Beta-glucosylceramide: a novel method for enhancement of natural killer T lymphoycte plasticity in murine models of immune-mediated disorders

BACKGROUND

beta-Glucosylceramide, a naturally occurring glycolipid, exerts modulatory effects on natural killer T (NKT) lymphocytes.

AIM

To determine whether beta-glucosylceramide can alter NKT function in opposite directions, colitis was induced by intracolonic installation of trinitrobenzenesulphonic acid, and hepatocellular carcinoma (HCC) was induced by transplantation of Hep3B cells.

METHODS

The immunological effect of beta-glucosylceramide was assessed by analysis of intrahepatic and intrasplenic lymphocyte populations, serum cytokines and STAT protein expression.

RESULTS

Administration of beta-glucosylceramide led to alleviation of colitis and to suppression of HCC, manifested by improved survival and decreased tumour volume. The beneficial effects were associated with an opposite immunological effect in the two models: the peripheral:intrahepatic CD4:CD8 lymphocyte ratio increased in the colitis model and decreased in the HCC group. The peripheral:intrahepatic NKT lymphocyte ratio decreased in beta-glucosylceramide-treated mice solely in the HCC model. The effect of beta-glucosylceramide was associated with decreased STAT1 and 4 expression, and with overexpression of STAT6, along with decreased interferon gamma levels in the colitis model, whereas an opposite effect was noted in the HCC model.

CONCLUSIONS

beta-glucosylceramide alleviates immunologically incongruous disorders and may be associated with "fine tuning" of immune responses, by changes in plasticity of NKT lymphocytes.

Solid organ second malignant neoplasms among children diagnosed with malignant bone tumors treated on Children Cancer Study Group/Pediatric Oncology Group protocols after 1980

9007

Background: The growing number of individuals surviving childhood cancer has increased the awareness and recognition of long-term sequelae. One of the most worrisome complications following cancer therapy is the development of second malignant neoplasms (SMN), in particular, late-occurring solid second malignancies related radiation therapy. Methods: We describe the incidence of solid organ SMN in survivors of pediatric malignant bone tumors (MBT) treated on legacy CCG/POG protocols from 1980 to 2005. This retrospective cohort study included 2,842 patients, 1,686 treated for osteosarcoma (OS) and 1,156 treated for Ewings Sarcoma (ES). The cohort included 56% males and 44% females, with a median age at primary diagnosis of 13 years. The median length of follow-up was 4.3 years (range: 0 to 20.9 years). Results: At the time of the analysis, 64% of patients in this study are alive. Seventeen patients with solid organ SMN were identified, and included three patients with breast cancer, three with malignant fibrous histiocytoma, two with osteosarcoma, and 9 patients with other solid organ malignancies. The standardized incidence ratio (SIR=observed/expected cases) was 2.9 (95% confidence interval [CI], 1.4–5.4) for patients treated for OS and 5.0 (95%CI 2.6–9.4) for patients treated for ES. The median time from diagnosis to develop solid organ SMN was 7 years (range: 1 to 13 years). The 10-year cumulative incidence of solid organ SMN for the entire cohort was 1% (95%CI 0.6–2%). In univariate analysis, treatment with etoposide, cyclophosphamide or radiotherapy were each associated with a higher than expected incidence of cancer with SIR of 4.8 (95% CI, 2.5–9.5), 5.8 (95% CI, 3.5–9.5) and 4.1 (95% CI, 2.4–7.1), respectively. Conclusions: Solid organ SMNs are rare after treatment for OS and ES, although higher in patients treated for ES. Recurrence remains the most significant problem for patients diagnosed with MBT and development of improved therapies with fewer long-term consequences remains paramount. However, solid organ cancers are likely to increase with longer follow-up. Therefore, surveillance should focus on monitoring for both recurrence of primary malignancies and development of SMN.

No significant financial relationships to disclose.

