Responsiveness to Change and Minimally Important Differences of the Patient-Reported Outcomes Measurement Information System Gastrointestinal Symptoms Scales

BACKGROUND

The NIH-sponsored Patient-Reported Outcomes Measurement Information System (PROMIS) Gastrointestinal (GI) Symptoms scales were developed to assess patients' GI symptoms in clinical settings.

AIMS

To assess responsiveness to change and provide minimally important difference (MID) estimates for the PROMIS GI Symptoms scales.

METHODS

A sample of 256 GI outpatients self-administered the eight PROMIS GI Symptoms scales (gastroesophageal reflux, disrupted swallowing, diarrhea, bowel incontinence/soilage, nausea and vomiting, constipation, belly pain, and gas/bloating/flatulence) at two visits. Patient self-reported and physician-reported assessments of the subjects' overall GI condition were employed as change anchors. In addition, we prospectively assessed change at both visits using a GI-symptom anchor, the Gastrointestinal Symptom Rating Scale (GSRS). Responsiveness to change was assessed using F-statistics. The minimally changed group was those somewhat better or somewhat worse on the retrospective anchors and changing by one category on the modified GSRS (e.g., from slight to mild discomfort to moderate to moderately severe discomfort).

RESULTS

Responsiveness to change was statistically significant for 6 of 8 PROMIS scales using the self-report GI anchor, 3 of 8 scales using the physician-reported anchor, and 5 of 5 scales using the corresponding GSRS scales as anchors. The MID estimates for scales for improvement and worsening were about 0.5-0.6 SD using the GSRS anchor and generally larger in magnitude than the change for the "about the same" group.

CONCLUSIONS

The responsiveness and MID estimates provided here for the PROMIS GI Symptoms scales can aid in scale score interpretation in clinical trials and observational studies.

Development of the NIH Patient-Reported Outcomes Measurement Information System (PROMIS) gastrointestinal symptom scales

OBJECTIVES

The National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS(®)) is a standardized set of patient-reported outcomes (PROs) that cover physical, mental, and social health. The aim of this study was to develop the NIH PROMIS gastrointestinal (GI) symptom measures.

METHODS

We first conducted a systematic literature review to develop a broad conceptual model of GI symptoms. We complemented the review with 12 focus groups including 102 GI patients. We developed PROMIS items based on the literature and input from the focus groups followed by cognitive debriefing in 28 patients. We administered the items to diverse GI patients (irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), systemic sclerosis (SSc), and other common GI disorders) and a census-based US general population (GP) control sample. We created scales based on confirmatory factor analyses and item response theory modeling, and evaluated the scales for reliability and validity.

RESULTS

A total of 102 items were developed and administered to 865 patients with GI conditions and 1,177 GP participants. Factor analyses provided support for eight scales: gastroesophageal reflux (13 items), disrupted swallowing (7 items), diarrhea (5 items), bowel incontinence/soilage (4 items), nausea and vomiting (4 items), constipation (9 items), belly pain (6 items), and gas/bloat/flatulence (12 items). The scales correlated significantly with both generic and disease-targeted legacy instruments, and demonstrate evidence of reliability.

CONCLUSIONS

Using the NIH PROMIS framework, we developed eight GI symptom scales that can now be used for clinical care and research across the full range of GI disorders.

Targeted disruption of the murine Fanconi anemia gene, Fancg/Xrcc9

Fanconi anemia (FA) is a human autosomal recessive cancer susceptibility disorder characterized by cellular sensitivity to mitomycin C and ionizing radiation. Six FA genes (corresponding to subtypes A, C, D2, E, F, and G) have been cloned, and the encoded FA proteins interact in a common cellular pathway. To further understand the in vivo role of one of these human genes (FANCG), we generated a targeted disruption of murine Fancg and bred mice homozygous for the targeted allele. Similar to the phenotype of the previously described Fancc(-/-) and Fanca(-/-) mice, the Fancg(-/-) mice had normal viability and no gross developmental abnormalities. Primary splenic lymphocytes, bone marrow progenitor cells, and murine embryo fibroblasts from the Fancg(-/-) mice demonstrated spontaneous chromosome breakage and increased sensitivity to mitomycin C and, to a lesser extent, ionizing radiation. Fancg(-/-) lymphocytes had a defect in the FA pathway, based on their failure to activate the monoubiquitination of the downstream Fancd2 protein in response to IR. Finally, Fancg(-/-) mice had decreased fertility and abnormal gonadal histology. In conclusion, disruption of the Fancg gene confirms the role of Fancg in the FA pathway. The Fancg(-/-) mouse may be useful as an animal model for future gene therapy and cancer susceptibility studies.

