Therapy-related Myeloid Neoplasms in Children: A Single-institute Study.

Therapy-related myeloid neoplasm (t-MN) in the pediatric population is not well characterized. We studied 12 pediatric patients diagnosed with t-MN in our institution since 2006. The median age at the t-MN diagnoses was 14.8 years (range, 9 to 20 y). The primary malignancies included 9 solid tumors and 3 hematopoietic malignancies. Rhabdomyosarcoma (n=4) was the most common primary malignancy. Five of the 9 patients with solid tumors and all 3 patients with hematopoietic malignancies had primary neoplasms involving bone marrow. The median latency period was 5.2 years (range, 1.8 to 13.8 y). Thrombocytopenia was present in all patients at the t-MN diagnoses. Complete or partial monosomy of chromosome 5 or 7 were the 2 most common cytogenetic abnormalities. A quarter of patients demonstrated a genetic predisposition to t-MN: 1 with Li-Fraumeni syndrome with a germline TP53 R248Q mutation, 1 with Noonan syndrome with a somatic mutation (PTPN11 S502T), and 1 with a constitutive chromosomal translocation [t(X;9)(p22;q34)] and a germline TP53 L130V mutation. Outcomes remain poor. Two patients survived 3 and 5.1 years after hematopoietic stem cell transplantation.

Gastric Antral Mucosal Changes in Children With Intestinal Metaplasia.

Objectives: The gastric mucosal change accompanying gastric antral intestinal metaplasia (IM) in the pediatric population and its clinical implications remain unclear. Methods: We retrieved all patients younger than 18 years who had upper GI endoscopy with a pathology diagnosis of antral IM between 2009 and 2020. Each biopsy was evaluated for the presence of dysplasia, Helicobacter pylori, gastritis, and other pathologic changes. Results: A total of 134 patients with antral IM were identified; 72 (53.7%) with coexisting pathology including chronic gastritis (n = 22), reactive gastropathy (n = 16), focal mild chronic inflammation (n = 13), gastric eosinophilia (n = 9), chronic active gastritis associated with (n = 2) and without Helicobacter infection (n = 3), and others (n = 7). The remaining 62 (46.3%) showed isolated IM. Gastric IM increased with age, and was often accompanied by other pathologic changes, especially in female children. Twenty-seven patients had follow up biopsies; 11 of the 27 patients (40.7%) showed persistent IM in at least one repeat biopsies. None demonstrated dysplasia. Conclusions: In children, antral IM increases with age and often coexists with other pathologic changes. Gastric IM could persist for at least months to years in a significant subset of patients with chronic gastritis and gastric eosinophilia.

Novel CUBN Mutation in a Young Child With Megaloblastic Anemia.

Inherited disorders of cobalamin (Cbl, vitamin B12) metabolism are rare causes of megaloblastic anemia and neurologic abnormalities. More prevalent in certain ethnic groups, these disorders occur despite adequate Cbl intake and usually result from abnormal vitamin cell transport or processing. Cubilin (CUBN, intrinsic factor-cobalamin receptor) is the intestinal receptor for the endocytosis of intrinsic factor-vitamin B12. Its gene is localized to chromosome 10p13 and mutations involving CUBN have been described in patients with congenital megaloblastic anemia. In this report, we describe a novel CUBN pathogenic variant in a child with megaloblastic anemia.

Post-Transplant Lymphoproliferative Disorder Presenting as a Gastrointestinal Fistulous Tract in a Heart Transplant Recipient: Case Report and Literature Review.

We present a challenging case of Epstein-Barr virus-related isolated small bowel post-transplant lymphoproliferative disorder (PTLD) in a pediatric heart transplant recipient presenting as recurrent gastrointestinal (GI) bleeding and subsequently a GI fistulous tract with associated intra-abdominal abscess. Diagnosis was not confirmed until exploratory laparoscopy was performed, with excision of the fistulous tract revealing evidence of PTLD on pathology. Early diagnosis of GI-PTLD remains a challenge, especially if isolated in the small intestine. Diagnosis may rely on positron emission tomography/ computed tomography scan (PET/CT) or invasive intervention to obtain appropriate tissue samples for pathology diagnosis.

Stability of electrolyte determinations on the Siemens Advia 1800 analyzer.