The role of axillary lymph node dissection in breast cancer patients with sentinel lymph node micrometastases

AIM

To identify by means of clinical and histopathological features a subset of breast cancer patients with sentinel lymph-node (sN) micrometastases and metastatic disease confined only to the sN in order to spare them an unnecessary axillary lymph node dissection (ALND).

MATERIALS AND METHODS

From January 1998 to December 2004, 116 patients with sN micrometastases underwent standard ALND for early-stage (T1-2 N0 M0) invasive breast cancer; clinical and histopathologic parameters were prospectively collected and evaluated by means of univariate and logistic regression analysis in order to identify which patients with sN micrometastases were free of metastasis in axillary non-sN.

RESULTS

Sixteen of 116 patients with sN micrometastases had tumour involvement of non-sN, with six and 10 patients having non-sN micrometastases and macrometastases, respectively. None of 19 patients with primary tumour measuring </= 10 mm had tumour-positive non-sN; moreover, none of 15 patients with G1 tumours had non-sN metastases. The mean tumour size in patients with non-sN involvement was 21.3 mm (range, 12-40 mm). Univariate test of association between clinical and histopathologic features and non-sN status showed that the primary tumour size (P=0.005) and the presence of lymphovascular invasion (P=0.000) were the only significant predictors of non-sN involvement. By logistic regression, primary tumour size (P=0.011), lymphovascular invasion (P=0.001), and size of sN micrometastases were the only variables remaining into the model, although the latter parameter was not statistically significant.

CONCLUSIONS

In patients with sN micrometastases, primary tumour size and lymphovascular invasion significantly predict non-sN status; notably, no patient with T1a-T1b and/or G1 tumours had non-sN metastases so that they could be spared an unnecessary ALND.

Thumb replantation: a retrospective review of 103 cases

Replantation has become the state of the art reconstruction for an amputated thumb. The aim of our study was to review our series of thumb replantations over a period of 12 years at the Bellevue Hospital Center in New York City. The mechanism of injury, level of amputation, and use of vein grafts was reviewed and correlated with survival rates of the replanted thumbs. The overall survival rate was 91.3%. Of the 12 thumbs that were re-explored for vascular compromise, 75% were successfully salvaged. Our study also indicates that there is no statistical difference in survival of thumb replants when comparing the mechanism of injury, the level of amputation, and the use of vein grafts. However, the use of vein grafting seemed to be beneficial in the successful outcome of replantation in severe crush and avulsion injuries, even though the values did not reach statistical significance. We conclude that thumb replantation is associated with very high survival rate, regardless of the mechanism of injury or level of amputation, and should be attempted in all cases. An early reexploration for vascular problems yields a high salvage rate and should be performed in all cases. We also recommend the use of vein grafts in severe crush and avulsion injuries.

[Definitive breast cancer surgery as an outpatient: rationale and our experience]

INTRODUCTION

The objective of this study was to evaluate the feasibility of outpatient breast definitive surgery.

CASE AND METHODS

Between January 2001 and September 2003 181 definitive breast cancer surgical approaches were performed at Surgical Department of Genoa University on 173 patients. Mean age was 60 years (28-92). All the patients were discharged the day of surgery or the day after in the morning.

RESULTS

There were no major complications or deaths. The specific complication rate was similar to inpatient setting and there was no readmission. The patients' quality of life and satisfaction were satisfactory or good.

DISCUSSION

In conclusion, holding in due consideration some philosophical and technical changes, breast cancer surgery can be safely and comfortably performed on an outpatient basis.

Enhanced coronary blood flow and abnormal blood flow in the aortic isthmus in severe fetal anemia

Coronary arteries are not normally visualized by fetal echocardiograms. Reversal of flow in the transverse aortic arch is most often seen in association with severe coarctation. We describe a case of a near-term fetus whose fetal echocardiogram showed very prominent coronary arteries and severe reversal of flow in the transverse aorta suggestive of a coarctation who was postnatally confirmed to have normal intracardiac and aortic anatomy. We discuss the pitfalls in clinical diagnosis in this case to alert pediatric cardiologists of transient perturbations in physiology masquerading as heart disease.

