Langerhans cell histiocytosis in children: A retrospective case series of 126 cases.

BACKGROUND/OBJECTIVES: Langerhans cell histiocytosis (LCH), a rare neoplasm of hematopoietic myeloid precursor cells, is clinically characterized by spontaneously resolving lesions to a progressive life-threatening multisystem disorder. Diagnosing LCH in children is challenging as it mimics other skin disorders. This study describes the varied clinical presentation and disease course in children less than 18 years diagnosed with LCH. METHODS: We performed a retrospective observational study of all cases diagnosed with LCH presenting to a children's hospital in the last 26 years. Data on history, cutaneous and systemic examination, and laboratory evaluation performed, were recorded. RESULTS: A total of 126 children diagnosed with LCH were included in the study. There were 68% cases limited only to skin, and 32% children with multisystem involvement at the initial presentation. Scaly papules were the most common morphologic finding in skin. The skeletal system was the second most common organ system to be affected. Failure to thrive was a common symptom. Progression of skin to systemic involvement was seen in 27.9%. In 76.7%, skin lesions cleared over a period of 2 to 4 years. Complete remission was seen in 56.9% of children over a period of 3 to 7 years, while 8.1% children died of complicationsand 31.8% were lost to follow-up. CONCLUSIONS: Long-term follow-up in this study has shown cutaneous LCH without systemic involvement has a good prognosis. Skin involvement,along with failure to thrive, was the most common clinical presentation in our study. The skeletal system was the second most common organ system involved.

Elevated Troponin I as a Marker for Unfavorable Outcomes in Acute Ischemic Stroke.

OBJECTIVE: To assess if elevated cardiac troponin I (cTnI) serves as a sign of unfavorable functional outcomes in ischemic stroke. METHODS: In this single-center prospective cohort study, 100 consecutive patients admitted with acute ischemic stroke (normal troponin I group n = 52, raised troponin I group n = 48) were included. Hospital mortality was documented in both groups; the remaining patients were followed up to 90 days. Then two groups were compared in terms of unfavorable short-term outcomes (Modified Rankin Scale > 3) and mortality. Multivariate logistic regression was conducted to determine the predictive value of elevated cTnI. The Kaplan-Meier curve was drawn and compared to determine the difference in survival between the two groups. To find out the most probable cut-off level for an unfavorable outcome, a receiver operating characteristic (ROC) analysis was conducted. RESULT:  A higher frequency of coronary artery disease (p=0.030), higher National Institutes of Health Stroke Scale (NIHSS) (p=0.008) score, and lower Glasgow Coma Scale (GCS) (p=0.002) was observed in raised troponin I group. Even after the exclusion of confounding elevated troponin I was found to be an independent predictor of unfavorable outcomes (adjusted odds ratio, OR 8.25 {95% confidence interval, CI: 2.65-25.75}; p<0.001). The patients with raised troponin I had a significantly lower rate of survival after 90 days (p=0.022). The elevated troponin I was observed to have a significantly high accuracy (p<0.001; area under curve, AUC: 0.768 {moderate accuracy}, 95% CI: 0 .676 to 0.861) in predicting unfavorable outcomes. CONCLUSION: Elevated cTnI is independently associated with unfavorable short-term outcomes. It is also associated with a lower rate of survival.

Higher calpastatin levels correlate with resistance to calpain-mediated proteolysis and neuronal apoptosis in juvenile rats after spinal cord injury.

While the average age for patients admitted with spinal cord injury is 32 years, patients under the age of 16 account for 5% of spinal cord injured persons. For these younger patients, an increased mortality up to 24 h post-injury has been reported, however, survivors may regain more function than their adult counterparts, suggesting that age may play a role in injury tolerance. While the use of growth factors as a therapy for spinal cord injury is well researched, the response of the developing cord to secondary injury has not been thoroughly investigated. Following spinal cord injury, Ca(2+) influx can activate enzymes such as calpain, a Ca(2+)-dependent protease, which plays a role in the pathogenesis of spinal cord injury in rats. The present investigation revealed that following spinal cord injury, calpain upregulation was significantly less (15.3%) in the 21-day-old rats than in either 45-day-old (70%) or 90-day-old (99.6%) rats, as shown by Western blot and in situ immunofluorescent studies. Expression of the endogenous calpain inhibitor, calpastatin, was significantly higher in juvenile rats than adult rats. Juvenile rats with spinal cord injury also showed a reduced Bax:Bcl-2 ratio (4:1 vs. 6:1), reduced caspase-3 staining, reduced myelin loss (3% vs. 18%), and less neuronal DNA damage, as compared to older rats. These results suggest that increased calpastatin levels found in juvenile rats muted calpain activity and neuronal apoptosis, following spinal cord injury.