BACKGROUND: It is sometimes necessary for the laboratory to re-test samples for critical serum electrolyte levels. It is important to assure reproducibility of results when testing is performed on stored, refrigerated samples. We have tested the reproducibility of results for the critical electrolytes, Na, K, Cl and Ca, from ten randomly selected patients'sera over our maximum storage period of nine (9) days on the Siemens Advia 1800 analyzer. The ranges for each electrolyte were 131-150 meq/L (Na), 3.4-5.2 meq/L (K), 101-123 meq/L (Cl) and 7.3-9.9 mg/dL (Ca). METHODS: We used ion-selective electrodes for Na, K and Cl and the ortho-cresolphthalein dye method for Ca. RESULTS: We find that the reproducibility of determinations for all of these electrolytes was excellent, i.e. the coefficients of variation for each electrolyte determination for each patient were low. CONCLUSION: The methods of measurement for these electrolytes on the Advia 1800 are reliable and reproducible.

Smartphone Use, Technology Affordance for Healthcare and Elders' Life Satisfaction.

Previous studies have examined how smartphones influence the life satisfaction of the elderly, but the existence of conflicting conclusions suggests the existence of a "black box". In this study, using a survey from 941 elders, we examine whether smartphone use can improve life satisfaction of the elders by inducing emotional affordance offered by social networking Apps and functional affordance offered by healthcare system Apps. It is found that both emotional affordance and functional affordance acted as intermediating variables between the use of smartphone and elders' life satisfaction. In addition, it is founded that living arrangement with adult children moderates the positive impact of smartphone use on functional affordance, but there was no such moderating effect on emotional affordance. This study offers insights about how digital healthcare innovation will be applied to increase well-being of elders by applying framework of selective optimization with compensation.

Acute Liver Failure in a Healthy Young Female With COVID-19.

Several well-described manifestations of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been reported. Among them, a transient elevation of liver enzymes is the typical presentation of coronavirus disease 2019 (COVID-19) liver-related injury. The mechanism of liver involvement is likely a combination of viral injury and immune-mediated inflammation. In contrast, acute liver failure in the setting of COVID-19 has rarely been reported. Herein, we report a case of pediatric acute liver failure in a previously healthy female adolescent infected with SARS-CoV-2 with biopsy evidence of replicating virus in hepatocytes, which has not been previously reported.

Multiphoton microscopy in the diagnostic assessment of pediatric solid tissue in comparison to conventional histopathology: results of the first international online interobserver trial.

Purpose: Clear resection margins are paramount for good outcome in children undergoing solid tumor resections. Multiphoton microscopy (MPM) can provide high-resolution, real-time, intraoperative microscopic images of tumor tissue. Objective: This prospective international multicenter study evaluates the diagnostic accuracy, feasibility, and interobserver congruence of MPM in diagnosing solid pediatric tissue and tumors for the first time. Material and methods: Representative fresh sections from six different neonatal solid tissues (liver, lung, kidney, adrenal gland, heart muscle, testicle) and two types of typical pediatric solid tumors (neuroblastoma, rhabdomyosarcoma) with adjacent nonneoplastic tissue were imaged with MPM and then presented online with corresponding H&E stained slides of the exact same tissue region. Both image sets of each tissue type were interpreted by 38 randomly selected international attending pediatric pathologists via an online evaluation software. Results: The quality of MPM was sufficient to make the diagnosis of all normal tissue types except cardiac muscle in >94% of assessors with high interobserver congruence and 95% sensitivity. Heart muscle was interpreted as skeletal muscle in 55% of cases. Based on MPM imaging, participating pathologists diagnosed the presented pediatric neoplasms with 100% specificity, although the sensitivity reached only about 50%. Conclusion: Even without prior training, pathologists are able to diagnose normal pediatric tissues with valuable accuracy using MPM. While current MPM imaging protocols are not yet sensitive enough to reliably rule out neuroblastoma or rhabdomyosarcoma, they seem to be specific and therefore useful to confirm a diagnosis intraoperatively. We are confident that improved algorithms, specific training, and more experience with the method will make MPM a valuable future alternative to frozen section analysis. Registration: The trial was registered at www.researchregistry.com, registration number 2967.

DC-SIGN (CD209) recognition of Neisseria gonorrhoeae is circumvented by lipooligosaccharide variation.

