Comparison of Outcomes Between Surveillance Ultrasound and Completion Lymph Node Dissection in Children and Adolescents With Sentinel Lymph Node-Positive Cutaneous Melanoma

OBJECTIVE

To determine the impact of nodal basin ultrasound (US) surveillance versus completion lymph node dissection (CLND) in children and adolescents with sentinel lymph node (SLN) positive melanoma.

BACKGROUND

Treatment for children and adolescents with melanoma are extrapolated from adult trials. However, there is increasing evidence that important clinical and biological differences exist between pediatric and adult melanoma.

METHODS

Patients ≤18 years diagnosed with cutaneous melanoma between 2010 and 2020 from 14 pediatric hospitals were included. Data extracted included demographics, histopathology, nodal basin strategies, surveillance intervals, and survival information.

RESULTS

Of 252 patients, 90.1% (n=227) underwent SLN biopsy (SLNB), 50.9% (n=115) had at least 1 positive node. A total of 67 patients underwent CLND with 97.0% (n=65/67) performed after a positive SLNB. In contrast, 46 total patients underwent US observation of nodal basins with 78.3% (n=36/46) of these occurring after positive SLNB. Younger patients were more likely to undergo US surveillance (median age 8.5 y) than CLND (median age 11.3 y; P =0.0103). Overall, 8.9% (n=21/235) experienced disease recurrence: 6 primary, 6 nodal, and 9 distant. There was no difference in recurrence (11.1% vs 18.8%; P =0.28) or death from disease (2.2% vs 9.7%; P =0.36) for those who underwent US versus CLND, respectively.

CONCLUSIONS

Children and adolescents with cutaneous melanoma frequently have nodal metastases identified by SLN. Recurrence was more common among patients with thicker primary lesions and positive SLN. No significant differences in oncologic outcomes were observed with US surveillance and CLND following the identification of a positive SLN.

Bilateral orbital myositis in a patient with rheumatoid arthritis on treatment with tofacitinib: a report and review of literature

Orbital myositis is a rare inflammatory condition affecting the extraocular muscles of the eyes. It has also been linked to systemic autoimmune diseases. We present a case of orbital myositis in a 57-year-old male undergoing treatment for rheumatoid arthritis (RA) with tofacitinib, a Janus kinase inhibitor (JAK). Prompt administration of intravenous steroids led to rapid symptom improvement. To date, only six published cases have documented the association between RA and orbital myositis. This is the first description of orbital myositis occurring during treatment with the anti-inflammatory drug tofacitinib, an increasingly used disease-modifying anti-rheumatic drug (DMARD). We review the literature and emphasize the importance of ongoing vigilance regarding adverse events linked to tofacitinib.

A case of bowel perforation secondary to burn conversion

SUMMARY

Burn conversion is a process by which superficial partial-thickness burns spontaneously progress into deep partialthickness or full-thickness wounds. Factors that influence this process centre around poor perfusion which can be related to either too much or too little fluid resuscitation, infection, free radical damage, and metabolic or nutritional derangements. Therein lies the role of preventative strategies, i.e., adequate fluid resuscitation, prompt identification and management of sepsis, correction of electrolyte derangements and early institution of feeds. Prevention of burn conversion could prevent the need for surgical intervention and improve the morbidity and mortality of burns patients.

Delayed management of paediatric burn sepsis resulting in limb loss

SUMMARY

Primary health care centres, community health centres and district hospitals often have medical staff that have minimal exposure to paediatric patients. This may contribute to the challenge of recognising a critically ill paediatric patient. It is already a difficult task as many clinicians are not comfortable or well equipped to manage burn patients, even in regional or tertiary facilities. Identification of the systemic inflammatory response syndrome (SIRS) versus sepsis is difficult in burns owing to the clinical presentation. Identifying the clinical signs determines the need for immediate treatment (i.e., fluid resuscitation) no matter the cause. Investigations will follow to determine the cause, further management and response to treatment. These two cases illustrate the deficit in skill and knowledge in the identification of the sick burninjured child. Although telemedicine has made large advances in allowing access to expert advice in remote locations, its usefulness is dependent on the clinical signs being identified and adequately portrayed to the expert. The way forward is better undergraduate and postgraduate training in this area with an emphasis on clinical acumen.

Amputations secondary to burn injuries in a resource-limited setting

INTRODUCTION

Amputations are a devastating consequence of severe burns. Amputations in a resource-limited setting are challenging as rehabilitation services available to these patients are inconsistent and often fragmented. Epileptic patients are a particularly vulnerable group when it comes to burn-injuries and often sustain deeper burns. The aim of this study is to analyse amputations secondary to burn injuries. We seek to identify vulnerable groups as a means for advocacy efforts to reduce the devastation of an amputation secondary to a burn injury. This paper highlights the burden of these injuries on the healthcare system and emphasizes the need for additional trained therapists for the rehabilitation of these patients.

METHODS

A retrospective database review was conducted. All burns admissions who underwent an amputation between 1 February 2016 and 31 January 2019 were considered.

