonic chromoscopic colonoscopy for the detection of diminutive and flat colorectal lesions while controlling for extubation time and lavage effect.

METHODS

Consecutive patients attending for routine colonoscopy were randomised to either pan-chromoscopy using 0.5% indigo carmine (IC) or targeted chromoscopy (control group). A minimum diagnostic extubation time was set at eight minutes with controls undergoing a matched volume of saline wash.

RESULTS

A total of 260 patients were randomised; 132 controls and 128 to pan-colonic chromoscopy. Extubation times did not differ significantly between the control (median 15 minutes (range 8-41)) and chromoscopy (median 17 minutes (range 8-39)) groups. The volume of IC used in the pan-chromoscopy group (median 68 ml (range 65-90)) and normal saline used in the control group (69 ml (range 60-93)) did not differ significantly. There was a statistically significant difference between the groups regarding the total number of adenomas detected (p<0.05) with significantly more diminutive (<4 mm) adenomas detected in the pan-chromoscopy group (p = 0.03). Pan-chromoscopy diagnosed more diminutive and flat lesions in the right colon compared with controls (p<0.05), with more patients with multiple adenomas (>3) detected using pan-chromoscopy (p<0.01). Hyperplastic lesions were more commonly detected in the pan-chromoscopy group compared with controls (p<0.001). More hyperplastic polyps were detected in the left colon (86% rectosigmoid) using chromoscopy compared with controls.

CONCLUSION

Chromoscopy improves the total number of adenomas detected and enhances the detection of diminutive and flat lesions. Importantly, eight diminutive lesions had foci of high grade dysplasia. Chromoscopy may benefit patients, assuming a high risk of colorectal cancer, and help in risk stratification and planning follow up colonoscopy intervals.

BFM-oriented treatment for children with acute lymphoblastic leukemia without cranial irradiation and treatment reduction for standard risk patients: results of DCLSG protocol ALL-8 (1991-1996)

Modern treatment strategies, consisting of intensive chemotherapy and cranial irradiation, have remarkably improved the prognosis for children with acute lymphoblastic leukemia. However, patients with a potential for cure are at risk of severe acute and late adverse effects of treatment. Furthermore, in 25-30% of patients treatment still fails. The objectives of the DCLSG study ALL 8 were to decrease the toxicity and to increase the effectivity of BFM-oriented treatment. Decrease of toxicity was aimed at by confirmation of the results of the previous DCLSG study ALL-7, showing that the majority (94%) of children with ALL can successfully be treated with BFM-oriented therapy without cranial irradiation, and by reduction of treatment for standard risk (SRG) patients. To increase the cure rate in medium risk (MRG) patients the efficacy of high doses of intravenous 6-mercaptopurine (HD-6MP) during protocol M and in SRG patients the efficacy of high doses of L-asparaginase (HD-L-ASP) during maintenance treatment was studied in randomized studies. Patient stratification and treatment were identical to protocol ALL-BFM90, with the following differences: no prophylactic cranial irradiation, SRG patients received only phase 1 of protocol I. Four hundred and sixty-seven patients entered the protocol: 170 SRG, 241 MRG and 56 HRG patients. The 5 years event-free survival rate for all patients was 73% (s.e. 2%); for SRG, MRG and HRG patients 85% (s.e. 3%), 73% (s.e. 3%) and 39% (s.e. 7%), respectively. In patients >1 year of age at diagnosis unfavorable prognostic factors were male sex, >25% blasts in the bone marrow at day 15 and initial white blood cell count (WBC) >50 x 10(9)/l. The cumulative risk of CNS relapse rate was 5% (s.e. 1%) at 5 years. These results confirm that the omission of cranial irradiation in BFM-oriented treatment does not jeopardize the overall good treatment results, nor does early reduction of chemotherapy in SRG patients. No benefit was observed from treatment intensification with HD-L-ASP in SRG patients, nor from HD-6MP in MRG patients.