Neisseria gonorrhoeae (GC) or Escherichia coli HB101 (hereafter referred to as E. coli) expressing opacity (Opa) proteins adhere to human host cells and stimulate phagocytosis as a result of the interaction of certain Opa proteins to carcinoembryonic antigen-related cellular adhesion molecule 1 (CEACAM1; CD66a) receptors. Our experiments show that the Opa-CEACAM1 interaction does not play a significant role in adherence between these bacteria and dendritic cells (DCs). Instead, phagocytosis of GC and E. coli by DCs is mediated by the DC-specific intercellular adhesion molecule-grabbing nonintegrin, (SIGN; CD209) receptor. DC-SIGN recognition and subsequent phagocytosis of GC are limited, however, to a lipooligosaccharide (LOS) mutant (lgtB) of GC. This conclusion is supported by experiments demonstrating that HeLa cells expressing human DC-SIGN (HeLa-DC-SIGN) bind exclusively to and engulf an lgtB mutant of GC, and this interaction is blocked specifically by an anti-DC-SIGN antibody. The experiments suggest that LOS variation may have evolved as a mechanism for GC to avoid phagocytosis by DCs.

T-cell prolymphocytic leukemia in an adolescent with ataxia-telangiectasia: novel approach with a JAK3 inhibitor (tofacitinib).

A 19-year-old ataxia-telangiectasia patient with T-cell prolymphocytic leukemia harbored 2 JAK3-activating hotspot mutations.The patient suffered toxicities with chemotherapy, but demonstrated a clinical response to novel use of a JAK3 inhibitor (tofacitinib).

A retrospective analysis of ten symptomatic multiple myeloma patients with HIV infection: a potential therapeutic effect of HAART in multiple myeloma.

The impact of highly active anti-retroviral therapy (HAART) in multiple myeloma (MM) is unknown. Ten HIV+ and 28 HIV-negative patients were retrospectively identified out of 262 cases of MM diagnosed at Kings County Hospital Center since the introduction of HAART in 1996. The HIV+ MM patients on HAART had superior overall survival (OS) (Fisher exact, p=0.008; log-rank, p=0.012) and progression free survival (PFS) (Fisher exact, p=0.007; log-rank, p=0.009) than the HIV-negative MM patients. HAART alone blocked the production of serum M-protein. We propose that HARRT should be explored for the treatment of both HIV+ and HIV-negative MM patients.

Comparison of glucose determinations on blood samples collected in three types of tubes.

Because of the metabolism of serum glucose in collection tubes containing blood samples, serum glucose levels may be found to decrease over time. Several types of collection tubes have been designed to, at least partially, block glucose metabolism by red blood cells in blood collection tubes that may not be analyzed immediately after blood collection. These include red-top collection tubes with serum separator, grey-top tubes with a fluoride glycolysis inhibitor, and heparin-containing green-top tubes which prevent clot formation. As part of a quality assurance project, we investigated whether glucose levels differed in the three tube types from each of 18 volunteers on a prolonged standing of 4 hours. We then determined the glucose concentrations of all three tubes from each of the 18 volunteers. We used refrigerated samples over a five-day period to determine if the initial values were reproducible. Surprisingly, after standing for four hours at room temperature, we found that the glucose levels in the three tubes from each volunteer were statistically indistinguishable from one another using the two-tailed paired t-test. Also, a linear regression analysis showed that the values of glucose for the three pairs of two tube types were closely correlated with one another, with correlation coefficients of >0.97, slopes close to 1, and Y-intercepts close to 0. These results suggest that blood collection in any of these tubes will render similar values for serum glucose even after standing for four hours. The tubes were then refrigerated at 4°C and re-analyzed after another six hours and then once per day for the next four days. Beginning at the first day at the six-hour determination, the glucose levels in the red- and grey-top tubes were statistically indistinguishable from one another but not in the red- and green-top tubes and in the grey- and green-top tubes. This was due to a steady decrease in the glucose levels in the green-top tubes. The glucose levels in the red- and grey-top tubes from each volunteer remained constant over the five-day period so that the coefficients of variation (CV) were low. In contrast, due to the decrease of glucose levels in the green-top tubes, the CVs for repeated glucose determinations in these tubes were high. Interestingly, a regression analysis of the glucose values for all three sets of paired tubes showed high (> 0.97) correlation coefficients and slopes close to 1. However, a regression analysis of the glucose values in the red- and green-top and grey- and green-top tubes at day five showed Y-intercepts of about -32 suggesting that there is a constant decrease of glucose in the green-top tubes that amounts to approximately 6 mg/dL per day over five days. These results suggest that red-top tubes with serum separator or grey-top tubes with a fluoride glycolysis inhibitor may be used for reproducible glucose determinations.

Influence of ERK activation on decreased chemotaxis of mature human cord blood monocyte-derived dendritic cells to CCL19 and CXCL12.

