Outcomes of haematopoietic stem cell transplantation for inherited metabolic disorders: a report from the Australian and New Zealand Children's Haematology Oncology Group and the Australasian Bone Marrow Transplant Recipient Registry.

We report a retrospective analysis of 53 haematopoietic stem cell transplants for inherited metabolic disorders performed at ANZCHOG transplant centres between 1992 and 2008. Indications for transplant included Hurler syndrome, ALD, and MLD. The majority of transplants utilized unrelated donor stem cells (66%) with 65% of those being unrelated cord blood. Conditioning therapy was largely myeloablative, with Bu plus another cytotoxic agent used in 89% of recipients. Primary graft failure was rare, occurring in three patients, all of whom remain long-term survivors following the second transplant. The CI of grade II-IV and grade III-IV acute GVHD at day +100 was 39% and 14%, respectively. Chronic GVHD occurred in 17% of recipients. TRM was 12% at day +100 and 19% at one yr post-transplant. OS at five yr was 78% for the cohort, 73% for patients with ALD and 83% for patients with Hurler syndrome. There was no statistically significant difference in overall survival between unrelated marrow and unrelated cord blood donor groups. The development of interstitial pneumonitis was an independent variable shown to significantly impact on TRM and OS. In summary, we report a large cohort of patients with inherited metabolic disorders with excellent survival post-allogeneic transplant.

The molecular genetics of Marfan syndrome and related disorders.

Marfan syndrome (MFS), a relatively common autosomal dominant hereditary disorder of connective tissue with prominent manifestations in the skeletal, ocular, and cardiovascular systems, is caused by mutations in the gene for fibrillin-1 (FBN1). The leading cause of premature death in untreated individuals with MFS is acute aortic dissection, which often follows a period of progressive dilatation of the ascending aorta. Recent research on the molecular physiology of fibrillin and the pathophysiology of MFS and related disorders has changed our understanding of this disorder by demonstrating changes in growth factor signalling and in matrix-cell interactions. The purpose of this review is to provide a comprehensive overview of recent advances in the molecular biology of fibrillin and fibrillin-rich microfibrils. Mutations in FBN1 and other genes found in MFS and related disorders will be discussed, and novel concepts concerning the complex and multiple mechanisms of the pathogenesis of MFS will be explained.

Estrogen as treatment of hemorrhagic cystitis in children and adolescents undergoing bone marrow transplantation.

Hemorrhagic cystitis (HC) after allogeneic hematopoietic stem cell transplantation (HSCT) can cause significant morbidity and mortality. Previous reports have suggested a role for estrogen in the control of HC in adult patients. Here, we describe the clinical courses of 10 children and adolescents treated with estrogen for HC following HSCT. Eight patients (80%) experienced a significant improvement in their hematuria following the commencement of therapy, with six (60%) undergoing resolution of macroscopic hematuria, without any recurrences. The treatment was well tolerated by the majority of patients, with only one patient needing to interrupt treatment (hepatotoxicity). We conclude that estrogen is well tolerated and often effective, and should be considered as an adjunctive treatment option in children and adolescents with HC following HSCT.

Prevention of cyclophosphamide/cytarabine-induced emesis with ondansetron in children with leukemia.

Ondansetron, a 5HT3 antagonist, was given to 20 children aged 4 to 18 years who were undergoing treatment with the Australian and New Zealand Childhood Cancer Study Group Acute Lymphocytic Leukaemia (ALL) Study V Protocol. The study was open, dose ranging, and noncomparative, and designed to evaluate safety and efficacy of ondansetron in preventing nausea and vomiting caused by cyclophosphamide intravenous (IV) 1,000 mg/m2 day 1, and cytarabine IV subcutaneously (SC) 75 mg/m2 on days 2 to 5. Ten patients were given ondansetron 5 mg/m2 IV (group A) and subsequently another 10 patients were given ondansetron 3 mg/m2 IV (group B). Oral ondansetron was given for 14 doses, at the same dosage for both groups, commencing simultaneously with the IV infusion and continuing at 8 hourly intervals, ie, until day 5. The oral dose was based on surface area with the following schedule: 0.3 to 0.6 m2, 2 mg; 0.6 to 1 m2, 3 mg; and greater than 1 m2, 4 mg. Vomiting on the first day of chemotherapy was reported in group A by one patient and by one patient in group B. Vomiting during days 2 to 5 was reported by two group-A patients and by three group-B patients. Nausea was recorded on day 1 by one patient in group A, and two in group B, and on days 2 to 5 by three patients in group A, and by seven in group B. All patients were alert during treatment with ondansetron and there was no dystonia. There were no changes in renal function or hematology values that could be ascribed to the study drug. Transient elevations in bilirubin and liver enzymes were observed. We conclude that our results indicate that ondansetron is a safe and extremely effective single-agent antiemetic with minimal side effects, when administered both IV and orally.

