Pulmonary Vein Occlusion After Surgical Atrial Fibrillation Ablation and Left Atrial Appendage Occlusion

We report a case of pulmonary vein (PV) occlusion in a patient with a history of surgical atrial fibrillation ablation and left atrial appendage occlusion with unsuccessful endovascular management. Delayed diagnosis of PV stenosis post-ablation can make interventional treatment options less likely to be successful. (Level of Difficulty: Intermediate.).

Abstract P123: Accuracy Of Hypertensive Emergency Diagnosis Code In Administrative Database: Insights From National Inpatient Sample 2017

Background: Hypertensive emergency (HTNE) diagnostic code was introduced, in the US, in October 2016 to improve identification of patients with end-organ damage due to high blood pressure but its impact is unclear.

Objective: To assess the accuracy of HTNE code using administrative data.

Methods: We used National Inpatient Sample 2017 to identify adult patients, age ≥18 years, with International Classification of Disease-10th Clinical modification (ICD-10-CM) code of I16.1. We used the presence of end-organ damage diagnostic codes to identify true HTNE.

Results: A total of 194,495 patients had a diagnosis of HTNE. Of these only 144,070 (74.1%) had a concomitant diagnosis of end-organ damage. Baseline characteristics of entire cohort stratified by presence of target organ damage (Table 1A) and frequency of end-organ damage in true HTNE patients (Table 1B) are shown. Patients with true HTNE were likely to be older and male with higher co-morbidity burden. There was also significant difference in outcomes between two groups with a higher proportion of true HTNE patients experiencing longer length of stay and increased mortality which is in-line with previous studies.

Conclusions: The accuracy of hypertensive emergency diagnosis code is low with positive predictive value of 74.1% and caution is advised when using with administrative data. Further studies, using individual patient discharge records, are required to validate HTNE code.

P4171Population characteristics, interventions and outcomes in hospitalized orthotopic heart transplant patients with sudden cardiac arrest: a nationwide United States analysis from 2007 to 2015

Background

Sudden cardiac arrest (SCA) is a leading cause of death in the United States (US), claiming up to 450,000 lives annually and accounting for ∼25% of deaths following orthotopic heart transplantation (OHT),

Purpose

We sought to characterize OHT patients suffering SCA and their subsequent management, in comparison to the general, native heart (NH) population, using a large national inpatient database.

Methods

A cross-sectional analysis was performed among US OHT & NH patients hospitalized with incident SCA or ventricular fibrillation/flutter. We analyzed demographics, baseline characteristics, procedural utilization and outcomes. Groups were compared with standard statistical techniques. A P-value <0.05 was considered significant.

Results

From 2007–2015, 920 SCA admissions were identified among 121,083 (0.8%) OHT hospitalizations, compared to 1,731,658 (0.6%) in the general population (P<0.001). OHT patients were younger (P<0.001) and predominantly men (P<0.001). More OHT patients had diabetes (P=0.01), while the NH group had more coronary disease (P=0.01). Mechanical circulatory support use was similar in both groups overall, and OHT patients were more likely to undergo transplantation (P=0.015). Pacemaker/defibrillator implants were more common in NH than OHT patients (P<0.001). Acute kidney injury and in-hospital mortality were significantly greater in OHT patients.

Table 1. SCA in OHT & general populations Orthotopic Heart Transplant General Population P-value (N=121,083) (N=278,463,550) Sudden cardiac arrest (SCA) events, n (%) 920 (0.8%) 1,731,658 (0.6%) <0.001 Age, mean (SD) 57 (17) 66 (16) <0.001 Male sex, n (%) 644 (72%) 1,004,362 (58%) <0.001 Coronary artery disease, n (%) 275 (30%) 675,908 (39%) 0.012 Mechanical circulatory support, n (%) 64 (7%) 104,151 (6%) 0.230 Repeat heart transplantation, n (%) 5 (0.5%) 1199 (0.1%) 0.015 Pacemaker or defibrillator implant, n (%) 45 (5%) 136,314 (8%) <0.001 In-hospital mortality, n (%) 555 (60%) 932,812 (54%) 0.014 Cardiogenic shock, n (%) 78 (8%) 208,778 (12%) <0.001 Acute kidney injury, n (%) 418 (45%) 608,035 (35%) 0.003

Conclusions

SCA hospitalizations occur more often and with higher mortality in OHT patients compared to the general population. Earlier recognition of at-risk patients may result in improved utilization of potentially life-saving therapies.

