Survey of acupuncturists: practice characteristics and pediatric care

OBJECTIVE

To describe the practice characteristics and pediatric care provided by licensed acupuncturists.

DESIGN

Cross-sectional survey.

SETTING

Boston metropolitan area.

SUBJECTS

227 licensed acupuncturists were surveyed; 140 (62%) responded.

MAIN OUTCOME MEASURES

(1) DEMOGRAPHICS, (2) practice characteristics, (3) pediatric care, (4) recommendations of peers recognized as experts in pediatric acupuncture.

RESULTS

(1) DEMOGRAPHICS: 70% Caucasian, 61% female; (2) practice characteristics: average of 39 visits weekly with an average charge of $54 for a 57-minute visit; patients were typically scheduled for follow-up once or twice weekly; only 5% of fees were covered by insurance; 80% recommended herbal remedies and 66% dispensed herbs in the office; (3) few acupuncturists treated more than one child per week; most used non-needle techniques or Japanese-style acupuncture to stimulate points in children; 85% would refer a febrile two-week-old infant immediately to a physician; (4) only 17 acupuncturists were recommended by three or more peers and saw three or more patients weekly; their practices were all in wealthy suburban areas.

CONCLUSIONS

Most acupuncturists in the Boston area are Caucasian and female. Compared with physicians, they schedule patients for more frequent follow-up, allocate more time, are less likely to be reimbursed by insurance, and treat fewer children. Additional studies are needed to assess effectiveness, quality, and access to acupuncture services for adults and children.

Late ophthalmological complications after total body irradiation in non-human primates

PURPOSE

To investigate the long-term effects of total body irradiation (TBI) on the incidence and time course of ocular complications.

MATERIALS AND METHODS

Rhesus monkeys treated with TBI photon doses up to 8.5 Gy and proton doses up to 7.5 Gy were studied at intervals up to 25 years post-irradiation. They were compared with control groups with a similar age distribution. Cataract formation and ocular fundus lesions were scored according to a standardized protocol. Fluorescein angiography and histopathology was performed in selected animals.

RESULTS

Cataract formation occurred after a latent period of 3-5 years. Significant cataract induction was observed for photon-doses of 8 and 8.5 Gy and beyond 20 years after proton irradiation. The severity of the lesions represents significant impairment of vision and would require cataract surgery if similar results occurred in human bone marrow transplant patients. Fluorescein angiography demonstrated a normal pattern of retinal vessels in 13 out of 14 animals (93%) from the irradiated group and in eight out of nine animals (89%) from the control group. No additional lesions apart from age-related degenerative changes could be demonstrated. Histological evaluation revealed no radiation-associated vasculopathy.

CONCLUSIONS

Radiation alone for doses up to 8.5 Gy of photons does not carry a potential risk for fundus pathology, whereas clinically important cataract induction should be anticipated within 5 years after photon doses of 8.0 and 8.5 Gy and proton doses in excess of 2.5 Gy.

Ras proteins induce senescence by altering the intracellular levels of reactive oxygen species

Human diploid fibroblasts eventually lose the capacity to replicate in culture and enter a viable but nonproliferative state of senescence. Recently, it has been demonstrated that retroviral-mediated gene transfer into primary fibroblasts of an activated ras gene (V12ras) rapidly accelerates development of the senescent phenotype. Using this in vitro system, we have sought to define the mediators of Ras-induced senescence. We demonstrate that expression of V12Ras results in an increase in intracellular and in particular, mitochondrial reactive oxygen species. The ability of V12Ras to induce growth arrest and senescence is shown to be partially inhibited by coexpression of an activated rac1 gene. A more dramatic rescue of V12Ras-expressing cells is demonstrated when the cells are placed in a low oxygen environment, a condition in which reactive oxygen species production is inhibited. In addition, in a 1% oxygen environment, Ras is unable to trigger an increase in the level of the cyclin-dependent kinase inhibitor p21 or to activate the senescent program. Under normoxic (20% O2) conditions, the V12Ras senescent phenotype is demonstrated to be unaffected by scavengers of superoxide but rescued by scavengers of hydrogen peroxide. These results suggest that in normal diploid cells, Ras proteins regulate oxidant production and that a rise in intracellular H2O2 represents a critical signal mediating replicative senescence.

Mortality in beagles irradiated during prenatal and postnatal development. I. Contribution of non-neoplastic diseases

To evaluate the lifetime health effects of exposure to ionizing radiation during development, 1,680 beagles received whole-body exposures to 60Co gamma rays or sham exposures. Eight groups of 120 dogs each received mean doses of 15.6-17.5 or 80.8-88.3 cGy in early, mid- or late gestation, at 8, 28 or 55 days after breeding, or at 2 days after birth. Another group of 120 dogs received a mean dose of 82.6 cGy as 70-day-old juveniles and one group of 240 dogs received a mean dose of 81.2 cGy as 365-day-old young adults. Sham irradiations were given to 360 controls. Sexes were equally represented. There was no significant effect of irradiation on mean survival times in any groups. In 1,343 dogs allowed to live out their life span, chronic renal disease was a common cause of mortality, and irradiation in the late fetal or juvenile periods potentiated this disease, resulting in increased mortality due to renal failure. This was consistent with earlier findings of the high radiosensitivity of the kidney in the perinatal period. Hypothyroidism associated with atrophic thyroiditis was decreased by irradiation, a finding contrary to expectation and not easily explained. Diabetes mellitus was increased by irradiation in the mid- and late gestation and juvenile periods, a finding which is intriguing based on early reports of a similar finding in atomic bomb survivors. Though convulsive seizures were a common cause of mortality in the dogs, there was no evidence for increased risk associated with prenatal irradiation as has been reported in humans. Genetic analyses indicated that renal disease, hypothyroidism, diabetes mellitus and convulsive seizures all had a heritable component, but that this did not influence or bias the radiation responses evaluated.