Dose-intensive cyclophosphamide with etoposide and vincristine for pediatric solid tumors: a phase I/II pilot study by the Australia and New Zealand Childhood Cancer Study Group.

PURPOSE: This pilot study of the Australia and New Zealand Childhood Cancer Study Group investigated the effectiveness and toxicity of a regimen incorporating vincristine (VCR), etoposide, and divided-dose, escalating cyclophosphamide (CPA) (VETOPEC) in 23 patients aged 1 to 20 years with solid tumors. PATIENTS AND METHODS: Seventeen patients (group A) had recurrent or refractory tumors after prior multiagent therapy, and six patients (group B) with adverse prognostic indicators were treated at initial presentation. Treatment cycles were 21 to 28 days and consisted of vincristine (0.05 mg/kg) on days 1 and 14, with etoposide (2.5 mg/kg/d) plus escalating CPA on days 1, 2, and 3. The CPA dosage was escalated from 30 mg/kg/d in cycle no. 1 by 5 mg/kg/d in each cycle to a maximum of 55 mg/kg/d in cycle no. 6. RESULTS: Of 20 patients assessable for tumor response, 19 (95%) responded after two to six cycles of VETOPEC: seven complete responses (CRs); eight very good partial responses (VGPRs); and four partial responses (PRs). In group A, 13 of 14 (93%) assessable patients responded (five CRs, four VGPRs, four PRs), and in group B, five stage IV and one stage III patient achieved two CRs and four VGPRs. The principal toxicity was myelosuppression. Grade IV neutropenia occurred after 98% of cycles, and the incidence of grade IV thrombocytopenia increased from 37% after cycle no. 1 to 91% after cycle no. 6 (P = .002). A total of 115 cycles delivered were followed by 62 febrile admissions (54%), and showed a significant rise with increasing cycles (P = .001). One patient died of septicemia. CONCLUSION: This combination and scheduling produced a high response rate in patients with recurrent, refractory, or advanced solid tumors of childhood. Further studies of this regimen and of strategies to reduce hematologic toxicity are warranted.

Detection of human papillomaviruses in paraffin-embedded condylomata acuminata--comparison of immunohistochemistry, in situ hybridization, and polymerase chain reaction.

The polymerase chain reaction (PCR) is used for detection of human papillomavirus (HPV) DNA in paraffin-embedded tissue sections of condylomata acuminata. Incorporation of biotinylated nucleotides during the amplification process allows a highly sensitive, fast, and non-isotopic detection of viral DNA in a subsequent Southern dot blot. In 100% (13 of 13) of histologically confirmed condylomata, HPV-6 or -11 could be detected by polymerase chain reaction. By in situ hybridization 77% (10 of 13) and by immunohistochemistry (IHC) 69% (nine of 13) positive results were obtained. Because HPV genital infection is linked to penile and cervical dysplasia, polymerase chain reaction provides a powerful and highly sensitive tool for epidemiologic studies on sexual transmission of HPV.

Cytokine regulation of proteoglycan production in fibroblasts: separate and synergistic effects.