Fusion of the homeobox gene HLXB9 and the ETV6 gene in infant acute myeloid leukemias with the t(7;12)(q36;p13)

Recently, we and others reported a recurrent t(7;12)(q36;p13) found in myeloid malignancies in children < or =18 months of age and associated with a poor prognosis. Fluorescence in situ hybridization studies mapped the 12p13 breakpoint to the first intron of ETV6 and narrowed down the region of 7q36 involved. By using the sequences made public recently by the Human Genome Project, two candidate genes in 7q36 were identified: the homeobox gene HLXB9 and c7orf3, a gene with unknown function. Reverse transcription-PCR of two cases with t(7;12), using primers for c7orf3 and ETV6, was negative. However, reverse transcription-PCR for HLXB9-ETV6 demonstrated alternative splicing; the two major bands corresponded to fusion of exon 1 of HLXB9 to exons 2 and 3, respectively, of ETV6. The reciprocal ETV6-HLXB9 transcript was not detected. It remains to be elucidated if the leukemic phenotype is attributable to the formation of the HLXB9-ETV6 fusion protein, which includes the helix-loop-helix and E26 transformation-specific DNA binding domains of ETV6 or to the disruption of the normal ETV6 protein.

DMBA-induced toxic and mutagenic responses vary dramatically between NER-deficient Xpa, Xpc and Csb mice

Heterogeneity in cancer susceptibility exists between patients with an inherited defect in nucleotide excision repair (NER). While xeroderma pigmentosum (XP) patients have elevated skin cancer rates, Cockayne syndrome (CS) patients do not appear to have increased cancer susceptibility. To investigate whether differences in mutagenesis are the basis for the variability in cancer proneness, we studied mutagenesis at the X-chromosomal Hprt gene and the autosomal Aprt gene in splenic T-lymphocytes after 7,12-dimethyl-1,2-benz[a]anthracene (DMBA) exposure in total NER-deficient Xpa mice, global genome repair (GGR)-deficient Xpc mice and transcription coupled repair (TCR)-deficient Csb mice. Surprisingly, while all intraperitoneally-treated Xpc(-/-) mice survived a dose of 40 mg/kg DMBA, a substantial fraction of the treated Xpa(-/-) and Csb(-/-) mice died a few days after treatment with a 20-fold lower dose. Functional TCR of DMBA adducts in Xpc(-/-) mice thus appears to alleviate DMBA toxicity. However, the mutagenic response in Xpc(-/-) mice was +/- 2-fold enhanced at both the Hprt and the Aprt gene compared to heterozygous controls, indicating that GGR at least partially removes DMBA adducts from the genome overall. DMBA-induced SCE frequencies in mouse dermal fibroblasts were significantly enhanced in Xpa- and Csb-, but not in Xpc-deficient background compared to the frequency in normal fibroblasts. These results indicate that both damage-induced cytotoxicity as well as intra-chromosomal recombinational events were not correlated to differences in cancer susceptibility in human NER syndrome patients.

Molecular cytogenetic and clinical findings in ETV6/ABL1-positive leukemia

Rearrangements of 12p, resulting from deletions or translocations, are common findings in hematologic malignancies. In many cases, these rearrangements target the ETV6 gene (previously called TEL) located at 12p13. Various partner genes have been implicated in the formation of fusion genes with ETV6. These include PDGFRB, JAK2, NTRK3, ABL2, and ABL1, each of which encodes for proteins with tyrosine kinase activity. To date, ETV6/ABL1 transcripts have been detected in only four patients with a leukemic disorder. Here, we describe one adult with chronic myeloid leukemia and a child with T-cell acute lymphocytic leukemia with ETV6/ABL1. Molecular cytogenetic analysis confirmed that formation of an ETV6/ABL1 fusion in these patients required at least three chromosomal breaks and showed that each of these translocations is the result of a complex chromosomal rearrangement. Molecular analysis showed the presence of two fusion transcripts in both patients as the result of alternative splicing, questioning the suggested role of these transcripts in the lineage specificity. Clinical findings of these patients were compared to those of previously reported cases, and the possible clinical and biological similarities between ETV6/ABL1 and other fusion genes leading to increased tyrosine kinase activity are discussed.

