Thrombotic thrombocytopenic purpura. A case report & review of the literature.

Thrombotic thrombocytopenic purpura (TTP) is a rare potentially fatal disease characterized by disseminated capillary fibrin thrombi. The pathogenesis is complex and involves endothelial and platelet abnormalities. We describe a fatal case of TTP with a brief review of the literature.

Chlorhexidine gluconate (CHG) activity against clinical isolates of vancomycin-resistant Enterococcus faecium (VREF) and the effects of moisturizing agents on CHG residue accumulation on the skin.

The effectiveness of skin decontamination by chlorhexidine gluconate (CHG) in the presence of commonly-used skin moisturizing lotions was evaluated using vancomycin-resistant Enterococcus faecium (VREF) as a representative nosocomial pathogen. Anti-bacterial efficacy was determined in vitro using pigskin preparations inoculated with five VREF clinical isolates to evaluate Calgon Vestal 2 and 4% (by weight) CHG solutions in comparison with Hibiclens Antiseptic Antimicrobial Cleaner (4% CHG solution). Control inocula were determined for each experiment from recovery of VREF harvested directly from the surface of each control piece of skin. These CHG formulations were evaluated in the presence and absence of Calgon Vestal 'Lotion Soft Skin Conditioner' (LSSC) to determine potential interactions of CHG with LSSC, and also with ¿Vaseline Intensive Care' lotion as a CHG-deactivating agent. The 2% Calgon Vestal CHG alone reduced VREF 10(2)-10(3)-fold, as well as 10(3)-10(4)-fold when LSSC was present, and was as efficacious as either 4% CHG solution when these were tested in the presence of LSSC. Four percent Calgon Vestal CHG produced reductions of 10(3)-10(5)-fold with or without LSSC present. Conversely, ¿Hibiclens' showed similar reductions in the presence of LSSC to that for the Calgon Vestal 4% CHG, but only a 10(1)-10(3)-fold reduction without LSSC. ¿Vaseline Intensive Care' lotion completely inactivated the VREF-killing effects for all of the CHG formulations tested, while LSSC and ¿Vaseline Intensive Care' lotion both showed minimal activity alone against these VREF isolates. These results indicate that the Calgon Vestal 2% CHG solution is as effective against VREF, even in the presence of LSSC, as either the 4% Calgon Vestal or Hibiclens 4% CHG formulations; the use of this lower concentration of CHG may be associated with less irritation, particularly with concomitant use of LSSC.

Expression of TrkA, TrkB and TrkC in human neuroblastomas.

There is considerable interest in the role of the TRK family of neurotrophin receptors in regulating the survival, growth and differentiation of normal and neoplastic nerve cells. Indeed, there is increasing evidence that TRK genes play an important role in the biology and clinical behavior of neuroblastomas, tumors of the peripheral nervous system. Evidence from several independent studies suggests that high expression of TrkA is an indicator of favorable outcome, and there is an inverse correlation between TrkA expression and N-myc amplification. In addition, some primary neuroblastomas differentiate in vitro in the presence of NGF but die in its absence. We have evidence that coexpression of full-length TrkB and BDNF is associated with N-myc amplification and may represent an autocrine survival pathway. Conversely, truncated TrkB is expressed predominantly in differentiated tumors. Finally, Trk-C is expressed in favorable neuroblastomas, essentially all of which also express TrkA. In summary, the study of neurotrophin receptor expression and function in neuroblastomas may provide important insights into the role that these pathways play in the pathogenesis and clinical behavior of this tumor. Ultimately, these pathways may provide attractive targets for the development of therapy aimed at inducing differentiation or programmed cell death in these tumors.

Expression and function of the nerve growth factor receptor (TRK-A) in human neuroblastoma cell lines.