Carbon innumeracy

Individuals must have a quantitative understanding of the carbon footprint tied to their everyday decisions to make efficient sustainable decisions. We report research of the innumeracy of individuals as it relates to their carbon footprint. In three studies that varied in terms of scale and sample, respondents estimate the quantity of CO₂ released when combusting a gallon of gasoline in comparison to several well-known metrics including food calories and travel distance. Consistently, respondents estimated the quantity of CO₂ from gasoline compared to other metrics with significantly less accuracy while exhibiting a tendency to underestimate CO₂. Such relative absence of carbon numeracy of even a basic consumption habit may limit the effectiveness of environmental policies and campaigns aimed at changing individual behavior. We discuss several caveats as well as opportunities for policy design that could aid the improvement of people’s quantitative understanding of their carbon footprint.

Detection of Juvenile Sleep Deprivation by Stochastic Optimization of Pupillographic Records

Objective: To address the challenging problem of measuring juvenile sleep deprivation, we test the hypothesis that a pupillographic method found successful for adult narcoleptics might also discriminate between sleep deprived juveniles acting as their own controls.

Methods: A linear, nonstationary model relating pupillary diameter and a random photic stimulus are estimated by recursive regressions from pupillographic records of 8 juveniles of median age 7 years acting as their own rested controls. The estimated pupillary impulse response noise functions are stochastically optimized using the Kullback divergence measure to maximally separate the sleep deprived records from the control records.

Results: Both the average and covariance statistics of the estimated pupillary noise functions exhibit statistically significant differences between sleep deprived and rested subjects. The main result is that sleep deprivation decreases pupillary noise variance; a finding consistent with a previous study of adult narcoleptics. Further, it was found that virtually the same stochastic parameters were optimal for the juvenile sleep deprived data and for the previous adult narcoleptic study.

Conclusions: Although our results are preliminary, the consistent reduction of pupillary noise appears to justify a comprehensive clinical trial across a broad range of age classes. In addition, the finding that the same parameters stochastically optimze both juvenile and adult recordings suggests the procedure holds promise as a clinical test which could produce sleep deprivation measures simultaneous with data collection.

Low incidence of left atrial delayed enhancement with MRI in patients with AF: a single-centre experience

BACKGROUND

Atrial fibrillation (AF) is the most common sustained atrial arrhythmia. One potential target for ablation is left atrial (LA) scar (LAS) regions that may be the substrate for re-entry within the atria, thereby sustaining AF. Identification of LAS through LA delayed gadolinium enhancement (LADE) with MRI has been proposed.

OBJECTIVES

We sought to evaluate LADE in patients referred for catheter ablation of AF.

METHODS

Prospective analysis was conducted of consecutive patients who underwent pulmonary vein antrum isolation (PVAI) ablation for AF at a single institution. Patients underwent LADE with MRI to determine LAS regions before ablation. MRI data were analysed independently in accordance with prespecified institutional protocol by two staff cardiac radiologists to whom patient outcomes were masked, and reports of LADE were documented. Where no initial consensus occurred regarding delayed enhancement (DE), a third staff cardiac radiologist independently reviewed the case and had the deciding vote.

RESULTS

Of the 149 consecutive patients (mean (SD) age, 59 (9) years), AF was persistent in 64 (43%) and paroxysmal in 85 (57%); 45 (30%) had prior ablation. Only five patients (3%) had identifiable DE in LA walls (persistent AF, n=1; paroxysmal AF, n=4). LADE was present in two (4%) of the 45 patients with previous left PVAI. The presence of LADE was not associated with a higher recurrence rate of AF.

CONCLUSIONS

In contrast to previous studies, the finding of DE within LA walls was uncommon and, when present, did not correlate with AF type or risk of AF recurrence. It therefore is of unclear clinical significance.

