Novel homozygous mutation (c.175delG) in platelet glycoprotein ITGA2B gene as cause of Glanzmann's thrombasthenia type I.

BACKGROUND: Glanzmann's thrombasthenia (GT), is a rare autosomal recessive bleeding disorder. Platelets from patients with GT show quantitative or qualitative defects of the platelet membrane glycoprotein (GP) IIb/IIIa complex. A variety of genetic defects in ITGA2B and ITGB3 (genes for GPIIb and GPIIIa) has been described causing the clinical entity of GT. PATIENTS: A newborn with bleeding symptoms (petechiae) platelet analyses revealed an inherited primary hemostasis disorder. METHODS/RESULTS: Analyses of patient's platelets using flow cytometry and immunoblotting showed absence of GPIIb protein and reduced amount of GPIIIa. Using restriction fragment length polymorphism heterozygosity for the deletion could be identified in the parents and in two siblings. Expression studies in mammalian cells revealed that the mutant GPIIb is missing and additionally affects the expression of wildtype GPIIIa. This deletion leads to a truncation at the very N-terminal region of the GPIIb protein. CONCLUSION: The present study describes a patient with GT associated with a novel homozygous deletion (c.175delG) in exon 1 of ITGA2B. This deletion led to a reading frameshift and caused a severely truncated form of GPIIb.

Surgical complications in abdominal tumor surgery in children. Experiences at a single oncological center.

INTRODUCTION: Surgical complications after tumor operations are frequent in children, with rates of up to 30% cited in the literature. Various approaches to reduce these complication rates have been attempted, with preoperative chemotherapy holding pride of place. One approach to minimize surgical complications is better preoperative preparation. In a retrospective analysis, we evaluated the complications associated with tumor surgery. MATERIAL AND METHODS: We retrospectively analyzed patient data from 1991 to 2007. The distribution of the various tumors, the type of surgery, and complications were evaluated. For neuroblastomas a differentiated analysis of complications was performed, which included staging and radiologically defined surgical risk factors (SRFs). Patients were divided into two groups: A and B. Intensified surgical planning with 3D visualization was used in patients of group B. RESULTS: A total of 145 operations for abdominal tumors were performed in 123 patients. The three most common diseases were neuroblastoma (36%), nephroblastoma (26%), and ovarian tumor (19%). In 68% of patients complete resection and in 19% of cases partial resection of the tumor was carried out; open biopsy was performed in 13%. A total of 15 (10.3%) complications developed: the incidence of complications for group A was 11.8% and 7.7% for group B (p=0.5). For nephroblastoma these figures were 27.9% and 21.2% (p=1.0). In the group of patients with neuroblastoma, six complications developed in patients from group A (21.4%) and one in a group B patient (4.2%) (p=0.107). 54% of neuroblastomas were completely and 33% partially resected; these figures and the distribution of SRFs were similar in the two groups. A significant increase in the risk of complications could be seen with an increase in SRFs (p=0.0267) and with disease stages 2 and 3 (p=0.016). Tumor reduction surgery was also associated with an increase in complications (p=0.086). CONCLUSIONS: In summary, tumor surgery is associated with considerable risks in children. Therefore it is very important to look for new approaches that could potentially minimize these risks. As the causes of surgical complications are multifactorial, we are of the opinion that intensified surgical planning can contribute to reducing risks. Particularly neuroblastoma surgery could profit from an increased use of 3D visualization and improved preoperative planning.

[3D-visualization by MRI for surgical planning of Wilms tumors]. / 3-D-Visualisierung in der MRT zur Operationsplanung von Wilms-Tumoren.