Kinetochore dynein: its dynamics and role in the transport of the Rough deal checkpoint protein

We describe the dynamics of kinetochore dynein-dynactin in living Drosophila embryos and examine the effect of mutant dynein on the metaphase checkpoint. A functional conjugate of dynamitin with green fluorescent protein accumulates rapidly at prometaphase kinetochores, and subsequently migrates off kinetochores towards the poles during late prometaphase and metaphase. This behaviour is seen for several metaphase checkpoint proteins, including Rough deal (Rod). In neuroblasts, hypomorphic dynein mutants accumulate in metaphase and block the normal redistribution of Rod from kinetochores to microtubules. By transporting checkpoint proteins away from correctly attached kinetochores, dynein might contribute to shutting off the metaphase checkpoint, allowing anaphase to ensue.

Functional analysis of patient-derived mutations in the Fanconi anemia gene, FANCG/XRCC9

OBJECTIVE

Fanconi anemia (FA) is an autosomal-recessive cancer susceptibility syndrome with seven complementation groups. Six of the FA genes have been cloned (corresponding to subtypes A, C, D2, E, F, and G) and the encoded proteins interact in a common pathway. Patient-derived mutations in FA genes have been helpful in delineating functional domains of FA proteins. The purpose of this work was to subtype FA patient-derived cell lines in our repository and to identify FA gene mutations.

METHODS

We subtyped 62 FA patients as type A, G, C, or non-ACG by using a combination of retroviral gene transfer and immunoblot analysis. Among these FA patients, we identified six FA-G patients for further analysis. We used a strategy involving amplification of FANCG/XRCC9 exons and direct sequencing to identify novel FANCG mutations in cell lines derived from these FA-G patients. We functionally analyzed FANCG mutant alleles by transducing the corresponding cDNAs into a known FA-G indicator cell line and scoring correction of MMC sensitivity.

RESULTS

Our results demonstrate a wide range of mutations in the FANCG gene (splice, nonsense, and missense mutations). Based on this mutational screen, a carboxy terminal functional domain of the FANCG protein appears to be required for complementation of FA-G cells and for normal assembly of the FANCA/FANCG/FANCC protein complex.

CONCLUSION

The identification of patient-derived mutant alleles of FA genes can provide important insights to the function of FA proteins. FA subtyping is also a necessary precondition for gene therapy.

Kinesin transport: driving kinesin in the neuron

A plethora of cytoplasmic motors contribute to the directed transport of a wide range of cellular organelles and molecules. Recent studies have advanced our understanding of cargo attachment to motor molecules and the regulation of intracellular transport.

A molecular genetic analysis of the interaction between the cytoplasmic dynein intermediate chain and the glued (dynactin) complex

The microtubule motor cytoplasmic dynein performs multiple cellular functions; however, the regulation and targeting of the motor to different cargoes is not well understood. A biochemical interaction between the dynein intermediate chain subunit and the p150-Glued component of the dynein regulatory complex, dynactin, has supported the hypothesis that the intermediate chain is a key modulator of dynein attachment to cellular cargoes. In this report, we identify multiple intermediate chain polypeptides that cosediment with the 19S dynein complex and two differentially expressed transcripts derived from the single cytoplasmic dynein intermediate chain (Cdic) gene that differ in the 3' untranslated region sequence. These results support previous observations of multiple Cdic gene products that may contribute to the specialization of dynein function. Most significantly, we provide genetic evidence that the interaction between the dynein intermediate chain and p150-Glued is functionally relevant. We use a genomic Cdic transgene to show that extra copies of the dynein intermediate chain gene act to suppress the rough eye phenotype of the mutant Glued(1), a mutation in the p150-Glued subunit of dynactin. Furthermore, we show that the interaction between the dynein intermediate chain and p150-Glued is dependent on the dosage of the Cdic gene. This result suggests that the dynein intermediate chain may be a limiting component in the assembly of the dynein complex and that the regulation of the interaction between the dynein intermediate chain and dynactin is critical for dynein function.

Unusual complications of warfarin therapy: skin necrosis and priapism

Skin necrosis and priapism are unusual complications of warfarin therapy. We report a teenager with warfarin-associated skin necrosis and priapism who was subsequently found to be a compound heterozygote for protein C deficiency and a heterozygote for the factor V Leiden mutation.

Combined thrombolytic and anticoagulant therapy for venous thrombosis in children

OBJECTIVES

To evaluate safety, efficacy, and outcome after combination thrombolytic and anticoagulant therapy.

STUDY DESIGN

An open nonrandomized clinical protocol with prospective standardized monitoring and data collection. Children with a documented first episode of deep vein thrombosis were treated with urokinase 4400 U/kg load and per hour with unfractionated heparin at 10 U/kg/h. At 48 hours heparin infusions were increased to achieve a therapeutic level for 5 days. Children were given therapeutic warfarin for at least 3 months. Outcome was assessed at 48 hours and > or =1 year with history, physical examination, high-resolution imaging, and Doppler ultrasonography +/- impedance and photo plethysmography.

RESULTS

Thirty-two children were treated. There was 1 thrombotic death, 1 nonfatal thrombus progression, and 1 pulmonary embolism. At 48 hours half of the children showed substantial clot lysis, and on follow-up these children had complete resolution and had no symptoms. Three children with poor early clot lysis had recurrent thromboemboli, pulmonary embolism, or both, 2 had limb pain and swelling, and 2 had asymptomatic swelling. Two children had minor bleeding, whereas systemic reactions were common.