The North American Electric Grid as an Exchange Network: An Approach for Evaluating Energy Resource Composition and Greenhouse Gas Mitigation

Using a complex network framework, the North American electric grid is modeled as a dynamic, equilibrium-based supply chain of more than 100 interconnected power control areas (PCAs) in the contiguous United States, Canada, and Northern Mexico. Monthly generation and yearly inter-PCA exchange data reported by PCAs are used to estimate a directed network topology. Variables including electricity, as well as primary fuels, technologies, and greenhouse gas emissions associated with power generation can be traced through the network, providing energy source composition statistics for power consumers at a given location. Results show opportunities for more precise measurement by consumers of emissions occurring on their behalf at power plants. Specifically, we show a larger range of possible factors (∼0 to 1.3 kgCO2/kWh) as compared to the range provided by the EPA's eGRID analysis (∼0.4 to 1 kgCO2/kWh). We also show that 66-73% of the variance in PCA-level estimated emissions savings is the result of PCA-to-PCA differences that are not captured by the larger eGRID subregions. The increased precision could bolster development of effective greenhouse gas reporting and mitigation policies. This study also highlights the need for improvements in the consistency and spatiotemporal resolution of PCA-level generation and exchange data reporting.

Outcomes and predictors of difficulty with coronary sinus lead removal

With increasing coronary sinus (CS) pacemaker leads for cardiac resynchronization therapy, the need to remove these leads has risen. The purpose of this study is to describe a single center's experience with CS lead removal and to attempt to identify predictors of difficulty with lead removal and complications. We reviewed all percutaneous endocardial CS lead removals performed at our institution through February 2010. Successful removal with traction alone was considered simple while complex extractions required traction devices and/or laser sheaths. Between December 1996 and February 2010, 125 CS leads were percutaneously removed ≥1 week post-implantation from 115 patients. One attempt at CS lead extraction was unsuccessful. The average duration since implantation for the CS leads was 1.54 years (± .75 years, range 8 days to 8.24 years). The majority of the leads were removed by simple traction (n = 114, 91.2 %). The remainder were removed by femoral approach with snare (n = 3, 2.4 %), locking stylet (n = 2, 1.6 %), or locking stylet and laser sheath (n = 6, 4.8 %). Half of CS leads in place greater than 4 years required complex extraction (n = 7/14, 50 %). CS complications (n = 11 patients, 8.8 %) included CS or tributary thrombosis (n = 7/102, 6.9 %) and CS dissection (n = 4/102, 3.9 %). Major non-CS complications (n = 2 patients, 1.6 %) included a cardiac tear requiring pericardiocentesis and thoracotomy (n = 1, 0.8 %) and subclavian vein tear requiring surgical repair (n = 1, 0.8 %). Minor non-CS complications (n = 9 patients, 7.2 %) included a pneumothorax (n = 1, 0.8 %), hematoma (n = 2, 1.6 %), subclavian vein thrombosis (n = 3, x%), and blood transfusion (n = 5, 4.0 %). A longer duration since implantation and larger lead diameter were associated with complex versus simple removal (p < .0001 and p = .0009 respectively). Percutaneous CS lead removal is successful by simple traction alone in the vast majority of cases. CS leads in place greater than 4 years, however, often require complex extraction. Specific extraction techniques can be implemented when simple traction is unsuccessful without an appreciable increase in complications.

Contrasting gray and white matter changes in preclinical Huntington disease: an MRI study

BACKGROUND

In Huntington disease (HD), substantial striatal atrophy precedes clinical motor symptoms. Accordingly, neuroprotection should prevent major cell loss before such symptoms arise. To evaluate neuroprotection, biomarkers such as MRI measures are needed. This requires first establishing the best imaging approach.

METHODS

Using a cross-sectional design, we acquired T1-weighted and diffusion-weighted scans in 39 preclinical (pre-HD) individuals and 25 age-matched controls. T1-weighted scans were analyzed with gross whole-brain segmentation and voxel-based morphometry. Analysis of diffusion-weighted scans used skeleton-based tractography. For all imaging measures, we compared pre-HD and control groups and within the pre-HD group we examined correlations with estimated years to clinical onset.

