Drug-induced hyperthermia with rhabdomyolysis in CLN3 disease.

CLN3 disease (MIM# 204200), the most prevalent of the neuronal ceroid lipofuscinoses (NCL), is an autosomal recessive disorder with juvenile onset characterized by blindness, epilepsy, dementia, psychiatric manifestations, and motor deterioration. Problems related to behavior, emotions and thought are among the main features. Antidepressant and antipsychotic drugs have been employed with variable results. Neuroleptic malignant syndrome (NMS) has previously been described in two patients with NCL, one with CLN3 disease and one with adult onset NCL of unclear genetic origin. Our aims were to describe the occurrence of drug-induced hyperthermia in pediatric patients with CLN3 disease from West and South Sweden and to delineate the range of associated clinical features. Our study identified four patients presenting with seven episodes of severe drug-induced hyperthermia and either NMS-like or Serotonin syndrome (SS)-like features. Possibly provoking drugs were risperidone, clozapine, olanzapine, haloperidol, quetiapine, and sertraline. The course was atypical, frequently prolonged, associated with rhabdomyolysis and status dystonicus, and resulted in the death of three of the patients. Our study points to a vulnerability to drug-induced hyperthermia in patients with CLN3 disease which we believe could be underreported. Interestingly the proposed pathophysiological mechanisms behind NMS and SS on one hand and CLN3 on the other hand seem to converge in a common mechanism involving dysregulation of the sympathetic nervous system.

Prenatal exposure to acetaminophen and children's language development at 30 months.

OBJECTIVE: To examine prenatal APAP exposure in relation to language development in offspring at 30 months of age. METHOD: A population-based pregnancy cohort study including 754 women who enrolled in the Swedish Environmental Longitudinal, Mother and child, Asthma and allergy (SELMA) study in pregnancy week 8-13. Two exposure measures were used: (1) maternally reported number of APAP tablets taken between conception and enrollment; (2) APAP urinary concentration at enrollment. Language development at 30 months was assessed by nurse's evaluation and parental questionnaire, including the number of words the child used (<25, 25-50 and >50). Main study outcome; parental report of use of fewer than 50 words, termed language delay (LD). RESULTS: 59.2% of women enrolled in weeks 8-13 reported taking APAP between conception and enrollment. APAP was measurable in all urine samples and urinary APAP was correlated with the number of APAP taken during pregnancy (P<0.01). Language delay was more prevalent in boys (12.6%) than girls (4.1%) (8.5% in total). Both the number of APAP tablets and urinary APAP concentration were associated with greater LD in girls but not in boys. The adjusted odds ratio (OR) for LD among girls whose mothers reported >6 vs. 0 APAP tablets was 5.92 (95% confidence interval (CI) 1.10-31.94). The OR for LD in girls whose mothers' urinary APAP was in the highest compared to the lowest quartile was 10.34 (95% CI 1.37-77.86). While it cannot be ruled out, our available data do not support confounding by indication. CONCLUSIONS: Given the prevalence of prenatal APAP use and the importance of language development, these findings, if replicated, would suggest that pregnant women should limit their use of this analgesic during pregnancy.

Germ cell apoptosis after treatment of cryptorchidism with human chorionic gonadotropin is associated with impaired reproductive function in the adult.

Cryptorchidism results in impaired fertility. Reduced numbers of testicular germ cells can be shown histologically during the first years of life. The process causing germ cell loss in cryptorchid prepubertal boys is unknown, but it could be the result of a form of programmed cell death known as apoptosis. 25 adult men with a history of surgically treated cryptorchidism were studied, 15 of whom had received an unsuccessful human chorionic gonadotropin (hCG) therapy before orchidopexy. Apoptotic DNA fragmentation was assayed in testis biopsies taken during orchidopexy by end-labeling, both in extracted DNA and histochemically in situ. Only a few scattered apoptotic spermatogonias were seen by end-labeling of biopsies from patients not treated with hCG, whereas more extensive labeling of spermatogonia was seen after hCG treatment. As estimated by gel electrophoresis, the amount of low molecular weight DNA was 4.3-fold higher in the hCG-treated group when compared with the level in scrotal testis of non-hCG-treated patients (P < 0.001). About 20 yr after the biopsy, the low molecular weight DNA fragmentation correlated negatively with the testis volume (r = -0.84; P < 0.001) and positively with serum FSH levels (r = 0.73; P < 0.001). Findings in the semen analysis were similar between the groups. Apoptotic loss of spermatogonia after hCG treatment of cryptorchidism warrants reevaluation of the safety of this treatment.

A 19-year review of paediatric patients with acute scrotum.