Nerve growth factor (NGF) is known to play a critical role in the differentiation and survival of normal sympathetic neurons through its interaction with a specific cell surface receptor. We analyzed ten well-characterized neuroblastoma cell lines for the expression and function of endogenous and exogenous p140TRK-A, and p75LNGFR. Exogenous LNGFR or TRK-A (or both) were introduced by transfection into three neuroblastoma cell lines. Transfected and untransfected neuroblastoma cell lines were analyzed by Northern analysis as well as tyrosine phosphorylation studies. Results indicate that endogenous TRK-A is expressed and/or p140TRK-A is phosphorylated in 10 of 10 cell lines. However, no other downstream responses to NGF stimulation (such as tyrosine phosphorylation of PLC gamma 1, PI-3 kinase, ERK1 and ERK2, induction of FOS and NGFI-A mRNAs, and neurite extension) were observed in the unresponsive cell lines. Transfection with p75LNGFR alone had no effect on responses to NGF stimulation. Three cell lines stably transfected with TRK-A exhibited early responses to NGF stimulation, but neurite extension was not observed. Our results indicate that endogenous TRK-A in non-responsive cell lines is either defective, or present in amounts below a threshold level required to elicit measurable responses to NGF. Furthermore, even after transfection with exogenous TRK-A, early responses were restored but later events such as neurite outgrowth did not occur, suggesting that downstream responsiveness is blocked as well.

Expression and function of TRK-B and BDNF in human neuroblastomas.

There is considerable interest in the role of the TRK family of neuotrophin receptors in regulating growth and differentiation in normal and neoplastic nerve cells. A neuroblastoma is a common pediatric tumor derived from the neural crest, and the majority of favorable neuroblastomas express a high level of TRK-A mRNA. However, little is known about the expression or function of TRK-B in these tumors. TRK-B encodes a tyrosine kinase that binds to brain-derived neuotrophic factor (BDNF), as well as neurotrophin-3 (NT-3) and NT-4/5. We have studied the N-myc-amplified human neuroblastoma cell line, SMS-KCN, which expresses both TRK-B and BDNF. Exogenous BDNF induces tyrosine phosphorylation of TRK-B as well as phosphorylation of phospholipase C-gamma 1, the extracellular signal-regulated kinases 1 and 2, and phosphatidylinositol-3 kinase. BDNF also induces expression of the immediate-early genes c-FOS and NGFI-A but not NGFI-B or NGFI-C. In addition, BDNF appears to promote cell survival and neurite outgrowth. SMS-KCN cells also express TRK-A, which is phosphorylated in response to nerve growth factor. However, the downstream TRK-A signaling is apparently defective. Finally, we determined that in a series of 74 primary neuroblastomas, 36% express TRK-B mRNA, 68% express BDNF mRNA, and 31% express both. Truncated TRK-B appears to be preferentially expressed in more-differentiated tumors (ganglioneuromas and ganglioneuroblastomas), whereas full-length TRK-B is expressed almost exclusively in immature neuroblastomas with N-myc amplification. Our findings suggest that in TRK-B-expressing human neuroblastomas, BDNF promotes survival and induces neurite outgrowth in an autocrine or paracrine manner. The BDNF/TRK-B pathway may be particularly important for growth and differentiation of neuroblastomas with N-myc amplification.

Association between high levels of expression of the TRK gene and favorable outcome in human neuroblastoma.

BACKGROUND AND METHODS: The nerve growth factor receptor is expressed in some neuroblastomas, in which its primary component is encoded by the TRK protooncogene. To determine the relation of the expression of TRK messenger RNA in neuroblastomas to other clinical and laboratory variables, we studied frozen tumor samples from 77 patients. In addition, we tested two primary neuroblastomas that expressed TRK for responsiveness to nerve growth factor. RESULTS: TRK expression strongly correlated with favorable tumor stage (I, II, and IVS vs. III and IV), younger age (< 1 year vs. > or = 1 year), normal N-myc copy number, and low level of N-myc expression. N-myc amplification (indicated by a high copy number) correlated with advanced tumor stage, older age, an adrenal site of the primary tumor, low level of expression of TRK, and high level of expression of N-myc. Analysis of five-year cumulative-survival rates demonstrated an association of a very favorable outcome with a high level of TRK expression (86 percent vs. 14 percent) and with normal N-myc copy number (84 percent vs. 0 percent). Univariate analysis showed that these two variables were the most powerful predictors of outcome (chi-square = 51.30, P < 0.001; and chi-square = 93.61, P < 0.001, respectively). TRK expression still had significant prognostic value when the analysis was restricted to tumors without N-myc amplification. In primary cultures of neuroblastoma cells expressing TRK, exposure to nerve growth factor induced early gene expression and neurite outgrowth, but deprivation of nerve growth factor led to neuronal cell death. CONCLUSIONS: A high level of expression of the TRK proto-oncogene in a neuroblastoma is strongly predictive of a favorable outcome. A tumor with a functional nerve growth factor receptor may be dependent on the neurotrophin nerve growth factor for survival and may regress in its absence, allowing a new approach to the treatment of certain patients with neuroblastoma.