Estrogen as a neuroprotective agent in the treatment of spinal cord injury.

The following review is a brief discussion about spinal cord injury and the possibility of using estrogen as a neuroprotective agent. There are several pathways by which secondary cell death can occur following spinal cord injury, including infiltration of inflammatory cells, generation of reactive oxygen species, decreases in spinal cord blood flow, and increases in intracellular Ca(2+) levels. This secondary damage leads to apoptotic cell death, and the neuroprotective effects of pharmacologic agents have been investigated using experimentally induced spinal cord injury in animals. Currently, only high-dose methylprednisolone is advocated for the treatment of patients following spinal cord injury. Estrogen has been shown to be neuroprotective in both in vitro and in vivo studies. There are several possible mechanisms of action by which estrogen may attenuate damage following spinal cord injury and improve functional outcome. Estrogen has been shown to have anti-inflammatory properties. Estrogen levels are correlated with an increase in post-traumatic blood flow to injured tissue. Estrogen may also upregulate protein levels of anti-apoptotic Bcl-2 and may attenuate the post-traumatic influx of Ca(2+).

Estrogen attenuates oxidative stress-induced apoptosis in C6 glial cells.

We examined the mechanism of 17beta-estradiol (estrogen)-mediated inhibition of apoptosis in C6 (rat glioma) cells following exposure to hydrogen peroxide (H(2)O(2)). Cells were preincubated with 4 microM estrogen for 2 h and then exposed to 100 microM H(2)O(2) for 24 h. Exposure to H(2)O(2) caused significant increases in intracellular calcium (Ca(2+)), as determined by fura-2, which was attenuated by preincubation with estrogen. H(2)O(2) and ionomycin caused cell death in a dose-dependent manner, as measured by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) assay. Preincubation with estrogen restored viability in cells exposed to H(2)O(2) but not in cells exposed to ionomycin. Western blot analysis showed an increase in Bax/Bcl-2 ratio, calpain activity, and caspase-3 activity following treatment with H(2)O(2), and estrogen pretreatment decreased levels of all three. Cell morphology, as evaluated by Wright staining, indicated apoptosis in cells treated with H(2)O(2), and pretreatment with estrogen reduced apoptosis. Results from MTT and Wright staining were further supported by the terminal deoxyribonucleotidyl transferase (TdT)-mediated dUTP Nick End Labeling (TUNEL) assay. These results indicate a role for estrogen in preventing apoptosis in C6 glial cells exposed to H(2)O(2). Our results suggest that estrogen may have a protective role in minimizing glial cell apoptosis in neurological diseases such as demyelinating disease or central nervous system trauma.

EWS Knockdown and Taxifolin Treatment Induced Differentiation and Removed DNA Methylation from p53 Promoter to Promote Expression of Puma and Noxa for Apoptosis in Ewing's Sarcoma.

Ewing's sarcoma is a pediatric tumor that mainly occurs in soft tissues and bones. Malignant characteristics of Ewing's sarcoma are correlated with expression of EWS oncogene. We achieved knockdown of EWS expression using a plasmid vector encoding EWS short hairpin RNA (shRNA) to increase anti-tumor mechanisms of taxifolin (TFL), a new flavonoid, in human Ewing's sarcoma cells in culture and animal models. Immunofluorescence microscopy and flow cytometric analysis showed high expression of EWS in human Ewing's sarcoma SK-N-MC and RD-ES cell lines. EWS shRNA plus TFL inhibited 80% cell viability and caused the highest decreases in EWS expression at mRNA and protein levels in both cell lines. Knockdown of EWS expression induced morphological features of differentiation. EWS shRNA plus TFL caused more alterations in molecular markers of differentiation than either agent alone. EWS shRNA plus TFL caused the highest decreases in cell migration with inhibition of survival, angiogenic and invasive factors. Knockdown of EWS expression was associated with removal of DNA methylation from p53 promoter, promoting expression of p53, Puma, and Noxa. EWS shRNA plus TFL induced the highest amounts of apoptosis with activation of extrinsic and intrinsic pathways in both cell lines in culture. EWS shRNA plus TFL also inhibited growth of Ewing's sarcoma tumors in animal models due to inhibition of differentiation inhibitors and angiogenic and invasive factors and also induction of activation of caspase-3 for apoptosis. Collectively, knockdown of EWS expression increased various anti-tumor mechanisms of TFL in human Ewing's sarcoma in cell culture and animal models.

Estrogen treatment of spinal cord injury attenuates calpain activation and apoptosis.