PURPOSE: To improve surgical planning of kidney tumors in childhood (Wilms tumor, mesoblastic nephroma) after radiologic verification of the presumptive diagnosis with interactive colored 3D-animation in MRI. MATERIALS AND METHODS: In 7 children (1 boy, 6 girls) with a mean age of 3 years (1 month to 11 years), the MRI database (DICOM) was processed with a raycasting-based 3D-volume-rendering software (VG Studio Max 1.1/Volume Graphics). The abdominal MRI-sequences (coronal STIR, coronal T1 TSE, transverse T1/T2 TSE, sagittal T2 TSE, transverse and coronal T1 TSE post contrast) were obtained with a 0.5T unit in 4 - 6 mm slices. Additionally, a phase-contrast-MR-angiography was applied to delineate the large abdominal and retroperitoneal vessels. A notebook was used to demonstrate the 3D-visualization for surgical planning before surgery and during the surgical procedure. RESULTS: In all 7 cases, the surgical approach was influenced by interactive 3D-animation and the information found useful for surgical planning. Above all, the 3D-visualization demonstrates the mass effect of the Wilms tumor and its anatomical relationship to the renal hilum and to the rest of the kidney as well as the topographic relationship of the tumor to the critical vessels. One rupture of the tumor capsule occurred as a surgical complication. For the surgeon, the transformation of the anatomical situation from MRI to the surgical situs has become much easier. CONCLUSION: For surgical planning of Wilms tumors, the 3D-visualization with 3D-animation of the situs helps to transfer important information from the pediatric radiologist to the pediatric surgeon and optimizes the surgical preparation. A reduction of complications is to be expected.

Congenital neuroblastoma mimicking early onset sepsis.

UNLABELLED: A newborn girl presented with symptoms of severe early onset sepsis but also with systemic hypertension (SH) at age 3 h. Plasma catecholamine (CAT) levels were extremely elevated, reflecting increased release of CAT from a congenital neuroblastoma (NB). Clinical symptoms at time of admission were: prolonged capillary refill (5 s), tachycardia, tachydyspnoea, metabolic acidosis (pH 7.17, lactate 11.8 mmol/l), fever (38.4 degrees C) and SH: 90/50/65 mmHg (systolic/diastolic/mean). The infant experienced organ failure (lung, heart, liver). A retroperitoneal dumbbell tumour was detected. Plasma CAT levels at age 15 h were: noradrenaline 219 nmol/l; adrenaline 13 nmol/l; and dopamine 65.3 nmol/l. SH responded to intermittent alpha-adrenergic blockage. CAT-related symptoms ceased within 1 week. The intraspinal NB was surgically removed when cord compression became symptomatic. The neurological and developmental state is normal at age 17 months. The abdominal NB regressed spontaneously. CONCLUSION: A neuroblastoma should be considered in newborn infants presenting with a shock-like condition together with systemic hypertension.

Mediastinal masses diagnosed as thymus hyperplasia by fine needle aspiration cytology.

OBJECTIVE: Thymic hyperplasia in the anterior mediastinum can occur in healthy children as idiopathic thymic hyperplasia or as a rebound effect after administration of chemotherapy in patients with malignancies. Thymic hyperplasia after chemotherapy is a well-documented phenomenon, particularly in children and less frequently in adults. Both forms of thymic hyperplasia are a diagnostic challenge, and most patients undergo surgical exploration. Fine needle aspiration cytology (FNAC) has supposed to be inadequate to diagnose benign thymic hyperplasia and to separate it from malignant disease. STUDY DESIGN: We report the cytologic findings on eight patients presenting with a mass in the anterior mediastinum that was diagnosed as thymic hyperplasia on FNAC. In five patients the masses developed after chemotherapy. The remaining three patients were healthy children. Three patients underwent ultrasound-guided aspiration; in five cases the procedure was performed under computerized guidance. RESULTS: In all eight patients the cytologic smears showed a mixed population of lymphoid cells. Cytologic diagnosis of thymic hyperplasia was confirmed by immunophenotyping in three patients and by follow-up studies in all of them (median, 68 months; range, 8-113). CONCLUSION: In contrast to previous reports, this study demonstrated the utility of FNAC as a front-line investigative procedure in diagnosing thymic hyperplasia.

Toxicity and effectiveness of high-dose idarubicin during AML induction therapy: results of a pilot study in children.