Proposal for a new definition of congenital complete atrioventricular block

The classic old definition of congenital heart block by Yater (1929) is still generally accepted: 'Heart block established in a young patient. There must be some evidence of the existence of the slow pulse at a fairly early age and absence of a history of any infection which might cause the condition after birth: notably diphtheria, rheumatic fever, chorea and congenital syphilis'. However, other definitions are used. We systematically reviewed 1825 cases from 38 separate studies. We conclude that complete AV blocks detected in utero in the absence of structural abnormalities differ from blocks detected later in life with respect to pathogenesis (they are generally associated with maternal anti-Ro/SSA antibodies), poorer childhood prognosis, increased risk of developing late-onset dilated cardiomyopathy, different maternal clinical features and increased risk of recurrence in future pregnancies. For these reasons we propose a new modern definition of congenital complete AV block which might be acceptable to cardiologists, rheumatologists, pediatricians and obstetricians: 'an AV block is defined as congenital if it is diagnosed in utero, at birth or within the neonatal period (0-27 days after birth)'.

Awareness of glaucoma, and health beliefs of patients suffering primary acute angle closure

AIM

To evaluate the factors associated with lack of awareness of glaucoma and late presentation to the doctor in Singapore Chinese patients with acute angle closure (AAC) METHODS: A prospective, hospital based case series of 105 patients aged 35 years and above who presented with a first attack of AAC in a tertiary hospital in Singapore was conducted. A research assistant interviewed all patients face to face in clinic and recorded demographic factors, awareness of glaucoma, and subjective barriers to seeing a doctor. The time from onset of symptoms to presentation at the clinic was noted.

RESULTS

Overall, 22.9% of patients had heard of glaucoma. The multivariate adjusted odds ratio (OR) of unawareness of glaucoma in older people (> 60 years) was 1.5 (95% confidence interval (CI) 0.5 to 4.6), 3.2 (95% CI 1.1 to 9.2) for adults who were not working, and 13.8 (95% CI 1.3 to 146.7) for patients who had less than a pre-university education. A significant proportion (31.7%) of patients presented to the doctor 24 hours or more after symptoms occurred. In a multiple logistic regression model, the adjusted OR of late presentation was 8.5 (95% CI 1.04 to 69.5) if there was no car access, 5.0 (95% CI 1.0 to 24.6) if the patients spoke Chinese, and 3.3 (95% CI 0.9 to 11.9) if there was nobody to accompany to hospital.

CONCLUSION

Glaucoma awareness among patients suffering AAC was not high. Lack of awareness was associated with increasing age, lack of formal education, and unemployment. A significant proportion of patients seek medical attention late. Risk factors for late presentation include lack of car access, nobody to accompany the patient, and speaking the Chinese language primarily. Health education programmes may help increase the knowledge and awareness of glaucoma.

Fetal cardiac function assessed by Doppler myocardial performance index (Tei Index)

OBJECTIVES

The Tei Index (TI) is a useful, non-invasive, Doppler-derived myocardial performance tool which can be used to assess aspects of systolic and diastolic function. The aim of this study was to determine normal values of fetal left ventricular (LV) TI in second- and third- trimester fetuses and to compare these to other values reported in the literature.

METHODS

Doppler waveforms of the LV outflow tracts were obtained in 74 second- and early third-trimester fetuses. The LV isovolumic contraction time (ICT), isovolumic relaxation time (IRT) and ejection time (ET) were measured and the TI calculated using the formula (ICT + IRT)/ET. The literature on LV myocardial function in the fetus was also reviewed.

RESULTS

The normal TI in second- and early third-trimester fetuses (18-31 weeks' gestation) was 0.53 +/- 0.13. The ICT was 43 +/- 14 ms, the ET was 173 +/- 16 ms and the IRT was 48 +/- 13 ms.

