Hematopoietic stem cell transplantation does not increase the risk of infection-related complications for pediatric patients with Hodgkin and non-Hodgkin lymphomas: A multicenter nationwide study

BACKGROUND

Hodgkin (HL) and non-Hodgkin lymphoma (NHL) represent a spectrum of lymphoid malignancies that are often curable with currently applied treatment regimens; however, 15%-30% of lymphoma patients still suffer from relapsed or refractory (rel/ref) disease. Although hematopoietic stem cell transplantation (HSCT) improves outcomes of second-line therapy for lymphoma in childhood, the complication rates in this group of patients, especially infectious complications (IC), remain unclear.

OBJECTIVE

The aim of this population-based cohort study was a retrospective analysis of incidence, epidemiology and profile of bacterial infections (BI), invasive fungal disease (IFD), and viral infections (VI) in primary or rel/ref lymphoma patients, both HL and NHL.

PATIENTS AND METHODS

We subdivided lymphoma patients into three groups: patients with primary conventional chemotherapy/radiotherapy regimens (group A), patients with rel/ref lymphoma treated with second-line chemotherapy (group B), and rel/ref lymphoma patients who underwent HSCT (group C). The medical records of the patients were biannually reported by each pediatric oncology center, and the data were analyzed centrally.

RESULTS

Within 637 patients with primary lymphoma, at least one IC was diagnosed in 255 (40.0%), among 52 patients with rel/ref lymphoma 24 (46.2%) ICs were observed, and in transplanted group, 28 (57.1%) out of 49 children were diagnosed with IC (P = .151). The distribution of etiology of IC differed between the patient groups (A, B, C), with a predominance of BI in group A (85.6% vs 72.0% and 47.9%, respectively), VI in group C (9% and 16.0% vs 46.6%, respectively), and IFD in group B (5.4% vs 12.0% vs 5.5%, respectively). Overall, 500 (68.0%) episodes of bacterial IC were diagnosed in the entire group. Apart from HL patients treated with chemotherapy, in all the other subgroups of patients Gram-positives were predominant. The rate of multidrug-resistant bacteria was high, especially for Gram-negatives (41.1% in group A, 62.5% in group B, and 84.6% in group C). The infection-related mortality was comparable for each group.

CONCLUSIONS

The incidence of IC was comparable during first- and second-line chemotherapy and after HSCT, but their profile was different for primary or re/ref lymphoma and depended on the type of therapy.

Fulminant Reversible Cerebral Vasoconstriction Syndrome

Reversible cerebral vasoconstriction syndrome (RCVS) is increasingly being recognized as a diagnosis in patients presenting with thunderclap headaches. In the vast majority of the cases, the syndrome follows a benign course and patients recover completely without any significant therapeutic intervention. In the rarest of cases, RCVS follows a monophasic course with rapid worsening, severe neurological deficits, and poor outcomes. We present the case of a 25-year-old female who presented with headaches which were worsening over 1 week. She was admitted to the hospital and rapidly worsened to develop severe neurological deficits over the next day. Initial computed tomography scan showed areas of hemorrhage and multiple ischemic strokes. Computed tomography angiogram and a conventional cerebral angiogram both revealed multifocal vasoconstriction, highly suggestive of RCVS. Despite aggressive medical and surgical management, the patient continued to worsen and eventually died. Autopsy findings did not show evidence of vasculopathy or any other underlying disorder, further supporting the diagnosis of RCVS. The RCVS is usually a benign self-remitting condition which commonly affects young females and presents with an insidious onset of headaches. Rarely, it can have a fulminant course with devastating outcomes. This case illustrates an exceptionally uncommon clinical course of RCVS and the challenges in its treatment.

The Relationship Between Brain MR Spectroscopy and Disability in Multiple Sclerosis: 20-Year Data from the U.S. Glatiramer Acetate Extension Study

BACKGROUND AND PURPOSE

Conventional MRI techniques do not necessarily provide information about multiple sclerosis (MS) disease pathology or progression. Nonconventional MRI techniques, including proton magnetic resonance spectroscopy (¹H‐MRS), are increasingly used to improve the qualitative and quantitative specificity of MR images. This study explores potential correlations between MRI measures of disease and disability progression as measured by the Expanded Disability Status Scale (EDSS), Functional Systems (FS), and ambulation index scores in a unique cohort of MS patients treated with glatiramer acetate that has been closely monitored for over 20 years.

