T and B cell clonal expansion in Ras-associated lymphoproliferative disease (RALD) as revealed by next-generation sequencing.

Ras-associated lymphoproliferative disease (RALD) is an autoimmune lymphoproliferative syndrome (ALPS)-like disease caused by mutations in Kirsten rat sarcoma viral oncogene homologue (KRAS) or neuroblastoma RAS viral (V-Ras) oncogene homologue (NRAS). The immunological phenotype and pathogenesis of RALD have yet to be studied extensively. Here we report a thorough immunological investigation of a RALD patient with a somatic KRAS mutation. Patient lymphocytes were analysed for phenotype, immunoglobulin levels and T cell proliferation capacity. T and B cell receptor excision circles (TREC and KREC, respectively), markers of naive T and B cell production, were measured serially for 3 years. T and B cell receptor repertoires were studied using both traditional assays as well as next-generation sequencing (NGS). TREC and KREC declined dramatically with time, as did T cell receptor diversity. NGS analysis demonstrated T and B clonal expansions and marked restriction of T and B cell receptor repertoires compared to healthy controls. Our results demonstrate, at least for our reported RALD patient, how peripheral T and B clonal expansions reciprocally limit lymphocyte production and restrict the lymphocyte receptor repertoire in this disease. Decreased naive lymphocyte production correlated with a clinical deterioration in our patient's immune status, suggesting that TREC and KREC may be used as an aid in monitoring disease progression. Both the methodologies used here and the conclusions regarding immune homeostasis may be applicable to the research of ALPS and other immune dysregulation syndromes.

Towards a body hair atlas of women of caucasian ethnicity.

OBJECTIVE: A preliminary study was conducted in 17 female volunteers (mean age 29.8 years) to gain deeper insights into the characteristics of terminal Caucasian female body hair of different body parts. The focus on Caucasian women was driven by the high number of different scalp hair phenotypes in this ethnicity and intended to identify relevant differences between body areas to improve body hair removal approaches. METHODS: Multiple growth parameters and structural parameters were assessed for hair on the upper arm, forearm, upper leg, lower leg, axilla and intimate area and compared to scalp data. RESULTS: In particular, macroscopic and much less microscopic or hair surface properties differ strikingly in the investigated body areas. Hair density on the body is much lower than on scalp with the highest hair density in the axilla and intimate area. Multihair follicular units are described for scalp but were also found to a smaller proportion in the axilla and the intimate area. Substantial percentages of hair triplets are only found on the scalp and intimate area. Hair diameter is highest in the intimate area, followed by axillary and lower leg hair and correlates with a faster hair growth rate. The angle of emerging hair is smallest in the intimate area, axilla and on the lower leg. Hair shafts on the lower leg and in the axilla have most overlapping cuticle layers, but independent of body region, no significant differences in the mean thickness of cuticle layers were detectable. In addition, no differences were found in the mean distance between cuticle layer edges along the hair shaft and the hair surface roughness. Hair on the scalp, forearm, upper arm and upper leg had an almost round shape, whereas hair of the lower leg, intimate area and axilla had more elliptical shape. Hairs on the arm showed the highest luminance values and no visible medulla. The darkest hairs were in the axilla and intimate area containing the highest level of visible medulla in hair shafts. CONCLUSION: To our knowledge, this is the first systematic study comparing terminal hair properties in all cosmetically relevant body regions in Caucasian women.

Lymphomatous T-cell leukemia in two Arab children. Is there a role for an environmental effect.

Two Arab children from the Gaza strip presented with fever, weakness, hepatosplenomegaly, lymphadenopathy and leukocytosis. The peripheral and bone marrow blasts had an immunophenotype compatable with T-cell acute lymphoblastic leukemia, and exhibited unusual markers (CD2+, CD3+, CD4-, CD8-). Cytogenetic studies revealed t(8;14)(q24;q11), possibly involving the alpha/delta locus of the T-cell receptor gene on chromosome 14 rather than the immunoglobulin heavy-chain locus usually involved in the t(8;14)(q24;q32), which is typical for Burkitt's leukemia/lymphoma. One of the children had a brother who died of T-cell acute lymphoblastic leukemia a few years later, however, his blasts showed deletion of chromosome 12. The possible role for environmental factors associated with low socioeconomic status, as well as of genetic factors in leukemogenesis are discussed.

In vivo clonal evolution of pre-B to B-cell acute lymphoblastic leukemia in childhood.