Dendritic cells (DCs) are important regulators in graft-versus-host disease (GVHD). To gain insight into cord blood (CB) DC immunology, we compared chemotactic responses of mature monocyte-derived DCs and maturation agent lipopolysaccharide (LPS)-induced signaling between CB and adult blood (AB). Mature CB DCs expressed reduced CCR7, but increased CXCR4. This was associated with reduced migratory efficiency toward both CCR7 ligand CCL19 and CXCR4 ligand CXCL12. LPS induced higher extracellular signal-regulated kinase (ERK) phosphorylation in CB than in AB DCs. Specific inhibition of ERK during CB DC maturation enhanced LPS-induced up-regulation of CCR7 and CXCR4 on CB DCs and their chemotaxis toward CCL19 and CXCL12, to a level similar to that of mature AB DCs. Overall, monocyte-derived CB DCs responded to LPS with stronger and sustained ERK activation, which negatively correlated with LPS-induced up-regulation of CCR7 and CXCR4 on CB DCs and their migratory responses. These findings may have potential relevance to better understanding DC function in CB transplantation.

TGF-beta combined with M-CSF and IL-4 induces generation of immune inhibitory cord blood dendritic cells capable of enhancing cytokine-induced ex vivo expansion of myeloid progenitors.

Tolerogenic dendritic cells (DCs) may be valuable in transplantation for silencing immune reaction. Macrophage colony-stimulating factor (M-CSF)/IL-4 induces differentiation of cord blood (CB) monocytes into DCs (M-DCs) with tolerogenic phenotype/function. We assessed whether factors produced by tolerogenic DCs could modulate hematopoiesis. TGF-beta1 added to CB M-DC cultures induced bona fide DC morphology (TGF-M-DCs), similar to that of DCs generated with TGF-beta and granulocyte-macrophage colony-stimulating factor (GM-CSF)/IL-4 (TGF-GM-DCs). Of conditioned media (CM) produced from TGF-M-DCs, TGF-GM-DCs, M-DCs, and GM-DCs, TGF-M-DC CM was the only one that enhanced SCF, Flt3 ligand, and TPO expansion of myeloid progenitor cells ex vivo. This effect was blocked by neutralizing anti-M-CSF Ab, but protein analysis of CM suggested that M-CSF alone was not manifesting enhanced expansion of myeloid progenitors. LPS-stimulated TGF-M-DCs induced T-cell tolerance/anergy as effectively as M-DCs. TGF-M-DCs secreted significantly lower concentrations of progenitor cell inhibitory cytokines and were less potent in activating T cells than TGF-GM-DCs. Functional differences between TGF-M-DCs and TGF-GM-DCs included enhanced responses to LPS-induced ERK, JNK, and P38 activation in TGF-M-DCs and their immune suppressive-skewed cytokine release profiles. TGF-M-DCs appear unique among culture-generated DCs in their capability for silencing immunity while promoting expansion of myeloid progenitors, events that may be of therapeutic value.

Macrophage colony-stimulating factor drives cord blood monocyte differentiation into IL-10(high)IL-12absent dendritic cells with tolerogenic potential.

Immature dendritic cells (DCs) induce tolerance and mature DCs induce inflammatory immune responses. However, the likelihood of maturation of immature DCs in vivo limits its potential application for suppression of unwanted immune reactions in vivo. The aim of this study was to generate DCs with anti-inflammatory properties in both the immature and mature states. GM-CSF combined with IL-4 drives monocyte differentiation into DCs. As M-CSF is a critical cytokine in development of the monocytic lineage and its level is dramatically elevated in immunosuppressive conditions, we investigated whether M-CSF could replace GM-CSF and generate DCs with distinct functions from umbilical cord blood monocytes. Highly purified umbilical cord blood monocytes cultured with M-CSF and IL-4, in a GM-CSF-independent fashion, differentiated into IL-10(high)IL-12absent cells with a DC phenotype (termed M-DC). Single time stimulation with immature DCs (both M-DCs and DCs) derived from cord blood induced hyporesponsive and regulatory CD4+ T cells. In contrast to mature DCs, mature M-DCs induced decreased Th1 differentiation and proliferation of naive CD4+ T cells in both primary and secondary allogeneic MLR and showed tolerogenic potential. These results demonstrate an unrecognized role for M-CSF in alternative differentiation of monocytes into anti-inflammatory M-DCs and suggest that M-CSF-induced DCs may be of use for suppressing unwanted immune responses.