CONCLUSIONS

Combination therapy in children (urokinase and unfractionated heparin) was safe and efficacious. A prospective, randomized, controlled study in children is needed.

Swallowing dynein: a missing link in RNA localization?

Localization of bicoid messenger RNA to the anterior cortex of the developing oocyte is essential for correct anterior-posterior patterning of the Drosophila embryo. It now seems that the Swallow protein functions as an adaptor, bridging bicoid mRNA to dynein, a molecular motor that would transport the complex anteriorly along microtubules.

Antiphospholipid antibodies and coagulation regulatory protein abnormalities in children with pulmonary emboli

PURPOSE

To evaluate the demographics, presentation, family history, and laboratory findings in children with clinically recognized pulmonary emboli.

METHODS

Data were collected about children with clinically recognized pulmonary emboli from 1987 to 1994 at two pediatric hematology referral centers.

RESULTS

Sixteen children, mean age 11.8 years (standard deviation 4.69 years) including 11 boys were affected. Lower extremity thromboses were present in 7/14 children evaluated. Eight of the 16 children were apparently well before development of pulmonary emboli; seven were found to have antiphospholipid antibodies. None of the 15 children tested were antithrombin III deficient. One of 14 children tested was protein C deficient. Three of 13 children tested were protein S deficient or had a free protein S antigen at the fifth percentile. One of 10 children tested had an acquired dysfibrinogenemia. Two of nine children tested had the Factor V Leiden mutation.

CONCLUSIONS

Our limited data suggest at least 70% of children with pulmonary emboli referred for hematology evaluation have antiphospholipid antibodies and coagulation regulatory protein abnormalities.

The effects of temperature and synaptic blockade in vitro on neurons of the horizontal limb of the diagonal band of Broca in the rat basal forebrain

We studied the thermosensitivity of neurons in the rat horizontal limb of the diagonal band of Broca (HDB) in vitro under normal conditions and under conditions of a low calcium/high magnesium synaptic blockade (SB). Of 52 HDB neurons tested, 34 neurons (65%) were warm-sensitive (WS), three neurons (6%) were cold-sensitive (CS), 11 neurons (21%) were temperature-insensitive (TI) and four additional neurons (8%) were both warm- and cold-sensitive (WS/CS). Of 34 neurons tested for thermosensitivity under SB, 11 were WS, 4 were CS and 19 were TI. Nearly half (48%) of the WS neurons maintained warm sensitivity under SB, 43% became TI and 9% became CS. Baseline firing rates of neurons significantly decreased during SB and then increased during recovery from SB. In addition, a distinct anatomical distribution of thermosensitive neurons was found in the HDB. The most ventral aspect of the HDB (interaural +0.9-1.3 mm) had proportionally fewer temperature sensitive neurons (65% vs. 88%) than areas more dorsal (interaural +1.3-1.7 mm), and only one of seven ventral HDB neurons (14%) remained thermosensitive during SB. In the dorsal HDB, 65% of the neurons maintained thermosensitivity during SB. These results demonstrate that the HDB contains inherently thermosensitive neurons, and that a difference in thermal characteristics exists between the ventral and dorsal HDB neurons.

Childhood thrombosis

OBJECTIVE

The objective of our study was to evaluate the age, sex, clinical conditions, family history, site, catheter association, means of radiologic evaluation, development of pulmonary involvement, prevalence of antithrombin III, protein C and protein S deficiencies, and lupus anticoagulants in children who suffered a thrombotic event.

METHODS

Data were collected on children over 1 month of age who had or developed a thrombotic event from 1987 through 1993 at two pediatric centers.

RESULTS

Sixty-one children (mean age, 10 years) suffered a thrombotic event. Males and females were equally affected. A variety of clinical prothrombotic conditions similar to those described in adults could be identified for two thirds of the children. Family history was positive in seven children. The primary thrombotic site for two thirds of the children was the central nervous system and other centrally located blood vessels. Diagnosis of the primary thrombotic site was primarily by ultrasound. A central vascular access device was associated with 25% of thromboses. Lung involvement occurred in 20%. Two thirds of the children were evaluated for a lupus anticoagulant and a deficiency of protein C and protein S; two thirds had one of these diagnosed. For further analyses, children without an underlying prothrombotic systemic illness or precipitant at the time of thrombosis (n = 20) were compared to those with these conditions (n = 41). Central nervous system thromboses were significantly increased in the children without prothrombotic conditions. The prevalence of a deficiency of protein C or protein S or the presence of a lupus anticoagulant approached 90% in the group without prothrombotic conditions as compared with 50% in the other group.

CONCLUSION

We conclude that prospective multicenter pediatric thrombosis studies are warranted to confirm our preliminary findings of a high incidence of lupus anticoagulants and protein C and protein S deficiency in children with thromboses.