Two cases are described that provide further evidence for clonal evolution in pre-B-cell acute lymphoblastic leukemia. Two infants, whose lymphoblasts at diagnosis were morphologically subtyped as L1 and immunophenotyped as HLA DR+, CD19+, CD10+/- and C mu-, were induced and maintained in remission. One child relapsed 6 months after initiation of therapy. This time his lymphoblasts had L3 morphology and immunophenotyping demonstrated the appearance of surface immunoglobulins. The second child relapsed 18 months after initiation of therapy with a lymphomatous picture. He also had peripheral and bone marrow blasts with L3 morphology and surface immunoglobulins. A lymph node biopsy showed diffuse small non-cleaved lymphoma with a 'starry sky' appearance compatible with Burkitt's lymphoma. Only one case with a similar clonal evolution has been reported in the literature, but no surface immunoglobulins were demonstrated. The significance of clonal evolution in these cases and its potential practical implications are discussed.

HLA-A11 is associated with poor prognosis in childhood acute lymphoblastic leukemia (ALL).

A possible association between HLA antigens, susceptibility or resistance to leukemia, and responsiveness to treatment has been studied in 144 patients with childhood acute lymphoblastic leukemia (ALL) and compared to other prognostic factors, i.e. white blood cell (WBC) counts, age at onset, sex, ethnic origin, and cell surface markers. All sequentially newly diagnosed children (97) comprised the group for the prospective study (PSG) and were followed for 6 years. The group included 37 patients classified as T-ALL, 41 as CALLA+, 27 as NULL, 12 as B and pre-B, and 27 unclassified patients, who were diagnosed before 1980. During the follow-up period, 45 patients of the PSG died. Forty-seven patients designated long-term survivors (LTS) have been followed 6-20 years after diagnosis, having completed a 3-5 year course of anti-leukemia therapy, and having remained disease free thereafter. High WBC counts at diagnosis and T-cell-surface markers were associated with poor prognosis, as were enthnic origin and specific HLA antigens. Thus, there was one (1) a significant increase in HLA-A30 and a decrease in HLA B-14 in the PSG Jewish patients; and (2) a complete absence of HLA-ALL in LTS while, in the PSG, 8 of 9 HLA-All-positive patients died during the follow-up period. This suggests that HLA-All is associated with poor prognosis in childhood ALL.

B-cell lymphoma developing in the donor 9 years after donor-origin acute myeloid leukemia post bone marrow transplantation.

Donor-cell leukemia post bone marrow transplantation is a rare event. Most of the cases reported to date have developed in cells from an HLA-matched sibling, who had no evidence of malignant disease before or following the occurrence of donor-origin leukemia. We describe a 17-year-old female who developed B-cell lymphoma 9 years following the occurrence of donor-origin acute myeloid leukemia in her brother for whom she had donated marrow. Cytogenetic analysis of the tumor revealed multiple chromosomal aberrations. The donor was heterozygous for the Ashkenazi mutation of Bloom's syndrome, suggesting that donor-type leukemia could have resulted from genomic instability in the donor cells.

Multilineage hematopoietic engraftment after allogeneic peripheral blood stem cell transplantation without conditioning in SCID patients.

Successful stem cell transplantation for patients with severe combined immunodeficiency (SCID) from matched family donors without conditioning results in engraftment of T lymphocytes. B lymphocytes engraft in only 50% of the cases, while myelopoiesis and erythropoiesis remain of host origin. Full hematopoietic engraftment was reported in one case after bone marrow transplantation without conditioning for a SCID patient. We studied three SCID patients who were transplanted with unmodified mobilized peripheral blood from HLA-identical family sex-mismatched members. They received megadoses of stem cells (18-23 x 10(6)CD34/kg). In contrast to the expected mixed chimerism that usually occurs in the absence of conditioning, we found in our patients 100% donor cell engraftment based on fluorescence in situ hybridization (FISH) and microsatellite techniques. Subset analysis of the engrafted cells using a multiparametric system enabling a combined analysis of morphology, immunophenotyping and FISH showed that both T and B lymphocytes and myeloid cells were of donor origin in two patients, while T lymphocytes and myeloid cells were of donor origin in the third. In the two cases with ABO incompatibility, erythroid engraftment was evidenced by blood group conversion from recipient to donor type. Multilineage donor engraftment is possible in SCID patients even without conditioning.

Successful treatment of invasive aspergillosis in chronic granulomatous disease by granulocyte transfusions followed by peripheral blood stem cell transplantation.

Chronic granulomatous disease (CGD) is a primary immunodeficiency disorder characterized by impaired microbial killing and susceptibility to bacterial and fungal infections. Cure of the disease can be achieved by stem cell transplantation when performed early in its course, and before severe infections have developed. Invasive aspergillosis constitutes a very high risk for transplantation. We report a 4-year-old boy with X-linked CGD who underwent successful HLA-identical peripheral blood stem cell (PBSC) transplantation during invasive pulmonary aspergillosis and osteomyelitis of the left fourth rib, which was unresponsive to antifungal treatment. During the 2 months prior to the transplant he received G-CSF-mobilized granulocyte transfusions (GTX) from unrelated donors three times a week in addition to the antifungal treatment. This resulted in clinical improvement in his respiratory status. He also received GTX during the aplastic period after the conditioning regimen, until he had engrafted. Post-transplant superoxide generation test revealed that neutrophil function was within normal range. One year post transplant the CT scan showed almost complete clearance of the pulmonary infiltrates and a marked improvement in the osteomyelitic process. Based on other reports and our own experience, GTX can serve as important treatment in patients with CGD who have failed conventional anti-fungal treatment and for whom stem cell transplantation is the only chance for cure.

