Cardiovascular imaging in children and adults following Kawasaki disease.

Kawasaki disease (KD) is a paediatric vasculitis with coronary artery aneurysms (CAA) as its main complication. Two guidelines exist regarding the follow-up of patients after KD, by the American Heart Association and the Japanese Circulation Society. After the acute phase, CAA-negative patients are checked for cardiovascular risk assessment or with ECG and echocardiography until 5 years after the disease. In CAA-positive patients, monitoring includes myocardial perfusion imaging, conventional angiography and CT-angiography. However, the invasive nature and high radiation exposure do not reflect technical advances in cardiovascular imaging. Newer techniques, such as cardiac MRI, are mentioned but not directly implemented in the follow-up. Cardiac MRI can be performed to identify CAA, but also evaluate functional abnormalities, ischemia and previous myocardial infarction including adenosine stress-testing. Low-dose CT angiography can be implemented at a young age when MRI without anaesthesia is not feasible. CT calcium scoring with a very low radiation dose can be useful in risk stratification years after the disease. By incorporating newer imaging techniques, detection of CAA will be improved while reducing radiation burden and potential complications of invasive imaging modalities. Based on the current knowledge, a possible pathway to follow-up patients after KD is introduced. Key Points • Kawasaki disease is a paediatric vasculitis with coronary aneurysms as major complication. • Current guidelines include invasive, high-radiation modalities not reflecting new technical advances. • Cardiac MRI can provide information on coronary anatomy as well as cardiac function. • (Low-dose) CT-angiography and CT calcium score can also provide important information. • Current guidelines for follow-up of patients with KD need to be revised.

Pregnancy in women with a history of Kawasaki disease: management and outcomes.

OBJECTIVE: To characterise the obstetrical management and outcomes in a series of women with a history of Kawasaki disease (KD) in childhood. DESIGN: Retrospective case series. SETTING: Tertiary healthcare setting in the USA. POPULATION: Women with a history of KD in childhood. METHODS: Women completed a detailed health questionnaire and participated in research imaging studies as part of the San Diego Adult KD Collaborative Study. MAIN OUTCOME MEASURES: Obstetrical management, complications during pregnancy and delivery, and infant outcomes. RESULTS: Ten women with a history of KD in childhood carried a total of 21 pregnancies to term. There were no cardiovascular complications during labour and delivery despite important cardiovascular abnormalities in four of the ten subjects. Pregnancy was complicated by pre-eclampsia and the post-partum course was complicated by haemorrhage in one subject each. Two of the 21 progeny subsequently developed KD. CONCLUSIONS: Women with important cardiovascular sequelae from KD in childhood should be managed by a team that includes both a maternal-fetal medicine specialist and a cardiologist. Pre-pregnancy counselling should include delineation of the woman's current functional and structural cardiovascular status and appropriate adjustment of medications, but excellent outcomes are possible with appropriate care. Review of the English and Japanese literature on KD and pregnancy revealed the occurrence of myocardial infarction during pregnancy in women with missed KD and aneurysms that were not diagnosed until their acute event. Our study highlights the need for counselling with regard to the increased genetic risk of KD in offspring born to these mothers.

Immune-monitoring in Kawasaki disease patients treated with infliximab and intravenous immunoglobulin.

The expansion of regulatory T cells (Treg ) controls inflammation in children with acute Kawasaki disease (KD). Blockade of tumour necrosis factor (TNF)-α is an emerging therapy for KD patients with refractory inflammation, but there is concern that this therapy could impede the host immune regulation. To define the effect of TNF-α blockade, we conducted ex-vivo immune-monitoring in KD subjects who participated in a randomized, double-blind, placebo-controlled clinical trial of the addition of infliximab to standard intravenous immunoglobulin (IVIG) therapy. We enumerated circulating myeloid and plasmocytoid dendritic cells (DC), regulatory T cells (Treg ) and memory T cells (Tmem ) in 14 consecutive, unselected KD patients (seven treated with IVIG, seven with IVIG + infliximab) at three time-points: (i) acute phase prior to treatment, (ii) subacute phase and (iii) convalescent phase. Myeloid DC (mDC), but not plasmacytoid DC (pDC), were numerous in the peripheral blood in acute KD subjects and decreased in the subacute phase in both IVIG(-) and IVIG (+) infliximab-treated groups. The co-stimulatory molecule for antigen presentation to T cells and CD86 decreased in mDC from acute to subacute time-points in both treatment groups, but not in the single patient who developed coronary artery aneurysms. We also defined tolerogenic mDC that expand in the subacute phase of KD not impaired by infliximab treatment. Treg and Tmem expanded after treatment with no significant differences between the two groups. Treatment of KD patients with infliximab does not adversely affect generation of tolerogenic mDC or the development of T cell regulation and memory.