We have studied the effects of cytokines, separately or in combination, on the production of proteoglycans in confluent cultures of fibroblasts. The cytokines used were the transforming growth factor-beta (TGF-beta), the platelet derived growth factor-AA (PDGF-AA), the platelet derived growth factor-BB (PDGF-BB) and the epidermal growth factor (EGF). Hyaluronan production increased in cells treated with TGF-beta, PDGF-AA and PDGF-BB. Combining pairs of factors did not contribute further to hyaluronan production, whereas the triple combination of EGF, TGF-beta and PDGF-BB induced an additional 1.9-fold increase. Proteoglycan production was only increased by TGF-beta alone. As for hyaluronan, combining pairs of the cytokines had no further effect on metabolism, whereas the combination of EGF, TGF-beta and PDGF-BB induced a further 1.6-fold increase in production and secretion. Compared with the control, an extensive increase in proteoglycan production was generated by the combination of EGF, TGF-beta and PDGF-BB, 7-fold for biglycan, approximately 5-fold for versican and hyaluronan and 2.4-4-fold for heparan sulfate proteoglycan and decorin. Compared with TGF-beta alone, this combination increased, in falling order, the production of heparan sulfate proteoglycan, hyaluronan, biglycan, decorin and versican. The mRNA levels for the various proteoglycans did not completely agree with the changes in production, suggesting that changes not only in synthesis but also in rate of degradation generate these variations. The data indicate that cytokines cooperate to produce a proper and physiological response, one needed by the organism during physiological and pathophysiological remodeling.

Marrow function reconstitution by fraction 3 of Percoll-density-gradient-separated cells.

Eight children with advanced tumors or acute myeloid leukemia were treated either with very-high-dose multi-agent chemotherapy (4) or marrow ablative high-dose melphalan (4) followed by autologous marrow rescue, using only fraction 3 from a Percoll-discontinuous density gradient separation of bone marrow buffy coats. Each patient received less than 20% of the number of cells usually reinfused from the buffy coat. The yield of CFU-c in Percoll gradient 3 was similar to the yield obtained from whole buffy coats of bone marrow. Reconstitution of marrow function with a neutrophil count greater than 0.5 X 10(9)/L and platelet count greater than 50 X 10(9)/L occurred in 7 patients in a medium time of 15 and 16 days, respectively--a time comparable to that following infusion of whole buffy coat in 20 other patients. In one patient, hemopoietic recovery was considerably delayed, suggesting that fraction 3 from the Percoll gradient had been relatively ineffective in marrow reconstitution. We conclude that fraction 3 from marrow separated on Percoll gradients has the advantages of small volume and good recovery of marrow stem cells and can promptly reconstitute marrow function in the majority of children treated with very-high-dose chemotherapy or marrow ablative doses of melphalan.

An inhibitor to factor VIII:C in a patient with possible combined haemophilia A and von Willebrand's disease.

A factor VIII inhibitor has been found in a patient with an unusual combination of factor VIII-related properties. The inhibitor is directed specifically against the clotting activity (VIII:C) of the factor VIII complex. It behaves in a similar fashion to high responding inhibitors of factor VIII seen in haemophilia A patients and it was characterised as an immunoglobulin of the IgG class. Laboratory results from the patient and his family show considerable variation of factor VIII-related properties between various individuals. Overall, the data suggests the co-existence of haemophilia A and von Willebrand's disease in the family and the presence of both diseases in the patient.

Alloresponses to HLA-DP detected in the primary MLR: correlation with a single amino acid difference.

