A Rare Case of Methemoglobinemia after Ifosfamide Infusion in a 3-Year-Old Patient Treated for T-ALL.

Methemoglobinemia is a potentially life-threatening, rare condition in which the oxygen-carrying capacity of hemoglobin is diminished. We present the case of a 3-year-old boy treated for T-cell acute lymphoblastic leukemia (T-ALL) who developed methemoglobinemia (MetHb 57.1%) as a side effect of ifosfamide administration. Due to his critical condition, the patient was transferred to the intensive care unit (ICU). The therapy included methylene blue administration, an exchange transfusion, catecholamine infusion, and steroids. Improving the general condition allowed for continuing chemotherapy without ifosfamide and completion of the HR2 block. Vigilance for methemoglobinemia as a very rare side effect should be widespread when using ifosfamide in the treatment protocols.

Diabetic ketoacidosis incidence among children with new-onset type 1 diabetes in Poland and its association with COVID-19 outbreak-Two-year cross-sectional national observation by PolPeDiab Study Group.

BACKGROUND: There are several observations that the onset of coronavirus 19 (COVID-19) pandemic was associated with an increase in the incidence of diabetic ketoacidosis (DKA). However, due to heterogeneity in study designs and country-specific healthcare policies, more national-level evidence is needed to provide generalizable conclusions. OBJECTIVE: To compare the rate of DKA in Polish children diagnosed with type 1 diabetes (T1D) between the first year of COVID-19 pandemic (15 March 2020 to 15 March 2021) and the preceding year (15 March 2019 to 15 March 2020). METHODS: Reference centers in 13 regions (covering ~88% of Polish children) retrospectively reported all new-onset T1D cases in children from assessed periods, including DKA status at admission, administered procedures and outcomes. Secondly, we collected regions' demographic characteristics and the daily-reported number of COVID-19-related deaths in each region. RESULTS: We recorded 3062 cases of new-onset T1D (53.3% boys, mean age 9.5 ± 4.3 years old) of which 1347 (44%) had DKA. Comparing pre- and post-COVID-19 period, we observed a significant increase in the rate of DKA (37.5%-49.4%, p < .0001). The fraction of moderate (+5.4%) and severe (+3.4%) DKA cases increased significantly (p = .0089), and more episodes required assisted ventilation (+2.1%, p = .0337). Two episodes of DKA during 2020/2021 period were fatal. By region, change in DKA frequency correlated with initial COVID-19 death toll (March/April 2020) (R = .6, p = .0287) and change in T1D incidence (R = .7, p = .0080). CONCLUSIONS: The clinical picture of new-onset children T1D in Poland deteriorated over a 2-year period. The observed increase in the frequency of DKA and its severity were significantly associated with the overlapping timing of the COVID-19 epidemic.

Altered epigenetic regulation of homeobox genes in human oral squamous cell carcinoma cells.

To gain insight into oral squamous cell carcinogenesis, we performed deep sequencing (RNAseq) of non-tumorigenic human OKF6-TERT1R and tumorigenic SCC-9 cells. Numerous homeobox genes are differentially expressed between OKF6-TERT1R and SCC-9 cells. Data from Oncomine, a cancer microarray database, also show that homeobox (HOX) genes are dysregulated in oral SCC patients. The activity of Polycomb repressive complexes (PRC), which causes epigenetic modifications, and retinoic acid (RA) signaling can control HOX gene transcription. HOXB7, HOXC10, HOXC13, and HOXD8 transcripts are higher in SCC-9 than in OKF6-TERT1R cells; using ChIP (chromatin immunoprecipitation) we detected PRC2 protein SUZ12 and the epigenetic H3K27me3 mark on histone H3 at these genes in OKF6-TERT1R, but not in SCC-9 cells. In contrast, IRX1, IRX4, SIX2 and TSHZ3 transcripts are lower in SCC-9 than in OKF6-TERT1R cells. We detected SUZ12 and the H3K27me3 mark at these genes in SCC-9, but not in OKF6-TERT1R cells. SUZ12 depletion increased HOXB7, HOXC10, HOXC13, and HOXD8 transcript levels and decreased the proliferation of OKF6-TERT1R cells. Transcriptional responses to RA are attenuated in SCC-9 versus OKF6-TERT1R cells. SUZ12 and H3K27me3 levels were not altered by RA at these HOX genes in SCC-9 and OKF6-TERT1R cells. We conclude that altered activity of PRC2 is associated with dysregulation of homeobox gene expression in human SCC cells, and that this dysregulation potentially plays a role in the neoplastic transformation of oral keratinocytes.