Efficacy and safety of heparin anticoagulation for neonatal renal vein thrombosis

PURPOSE

We report on the safety and efficacy of heparin anticoagulation for the treatment of neonatal renal vein thrombosis.

PATIENTS AND METHODS

Six consecutive, prospectively identified, critically ill neonates with renal vein thrombosis were studied. Diagnosis of renal vein thrombosis was based on history and examination and confirmed with renal ultrasound. All neonates were treated with continuous i.v. heparin titrated to achieve a therapeutic whole blood clotting time and/or APTT.

RESULTS

Renal vein thrombosis was bilateral for three of six neonates. Heparin infusion rates varied from 8 to 40 U/kg/h and were administered for 7-14 days. Two neonates developed hemorrhagic complications; one had disseminated intravascular coagulation but did not hemorrhage until heparin toxicity ensued, and another was well until an umbilical catheter was removed while he was therapeutically heparinized. Renal outcome at 3 months to 6 years showed hypertension in one neonate, atrophic kidneys in two, and both hypertension and an atrophic kidney in one.

CONCLUSIONS

Bleeding was a significant complication of heparin therapy for neonatal renal vein thrombosis. Renal dysfunction was not prevented in four of six neonates treated with heparin. Alternative approaches to titrate heparin, alternative anticoagulants, or fibrinolytic therapy should be considered as therapy for neonatal renal vein thrombosis.

Disruption of mitotic spindle orientation in a yeast dynein mutant

Dynein motor isoforms have been implicated as potential kinetochore-associated motors that power chromosome-to-pole movements during mitosis. The recent identification and sequence determination of genes encoding dynein isoforms has now permitted the in vivo analysis of dynein function in mitosis. In this report we describe the identification and mutational analysis of the gene, DHC1, encoding a dynein heavy chain isoform in Saccharomyces cerevisiae. Sequence analysis of a 9-kb genomic fragment of the DHC1 gene predicts a polypeptide highly homologous to dynein sequences characterized from sea urchin, Dictyostelium, Drosophila, and rat. Mutations in the yeast dynein gene disrupt the normal movement of the spindle into budding daughter cells but have no apparent effect on spindle assembly, spindle elongation, or chromosome segregation. Our results suggest that, in yeast, a dynein microtubule motor protein has a nonessential role in spindle assembly and chromosome movement but is involved in establishing the proper spindle orientation during cell division.

Monozygotic twin girls with congenital malformations resembling fanconi anemia

Monozygotic (MZ) twin girls, diagnosed at birth to have Fanconi anemia (FA) on the basis of multiple anomalies and an apparently increased baseline chromosomal breakage frequency in one twin, have been followed prospectively for 13 years. They have not developed aplastic anemia or other hematologic manifestations of FA. There was no evidence for increased baseline or diepoxybutane (DEB)-induced chromosomal breakage in either twin when the studies were repeated in Denver as well as in New York. Since the cellular phenotype must be considered in establishing the diagnosis of FA, these MZ twins should not be classified as affected with FA. Using the scoring system for FA diagnosis developed by Auerbach et al. [1989], the probability coefficients of their having FA based solely on clinical findings, prior to DEB testing, were .75 and .92, respectively. When the combination of their anomalies are taken together, their FA probability coefficient is .98. Through the International FA Registry, 15 additional patients have been identified with an FA probability score of .75 or greater, but who have not developed aplastic anemia and who are DEB negative. These patients, as well as the twins described in this report, are most likely a heterogeneous group and may represent other syndromes like Holt-Oram, VATER, VACTERL and IVIC, with genetic as well as nongenetic etiologies. These cases demonstrate the importance of testing with DEB or other DNA crosslinking agent in order to discriminate between FA and other syndromes with a similar phenotype.

Hemolysis due to branch pulmonary stenosis after the arterial switch procedure

An infant with d-transposition of the great arteries underwent arterial switch operation using the modified Jatene technique. Severe bilateral branch pulmonary artery stenosis and mechanical hemolysis subsequently developed. The hemolysis resolved after surgical repair of the stenotic arteries. Probable causes are discussed.

Heterogeneity of acute "undifferentiated" leukemia of childhood: ultrastructural, immunophenotypic, and karyotypic analyses

The present study was undertaken in an attempt to reclassify the 19 cases of childhood acute undifferentiated leukemia (AUL) diagnosed at our institution during the past 12 years. Based on ultrastructural and immunophenotypic data, seven of the cases were reclassified as lymphoid, nine as myeloid, and three remain unclassifiable. Clinical features, clonal karyotypes, and responses to treatment were also examined. Abnormal clonal karyotypes were found in 16 of 17 cases, including eight cases with translocations, three with monosomy 7 or 7q, and one with numerous complex structural rearrangements. Fourteen patients had greater than 10% French-American-British L2 blasts in bone marrow. Although nine of 15 patients who initially received induction therapy for acute lymphoblastic leukemia (ALL) achieved remission, only one patient is a long-term survivor. Only one of 10 patients who received therapy for acute nonlymphoblastic leukemia during the course of their disease remains a long-term survivor. These data suggest that the majority of cases of AUL can be reclassified as either myeloid or lymphoid leukemias, that AUL is associated with a high frequency of chromosomal abnormalities, and that AUL carries a very poor prognosis.

