Health-related quality of life in long-term survivors of acute lymphoblastic leukemia in childhood and adolescence.

PURPOSE: Children with acute lymphoblastic leukemia (ALL), the commonest form of cancer in this age group, suffer considerable morbidity during treatment, with the majority returning to good health soon after therapy has been completed, as reflected in health-related quality of life (HRQL). However, survivors are at risk of many adverse health outcomes later, including obesity, measured by body mass index (BMI), that is compounded by limited physical activity. This study examined the HRQL of long-term survivors of ALL and its relationship to BMI and physical activity. METHODS: A cohort of 75 subjects who were more than 10 years from diagnosis was assessed for BMI (weight in kg/height in m2) and completed two questionnaires. HRQL was measured by the multi-attribute, preference-based Health Utilities Index (HUI) instrument HUI23S4.15Q designed for self-report, and physical activity was quantified by the Habitual Activity Estimation Scale. RESULTS: The mean utility scores for overall HRQL (HUI2 = 0.88, HUI3 = 0.83) were similar to those in the Canadian and US general population segments of equivalent age (HUI2 = 0.86, HUI3 = 0.85). However, the minimum scores (HUI2 = 0.23, HUI3 = -0.09) revealed a group of survivors with notable disabilities in the attributes of hearing, emotion, cognition, and pain. There were no statistically significant correlations between HRQL and BMI or between HRQL and physical activity, except for deafness and inactivity on weekdays. CONCLUSIONS: Overall, long-term survivors of ALL in childhood enjoy good HRQL but some experience appreciable disability, though this is not associated with BMI or, in the main, with physical activity.

Female embryonic lethality in mice nullizygous for both Msh2 and p53.

The mutator hypothesis of tumorigenesis suggests that loss of chromosomal stability or maintenance functions results in elevated mutation rates, leading to the accumulation of the numerous mutations required for multistep carcinogenesis. The human DNA mismatch repair (MMR) genes are highly conserved homologues of the Escherichia coli MutHLS system, which contribute to genomic stability by surveillance and repair of replication misincorporation errors and exogenous DNA damage. Mutations in one of these MMR genes, hMSH2, account for about half of all cases of genetically linked hereditary non-polyposis colorectal cancer. Loss of function of p53 has also been proposed to increase cellular hypermutability, thereby accelerating carcinogenesis, although a clear role for p53 in genomic instability remains controversial. p53 is mutated frequently in a wide range of human cancers, including colonic tumours. Both Msh2- and p53-targeted knockout mice are viable and susceptible to cancer. Here we demonstrate that combined Msh2 and p53 ablation (Msh2-/-p53-/-) results in developmental arrest of all female embryos at 9.5 days. In contrast, male Msh2-/-p53-/- mice are viable, but succumb to tumours significantly earlier (t1-2 is 73 days) than either Msh2-/- or p53-/- littermates. Furthermore, the frequency of microsatellite instability (MSI) in tumours from Msh2-/-p53-/- mice is not significantly different than in Msh2-/- mice. Synergism in tumorigenesis and independent segregation of the MSI phenotype suggest that Msh2 and p53 are not genetically epistatic.

Severe attenuation of the B cell immune response in Msh2-deficient mice.

Recently, results obtained from mice with targeted inactivations of postreplication DNA mismatch repair (MMR) genes have been interpreted to demonstrate a direct role for MMR in antibody variable (V) gene hypermutation. Here we show that mice that do not express the MMR factor Msh2 have wide-ranging defects in antigen-driven B cell responses. These include lack of progression of the germinal center (GC) reaction associated with increased intra-GC apoptosis, severely diminished antigen-specific immunoglobulin G responses, and near absence of anamnestic responses. Mice heterozygous for the Msh2 deficiency display an "intermediate" phenotype in these regards, suggesting that normal levels of Msh2 expression are critical for the B cell response. Interpretation of the impact of an MMR deficiency on the mechanism of V gene somatic hypermutation could be easily confounded by these perturbations.

Increased hypermutation at G and C nucleotides in immunoglobulin variable genes from mice deficient in the MSH2 mismatch repair protein.

Rearranged immunoglobulin variable genes are extensively mutated after stimulation of B lymphocytes by antigen. Mutations are likely generated by an error-prone DNA polymerase, and the mismatch repair pathway may process the mispairs. To examine the role of the MSH2 mismatch repair protein in hypermutation, Msh2-/- mice were immunized with oxazolone, and B cells were analyzed for mutation in their VkappaOx1 light chain genes. The frequency of mutation in the repair-deficient mice was similar to that in Msh2+/+ mice, showing that MSH2-dependent mismatch repair does not cause hypermutation. However, there was a striking bias for mutations to occur at germline G and C nucleotides. The results suggest that the hypermutation pathway frequently mutates G.C pairs, and a MSH2-dependent pathway preferentially corrects mismatches at G and C.