BACKGROUND AND AIMS: The aim of the study was to compare incidence, symptoms and signs of spermatic cord torsion to those of other conditions causing acute scrotum. MATERIAL AND METHODS: Records of 388 consecutive boys under 17 years of age treated for acute scrotum at The Hospital for Children and Adolescents in Helsinki in 1977-1995 were reviewed. During the period studied all patients with acute scrotum underwent urgent surgery to ensure accurate diagnosis and treatment. The duration and characteristics of the symptoms, clinical findings prior to operation and the age of the patients were registered. RESULTS: Scrotal explorations revealed 100 cases (26%) of spermatic cord torsion (SCT), 174 cases (45%) of torsion of the testicular appendage (AT), 38 cases (10%) of epididymitis (ED), 32 cases (8%) of incarcerated inquinal hernias and 44 (11%) other conditions. During the first year of life SCT was the most common cause of acute scrotum, another peak incidence being in adolescence. Almost half of the boys with AT were nine to 12 years of age (median 11). Except for infants, the patients' acute symptoms were pain (SCT 88%, AT 94%, ED 76%). Swelling in the hemiscrotum was found in 44% of SCT, in 39% of AT and in 88% of ED cases. Epididymitis was also accompanied by erythema (37%), but infrequently with fever (in 16%). Erythema was found also in AT (32%), but the "blue dot sign" was found positive in only 17 (10%) of the boys with AT. Three quarters of the boys who were operated on within six hours from onset of symptoms had testicle torsion. All testicles were saved when detorsion was performed within six hours, but salvage was possible in only half of the cases when symptoms had lasted more than six but less than 12 hours. CONCLUSIONS: The high probability of SCT among those admitted to an emergency department within six hours from the onset of the symptoms justifies immediate surgical exploration.

Urinary excretion of dicarboxylic acids from patients with the Zellweger syndrome. Importance of peroxisomes in beta-oxidation of dicarboxylic acids.

The urinary excretion of adipic acid, suberic acid and sebacic acid from two patients with the cerebrohepato-renal syndrome of Zellweger was studied. The patients had a complete lack of peroxisomes in the liver as judged by electron microscopy. In the non-ketotic state, the total excretion of free and conjugated adipic acid, suberic acid and sebacic acid was increased by about 100%, 200% and 350%, respectively, as compared to the corresponding excretion from six healthy infants of the same age. The excretion of free dicarboxylic acid was increased to a considerably lesser extent than the free + conjugated dicarboxylic acid. In view of the presence of adipic acid in urine of the Zellweger patients, it is concluded that peroxisomes are not obligatory for beta-oxidation of medium-chain dicarboxylic acids in vivo. The relative accumulation of suberic acid and sebacic acid as compared to adipic acid is, however, consistent with a relative block in the conversion of suberic acid and sebacic acid into adipic acid in patients with the Zellweger syndrome.

Percutaneous needle biopsy preceding preoperative chemotherapy in the management of massive renal tumors in children.

While the National Wilms' Tumor Study (NWTS) Group in the United States puts an emphasis on accurate staging and histology before any therapy is given for Wilms' tumor, the International Society of Pediatric Oncology (SIOP) in Europe focuses on preoperative therapy and safer surgery. Our current approach combines the benefits of both policies in the management of massive renal tumors in children. In seven consecutive patients we first obtained a percutaneous posterior needle biopsy to obtain adequate tissue for histology, and proceeded with preoperative chemotherapy with vincristine and dactinomycin until tumor shrinkage was sufficient. Tumor removals were feasible and uneventful. At the time of operation, two tumors were found to be totally or almost totally necrotic. In the others, which still included viable tumor, the histology corresponded well to the needle biopsy findings. One case with unfavorable histology and one with rhabdoid sarcoma would have been missed and given suboptimal therapy without the primary needle biopsy. As possible biopsy-related complications, subcapsular intratumoral bleeding was recognized in two patients. We conclude that percutaneous posterior needle biopsy is safe and yields definite, detailed histology in massive renal tumors in children. Preoperative chemotherapy facilitates surgery in these patients.

In vivo purging of bone marrow in children with poor-risk neuroblastoma for marrow collection and autologous bone marrow transplantation.