Transient erythroblastopenia of childhood. A review of 26 cases and reassessment of indications for bone marrow aspiration

Clinical and hematological presentations of 26 consecutive patients with transient erythroblastopenia of childhood diagnosed during July 1979 to September 1986 were compared with 26 patients with acute leukemia who presented with anemia and a normal platelet count. It was easy to distinguish acute leukemia from transient erythroblastopenia of childhood on a clinical and laboratory basis. In most cases, bone marrow examination was not necessary.

Treatment of t(4;11) acute leukemia with aggressive multiagent chemotherapy. Preliminary results

Acute leukemia patients with a 4;11 translocation have had a poor prognosis in the past, averaging 9 months survival from diagnosis. Three patients from The Children's Hospital of Denver were reported in 1982--all died. This report describes five additional patients who fared better. Aggressive treatment during induction and maintenance with intensive alternating non-cross-resistant chemotherapeutic agents may have contributed to the improved survival.

Severe protein C deficiency in newborn infants

Eleven infants initially seen in the neonatal period had levels of protein C suggestive of homozygous protein C deficiency but as an apparently acquired condition. Family studies failed to document parental carrier status, the clinical course was not typical of that reported with homozygous protein C deficiency, and protein C levels increased in all restudied infants, six of whom received heparin anticoagulation. No infant had evidence of vitamin K deficiency. Care is advised in the evaluation of infants with low levels of protein C. Parental blood studies, delayed testing, and serial assays can help to establish the correct diagnosis.

Neonatal aortic thrombosis associated with the lupus anticoagulant

The lupus anticoagulant has been associated with clinical thrombosis and poor pregnancy outcome. There are no published reports of its detection in neonates born to affected mothers. We report such a case associated with neonatal aortic thrombosis.

Premature chromosome condensation as a predictive indicator of relapse in children and adolescents with acute leukemia: initial observations

Premature chromosome condensation has been used to determine a proliferative potential index (PPI) in a study of children in leukemia remission at varying times during the disease. Values 35% and greater were considered predictive of relapse. Such values preceded relapse with a mean of 5 months in acute lymphoblastic leukemia (ALL) patients who had previously relapsed and in myeloid leukemia patients. ALL patients followed from diagnosis and children off therapy had fluctuating and false predictive PPI values preceding long courses of continued remission. This study suggests that the PPI as a predictive indicator for relapse may be useful for patients with ALL who have previously relapsed and for patients with myeloid leukemias. Future exploration to further evaluate this mechanism of prediction is to be attempted by investigating the ability to obtain similar and more detailed information through the use of peripheral blood rather than bone marrow samples.

Methodology of premature chromosome condensation and its potential for relapse prediction in acute leukemia of children and adolescents

Premature chromosome condensation has been examined as a method for measuring the proliferative potential of bone marrow cells derived from children with acute leukemia with the intention of finding a predictor of relapse. A proliferative potential index (PPI) has been determined for patients with active disease at diagnosis and relapse, as well as at onset of remission and at extramedullary relapse. A modification of the technique established by Hittelman is described, which can be easily performed by the leukemia cytogeneticist. A PPI of 35% or greater is usually obtained for patients at diagnosis or in relapse. At the onset of remission, the PPI declines to values significantly below 35% and during extramedullary relapse the value of the PPI is near normal (12%). The method for the determination of the PPI is given in detail.

Modulation of erythrocyte membrane mechanical stability by 2,3-diphosphoglycerate in the neonatal poikilocytosis/elliptocytosis syndrome

To explain the transient anemia and poikilocytosis seen during infancy in hereditary elliptocytosis (HE), we resealed erythrocyte (RBC) ghosts from affected children or their elliptocytic parents with 2,3-diphosphoglycerate (DPG) (0-8 mM), a compound that dissociates membrane skeletons, then measured ghost mechanical stability in the ektacytometer. Without added 2,3-DPG, ghost mechanical stability was subnormal in infantile poikilocytosis (IP) and HE but was even more abnormal in hereditary pyropoikilocytosis (HPP). Addition of 2,3-DPG (2.55 mM) to IP or HE ghosts, decreased their stability to that of HPP ghosts (without 2,3-DPG). Nonphysiological 2,3-DPG levels (6-8 mM) were required to elicit a similar effect in normal ghosts. The data suggest that free 2,3-DPG, present in neonatal RBC as a consequence of diminished binding to HbF, may render HE susceptible to in vivo fragmentation. The developmental switch from fetal to adult hemoglobin, by diminishing available free 2,3-DPG, may explain the abatement of poikilocytosis and hemolytic anemia that accompanies maturation.