Successful human umbilical cord blood stem cell transplantation without conditioning in severe combined immune deficiency.

A 2-month-old girl with severe combined immunodeficiency (SCID), presented with mild staphylococcal skin infection, lymphopenia, low T cell number, absence of B cells, high number of NK cells, and a negligible response to mitogens. Since her older brother died as a result of SCID 2 years earlier, cord blood was harvested from a sister born 2 1/2 years earlier, who was normal and fully matched both by serology and molecular typing. In view of her clinical condition and in spite of a high number of NK cells with normal activity, HUCBT without preparative conditioning was performed. No G-CSF was administered. Engraftment with mixed chimerism was evident 3 weeks post transplantation. There were no peritransplantation complications. Eighteen months post transplantation, the girl is in excellent condition, blood counts are normal, T cell engraftment is complete, B cell engraftment is proceeding gradually, and the mitogen stimulation tests are normal. Due to the unique nature of HUCB hematopoietic cells, engraftment without conditioning may be possible in patients with SCID with fully matched donors. This is the first HUCBT performed without conditioning.

In vitro proliferative advantage of bone marrow cells with tetrasomy 8 in Ewing sarcoma.

We describe a case of a 14.5-year-old boy with a clinically aggressive pelvic Ewing sarcoma. The tumor cells showed the presence of a typical t(11;22)(q24;q12) aberration and gains of chromosomes 8, 10, 14, and 21. To determine the size of the trisomy and tetrasomy 8 clones an interphase analysis by fluorescence in situ hybridization with a centromere-specific chromosome 8 probe was performed. Significant quantitative differences between metaphase and interphase data were obtained. It was shown that culturing of bone marrow cells leads to enrichment of tetrasomy 8 population that may be explained by the proliferative advantage of the tetrasomy 8 cells.

Linear and nonlinear models of patient satisfaction with medical care.

The relationship between overall patient satisfaction with medical care and satisfaction with various aspects of health services is explored in a community survey of 225 service consumers. Three alternative models are examined: (i) linear compensatory model; (2) nonlinear conjunctive model; and (3) nonlinear disjunctive model. The results indicate that the nonlinear, noncompensatory models predict overall satisfaction as well as does the linear compensatory model. The pattern of findings is different for men and women. The implications of the findings are discussed.

On a shared intergenerational experience--a short-term intervention with a Holocaust survivor as part of a lengthy course of therapy.

The article describes a short-term therapeutic relationship between a Holocaust survivor and a younger therapist, whose family members experienced the Holocaust themselves. It took place against the background of the patient's complex relationships with her parents and brother in the past, with her husband, daughters and grandchildren in the present, as well as of traumatic experiences during the Holocaust. The author relates in particular to the force and place of the thoughts, fantasies, memories and physical sensations that assailed him throughout the process in which he formulated the verbal interventions he found himself making. The purpose of this article is to emphasize the relational aspects of this therapeutic relationship and the fruitful intergenerational encounter and its role in shaping the nature of the therapeutic interaction.

Fiberoptic bronchoscopy and bronchoalveolar lavage for the evaluation of pulmonary disease in children with primary immunodeficiency and cancer.

BACKGROUND: Patients with childhood cancer or primary immunodeficiencies (PID) are at high risk for developing pulmonary infections and non-infectious complications. The broad differential diagnoses and the critical condition of these patients often drive physicians to start broad-spectrum antibiotic therapy before a definite diagnostic procedure is performed. A definite diagnosis may be achieved in these situations by fiberoptic bronchoscopy (FOB) and bronchoalveolar lavage (BAL). PATIENTS AND METHODS: The records of 58 PIDs and cancer (immunocompromised group) pediatric patients who underwent 62 fiberoptic bronchoscopies between 2000 and 2004 were retrospectively reviewed and compared to 158 non-cancer patients who underwent 182 fiberoptic bronchoscopies during the same period. RESULTS: The overall diagnostic rate achieved by macroscopic inspection of purulent secretions or hemorrhage, abnormal cell count, and infectious agent isolation in the immunocompromised patients was 84%. A definite organism was recovered in 53.2% of the patients. Probable infection defined as purulent secretions or abnormal cell count without infectious agent isolation was diagnosed in another 21% of the patients. The rate of complications was 30.6%. In the control group, the overall diagnostic rate was 76.9% (n.s) and an infectious agent was demonstrated in 12.1% (P < 0.001). Probable infection was diagnosed in 24.2% (n.s) while the rate of complications was lower (15%) (P < 0.01). CONCLUSIONS: Rapid and accurate diagnoses were achieved in most procedures performed on immunocompromised patients. Although the rate of complications was higher in the immunocompromised group, they were usually very mild with no mortality. Based on these results, broncoalveolar lavage should be considered as an initial diagnostic tool in pediatric immunocompromised patients with pulmonary complications.