BACKGROUND: Idarubicin (IDR) is one of the most effective, but also toxic drugs in the treatment of AML. The standard dose used in children and adults is 8-12 mg/m2 during induction. PATIENTS AND METHODS: To improve outcome, we increased the IDR dose from 12 mg/m2 (standard dose in study AML-BFM 93), applied over three days during induction therapy (AIE = Ara-C, Idarubicin, Etoposide) to 14 mg/m2 in a pilot study including 17 patients (16 with de novo AML, one with secondary AML). Outcome and toxicities were compared with the other patients of study AML-BFM 93, treated with 3 x 12 mg/m2 IDR or 6 x 30 mg/m2 daunorubicin (DNR). RESULTS: Patients of the pilot study achieved a good blast cell reduction in the bone marrow on day 15, a high CR rate of 94% and a low relapse rate (3/17 pts.), however, not significantly different to the IDR (12 mg/m2) group. Hematological toxicity was high, median duration until neutrophil recovery > 500/microliter was 25.0 (12-66) days, and similar to the IDR (12 mg/m2) and DNR groups. Duration of thrombocytopenia (time to > 20,000/microliter) was 21 (10-66) days in the pilot study compared to 19 (7-26) days in DNR patients (p = 0.08). Four of 17 pilot patients presented with severe WHO grades 3/4 of mucositis during induction. One patient died in long-lasting aplasia after the 3rd treatment block. CONCLUSION: Results of this pilot study show that the IDR 14 mg/m2 regimen was effective but also toxic. According to our results which, however, are based on small patient numbers, an improved outcome compared to the IDR 12 mg/m2 regimen seems to be unlikely, therefore the possibly increased toxicity might not be acceptable.

Acute myelogenous leukemia after treatment for malignant germ cell tumors in children.

PURPOSE: To identify the long-term sequelae of therapy for malignant germ cell tumors (GCTs). PATIENTS AND METHODS: Between 1980 and 1998, 1,132 patients were prospectively enrolled onto the German nontesticular GCT studies. A total of 442 patients received chemotherapy using combinations of the drugs cisplatin, ifosfamide, etoposide, vinblastine, and bleomycin, and 174 patients were treated with a combination of chemotherapy and radiotherapy. Median follow-up duration was 38 months (range, 6 to 199 months). RESULTS: Six patients developed therapy-related acute myelogenous leukemia (t-AML). There was no t-AML among patients treated with surgery (n = 392) or radiotherapy only (n = 124). The Kaplan-Meier estimates of the cumulative incidence (at 10 years) of t-AML were 1.0% for patients treated with chemotherapy (three of 442) and 4.2% for patients treated with combined chemotherapy and radiotherapy (three of 174). Notably, four of these six patients had been treated according to a standard protocol with modest cumulative chemotherapy doses. Five patients had received less than 2 g/m(2) epipodophyllotoxins, and four patients had received less than 20 g/m(2) ifosfamide. Four patients presented with AML, two with myelodysplasia in transformation to AML. In five patients, cytogenetic aberrations were found, four of which were considered characteristic for t-AML. Four patients died despite antileukemic therapy. One patient is alive but suffered a relapse of his GCT, and one patient is alive and well. No secondary solid neoplasm was observed. CONCLUSION: In patients with AML after treatment for GCT, several pathogenetic mechanisms must be considered. AML might evolve from a malignant transformation of GCT components without any influence of the chemotherapy. On the other hand, the use of alkylators and topoisomerase II inhibitors is associated with an increased risk of t-AML. Future studies will show if the reduction of treatment intensity in the current protocol reduces the risk of secondary leukemia in these patients.

Anaemia, thrombocytopenia and coagulopathy due to occult diffuse infantile haemangiomatosis of spleen and pancreas.

UNLABELLED: Diffuse infantile haemangiomatosis of the spleen is a very rare lesion. Large haemangiomas may cause trapping of platelets and coagulation disorders known as Kasabach-Merrit syndrome. We here report the case of an infant with splenic and pancreatic haemangiomatosis presenting with life-threatening thrombocytopenia, anaemia and intravascular coagulation. Diagnosis was hampered by reactive erythroblastosis and non-conclusive radiological findings. While treatment with corticosteroids was ineffective, administration of antithrombin III improved coagulation parameters. After splenectomy the child recovered promptly and has remained free of disease for 3 years to date. CONCLUSION: Occult visceral haemangiomatosis without visible cutaneous haemangiomas should be included in the differential diagnosis of thrombocytopenia, anaemia and consumption coagulopathy. Antithrombin III treatment may be considered to overcome bleeding problems in patients with Kasabach-Merrit syndrome.

GH, IGF-I, IGFBP-3 and IGFBP-2 in cerebrospinal fluid of infants, during puberty and in adults.