Mortality in beagles irradiated during prenatal and postnatal development. II. Contribution of benign and malignant neoplasia

To evaluate the lifetime carcinogenic hazards of exposure to ionizing radiation during development, 1,680 beagles received whole-body exposures to 60Co gamma rays or sham exposures. Eight groups of 120 dogs each received mean doses of 15.6-17.5 or 80.8-88.3 cGy in early, mid- or late gestation, at 8, 28 or 55 days postcoitus or at 2 days after birth. Another group of 120 dogs received a mean dose of 82.6 cGy as 70-day-old juveniles and one group of 240 dogs received a mean dose of 81.2 cGy as 365-day-old young adults. Sham irradiations were given to 360 controls. Sexes were equally represented. In 1,343 dogs allowed to live out their life span, neoplasia was a major disease, contributing to mortality in 40% of the dogs. There was a significant increase in benign and malignant neoplasms occurring in young dogs (<4 years old), including fatal malignancies, after irradiation in the perinatal (late fetal and neonatal) periods. The lifetime incidence of fatal neoplasms was also increased in dogs irradiated perinatally. Three malignancies-lymphomas, hemangiosarcomas and mammary carcinomas-accounted for 51% of all fatal tumors. There was an apparent lifetime increase and earlier onset of lymphomas in dogs exposed as fetuses. Fatal hemangiosarcomas were increased in dogs irradiated early and late in gestation. Fatal mammary carcinomas were not increased by irradiation, although non-fatal carcinomas were increased after perinatal exposure. Myeloproliferative disorders and central nervous system astrocytomas appeared to be increased in perinatally irradiated dogs. These data suggest that irradiation in both the fetal and neonatal periods is associated with increased early onset and lifetime cancer risk.

Penetrating pencil injury: an unusual case of child abuse

OBJECTIVE

We report an unusual case of penetrating pencil injury in a young child that turned out to be a case of physical abuse.

METHOD

This is a case report with review of the literature.

RESULTS

A 4-year-old boy was brought by his mother to the accident and emergency department for a penetrating wound of the right hand. He was said to have injured himself during a fall at home while holding a sharpened lead pencil. The pencil broke after penetrating the hypothenar eminence, leaving the graphite tip embedded in the palm. On surgical exploration, a piece of graphite measuring 1.3 cm was removed. The injury was actually inflicted by his mother because he failed to complete his homework properly. Deep penetrating injuries associated with the lead pencil are uncommon events in the medical literature. They are often reported as accidental and usually involve the oropharynx and the orbit.

CONCLUSION

Deep penetrating injury with a pencil is unusual in childhood and the public should be made aware of the possibility of nonaccidental injury.

Prevention of beta-thalassemia major by antenatal screening in Hong Kong

The thalassemias are common in Hong Kong. One of the severe forms, beta-thalassemia major, has been preventable locally by antenatal screening since 1983. Yet new patients are still being diagnosed. In this retrospective study, 34 children with severe beta-thalassemia syndromes were diagnosed in two major public hospitals between 1990 and 1996. They included one pair of identical twins and two pairs of siblings. Twenty-seven (79%) had homozygous beta-thalassemia and seven (21%) had beta E thalassemia. All but four (12%) were transfusion dependent. Fifty-five (89%) parents had been evaluated for their thalassemia status. Forty-eight had beta-thalassemia traits and seven were hemoglobin E carriers. The reasons for the birth of these children with severe beta-thalassemia syndromes were (1) late or no antenatal visit (n = 8, 24.2%), including three cross-border deliveries in which the pregnant mothers came from mainland China to Hong Kong for confinement, (2) lack of maternal screening (n = 13, 39.4%), (3) lack of paternal screening (n = 7, 21.2%), (4) parental refusal (n = 3, 9.1%), and (5) unknown (n = 2, 6.1%). These findings suggest that several factors undermine the effectiveness of antenatal screening for prevention of thalassemias. Many medical practitioners and the general public are still not aware of the screening procedures. The migration of population from mainland China to Hong Kong may result in the birth of many more children with beta-thalassemia major.

The role of yeast VDAC genes on the permeability of the mitochondrial outer membrane

In addition to the POR1 gene, which encodes the well-characterized voltage dependent anion-selective channel (YVDAC1) of the mitochondrial outer membrane, the yeast Saccharomyces cerevisiae contains a second gene (POR2) encoding a protein (YVDAC2) with 50% sequence identity to YVDAC1. Mitochondria isolated from yeast cells deleted for the POR1 gene (delta por1) had a profoundly reduced outer membrane permeability as measured by the ability of an intermembrane space dehydrogenase to oxidize exogenously added NADH. Mitochondria missing either YVDAC1 or both YVDAC1 and YVDAC2 showed a 2-fold increase in the rate of NADH oxidation when the outer membrane was deliberately damaged. Mitochondria from parental cells showed only a 10% increase indicating that the outer membrane is highly permeable to NADH. In the absence of YVDAC1, we calculate that the outer membrane permeability to NADH is reduced 20-fold. The low NADH permeability in the presence of YVDAC2 was not due to the low levels of YVDAC2 expression as mitochondria from cells expressing levels of YVDAC2 comparable to those of YVDAC1 in parental cells showed no substantial increase in NADH permeability, indicating a minimal role of YVDAC2 in this permeability. The residual permeability may be due to other pathways because cells missing both genes can still grow on nonfermentable carbon sources. However, YVDAC1 is clearly the major pathway for NADH flux through the outer membrane in these mitochondria.

Impairments of mental rotation in Parkinson's disease

It is controversial whether parkinsonian patients are impaired on visuospatial tasks. In the present study, patients and normal control subjects judged whether pairs of wire-frame figures in different orientations were the same or different. The orientation difference between the figures was either in the picture plane (around the z-axis, or two-dimensional) or in depth (around the y-axis, or three-dimensional). Reaction times and error rates were measured. For the two-dimensional task, there were no significant differences in errors between the two groups, though Parkinsonian subjects were significantly slower to respond than the control group. In the three-dimensional task, patients had a different pattern of reaction times from the controls and made significantly more errors, which were systematic at large angular differences. The results suggest a visuospatial deficit in Parkinson's disease, which reflects problems in some aspect of the perception of extra-personal space.