Unique alpha-spectrin mutant in a kindred with common hereditary elliptocytosis

We report here a unique variant of alpha spectrin in a kindred with hereditary elliptocytosis. This novel red blood cell-membrane protein migrated to a position between the normal alpha- and beta-spectrin subunits in SDS polyacrylamide gel electrophoresis. It was identified as an alpha spectrin by its binding to anti-alpha spectrin antibodies, by the absence of a phosphorylation site, and by the normal 1:1 stoichiometry between total alpha- and beta-spectrin molecules. The quantity of the alpha-spectrin mutant, expressed as a percentage of the total alpha spectrin, varied from 9.9-45.2% among six affected individuals. Two-dimensional electrophoretic analysis of spectrin tryptic digests was qualitatively normal but showed a decreased quantity of a normal alpha IV fragment. The variable quantity of alpha-spectrin mutant among family members correlated directly with the increased percentage of spectrin dimers in cold low ionic strength spectrin extracts (r = 0.92) and inversely with red blood cell ghost mechanical stability (r = -0.98). The data suggest that this new alpha-spectrin mutant is responsible for decreased spectrin dimer-dimer association and for red cell instability in affected individuals.

Experience with donors matched for minor blood group antigens in patients with sickle cell anemia who are receiving chronic transfusion therapy

Clinically significant alloimmunization to red cell antigens occurred in 28 percent of transfused patients in a sickle cell clinic. Therefore, a prospective study was undertaken to determine whether matching donors carefully for 17 blood group antigens would diminish the risk of further alloimmunization in patients on a chronic transfusion program. Alloantibodies had developed previously in 8 of the 12 patients. After chronic transfusion with selected donors, four new antibodies developed in three patients. Three antibodies were due to errors in phenotyping or matching, and one was due to an antigen that was not tested for in the protocol. The incidence of developing antibodies per unit transfused was diminished tenfold when selected donors were used. Autoantibodies developed in five patients (42%), but these did not seriously interfere with the transfusion therapy. It was concluded that matching for red cell antigens may diminish the incidence of alloimmunization in patients with sickle cell anemia requiring transfusion.

Rapid rate of tubulin dissociation from microtubules in the mitotic spindle in vivo measured by blocking polymerization with colchicine

At metaphase, the amount of tubulin assembled into spindle microtubules is relatively constant; the rate of tubulin association equals the rate of dissociation. To measure the intrinsic rate of dissociation, we microinjected high concentrations of colchicine, or its derivative colcemid, into sea urchin embryos at metaphase to bind the free tubulin, thereby rapidly blocking polymerization. The rate of microtubule disassembly was measured from a calibrated video signal by the change in birefringent retardation (BR). After an initial delay after injection of colchicine or colcemid at final intracellular concentrations of 0.1-3.0 mM, BR decreased rapidly and simultaneously throughout the central spindle and aster. Measured BR in the central half-spindle decreased exponentially to 10% of its initial value within a characteristic period of approximately 20 s; the rate constant, k = 0.11 +/- 0.023 s-1, and the corresponding half-time, t 1/2, of BR decay was approximately 6.5 +/- 1.1 s in this concentration range. Below 0.1 mM colchicine or colcemid, the rate at which BR decreased was concentration dependent. Electron micrographs showed that the rapid decrease in BR corresponded to the disappearance of nonkinetochore microtubules; kinetochore fiber microtubules were differentially stable. As a control, lumicolchicine, which does not bind to tubulin with high affinity, was shown to have no effect on spindle BR at intracellular concentrations of 0.5 mM. If colchicine and colcemid block only polymerization, then the initial rate of tubulin dissociation from nonkinetochore spindle microtubules is in the range of 180-992 dimers per second. This range of rates is based on k = 11% of the initial polymer per second and an estimate from electron micrographs that the average length of a half-spindle microtubule is 1-5.5 micron. Much slower rates of tubulin association are predicted from the characteristics of end-dependent microtubule assembly measured previously in vitro when the association rate constant is corrected for the lower rate of tubulin diffusion in the embryo cytoplasm. Various possibilities for this discrepancy are discussed.

Bone marrow monosomy 7: hematologic and clinical manifestations in childhood and adolescence

The hematologic manifestations and clinical course are described for six children and adolescents with bone marrow monosomy 7. One child with secondary acute myelogenous leukemia had monosomy 7 plus a marker chromosome; the remaining patients had marrow monosomy 7 as the only karyotypic abnormality. The hematologic abnormalities were diverse, but the majority of patients had a smoldering preleukemic or myeloproliferative phase. Leukemic blasts were either undifferentiated or demonstrated evidence of myeloid differentiation. All patients responded poorly to antileukemic therapy. Bone marrow monosomy 7 was observed in one patient with severe marrow hypoplasia. Antileukemic therapy in another patient with greater than 30 per cent marrow blasts was associated with the development of a bone marrow myeloproliferative disorder with persistence of the monosomy 7 karyotype. We speculate that monosomy 7 may be a specific marker for a pluripotent hematopoietic stem cell abnormality that is associated with either blastic leukemia or a myeloproliferative disorder.