Altered histone mark deposition and DNA methylation at homeobox genes in human oral squamous cell carcinoma.

We recently reported a role of polycomb repressive complex 2 (PRC2) and PRC2 trimethylation of histone 3 lysine 27 (H3K27me3) in the regulation of homeobox (HOX) (Marcinkiewicz and Gudas, 2013, Exp Cell Res) gene transcript levels in human oral keratinocytes (OKF6-TERT1R) and tongue squamous cell carcinoma (SCC) cells. Here, we assessed both the levels of various histone modifications at a subset of homeobox genes and genome wide DNA methylation patterns in OKF6-TERT1R and SCC-9 cells by using ERRBS (enhanced reduced representation bisulfite sequencing). We detected the H3K9me3 mark at HOXB7, HOXC10, HOXC13, and HOXD8 at levels higher in OKF6-TERT1R than in SCC-9 cells; at IRX1 and SIX2 the H3K9me3 levels were conversely higher in SCC-9 than in OKF6-TERT1R. The H3K79me3 mark was detectable only at IRX1 in OKF6-TERT1R and at IRX4 in SCC-9 cells. The levels of H3K4me3 and H3K36me3 marks correlate with the transcript levels of the assessed homeobox genes in both OKF6-TERT1R and SCC-9. We detected generally lower CpG methylation levels on DNA in SCC-9 cells at annotated genomic regions which were differentially methylated between OKF6-TERT1R and SCC-9 cells; however, some genomic regions, including the HOX gene clusters, showed DNA methylation at higher levels in SCC-9 than OKF6-TERT1R. Thus, both altered histone modification patterns and changes in DNA methylation are associated with dysregulation of homeobox gene expression in human oral cavity SCC cells, and this dysregulation potentially plays a role in the neoplastic phenotype of oral keratinocytes.

Blood sugar levels are higher in obese young children in Sweden than in Poland.

AIM: An elevated fasting glucose level is an early sign of metabolic dysfunction in obese children. This study compared fasting glucose levels in obese young children in Poland and Sweden. METHODS: We identified 109 obese children aged between two and 10 years from a Polish obesity register, with a mean BMI SDS (SD) of 3.72 (0.86). Each Polish child was matched by gender, age and degree of obesity, with ten children (n = 1090) from BORIS, the Swedish national childhood obesity treatment register. A group of 86 Swedish nonobese children served as controls. RESULTS: The mean fasting glucose values of the Polish, Swedish and nonobese cohorts were 4.73 (0.51) mmol/L, 4.92 (0.50) mmol/L and 4.56 (0.39) mmol/L, respectively. After adjusting for variables affecting fasting glucose, the mean glucose value of the Swedish obese children was 0.20 mmol/L higher than that of Polish obese children (p < 0.0001) and 0.41 mmol/L higher than in nonobese controls (p < 0.0001). CONCLUSION: Swedish obese young children had higher glucose levels than Polish obese young children. This suggests that Swedish obese children face a higher risk of the prediabetic stage impaired fasting glycaemia.

Nonalcoholic fatty liver disease in children with obesity- observations from one clinical centre in the Western Pomerania region.

Nonalcoholic fatty liver disease (NAFLD) is a growing health problem in the pediatric population, due to the constantly increasing percentage of children with obesity. The objective of the study was to assess the occurrence of NAFLD based on ultrasound (USG) analysis and the use of alanine aminotransferase (ALT) in children with overweight and obesity depending on glucose tolerance. Medical records of 228 consecutive patients aged 2-18 years with overweight and obesity were reviewed retrospectively. Based on the oral glucose tolerance test children were divided into groups according to the severity of carbohydrate metabolism disorders. ALT, lipid parameters and insulin sensitivity indices HOMA, Matsuda and Quicki were analyzed. NAFLD was diagnosed (based on the USG) in 51 patients (23.61%) - the incidence in the impaired glucose tolerance (IGT) and type 2 diabetes (T2DM) group was significantly higher when compared to ones without glucose intolerance. Because of extreme values of metabolic parameters in TDM2 children being outliers, they were not considered in the statistical analysis of the study. 22 (11.58%) patients had elevated ALT values, of which 12 (54.55%) had hepatic steatosis features on ultrasound. 72.73% (n=32) patients with fatty liver features on USG had ALT values considered normal with cut-off point 42 U/l accepted in this study. Almost every fourth obese child in the study group presents features of fatty liver in ultrasound examination. Although ultrasound is not recommended by North American Society For Pediatric Gastroenterology, Hepatology &Nutrition(NASPGHAN) for the diagnosis of NAFLD in children, it allows identifying a high percentage of children with features of fatty liver. This percentage increases significantly in children with glucose intolerance.