Family-based association analysis implicates IL-4 in susceptibility to Kawasaki disease.

Several compelling lines of evidence suggest an important influence of genetic variation in susceptibility to Kawasaki disease (KD), an acute vasculitis that causes coronary artery aneurysms in children. We performed a family-based genotyping study to test for association between KD and 58 genes involved in cardiovascular disease and inflammation. By analysis of a cohort of 209 KD trios using the transmission disequilibrium test, we documented the asymmetric transmission of five alleles including the interleukin-4 (IL-4) C(-589)T allele (P=0.03). Asymmetric transmission of the IL-4 C(-589)T was replicated in a second, independent cohort of 60 trios (P=0.05, combined P=0.002). Haplotypes of alleles in IL-4, colony-stimulating factor 2 (CSF2), IL-13, and transcription factor 7 (TCF7), all located in the interleukin gene cluster on 5q31, were also asymmetrically transmitted. The reported associations of KD with atopic dermatitis and allergy, elevated serum IgE levels, eosinophilia, and increased circulating numbers of monocyte/macrophages expressing the low-affinity IgE receptor (FCepsilonR2) may be related to effects of IL-4. Thus, the largest family-based genotyping study of KD patients to date suggests that genetic variation in the IL-4 gene, or regions linked to IL-4, plays an important role in KD pathogenesis and disease susceptibility.

Kawasaki disease: the mystery continues.

Kawasaki disease (KD) is an acute vasculitis of infancy and early childhood that continues to baffle researchers and clinicians alike. Although the acute illness resolves spontaneously, permanent damage to the coronary arteries occurs in 20-25% of untreated children. The cause of KD remains unknown and there is no specific laboratory test to identify affected children. Nonetheless, high dose intravenous g-globulin plus aspirin administered within the first 10 days of fever significantly reduces the risk of coronary artery damage by unknown mechanisms. KD thus presents a unique dilemma: the disease may be difficult to recognize, there is no diagnostic laboratory test, there is an extremely effective therapy, and there is a 25% chance of serious cardiovascular damage or death if the therapy is not administered. This review will highlight some of the many unanswered questions about KD.

Increased frequency of alleles associated with elevated tumor necrosis factor-alpha levels in children with Kawasaki disease.

Genetic polymorphisms influence the magnitude of the cytokine response after an inflammatory stimulus. To determine whether such polymorphisms might play a role in Kawasaki disease (KD), we analyzed white and Japanese children with KD and control populations for two polymorphic loci in which the A allele is associated with high tumor necrosis factor-alpha secretion. The lymphotoxin-alpha+250 A/A genotype was overrepresented among white children with KD compared with controls (0.59 versus 0.36; p = 0.013). The tumor necrosis factor-alpha-308 A/G genotype was overrepresented among whites with KD who had coronary artery abnormalities compared with those with normal echocardiograms (0.36 versus 0.09; p = 0.044). No significant difference was seen at either locus between Japanese children with KD and Japanese controls. The increased frequency of the high secretor alleles in white children with KD suggests that these loci may be related to susceptibility to KD and to outcome after disease.

Computer-assisted analysis of the oral brush biopsy.

Computer-assisted analysis of the oral brush biopsy is a recently introduced tool that determines the significance of an oral lesion. The oral brush biopsy is minimally invasive, requires no anesthesia, and definitively distinguishes benign from precancerous and cancerous lesions. Oral brush biopsy specimens are analyzed with the aid of a highly specialized neural network-based computer system specifically designed to detect oral epithelial precancerous and cancerous cells.