Spontaneous and mutagen-induced transformation of primary cultures of Msh2-/- p53-/- colonocytes.

Loss of function of mismatch repair (MMR) genes underlies hereditary nonpolyposis colorectal cancer (HNPCC). However, the inability to maintain primary colon epithelial cells in culture has limited the analysis of the contribution of MMR gene defects to colorectal tumorigenesis. We have now established primary cultures of epithelial cells from the colon crypts of Msh2-/- p53-/- double-knockout mice. These cells undergo spontaneous transformation (soft agar colonies and s.c. tumor formation), with a progressively shorter latency as a function of increasing passages in culture. Treatment of early passage cells with the mutagen methylmethane thiosulfonate (MMS) further decreases the transformation latency of Msh2-/- p53-/- cells. Spontaneous transformation of p53-/- colonocytes is only observed using late passage cells, and methylmethane thiosulfonate-treated early passage p53-/- colonocytes do not form tumors when injected into immunodeficient mice. Together, these findings support the pathogenic role of MMR gene inactivation in colorectal tumorigenesis and provide an experimental model for the serial assessment of the molecular phenotype associated with Msh2 deficiency.

Apoptosis induced by overexpression of hMSH2 or hMLH1.

Mutations of the mismatch repair genes hMSH2 and hMLH1 have been found in a high proportion of individuals with hereditary nonpolyposis colon cancer (HNPCC), establishing the link between mismatch repair and cancer. Tumor cell lines that are deficient in mismatch repair develop a mutator phenotype that appears to drive the accumulation of mutations required for tumor development. However, mutations of other mismatch repair genes such as hPMS2 can lead to a mutator phenotype, although inherited mutations of these genes are rare in HNPCC families. Here, we show that overexpression of hMSH2 or hMLH1 but not of hMSH3, hMSH6, or hPMS2 induces apoptosis in either repair-proficient or -deficient cells. Furthermore, primary mouse embryo fibroblasts derived from Msh2-deficient mice lose their ability to undergo apoptosis after treatment with N-methyl-N'-nitro-N-nitrosoguanidine. These results suggest that the mismatch repair proteins hMSH2 and hMLH1 may be components of a pathway that influences apoptosis. We consider the possibility that loss of apoptosis as a result of hMSH2 or hMLH1 deficiency may be an additional factor in cancer predisposition in HNPCC.

Isolation and mapping of a human septin gene to a region on chromosome 17q, commonly deleted in sporadic epithelial ovarian tumors.

Allele losses from chromosome 17 are common in sporadic ovarian tumors. Previously, we reported high rates of LOH (up to 70%) from 17q25 at the marker THH59 in a bank of malignant ovarian tumors. We have extended this study to 70 tumors with 17 markers from the long arm of chromosome 17. In most cases, the data are consistent with whole chromosome loss, but we have identified a minimal region of deletion that is centered around 4 microsatellites with zero recombination at map position 106.9 cM. A P1/BAC contig across the region (approximately 200 kb) was constructed and used to determine the precise position and order of the microsatellites. The contig was shown to hybridize to 17q25 by fluorescence in situ hybridization analysis. The DNA sequence of the entire contig was determined and analyzed by BLAST searches. A 4-kb cDNA was subsequently identified with homology to the yeast, Drosophila and mammalian septin family of genes. We have designated this gene Ovarian/Breast (Ov/Br) septin. Two splice variants were demonstrated within the 200-kb contig, which differ only at exon 1. Within the contig, approximately 45% of the septin alpha transcript was identified and 38% of the septin beta transcript. The septins are a family of genes involved in cytokinesis and cell cycle control. Their known functions are consistent with the hypothesis that the human 17q25 septin gene is a candidate for the ovarian tumor suppressor gene.

C-cell and thyroid epithelial tumours and altered follicular development in transgenic mice expressing the long isoform of MEN 2A RET.

Gain-of-function mutations in the gene encoding the receptor tyrosine kinase RET have been identified as the aetiological factor for multiple endocrine neoplasia type 2A (MEN2A). MEN2A is a dominantly-inherited cancer predisposition syndrome characterized by medullary thyroid carcinoma, a tumour of the calcitonin-producing thyroid C-cells. There are three isoforms of RET: RET9, RET43 and RET51, and although in vitro evidence suggests they vary in cellular transformation activities, little is known about their function in tumorigenesis in vivo. To address this, we used RET51 cDNA to construct mice in which the most frequent MEN2A mutation, Cys-634-Arg, was expressed under the control of the human calcitonin promoter (CT-2A mice). These mice developed C-cell tumours resembling human MTC and follicular tumours resembling human papillary thyroid carcinoma (PTC) depending on the founder line examined. One founder line developed compound MTC/PTC at low frequency (8%) and pancreatic cystadenocarcinoma. CT-2A mice also displayed a developmental defect in thyroid follicular structure, in which much of the thyroid was occupied by large irregular cystic follicles thought to be derived from the ultimobranchial body, a developmental precursor of the thyroid gland. The CT-2A mice will provide a suitable model to further study the effects of the MEN 2A RET mutation in vivo.

