Diagnostic and Treatment Challenges for Acquired Hemophilia A in Pediatrics: Report of 2 Cases.

Acquired hemophilia A (AHA) occurs rarely in children. We report 2 cases of adolescent females with AHA. The first case underwent bone marrow aspiration/biopsy during workup, which was complicated by bleeding. Bleeding resolved after initiation of therapy with cyclophosphamide and glucocorticoid, but despite the addition of rituximab, she did not achieve complete remission until treatment with intravenous immunoglobulin. In the second case, we observed that a mixing study without incubation will not detect an acquired factor VIII inhibitor, but further workup based on suspicion for AHA led to the correct diagnosis. Both had significant medication toxicity which required treatment modification.

Association of worse prognosis with an aberrant diurnal cortisol rhythm in patients with advanced lung cancer.

A flatter diurnal rhythm of cortisol has been reported to be associated with early mortality in patients with metastatic breast cancer. The clinical stage of disease at the time of diagnosis and the patient's performance status (PS) are known to be important prognostic factors for lung cancer (LC) survival. The authors examined the relationship between diurnal cortisol rhythms and these prognostic factors in patients with advanced LC. Cortisol concentrations were measured in saliva samples collected from 52 patients (37 males/15 females) with advanced LC and from 56 healthy subjects (32 males/24 females) to characterize the diurnal cortisol rhythm, specifically the cortisol awakening response (CAR) and diurnal cortisol decline (DCD). Variations of CAR and DCD in the patients were analyzed according to their clinical disease stage and PS score, and the differences in CAR and DCD between patients and healthy controls were compared. The patient group showed significantly reduced diurnal cortisol secretory activity and rhythmicity, compared with healthy controls. When the patients were subgrouped according to their clinical disease stage, patients with stage 4 disease showed significantly reduced CAR and flatter DCD compared with the healthy controls. However, the CAR and DCD in patients with stage 3a and 3b disease were comparable to those of healthy controls. Neither the CAR nor the DCD showed stepwise changes as the disease stage worsened. When patients were subgrouped according to their Eastern Cooperative Oncology Group (ECOG) PS score, there was stepwise reduction in the CAR and flattening of the DCD as the PS score increased. Both an abolished CAR and a flattened DCD were common in patients with ECOG PS scores of 3 and 4. These results indicate that alteration of the diurnal cortisol rhythm in patients with advanced LC is more closely associated with their PS score than with their clinical disease stage. Gradual alteration of the CAR and DCD, indicative of loss of 24-h cortisol rhythm, in concert with increase in PS score implies that endogenous circadian rhythms may also be disintegrating as the PS score worsens in these patients.

Cellular uptake and photodynamic activity of protein nanocages containing methylene blue photosensitizing drug.

This study reports that photosensitizers encapsulated in supramolecular protein cages can be internalized by tumor cells and can deliver singlet oxygen intracellularly for photodynamic therapy (PDT). As an alternative to other polymeric and/or inorganic nanocarriers and nanoconjugates, which may also deliver photosensitizers to the inside of the target cells, protein nanocages provide a unique vehicle of biological origin for the intracellular delivery of photosensitizing molecules for PDT by protecting the photosensitizers from reactive biomolecules in the cell membranes, and yet providing a coherent, critical mass of destructive power (by way of singlet oxygen) upon specific light irradiation for photodynamic therapy of tumor cells. As a model, we demonstrated the successful encapsulation of methylene blue (MB) in apoferritin via a dissociation-reassembly process controlled by pH. The resulting MB-containing apoferritin nanocages show a positive effect on singlet oxygen production, and cytotoxic effects on MCF-7 human breast adenocarcinoma cells when irradiated at the appropriate wavelength (i.e. 633 nm).

Intranasal endoscopic diagnosis and treatment in congenital nasolacrimal duct obstruction.

BACKGROUND AND OBJECTIVE: To identify the causes of congenital nasolacrimal duct obstruction using intranasal endoscopy. PATIENTS AND METHODS: Eleven children with symptoms of epiphora since birth were selected for treatment. A silicone tube was inserted after identifying the causes of prior probing failures by observing the probing tip directly with intranasal endoscopy. RESULTS: As confirmed through intranasal endoscopic examination, tearing was caused by mucosal obstruction, submucosal passing of the probe, pus collection, and inferior turbinate impaction. The probe passed into the submucosal space in 5 patients and, by performing probing medially instead in the usual posterolateral direction, probing succeeded in 4 patients. One case was accompanied by a bone abnormality; we bent the probe tip into the nasal cavity to form the lacrimal pathway. CONCLUSION: By using intranasal endoscopy, a silicone tube can be inserted under direct visualization and any causative abnormalities can be identified. This can also minimize the intranasal trauma sometimes caused by blind probing.