Reporter gene expression in fish following cutaneous infection with pantropic retroviral vectors.

A central issue in gene delivery systems is choosing promoters that will direct defined and sustainable levels of gene expression. Pantropic retroviral vectors provide a means to insert genes into either somatic or germline cells. In this study, we focused on somatic cell infection by evaluating the activity of 3 promoters inserted by vectors into fish cell lines and fish skin using pantropic retroviruses. In bluegill and zebrafish cell lines, the highest levels of luciferase expression were observed from the 5' murine leukemia virus long terminal repeat of the retroviral vector. The Rous sarcoma virus long terminal repeat and cytomegalovirus early promoter, as internal promoters, generated lower levels of luciferase. Luciferase reporter vectors infected zebrafish skin, as measured by the presence of viral DNA, and expressed luciferase. We infected developing walleye dermal sarcomas with retroviral vectors to provide an environment with enhanced cell proliferation, a condition necessary for integration of the provirus into the host genome. We demonstrated a 4-fold to 7-fold increase in luciferase gene expression in tumor tissue over infections in normal walleye skin.

Infectious hypodermal and hematopoietic necrosis virus of shrimp is related to mosquito brevidensoviruses.

We purified and sequenced infectious hypodermal and hematopoietic necrosis virus (IHHNV), a small DNA virus of shrimp, from wild Penaeus stylirostris. The virion has a buoyant density of 1.45 as determined by cesium chloride gradient. Analysis of 3873 nucleotides of the viral genome revealed three large open reading frames (ORFs) and parts of the noncoding termini of the viral genome. The left, mid, and right ORFs on the complementary (plus) strand have potential coding capacities of 666 amino acids (aa) (75.77 kDa), 363 aa (42.11 kDa), and 329 aa (37.48 kDa), respectively. The overall genomic organization is similar to that of the mosquito brevidensoviruses. The left ORF most likely encodes the major nonstructural (NS) protein (NS-1) since it contains conserved replication initiator motifs and NTP-binding and helicase domains similar to those in NS-1 from all other parvoviruses. The IHHNV putative NS-1 shares the highest aa sequence homology with the NS-1 of mosquito brevidensoviruses, Aedes densovirus and Aedes albopictus parvovirus. A search for putative splicing sites revealed that the N-terminal region of NS-1 is very likely located in a small ORF upstream of the left ORF. The right ORF is presumed to encode structural polypeptides (VPs), as in other parvoviruses. Two putative promoters, located upstream of the left and right ORFs, are presumed to regulate expression of NS and VP genes, respectively. Thus, IHHNV is closely related to densoviruses of the genus Brevidensovirus in the family Parvoviridae, and we therefore propose to rename this virus Penaeus stylirostris densovirus (PstDNV).

Infection of cultured embryo cells of the pacific oyster, Crassostrea gigas, by pantropic retroviral vectors.

The inability to stably introduce and express foreign genes has hampered basic research in molluscan species. We cultured cells from dissociated embryos of the Pacific oyster, Crassostrea gigas, and infected these primary cultures with pantropic retroviral vectors containing the envelope glycoprotein of vesicular stomatitis virus. Luciferase transgene expression mediated by different heterologous promoters was demonstrated for at least 9 d after infection of the cells. Surprisingly, the promoter reproducibly mediating the highest level of luciferase expression was the retroviral promoter (U3 region of long terminal repeat) from the Moloney murine leukemia virus. The infection efficiency using a low multiplicity of infection (0.05) was estimated by quantitative polymerase chain reaction to be between 0.1-0.5%. This system will facilitate studies of gene expression and regulation and should be widely applicable to other molluscan species.

Prevention and detection of lip cancer--the dentist's role.

With their attention to the oral area, dentists are in an excellent position not only to diagnose lip cancer, but also to counsel patients in its prevention. Patients need to be educated on the dangers of ultraviolet radiation and the measures available to decrease exposure to it. This article discusses the circumstances that increase the chance of developing lip cancer, the variety of ways to decrease that chance, and the recognition and treatment of premalignant and malignant lip lesions.