Long-term follow-up of Dutch Childhood Leukemia Study Group (DCLSG) protocols for children with acute lymphoblastic leukemia, 1984-1991

Here we report the long-term results of the DCLSG protocols ALL-6 and -7 with special emphasis on the incidence of CNS relapse after treatment without cranial irradiation. In DCLSG protocol ALL-6 (1984-1988), designed for patients with ALL non-high risk (ALL-NHR) (WBC <50 x 10(9)/l, no mediastinal mass, no B cell phenotype and no CNS involvement at diagnosis, comprising 71% of all ALL patients), CNS prophylaxis consisted of a combination of three methods of chemotherapeutic CNS prophylaxis (the use of dexamethasone during induction and maintenance therapy, i.v. medium dose methotrexate and prolonged administration of intrathecal triple therapy). Total duration of treatment: 116 weeks. 190 patients were enrolled in the study. At 10 years, the EFS rate for all patients is 81.5 +/- 2.8%, the survival rate 84.8 +/- 2.7%, and the cumulative incidence of isolated CNS relapse 1.1 +/- 0.8%. The 10-year survival rate for the 139/190 (73.1%) patients with standard risk non-T lineage ALL according to the NCI risk criteria is 80.5 +/- 3.4%. DCLSG protocol-7 was identical to the intensive ALL-BFM-86 protocol, but cranial irradiation was restricted to patients with initial CNS involvement. Patients were stratified into three risk groups (SRG, RG and EG). Treatment duration was 18 months. 218 patients were enrolled in the study. At 10 years, the EFS rate for all patients is 63.4 +/- 3.3%, the survival rate 76.4 +/- 3.0%, the 5-year cumulative incidence of isolated CNS relapse 5.7 +/- 1.8%. The EFS rate at 10 years of the 127/218 (58.3%) patients with standard risk non-T-lineage ALL according to the NCI risk criteria was 67.9 +/- 4.3%, which is not significantly different from the results achieved in this category of patients with the moderately intensive treatment according to protocol ALL-6 (logrank P = 0.17). These DCLSG studies indicate that omission of cranial irradiation does not jeopardize the overall good results.

Characterization of mRAD18Sc, a mouse homolog of the yeast postreplication repair gene RAD18

The RAD18 gene of the yeast Saccharomyces cerevisiae encodes a protein with ssDNA binding activity that interacts with the ubiquitin-conjugating enzyme RAD6 and plays an important role in postreplication repair. We identified and characterized the putative mouse homolog of RAD18, designated mRAD18Sc. The mRAD18Sc open reading frame encodes a 509-amino-acid polypeptide that is strongly conserved in size and sequence between yeast and mammals, with specific conservation of the RING-zinc-finger and the classic zinc-finger domain. The degree of sequence conservation between mRAD18Sc, RAD18, and homologous sequences identified in other species (NuvA from Aspergillus nidulans and Uvs-2 from Neurospora crassa) is entirely consistent with the evolutionary relationship of these organisms, strongly arguing that these genes are one another's homologs. Consistent with the presence of a nuclear translocation signal in the amino acid sequence, we observed the nuclear localization of GFP-tagged mRAD18Sc after stable transfection to HeLa cells. mRNA expression of mRAD18Sc in the mouse was observed in thymus, spleen, brain, and ovary, but was most pronounced in testis, with the highest level of expression in pachytene-stage primary spermatocytes, suggesting that mRAD18Sc plays a role in meiosis of spermatogenesis. Finally, we mapped the mRAD18Sc gene on mouse chromosome 6F.

Effectiveness of the particle repositioning maneuver in subtypes of benign paroxysmal positional vertigo

OBJECTIVES

To assess the efficacy of the particle repositioning maneuver (PRM) in patients presenting with idiopathic benign paroxysmal positional vertigo (BPPV) compared with those with evidence of additional peripheral vestibulopathies.

METHODS

Retrospective administration of the Dizziness Handicap Inventory (DHI) to 41 patients with primary BPPV and 31 patients with secondary BPPV to subjectively evaluate their symptoms before and after the PRM.

RESULTS

Both groups indicated a marked improvement in symptoms after the PRM. Only two patients reported an increase in their symptoms after the PRM and both had secondary BPPV.

CONCLUSIONS

The PRM was found to be highly effective in all forms of BPPV, but careful history and judicious testing may identify patients requiring additional intervention to relieve their symptoms.