During diagnostic lumbar punctions cerbrospinal fluid (CSF) was collected for the determination of GH, IGF-I, IGFBP-3 and IGFBP-2. The patients were 0.3 to 68 years od and suffered from viral infections, leukemias, M. Hodgkin or multiple sclerosis. Only CSF samples without any pathological alterations were analysed. In infants and adults CSF GH concentrations significantly declined with age, while IGF-I and the two binding proteins were unrelated to age. GH was not correlated to IGF-I, IGFBP-3 or IGFBP-2. However, IGF-I was strongly related to IGFBP-3 (r = 0.529; < 0.001) and IGFBP-2 (r = 0.796; < 0.001) as was IGFBP-3 to IGFBP-2 (r = 0.685; < 0.001), suggesting dependence of the three variables. With IGFBP-3 or IGFBP-2 as control variables (partial correlation) IGF-I was no longer related to the binding proteins, while the relation of IGFBP-3 to IGFBP-2 remained unchanged with IGF-I as the control variable (r = 0.687; < 0.001). The results suggest that the age-related decrease of CSF GH may contribute to the age-dependent decline of GH receptors in brain, which are up-regulated by GH. Furthermore, in CSF IGF-I concentrations were determined by the two binding proteins. It may be speculated that the transfer of IGF-I through the blood CSF barrier or its production in brain may be closely related to the IGF-binding proteins.

Molecular cloning of osteoma-inducing replication-competent murine leukemia viruses from the RFB osteoma virus stock.

We report the molecular cloning of two replication-competent osteoma-inducing murine leukemia viruses from the RFB osteoma virus stock (M. P. Finkel, C. A. Reilly, Jr., B. O. Biskis, and I. L. Greco, p. 353-366, in C. H. G. Price and F. G. M. Ross, ed., Bone--Certain Aspects of Neoplasia, 1973). Like the original RFB osteoma virus stock, viruses derived from the molecular RFB clones induced multiple osteomas in mice of the CBA/Ca strain. The cloned RFB viruses were indistinguishable by restriction enzyme analysis and by nucleotide sequence analysis of their long-terminal-repeat regions and showed close relatedness to the Akv murine leukemia virus.

In vitro packaging of plasmid DNA oligomers by Salmonella phage P22: independence of the pac site, and evidence for the termination cut in vitro.

In vitro packaging experiments with phage P22 using artificially ligated plasmid concatemers have shown that the pac site is not necessary for DNA packaging although in vivo this initiation signal is indispensable. This indicates that the phage-coded protein gp3 also executes other important functions during phage maturation in addition to the recognition of pac, or that its site specificity is lost in vitro. It has been shown previously that gp3 is necessary for in vitro packaging. Further, it was demonstrated that DNA which is only 74% of headful size cannot be packaged. Oversized DNA, however, is cut in vitro to unit length.

[Is electroshock not a therapy?]. / Ist Elektroschock keine Therapie?

Ever since it was introduced, electric convulsion therapy (ECT) has been a subject of reports presenting spectacular successes and alarming side effects. The appearance of psychopharmaceutic therapy made ECT appear completely superfluous and, therefore, dispensable. However, this conclusion proved to be premature: ECT retained its defined justification. We therefore counter Breggin's polemic allegation that "Electric convulsions are no therapy" with our own experience that "Electric convulsions are therapy" and proceed to justify our opinion. After a detailed description of the origins of the criticisms voiced against ECT, its risks and side effects are discussed from the clinical and cerebro-electrical standpoint and compared with the risks and side effects of other forms of psychiatric somatotherapy. Severe and irrepairable damage by ECT can now be avoided and; in fact, has never been observed among our patients. It must also be pointed out that, far from excluding each other, ECT and psycho- or social therapy are often complementary or even mutually necessary.

In vitro packaging of mature phage DNA by Salmonella phage P22.

Mature, headful-sized DNA extracted from the Salmonella phages P22 and L, and P22/L-hybrid phages can be encapsulated in vitro by means of a packaging system for exogenous DNA. The probability of packaging reaches about 10(-3) per headful-sized molecule. The absence of in vitro recombination was demonstrated, to eliminate the possibility that such a process had created concatemers. The endonucleolytic cut at the pac site, which initiates sequential packaging in vivo, does not occur with the mature DNA substrate in vitro. The position of pac on the molecule is not important but the pac-recognizing phage protein gp3 is indispensable for in vitro encapsulation.