Prognosis in acute lymphoblastic leukemia of childhood as determined by cytogenetic studies at diagnosis

Fifty-one children with acute lymphoblastic leukemia on a common protocol of treatment were classified according to presence or absence of chromosomal abnormalities found at the time of diagnosis in bone marrow and/or blood. Twenty-two or 43% had normal karyotypes while 29 (57%) had clonal abnormalities using the Giemsa-trypsin banding technique. Thirteen of the 29 (45%) chromosomally abnormal patients relapsed while only three of 21 (14%) with normal karyotypes have relapsed with a median follow-up of 49.5 months (42-76 months). (One child with a normal karyotype did not respond to therapy.) Several hypotheses have been offered to attempt to explain the significantly better prognosis of patients with no observable initial chromosomal aberrations.

Giemsa-11 technique. Applications in the chromosomal characterization of hematologic specimens

Use of the Giemsa-11 procedure for the localization of heterochromatic regions of human chromosomes and for differentiation of primate and rodent chromosomes has been somewhat limited since its discovery in 1972. An adaptation of this technique to the cytogenetic characterization of hematologic specimens has aided in the interpretation of translocations, deletions, and inversions involving human chromosome 9. The chromosomal analyses of 10% of over 100 patients, principally leukemic, were aided through the use of this auxiliary procedure. The diseases of these patients are given and portions of karyotypes are presented to show clarification of abnormalities made possible through the use of the Giemsa-11 technique.

9;22;15 complex translocation in Ph1 chromosome positive CML revealed by Giemsa-11 procedure in apparent lymphoid cells of blastic crisis

A Ph1 chromosome positive chronic myeloid leukemia patient whose chronic phase lasted 7.5 years experienced a blastic transformation originating in the spleen. The spleen was infiltrated with undifferentiated blast cells that on cytogenetic analysis had a hyperdiploid karyotype and were Ph1 chromosome positive. The blast cells were negative for PAS, peroxidase. Sudan black and esterase stains. They were non-T, non-B with TdT activity. Remission was achieved in response to prednisone, vincristine, and adriamycin. Ph1 positive cells were present with cells responding to PHA stimulation throughout the course of the disease. A Giemsa-11 staining procedure male possible the ascertainment of a No. 9 translocation chromosome in blastic crisis cells that had also been present in Ph1 chromosome positive cells early in the disease. The presence of this translocation initially in myeloid cells and subsequently in apparent lymphoid cell types suggests the origin of this patient's leukemia as a pluripotential stem cell.

Acquired von Willebrand's disease in association with Wilm's tumor: regression following treatment

A 9-yr-old female presented with a Wilm's tumor and a coagulopathy consistent with von Willebrand's disease. Factor VIII procoagulant activity (VIII C), factor VIII related antigen (VIIIR:Ag), and von Willebrand factor activity (VIII:vWf) were decreased. There was no evidence for a circulating inhibitor of the factor VIII molecular complex. von Willebrand's antigen II (vW AgII), which is deficient in hereditary von Willebrand's disease, was decreased below detectable levels in this patient. The coagulation studies, VIIIR:Ag, and vW AgII levels returned to normal following therapy of the Wilm's tumor. Wilm's tumor must be included as one of the malignancies associated with acquired von Willebrand's disease. Immunofluorescent studies of the tumor specimen showed normal endothelial staining of VIIIR:Ag by semiquantitative techniques and a lack of specific tumor adsorption of VIIIR:Ag The presence of normal amounts of tissue VIIIR:Ag has not previously been demonstrated in acquired von Willebrand's disease. Since we failed to demonstrate an inhibitor in the plasma in this patient, the etiology of the acquired von Willebrand's disease in this patient appears to differ from other cases of acquired von Willebrand's disease. The finding that vW AgII is decreased in this patient, similar to that reported in hereditary von Willebrand's disease, supports the close association of vW AgII to VIIIR:Ag, even though they are immunologically and biochemically distinct.

Successful treatment of lymphohistiocytic reticulosis with phagocytosis with epipodophyllotoxin VP 16-213

Lymphohistiocytic reticulosis with phagocytosis is a rare, familial disorder affecting infants and children. It is characterized by fever, pancytopenia, hepatosplenomegaly, and a rapidly fatal course. Prior attempts to treat this disease have been unsuccessful. We describe two patients with lymphohistiocytic reticulosis with phagocytosis and hyperlipidemia. A sibling of one patient had died of the same disease. One patient also had abnormal lymphocyte response to mitogens. Both patients who were treated with epipodophyllotoxin VP 16-213 (VP-16) had remission of their disease and resolution of hyperlipidemia. VP-16 appears to be an effective agent for treating lymphohistiocytic reticulosis with phagocytosis.

Myelogenous leukemia evolving during the course of lymphoid malignancy in children

Two children who presented initially with a lymphoid malignancy were noted to develop recurrences with myeloid features late in the course of their disease. In both cases, evidence of lymphoid differentiation was present in the myelogenous cells that were Ph1 chromosome negative. The first patient had acute myelogenous leukemia and developed a recurrence with morphologic features of acute myelogenous leukemia. Terminal transferase was present in the myelogenous blasts. The second patient initially had a diffuse lymphoblastic non-Hodgkin lymphoma. During the course of her illness she developed a myeloproliferative disorder characterized by basophilic meningitis, splenomegaly, and hypereosinophilia. Lymphocyte T-cell (E-rosette) markers were present on the eosinophils. These observations lend further support to the hypothesis of varying lymphoid and myeloid differentiation in certain cases of leukemia.