RESULTS

A total of 1575 patients were admitted during the study period. Fifty-four percent of the admissions were paediatric patients. The amputation rate in the paediatric population was 1.5% (13/850) while in the adult population it was 4.8% (35/724) . Most paediatric amputations were as a result of electrical injuries. Flame burns were most likely to result in amputations in the adult group and convulsions were the leading circumstance leading to the injury. There was no significant difference in sepsis or length of stay between the groups. There were no mortalities in the paediatric group but there was an 11% mortality rate in the adult group.

CONCLUSION

The incidence of amputations in burns is low, however, it remains a devastating morbidity. Epileptics are a vulnerable group and these patients account for the most amputations among adult burns patients. Education interventions are needed regarding their diagnosis, administration of their medication and the importance of compliance. Advocacy efforts to ensure constant supply of anti-epileptic drugs at the clinics and other district level health facilities is also essential. Electrical injuries in children are not as common as hot water scalds, however, they are more likely to result in amputation. Communities need to be informed of the risk associated with illegal electrical connections and initiatives need to drive the safe provision of affordable electricity to these under-privileged, vulnerable communities.

Bioprocess enhancement of feather degradation using alkaliphilic microbial mixture

1. The main aim of this work is to develop a robust method to generate a microbial mixture which can successfully degrade poultry feathers to overcome environmental problems. 2. Four different alkaliphilic microbes were isolated and shown to degrade poultry feathers. 3. Two of the isolates were phylogenetically identified as Lysinibacillus and the others were identified as Nocardiopsis and Micrococcus. 4. The best microbial co-culture for white and black feather degradation was optimised for pH, temperature and relative population of the isolates to achieve almost 96% of degradation compared with a maximum of 31% when applying each isolate individually. 5. The maximum activity of keratinase was estimated to be 1.5 U/ml after 3 d for white feathers and 0.6 U/ml after 4 d for black feathers in a basal medium containing feather as the main carbon source. Additionally, non-denaturing polyacrylamide gel electrophoresis showed 4 and 3 protease activity bands for white and black feather, respectively. 6. This study provides a robust method to develop potential new mixtures of microorganisms that are able to degrade both white and black feathers by applying a Central Composite Design.

The effect of three whitening oral rinses on enamel micro-hardness

The purpose of this study was to determine the effect on human enamel micro-hardness of three over-the-counter whitening oral rinses available in South Africa. Enamel fragments were gathered into three groups of 15 each. One group was exposed to Colgate Plax Whitening Blancheur, the second group to White Glo 2 in 1 and the third to Plus White, in each case for periods recommended by the respective manufacturers. Surface micro-hardness of all groups was measured before and after a 14 day treatment period. pH levels of the oral rinses were also determined with a combination pH electrode. Pre- and post- treatment data were analysed by the Wilcoxon Signed Rank Sum Test. According to the micro-hardness values no significant (p > 0.05) enamel damage was found as a result of treatment. However, it was observed that Colgate Pax and White Glo decreased the enamel hardness, an early sign of enamel damage, while Plus White showed a small increase in hardness. The three whitening oral rinses on the South African market do not damage the tooth enamel significantly when used as recommended by the manufacturers. However, extending the contact period and increasing the frequency of application might lead to damage of enamel.

Purification and characterization of Bacillus thuringiensis vegetative insecticidal toxin protein(s)

Bacillus thuringiensis subsp. aegypti C18 is an Egyptian isolate, obtained from dead pink bollworm larvae. Insecticidal active proteins against different insect were purified from BtaC18 strain during vegetative states. Both the bacterial pellet and cell-free supernatant obtained during vegetative growth had insecticidal activity against black cutworm (BCW). Bioassays revealed that the pellet after 48 h of growth is more potent and toxic against BCW. The toxin in the pellet was active at very high temperatures but lost toxicity after boiling or autoclaving. Proteins extracted from the BtaC18 pellet were further purified by ammonium sulfate precipitation, and the 40% fraction was then subjected to fast protein liquid chromatography (FPLC). Seven major protein peaks were detected after FPLC (Pi- a, b, c, d, e, f and g). Pic protein fraction was active against BCW with an estimated LC50  = 26 ng cm(-2) , Pid protein killed 50% of European corn borer (ECB) at 46 ng cm(-2) , and Pif showed insecticidal activity against western corn root worm (WCRW) with estimated LC50 was 94 ng cm(-2) . Based on the significant and high toxicity of Pic against BCW and Pif against WCRW, the 88- and 44-kDa proteins were further characterized by N-terminal amino acid sequencing.

SIGNIFICANCE AND IMPACT OF THE STUDY

Insecticidal activity of Bacillus thuringiensis subsp. aegypti was determined, and its vegetative insecticidal protein was subjected to FPLC for protein purification. This work contributes to improve understanding the different toxins secreted during vegetative growth of Bt. Moreover, the N-terminal amino acid sequences of 88-kDa protein was only 92% identical to that of vip3A, and for 44 kDa was 92% identical with Cry35a, suggesting that we might have identified a new genes. Finally, we have proven these proteins to be novel insecticidal agents that may complement the use of known insecticidal proteins derived from Bacillus.

Guidelines for the selection of tooth whitening products amongst those available on the market

BACKGROUND

Several tooth whiteners are available on the market, and the ideal choice should be determined by efficacy and optimal clinical results.

OBJECTIVES

The purpose of this study was to compare the reported clinical success rates of different tooth whitening products.