Rapid and sensitive detection of all types of MLL gene translocations with a single FISH probe set

The MLL gene on chromosome 11 band q23 is frequently involved in chromosome translocations in acute lymphoblastic leukemia and acute myeloid leukemia. The translocation results in the formation of a fusion gene on the derivative 11 chromosome consisting of the 5' part of the MLL gene and the 3' part of another gene; already more than 30 different partner chromosome regions have been described. MLL gene rearrangements are generally correlated with a poor prognosis. Therefore the presence of an 11q23 aberration has direct implications for treatment stratification, making early and rapid detection of utmost importance. In this study, we developed a FISH probe set for detection of MLL gene rearrangements according to strict design criteria. The cosmid probes are derived from the flanking regions of the MLL breakpoint region on chromosome 11 and when used in dual colored FISH experiments give rise to a split of the normally colocalizing (fused) signals in case of a translocation. This split signal was observed in seven out of 10 cases with an 11q23 translocation with various partner chromosomes. In the three other cases, a deletion of the 3' part of the MLL gene, downstream of the breakpoint region was also found. A low false positive value of only 1.7% was obtained for interphase cells in contrast to conventional dual colored FISH where the creation of a fusion signal has cut off values of at least 5-10%. A major advantage of our type of probe set is the application of a single FISH experiment to detect all types of MLL translocations. Moreover, since this cosmid probe set can be used for either interphase or metaphase studies, metaphases are no longer a prerequisite for detecting the presence of an 11q23 translocation. Nevertheless, metaphase FISH with the new probe set is helpful in determining the partner chromosome and therefore may lead to the identification of new partner genes.

Intensive treatment of children with acute lymphoblastic leukemia according to ALL-BFM-86 without cranial radiotherapy: results of Dutch Childhood Leukemia Study Group Protocol ALL-7 (1988-1991)

In The Netherlands from July 1988 to October 1991, children (0 to 16 years of age) with de novo acute lymphoblastic leukemia (ALL) were treated according to protocol ALL-7 of the Dutch Childhood Leukemia Study Group (DCLSG). In this protocol, chemotherapy and treatment stratification were identical to the ALL-BFM-86 protocol (Reiter et al, Blood 84:3122, 1994), but cranial irradiation was restricted to patients with initial central nervous system (CNS) involvement. Patients were stratified into 3 risk groups, based on leukemia cell mass and response to initial treatment: standard-risk group (SRG), risk group (RG), and experimental group (EG). As in ALL-BFM-86, a randomized study on late intensification (protocol S) was performed in RG patients, and during the study (since October 1990), early reinduction treatment (protocol II) was introduced for SRG patients. Treatment duration for all patients was 18 months. Two hundred eighteen children entered the study: 74 SRG, 127 RG, and 17 EG patients. The overall complete remission (CR) rate was 98%. The 5-year event-free survival (EFS) for all DCLSG ALL-7 patients was 65. 3% (standard error [SE] 3.2%), which was significantly different from the 73% (SE 1%) 5-year EFS achieved in the ALL-BFM-86 study (P =.02, Z-test). However, restricting the analysis to SRG patients receiving protocol II with a total duration of treatment of 18 months, the 5-year EFS rates were 64.6% (SE 4.0%) and 67% (SE 4%), respectively, and no significant difference could be established (P =.67, Z-test). The 5-year EFS rates for SRG, RG, and EG patients were 63.5% (SE 5.6%), 66.6% (SE 4.2%), and 63.3% (SE 12.0%), respectively. SRG patients receiving protocol II fared better than patients not receiving protocol II (5-year EFS 76.7% [SE 7.7] and 54. 5% [SE 7.5], respectively). No difference in 5-year EFS was observed in RG patients randomized to receive or not to receive late intensification with protocol S. The overall CNS relapse rate at 5 years was 5.5%. The incidence rate at 5 years was 11.4% in SRG patients not receiving protocol II, whereas no CNS relapses occurred in SRG patients receiving protocol II. Six children died in first complete remission and 2 children developed a second malignancy (thyroid carcinoma and acute nonlymphoblastic leukemia). Systemic high-dose methotrexate (MTX) and intrathecal chemotherapy is a safe and effective method of CNS prophylaxis in the context of BFM-oriented treatment for all children with ALL, regardless of the risk group (with the possible exception of T-ALL patients with high white blood cell counts). The results of the DCLSG ALL-7 study confirm those of the ALL-BFM-86 study showing that early reinduction with protocol II is essential in the treatment of SRG patients and that late intensification with protocol S does not improve the prognosis for RG patients.