The one-way mixed lymphocyte reaction (MLR-1) response was measured in both directions in 50 HLA-A, B, DR and DQ identical pairs and the role of DP studied in MLR stimulation. DR, DQ and DP typing was performed at the allele level by the polymerase chain reaction-sequence specific oligotyping (PCR-SSO) technique. The group consisted of 19 potential bone marrow transplant recipients and 34 matched unrelated donors. When more than one matched donor was available for a patient, donor/donor MLR-1 was also studied. DP identity was observed in 3 out of 50 pairs (6%), however due to homozygosity no incompatibility was present in the stimulating cells in 21 out of 100 cases (21%). There was a significant difference in the range of relative responses (RR) between zero DPB1 mismatches and one (p = 0.002) and two (p = 0.02) DPB1 mismatches: 52.4% of cases in the zero DPB1 mismatch group had RR < 1.0% compared with 31.6% and 27.3% in the one and two DPB1 mismatches. Stimulation by DPB1*0201 and 0301 gave the highest RR (12.9 +/- 22.5 and 17.5 +/- 17.0, respectively) while stimulation with DPB1*0401 and 0402 resulted in low levels of T cell response (1.3 +/- 8.2 and 0.6 +/- 11.5, respectively). When the responses were restricted to DPB1*0401 homozygotes to standardise for responder type similar results were obtained (DPB1*0201 v DPB1*0402 p = 0.008). The protein products of the DPB1*0201 and 0402 alleles differ by a single amino acid at position 69 (DPB1*0402--Lysine, DPB1*0201--glutamic acid). A further analysis was performed therefore scoring responders and stimulators as glutamic acid positive (E+) or negative (E-). There was a highly significant increase in the response to E+ stimulators compared with E- stimulators (p = 0.004). There was also a significant difference in the distribution of relative responses between the E+ stimulator group and the subgroups of E- responders/E- stimulators (p = 0.012) and E+ responders/E- stimulators (p = 0.009). However the amino acid difference at position 69 does not explain all responses due to DP in the MLR-1 as evidenced by the strong responses observed in cases where DPB1*0301 (lysine pos.) was the only difference on the stimulator cells. The results indicate that not all DP incompatibilities elicit a measurable T cell MLR response, but where a response does occur residue 69 in the first domain of DP appears to be pivotal. These results may have implications with respect to GVHD in bone marrow transplantation.

Clinicopathological characteristics of acute lymphoblastic leukemia with the 4;11 chromosome translocation.

Analysis of the bone marrow karyotype in 109 consecutive untreated patients with acute lymphoblastic leukemia (ALL) by the G-banding technique revealed the presence of a translocation between specific sites on the long arms of chromosomes 4 and 11, [t(4;11) (q21;q23)] in 3 adults and 2 children. Splenomegaly was present in all patients, marked leukocytosis in 4, and retinal hemorrhages in the absence of significant mucocutaneous bleeding in 3. Complete remission defined by conventional morphological criteria was achieved with combination chemotherapy in all instances, but the duration of remission was brief in 3. Three patients were studied in relapse, and clonal evolution was found to have occurred in 2. Analysis of our data in conjunction with other published reports suggests this specific karyotypic abnormality characterizes a small subgroup of ALL in which there is a strong association with recognized clinical and laboratory indices of poor prognosis, in particular its frequent occurrence in children under the age of 2.5 yr. There is a propensity to undergo clonal evolution, and the possibility exists that such a development is associated with poor prognosis.

The bovine allantoic and amniotic epithelia. SEM and TEM studies.

The ectodermal and endodermal coverings of the allanto-amniotic membrane in cattle fetuses of various gestational ages have been studied by scanning and transmission electron microscopy. We have observed that the allantoic and amniotic epithelia have rather similar cells which are rich in filaments but poor in organelles. Neither epithelium reflects its different origin nor the differences in the composition of the two fetal fluids. Maturation changes occur in the pattern of the various surface specializations until midterm. Coral-like luminal outgrowths, which also contain organelles, were observed in both epithelia, whereas microplicae had formed only on fully differentiated amniotic cells. Interspersed smooth-surface cells in the allantoic epithelium that differ also in nuclear shape, glycocalyx, and mitochondria are regarded as a second cell type. Besides fluid-filled blisters and cornified pustules, the most typical feature of the amniotic epithelium is a rather regular lateral cell interdigitation with tongue-like lamellae of even thickness. Micropinocytotic vesicles are more frequent than in the allantois. Both epithelia possess similar tight junctions; no morphological or histochemical indications of an active sodium transport were evidenced.

Architecture of the mesonephric nephron in pig and rabbit.

As a precondition for determining nephron profiles in sections, mature mesonephric nephrons from pig and rabbit embryos were isolated by a maceration technique in order to demonstrate nephron architecture, length, and diameter. In the pig the proximal tubule is largely constant. In the distal tubule the pre-attachment zone shows the greatest variation. The zone of attachment ot the corpuscle and the ventrolaterally directed post-attachment coil has a predictable course as does the collecting tubule. In contrast to earlier reports, the nephron shows no drastic differences in tubule diameter and is up to 33 mm long. The proportional length of the three major nephron segments is surprisingly constant. The rabbit nephron, although much shorter (4 mm) and simpler, with an alomst S-shaped pattern, is less easily understood in sections. Marked irregularities in its course are caused by the different behaviour of the terminal proximal segments. The distal tubule shows an ampullary dilatation in the attachment zone but can be very narrow in the pre-attachment part.