Epidural haematoma and stroller-associated injury

We present a severe case of head injury in an infant associated with stroller use and review similar reports from the literature. A case report and a literature search of the Medline database from 1966 to 6/1996 using the terms 'perambulator', 'parm', 'stroller', or 'baby carriage'. Reports in English describing injuries associated with their use are reviewed. We report a case of epidural haematoma in a 10 months old girl who sustained the injury after falling from a stroller. Safety harnesses were not worn during the incident. There was no skull fracture. Complete recovery followed surgical evacuation of the blood clot. Five reports describing stroller-related injuries were found in the English literature. Most injuries were mild. Three cases of death were reported of which two were classified as child abuse. The prevalence of unintentional stroller-associated injury is not clear. Mild injury, mostly to the head region, is probably common. Life-threatening injuries are rare but these are potentially preventable if strollers are properly designed and safety recommendations are followed.

Making the female condom a "reality" for adolescents

Alarming rates of pregnancy, sexually transmitted diseases, and human immunodeficiency virus infection among adolescents point to the need for expanding contraceptive options for adolescents. The female condom-a female-controlled barrier method that protects both partners from sexually transmitted diseases-marks an important breakthrough in contraceptive technology. This report reviews current research on the efficacy and acceptability of the female condom and considers the feasibility of its use in the adolescent population. Specifically, the authors first consider the factors that affect teenage condom (and other contraceptive) use (efficacy, cost and availability, and acceptability) and then apply the mechanics of the female condom to these issues. Based on this analysis, recommendations for future steps to be taken by researchers, adolescent health practitioners, and the manufacturer of the female condom are presented.

Intrathecal methotrexate overdose

We report two cases of intrathecal methotrexate overdose. A 3-y-old girl with acute lymphoblastic leukaemia and a 4-y-old boy with Burkitt's lymphoma were to receive an intrathecal injection of methotrexate after completion of intravenous methotrexate infusion. Instead of 12.5 mg, they both received a dose of 125 mg. Both children developed generalized convulsion 3 h after the overdose, but afterwards recovered completely. Intravenous folinic acid and dexamethasone rescue were employed, but no attempt was made to exchange the cerebrospinal fluid. In addition to the staff's failure to check the drug label carefully, the marked resemblance of the two dose preparations of methotrexate (50 mg/5 ml and 500 mg/5 ml) may have been contributory.

Non-neoplastic and neoplastic thyroid disease in beagles irradiated during prenatal and postnatal development

To evaluate the lifetime hazards of exposure to ionizing radiation, 1,680 beagles received whole-body exposures to 60Co gamma rays or sham exposures during development. Eight groups of 120 dogs each received mean doses of 16-18 or 81-88 cGy at 8, 28 or 55 days of gestation, or at 2 days after birth. One group of 120 dogs received a mean of 83 cGy at 70 days of age and one group of 240 dogs received a mean of 81 cGy at 365 days of age. Sham irradiations were given to 360 controls. Sexes were equally represented. In 1,343 dogs allowed to live out their life span, heritable lymphocytic thyroiditis with hypothyroidism was a major contributor to mortality. Irradiated dogs had a decreased risk for hypothyroidism, a finding that was surprising and not easily explained. Of the 1,343 life-span dogs, those exposed as neonates at 2 days of age or as juveniles at 70 days of age had evidence for an increased risk for thyroid follicular cell neoplasia. Hypothyroid dogs had a significantly increased risk for thyroid neoplasia, including greater risk for carcinomas, but no evidence of a greater sensitivity to radiation-induced tumors. In dogs with normal thyroid function irradiated at 2 or 70 days of age there was increased risk for benign and malignant follicular cell neoplasms, including multiple neoplasms. No difference between sexes was noted. These findings related to age sensitivity in the dog were consistent with the high risk for radiogenic thyroid neoplasia in humans after exposure during early childhood.

The role of pyridine dinucleotides in regulating the permeability of the mitochondrial outer membrane

Both NADH and NADPH reduce the permeability of the mitochondrial outer membrane to ADP. This is specific for the outer membrane and uncorrelated with the respiratory control ratio. This could result in a 7-fold difference between the concentration of ADP in the intermembrane space and that in the external environment (at 5 microM ADP). In both cases the permeability declines by a factor of 5, but NADH is more potent: KD = 86 microM for NADH versus 580 microM for NADPH. The lower apparent affinity for NADPH is partly explained by Mg2+-NADPH being the active species, and under our conditions only 30% of the NADPH is in this form. The corrected KD is 184 microM. Free NADH has the same charge as the Mg2+-NADPH complex, and thus both likely bind to the same site. The ability of NADH and NADPH to induce the closure of reconstituted VDAC channels is consistent with VDAC being the main pathway for metabolite flow across the outer membrane. Oncotic pressure, effective at inducing VDAC closure, also decreases the outer membrane permeability. Thus, in the presence of cytosolic colloidal osmotic pressure NAD(P)H may inhibit mitochondrial catabolic pathways and divert reducing equivalents to anabolic pathways.