Kawasaki disease.

Kawasaki disease is a leading cause of acquired heart disease in children in the USA. An acute vasculitis of unknown etiology, it occurs predominantly in infancy and early childhood, and more rarely in teenagers. Coronary artery aneurysms or ectasia develop in approximately 15-25% of children with the disease. Treatment with intravenous gamma globulin, 2 g per kg, in the acute phase reduces this risk three- to fivefold. Angiographic resolution occurs in approximately one-half of aneurysmal arterial segments, but these show persistent histologic and functional abnormalities. The remainder continue to be aneurysmal, often with development of progressive stenosis or occlusion. The worst prognosis occurs in children with so-called 'giant aneurysms', i.e. those with a maximum diameter greater than 8 mm, because thrombosis is promoted both by sluggish blood flow within the massively dilated vascular space and by the frequent development of stenotic lesions. Serial stress tests with myocardial imaging are mandatory in the management of patients with Kawasaki disease and significant coronary artery disease to determine the need for coronary angiography and transcatheter interventions or coronary bypass surgery. Continued long-term surveillance in patients with and without detected coronary abnormalities is necessary to determine the natural history of Kawasaki disease.

Actinic cheilitis: a review of 152 cases.

OBJECTIVE: The purpose of this study was to determine whether any clinical or histopathologic variables are associated with the severity of epithelial change in lesions of actinic cheilitis. STUDY DESIGN: A total of 152 acceptable cases of actinic cheilitis were identified from 66,067 cases accessioned from February 1989 to June 1998. For each case, the clinical information supplied by the submitting practitioner at the time of the biopsy and 8 histopathologic variables were evaluated. RESULTS: The following 5 histopathologic variables were positively correlated with an increased degree of epithelial change: acanthosis, basophilic change within the connective tissue, the presence of inflammation within the connective tissue, perivascular inflammation, and thickness of the keratin layer. None of the clinical variables was associated with an increased degree of epithelial change. CONCLUSIONS: The presence of any of the aforementioned histopathologic changes should prompt a close evaluation of the lesion for the presence of either epithelial dysplasia or carcinoma.

Pantropic retroviral vectors mediate gene transfer and expression in Entamoeba histolytica.

Transformation of Entamoeba histolytica has been previously reported, but the foreign genes have all been replicated episomally. Pantropic retroviral vectors based on the Moloney murine leukemia virus with the envelope glycoprotein of vesicular stomatitis virus (VSV-G) have an extremely broad host range and can be concentrated to high titer. To investigate whether these pseudotyped, pantropic vectors can mediate gene transfer and expression in E. histolytica, we constructed a retroviral vector, in which a hygromycin phosphotransferase is expressed from the E. histolytica actin promoter. Data confirm the infection, integration, and expression of a foreign gene mediated by the provirus. To our knowledge, this is the most evolutionarily distant example of successful integration and expression of a mammalian retrovirus. Pantropic retroviral vectors may thus facilitate genetic analysis in species lacking transformation systems.

Infection of lepidoptera with a pseudotyped retroviral vector.

Studies requiring the introduction and expression of manipulated gene constructs have been technically difficult in non-drosophilid insects. Retroviruses can be engineered to be replication defective and to serve as vectors for gene constructs of interest. In this study, pseudotyped MoMLV(VSV-G) retroviral vectors are shown to successfully infect lepidopteran cells in vitro and in vivo. In Spodoptera frugiperda cells in vitro and in Manduca sexta in vivo, infection and conversion to proviral DNA were confirmed by PCR amplification and Southern blot hybridization of vector-specific sequences. Gene expression and integration of proviral DNA were also documented in vitro. This is the first report of retroviral infection in lepidoptera and suggests that pseudotyped retroviral vectors could be powerful tools in gene manipulation studies of non-drosophilid insects.

Transgenic cattle produced by reverse-transcribed gene transfer in oocytes.