SEARCH STRATEGY

The relevant literature (1998 - 2011) was studied, using as sources the databases: Google Scholar, Science Direct, Medline and Pubmed.

SELECTION CRITERIA

The material was clearly identified, the manufacturers' instructions were respected and the sample size stated.

RESULTS AND CONCLUSIONS

This descriptive report on 49 papers focuses on the total colour change, measured with a calibrated shade guide and also numerically (colourimeter, chromameter or spectrophotometer), the relapse of the colour change and tooth sensitivity. In general, the dentist-supervised at-home bleaching and the in-office treatment gave approximately the same initial percentage improvement of tooth whitening. However, the relapse after a four week or longer period was significantly higher for the in-office treatment. The treatment of choice should be a dentist supervised at-home bleaching product which generally contains approximately 10% carbamide peroxide applied over about 14 days for about eight hours per night. Tooth sensitivity should not be a general problem although some subjects might choose to discontinue treatment as a result of sensitivity.

Ischaemic posterior circulation stroke in State of Qatar

BACKGROUND

Ischaemic stroke features may show regional differences. Posterior circulation stroke (PCS) is of special interest, as symptomatology, course and outcome are usually different and complex. No significant studies or registries have reported on the characteristics and outcomes of PCS in our region.

METHODS

We prospectively collected data of 116 patients with PCS admitted from 2005 through 2008 in the only stroke admitting hospital in Qatar. Demographics, risk factors, clinical signs/symptoms, pattern of presentation, aetiology, imaging features, complications and outcome at discharge and follow-up were recorded.

RESULTS

Mean age was 53 years with 25% aged < or = 45, 85% were males. Demographically 47% were Arabs and 51% of South-Asian origin. Mean duration from onset to presentation was 29 h. Major risk factors were obesity (66%) and hypertension (61%). Minimal or fluctuating symptoms were present in 64%, while 9% had maximal deficit at onset. Thirty nine per cent had lesions in proximal territory and 23% in multiple territories. Around 41% had no occlusion, 16% had vertebro-basilar, 16% vertebral, 8% basilar occlusion. Etiologically 53% patients had large artery disease, 16% small vessel disease, and 17% cardioembolism. Seventy per cent of patients were discharged home, while 10% expired. Modified Rankin score (mRS) at discharge was < or = 2 in 53% and > or = 4 in 13% patients. At 30-day follow-up, 68% had mRS of < or = 2. Ninety-day survival status showed 89% alive with mRS < or = 2 in 73%.

CONCLUSION

The aetiology and lesion topography of PCS in this heterogeneous population differs from the pattern observed in other populations.

Effect of prostaglandin E2, lipopolysaccharide, IFN-gamma and cytokines on the generation and function of fast-DC

BACKGROUND

Recent reports have described a new strategy for differentiation and maturation of monocyte-derived DC within only 48 h of in vitro culture (fast-DC). We compared the ability of various maturation stimuli with the generation of Ag-specific T-cell responses and generation of functional fast-DC.

METHODS

CD14+ cells were treated with GM-CSF and IL-4 for 1 day to generate immature DC, and were then matured with either inflammatory cytokines or a combination of lipopolysaccharide (LPS) and INF-gamma. Mature DC were then used to study the effect of prostaglandin E2 (PGE2) on the stimulatory function of fast-DC.

RESULTS

fast-DC were CD14- and expressed mature DC surface markers, and maintained this phenotype after withdrawing the cytokine from culture. Treatment of fast-DC with a combination of LPS and INF-gamma promoted the maturation of highly uniform fast-DC. The T-cell proliferative response to DC was enhanced by inclusion of PGE2 in the MCM-mimic (TNF-a, IL-1 a, IL-6, PGE2) cocktail.

DISCUSSION

fast-DC are very effective; they not only reduce the labor, cost and time required for in vitro DC development, but may also represent a model more closely resembling DC differentiation from monocytes in vivo.

Renal transplantation in children with abnormal lower urinary tract

OBJECTIVE

This retrospective study reports the outcomes as well as pre- and posttransplant urologic treatments of renal transplantation for children with an abnormal lower urinary tract (LUT).

METHODS

Between March 1981 and December 2001, 195 children (< or =18 years of age) received live-donor kidney transplants. The 15 recipients (14 boys and 1 girl, mean age 13.5 +/- 3 years) who had lower urinary tract disorders included posterior urethral valves (PUV) with valve bladder (n=12) and neuropathic bladders secondary to meningomyelocele (n=3). These children were evaluated by voiding cystourethrogram, cystourethroscopy, and cystometry. The children with PUV were maintained on clean intermittent catheterization (CIC) and a detrusor relaxant at least 3 months before transplantation. Augmentation ileocystoplasty or continent cutaneous diversion were used in three patients. The graft and patient survivals as well as complications in this cohort was compared with a group of children with normal LUT, who underwent renal transplantation during the same period.

RESULTS

One child died in the early posttransplant period due to rupture of the external iliac artery. Follow-up ranged from 6 months to 16 years (mean=4.5 years). During the same period the graft and patient survival rates were comparable between the group of children with versus without abnormal LUT. Furthermore, mean serum creatinine and creatinine clearance values were also comparable. The group with an abnormal LUT showed a higher incidence of urinary fistula (3/14) and recurrent UTI and/or bacteremia (4/14).