RESULTS

Pre-HD individuals had lower gross gray matter (GM) and white matter (WM) volume. Voxel-wise analysis demonstrated local GM volume loss, most notably in regions consistent with basal ganglia-thalamocortical pathways. By contrast, pre-HD individuals showed widespread reductions in WM integrity, probably due to a loss of axonal barriers. Both GM and WM imaging measures correlated with estimated years to onset.

CONCLUSIONS

Using automated, observer-independent methods, we found that GM loss in pre-HD was regionally specific, while WM deterioration was much more general and probably the result of demyelination rather then axonal degeneration. These findings provide important information about the nature, relative staging, and topographic specificity of brain changes in pre-HD and suggest that combining GM and WM imaging may be the best biomarker approach. The empirically derived group difference images from this study are provided as regions-of-interest masks for improved sensitivity in future longitudinal studies.

Patient-specific transfusion-related acute lung injury

Transfusion-related acute lung injury (TRALI) is one of the leading causes of transfusion-associated mortality. The inadvertent transfusion of neutrophil antibodies can cause pulmonary transfusion reactions and TRALI. However, not all patients transfused with neutrophil antibodies experience transfusion reactions. A 22-year-old man with severe aplastic anaemia (SAA) experienced TRALI after a platelet transfusion. The donor was found to be alloimmunized to human neutrophil antigen (HNA)-3a, an antigen expressed by neutrophils from approximately 90% of Caucasians. Eleven other platelet components from this donor were transfused prior to this event and two caused reactions: one chills and one TRALI. Both episodes of TRALI occurred in the same male patient with SAA. The fact that one patient experienced TRALI following both exposures to anti-HNA-3a from the same donor whereas nine other recipients did not adds evidence to the observation that patient factors make a significant contribution to neutrophil antibody-mediated transfusion reactions.

A preliminary comparison of the prevalence of transfusion reactions in recipients of platelet components from donors with and without human leucocyte antigen antibodies

BACKGROUND

Human leucocyte antigen (HLA) antibodies have been implicated in transfusion-related acute lung injury, but the probability that the transfusion of a blood component containing HLA antibodies will cause a reaction is not known. This study compared the prevalence of reactions associated with the transfusion of platelet components with and without HLA antibodies.

STUDY DESIGN AND METHODS

This retrospective study tested 96 consecutive apheresis platelet donors for HLA class I and II antibodies. Matched control donors without HLA antibodies were selected and records were reviewed to determine the proportion of components from each group that caused reactions. In addition, all apheresis platelet donors involved with two or more reactions were identified and tested for HLA class I antibodies.

RESULTS

Five of the 96 donors had antibodies to class I or class II antigens and, of these, four had components transfused. The prevalence of reactions to components from these four donors with HLA antibodies and the 12 matched control donors without antibodies was similar (three reactions to 167 transfusions or 1.8% vs. three to 295 or 1.0%, respectively, P = 0.32). A retrospective review of the transfusion records from all platelet donors found that components from 22 caused two or more reactions and three (13.6%) had antibodies to HLA class I compared to 4.2% of the consecutively selected donors (P = 0.12). None of the patients experienced transfusion-related acute lung injury.

CONCLUSION

Reactions associated with transfusion of apheresis platelets containing HLA antibodies are unusual.

Should selecting saviour siblings be banned?

By using tissue typing in conjunction with preimplantation genetic diagnosis doctors are able to pick a human embryo for implantation which, if all goes well, will become a "saviour sibling", a brother or sister capable of donating life-saving tissue to an existing child. This paper addresses the question of whether this form of selection should be banned and concludes that it should not. Three main prohibitionist arguments are considered and found wanting: (a) the claim that saviour siblings would be treated as commodities; (b) a slippery slope argument, which suggests that this practice will lead to the creation of so-called "designer babies"; and (c) a child welfare argument, according to which saviour siblings will be physically and/or psychologically harmed.

Detection of juvenile sleep deprivation by stochastic optimization of pupillographic records

OBJECTIVE

To address the challenging problem of measuring juvenile sleep deprivation, we test the hypothesis that a pupillographic method found successful for adult narcoleptics might also discriminate between sleep deprived juveniles acting as their own controls.

