Ferritin and increased vs upper reference interval tibc saturation to identify increased iron stores in African Americans.

BACKGROUND: Increased serum ferritin (SF) in combination with increased total iron binding capacity saturation (TS) in the upper reference internal was evaluated to identify African Americans with increased iron stores. METHODS: Among 16,856 primary care-based African Americans screened at Howard University Field Center of the Hereditary Hemochromatosis and Iron Overload Screening (HEIRS) Study, 142 with SF >500 microg/l women or >700 microg/l men and increased TS (>45% women or >50% men; main study) and 146 with similar ferritin increases and upper reference interval TS (30-45% women or 35-50% men; ancillary study) were offered clinical evaluation to confirm increased SF and identify the cause. RESULTS: Repeat SF remained increased in 83% of 92 participants with increased TS initially (main study) vs 58% of 64 with upper reference interval TS initially (ancillary study) (P=0.0002). These persistent SF increases were associated with blood transfusions (treatment for sickle cell disease) in 20% of 76 main study and 11% of 37 ancillary study participants (P=0.4). Ninety percent of participants with persistent non-transfusional increased SF in the main study and 85% in the ancillary study had alanine-aminotransferase, aspartate-aminotransferase, C-reactive protein and/or hemoglobin values outside of the reference interval. Increased iron stores were documented by phlebotomy or liver biopsy in 4 of 7 main study and 2 of 2 ancillary study participants with persistent non-transfusional increase in SF. CONCLUSION: Increased iron stores occur in African Americans with increased SF in combination with either increased or upper reference interval TS. Limiting clinical evaluation to only those individuals with both increased SF and increased TS will miss individuals with increased iron stores.

l-selectin gene polymorphisms and complications of sickle cell disease.

We had found high expression of L-selectin and alphaMbeta2 integrin on leukocytes in patients with complications of sickle cell disease (SCD). In non-SCD patients, L-selectin polymorphisms are associated with vasculopathy and nephropathy. Our objective was to determine if L-selectin gene polymorphisms affect leukocyte expression of the protein, or the development of complications in SCD. By polymerase chain reaction with sequence-specific primers incorporating mismatches at the 3'-end, we analysed DNA from 142 HbSS patients and 102 healthy, racially matched, HbAA controls; to detect the F206L, T49S, and P213S L-selectin gene polymorphisms. All patients were assessed for complications of SCD. Steady-state expression of L-selectin on leukocytes was measured by flow cytometry in 44 patients. We excluded HbSS patients on hydroxyurea, with any other disease, pregnancy, or HbF > or = 10%. There were no significant differences in distribution of F206L, T49S or P213S l-selectin gene polymorphisms between patients and controls (chi(2) = 0.1, P > 0.05). There was no association between any of these gene polymorphisms and high expression of L-selectin by leukocytes, or the development of complications in SCD (chi(2) = 2.37, P > 0.05). The findings suggest that these three gene polymorphisms do not predispose to high leukocyte expression of L-selectin, or development of complications in SCD.

Pulmonary hypertension in children and adolescents with sickle cell disease.

The prevalence of pulmonary hypertension (PHTN) in the pediatric sickle cell disease (SCD) population is not known despite its high prevalence in adult patients. Our hypothesis was that increased pulmonary artery pressures (PAPs) would be found in SCD children and adolescents, especially those with a history of pulmonary complications: acute chest syndrome, obstructive sleep apnea, asthma, and reactive airway disease. Fifty-two SCD children, 23 of whom had underlying pulmonary disease, were screened for PHTN, which was defined as a tricuspid regurgitant jet velocity (TRV) of at least 2.5 m/s. Twenty-four (46.15%) SCD patients had increased PAP (i.e., TRV > or =2.5 m/s), and 6 (11.5%) had significant PHTN (i.e., TRV > or =3.0 m/s). Pulmonary disease was marginally associated with PHTN (odds ratio 2.80 and confidence interval 0.88 to 8.86; p = 0.0795). As in adult SCD patients with PHTN, this complication was correlated with the degree of hemolysis as manifested by significantly higher lactate dehydrogenase and bilirubin, lower hemoglobin and hematocrit levels, and a strong association with Hb-SS phenotype. However, after statistical adjustment for age and sex, increased serum LDH was not associated with the development of PHTN. Further studies are needed to clarify the prevalence and mechanisms of PHTN in pediatric and adolescent patients with SCD.

Neonatal alveolar rhabdomyosarcoma with skin and brain metastases.

BACKGROUND: Approximately 5-10% of patients with rhabdomyosarcomas (RMS) are diagnosed during the first year of life, and their clinical characteristics have been well documented. However, because RMS rarely occurs during the neonatal period, little is known about neonatal RMS. METHODS: Four patients with neonatal RMS were treated at St. Jude Children's Research Hospital between 1962 and 1999. The authors report the results of a review of these patients and of cases described in the literature. Clinical, radiologic, and pathologic features of these patients and their outcomes were evaluated. RESULTS: One patient with embryonal RMS was treated successfully with a combination of systemic chemotherapy and local control measures. The other three patients had alveolar RMS. Two of them had multiple skin and subcutaneous metastatic nodules at the time of diagnosis and developed brain metastases early in their course. In one of these patients, the PAX3-FKHR fusion transcript was detected. Three other similar cases of neonatal alveolar RMS with metastases to the skin and brain have been reported in the literature. CONCLUSIONS: A distinct syndrome of neonatal RMS is described. This syndrome is characterized by alveolar histology, multiple skin and subcutaneous metastases, and fatal outcome as the result of early brain metastasis.