Suspected Malignant Thyroid Nodules in Children and Adolescents According to Ultrasound Elastography and Ultrasound-Based Risk Stratification Systems-Experience from One Center.

The risk of malignancy in thyroid nodules correlates with the presence of ultrasonographic features. In adults, ultrasound risk-classification systems have been proposed to indicate the need for further invasive diagnosis. Furthermore, elastography has been shown to support differential diagnosis of thyroid nodules. The purpose of our study was to assess the application of the American Thyroid Association (ATA), British Thyroid Association (BTA) ultrasound risk-classification systems and strain elastography in the management of thyroid nodules in children and adolescents from one center. Seventeen nodules with Bethesda III, IV, V and VI were selected from 165 focal lesions in children. All patients underwent ultrasonography and elastography followed by fine needle aspiration biopsy. Ultrasonographic features according to the ATA and BTA stratification systems were assessed retrospectively. The strain ratio in the group of thyroid nodules diagnosed as malignant was significantly higher than in benign nodules (6.07 vs. 3.09, p = 0.036). According to the ATA guidelines, 100% of malignant nodules were classified as high suspicion and 73% of benign nodules were assessed as low suspicion. Using the BTA U-score classification, 80% of malignant nodules were classified as cancerous (U5) and 20% as suspicious for malignancy (U4). Among benign nodules, 82% were classified as indeterminate or equivocal (U3) and 9% as benign (U2). Our results suggest that application of the ATA or BTA stratification system and elastography may be a suitable method for assessing the level of suspected malignancy in thyroid nodules in children and help make a clinical decision about the need for further invasive diagnosis of thyroid nodules in children.

Rare clinical manifestation of multiple endocrine neoplasia type 1.

OBJECTIVE: Multiple endocrine neoplasia type 1 (MEN1) is a rare disorder characterized by tumors in various endocrine glands. It is caused by a mutation in the MEN1 gene. This gene encodes menin, a protein that regulates cell proliferation. The clinical manifestation of the syndrome most commonly involves hyperparathyroidism and pancreatic, pituitary gland, and adrenocortical adenomas. Although the first symptoms of the disease usually occur in patients under the age of 20, the data on MEN1 in children is scarce. Here, we report a case study of a familial MEN1 syndrome with a central nervous system ganglioglioma, a manifestation that has not been characterized so far. CASE REPORT: The diagnosis of a 17-year-old boy with hypoglycemia of unknown origin revealed the presence of a pancreatic tumor. As kidney stone disease and acute pancreatitis were reported in his father, and his asymptomatic sister was initially diagnosed with a pancreatic tumor, a familial MEN1 syndrome was suspected. Indeed, a pathogenic mutation within the MEN1 gene was detected. Further diagnosis revealed primary hyperparathyroidism in both children and their father, which is typical of MEN1. The girl also presented with hydrocephalus caused by ganglioglioma of the central nervous system. Surgical treatment was successfully conducted in both children. CONCLUSIONS: The reported family case provides evidence of the diagnostic and therapeutic difficulties related to the MEN1 syndrome. In children, the benefits of an early surgery should be considered in relation to the risks of possible surgical complications and consequences of a loss of endocrine gland function.

Assessment of the metabolic control in children with type 1 diabetes.

INTRODUCTION: The increase in morbidity of type 1 diabetes (T1D) is observed in Poland and worldwide, particularly among the youngest patients. To prevent chronic hyperglycemia's complications, it is advised to maintain best possible metabolic control from the time of diagnosis of the disease. AIM: The purpose of this research is to evaluate adherence to medical recommendations in regard to appropriate metabolic control of T1D in children, based on Polish Diabetes Association (PTD) 2019 criteria. MATERIAL AND METHODS: The medical records of 388 patients with T1D hospitalized in our department between June 2018 and July 2019 were analyzed. Two hundred patients hospitalized for routine control tests were enrolled in the study. The patients were evaluated with respect to meeting the criteria for metabolic control recommended by PTD 2019 including gender, duration of disease and treatment technique. The relation between the percentage of HbA1c and age, duration of the disease and lipid metabolism was studied. RESULTS: In the assessed group 7% of patients met all PTD's criteria of metabolic control. There was a statistically significant difference in percentage of HbA1c in serum between girls and boys (12.64% vs. 26.55%, p = 0.02). The trend was observed between patients with T1D lasting less than or equal 3 years and those with long-standing disease (28.72% vs. 13.21%, p = 0.007). A significant, positive correlation was demonstrated between percentage of HbA1c and low-density lipoprotein (LDL) level (r = 0.244), triglyceride (TG) level (r = 0.234) and duration of the disease (r = 0.278). CONCLUSIONS: A low percentage of patients is able to achieve all aims stated by the PTD.