Associations between lymphocytic thyroiditis, hypothyroidism, and thyroid neoplasia in beagles

The thyroids were evaluated in 276 control Beagles that were allowed to live out their full life span (mean = 12 years) in a closed breeding colony. Lymphocytic thyroiditis was found in 26.3% of the dogs. This lesion was characterized by lymphoplasmacytic inflammation accompanied by follicular destruction. The thyroiditis was progressive, resulting in severe atrophy of follicular tissue, and 44 dogs (15.9%) were diagnosed as hypothyroid at the time of death. In accordance with the experimental protocol, hypothyroid dogs were not given thyroxine replacement therapy. There was a high degree of heritability for the hypothyroidism. Hypothyroid dogs had an increased risk for thyroid follicular epithelial neoplasia and, in particular, for follicular adenocarcinomas. Twenty-four of the 44 hypothyroid dogs (54.5%) had one or more follicular thyroid neoplasms, whereas only 53 of the 232 (22.8%) clinically euthyroid dogs had similar tumors. Multiple thyroid tumors were present in 14 of the 44 (31.8%) hypothyroid dogs but in only 12 of the 232 (5.2%) euthyroid dogs. One or more follicular adenocarcinomas were present in 15 of the 44 (34.1%) hypothyroid dogs but in only 16 of the 232 (6.9%) euthyroid dogs. There was no difference in prevalence of hypothyroidism or tumors between the sexes. The strong association between progressive lymphocytic thyroiditis, hypothyroidism, and thyroid follicular neoplasia in these Beagles probably relates to promotion of residual follicular epithelium by chronic excess thyrotropin stimulation.

The use of fiberoptic endoscopy in anesthesia

The fiberoptic bronchoscope has contributed greatly to the practice of anesthesiology over the past 30 years. It has become an indispensable tool in the approach to the difficult airway, as well as the placement and positioning of double-lumen tubes for thoracic surgery. The equipment, preparation, and methods for using the endoscope in anesthesia, are presented here.

Plesiomonas shigelloides septicemia: case report and literature review

A 13-year-old girl with Plesiomonas shigelloides septicemia is reported. The infection occurred while she was receiving an allogeneic bone marrow transplantation for acute promyelocytic leukemia. Treatment with ciprofloxacin was successful. Twenty-one cases of Plesiomonas septicemia have been reported in the literature. Immunocompromised hosts, especially neonates, are commonly affected. The case mortality rate is high, with 13 of the reported patients dying of the infection. Successful treatment relies on the early identification of the organism and implementation of effective antibiotics.

Malignant peripheral neuroectodermal tumor in an infant with neurofibromatosis type 1

A case of multifocal malignant peripheral neuroectodermal tumor (PNET) arising from a plexiform neurofibroma in a 4-month-old Chinese boy with neurofibromatosis type 1 (NF-1) is described. Cytogenetic culture demonstrated hypotriploid karyotype with an abnormal clone characterized by 59-60, XY, +2, +3, +6, +8, +8, +12, +i(13)(q10), +der(14)t(1;14)(q21;q32), +16, +19, +20, +mar[cp3] with no apparent abnormality of chromosome 17. The child was treated with combination chemotherapy comprising ifosphamide, vincristine and doxorubicin. Despite initial partial response the child finally died of tumor progression and pulmonary metastases 8 months after diagnosis. We believe this is the first reported case of PNET in a child with NF-1 and may support an association between these two disorders of neural crest origin.

High spinal anesthesia after epidural test dose administration in five obstetric patients

BACKGROUND AND OBJECTIVES

A commonly used test dose in parturients receiving continuous lumbar epidural analgesia for labor consists of 3 mL of dextrose-free 1.5% lidocaine with 1:200,000 epinephrine.

METHODS

of 1,962 obstetric epidural anesthetics administered over a 17-month period, unintentional subarachnoid placement of the epidural catheter was detected by injection of the test dose in five laboring patients. The characteristics of the resulting subarachnoid blocks were studied.

RESULTS

After negative aspiration for cerebrospinal fluid in each case, test dose injection resulted in the rapid onset of high sensory block with associated motor and sympathetic block, accompanied by significant hypotension requiring aggressive treatment.

CONCLUSIONS

While this test dose appears to be a sensitive indicator of an unexpected subarachnoid catheter, the resulting excessive spinal blocks in these laboring patients raise the question of its safety.

Aminoacetyl moiety as a potential surrogate for diacylhydrazine group of SC-51089, a potent PGE2 antagonist, and its analogs

8-Chlorodibenz[b,f][1,4]oxazepine-10(11H)-carboxylic acid, 2-[1-oxo-3-(4-pyridinyl)propyl]hydrazide, monohydrochloride (1, SC-51089) is a functional PGE2 antagonist selective for the EP1 receptor subtype with antinociceptive activity. During metabolism in cultured rat hepatocytes, SC-51089, which contains a diacylhydrazine moiety, has been shown to release hydrazine. Analogs of SC-51089, in which the diacylhydrazine functionality has been replaced by isosteric and isoelectronic groups, have been synthesized and have been shown to be analgesics and PGE2 antagonists of the EP1 subtype. This report discusses the structure-activity relationships within these series.

Hypertransfusion for spinal cord compression secondary to extramedullary hematopoiesis

A 19-year-old girl with thalassemia intermedia presented with signs of thoracic spinal cord compression secondary to extramedullary hematopoiesis. She was started on a transfusion regimen to maintain a hemoglobin level of more than 12.5 g/dL. Clinical signs disappeared within the first week and circulating erythroblastemia was completely suppressed by the second week. Magnetic resonance imaging 4 weeks after diagnosis revealed near-complete resolution of the extradural mass, followed by gradual improvement in the posterior tibial somatosensory evoked potentials. Transfusion therapy may be diagnostically and therapeutically useful in spinal cord compression secondary to extramedullary hematopoiesis, obviating the need for surgery or radiotherapy.

Mixed chimerism following bone marrow transplantation for severe combined immunodeficiency: a study by DNA fingerprinting and simultaneous immunophenotyping and fluorescence in situ hybridisation

We report a girl with severe combined immunodeficiency (SCID) who had a paternal T-depleted bone marrow transplant (BMT) when 11 months old. Engraftment was documented but karyotyping of marrow cells 1 year after BMT showed recipient metaphases (XX) only. However, she remained clinically well and further analysis y karyotyping of PHA-cultured peripheral blood mononuclear cells (PBMC) showed donor metaphases (XY) only. DNA fingerprinting confirmed mixed chimerism in the peripheral blood. The granulocytes were of recipient origin and the PBMC of mixed origin, the donor proportion of which increased after culture with PHA. Using simultaneous immunophenotyping and fluorescence in situ hybridisation (FISH) with chromosomes X and Y-specific probes, circulating T cells were demonstrated to be of donor origin whereas B cells and myeloid cells were mostly of recipient origin.