CONCLUSION

The TI can be easily obtained in the fetus without the need for precise anatomic imaging. The TI may be a useful tool to explore fetal myocardial function in different clinical situations.

[Biliary ileus. Considerations in surgical strategy]

Gallstone ileus is the small bowel obstruction due to one or more biliary calculi stopped in the enteric lumen. This older patient pathology is often associated with other comorbid medical conditions. Two clinical reports are analyzed and the various surgical procedures critically evaluated.

Balance findings in a child before and after a mild head injury

OBJECTIVE

This case study reviews the preinjury and postinjury balance performance of an 11-year-old child who sustained a mild head injury.

DESIGN

A prospective design was used to document balance 5 days before injury and 1, 4, and 12 weeks after injury.

OUTCOME MEASURES

The assessments used were the balance subtest of the Bruininks-Oseretsky Test of Motor Proficiency, the Pediatric Clinical Test of Sensory Interaction for Balance, and the Postural Stress Test.

RESULTS

One week after the trauma, balance deficits were observed in the three tests. The deficits improved 4 weeks after the injury, and performance remained stable over the following 2 months for two of the evaluations except for the Postural Stress Test performance, which failed to improve in the 3-month period after trauma.

CONCLUSIONS

The good recovery of balance skills observed over the first month after injury seems to validate the current activity restrictions imposed on children after a mild head injury. However, the persistence of poor performance in the area of reactions to external perturbations indicates that some deficits may persist beyond what is expected with this population.

Further evidence of association between behavioral inhibition and social anxiety in children

OBJECTIVE

The authors sought to examine psychopathological correlates of behavioral inhibition in young offspring of parents with panic disorder and/or major depression.

METHOD

Behavioral inhibition, determined by using standard laboratory observations, was assessed in four groups of children (age 2-6 years): 129 children of parents with both panic disorder and major depression, 22 children of parents with panic disorder alone, 49 children of parents with major depression alone, and 84 comparison children of parents with neither panic disorder nor major depression. Psychopathology in children > or =5 years was compared between children with behavioral inhibition (N=64) and without (N=152).

RESULTS

Social anxiety disorder (social phobia or avoidant disorder) was significantly more likely to be found in the children with behavioral inhibition (17%) than in those without (5%). Noninhibited children were significantly more likely than inhibited children to have disruptive behavior disorders (20% versus 6%, respectively) and had higher scores on the attention problems scale of the Child Behavior Checklist (mean=52.1 versus 50.8).

CONCLUSIONS

This study adds to the growing literature suggesting an association between behavioral inhibition and social anxiety disorder and an inverse relationship between inhibition and disruptive behavior disorders.

Risk factors for late-onset infection following glaucoma filtration surgery

OBJECTIVE

To determine the risk factors for late-onset infection following glaucoma filtration surgery.

METHODS

We performed a case-control study comparing 131 cases of late-onset infection collected from 27 surgeons at 10 centers with 500 controls matched for date of surgery and surgeon. The criterion for the presence of infection was severe anterior chamber reaction occurring later than 4 weeks after surgery. An opaque bleb and positive culture results were not required for diagnosis. Risk factors were identified by univariate and multivariate logistic regression analyses.

RESULTS

Some of the risk factors that were statistically significant in the multivariate model after adjusting for age, race, and sex were (1) performance of a full-thickness rather than a guarded procedure (risk ratio [RR], 13.1; 95% confidence interval [CI], 2.12-80.9), (2) filtration surgery performed without concurrent cataract surgery (RR, 2.25; 95% CI, 1.24-4.08), (3) use of mitomycin (RR, 2.48; 95% CI, 1.06-5.83), (4) intermittent use of antibiotics after surgery (RR, 2.10; 95% CI, 1.09-4.02), and (5) continuous use of antibiotics after surgery (RR, 5.94; 95% CI, 2.09-16.9).