METHODS

A linear, nonstationary model relating pupillary diameter and a random photic stimulus are estimated by recursive regressions from pupillographic records of 8 juveniles of median age 7 years acting as their own rested controls. The estimated pupillary impulse response noise functions are stochastically optimized using the Kullback divergence measure to maximally separate the sleep deprived records from the control records.

RESULTS

Both the average and covariance statistics of the estimated pupillary noise functions exhibit statistically significant differences between sleep deprived and rested subjects. The main result is that sleep deprivation decreases pupillary noise variance; a finding consistent with a previous study of adult narcoleptics. Further, it was found that virtually the same stochastic parameters were optimal for the juvenile sleep deprived data and for the previous adult narcoleptic study.

CONCLUSIONS

Although our results are preliminary, the consistent reduction of pupillary noise appears to justify a comprehensive clinical trial across a broad range of age classes. In addition, the finding that the same parameters stochastically optimize both juvenile and adult recordings suggests the procedure holds promise as a clinical test which could produce sleep deprivation measures simultaneous with data collection.

A comparison of enzyme-linked immunoabsorbent assays and flow cytometry techniques for the detection of HLA specific antibodies

LATM, Quikscreen (QS), and B-Screen (QSB) are ELISA-based tests for the detection of HLA specific antibodies. FlowPRA beads are microparticles coated with HLA antigens for the detection of HLA specific antibodies by flow cytometry. The aim of this study was to evaluate the sensitivity and specificity of the LATM, QS, QSB, and FlowPRA screening tests. One hundred sixty-three sera from renal transplant patients were tested using LATM, FlowPRA, QS, and QSB. Discrepant results were further investigated using complement dependent cytotoxicity, QuikID, and PRA-STAT. When QS was compared with LATMI and FlowPRAI for the detection of HLA class I specific antibodies the overall concordance was 82.8% with no particular specificity missed by any one test. Comparing QSB with LATMII and FlowPRAII, for the detection of HLA class II specific antibodies, there was 90.7% concordance. Although the overall concordance was better for class II specific antibodies, QSB failed to detect antibodies to HLA-DQ in a number of samples from different patients. Of the methods tested, flow cytometry using FlowPRA beads appeared to be the most sensitive and specific, missing the least number of specificities. However, the ELISA methods offer the advantage of being more suitable for testing large numbers of samples in a more time- and cost-effective manner.

CHARGE association with choanal atresia and inner ear hypoplasia in a child with a de novo chromosome translocation t(2;7)(p14;q21.11)

A 3-year-old boy was diagnosed with CHARGE association on the basis of bilateral choanal atresia, absence of the semicircular canals, hypoplastic cochleae, genital hypoplasia, growth and developmental delays, cranial nerve dysfunction, and facial anomalies. Ophthalmologic and cardiac evaluations were normal. He was found to have an apparently balanced t(2;7)(p14;q21.11) chromosomal translocation. Parental karyotypes were normal. Although there is evidence suggesting a genetic basis for CHARGE association, individuals with chromosomal abnormalities and CHARGE are rare. In the described patient, the presence of characteristic CHARGE features suggests that the t(2;7)(p14;q21.11) translocation breakpoints may cause a deletion or disruption of genes within the involved regions that are involved in the generation of the CHARGE association phenotype.

A multicenter investigation with D-FISH BCR/ABL1 probes

Twenty-eight laboratories evaluated a new fluorescence in situ hybridization (FISH) strategy for chronic myeloid leukemia. In a three-part study, bcr/abl1 D-FISH probes were used to study bone marrow specimens. First, laboratories familiarized themselves with the strategy by applying it to known normal and abnormal specimens. Then, collectively the laboratories studied 20 normal and 20 abnormal specimens blindly and measured workload. Finally, each laboratory and two experts studied six serial dilutions with 98-0% abnormal nuclei. Using the reported normal cutoff of < 1% abnormal nuclei, participants reported no false-negative cases and 15 false-positive cases (1-6.6% abnormal nuclei). Results provided by participants for serial dilutions approximated the expected percentages of abnormal nuclei, but those from the experts exhibited greater precision. The clinical sensitivity, precision, nomenclature, workload, recommendations for training, and quality assurance in methods using D-FISH in clinical practice are discussed.