[Antihistaminic therapy of chronic urticaria. Results of a multicenter study with azatadine and terfenadine]. / Antihistaminika-Behandlung bei chronischer Urtikaria. Ergebnisse einer Multicenter-Studie mit Azatadin und Terfenadin.

A comparative double-blind multicenter trial was carried out in six German dermatology clinics involving patients with long-term continuous urticaria. After a five-day washout and initial assessment of the urticaria symptomatology oral antihistamine treatment was started with 2 X 1 mg Azatadine or 2 X 60 mg Terfenadine daily. After seven to ten days' treatment the target symptoms wheals, erythema and itching recovered in all but 4% of the azatadine patients and 21% of the terfenadine patients. Azatadine showed significantly stronger antiallergic efficacy for all symptoms. Both substances caused a certain degree of sedation, but in varying intensity. In all patients developing sedation this undesired side effect disappeared after three days in spite of continuous therapy.

Comparative investigation of the antiproliferative efficacy of alclometasone.

In this study, the antiproliferative activity of a 0.05% alclometasone ointment (Alc, Delonal) on the epidermis of the mouse tail was investigated. We have found that Alc thins the epidermis to approximately the same extent as hydrocortisone acetate (1%), but has an extremely slighter epidermal thinning effect than betamethasone (betametasone-17,21-dipropionate, 0.064%, Diprosis). The incorporation rate of 3H-thymidine triphosphate into the DNA was inhibited to almost the same extent. In conclusion the small antiproliferative effect of Alc shows no correlating effects compared with its high vasoconstrictory efficacy.

Malignant peripheral primitive neuroectodermal tumor (PNET) of the kidney.

We describe a 61-year-old patient with primitive neuroectodermal tumor (PNET) arising from the kidney. Despite intensive treatment including surgery, combination chemotherapy and radiotherapy, rapid progression of the tumor was encountered and the patient died within six months with widespread disease. This appears to be the first recorded case of PNET of the kidney.

Hormonal treatment in pregnancy: a possible risk factor for neuroblastoma.

In the last 4 years, 24 cases of neuroblastoma were treated in the Pediatric Hematology-Oncology Unit at the Chaim Sheba Medical Center, 8 of whom were under 1 year of age. Four of them were the product of a pregnancy-induced or preserved by gonadotropins, clomiphene citrate, or progestational hormones. These drugs are known to produce a higher than normal level of estradiol or progesterone in the early stages of pregnancy. Our observation led to the hypothesis that high levels of progestational hormones given during pregnancy are a risk factor for neuroblastoma in infancy.

Successful pregnancy after high-dose cyclophosphamide and ifosfamide treatment in two postpubertal women.

Alkylating agents, especially cyclophosphamide, are known to have a destructive effect on the ovaries and to result in sterility in many young women treated with these drugs. This is especially true when the treatment is given to postpubertal women. The authors describe 2 postpubertal women aged 16 and 25 suffering from Ewing sarcoma who were treated with the very aggressive Sloan-Kettering protocol, which includes high-dose cyclophosphamide and ifosfamide in addition to other drugs. Both women had spontaneous pregnancies and delivered normal babies. The significance of these cases in view of the experimental various reproductive preservation measures offered to such women is discussed.

Increased spindle resistance to antimicrotubule agents in cells prone to chromosomal nondisjunction.

The cytological behavior of the spindle apparatus was studied in cells prone to nondisjunction (ND), i.e., PHA-stimulated lymphocytes derived from children suffering from different types of neoplasia. These cells, which exhibited a high frequency of nonspecific aneuploidy, revealed an increased resistance of the spindle fibers to colchicine, podophyllotoxin, and cold, which was several times that of lymphocytes derived from healthy children. The results are in accord with previous findings showing a high resistance of spindle microtubules to the antimicrotubular agents colchicine, podophyllotoxin, vinblastine, and cold in PHA-stimulated lymphocytes derived from individuals prone to meiotic ND. It is therefore assumed that high resistance of the spindle apparatus to antimicrotubule agents characterizes cells at high risk for aneuploidy, and possibly, the overstabilized spindle fibers are responsible for failure of chromosomal disjunction.