CONCLUSIONS

Renal transplantation is feasible with good results for children with abnormal LUT. Pre- and posttransplant urologic management is critical for a successful outcome. However these children display a high incidence of urologic and infectious complications.

Sliding hernia containing the ureter--a rare cause of graft hydroureteronephrosis: a case report

Obstructive uropathy following renal transplantation is frequently reported. However, ureteral obstruction due to its incorporation in a sliding hernia is a rare event. Herein, we report a case of late graft hydroureteronephrosis secondary to a sliding hernia containing the transplanted ureter. The diagnosis was confirmed with the aid of magnetic resonance urography and antegrade urography. Following hernioplasty, a decrease of serum creatinine level was achieved with significant decompression of the system.

Generation of Ag-specific cytotoxic T lymphocytes by DC transfected with in vitro transcribed influenza virus matrix protein (M1) mRNA

BACKGROUND

Application of DC transfected with tumor Ag RNA is promising for DC-based tumor immunotherapy. In this study, Ag-specific cytotoxic T lymphocytes (CTL) were generated by priming lymphocytes with DC transfected with in vitro transcribed (IVT) influenza virus matrix protein M1 (M1) mRNA.

METHODS

Human UC blood-CD34+ cell-derived DC were transfected with IVT mRNA encoding either the enhanced green fluorescence protein (EGFP), or M1 by square-wave electroporation. DC were confirmed to have typical morphology and phenotype. DC transfected with IVT EGFP mRNA were analyzed with the FACScan flow cytometer, to confirm the efficiency of this transfection method. On Days 7, 14, 21 and 28 after the start of DC culture, DC were harvested and electroporated with M1 mRNA. The transfected DC were co-cultured with autologous UC blood CD34- cells. One week after the fourth priming of autologous CD34 negative cells with M1 mRNA electroporated DC, Ag-specific CTL activity was evaluated. To prepare target cells, M1 mRNA was added to autologous DC 48 h prior to CTL assays.

RESULTS

Our CTL assays results indicate that UC blood CD34+ cell-derived DC transfected with M1 mRNA by electroporation stimulated Ag-specific CTL responses that are capable of recognizing and lysing autologous DC loaded with M1 mRNA. M1 mRNA transfected DC-primed CTL showed a significant cytotoxic activity against M1 mRNA loaded autologous DC, while nearly baseline cytotoxic activity was recorded for the M1 mRNA unloaded DC.

DISCUSSION

Our results showed that mRNA-transfected DC are potent stimulators of T-cell immunity in vitro. In addition, mRNA-loaded DC can function as targets in CTL cytotoxicity assays, which offer a practical substitute for tumor cells in assays to test the immunological effects of specific Ags.

High-energy transurethral microwave thermotherapy: symptomatic vs urodynamic success

OBJECTIVE

To evaluate the subjective and objective treatment results of high-energy transurethral microwave thermotherapy (TUMT) for symptomatic benign prostatic hyperplasia (BPH), and investigate the possible variables for predicting symptomatic and/or urodynamic success.

PATIENTS AND METHODS

Between October 1998 and October 2000, 40 men with BPH underwent high-energy TUMT using the Targis device (Urologix, Inc., Minneapolis, MN, USA). Evaluation after treatment included a clinical determination of the symptom score, a urodynamic assessment by peak flow rate and pressure-flow, magnetic resonance imaging (MRI), transrectal ultrasonography and endoscopy. The objective and subjective success was correlated with several variables before, during and after treatment.

RESULTS

All patients completed at least 1 year of follow-up after TUMT as monotherapy. The symptom score improved from a median (range) of 20.5 (11-28) initially to 9 (0-28) (P < 0.001). Twenty-two patients (55%) had a marked and 11 (28%) a moderate response, giving an overall subjective success rate of 83%. Similarly, there was a significant improvement in peak flow rate, from 9.2 (4.4-13.4) to 15 (3.3-22.9) mL/s (P < 0.001). Twenty-one patients (53%) had a maximum flow rate of > 15 mL/s while in eight (20%) it was 10-15 mL/s. Only 20 patients changed from unobstructed on the pressure-flow nomogram, i.e. an overall objective success rate of 50%. Gadolinium-enhanced T1-weighted MRI 1 week after treatment showed a median (range) perfusion defect of 20.7 (5.5-76.6)% of the total gland volume. Despite this persisting in all patients, a well-defined cavity was apparent in only in seven (18%) at the final evaluation. Cystoscopy 1 month after therapy showed evidence of necrotic tissue occupying the prostatic fossa in all patients. Younger patients were more likely to be urodynamically successful, and a higher grade of obstruction predicted symptomatic success.

CONCLUSION

High-energy TUMT can induce considerable necrosis of the prostate, as shown by MRI and cystoscopy. Although there was an adequate improvement in most patients' symptoms, there was a successful urodynamic change to unobstructed in only half the patients. Younger patients and those with a higher grade of obstruction were more likely to have urodynamic and symptomatic success, respectively.