Inverse relationship between trk expression and N-myc amplification in human neuroblastomas.

We examined the expression of the trk protooncogene in a series of 82 neuroblastomas to determine its relationship to N-myc amplification and expression, disease stage, patient age, and survival. We found that virtually all stage I, II, and IV-S patients had moderate to high levels of trk expression, whereas most advanced stage neuroblastomas had low or absent levels. All but one tumor with N-myc amplification had low or absent trk expression, and the one exception was regressing at the time it was resected. Conversely, all neuroblastomas identified by mass screening had moderate to high expression of trk, and all these patients are surviving. Thus, trk expression was associated with an absence of N-myc amplification, lower disease stage, lower patient age, and favorable outcome. Tumors with high trk expression may be more likely to differentiate, regress spontaneously, or respond well to therapy.

Multiple defects of the nerve growth factor receptor in human neuroblastomas.

Neuroblastoma is a tumor of postganglionic sympathetic origin, and nerve growth factor (NGF) is normally required for the survival and differentiation of sympathetic neuroblasts. Since the biological activity of NGF is mediated by the NGF receptor (NGFR), we hypothesized that defects in the NGF/NGFR pathway may play a role in maintenance of the undifferentiated state of neuroblastomas. To test this hypothesis, we examined the structure of the NGFR at the DNA, RNA, and protein levels in a panel of 10 neuroblastoma cell lines. In addition, we examined the function of the NGFR in these lines by analysis of NGF binding kinetics, as well as by the ability of NGF to induce c-fos expression and neurite outgrowth. Southern blot analysis showed that all 10 cell lines possess apparently normal NGFR genes. Northern blot and ligand binding/immunoprecipitation assays revealed four receptor-positive cell lines (NGP, NLF, SK-N-SH, and LA-N-6), with NGFR mRNA and protein of expected sizes (3.8 kilobases and Mr approximately 75,000, respectively). NGF binding assays and Scatchard analyses were performed on the four NGFR-positive lines. The NGP line possesses only low-affinity receptor (Kd approximately 3.5 x 10(-9)), whereas the other three lines express both low- and high-affinity forms (Kd approximately 10(-9) and Kd approximately 10(-11), respectively). However, none of the 10 lines exhibited a response to NGF treatment as assayed by c-fos mRNA induction and neurite extension.(ABSTRACT TRUNCATED AT 250 WORDS)

Phenoxybenzamine in the treatment of causalgia. Report of 40 cases.

Forty consecutive cases of causalgia treated during a 7-year period are presented. The patients ranged in age between 17 and 55 years, and all patients were males who received their nerve injuries from missile or shrapnel wounds. The greater occipital nerve was involved in two cases, median nerve in 10, sciatic nerve in 12, brachial plexus in seven, cauda equina in five, and multiple nerves in four cases. Each patient was treated with phenoxybenzamine, a postsynaptic alpha 1-blocker and presynaptic alpha 2-blocking agent. The drug was given orally in gradually increasing increments until a maximum daily dose of 40 to 120 mg was reached. Duration of treatment was usually 6 to 8 weeks. Total resolution of pain was achieved in all cases. The follow-up period ranged between 6 months and 6 years. Side effects of phenoxybenzamine were minimal and transient, consisting primarily of mild orthostatic hypotension and ejaculatory problems. We conclude that oral phenoxybenzamine is a simple, safe, and effective treatment of causalgia.