Germline homozygous mutations at codon 804 in the RET protooncogene in medullary thyroid carcinoma/multiple endocrine neoplasia type 2A patients.

The effect of mutations at codon 804 in the RET protooncogene is disputed. Some studies have suggested that the V804L mutation causes the low penetrance multiple endocrine neoplasia type 2 syndrome, with late onset and relatively indolent course, whereas others have reported that V804L and V804M have an aggressive potential. In this paper, we report three apparently unrelated medullary thyroid carcinoma cases homozygous for these mutations. To clarify the phenotypic heterogeneity associated with these mutations, we compare the clinical data and age of diagnosis among these three homozygous patients, six other heterozygous cases from the same populations, and other homozygous and heterozygous subjects reported previously. The data are consistent with a model in which codon 804 mutations have low penetrance, the developing of medullary thyroid carcinoma being associated with a second germline or somatic mutation. The activity and (in the case of somatic mutations) timing of these other genetic alterations in the RET gene may explain the wide clinical variability associated with germline mutations at codon 804.

Chromosomal sequences flanking an efficiently expressed transgene dramatically enhance its expression.

The expression of transgenes in mice is influenced strongly by their site of integration in the genome. To test whether the chromosomal sequences immediately flanking a site of integration could positively influence expression we isolated the 5' and 3' chromosomal sequences from an efficiently expressed transgenic locus. These chromosomal sequences were incorporated into transgene constructs and these were then introduced into mice. Linking them to the original transgene dramatically enhanced its expression and conferred a degree of position independent expression upon it. However, the results were not as marked when these sequences were linked to other constructs, showing that the effectiveness of such flanking chromosomal sequences is highly dependent on the nature of the transgene used.

Adenosine induced transient cardiac standstill in catheter interventional procedures for congenital heart disease.

OBJECTIVE: To describe the use of intravenous adenosine to create transient cardiac standstill during balloon dilatation procedures for congenital heart defects. SETTING: A tertiary paediatric cardiac centre. DESIGN AND PATIENTS: This was a prospective pilot study. Thirteen patients born with congenital heart disease and who had stenotic lesions requiring relief were considered for the technique. All were suitable for balloon dilatation. Their ages ranged from 2 months to 30 years, mean (SD) 9.9 (9.8) years. The dose of adenosine varied from 0.125 mg/kg to 0.555 mg/kg, mean 0.33 (0.127). RESULTS: Two patients only developed sinus bradycardia in response to adenosine, which may have been related to the technique of administration. The other 11 experienced a period of asystole, which ranged from 2.4 to 10.8 seconds, mean 4.99 (2.27), and a total atrioventricular block period of 5.0 to 21.2 seconds, mean 9.47 (4.64). The interval between adenosine injection and the onset of asystole varied from 2.4 to 15.8 seconds, mean 8.05 (3.6), depending on cannula size, site of administration, and cardiac output. The peak gradient across the stenotic lesions fell from 52.3 (23.7) to 17.8 (11.9) mm Hg (p < 0.001). Apart from one short episode of atrial fibrillation there were no complications. CONCLUSIONS: Intravenous adenosine is a safe and effective agent for creating transient cardiac standstill during balloon dilatation procedures for congenital heart disease. This achieves stability which is likely to improve results and reduce complications. It may have applications in other fields of cardiac intervention where an immobile heart is desirable during the critical phase of a procedure.

The incidence of post dural puncture headache in children.

One hundred and five children with malignant disease attended for lumbar puncture which was performed under general anaesthesia. A questionnaire was answered over the next three days to determine the incidence of post dural puncture headache Ninety-seven questionnaires were returned and the results show that no child aged under ten years developed a headache. Of the children aged 10-12 years, two out of seventeen developed a headache (11.8%). In children aged 13-18 years, five out of ten developed a headache (50%).

Remifentanil infusion for major abdominal surgery in small infants.

Neonates are known to be sensitive to volatile anaesthetic agents which may lead to prolonged recovery. In this study, a remifentanil infusion was used in conjunction with an infusion of epidural ropivacaine and isoflurane anaesthesia for major abdominal surgery in small infants. This led to a short recovery time for infants aged 7 days to 3 months but a prolonged recovery in those under the age of 7 days. Good perioperative analgesia was achieved.

Assessment of a hygroscopic heat and moisture exchanger for paediatric use.

A laboratory study of a widely available heat and moisture exchanger marketed for paediatric use was undertaken. The deadspace, measured by volume displacement, was 12 ml, similar to that of a standard catheter mount for paediatric use. Pressure drop across the device was measured at several different flows in five samples of the device in both the dry and wet state. Calculated resistance proved to be markedly lower when compared with that of other anaesthetic equipment such as tracheal tubes, and with similar humidification devices for paediatric use.