Urological complications after living-donor renal transplantation

OBJECTIVE

To determine the incidence and management of urological complications after 1200 consecutive live-donor renal transplantations, all of which were carried out in one centre; the possible risk factors and the effect on patient and graft survival were also assessed.

PATIENTS AND METHODS

Data were retrieved from an electronic database; the incidence of urological complications was determined, and correlated with relevant risk factors by univariate and multivariate analysis. The effect on patient and graft survival was assessed using Kaplan-Meier statistics.

RESULTS

There were 100 complications in 96 patients (8%); urinary leaks occurred in 37, ureteric strictures in 23 and lymphoceles causing ureteric obstruction in 17. Percutaneous needle biopsy was complicated by haematuria and clot anuria in six patients. Late complications included 11 cases of stones, four of bladder malignancy and two of haemorrhagic cystitis. There was evidence that the age of the recipients (< 10 years), method of establishing urinary continuity (uretero-ureteric anastomosis) and a high dose of steroids had an independent positive effect on the incidence of urological complications. However, their development did not influence graft or patient survival.

CONCLUSION

When there is meticulous attention to the technical details, renal transplantation should incur few urological complications. Early intervention with percutaneous drainage reduces morbidity and the likelihood loss of graft function. Proper and prompt management should not affect the graft and/or the patient's survival.

Activation of hepatic NKT cells and subsequent liver injury following administration of alpha-galactosylceramide

It has been established that alpha-galactosylceramide (alpha-GalCer), a glycolipid, is recognized by natural killer T (NKT) cells together with the monomorphic MHC-like antigen, CD1d, in mice and humans. In this study, we examined how NKT cells are modulated by in vivo administration of alpha-GalCer in mice. When 2 microg (or more)/mouse of alpha(-GalCer was injected i.p., the majority of NKT cells disappeared in the liver and spleen, possibly undergoing apoptosis, on day 1. At this time, NKT cytotoxicity seen in liver lymphocytes also disappeared. In parallel with this numerical and functional change of NKT cells, there was always concomitant hepatocyte damage, as shown by histology and elevated levels of transaminases. Subsequently, the number and function of NKT cells continued to increase from day 3 to day 7. The response seen in hepatic (and splenic) NKT cells did not occur in thymic NKT cells. All these phenomena induced in the liver did not appear in NKT-deficient mice such as beta2-microglobulin(-/-) and CD1d(-/-) mice. These results shed further light on the in vivo interaction between NKT cells and alpha-GalCer in mice.

Activation of hepatic NKT cells and subsequent liver injury following administration of alpha-galactosylceramide

It has been established that alpha-galactosylceramide (alpha-GalCer), a glycolipid, is recognized by natural killer T (NKT) cells together with the monomorphic MHC-like antigen, CD1d, in mice and humans. In this study, we examined how NKT cells are modulated by in vivo administration of alpha-GalCer in mice. When 2 microg (or more)/mouse of alpha(-GalCer was injected i.p., the majority of NKT cells disappeared in the liver and spleen, possibly undergoing apoptosis, on day 1. At this time, NKT cytotoxicity seen in liver lymphocytes also disappeared. In parallel with this numerical and functional change of NKT cells, there was always concomitant hepatocyte damage, as shown by histology and elevated levels of transaminases. Subsequently, the number and function of NKT cells continued to increase from day 3 to day 7. The response seen in hepatic (and splenic) NKT cells did not occur in thymic NKT cells. All these phenomena induced in the liver did not appear in NKT-deficient mice such as beta2-microglobulin(-/-) and CD1d(-/-) mice. These results shed further light on the in vivo interaction between NKT cells and alpha-GalCer in mice.

Nocturnal enuresis in men with an orthotopic ileal reservoir: urodynamic evaluation

PURPOSE

We evaluated the urodynamic features of enuretic and continent patients with an orthotopic neobladder.

MATERIALS AND METHODS

Included in our study were 100 men with an orthotopic hemi-Kock or W neobladder and a minimum followup of 1 year. Of the patients 50 were completely continent day and night, and 50 had enuresis without evidence of an underlying organic etiology, such as stones, reflux or urethral stricture.

RESULTS

Univariate analysis showed significantly higher pressure and a larger volume of post-void residual urine in the men with enuresis. In addition, maximum urethral pressure, maximum flow and compliance were decreased in the enuretic group compared to the continent group. Multivariate analysis revealed that post-void residual urine volume, frequency and maximum amplitude of uninhibited contractions are the most critical parameters affecting nocturnal continence.

CONCLUSIONS

The cystometric parameters significantly associated with nocturnal enuresis in patients with an orthotopic reservoir are post-void residual urine volume, frequency and maximum amplitude of uninhibited contractions. Urethral pressure and flow parameters did not sustain significance on multivariate analysis.

[Demonstration of HFE polymorphism in German patients with hereditary hemochromatosis]

BACKGROUND AND OBJECTIVE

Hereditary haemochromatosis (HH) is the most common genetically determined disease of the white population which by iron overload causes multiorgan functional impairment. Recently the gene for HH (HFE gene) has been located on chromosome 6. The development of HH is thought to be caused by two point mutations that lead to an amino acid exchange of tyrosine for cysteine on codon 282 (Cys282Tyr) and of histidine by aspargic acid on codon 63 (His63Asp).