PURPOSE: To evaluate the following prospectively in poor-risk neuroblastoma (NBL) patients: (1) the feasibility and efficacy of in vivo purging of bone marrow; and (2) the outcome after autologous bone marrow transplantation (ABMT) when immunologically tumor-free, unpurged autografts were used. PATIENTS AND METHODS: Twenty-three children with poor-risk NBL were evaluated during induction chemotherapy by repeat bone marrow examinations, including aspirate, biopsy, and an immunofluorescence method using the anti-GD2 monoclonal antibody 3A7. Nineteen patients completed the program with surgery with or without local irradiation followed by ABMT. RESULTS: Autologous bone marrow grafts, both immunologically and cytologically clean, were obtained and used in 19 of 23 children. The overall 4-year disease-free survival of the 19 grafted children was 53%, with a toxic death rate of 16% and a posttransplant relapse rate of 37%. According to the in vivo purging efficacy of the 18 children with initial marrow disease, the following three groups were formed: patients with (1) perfect in vivo purging (n = 5); (2) eventually successful in vivo purging (n = 8); and (3) unsuccesful in vivo purging (n = 5). The 4-year DFS was 100%, 67%, and 0%, respectively (P < 0.001). The five patients with unsuccessful in vivo purging failed because of resistant/progressive bulky disease. CONCLUSION: In patients with poor-risk NBL, in vivo purging of bone marrow by conventional chemotherapy is feasible, can be monitored, and the purging efficacy during the first 3 months after diagnosis is a strong prognostic factor reflecting tumor responsiveness to therapy. Autografting with immunologically clean, unpurged marrows gives a DFS well comparable to previous studies using ex vivo purging.

Predictive factors associated with significant urinary tract abnormalities in infants with pyelonephritis.

BACKGROUND: Major urinary tract abnormalities are detected in 20 to 40% of infants with acute pyelonephritis (APN). Early detection of structural defects is essential for protecting the kidneys from reinfection and subsequent scarring. The purpose of this study was to investigate whether any factors present during the acute phase of infection could predict the presence of existing significant urinary tract abnormalities in infants. METHODS: A prospective study of 180 infants, aged 1 to 24 months, with APN was conducted. Blood and urine samples were collected. Renal ultrasound (US) was performed within 0 to 6 days from admission. Final diagnosis of the urinary tract anatomy was elucidated using the results of two or more radiologic imaging studies. RESULTS: Risk factors for the presence of significant urinary tract abnormalities in infants were pathogens other than Escherichia coli in urine [relative risk (RR) 3.4, 95% confidence interval (CI) 2.2 to 5.3; P = 0.001], positive blood culture (RR 2.3, 95% CI 1.3 to 4.0; P = 0.039), young age (1 to 6 months) (RR 2.2, 95% CI 1.3 to 3.9; P = 0.004), lack of papG adhesin genes of E. coli in urine (RR 2.1, 95% CI 1.2 to 3.9; P = 0.016) and abnormal renal US (RR 2.0, 95% CI 1.2 to 3.4; P = 0.008). CONCLUSIONS: Infants 1 to 6 months of age with APN caused by bacteria other than E. coli or by papG-negative E. coli strain, positive blood culture and abnormal renal US carry an increased risk for significant urinary tract abnormalities and need enforced follow-up.

Maximal preservation of renal function in patients with bilateral Wilms' tumor: therapeutic strategy of late kidney-sparing surgery and replacement of radiotherapy by high-dose melphalan and stem cell rescue.

In children with bilateral Wilms' tumor, the therapy should aim at maximal preservation of renal parenchyma and function. Local radiotherapy may give rise to second malignant neoplasms and may impair renal function. We present a therapeutic strategy without any irradiation. Three children were diagnosed with bilateral Wilms' tumor at ages from 6 months to 5 years. Each patient had a massive tumor with local stage III on one side; one had pulmonary metastases. The therapeutic strategy was first to obtain tissue for histology by percutaneous needle biopsy, to administer pre-operative chemotherapy until desired tumor shrinkage, and then to perform kidney-sparing resective surgery. After a period of conventional chemotherapy, the patients were consolidated with high-dose (HD) melphalan and ABMT. Renal parenchyma spared post-surgery (right/left) was 0%/70%, 60%/40% and 40%/60% of the original kidney volumes. The toxicity of the ABMT procedure was mild, the patients engrafted promptly, and were discharged on days +14 to +27. All patients survive disease-free, 3 years 4 months to 4 years 5 months post-transplant. Our program resulted in good preservation of renal parenchyma and normal function, and we consider the risk of this ABMT program smaller than the late consequences of local radiotherapy for children with bilateral Wilms' tumor. The therapeutic strategy described merits further evaluation.

Comparative genomic hybridization reveals changes in DNA-copy number in poor-risk neuroblastoma.

Aggressive neuroblastoma remains a therapeutic challenge, and additional understanding of its biology is of paramount importance. Changes in DNA-copy number were analysed in the neuroblastoma cells of 27 patients using comparative genomic hybridization (CGH). Eighteen of the patients had a poor risk disease (16/18 stage IV) and 9 had a non-poor-risk disease (3/9 stage I-II, 2/9 stage III, and 4/9 stage IVS). Changes in DNA-copy number were detected in 72% of the poor-risk and 22% of the non-poor-risk tumors with gains of chromosomal material being more prevalent than losses. Gains were most common in chromosomes 2, 7, and 17 and losses in chromosome 11. Changes in DNA-copy number were multiple in all but one of the patients with poor-risk disease. The applicability of CGH in studies on the genomic changes in pediatric malignancies is demonstrated by our data also adding weight to the argument of multiple elements with oncogenic and/or tumor suppressor potential being involved in the aggressive phenotype of poor-risk neuroblastoma.