Listeria septicemia complicating bone marrow transplantation for Diamond-Blackfan syndrome

Infection with Listeria monocytogenes is uncommon in patients receiving cytotoxic chemotherapy, and is even rarer among recipients of bone marrow transplantation. Hemosiderosis, either idiopathic or caused by transfusion, appears to be another risk factor. We report a 3-year-old Chinese girl with transfusion-dependent Diamond-Blackfan syndrome who had L. monocytogenes septicemia when she received an allogeneic bone marrow transplantation. She was treated successfully with intravenous ampicillin. Our case adds to the clinical evidence that patients with iron overload are susceptible to listeriosis, particularly when they are immunocompromised and do not receive iron-chelation treatment.

Growth hormone treatment of short Chinese children with beta-thalassaemia major without GH deficiency

OBJECTIVE

Despite regular transfusion and desferrioxamine treatment, growth failure is commonly seen in adolescent children with beta-thalassaemia major. The growth failure has been thought to be due to GH resistance rather than GH deficiency. We investigated the effect of GH on short non-GH deficient children with beta-thalassaemia.

DESIGN

Recombinant human GH was given in a dose of 0.14 IU/kg/day subcutaneously in an open study.

PATIENTS

Fifteen prepubertal Chinese children with beta-thalassaemia major (ranging from 7.16 to 14.7 years in age) with height -1.5 SD or more below the population mean for age and a growth velocity of less than 5 cm/year were treated with growth hormone for one year. All children had peak GH response > 15mlU/l to insulin induced hypoglycaemia and normal thyroid function and adrenal reserve.

MEASUREMENTS

Anthropometric measurements were performed every 3 months. Morning urine was tested twice weekly for glycosuria. Blood count, renal and liver function tests, fasting blood glucose, IGF-I and fructosamine levels were assessed at entry and every 3 months during treatment. Fasting insulin was measured before and after 3 and 12 months of GH treatment. Skeletal maturity was assessed before and after one year of treatment.

RESULTS

Treatment was stopped in two children after 6 months because of poor growth response and noncompliance with treatment and in one child at 9 months because of bone marrow transplantation. In the 13 children, the growth velocity increased from 3.6 +/- 0.7 cm/year to 8 +/- 1.2 cm/year after one year of GH treatment (P < 0.001). IGF-I was low before treatment (10.1 +/- 2.7 nmol/l), rising significantly to 15.8 +/- 4.8, 18.4 +/- 4.6, 19.3 +/- 6.4 and 21.9 +/- 7.5 nmol/l at 3, 6, 9 and 12 months of treatment (P < 0.005). The mean pretreatment bone age in the 13 children was 9.58 +/- 1.41 years and increased to 10.53 +/- 1.43 years after one year of treatment (delta BA/CA 0.95 +/- 0.3 years). None of the patients developed glycosuria or hypertension. There was no significant change in blood count, renal and liver function, thyroid function, fasting blood glucose or insulin concentrations during treatment.

CONCLUSION

Growth failure in these children with normal GH reserve and low serum IGF-I concentrations would suggest GH insensitivity. Supraphysiological doses of exogenous GH can cause a significant increase in serum IGF-I levels and a significant improvement in short-term growth of short children with beta-thalassaemia major.

A cross-sectional study of growth, puberty and endocrine function in patients with thalassaemia major in Hong Kong

METHODOLOGY

A cross-sectional study of growth, puberty and endocrine function was performed on 35 girls and 33 boys with thalassaemia major.

RESULTS

Despite regular transfusion and chelation therapy, 75% of the girls and 62% of the boys over the age of 12 years were below the third percentile for height. Hypogonadotropic hypogonadism was found in a similar percentage of patients. Moderate to marked zinc deficiency secondary to chelation therapy was considered unlikely because normal serum zinc levels were found in all but three of our patients, but we could not exclude the possibility of a marginal status of zinc nutrition causing growth failure. Growth hormone deficiency and diabetes mellitus were sometimes encountered but hypothyroidism, hypoparathyroidism and adrenal insufficiency were rare among our patients. Most of the patients with growth failure had normal growth hormone (GH) response to insulin induced hypoglycaemia. The serum insulin-like growth factor-1 (IGF-1) levels were low in our patients and no significant difference in the serum IGF-1 levels was found between prepubertal children with or without growth failure (0.4 +/- 0.1 mU/mL vs 0.37 +/- 0.11 mU/mL, P = 0.39). Similarly, no difference in the serum IGF-1 levels was found between pubertal children with or without growth failure (0.48 +/- 0.2 U/mL vs 0.56 +/- 0.14 U/mL, P = 0.26).

CONCLUSIONS

Delayed sexual maturation and a possible defect in growth unrelated to the GH-IGF-1 axis may be responsible for the growth failure in adolescent children with thalassaemia major.