The pig mesonephros. III. Distal tubule, collecting tubule, and Wolffian duct: SEM- and TEM-studies.

The ultrastructure of the distal and collecting tubules of mature pig mesonephroi (41st gestational day) was studied in perfusion-fixed embryos. In the distal tubule, the three subsegments postulated on the basis of enzyme histochemistry show only minor differences of their luminal surfaces, mostly of cell size. TEM photographs reveal a single cell type with interdigitating basolateral processes, frequently flattened to 30-120 nm lamellae devoid of organelles. Larger interdigitating processes harbor vertically oriented mitochondria in the form of indented plates. The macula densa cells are small, do not interdigitate, and have distended intercellular spaces. The collecting tubule starts with a dorsal convolution, in which intercalated cells (with apical microfolds and numerous mitochondria) occur in addition to interdigitating cells. Further down this segment, the interdigitating cells are gradually replaced by principal cells characterized by interlocking lateral microvilli, basal infoldings, and relatively few organelles. Intercalated cells extend into the Wolffian duct. Although the pig mesonephros has the most differentiated nephron of the mammals studied so far, with metanephros-like cells, its intrinsic urinary concentrating capacity appears to be low in view of its vascularization pattern and nephron architecture.

The pig mesonephros. I. Enzyme histochemical observations on the segmentation of the nephron.

Cryostat sections from the mesonephros of various pig embryos with a crown-rump-length of between 17 and 95 mm were used for light microscopical assays of acid hydrolases (acid phosphatase, beta-D-N-acetylglucosaminidase, beta-D-glucuronidase), oxidoreductases (succinic dehydrogenase, NADH- and NADPH-tetrazolium reductase) and adenosine triphosphatases (Mg2+- and Na+--K+-ATPase). Our main intention was to distinguish more accurately between the different parts of the pig's nephron, which is exceedingly long and coiled. The proximal tubule, that exhibits a high activity for acid phosphatase but none in beta-D-glucuronidase incubations, shows no subsegmentation apart from a stronger reaction of its initial segment that was apparent in three of our assays. In the distal tubule, a preattachment convolution, an attachment zone, and a postattachment coil can be discriminated by a synopsis of all histiograms. The beginning of the collecting tubule is situated in the middle of the organ and not at its dorsal face as was previously believed. Up to three different segments can be discriminated in the collecting tubule. The distal and the collecting tubule harbor on ouabain-sensitive Na+--K+-ATPase activity which decreases considerably towards the Wolffian duct. The enzymatic maturation of the mesonephric pig nephron is almost completed in 17 mm embryos.

The pig mesonephros. II. The proximal tubule: SEM, TEM and freeze-fracture images.

The ultrastructure of the proximal tubule of mature mesonephric nephrons was studied in perfusion-fixed pig embryos of the 41st gestational day. Despite its 8-12 mm long course, the proximal tubule possesses no cytologically different subsegments except its very last cells at the abrupt transition into the distal tubule. The first brush-bordered proximal tubule cells stand considerably within Bowman's capsule, abuting its attenuated cells. In SEM specimens, the average luminal cell diameters are 8 X 13 micron. The cells are 6-11 micron in height with overlying microvilli 2-4 micron long. Lateral faces of perfectly disjoined cells exhibit plate-like interdigitating processes projecting more than 5 micron deep into the neighboring cells. The basal cell face is completely covered with microvilli. The TEM pictures reveal an endocytic apparatus largely matching its metanephric counterpart. Mitochondria account for 23% of the cytoplasm and together with the many basolateral cell membranes indicate a high capacity for energy-dependent transport processes. Small basal lipid droplets represent a species peculiarity. Freeze-fracture specimens show an electrocoupling of the cells by gap junctions. The tight junction, with only 1-2 strands, characterizes a "leaky" epithelium. In most features, this tissue is as mature as its metanephric counterpart.

The current potential of plastination.