Relative leptin deficiency in children with severe early-onset obesity (SEOO) - results of the Early-onset Obesity and Leptin - German-Polish Study (EOL-GPS).

Background Severe early-onset obesity (SEOO) in children is a common feature of monogenic obesity. Gene defects of the leptin-melanocortin pathway can be analysed biochemically and genetically. The aim of this study was to search for children with leptin deficiency or biologically inactive leptin in a cohort of children with SEOO and to study associations between leptin parameters and anthropometric data. Methods The cohort included n = 50 children with SEOO (22 boys) who were recruited at one of four study centres (Germany: Ulm; Poland: Katowice, Szczecin, Rzeszow) between October 2015 and October 2017. Weight (kg) and height (m) were measured, Tanner stage was obtained and a fasting serum blood sample was taken. Serum levels of total leptin (LEP, ng/mL), biologically active leptin (bioLEP, ng/mL) and soluble leptin receptor (sLEPR, ng/mL) were measured. The body mass index (BMI [kg/m2]), BMI z-score (World Health Organization [WHO]), quotient of bioLEP/LEP and leptin-standard deviation score (LEP-SDS) (Tanner stage, BMI and sex-adjusted) were calculated. Results We did not find any child with leptin deficiency or biologically inactive leptin in our cohort. The serum LEP and bioLEP levels were strongly correlated with age (r = 0.50, p < 0.05) and BMI (r = 0.70; p < 0.0001). Girls had higher LEP and bioLEP levels (49.7 ± 35.9 vs. 37.1 ± 25.5 ng/mL, p > 0.05) as well as lower LEP-SDS than boys (-1.77 ± 2.61 vs. -1.40 ± 2.60, p > 0.05). sLEPR levels were negatively correlated with BMI values (r = -0.44; p < 0.05), LEP (r = -0.39; p < 0.05) and bioLEP levels (r = -0.37; p < 0.05). Interestingly, there was a strong inverse relationship between LEP-SDS and BMI (r = -0.72, p < 0.001). Conclusions In this cohort with SEOO, we identified no new cases of children with leptin deficiency or bioinactive leptin. A strong negative correlation between the LEP-SDS and BMI values could be interpreted as relative leptin deficiency in children with SEOO. In case this hypothesis can be confirmed, these children would benefit from a substitution therapy with methionyl human leptin (metreleptin™).

Papillary thyroid cancer in three children.

INTRODUCTION: Thyroid cancers (TC) are rare diseases in the pediatric population and represents 0.5-3% of all malignant tumors in children. Differenti-ated thyroid cancer (DTC) is a major TC in children. Every patient under 18 years of age diagnosed with a thyroid nodule should under-go a detailed medical examination. The screening test for children with an increased risk for DTC is ultrasound examination of the neck. Both ultrasound and clinical images of a tissue lesion are more important than its size. It should also be emphasized that autoimmune thyroiditis (AIT), a comorbid condition for TC, is increasingly often diagnosed in young patients. Because of the rare incidence of this kind of cancer, we present 3 case studies of patients with papillary thyroid carcinoma, hospitalized in the Department of Pediatrics, En-docrinology, Diabetology, Metabolic Diseases and Cardiology of Developmental Age at Pomeranian Medical University (PMU) in Szczecin.

Assessment pf physical fitness of 8 and 9-year-old children from Szczecin,Poland, involved in the obesity prevention program - pilot study.