METHODS

This was a multicenter, open‐label, cross‐sectional MRI substudy among participants in the GA‐9004 open‐label extension of the 36‐month, double‐blind GA‐9001 study, timed to coincide with the prospectively planned 20‐year clinical exam.

RESULTS

Of 64 patients who participated in the MRI substudy, results are presented for the 39 patients (61%) who had a ¹H‐MRS assessment at 20 years of treatment. Both total N‐acetylaspartate relative to total creatinine (tNAA/tCr) concentration ratio and T1 lesion volume were found to be robustly associated with disability levels with different statistical approaches. Gray matter (GM) volume was found to be a more consistent parameter than white matter (WM) volume for disability allocation. The elastic net algorithm showed a trade‐off between WM and GM volumes for disability estimation when different disability definitions were used.

CONCLUSIONS

Among patients with MS receiving long‐term glatiramer acetate therapy, consistent effects on disability levels indicated by EDSS and pyramidal FS score thresholds were found for tNAA/tCr concentration ratio and T1 lesion volume.

Longitudinal study of the substantia nigra in Parkinson disease: A high-field (1) H-MR spectroscopy imaging study

INTRODUCTION

The value of biomarkers in early diagnosis and development of therapeutics in Parkinson's disease (PD) is well established.

METHODS

We used proton magnetic resonance spectroscopy in a prospective, longitudinal study of 23 patients with early PD, naïve to dopaminergic therapy, and six age-matched healthy controls to examine the temporal changes in metabolic profile of substantia nigra over a period of 3 months.

RESULTS

N-acetyl aspartate to creatine ratio at month 3 was compared with baseline values in the PD and control groups, as well as the side-to-side difference of the ratio at baseline. By month 3, n-acetyl aspartate to creatine ratio had decreased by 4.4% in patients with PD (P = 0.024), without a concomitant change in healthy controls. The side-to-side asymmetry was significantly higher in the PD group (16.7%) vs. healthy controls (1.6%, P = 0.0024).

CONCLUSION

Estimation of change in the n-acetyl aspartate to creatine ratio appears to be a fast, quantifiable, and reliable marker of dopaminergic neuronal viability in PD.

Fibrinogen alpha and beta gene polymorphisms in pediatric stroke--case-control and family based study

BACKGROUND/PURPOSE

Data on the role of the -455G > A polymorphism of the gene encoding β fibrinogen subunit (FGB) and the Thr312Ala polymorphism of the gene for the α fibrinogen subunit (FGA) in childhood ischemic stroke are insufficient. Therefore the aim of the study was to evaluate a possible association between these two polymorphisms and arterial ischemic stroke.

METHODS

The study group consisted of 85 children after ischemic stroke, 146 of their parents and 159 controls. Both polymorphisms were genotyped using the restriction fragment length polymorphism method. Two study designs were used: a case-control model and a family-based transmission-disequilibrium test. Statistica 7.1 and EpiInfo 6 softwares were used in all analyses.

RESULTS

In the TDT test, a tendency to a higher transmission of the 312Ala allele of the FGA gene and the -455A allele of the FGB gene was observed, however, it was statistically non-significant. The frequencies of alleles and genotypes of both FGA and FGB genes polymorphisms did not differentiate children from both groups also in the case-control model. Additive or synergistic effects between FGA and FGB genes polymorphisms were not observed.

CONCLUSION

An analysis of the results obtained in this study and a critical review of previously published data indicate that examined gene polymorphisms are not related to ischemic stroke in children.

Spinal cord atrophy in multiple sclerosis and relationship with disability across clinical phenotypes

BACKGROUND

Several studies have shown a relationship between spinal cord atrophy and clinical disability in patients with multiple sclerosis (MS).

OBJECTIVES

We examined the correlation between cervical cord cross-sectional area at the C2 vertebral level (CSA-C2) and the expanded disability status scale (EDSS) in patients with relapsing-remitting and progressive forms of MS. The latter included both secondary and primary progressive MS patients.