Acute nonlymphoblastic leukemia in childhood

Cytogenetic studies have been done on a group of childhood patients over a period of 3 1/2 years in which time Giemsa trypsin banding was applied to all specimens. Fifteen of the 107 patients (14%) were diagnosed as having acute nonlymphoblastic leukemia (ANLL). Twelve of the 15 had chromosomal abnormalities. The most common was an involvement of the No. 7 chromosome which occurred in five patients. Three patients had trisomy 19. No correlation could be found between the disease subgroup and the karyotypic aberration in patients with anomalies involving a common chromosome.

Cytogenetic studies of chronic myelocytic leukemia in children and adolescents

In a 3 1/2 year cytogenetic study of 107 leukemia patients diagnosed in childhood and adloescence, 8 presented with chronic myelogenous leukemia (CML). Seven of the 8 had chromosomal abnormalities. Six had the Ph1 chromosome; 5 had the usual 9;22 translocation. Two patients had involvement with chromosome 15; one had a 9;15 translocation in Ph1 positive cells during remission while a second had a 1;15 translocation during blastic crisis. The 2 patients who did not have a Ph1 chromosome survived 13 and 30 months, respectively, considerably less time than the 4+ year survival in most of those with Ph1 positive CML.

Chromosome 1 abnormalities in relapse and terminal stages in childhood leukemia

Seven of 114 children with leukemia were shown to have abnormalities of chromosome 1. These included trisomy of parts of chromosome 1 as well as translocations of chromosome 1 to other chromosomes. The abnormalities were found during a relapse or terminal stage, after which the patient was refractory to therapy in all cases.

Unusual cytogenetics in a case of acute lymphoblastic leukemia

The cytogenetics in the study of a patient with acute lymphoblastic leukemia are presented. Initially, a large proportion of both unstimulated and phytohemagglutinin (PHA)-stimulated blood mitoses showed an abnormal karyotype with a 7;12 translocation and a trisomy 19. At the time of relapse, a PHA-stimulated culture showed the clonal abnormality as well as dicentric chromosomes in normal cells, the latter possibly resulting from treatment.

Multiple leukemic clones in acute leukemia of childhood

Two abnormal karyotypes representing clonal populations have been demonstrated in three patients in the early stage of acute leukemia. The karyotypes were apparently unrelated in one patient, while in the other two, a relationship was conjectured. Both clones were present before therapy in two patients. Although a clone resistant to therapy was associated with relapse in one case, in two cases a clone has persisted in the lymphocyte culture during drug treatment with the patients in remission.

Management of immature teratoma of the ovary in children by conservative resection and chemotherapy

Six patients with immature teratoma of the ovary were treated with surgery and chemotherapy. Surgical management consisted of unilateral salpingo-oophorectomy, biopsy and conservation of the contralateral ovary, and biopsy of peritoneal implants. Triple-agent chemotherapy with vincristine, actinomycin D, and cyclophosphamide was given to four patients and appeared to be beneficial. Radiation therapy was not employed. Local resection of teratomatous recurrences was frequently necessary. Thorough sampling of this tumor is mandatory for establishment of an exact pathologic diagnosis. All six patients are surviving in good health at 1-8-yr follow-up. The prognosis of immature teratoma in the child or adolescent appears more favorable than previously appreciated.

Hypercoagulability in childhood cancer

Thirty-two children with solid tumors (lymphangioma, fibrosarcoma, hepatocarcinoma, osteogenic sarcoma, rhabdomyosarcoma, lymphosarcoma, mesenchymoma, hepatoma, Ewing's sarcoma, reticulum cell sarcoma, neuroblastoma, Hodgkin's disease, and brain tumors) were studied for alterations in coagulation by means of platelet counts, platelet aggregation, thrombelastogram, procoagulant and antigenic factor VIII, fibrin split products, and antithrombin III level. Results indicated hypercoagulability as shown by abnormally short thrombelastograms and elevated factor VIII levels and platelet counts in approximately one-half of the group. With the exception of increased fibrin split products in a third of the patients, little laboratory or clinical evidence for disseminated intravascular coagulation was seen. Hypercoagulability, as noted in adult carcinoma patients, can also occur in childhood sarcoma patients.

Missing Y chromosome in juvenile chronic myelogenous leukemia

A child with Ph1-negative juvenile chronic myelogenous leukemia (CML) is presented. The only chromosomal abnormality in hematopoietic tissues consisted of an absent Y chromosome. While a missing Y chromosome in adult patients with CML may be associated with a better prognosis, the clinical course in our patient was as malignant as that usually observed in other children with Ph1-negative juvenile CML.