A critical requirement for integration of retroviruses, other than HIV and possibly related lentiviruses, is the breakdown of the nuclear envelope during mitosis. Nuclear envelope breakdown occurs during mitotic M-phase, the envelope reforming immediately after cell division, thereby permitting the translocation of the retroviral preintegration complex into the nucleus and enabling integration to proceed. In the oocyte, during metaphase II (MII) of the second meiosis, the nuclear envelope is also absent and the oocyte remains in MII arrest for a much longer period of time compared with M-phase in a somatic cell. Pseudotyped replication-defective retroviral vector was injected into the perivitelline space of bovine oocytes during MII. We show that reverse-transcribed gene transfer can take place in an oocyte in MII arrest of meiosis, leading to production of offspring, the majority of which are transgenic. We discuss the implications of this mechanism both as a means of production of transgenic livestock and as a model for naturally occurring recursive transgenesis.

The use of exfoliative cytology for the early diagnosis of oral cancers: is there a role for it in education and private practice?

BACKGROUND: Early detection of oral cancers is not easy, because oral precancerous lesions and early oral cancers can mimic many benign conditions in the mouth, leading to delays in diagnosis and treatment. There is a need to emphasize the early diagnosis of oral cancers in order to reduce the unacceptably high morbidity and mortality. METHODS: A survey regarding oral exfoliative cytology was completed by 132 dentists in Virginia who were randomly chosen from a mailing list. RESULTS: Less than half of the dentists (41.7%) had been taught how to obtain a cytologic smear, and only 26.0% knew the clinical indications for doing so. Only 9.2% of the dentists had ever obtained a cytologic smear in private practice. Of the 13 dentists in the survey who had done so, 12 had been trained in the technique. Interest in learning the cytologic technique and getting the needed supplies was indicated by 79.2% of the dentists. CONCLUSIONS: Diagnostic aids in the evaluation of oral mucosal lesions can serve an important role by identifying lesions that need to be biopsied in spite of a "benign" appearance. Exfoliative cytology, as well as vital staining, may aid in this goal. This has implications regarding undergraduate and postdoctoral education.

Pantropic retroviral vectors mediate somatic cell transformation and expression of foreign genes in dipteran insects.

The control of insects that transmit disease and damage crops has become increasingly difficult. The ability to genetically engineer insects would facilitate strategies to protect crops and block arthropod vector-borne disease transmission. Transformation vectors based on insect transposable elements have been developed, but most have limited host ranges. A promising alternative is the pantropic retroviral vector, which is packaged with the envelope glycoprotein from vesicular stomatitis virus and is replication-defective. We show here that pantropic murine retroviral vectors can mediate high-level expression of foreign genes in somatically transformed insect larvae and adults of three dipteran genera. This success demonstrates the potential for germline transformation mediated by pantropic retroviral vectors.

The effect of clinical information on the histopathologic diagnosis of oral epithelial dysplasia.

OBJECTIVES: The purpose of this study was to test the hypothesis that clinical information submitted with biopsy specimens helps pathologists be more consistent and accurate in diagnosing oral epithelial dysplasia. STUDY DESIGN: Each of six board-certified oral and maxillofacial pathologists examined the same set of 120 oral biopsies (involving diagnoses ranging from hyperkeratosis to severe epithelial dysplasia); they had examined these same biopsies in a previous study, but this time the clinical information was provided for each case. The examiner's diagnosis was compared to the sign-out diagnosis for each case. RESULTS: Rates of exact agreement with the sign-out diagnosis averaged 38.5%, and there was 85.4% agreement within one histologic grade. The rate of agreement in distinguishing epithelial dysplasia from no dysplasia was 71.4%. These results, when compared to those from a previous study in which the same examiners had evaluated the same slides but without clinical histories, represent a 2.5% to 20% decrease for exact agreement among the six pathologists, a 0% to 8.5% decrease for agreement within one histologic grade, and a 0% to 23.4% decrease for agreement regarding the presence or absence of epithelial dysplasia. CONCLUSIONS: When clinical information was used, accuracy and consistency among board-certified oral and maxillofacial pathologists in the diagnosis of oral epithelial dysplasia was not improved. In fact, there was a decrease in accuracy.