Congenital diaphragmatic hernia: a simplified postnatal predictor of outcome.

BACKGROUND/PURPOSE: The incidence of congenital diaphragmatic hernia (CDH) approximates 1 in 3000 births, with mortality rates up to 50%. The ability to accurately and easily predict the outcomes of these infants could be a valuable management tool. The purpose of this study was to develop and validate a simplified clinical method for predicting survival outcomes in infants born with CDH. METHODS: The Wilford Hall/Santa Rosa clinical prediction formula (WHSR(PF) = highest PaO2 - highest PCO2) was generated from arterial blood gas values obtained during the initial 24 hours of life, but before surgical repair or extracorporeal membrane oxygenation, in a local group of infants with CDH identified by prospective and retrospective review. The WHSR(PF) was validated using a comparative group from the Congenital Diaphragmatic Hernia Study Group (CHDSG). Bivariate, multivariable, and area under the receiver operating curve (AUC) analysis was performed using SigmaStat and SPSS statistical programs (SPSS, Chicago, Ill). RESULTS: As initially developed from the local data, the WHSR(PF) had a positive predictive value (PPV) of 82%, a negative predictive value of 88% and AUC of 0.87. When validated against the CDHSG data, the positive predictive value was 83%, negative predictive value was 66%, and AUC 0.79. Area under the receiver operating curve analysis by the previously published CDHSG predictive equation was 0.76. CONCLUSION: This novel formula is an easy to apply clinical tool with similar or better predictive abilities compared to previous methods of predicting survival in infants born with CDH. Currently, no method appears to have sufficient clinical accuracy for predicting the outcome of an individual infant with CDH. Further studies are indicated.

Evidence for expression of early myeloid antigens in mature, non-blast myeloid cells in myelodysplasia.

Myelodysplastic syndromes (MDS) are clonal hematopoietic stem cell disorders with frequent cytogenetic abnormalities. They can arise de novo or be related to therapy. Although blasts in MDS have been studied extensively, there is little information available on the mature, non-blast myeloid cells (NBMCs). We used a retrospective case-control study design. NBMC populations in MDS (48 cases) and in tumor-free control (12 cases) bone marrow samples were analyzed using multiparameter flow cytometry for mean side scatter (SSC) channel number and for expression of aberrant cell surface antigens. MDS cases were stratified on the basis of cytogenetic abnormalities. We report that NBMCs in MDS with normal karyotype expressed significantly higher HLA-DR than controls (P = 0.034). NBMCs in MDS cases with cytogenetic abnormalities and with > or =5% marrow blasts, compared with controls, had significantly higher CD34 and higher HLA-DR but lower CD10 and lower SSC mean channel number. CD34 expression in NBMCs was significantly greater in therapy-related MDS compared with de novo MDS ( P = 0.01), although the presence of cytogenetic abnormalities was not different ( P > 0.05). These data suggest that bone marrow, mature, NBMCs have phenotypic changes in MDS that are not seen in normal controls.

Rapid and accurate detection of monoclonal immunoglobulin heavy chain gene rearrangement by DNA melting curve analysis in the LightCycler System.

The detection of immunoglobulin heavy chain gene rearrangement (IgH-R) is a standard tool for distinguishing polyclonal from monoclonal B-cell populations. Current DNA-based polymerase chain reactions (PCR) strategies can diagnose monoclonal IgH-R either by measuring the length of the amplicon or by detecting gel mobility variations owing to sequence-dependent conformational changes. However, amplification and analysis remain sequential operations usually requiring manual transfer. We have developed a novel PCR strategy for detecting monoclonal IgH-R that monitors fluorescence of the specific double-stranded DNA binding dye SYBR Green I during melting curve analysis using the LightCycler System. We compared polyacrylamide gel electrophoresis (PAGE) versus melting curve analysis in 130 clinical DNA samples from formalin-fixed, paraffin-embedded (FFPE) tissues (mostly skin biopsies) of 128 patients. The identical FR3 primers were used to amplify the IgH variable region for both analytic techniques. We detected IgH-R in 24 DNA samples from FFPE tissue of 22 patients. Melting curve analysis, compared to PAGE, revealed no false negative and no false positive results, yielding both sensitivity and specificity equal to 100%. We also compared Southern blot analysis versus melting curve analysis in 23 clinical DNA samples from fresh-frozen lymph nodes of 23 patients. We detected IgH-R by melting curve analysis in 7 DNA samples from fresh-frozen lymph nodes. Melting curve analysis, compared to Southern blot analysis, revealed sensitivity equal to 58.3% (7 of 12) and specificity equal to 100% (11 of 11). We conclude that continuous fluorescence monitoring of PCR products with DNA melting curve analysis can rapidly and reproducibly distinguish polyclonal from monoclonal B-cell populations.

Frequent mutations in the ligand-binding domain of PML-RARalpha after multiple relapses of acute promyelocytic leukemia: analysis for functional relationship to response to all-trans retinoic acid and histone deacetylase inhibitors in vitro and in vivo.

This study identified missense mutations in the ligand binding domain of the oncoprotein PML-RARalpha in 5 of 8 patients with acute promyelocytic leukemia (APL) with 2 or more relapses and 2 or more previous courses of all-trans retinoic acid (RA)-containing therapy. Four mutations were novel (Lys207Asn, Gly289Arg, Arg294Trp, and Pro407Ser), whereas one had been previously identified (Arg272Gln; normal RARalpha1 codon assignment). Five patients were treated with repeat RA plus phenylbutyrate (PB), a histone deacetylase inhibitor, and one patient experienced a prolonged clinical remission. Of the 5 RA + PB-treated patients, 4 had PML-RARalpha mutations. The Gly289Arg mutation in the clinical responder produced the most defective PML-RARalpha function in the presence of RA with or without sodium butyrate (NaB) or trichostatin A. Relapse APL cells from this patient failed to differentiate in response to RA but partially differentiated in response to NaB alone, which was augmented by RA. In contrast, NaB alone had no differentiation effect on APL cells from another mutant case (Pro407Ser) but enhanced differentiation induced by RA. These results indicate that PML-RARalpha mutations occurred with high frequency after multiple RA treatment relapses, indicate that the functional potential of PML-RARalpha was not correlated with clinical response to RA + PB treatment, and suggest that the response to RA + PB therapy in one patient was related to the ability of PB to circumvent the blocked RA-regulated gene response pathway.