Transforming growth factor beta (TGF-beta) and obliterative bronchiolitis following pulmonary transplantation

BACKGROUND

Obliterative bronchiolitis (OB) characterised by small-airway fibrosis is a major cause of morbidity and mortality after lung transplantation. TGF-beta has been implicated in the pathogenesis of fibrosis.

METHODS

We immunohistochemically examined 380 transbronchial biopsies (from 91 pulmonary transplants) using TGF-beta polyclonal antibodies. OB and interstitial fibrosis were diagnosed and graded in all biopsies. Other potential histologic and clinical risk factors for OB were analysed.

RESULTS

Procedures were heart and lung (n = 32), bilateral sequential lung (n = 18), and single lung transplantation (n = 41). The incidence of OB in this group was 28.5%. In all patients with OB, TGF-beta was immunolocalized in the airways and lung parenchyma. TGF-beta expression was greater in OB patients (median score 8, range 5-12) in comparison to patients without OB (median score 4, range 1-13), p < .0001. Positive TGF-beta staining preceded the histologic confirmation of OB by 6 to 18 months. The development of OB was associated with two HLA mismatches at the A locus (p = .02); recurrent acute rejection episodes (p < .0005); lymphocytic bronchiolitis (p = .0001); and tissue eosinophilia, regardless of the rejection grade (p < .0001).

CONCLUSIONS

Increased expression of TGF-beta is a risk factor for the development of OB. Other risk factors are recurrent acute rejection, lymphocytic bronchiolitis, tissue eosinophilia, and two mismatches at the HLA-A locus. This suggests that the pathogenesis of progressive small airway fibrosis characteristic of OB may be inflammatory damage, followed by an aberrant repair process due to excessive TGF-beta production following allograft injury. Hence, modulation of TGF-beta levels or function by antagonists may represent an important approach to control OB.

The influence of histocompatibility on graft rejection and graft survival within a single center population of heart transplant recipients

BACKGROUND

We report a consecutive single center series of 261 patients who received first orthotopic heart transplants from 1986 to 1997. The 1- and 5-year graft survivals were 78 and 68%. The influence of histocompatibility was investigated by comparing graft survival and numbers of treated rejection episodes with HLA-A, -B, and -DR mismatches over different time periods.

FINDINGS

Recipients with six mismatches for HLA-A+-B+-DR combined (13.4%) had reduced survival at 7 years (47%) when compared with other recipients (64%). In the first year of transplant, recipients with four HLA-A+-B mismatches had significantly reduced actuarial graft survival (P=0.03) with the greatest influence apparent at 6 months [0-3 mismatches (n=193) 85% versus 4 mismatches (n=68) 69%; P=0.005, OR=2.1]. For 182 recipients with functioning hearts at 1 year, the number of rejection episodes treated within this time was strongly influenced by HLA-DR mismatch [0 DR mismatch (n=15) mean 1.2 rejection episodes versus 1 DR mismatch (n=76) mean 2.7 rejection episodes versus 2 DR mismatches (n=91) mean 3.8 rejection episodes: P=0.0002]. Of these 182 transplants, recipients who had more than four treated rejection episodes during the first year had a significantly reduced 7- year survival [<5 rejection episodes (n=133) 85% versus more than four rejection episodes (n=49) 66%; P=0.02, OR=3.4], as did those with two HLA-DR mismatches [0+1 mismatch (n=91) 87% versus 2 mismatches (n=91) 70%; P<0.05, OR=2.4].

INTERPRETATION

We show that graft loss in the first 6 months of transplant is significantly influenced by four HLA-A+-B mismatches. HLA-DR mismatch significantly increases the number of rejection episodes within the first year, without influencing graft survival. After 12 months both >4 rejection episodes in the first year and two HLA-DR mismatches are markers for late graft loss. We postulate that immunological graft loss in the first 6 months is dominated by the direct allorecognition pathway driven by HLA-DR mismatch. This mechanism is later lost or suppressed. Our data highlight HLA-DR mismatch as a marker for late graft loss and we show an advantage to avoiding transplanting hearts with six HLA-A+-B+-DR mismatches and to minimizing HLA-DR mismatches whenever possible.