METHODS

A total of 150 patients with MS were recruited from the Wayne State University MS clinic. Ninety-three had relapsing-remitting MS and 57 patients had progressive MS. MRI scan of the cervical cord was obtained for each patient. Correlation studies and multivariate regression analysis was performed, blinded to clinical status.

RESULTS

The mean age was 41.3 year old, 64.6% were women, mean disease duration was 11.2 years, CSA-C2 was 80.2mm(2) and mean EDSS was 3.8. There was significant correlation between CSA-C2 and EDSS (r -0.75, p<0.0001). Sub-group analysis showed CSA-C2 was 68.6mm(2) and 87.3mm(2) in the progressive and relapsing-remitting groups, respectively (p<0.0001). Multivariable regression showed that CSA-C2 was a significant predictor of disability independent of disease duration, and phenotype.

CONCLUSIONS

Our study demonstrates that CSA-C2 has a strong correlation with clinical disability in both RRMS and progressive MS. Greater spinal cord atrophy was seen in patients with progressive than relapsing-remitting MS. CSA-C2, disease duration, and phenotype are independent predictors of disability.

Fatal encephalitis due to BK virus in a patient with common variable immunodeficiency: a case report

Encephalitis due to BK virus is a rare condition. Here, we describe a young male patient with common variable immunodeficiency who developed fatal encephalitis due to BK virus. The patient presented initially with ocular symptoms that were followed by behavioral changes and spastic quadriparesis. Diagnosis was made by the compatible clinical findings and detection of viral DNA by polymerase chain reaction in the cerebrospinal fluid. To the best of our knowledge, this is the first report of BK virus encephalitis in a patient with common variable immunodeficiency. We suggest that BK virus should be suspected in cases of encephalitis; particularly in patients with immunodeficiency.

Pituitary abscess presenting two years after the diagnosis of a pituitary lesion in a patient with panhypopituitarism

Pituitary abscess is a rare condition. Here, we present the case of a young male patient who was initially found to have a pituitary lesion following the diagnosis of panhypopituitarism. Two years later, he presented with severe headache and was subsequently diagnosed intraoperatively with pituitary abscess. At a follow-up of 6 years after surgery, the patient was continuing to do very well. We discuss the differential diagnosis and demonstrate the evolution of the pituitary lesion on magnetic resonance imaging at four different time points: at the time of the detection of the initial lesion; two years later at the time of the diagnosis of the pituitary abscess; at 7 weeks post operatively; and finally after six years from the pituitary surgery.

Mondini malformation associated with diastematomyelia and presenting with recurrent meningitis

The authors report the case of 5-year-old girl who presented with 4 episodes of recurrent meningitis. Her initial workup revealed a lumbosacral dermoid sinus associated with diastematomyelia and a tethered cord. Therefore, a surgical repair to correct the anomaly was performed. However, another episode of meningitis occurred after surgery, and a subsequent temporal bone scan revealed the presence of left Mondini dysplasia. To the authors' knowledge, this is the first report of Mondini dysplasia in association with diastematomyelia.

Progressive multifocal leukoencephalopathy and relapsing-remitting multiple sclerosis: a comparative study

OBJECTIVE

To identify clinical and magnetic resonance imaging (MRI) features that distinguish progressive multifocal leukoencephalopathy (PML) from relapsing-remitting multiple sclerosis (RRMS).

DESIGN

Retrospective medical record review.

SETTING

Two urban teaching hospitals in Detroit, Michigan. Patients Forty-five confirmed PML cases and 100 patients with RRMS.

MAIN OUTCOME MEASURES

Clinical and MRI features distinguishing PML from RRMS.

RESULTS

Overall, monosymptomatic presentations were more common in multiple sclerosis (MS) than PML (85% vs 47%; P < .01). However, patients with PML presented more often with hemiparesis (24% vs 5%; P = .001) and altered mentation (19% vs 0%; P < .0001), whereas brainstem (2% vs 18%; P = .007) presentations were more common in patients with RRMS. Spinal cord and optic neuritis presentations were seen in 18% and 33% of patients with RRMS, respectively, but not in patients with PML (m < .0001). Brain MRI scans, available in 35 (78%) PML cases, revealed 7 lesion types. Large, confluent T2-weighted lesions (74% vs 2%; P < .0001) and deep gray matter lesions (31% vs 7%; P < .001) were more frequent in patients with PML than patients with RRMS. Crescentic cerebellar lesions (23% vs 0%; P < .001) were seen only in patients with PML. Gadolinium-enhancing (23%), transcallosal (9%), and periventricular (9%) lesions were noted in patients with PML. Brain magnetization transfer ratio (MTR) was low in both PML and MS lesions. However, normal-appearing brain tissue MTR in PML was higher than normal-appearing brain tissue MTR in RRMS (44.15% vs 41.04%; P = .002), suggesting that PML may be relatively more focal than MS.