CONCLUSIONS

Eyes undergoing full-thickness procedures or filtration surgery without cataract extraction are at increased risk for late infection. Intraoperative mitomycin and episodic or continuous antibiotic use after the postoperative period are associated with an increased risk of infection.

The novelty P3: an event-related brain potential (ERP) sign of the brain's evaluation of novelty

A review of the literature that examines event-related brain potentials (ERPs) and novelty processing reveals that the orienting response engendered by deviant or unexpected events consists of a characteristic ERP pattern, comprised sequentially of the mismatch negativity (MMN) and the novelty P3 or P3a. A wide variety of evidence suggests that the MMN reflects the detection of deviant events, whereas the P3a is associated more with the evaluation of those events for subsequent behavioral action. On the scalp, the novelty P3a is comprised of at least two aspects, one frontal the other posterior, each with different cognitive (and presumably neurologic) correlates. Intracranial ERP investigations and studies of patients with localized brain lesions (and, to some extent, fMRI data) converge with the scalp-recorded data in suggesting a widespread neural network, the different aspects of which respond differentially to stimulus and task characteristics.

Cytokine modulation with immune gamma-globulin in peripheral blood of normal children and its implications in Kawasaki disease treatment

Intravenous immune gamma-globulin (IVIG) is used successfully in the treatment of Kawasaki disease, with dose-dependent rapid resolution of symptoms such as fever and irritability and a decrease in ESR, WBCs, and platelets. The mode of action of IVIG in reducing this inflammatory response is not clearly understood. Recently anticytokine antibodies in IVIG have been demonstrated. Serum levels of proinflammatory cytokines have been shown to be elevated in patients with Kawasaki disease. The cytokine interleukin-6 (IL-6) is involved in the de novo production of acute-phase proteins by hepatocytes and cause thrombocytosis and fever in response to tissue injury. Patients receiving parenteral recombinant human IL-6 have dose-dependently experienced fever, malaise, chills, and acute-phase reaction. With high IL-6 concentrations, central nervous system toxicity has also been reported and IL-6 has been thought to mediate endothelial damage. We evaluated the response of stimulated blood cells of 12 normal children to IVIG in the release of the cytokines IL-6, IL-8, TNF-alpha. and IL-6 receptor (sIL-6R). The levels of cytokines IL-6, IL-8, and TNF-alpha (but not sIL-6R) in peripheral blood induced by stimulation with LPS were markedly reduced (P < 0.008) within 3 hr when incubated with IVIG compared to without IVIG. Thus we demonstrated that cells of normal children respond to IVIG in vitro by reducing cytokines such as IL-8, TNF-alpha, and IL-6 without affecting the level of receptor sIL-6R during an acute inflammatory response. We also found significantly higher IL-6 levels in children with Kawasaki disease compared to children with blood culture-negative febrile illnesses. In five children with Kawasaki disease we measured serum IL-6 before and after IVIG and assessed the clinical response to IVIG therapy. Therapy with IVIG was followed by a rapid resolution of symptoms in Kawasaki disease, with a significant decrease in serum IL-6. The attenuation of proinflammatory cytokine responses, especially IL-6, following infusions of IVIG may play an integral role in the rapid resolution of symptoms and decrease in the acute-phase proteins in children with Kawasaki disease. Cells of normal children were found to respond to the IVIG in a manner similar to that of the Kawasaki children.

Recognition and source memory for pictures in children and adults

The present experiment investigated the developmental aspects of source compared to item memory. College students and 7-8-year-old children viewed pictures drawn in red or green during a study phase, and were asked either to remember the pictures for a subsequent recognition test, or to remember both the pictures and their associated colors for a subsequent source memory test. In the test phase, new and old pictures were presented in black. In the recognition task, participants were asked to make binary old/new recognition judgments, while in the source task, they were asked to make trinary old-green/old-red/new source judgements. Performance on all tasks improved with increasing age, but the age difference for source was much larger than that for item memory. It has been suggested that the frontal lobes play a critical role in the retrieval of source information, and that this brain region relative to the medial temporal lobes continues to develop into late adolescence. Thus, it is possible that immaturity of the frontal lobes may be causally related to the children's lower performance on the source memory task.