INTRODUCTION: Increasing incidence of excess weight and poor physical fitness of children validates the need for preventive actions. The Szczecin municipality (gmina Szczecin) runs the "Odwazna ósemka" ("The Brave Eight") program - Prevention of excess weight and obesity in 8 and 9-year-old children attending elementary school in Szczecin, Poland. AIM: The assessment of physical fitness as well as the prevalence and intensity of excess body weight and blood pressure rates among the 8 and 9-year-old children attending elementary school in Szczecin, Poland. MATERIAL AND METHODS: Between 6th December 2016 and 3rd December 2017, 3407 8 and 9-year-old children were examined (1757 girls and 1650 boys). BMI (Body Mass Index) as well as WHR (Waist Hip Ratio) were calculated. All the children were assessed according to criteria established by the International Obesity Task Force (IOTF). The examination included basic anthropometric measurements, such as: body height and weight, waist and hip circumference, blood pressure, body constitution analysis, and physical fitness assessment. RESULTS: Excess body weight was diagnosed in 822 patients, which is 24.1% of the examined population. 369 patients were diagnosed with elevated blood pressure (10.8%). Very poor physical fitness - test abandoned before the completion (HR>180/min), was diagnosed in 151 children (4.5%), very poor physical fitness was diagnosed in 234 children (7%), poor physical fitness was diagnosed in 827 children (24.9%), sufficient physical fitness was diagnosed in 961 children (29.2%), good physical fitness was diagnosed in 650 children (19.5%), very good physical fitness was diagnose in 428 children (12.8%) and excellent in 70 children (2.1%). CONCLUSION: The fact of unsatisfactory physical fitness and excess body weight in children from Szczecin is unsettling. There is ceratainly a need for preventive measures in the broad sense.

The Chromatin-Associated Phf12 Protein Maintains Nucleolar Integrity and Prevents Premature Cellular Senescence.

Pf1, also known as Phf12 (plant homeodomain [PHD] zinc finger protein 12), is a member of the PHD zinc finger family of proteins. Pf1 associates with a chromatin-interacting protein complex comprised of MRG15, Sin3B, and histone deacetylase 1 (HDAC1) that functions as a transcriptional modulator. The biological function of Pf1 remains largely elusive. We undertook the generation of Pf1 knockout mice to elucidate its physiological role. We demonstrate that Pf1 is required for mid- to late gestation viability. Pf1 inactivation impairs the proliferative potential of mouse embryonic fibroblasts (MEFs) and is associated with a significant decrease in bromodeoxyuridine incorporation; an increase in senescence-associated ß-galactosidase (SA-ß-Gal) activity, a marker of cellular senescence; and elevated levels of phosphorylated H2AX (γ-H2A.X), a marker associated with DNA double-strand breaks. Analysis of transcripts differentially expressed in wild-type and Pf1-deficient cells revealed the impact of Pf1 in multiple regulatory arms of the ribosome biogenesis pathways. Strikingly, assessment of the morphology of the nucleoli exposed an abnormal nucleolar structure in Pf1-deficient cells. Finally, proteomic analysis of the Pf1-interacting complexes highlighted proteins involved in ribosome biogenesis. Taken together, our data reveal an unsuspected function for the Pf1-associated chromatin complex in the ribosomal biogenesis and senescence pathways.

Estrogen receptor-ß expression and pharmacological targeting in bladder cancer.

A role for estrogen signaling in urothelial carcinoma of the bladder (UCB) is suggested to be associated with more advanced disease with worse outcomes in women. Estrogen receptor ß (ERß) is the predominant receptor in bladder tissues. We aimed to ascertain whether ERß correlates with clinicopathological predictors of aggressive bladder cancer and worse survival outcomes. ERß was measured by immunohistochemistry in malignant and adjacent benign bladder tissues in patients (N=72) with UCB who underwent radical cystectomy. ERß expression was tested for statistical association with clinicopathological variables and patient survival. ERß expression was determined in bladder cancer cell lines, and the effects of the selective estrogen modulator tamoxifen and the ERß agonist diarylpropionitrile on cell growth were determined. The ERß level was significantly higher in malignant vs. benign urothelium (P<0.001) and was strongly associated with aggressive tumor histology characterized by lymphovascular (P=0.008) and perineural (P=0.006) invasion, and clinical histories of pelvic irradiation (P=0.005), hydronephrosis (P=0.022) and no intravesical chemotherapy (P=0.038). All patients with a high (>70%) percentage of ERß positivity in tissue with >3-month follow-up developed recurrent disease (P=0.009). Higher ERß level was predictive of worse recurrence-free and overall survival following cystectomy, after adjustment for tumor stage, and remained significantly associated with recurrence-free survival in the multivariable analysis including tumor stage, nodal stage and lymphovascular invasion. Activation of ERß in bladder cancer cell lines led to significant increases in proliferation, while pharmacological inhibition with tamoxifen blocked cell growth. Our study supports a role for ERß in aggressive UCB. Pharmacological targeting of ERß warrants further investigation as a therapeutic strategy in UCB.