CONCLUSIONS

There appear to be differences between the clinical and MRI characteristics of PML and RRMS, which may help distinguish new MS activity from PML. Magnetization transfer ratio studies may provide additional clues in improving early detection of PML in patients with preexisting MS and warrant further investigation.

Long-term study of brain 1H-MRS study in multiple sclerosis: effect of glatiramer acetate therapy on axonal metabolic function and feasibility of long-Term H-MRS monitoring in multiple sclerosis

Glatiramer acetate (GA) has several putative mechanisms of action with the potential of limiting sublethal axonal injury in the central nervous system (CNS). Brain proton magnetic resonance spectroscopy ((1)H-MRS) allows in vivo examination of axonal integrity by quantifying the neuronal marker N-acetylaspartate (NAA), often expressed as a ratio to creatine (Cr). We showed that treatment with GA led to improvement in NAA/Cr over a 2-year period. We now report the results of this ongoing study after 4 years of annual brain (1)H-MRS examinations. Compared to baseline, at year 4, patients receiving continuous GA therapy showed a 12.7% increase in NAA/Cr and (P= .03) in the multivoxel brain volume of interest (VOI) studied and by 9.6% (P= .04) in the normal-appearing white matter within the VOI. Three patients in the control group who began therapy with GA during the course of the study showed similar increases in NAA/Cr after the first year of therapy. These data support the long-term effect of GA on maintaining axonal metabolic function and protection from sublethal injury as well as the feasibility of employing brain (1)H-MRS in long-term investigative studies in MS.

Failure to develop multiple sclerosis in patients with neurologic symptoms without objective evidence

BACKGROUND

Many patients referred to multiple sclerosis (MS) centers with symptoms suggestive of MS are found to have normal neurologic examinations, normal or non-specific brain magnetic resonance imaging (MRI) scan findings, and normal cerebrospinal fluid (CSF). Persistent symptoms often lead to multiple consultations and repeated diagnostic investigations. We performed a study to evaluate the diagnostic utility of repeated evaluations in patients with normal initial assessments and persistent neurologic symptoms.

METHODS

143 patients were evaluated initially and 109 returned for a second evaluation after a mean interval of 4.4 years.

RESULTS

All 143 patients had normal initial examinations, brain MRI scans, screening blood tests, and CSF studies. Spinal cord imaging was normal in all patients tested (cervical cord, n = 126; 88.1%; thoracic cord, n = 58; 40.6%). Evoked potential studies were abnormal in a small percentage of patients: visual evoked potentials, VEP (8.1%), somatosensory evoked potentials, SSEP (4.9%), and brainstem auditory evoked potentials, BAEP (2.8%). All follow-up patients (n = 109) had normal examinations and MRI scans. Repeat CSF studies (n = 35; 32.1%) and spinal cord imaging (cervical cord n = 57; 52.3%; thoracic cord n = 32; 29.4%) were normal in all follow-up patients tested. No patients at initial presentation or at follow-up fulfilled diagnostic criteria for MS.

CONCLUSIONS

PATIENTS

and clinicians may be reassured that persistent neurologic symptoms in the absence of objective clinical evidence do not lead to the development of MS. Costly serial investigations should be carefully considered, particularly in the presence of normal neurologic examination at follow-up.

Leptomeningeal metastasis in a patient with squamous cell carcinoma of the uterine cervix: Report of a case and review of the literature

Leptomeningeal spread of advanced squamous cell carcinoma (SCC) of the uterine cervix is unusual. To our knowledge, very few cases were reported in the English literature. We report a case of a 39-yr-old woman who presented with leptomeningeal metastasis from a stage IIb SCC of uterine cervix. The diagnosis was made by cytomorphological examination of smears obtained from cerebrospinal fluid. The cytomorphological features are demonstrated.