PATIENTS AND METHODS

75 patients with phenotypically confirmed HH were examined genetically. The analysis of the HFE-gene mutation was done on genomic DNA by restriction digestion with the restriction enzymes Rsal and Mbol.

RESULTS

Homozygosity for the Cys282Tyr mutation was found in 66 (88%) of the patients, while two were heterozygous. Of seven patients with wild-type sequence of the amino acid position 282, three (43%) had a His63Asp exchange. Overall only four patients had neither of the two mutations.

CONCLUSIONS

Because of different geographical distributions, a knowledge of the mutation rate is important for patients with HH. to assess the diagnostic value of the gene test. For the first time gene analysis makes it possible to diagnose HH before clinically significant iron overload occurs. It may further improve prognosis of the disease by early application of therapeutic blood-letting.

Dendritic cells stimulate the expansion of PML-RAR alpha specific cytotoxic T-lymphocytes: its applicability for antileukemia immunotherapy

Dendritic cells (DC), the most potent "professional" antigen-presenting cells, hold promise for improving the immunotherapy of cancer. In this study, we investigated the ability of normal donor DC pulsed ex vivo with 12 mer PML-RAR alpha (A) peptide (SGAGEAAIETQS) to generate peptide specific autologous cytotoxic T-lymphocytes. The peptide pulsed DC-primed peripheral blood lymphocytes (PBL) displayed significantly higher cytotoxic activity compared with that of peptide non-pulsed DC-primed PBL against peptide-pulsed autologous macrophages (P<0.001). Both CD8+ and CD4+ T lymphocytes were involved in the effector cell populations. The PML-RAR alpha peptide-pulsed DC-primed T-cells were significantly superior in their production of GM-CSF and TNF-alpha, compared with peptide non-pulsed DC-primed T-cells. These intriguing preclinical studies, suggest that PML-RAR alpha pulsed-DC could be a promising immunotherapeutic modality for patients with acute promyelocytic leukemia.

[Hereditary hemochromatosis--new developments after discovery of the HFE gene]

Hereditary hemochromatosis (HH) is an autosomal recessive disorder of iron metabolism, resulting in an increased iron deposition and multiorgan failure. Recently a candidate gene of HH, termed HFE, has been identified on chromosome 6, coding for a protein homologous to major histocompatibility complex (MHC) class I molecules. Two mutations of the hemochromatosis gene leading to an exchange of cysteine to tyrosine at aminoacid 282 and histidine to asparagine at aminoacid 63, are retained responsible for the development of hereditary hemochromatosis. The Cys282Tyr-mutation disrupts a disulfid bond and thus abrogates binding of the mutant HFE-protein to beta 2-microglobulin and its presentation on the cell surface. The His63Asp-mutation seems to play a role in pH-regulated dissociation of the transferrin receptor/transferrin complex in the lysosome. Mutations of the HFE-protein alter the affinity of the transferrin receptor for its ligand transferrin and may thus cause an intracellular accumulation of iron. Knowledge of the responsible gene allows a molecular diagnosis of HH. The new genetic marker can be used for screening and confirmation of HH reducing the need for confirmatory liver biopsies. Compared to standard screening parameters like ferritin and transferrin saturation genetic testing will allow the diagnosis of HH in an early, asymptomatic state before iron accumulation has occurred. As a normal life expectancy of patients with HH can be achieved if iron reduction is initiated early, genetic testing may thus be of great benefit for patients with HH.

Activation of autologous or HLA-identical sibling cytotoxic T lymphocytes by blood derived dendritic cells pulsed with tumor cell extracts

This study describes the effect of dendritic cells (DC) pulsed with tumor cell extracts on the induction and activation of autologous and HLA-identical sibling tumor cell specific cytotoxic T lymphocytes (CTL). The subjects of the study were patients with hematological malignancies (acute myeloid leukemia, acute lymphoblastic leukemia, and multiple myeloma), and stem cell transplant donors. Although lymphocytes primed with non-pulsed DC did not show definite cytotoxic activity against autologous or HLA-identical sibling patient tumor cells, both autologous and HLA-identical sibling CTL activated by DC pulsed with tumor cell extracts demonstrated markedly significant killing activity against tumor cells in the fashion of higher cytotoxicity with the increase of effector:target ratio (p<0.05). These findings reveal that DC pulsed with tumor cell extracts could be efficiently applicable in anti-tumor immunotherapy for patients with hematological malignancies.

Generation of bcr-abl specific cytotoxic T-lymphocytes by using dendritic cells pulsed with bcr-abl (b3a2) peptide: its applicability for donor leukocyte transfusions in marrow grafted CML patients