Paradoxical response of a pineal immature teratoma to combination chemotherapy

A case of primary intracranial germ cell tumour is reported in a 5-year-old Chinese boy who presented with symptoms and signs of increased intracranial pressure. Computed tomography (CT) scan of the brain revealed a multicystic tumour over the pineal region. Stereotactic biopsy yielded enteric epithelium and isolated cells with hyperchromatic nuclei and high nuclear-to-cytoplasmic ratio, suggesting the diagnosis of an immature teratoma. Grossly elevated serum and cerebrospinal fluid (CSF) levels of alpha-fetoprotein and mildly elevated levels of beta human chorionic gonadotrophin suggested the simultaneous presence of embryonal tissues. Combination chemotherapy with cisplatin, etoposide, and bleomycin resulted in a gradual but complete normalisation of the serum and CSF tumour markers. Paradoxically, the patient's consciousness deteriorated and repeat CT scan after 3 months of treatment showed that the tumour was actually increasing in size. Complete surgical removal was attempted and histologic sections of the specimen revealed only mature teratomatous tissues. The child is now well and remains disease-free with minimal left hemiparesis 12 months after completion of treatment. This case illustrates the importance of combined neoadjuvant chemotherapy and surgery in the management of intracranial non-germinomatous germ cell tumour harbouring both germ cell and teratomatous components, while monitoring of both biochemical and radiological parameters are necessary in assessing the clinical behaviour of mixed germ cell tumours.

Beta-NADH decreases the permeability of the mitochondrial outer membrane to ADP by a factor of 6

Mitochondria with intact outer membrane (99% intact based on cytochrome c impermeability) were isolated and used to measure the permeability of their outer membrane to ADP. beta-NADH reduced the permeability in a concentration-dependent manner (KD = 87 +/- 5 microM) by a factor of 6. alpha-NADH and beta-NAD+ cannot mimic the action of beta-NADH. The mitochondrial outer membranes become rate-limiting in the presence of beta-NADH at low, physiologically relevant, ADP concentrations (< 30 microM). beta-NADH has been shown to increase the voltage dependence of VDAC (a major pathway for metabolite transport across the outer membrane) in a reconstituted system and this may be the way it acts on the isolated mitochondria. Inhibition of beta-NADH dehydrogenases does not inhibit the action of beta-NADH indicating that it is not acting by delivering reducing equivalents. The ability of beta-NADH, produced by glycolysis, to inhibit mitochondrial function by reducing the permeability of the outer membrane may be one pathway responsible for the Crabtree effect.

A prospective study of symptomatic bacteremia following platelet transfusion and of its management

BACKGROUND

The danger of bacteremia due to contaminated platelets is not well known. There are also no established guidelines for the management of febrile reactions after platelet transfusion.

STUDY DESIGN AND METHODS

To determine the risk of symptomatic bacteremia after platelet transfusion, 3584 platelet transfusions given to 161 patients after bone marrow transplantation were prospectively studied. Platelet bags were routinely refrigerated for 24 hours after transfusion. Septic work-up was initiated for a temperature rise of more than 2 degrees C above the pretransfusion value within 24 hours of platelet transfusion or a temperature rise of more than 1 degree C that was associated with chills and rigor. Diagnosis of bacteremia after platelet transfusion was made only when the pairs of isolates from the blood and the platelet bags were identical with respect to their biochemical profile, antibiotic sensitivity, serotyping, or ribotyping.

RESULTS

Thirty-seven febrile reactions, as defined above, occurred. Bacteremia subsequent to platelet transfusion was diagnosed in 10 cases. There was a 27-percent chance (95% CI, 15-43%) that these febrile reactions represented bacteremia that resulted from platelet transfusion. For a subgroup of 19 patients with a temperature rise of more than 2 degrees C, the risk of bacteremia was 42 percent (95% CI, 23-64%). Septic shock occurred in 4 of the 10 bacteremic patients. A rapid diagnosis was possible because the involved bacteria were demonstrated by direct Gram stain of the samples taken from the platelet bags of all 10 patients.

CONCLUSION

Significant febrile reactions after platelet transfusion are highly likely to be indicative of bacteremia. Routine retention of platelet bags for subsequent microbiologic study was useful in the investigation of these febrile reactions. Empiric antibiotic therapy is indicated.

Risks of radiation cataracts from interplanetary space missions

Recognition of the human risks from radiation exposure during manned missions in deep space has been fostered by international co-operation; interagency collaboration is facilitating their evaluation. Further co-operation can lead, perhaps by the end of this decade, to an evaluation of one of the three major risks, namely radiation cataractogenesis, sufficient for use in the planning of the manned mission to Mars.

Helium-ion-induced human cataractogenesis

Retrospective and ongoing analyses of clinical records from 347 primary intraocular melanoma patients treated with helium ions at LBL will allow examination of the exposure-response data for human cataract; which is a complication of the therapy from incidental exposure of the lens. Direct particle beam traversal of at least a portion of the lens usually is unavoidable in treatment of posterior intraocular tumors. The precise treatment planned for each patient permits quantitative assessment of the lenticular dose and its radiation quality. We are reporting our preliminary results on the development of helium-ion-induced lens opacifications and cataracts in 54 of these patients who had 10% or less of their lens in the treatment field. We believe these studies will be relevant to estimating the human risk for cataract in space flight.

Wilms' tumor with intracardiac extension: chemotherapy before surgery

The article describes two Chinese boys ages 2 and 3 years with unilateral Wilms' tumors complicated by intracaval and intracardiac extension. In contrast to the previously recommended treatment with surgery followed by chemotherapy and radiation therapy, the children were managed primarily with combination chemotherapy before definitive operation. Reduction of tumor size on serial imaging was documented, and no viable tumor cells were found when the involved kidney and right atrium were explored. Both patients remained alive without evidence of disease more than 5 years after initial diagnosis. A literature search revealed case reports and retrospective analyses of 70 patients with Wilms' tumors and intracardiac involvement, and a tendency toward preoperative chemotherapy with or without the addition of radiation therapy was observed. The overall outcome of this group of patients parallels the outcome of those without intracardiac extension by histology and stage. Wilms' tumor presenting with extension into the inferior vena cava and right atrium is thus rare and renders the affected child with additional cardiovascular complications and operative risks. As a result of the uncommon occurrence, a consensus on management based on prospective study would be difficult. The present report and the literature are supportive of the use of preoperative chemotherapy in the initial management of advanced Wilms' tumor extending into the right atrium.