Remembering the color of objects: an ERP investigation of source memory

Subjects studied pictures of common objects outlined in either red or green and were asked to memorize the objects and their associated colors. Event-related potentials (ERPs) were recorded during subsequent inclusion (i.e. item) and exclusion (i.e. source) memory tasks. The main goal of the experiment was to determine if brain signatures for familiarity and recollection, two behavioral processes thought to account for episodic memory performance, would be observed in the pattern of ERP results. For correctly recognized items, early, posterior old/new effects were recorded (approximately 300--600 ms) that did not differ in magnitude or scalp distribution between item and source memory tasks. A subsequent long-duration occipitally focused negativity (approximately 800 ms peak) was evident in the source but not the item memory task. The ERPs associated with 'source errors' in the source memory task also showed robust early old/new effects. However, 'source error' ERPs lacked frontal scalp activity compared to those associated with correct source attribution. The data suggest that a recollective response may require frontal involvement whereas a decision based on familiarity may not.

Positive predictive values of abused drug immunoassays on the Beckman Synchron in a veteran population

The pressure to reduce the cost of analytic testing makes it tempting to discontinue routine confirmation of urine specimens positive for drugs of abuse by immunoassay. Beyond the economic motivation, the requirement for confirmation should be driven by the positive predictive value of the screening tests. We have quantitated positive predictive values of our screening immunoassays in a large metropolitan Veterans Affairs Medical Center. We reviewed the confirmatory rate of urine specimens positive for drugs of abuse with Beckman Synchron reagents from June 1998 to June 1999 and tabulated the false-positive screening rate. There were 175 instances of false-positive screens during the 13 months we analyzed. Positive predictive values ranged from 0% (amphetamine) to 100% (THC). We determined that the low positive predictive value of the amphetamine assay in our laboratory was primarily due to the use of ranitidine (Zantac). Urine specimens containing greater than 43 microg/mL ranitidine were positive in our amphetamine assay. This concentration is routinely exceeded in our patients taking ranitidine. In our clinical and analytic setting, the Beckman THC assay did not require confirmation. The positive predictive values of the Beckman opiate, cocaine, barbiturate, propoxyphene, and methadone immunoassays dictate routine confirmatory testing in specimens that screen positive for these substances. Finally, because of its extreme sensitivity to ranitidine, the Beckman amphetamine assay has little utility in our laboratory setting.

Cognitive brain potentials in children at risk for schizophrenia: preliminary findings

Event-related brain potentials were recorded to auditory stimuli from children at risk for schizophrenia and normal control children who were part of two independent samples being followed longitudinally. Subjects were required to detect (with a reaction time response) one of two infrequent events (either a pitch change or a missing stimulus), each of which occurred 17 percent of the time, and was embedded in a sequence of frequent events occurring 66 percent of the time. The event-related potential (ERP) elicited by both infrequent stimuli consisted of a positive-going wave peaking at 350 msec for the pitch change ERP (P350) and 400 msec for the missing stimulus ERP (P400) and a slow wave, which overlapped with and extended beyond the P350 and P400 potentials. When the eliciting event was relevant, these potentials were significantly larger than when it was irrelevant. When the waveforms by the highrisk (HR) subjects were compared to those produced by the normal control (NC) subjects, the HR subjects of both samples showed significantly less late positive amplitude (P350 and P400) than the NC subjects, but only when the eliciting event was relevant. This effect appeared to be independent of reaction time, as reaction time means and variances were quite similar between risk groups. Other possible explanations for this amplitude reduction were explored. Since late positive component amplitude reduction has been consistently reported to characterize the waveforms of adult schizophrenics, the reduction seen in children at genetic risk for schizophrenia may be a premorbid indicator for the development of the psychosis.