Dendritic cells (DC), the most potent 'professional' antigen-presenting cells, hold promise for improving the immunotherapy of cancer. In this study, we investigated the ability of normal donor DC pulsed ex vivo with 12 mer bcr-abl (b3a2) peptide to generate b3a2-specific autologous or HLA-identical sibling donor's cytotoxic T-lymphocytes (CTL). DC that were grown from normal peripheral blood adherent cells or purified DC precursors in the presence of GM-CSF and IL-4, were pulsed with b3a2-peptide then were induced to become mature and functional cells by the addition of TNF-alpha. These peptide-pulsed mature DC elicited a potent b3a2-specific CTL response in vitro. The b3a2-peptide pulsed DC-primed peripheral blood lymphocytes (PBL) displayed significantly higher cytotoxic activity compared with peptide non-pulsed DC-primed PBL against target cells, which are b3a2 positive marrow cells derived from HLA-identical sibling chronic myelogenous leukemia (CML) patient, or peptide-pulsed autologous macrophages (P < 0.001). In addition, the b3a2 peptide-pulsed DC-primed and non-pulsed DC-primed PBL showed no cytotoxic response against peptide non-pulsed autologous macrophages. These findings revealed that normal donor PBL pre-immunized with b3a2-peptide pulsed autologous DC could increase the graft-versus-leukemia effect without exaggerating graft-versus-host-disease. Both CD8+ and CD4+ T lymphocytes were shown to be involved in the effector cell populations. The b3a2 peptide-pulsed DC-primed T cells were significantly superior in their production of GM-CSF and TNF-alpha compared with peptide non-pulsed DC-primed T cells. These intriguing preclinical results imply the feasibility of developing b3a2 peptide-DC based protocol for in vitro sensitization of normal donor leukocytes before donor leukocyte transfusions for patients with CML, who relapsed after HLA-matched sibling bone marrow transplantation.

Expression patterns of costimulatory molecules on cells derived from human hematological malignancies

In order to elucidate the possibility of costimulatory molecules-mediated immuno or immuno-gene therapy for human hematological malignancies, we analyzed 30 hematopoietic cell lines and cells obtained from 48 patients with hematological malignancies for the expression of costimulatory molecules such as CD80 and CD86. The 30 hematopoietic cell lines were composed of 4 cell lines derived from the patients with T-cell acute lymphoblastic leukemia (T-ALL), 3 from Philadelphia chromosome positive ALL (Ph1+ALL), 8 from acute myeloblastic leukemia (AML), 3 from acute promyelocytic leukemia (APL), 8 from chronic myeloid leukemia at blast crisis (CML-BC), 3 from Burkitt's lymphoma and one from follicular cell lymphoma. The expression of CD80 or CD86 was frequent on cell lines derived from the patients with CML-BC or Burkitt's lymphoma, while it was rare on cell lines from T-ALL. Subsequently we analyzed the cells obtained from 48 patients with hematological malignancies, which consisted of 6 samples from patients with ALL, 30 from AML, 2 from CML-BC, 3 from B-cell lymphoma and one from each acute mixed leukemia (AMixL), adult T cell leukemia (ATL), T-cell large granular lymphocytic leukemia (T-LGL leukemia), chronic lymphocytic leukemia (CLL), myelodysplastic syndrome (MDS)-RAEB in T, multiple myeloma (MM) or T-cell lymphoma. Among all the 48 cases, all cases except one case with CLL and two with B cell lymphoma were demonstrated to be negative for CD80 on the neoplastic cells. CD86 and HLA-DR were shown to be expressed in 50% and 88% of total 48 cases respectively. In 30 AML samples, CD86 was positive in 15 cases (50%), which was sharply in contrast with the finding that CD80 was not detected in any AML samples. HLA-DR was expressed in 25 AML samples (83%). We also treated seven human hematopoietic cell lines with IFN-gamma, IL-12 or IL-15 and observed whether these cytokines could induce or enhance the expression of CD40, CD54, CD58 and HLA-DR as well as CD80 and CD86. The present study demonstrated that the expression of CD86 could be upregulated not only by IFN-gamma, but also by IL-12 or IL-15 in some cell lines. These findings suggested the possibility that the absence of CD80 on neoplastic cells may be associated with the lack of efficient anti-tumor immunity in most patients with hematological malignancies and that the immuno or immuno-gene therapy manipulating the expression of costimulatory molecules such as CD80 may be a useful treatment modality for hematological malignancies.

Mitochondrial genomic markers confirm the presence of the camel strain (G6 genotype) of Echinococcus granulosus in north-western China

Twenty-eight isolates of E. granulosus, collected from humans at surgery, and a range of intermediate hosts, including sheep, cattle and camels from abattoirs in North and South Xinjiang Uygur Autonomous Region, People's Republic of China, were analysed for DNA sequence variation within regions of the mitochondrial cytochrome c oxidase I (COI) and NADH dehydrogenase subunit I (NDI) genes. The isolates were categorized into 2 distinct and uniform genotypic groupings, based on the sequences obtained, and the data clearly indicated that the camel/dog strain (G6 genotype) of E. granulosus as well as the cosmopolitan, common sheep strain (G1 genotype) occur in north Xinjiang. The presence of the camel strain has thus been confirmed in Xinjiang but it is evident from this and a previous molecular genetic survey of E. granulosus isolates from north-western China that the common sheep strain is the most predominant in the region. From the public health perspective, the majority of infected livestock will act as reservoirs of human infection there. During the course of the study, a polymerase chain reaction (PCR)-restriction fragment length polymorphism (RFLP) assay, based on the NDI sequence variation, was developed that allows rapid discrimination of the G1 and G6 genotypes.