Selection of reagents for human radioimmunotherapy.

Promising response rates are noted in patients with refractory Hodgkin's disease after radioimmunoglobulin therapy (RIT) with Yttrium-90 labeled polyclonal antiferritin. To explore the most efficacious selection of RIT reagents for use in humans, experimental animal data are reviewed for radiolabeled antiferritin and B72.3. Nude mice with subcutaneously implanted human malignancies provide an excellent primary screen for radiolabeled antibodies under consideration for use in humans. They provide information on the potential of a new reagent to target a human malignancy in vivo. The other determinant of the therapeutic ratio of RIT reagents--normal tissue toxicity--is best analyzed in large animals, such as dogs. Hematologic toxicity is dose limiting in all species and best predicted by a prescription of radiolabeled antibodies in mCi per kilogram body weight and the presence or absence of bone marrow targeting. Per cGy, RIT is more effective in causing BM damage in dogs than in rats. In dogs, bone marrow transplantation with autologous cryopreserved bone marrow cells or G-CSF treatment can accelerate hemopoietic recovery and granulopoiesis, respectively, after RIT. When dose escalation beyond bone marrow toxicity is performed, the liver (dog) or the intestinal tract (rat) become the next dose limiting tissue in dose escalation studies. Significant improvement in RIT results will be achieved when the normal liver uptake of chelated monoclonal antibody in dogs and in human patients can be prevented. The described animal models and continued investigations of RIT in patients with endstage Hodgkin's disease will allow for further improvement in the therapeutic ratio of RIT and the applicability of RIT in humans.

Participation of p53 protein in the cellular response to DNA damage.

The inhibition of replicative DNA synthesis that follows DNA damage may be critical for avoiding genetic lesions that could contribute to cellular transformation. Exposure of ML-1 myeloblastic leukemia cells to nonlethal doses of the DNA damaging agents, gamma-irradiation or actinomycin D, causes a transient inhibition of replicative DNA synthesis via both G1 and G2 arrests. Levels of p53 protein in ML-1 cells and in proliferating normal bone marrow myeloid progenitor cells increase and decrease in temporal association with the G1 arrest. In contrast, the S-phase arrest of ML-1 cells caused by exposure to the anti-metabolite, cytosine arabinoside, which does not directly damage DNA, is not associated with a significant change in p53 protein levels. Caffeine treatment blocks both the G1 arrest and the induction of p53 protein after gamma-irradiation, thus suggesting that blocking the induction of p53 protein may contribute to the previously observed effects of caffeine on cell cycle changes after DNA damage. Unlike ML-1 cells and normal bone marrow myeloid progenitor cells, hematopoietic cells that either lack p53 gene expression or overexpress a mutant form of the p53 gene do not exhibit a G1 arrest after gamma-irradiation; however, the G2 arrest is unaffected by the status of the p53 gene. These results suggest a role for the wild-type p53 protein in the inhibition of DNA synthesis that follows DNA damage and thus suggest a new mechanism for how the loss of wild-type p53 might contribute to tumorigenesis.

Levels of p53 protein increase with maturation in human hematopoietic cells.

Transfection of the wild-type p53 gene into malignant cell lines usually results in an inhibition of proliferation. However, the physiological function of the endogenous p53 gene product has been difficult to ascertain. In order to examine whether p53 is involved in the regulation of proliferation and/or differentiation of hematopoietic tissue, we modified a recently developed flow cytometric assay to assess p53 protein expression in normal human hematopoietic cells, primary leukemias, and selected leukemia cell lines. In normal human bone marrow, p53 protein was not detected in the proliferative, progenitor cell populations identified by the cell surface antigens CD34 (progenitor cells of multiple lineages) or glycophorin (erythroid precursors). In contrast, low but detectable levels of p53 protein were observed in the nonproliferative, mature lymphoid, granulocytic, and monocytic cell populations. Similarly, p53 levels increased and DNA synthesis decreased during 12-O-tetradecanoylphorbol-13-acetate-induced differentiation of ML-1 myeloblastic leukemia cells. Both of these results suggest that endogenous, wild-type p53 protein may play a role in hematopoietic cell maturation, possibly by contributing to the inhibition of proliferation that occurs during terminal differentiation. Leukemia cells deviated from this pattern of expression: (a) in contrast to the normal, proliferative bone marrow progenitor cells, a significant percentage of patient leukemia samples expressed detectable levels of p53 protein; and (b) leukemia cell lines exhibited lineage-specific abnormalities in p53 expression, with overexpression in lymphoid cell lines and lack of expression in myeloid cell lines.

Factitious anisocoria and orthostatic hypotension.

A 30-year-old woman employed by a veterinarian had many episodes of syncope. At presentation, she had anisocoria and premature ventricular beats. Hemodynamic workup revealed only moderate peripheral venous pooling. The circumstances of the fainting spells and eye examination led to the identification of medications which, if taken surreptitiously, will induce the perplexing clinical picture which the patient presented.