Low-dose midazolam infusion for oculoplastic surgery under local anesthesia

PURPOSE

Oculoplastic surgery with infiltration of local anaesthesia at the operative site performed as a day-case procedure is both efficient and cost-effective. Patients considered unsuitable for this because of fear or apprehension may, however, benefit from per-operative conscious sedation. We sought to study the efficacy and safety of this using midazolam, a water-soluble benzodiazepine.

METHOD

We have performed a controlled clinical trial comparing the effect of a low-dose intravenous infusion of midazolam (0.2 mg/ml of normal saline at a rate of 1 mg/h) with saline placebo on 48 subjects undergoing oculoplastic surgery with local anaesthesia. Patients were given pre- and post-operative questionnaires assessing, amongst other factors, anxiety levels, pain, degree of reported amnesia and psychomotor recovery.

RESULTS

Using the low-dose midazolam infusion no adverse cardiorespiratory reactions occurred. Patients receiving midazolam reported remembering significantly less about their operation than controls (p = 0.04) and showed significantly lower state-anxiety after their operation than before (p < 0.02). This change was not noted in the placebo group. There was no significant difference in the psychomotor performance of patients given midazolam compared with controls 2 h after surgery.

CONCLUSIONS

A low-dose continuous infusion of midazolam can be used to safely provide effective anxiolysis and conscious sedation with good psychomotor recovery during oculoplastic procedures in a day-case setting.

Promoter transgenics reveal multiple gonadotropin-releasing hormone-I-expressing cell populations of different embryological origin in mouse brain

Gonadotropin-releasing hormone-I (GnRH-I) is thought to be expressed by a single, highly spatially restricted group of neurons, which originate in the olfactory placode and migrate through the nose into the medial septum and hypothalamus from where they control fertility. Transgenic mice bearing a 13.5 kb GnRH-I-lacZ reporter construct were derived and found to express high levels of beta-galactosidase mRNA and protein within the septohypothalamic GnRH neurons in a correct temporal and spatial manner. Unexpectedly, low levels of beta-galactosidase were also present in three further populations of cells within the lateral septum, bed nucleus of the stria terminalis, and tectum. Analysis of wild-type mice with three different GnRH-I antibodies revealed distinct and transient patterns of GnRH-I peptide expression during development in all three of these populations revealed by transgenics. The synthesis of GnRH by cells of the lateral septum was the most persistent and remained until the third postnatal week. Embryonic "small eye" Pax-6 null mice, which fail to develop an olfactory placode, were also examined and shown to have equivalent populations of GnRH-I-immunoreactive cells in the lateral septum, tectum, and bed nucleus of the stria terminalis but none of the migrating cells that form the septohypothalamic GnRH population. These results prove that so-called "ectopic" expression in promoter transgenic lines can reflect authentic developmental patterns of gene expression. They further provide the first demonstration in mammalian brain that multiple neuronal populations of different embryological origin express GnRH-I peptide during embryonic and postnatal development.

Two-colour FISH detection of the inv(16) in interphase nuclei of patients with acute myeloid leukaemia

The inv(16)(p13q22) and t(16;16)(p13;q22) in acute myeloid leukaemia are associated with a relatively good prognosis but are difficult to detect using classic cytogenetics. We have designed a two-colour fluorescence in situ hybridization approach that uses two DNA probes that map close to and on either side of the inv(16) p-arm breakpoint region. This new strategy clearly detected the inv(16)(p13q22)/t(16;16)(p13;q22) on both metaphase chromosomes and in interphase nuclei, even when they are of poor quality. This procedure also detected the inv(16) in cases with an additional deletion of sequences proximal to the 16p-arm breakpoint which is present in 20% of all cases.