Spinal cord injury (SCI) is a devastating neurologic injury, and currently, the only recommended pharmacotherapy is high-dose methylprednisolone, which has limited efficacy. Estrogen is a multi-active steroid with anti-oxidant and anti-apoptotic effects. Estrogen may modulate intracellular Ca2+ and prevent inflammation. For this study, male rats were divided into three groups. Sham-group animals received a laminectomy at T12. Injured rats received both laminectomy and 40 gram centimeter force SCI. Estrogen-group rats received 4 mg/kg 17beta-estradiol (estrogen) at 15 min and 24 hr post-injury, and vehicle-group rats received equal volumes of dimethyl sulfoxide. Animals were sacrificed at 48 hr post-injury, and 1-cm segments of the lesion, rostral penumbra, and caudal penumbra were excised. The degradation of 68 kD neurofilament protein (NFP) and estrogen receptors (ER) was examined by Western blot analysis. Protein levels of calpain and the activities of calpain and caspase-3 were also examined. Levels of cytochrome c were determined in both cytosolic and mitochondrial fractions. Cell death with DNA fragmentation was examined using the TUNEL assay. At the lesion, samples from both vehicle and estrogen treated animals showed increased levels of 68 kD NFP degradation, calpain content, calpain activity, cytochrome c release, and degradation of ERalpha and ERbeta, as compared to sham. In the caudal penumbra, estrogen treatment significantly attenuated 68 kD NFP degradation, calpain content, calpain activity, levels of cytosolic cytochrome c, and ERbeta degradation. At the lesion, vehicle-treated animals displayed more TUNEL+ cells, and estrogen treatment significantly attenuated this cell death marker. We conclude that estrogen may inhibit cell death in SCI through calpain inhibition.

Estrogen attenuated markers of inflammation and decreased lesion volume in acute spinal cord injury in rats.

Spinal cord injury (SCI) is a devastating neurologic injury with functional deficits for which the only currently recommended pharmacotherapy is high-dose methylprednisolone, which has limited efficacy. Estrogen is a multi-active steroid that has shown antiinflammatory and antioxidant effects, and estrogen may modulate intracellular Ca(2+) and attenuate apoptosis. For this study, male rats were divided into three groups. Sham group animals received a laminectomy at T12. Injured rats received both laminectomy and 40 g x cm force SCI. Estrogen-group rats received 4 mg/kg 17beta-estradiol (estrogen) at 15 min and 24 hr post-injury, and vehicle-group rats received equal volumes of dimethyl sulfoxide (vehicle). Animals were sacrificed at 48 hr post-injury, and 1-cm-long segments of the lesion, rostral penumbra, and caudal penumbra were excised. Inflammation was assessed by examining tissue edema, infiltration of macrophages/microglia, and levels of cytosolic and nuclear NFkappaB and inhibitor of kappa B (IkappaBalpha). Myelin integrity was examined using Luxol fast blue staining. When compared to sham, vehicle-treated animals revealed increased tissue edema, increased infiltration of inflammatory cells, decreased cytosolic levels of NFkappaB and IkappaBalpha, increased levels of nuclear NFkappaB, and increased myelin loss. Treatment of SCI rats with estrogen reduced edema and decreased inflammation and myelin loss in the lesion and penumbral areas, suggesting its potential as a therapeutic agent. Further work needs to be done, however, to elucidate the neuroprotective mechanism of estrogen.

17beta-estradiol attenuates glutamate-induced apoptosis and preserves electrophysiologic function in primary cortical neurons.

Glutamate toxicity causes neuronal death in neurodegenerative diseases; hence, there is a need for therapeutic agents rendering functional neuroprotection. We tested the effects of 17beta-estradiol (estrogen) in rat primary cortical neurons after glutamate exposure. Wright staining and ApopTag assays indicated that 0.5 microM glutamate for 24 hr caused apoptosis. Glutamate-induced apoptosis correlated with upregulation of calpain, a proapoptotic shift in the Bax:Bcl-2 ratio, and increased activation of caspase-3. Pretreatment with 10 nM estrogen prevented apoptosis, attenuated calpain upregulation, shifted the Bax:Bcl-2 ratio toward survival, and decreased caspase-3 activation. Single-cell voltage-clamp techniques were used to record whole-cell currents associated with Na+ channels, N-methyl-D-aspartate receptor channels, and kainate receptor channels. No significant differences were recorded in membrane capacitance at -70 mV in neurons treated with estrogen or estrogen plus glutamate, relative to controls. Notably, no changes in capacitance indicated that neurons treated with estrogen and glutamate did not experience apoptosis-associated cell shrinkage. No membrane potential could be recorded in the neurons treated with glutamate due to apoptosis. All recorded currents were similar in amplitude and activation/inactivation kinetics in control neurons and neurons treated with estrogen plus glutamate. Estrogen thus preserved both neuronal viability and function in this in vitro glutamate toxicity model.