Chromosomal aneuploidy in leukemic blast crisis: a potential source of error in interpretation of bone marrow engraftment analysis by VNTR amplification

BACKGROUND

Polymerase chain reaction (PCR) amplification of polymorphic microsatellite or minisatellite DNA markers has proven to be a fast, sensitive, and specific technique in post-transplantation monitoring of bone marrow engraftment, as well as early detection of residual disease and relapse. Deletion or amplification of chromosomal segments carrying marker loci, as can occur in leukemia and other hematologic malignancies, may result in loss or increased dosage of marker alleles. Examination of these marker alleles by PCR therefore may give aberrant results, which might lead to misinterpretation of bone marrow transplantation (BMT) engraftment studies.

METHODS AND RESULTS

We report a case of chronic myelogenous leukemia treated by BMT. PCR amplification of the minisatellite at the apoB locus on chromosome 2 was used to monitor the donor bone marrow engraftment. The patient experienced relapse in blast crisis with a near-haploid karyotype with loss of recipient-specific apoB allele causing an aberrant PCR result for bone marrow engraftment that mimicked full donor engraftment.

CONCLUSIONS

Loss or gain of polymorphic DNA markers because of chromosomal losses or gains in some hematologic malignancies may affect the interpretation of bone marrow engraftment studies by PCR. When choosing polymorphic markers for such studies, it is important to avoid those that will be affected by expected chromosomal alteration, if possible. In addition, any abberant post-transplantation typing should prompt further investigation to rule out the possibility of chromosomal aberration. Review of all pertinent laboratory studies is important to avoid misinterpretation of results from a single test for engraftment analysis.

Familial Mondini dysplasia

OBJECTIVES/HYPOTHESIS

To determine the mode of inheritance of familial nonsyndromic Mondini dysplasia.

STUDY DESIGN

Correlative clinical genetic analysis of a single kindred.

METHODS

Clinical history, physical examination, audiologic analysis, computed tomography of the temporal bones, and cytogenetic analysis.

RESULTS

The male proband, three affected sisters, and an affected brother are offspring of unaffected parents. The mother and an unaffected brother have audiologic findings suggestive of heterozygous carrier status for a recessive hearing loss gene.

CONCLUSIONS

Pedigree analysis indicates autosomal recessive inheritance in this family. The observed inheritance and clinical, audiologic, and radiologic findings are different from those previously described for another family with nonsyndromic Mondini dysplasia. The phenotype in this study family therefore represents a distinct subtype, indicating clinical and genetic heterogeneity of this disorder. This information should facilitate future molecular linkage analyses and genetic counselling of patients with inner ear malformations.

Cytogenetic abnormalities and therapy-related myelodysplastic syndromes in rheumatic disease

OBJECTIVE

To describe the myelodysplastic syndromes (MDS) and cytogenetic abnormalities that occur in patients who have been treated with alkylating drugs for their rheumatic disease.

METHODS

Patients with rheumatic disease who developed MDS after current or previous treatment with alkylating drugs were selected for evaluation by chart review and cytogenetic studies.

RESULTS

Eight patients with rheumatic disease (mean age 56.9 years) developed MDS over the study period. Seven had received oral cyclophosphamide and 1 chlorambucil as their main immunosuppressive drug. The mean total cumulative dose of cyclophosphamide or chlorambucil was 118 gm and 6.5 gm, respectively, over a period of 2-10 years. The cytogenetic abnormalities included a deletion of all or part of chromosome 7 in 5 patients, while 4 had a deletion of part of the long arm of chromosome 5. Six of the patients have since died.

CONCLUSION

Large cumulative doses of cyclophosphamide and chlorambucil were associated with the development of MDS, the occurrence of abnormalities of chromosome 5 and/or chromosome 7 deletions, and a poor prognosis.