Environmental surveys conducted in the Gulf region following the Gulf War to identify possible neurobehavioral consequences

During the 1991 Gulf War, the Iraqi army set Kuwait oil wells on fire. Wells and some oil refineries were burned, resulting in Kuwait and the surrounding Gulf region being exposed to toxic gases. The oil fires reached their peak in February 1991. On March 7, the fires in some fields were still burning at peak strength. Sulfur dioxide, particulates, carbon monoxide, and nitrogen oxides were emitted into the atmosphere. All of these substances can cause adverse health effects, which vary according to concentration and duration of exposure. A survey conducted in Kuwait clinics and emergency rooms showed an increase in upper respiratory irritation consistent with environmental air sampling results, indicating occasional high levels of particulates. Patient visits related to gastrointestinal illness, heart disease, psychiatric illness, chronic bronchitis and emphysema, and bronchiectasis increased during the period following the burning of the oil wells. There was no documented evidence of an increase in visits for acute upper and lower respiratory infections or asthma. Public health workers must recognize the high priority of collecting long-term health data and developing public health systems to assess those data.

Activation by estrogen of the number and function of forbidden T-cell clones in intermediate T-cell receptor cells

When estrogen (1 mg/mouse) was subcutaneously administered once into mice, the number of liver MNC increased but the number of thymocytes decreased profoundly from Day 3 to Day 20. Phenotypic characterization revealed that the proportion of intermediate (int) TCR cells with IL-2 receptor beta-chain (IL-2R beta) was elevated in both the liver and the thymus. Attention was then focused on how forbidden clones were distributed among various T-cell subsets, including IL-2R beta+ int TCR cells and IL-2R beta-high TCR cells. IL-2R beta+ int TCR cells are generated through the extrathymic pathway in the liver and an alternative intrathymic pathway, whereas IL-2R beta- high TCR cells are generated through the mainstream of T-cell differentiation in the thymus. It was demonstrated that forbidden clones, V beta 3+ and V beta 11+ cells, in BALB/C mice (Mls-1b2a) were confined to IL-2R beta+ int TCR cells, irrespective of the administration of estrogen. Interestingly, the proportion of forbidden clones among int TCR cells increased in the liver but decreased in the thymus after the administration of estrogen. Liver MNC that contained a high level of forbidden clones showed unexpected high levels of spontaneous proliferation and of the proliferative response to immobilized anti-V beta mAb (even in the combination of forbidden clone stimulations). The present results reveal that the levels of both int TCR cells and forbidden clones that induce hepatocyte damage preferentially increase in the liver, one of the prime target organs in autoimmune diseases, when estrogen is administered.

A comparison of proliferative response to IL-7 and expression of IL-7 receptors in intermediate TCR cells of the liver, spleen, and thymus

It is well established that IL-7 supports the earliest differentiation of both T and B cells in fetal and adult life. On the other hand, mature lymphocyte subsets tend to decrease the response to IL-7 in case of T and B cells. In a recent study, NK1.1+ T cells in the thymus are also found to efficiently respond to IL-7 and express IL-7 receptors (IL-7R). This population is generated through an alternative intrathymic pathway. A similar population, namely, T cells with intermediate levels of TCR (i.e., int TCR cells) are known to be generated through extrathymic pathways. In this respect, the proliferative response to IL-7 and the expression of IL-7R in int TCR cells of various organs were compared. Whole liver MNC and isolated int TCR cells from the liver were found to proliferate in response to IL-7. Moreover, a considerable population of int TCR cells in both the liver and thymus were found to carry a higher density of IL-7R on the surfaces than high TCR cells. More precisely, the intensity of IL-7R on int TCR cells in the thymus was the highest but those on int TCR cells in other organs were slightly lower (i.e., int TCR cells in the thymus greater than int TCR cells in the liver greater than high TCR cells). Taken together with the result of expression of IL-7 mRNA by hepatocytes and thymic tissues, it is concluded that IL-7 is one of the most important growth factors for int TCR cells both in the liver and thymus.

Case Report: amyopathic dermatomyositis associated with transformed malignant lymphoma

Amyopathic dermatomyositis is a disease of unknown origin characterized by the specific skin lesions of dermatomyositis but without clinical or laboratory evidence of myopathy. During the past 15 years, a great controversy between the different reports concerning a possible association of dermatomyositis with malignancy has been noted. In this report, the authors describe a patient with amyopathic dermatomyositis who presented first with a benign hyperplasia of the lymph node, which finally transformed into frank malignant lymphoma. In addition to follow-up care, screening tests to search for occult malignancy in patients with amyopathic dermatomyositis (or dermatomyositis) are recommended.

Suppression of fluid accumulation following pericardial inflammation in a patient with primary chylopericardium

The patient was a 50-year-old woman with primary chylopericardium. Triglyceride rich chyloid fluid was continuously drained from the pericardial space through an indwelling catheter. A surgical procedure was scheduled since a medium chain triglyceride diet was insufficient to control the fluid accumulation. Before the operation, inflammatory signs were apparent around the indwelling catheter and the catheter was removed immediately. The inflammation was easily treated with antibiotics, and the pericardial effusion no longer accumulated during a follow-up period of 10 months. The inflammatory process may have caused fibrin production and tissue adhesion in the pericardial cavity, and these might have prevented an accumulation of chyloid fluid and occluded the connection between the thoracic duct and the pericardial cavity.