This review surveys the potential of plastination, a technique of tissue preservation introduced eight years ago. In this process, water and lipids in biological tissues are replaced by curable polymer which are subsequently hardened, resulting in dry, odorless and durable specimens. The procedure consists of the following steps - fixation, dehydration, forced impregnation in a vacuum, and hardening. The properties of the finished specimen are determined by the class of polymer used. Silicone yields flexible, resilient specimens, allows the broadest range of application, and provides satisfactory results with minimum equipment. Specimens plastinated with an epoxy-silicone copolymer are rigid enough to be polished, but are not unbreakable. This resin is used for thick, opaque body slices and showcase specimens. Epoxy resins are used for thin (2.5 mm), transparent body or organ slices. They are cast between polyester foils or glass plates and can be used for histological investigations. Polyester resin is used for the production of opaque brain slices, which gives excellent differentiation between grey and white matter. The application of plastination in research and the production of teaching specimens is discussed with special regard to the equipment required, cost, and feasibility of the processing.

Renal ontogeny: epithelial transport in the mammalian mesonephric proximal tubule.

The role of the mammalian mesonephric kidney is not completely understood. It has been established that outpouchings of the mesonephric excretory ducts give origin to parts of the urogenital system of the adult. It is also known that mammalian mesonephric urine is formed as an ultrafiltrate. The mesonephric renal tubules have Na+/K+ adenosine triphosphatase (Na+/K+ pump), secrete phenol red, and reabsorb protein. Prior to this work, the possibility of epithelial transport of ions and metabolic substrates across mammalian mesonephric tubules had not been directly evaluated. Proximal mesonephric tubules obtained from 17 to 18-days-old rabbit embryos were isolated and perfused in vitro. Continuous intracellular electrical recordings were obtained with Ling-Gerard-type microelectrodes and a high input impedance electrometer. In tubules perfused and bathed in standard mammalian Ringer's solutions, the average transmembrane electrical cell potential difference (PD) was -43 +/- 0.5 mV (76 cells). The cellular PD decreased by 30 percent when the temperature of the bath was cooled from 37 degrees C to 30 degrees C. The cells also depolarized by 25 percent in the first five minutes of exposure to 0.1 mM ouabain. In addition, the cell PD decreased by 40 and 60 percent when the extracellular potassium concentration was raised from five to 25 and 50 mM, respectively. The uptake of glucose and alanine was similarly electrogenic (delta:1 mV/mM). The cell PD, the K+ conductance, and the electrogenicity induced by luminal exposure to 5 mM glucose or alanine are significantly lower in the mesonephric as compared to the metanephric proximal tubules of the rabbit. These observations suggest that sodium-coupled transepithelial transport mechanisms, driven by the Na+/K+ pump, are already present in the mammalian mesonephric proximal tubule. Increases in the number of Na+/K+ pumps, conductive K+ channels, and sodium-substrate cotransporters seem to be at the core of proximal tubular ontogeny.

Hemispheric asymmetries in the recognition of animal photographs in different views.

The purpose of the present study was to determine the influence of atypical and prototypical views of real object representations on cognitive processing. Thirty normal subjects were submitted to right or left field tachistoscopic presentation of animal photographs in two experimental situations with different recognition tasks. In the first task, the animals were presented in the two different views and in the second, animals of different species were presented only in the prototypical view. A left visual field advantage was found in the recognition of atypical views and a right visual field advantage in the recognition of prototypical ones. The hemispheric processing for both recognition processes is discussed.

Percutaneous localization of small pulmonary metastases, enabling limited resection.

An adolescent patient with Ewing's sarcoma, who had undergone three previous thoracotomies for pulmonary metastases, presented with two further left-sided pulmonary metastases, measuring 5 mm and 10 mm in diameter. Chemotherapeutic options were limited, and pulmonary irradiation was inadvisable because of compromised respiratory function. Surgical resection was the favored therapeutic option. A method of accurately localizing the small lesions was devised, using a percutaneous needling technique under computed tomography guidance and the injection of barium and methylene blue. This localization enabled resection of the lesions, with minimal excision and manipulation of the surrounding normal parenchyma. This technique is useful for removal of small impalpable metastases when other modalities of therapy are not appropriate.