Follicular large cell lymphoma with immunoblastic features in a child with Wiskott-Aldrich syndrome: an unusual immunodeficiency-related neoplasm not associated with Epstein-Barr virus

Patients with Wiskott-Aldrich syndrome, a severe inherited immunodeficiency disorder, have a markedly increased risk of developing non-Hodgkin's lymphoma compared with the general population. These are uniformly diffuse aggressive B-cell neoplasms that resemble those seen in AIDS and the posttransplantation setting and also may be associated with Epstein-Barr virus. We report what to our knowledge is the first case of follicular lymphoma in a 14-year-old child with Wiskott-Aldrich syndrome. The neoplasm was composed predominantly of large cells with immunoblastic features, and it possessed light chain-restricted surface immunoglobulin, clonal immunoglobulin gene rearrangements, and a t(14;18). The tumor lacked Epstein-Barr virus sequences by in situ hybridization and Southern blot terminal repeat analysis. Interestingly, however, the tumor contained c-myc gene rearrangement.

Inflammatory myofibroblastic tumor: cytogenetic evidence supporting clonal origin

The inflammatory myofibroblastic tumor (IMT) is a distinctive but controversial lesion, usually occurring during childhood, composed of fascicles of bland myofibroblastic cells admixed with a prominent inflammatory infiltrate consisting of lymphocytes, plasma cells, and eosinophils. Often affecting the lung and associated with constitutional symptoms, this lesion has been variously termed plasma cell granuloma, inflammatory pseudotumor, inflammatory myofibrohistiocytic proliferation, and inflammatory fibrosarcoma to reflect divergent views concerning its pathogenesis and level of malignancy. Cytogenetic analysis of an intra-abdominal myxoid hamartoma, a probable variant of this lesion, and a pulmonary IMT demonstrated clonal chromosomal abnormalities, lending support to the view that the IMT might be a neoplasm. There have been few cases studied to date, however, and the extent of cytogenetic anomalies in IMTs is not known. Karyotype analyses were performed on IMTs showing typical histologic features from three children. In addition, one case was studied by fluorescence in situ hybridization. Seventeen of 20 metaphase cells examined from a pulmonary IMT in a 5.5-year-old girl had an abnormal 47,XX+r(ring) karyotype. Fluorescence in situ hybridization studies demonstrated that the ring chromosome contained sequences of chromosome 8. Of 40 metaphase cells studied from a mesenteric IMT in an 8-month-old boy, 12 showed clonal aberrations, characterized as 43,XY,add(1)(p36),add(2)(p24),-6,der(14,22)(q10;q10),-19. Each of 20 metaphase cells examined from a retroperitoneal IMT in a 14-year-old girl contained complex clonal and nonclonal aberrations, characterized as 46-47,X,-X,add(2)(p22),add(2)(q13),+add(2)(q13),+5,-6,+i(7)(p10),add(8)( p11.2),+del(9)(p13),add(11)(p11.2)add(11)(q25),-13,-16,-18,add(19)(q13.1 ),add(19)(q13.1),+20,-21,-22,+mar1,+1-2mars. The presence of clonal chromosomal aberrations in all of the three tumors indicates that the IMT is a neoplastic proliferation.

Chromosomes in autism and related pervasive developmental disorders: a cytogenetic study

Few studies have examined the occurrence of chromosome abnormalities in a large sample of patients with autism and related pervasive developmental disorders (PDDs). In the present report, the authors examined a consecutive series of 92 children with PDDs (DSM-III-R; 75 males and 17 females). A cytogenetic examination, including growth in folate deficient medium, was performed in all cases. Three patients (3.2%) (two females and one male) showed chromosome abnormalities: deletion of the long arm of chromosome 8; tetrasomy of chromosome 15; and XYY syndrome. Only the subject who had tetrasomy 15 met the criteria for autistic disorder, while the other were diagnosed as suffering from a PDD not otherwise specified (PDDNOS). Another patient showed an abnormal fragile site at Xq27 in three out of 100 cells. However, subsequent molecular studies did not confirm the presence of fragile-X syndrome. These results suggest that chromosome abnormalities are uncommon in traditional autism and may be relatively more common in people with PDDNOS.