Complete remission of t(11;17) positive acute promyelocytic leukemia induced by all-trans retinoic acid and granulocyte colony-stimulating factor

The combined use of retinoic acid and chemotherapy has led to an important improvement of cure rates in acute promyelocytic leukemia. Retinoic acid forces terminal maturation of the malignant cells and this application represents the first generally accepted differentiation-based therapy in leukemia. Unfortunately, similar approaches have failed in other types of hematological malignancies suggesting that the applicability is limited to this specific subgroup of patients. This has been endorsed by the notorious lack of response in acute promyelocytic leukemia bearing the variant t(11;17) translocation. Based on the reported synergistic effects of retinoic acid and the hematopoietic growth factor granulocyte colony-stimulating factor (G-CSF), we studied maturation of t(11;17) positive leukemia cells using several combinations of retinoic acid and growth factors. In cultures with retinoic acid or G-CSF the leukemic cells did not differentiate into mature granulocytes, but striking granulocytic differentiation occurred with the combination of both agents. At relapse, the patient was treated with retinoic acid and G-CSF before reinduction chemotherapy. With retinoic acid and G-CSF treatment alone, complete granulocytic maturation of the leukemic cells occurred in vivo, followed by a complete cytogenetical and hematological remission. Bone marrow and blood became negative in fluorescense in situ hybridization analysis and semi-quantitative polymerase chain reaction showed a profound reduction of promyelocytic leukemia zinc finger-retinoic acid receptor-alpha fusion transcripts. This shows that t(11;17) positive leukemia cells are not intrinsically resistant to retinoic acid, provided that the proper costimulus is administered. These observations may encourage the investigation of combinations of all-trans retinoic acid and hematopoietic growth factors in other types of leukemia.

Human acute myeloid leukemia cells with internal tandem duplications in the Flt3 gene show reduced proliferative ability in stroma supported long-term cultures

Recently, in-frame internal tandem duplications have been reported within the regions coding for the juxtamembrane through the first tyrosine kinase domain of the Flt3 gene. These duplications have been reported to lead to autophosphorylation of the receptor. In this study we investigated the effect of such mutations in the Flt3 gene on the in vitro proliferation of human acute myeloid leukemia cells. The mutations were detected in 10 out of 59 AML bone marrow samples analyzed and were not restricted to a specific FAB class or cytogenetic aberration. PCR analysis of those samples showed all mutations to be present in exon 11 of the gene. Whilst samples without a mutation of the Flt3 gene showed an increased cell production in response to either IL-3 and G-CSF or IL-6, SCF, TPO and Flt3L in long-term stroma supported cultures, mutant samples failed to do so. As we could not find a relationship between the absence of a response and either FAB class or cytogenetic aberrations, we interpret these results as an indication that the internal tandem duplications in the Flt3 gene are the prime cause of this unresponsiveness. Although our study does not explain the mechanism by which these mutations cause this unresponsiveness it does suggest that AML cells need a wild-type Flt3 for optimal in vitro proliferation.

Secondary T-acute lymphoblastic leukaemia mimicking blast crisis in chronic myeloid leukaemia

A 34-year-old man with chronic myeloid leukaemia (CML) firstly developed a lymphoid blast crisis of B-cell type. After a second chronic phase which lasted for > 4 years with maintenance chemotherapy of hydroxyurea, 6-mercaptopurine and methotrexate, he developed a T-cell acute lymphoblastic leukaemia of TcR-gammadelta+ type. Cytogenetic analysis revealed disappearance of the t(9;22) translocation and appearance of new abnormalities consistent with the diagnosis secondary acute leukaemia. To our knowledge, secondary leukaemia in CML has not previously been reported.

The hydroxyapatite orbital implant: post-operative pain

PURPOSE

To compare and quantify the degree of post-operative pain experienced by patients undergoing primary and secondary hydroxyapatite orbital implantation.

METHODS

A prospective survey design was employed to monitor patients' pain pre-operatively and up to 7 days post-operatively. Fifty-five consecutive patients undergoing primary and secondary hydroxyapatite orbital implantation were recruited over a period of 1 year. Standardised anaesthetic, operative and post-operative protocols were followed. During the patients' in-patient stay nurses completed a data proforma that required them to record patients' pain using an 11-item numerical rating scale. A self-completion proforma was given to patients to score their pain at home until the first post-operative out-patient appointment.

RESULTS

Patients undergoing primary implant surgery tend to experience more post-operative pain than those undergoing secondary implant surgery. A small proportion of patients experience severe post-operative pain.

CONCLUSION

Post-operative pain experienced by patients undergoing primary and secondary hydroxyapatite implantation has been underestimated. This study has provided the necessary data to enable such patients to be effectively counselled pre-operatively and to plan a rational discharge policy.