Monoamine oxidase activity in rat organs during pregnancy

To elucidate the involvement of MAO activity in rat pregnancy, female rats exhibiting at least 3 consecutive 4-day estrous cycles were used. The day of sperm-positive smears was designated as day 0 of pregnancy. The rats were sacrificed on day 2 of diestrus (diestrus-2) and days 7, 14 and 21 of gestation. The organs were collected and weighted, and mitochondrial fractions were prepared for MAO analysis with kynuramine dihydrobromide as substrate. Specific activity (pmol/mg of protein/min) in the ovary is significantly lower in rats on diestrus-2 (792 +/- 127) (mean +/- S.D.) than on day 14 (1,038 +/- 140) and day 21 (1,580 +/- 61) of pregnancy. However, the levels of MAO activity in the uterus of rats on diestrus-2 (899 +/- 266) is higher than on day 21 (570 +/- 80) of pregnancy. The MAO activity in the placenta on day 21 (644 +/- 82) was higher than day 14 (356 +/- 88) of pregnancy. Total MAO activity per organ (nmol/min) of ovary on day 21 (27.2 +/- 5.2) is higher than on diestrus-2 (8.7 +/- 3.0) and on day 14 (14.2 +/- 3.6). Our results suggest that MAO activity in rat reproductive organs such as uterus, ovary, and placenta might fluctuate significantly near term, in correlation with steroid levels, tissue catecholamine contents and so on, in order to maintain pregnancy.

Disseminated mediastinal carcinoma with chromosomal translocation (15;19). A distinctive clinicopathologic syndrome

BACKGROUND

A case of disseminated mediastinal carcinoma probably of thymic origin is reported in a 5-year-old boy with an anterior mediastinal mass associated with superior vena cava obstruction, tracheal deviation, right malignant pleural effusion, and evidence of bone metastasis. The diagnosis was based on findings of radiologic localization, light and electron microscopic study, and immunohistochemistry. The patient received combination chemotherapy but died of progressive disease.

METHODS

Cytogenic study on the pleural fluid was attempted, and a literature search for similar chromosomal aberration was performed.

RESULTS

Cytogenetic study of tumor cells from the pleural fluid revealed a clonal chromosomal abnormality of t(15;19)(q12;p13.1). Two patients with similar disease were reported in the English literature; their clinical courses, immunohistochemical findings, and t(15;19) were almost identical to those of the patient reported in this study.

CONCLUSION

The authors suggest that this translocation may be specific to thymic carcinoma and may indicate a particularly aggressive form of the disease. Carcinomas are rare in children, so the chromosomal translocation may serve as a helpful marker for the diagnosis.

Neurophysiologic study of beta-thalassemia patients

Neurophysiologic investigations were performed in 34 Chinese patients with beta-thalassemia major maintained on long-term desferrioxamine treatment to look for subclinical toxicity in the auditory, visual, peripheral, or central neural pathways. In the auditory pathway study, four patients (12%) had mild sensorineural hearing impairment. Two patients (6%) had increased P 100 latencies in the visual evoked potential study, and nine patients (26%) had abnormal electroretinogram results. All had normal electrooculograms. Ophthalmoscopic examination was abnormal in three patients (9%), and three (9%) had a visual field defect. In the peripheral or central nervous pathways, seven patients (21%) had sensory neuropathy, of which three cases were probably related to diabetes mellitus. All had normal motor conduction velocities. Four patients (12%) had increased cortical latencies of median or posterior tibial somatosensory evoked potential. Abnormalities in multiple neural pathways were seen in four patients (12%). There was a significant association between subclinical toxicity to the peripheral or central nervous systems and serum ferritin level (P < .03) and the presence of diabetes mellitus (P < .002). There was no significant relationship between the age, dosage, or duration of desferrioxamine used and the increased risk of neurotoxicity to the auditory, visual, peripheral, or central nervous systems. There was also no association between the risk of neurotoxicity and the serum zinc, copper, or fructosamine levels.

Bone marrow transplantation for thalassemia in Hong Kong: the early experience

The first experience of bone marrow transplantation (BMT) for thalassemia in Hong Kong is reported. Of the three children transplanted using a matched allogeneic donor, two have been surviving disease free 291 and 256 days post-BMT respectively. The other child rejected the graft and remained transfusion dependent. Mild graft versus host disease occurred in one of the children which subsided on cyclosporin A alone. The regimen-related toxicities were mild and easily manageable. Thus the result is encouraging and the procedure is now accepted as an option of treatment for good risk patients in Hong Kong.

Effect of ethanol and progesterone on monoamine oxidase activity in cultured cells of human term placenta

OBJECTIVE

The aim of this study was to evaluate the effect of ethanol and progesterone on the monoamine oxidase activity in cultured human term placental cells.

STUDY DESIGN

Human placental cells were prepared from normal human term placentas by enzymatic dispersion in Dulbecco's modified Eagle medium. The viability of placental cells prepared by our method was 90%, and the yield of placental cells was 0.6 x 10(6) cells per gram of wet placental tissue. Five milliliters of Dulbecco's modified Eagle medium containing 3 x 10(5) placental cells was plated in a 25 cm2 flask and cultured for 8 days in an incubator at 37 degrees C under an atmosphere of 5% carbon dioxide and 95% oxygen with a saturated humidity. During the culture period the culture medium was replenished every 2 days. A confluent monolayer condition was achieved after 8 days in culture. The cultured placental cells were treated with different concentrations of ethanol (0, 34.6, and 69.2 mmol/L) and progesterone (0, 16, and 32 mumol/L) on day 8 of culture for 48 hours. At the end of treatment placental cells from control and treated flasks were harvested for the analysis of monoamine oxidase activity by spectrophotometry. The effects of ethanol and progesterone on cultured placental cells were statistically analyzed by one-way analysis of variance followed by Duncan's multiple comparisons procedure.