Selectin glycoprotein ligands

Lectin selectins and their counter-receptors participate in discontinuous cell-cell interactions concurrent with leukocyte tethering and rolling on endothelium, which, in consequence, leads to leukocyte penetration to lymphatic organs and generation of inflammation sites. Counter-receptors are glycoproteins in which carbohydrate units, the direct selectin ligands, are built into the polypeptide framework. In this review, the distribution, structure and function of the main ligands and counter-receptors for P-, L- and E-selectins known so far, have been discussed. The common biosynthetic pathway of sialyl-Lewis x and sulpho-sialyl-Lewis x determinants of selectin ligands has been described.

Selectin glycoprotein ligands

Lectin selectins and their counter-receptors participate in discontinuous cell-cell interactions concurrent with leukocyte tethering and rolling on endothelium, which, in consequence, leads to leukocyte penetration to lymphatic organs and generation of inflammation sites. Counter-receptors are glycoproteins in which carbohydrate units, the direct selectin ligands, are built into the polypeptide framework. In this review, the distribution, structure and function of the main ligands and counter-receptors for P-, L- and E-selectins known so far, have been discussed. The common biosynthetic pathway of sialyl-Lewis x and sulpho-sialyl-Lewis x determinants of selectin ligands has been described.

In vitro effects of ethanolamine on insulin secretion

The effects of ethanolamine on insulin secretion by the perfused rat pancreas were examined. During the second phase of glucose-induced insulin secretion 5-minute perfusions of ethanolamine at final concentrations of 0.1, 1 and 10 mM inhibited insulin release in a dose-related manner. When given throughout the experiment the highest dose of ethanolamine markedly suppressed both phases of glucose-induced insulin release. The inhibitory effect of ethanolamine was blunted in the presence of phentolamine. It is concluded that ethanolamine inhibits glucose-induced insulin secretion by the perfused rat pancreas and that alpha-adrenergic receptors play a role in its actions on insulin output.

Anxiety and self-concept of learning disabled children

This study compares anxiety and self-concept among learning disabled children and their nondisabled peers. On—hundred learning disabled (LD) and 118 nondisabled children participated in the study which demonstrated significantly higher anxiety and lower self-concept in the first group. The differences emphasized the self-dissatisfaction of the LD group and their pawning related anxiety. Therapeutic implications of the results are discussed.

Contradictory Or Complementary? Reassessment Of Two Competing Theories Of The Structure Of Attitudes

The theories of Kerlinger and Eysenck on the nature of the dimensions underlying social attitudes are discussed. Integrating principles from both theories, an alternative approach to the issue is suggested and tested on the domain of attitudes towards education in relation to personality. The results of a multivariate analysis support Kerlinger's concept of the duality (vs. bipolarity) of the attitudinal domain, as well as Eysenck's theory about the reflection of personality on attitudes.

The Common Space of Personality Traits and Vocational Interests

Investigated relationships between personality traits and vocational interests. Cattell's (Research and Consultations Center of Educational Personnel, 1976) CAQ Part I and the Ramak interest inventory (Meir, 1975) based upon Roe's (1956) occupational classification system were administered to a sample of 397 university applicants. Canonical Correlation Analysis and Smallest Space Analysis were used to test two hypotheses (a) relationships exist between personality traits and vocational interests; and (b) personality traits which characterize occupational profiles are arranged in circular order corresponding to the configuration Of the vocational fields which represent those occupations. Both hypotheses were supported by the data.

Dimensions of Jewish-American identity

The main problem posed in this study is: What are the content and structure of Jewish and American identity? The Jewish-American Identity Scale, which was adapted and refined for this study, was administered in 1971 to four samples, totaling 1006 Jewish-American college students from various parts of the United States. Initially, factor analysis was applied to the separate samples. Intersample comparisons of factor structures indicated a high degree of congruency; consequently, the samples were combined for subsequent analyses. Factor analysis of the test scores demonstrated that most of the common factor variance was appropriated by two relatively orthogonal factors. Items dealing with American identity and those dealing with Jewish identity had medium to high loadings on the two respective factors. These findings supported the hypothesis of the duality and the orthogonality of dimensions of Jewish and American identity, and cast doubt on the notion forwarded by some researchers that Jewish-American identity forms a bipolar continuum.