RESULTS

A human placental cell culture system has been established from normal human term placentas. The monoamine oxidase activity in 8-day-cultured human term placental cells was significantly higher than that of freshly prepared placental cells. Ethanol concentrations at 34.6 and 69.2 mmol/L significantly increased and progesterone concentration at 32 mumol/L significantly decreased the monoamine oxidase activity.

CONCLUSION

These results suggest that the cultured human term placental cells can be used to examine the in vitro effects of ethanol and progesterone on monoamine oxidase activity. However, the physiologic significance of progesterone's inhibitory effect and the stimulatory effect of ethanol monoamine oxidase activity in the in vivo system have yet to be further investigated.

Hepatitis C virus antibody in multiply transfused Chinese with thalassaemia major

Thirty-four of 99 multiply transfused Chinese (49 females, 50 males) with thalassaemia major were positive for antibody to hepatitis C virus. There was no sex predominance in seropositivity with 18 females and 16 males positive. The mean (+/- SD) age and units of blood transfused were significantly higher in the seropositive patients (167 +/- 48 months, 206 +/- 82 units respectively) than the seronegative patients (113 +/- 56 months, 124 +/- 80 units respectively). The seropositive patients had higher mean (+/- SD) serum alanine aminotransferase, aspartate aminotransferase and ferritin concentrations (91 +/- 82 IU/L, 67 +/- 38 IU/L, 4797 +/- 2522 ng/ml respectively) than the seronegative patients (38 +/- 29 IU/L, 48 +/- 28 IU/L, 3620 +/- 2140 ng/ml respectively). Serum ferritin had an independent and significant effect on serum alanine aminotransferase in addition to that of seropositivity to hepatitis C virus.

Late cataractogenesis in primates and lagomorphs after exposure to particulate radiations

Rhesus monkeys that were exposed in 1969, at the age of approximately 2 years, to low doses of "mixed-energy" protons (10- and 110-MeV) are exhibiting progressive (degenerative) lenticular changes. We have conducted regular examinations of this group of monkeys for cataractogenic development since 1987, i.e., 18 years after irradiation, and the animals began to show enhanced degrees of lenticular opacification two years later. The lenses of age-matched controls (median lifespan in captivity approximately 24 years) continue to exhibit much lower levels of opacification (senile cataracts). Trends in the new data are consistent with the cataractogenic patterns observed for other groups of monkeys that were exposed at similar ages in 1964 and 1965 to protons of different energies, and which we began to monitor only 20-21 years later. Therefore, the new information from the mixed-energy group of monkeys provides insight into the development of late cataractogenic sequelae in the other groups of animals during the 2-3 years before we began to measure them. Comparisons are also made here among recent results from the different groups of primates and from New Zealand white (NZW) rabbits that were exposed when young to 56Fe ions and monitored continuously thereafter. This is done because analogous expression of radiation-induced degenerative cataractogenesis also occurs late in the lifespan of the lagomorphs (control median lifespan in captivity approximately 5-7 years), but in this case the cataractogenic profile has been documented through most of the post-irradiation lifespan.

Ultraviolet radiation, solar dermatosis, and cutaneous neoplasia in beagle dogs

Beagle dogs that were part of a life span study of the effects of low-level ionizing radiation during development were evaluated for the incidence of skin neoplasia and solar dermatosis. A total of 991 dogs up to 14 years of age were examined. The dogs were housed in gravel-based, outdoor pens with doghouses in a high-altitude, high-sunshine level environment. Solar dermatosis was restricted to the sparsely haired, nonpigmented abdominal skin. Skin neoplasms were either removed surgically or found at necropsy. Solar dermatosis was diagnosed in 363 of the 991 dogs, an incidence of 36.6%. There were 175 hemangiomas, hemangiosarcomas, or squamous cell carcinomas of the skin in the 991 dogs. Of these, 129 tumors occurred in dogs with, and only 46 in dogs without, solar dermatosis. Of the dogs with solar dermatosis, 93 (26%) had at least one of the three tumor types, compared to only 44 (7%) of dogs without solar dermatosis. Thirty-two dogs had multiple tumor types and solar dermatosis, compared to only two dogs with multiple tumor types and no solar dermatosis. There was a highly significant correlation (P less than 0.001) between the occurrence of these tumor types and solar dermatosis in the unpigmented abdominal skin. This correlation was strongest for the malignant neoplasms. Whole-body gamma-radiation exposures were delivered at one of three prenatal or three postnatal ages up to 1 year of age. There appeared to be an increased risk for hemangiosarcomas and squamous cell carcinomas in dogs with solar dermatosis and given gamma-ray exposures at 1 year of age. This suggests an interaction between exposures to ionizing and ultraviolet radiation.

Late cataractogenesis in rhesus monkeys irradiated with protons and radiogenic cataract in other species

Rhesus monkeys (Macaca mulatta) which were irradiated at ca. 2 years of age with acute doses (less than or equal to 5 Gy) of protons (32-2300 MeV) are exhibiting the late progressive phase of radiation cataractogenesis 20-24 years after exposure, the period during which we have been monitoring the sequelae of irradiation of the lens. The median life span of the primate is approximately 24 years. Analogous late ocular changes also occur in a similar period of the lifetimes of New Zealand White (NZW) rabbits (Oryctolagus cuniculus) exposed at 8-10 weeks of age to 460-MeV 56Fe ions. In this experiment, which has been in progress for ca. 6 years, we are following the development of radiation-induced lenticular opacification (cataractogenic profiles) throughout the life span. The median life span of the lagomorph is 5-7 years. Cataractogenic profiles for NZW rabbits irradiated with 20Ne and 40Ar ions and 60Co gamma photons were obtained previously. Reference is also made to measurements of the cataractogenic profiles of a short-lived rodent, the Fischer 344 rat (Rattus norvegicus) during the first year after exposure at 8-10 weeks of age to spread-Bragg-peak protons of 55 MeV nominal energy. The median life span of the rodent is reported to be 2-3 years.