A new rat model of arterial thrombosis with a platelet-rich head and an erythrocyte-rich tail: thrombolysis experiments with specific thrombin inhibition.

A model for thrombolysis in rats was developed. Repeated, focal external heating was applied to the carotid artery which leads to the development of a cyclic blood flow with slow, steady decreases followed by abrupt increases. When this cyclic blood flow stops spontaneously, the entire arterial segment (approximately 10 mm) can be demarcated with snares to create an arterial thrombus of fixed size, with a platelet-rich head and an erythrocyte-rich tail. The usefulness of the model was tested by evaluating the thrombolysis induced by a low dose of recombinant tissue-type plasminogen activator (rt-PA) alone and rt-PA in combination with standard heparin and recombinant hirudin. Re-canalization of the artery was measured as blood flow and as the residual 125I-radioactivity in the artery at the end of the experiment, resulting from 125I-fibrinogen incorporated during the formation of the thrombus. Both blood flow and 125I-activity measurements show that hirudin, but not heparin in combination with rt-PA, significantly improves thrombolysis, which is in accordance with previous experimental findings. It is concluded that the model, with a thrombus resembling the thrombus found in man after coronary occlusion, enables complicated experiments with thrombolysis frequently performed only in large animals to be performed in rats.

Bilateral Wilms' tumor and secondary malignancies.

A series of six patients with bilateral Wilms' tumor (nephroblastoma) is presented. Multimodal therapy yielded a survival rate of 83% at 2 yr of follow-up. However, at the end of a later follow-up period only two patients (33%) were alive. of the 4 patients who died. Only 1 died of Wilms' tumor. One died of complications of aggressive chemotherapy and two patients died after 12 and 16 yr following treatment of secondary malignant tumors arising in the irradiated region. Patients with bilateral tumor should be followed at regular intervals for the duration of life for the occurrence of secondary malignant tumors.

The low temperature vacuum embedding technique for X-ray microanalysis of the developing inner ear.

The method of low-temperature embedding in vacuo using methacrylate resins, was tested for X-ray microanalysis of the embryonic inner ear of the CBA/CBA mouse. Fetal inner ears were examined on gestational days 16 and 18. The technique was evaluated in comparison with earlier used preparation techniques for X-ray microanalysis. With plastic embedding, an improvement of the morphological resolution was achieved, which allows reliable structural identification on the subcellular level. Furthermore, the possibility of orientating of the specimen prior to sectioning provides a better controlled and less time-consuming sectioning.

Early development of the stato-acoustic and facial ganglia.

The early embryonic development of the stato-acoustic and geniculate ganglia was documented in CBA/CBA mice by light and transmission electron microscopy. The geniculate ganglion was identified at the 12-15 somite stage with its origin from the epibranchial placode as well as the neural crest. The VIII ganglion develops later at the 25-27 somite stage, having its origin both in the otic vesicle and in the neural crest cells.

X-ray microanalytic studies on developing otoconia.

The onset of otoconial development in the macula utriculi in CBA/CBA mice occurs on the fifteenth and sixteenth gestational days. Our study was concentrated on the early secretion of calcium in the areas of otoconial formation. The epithelial origin of otoconia is documented. Protrusions from supporting cells in the utricular and saccular epithelia contain very large quantities of calcium in addition to the normal cytoplasmic content of elements. The cell protrusions have an elemental composition clearly differing from that of otoconia as well as from neighbouring utricular cells with protrusions. A directed flow of calcium to developing otoconia from the supporting cells of the maculae is suggested.

Microanalytic and light microscopic studies on the developing otic capsule.

The structure of the middle layer of the bone of the otic capsule is histologically unique: it is of endochondral origin, has no Haversian canals and the ossification develops from several centres which fuse to form the hardest bone in the body. Our study has been concentrated on the development of the otic capsule in the CBA/CBA mouse, followed from the 13th gestational day to early postnatal age. In the 14th gestational day inner ear, a condensation of mesenchyme is detected around the membranous labyrinth. A cartilaginous capsule is present on the 15th-16th gestational day. Prior to birth, ossification centres occur close to the stapedial footplate. Serial cryosectioning of the newborn inner ear reveals very few regions containing high levels of calcium (microprobe analysis) although by light microscopy, several ossification centres can be identified.

Developmental stage-dependent pattern of inner ear expression of intermediate filaments.

The expression of vimentin, cytokeratins (CKs) and neurofilament (NF) proteins was analysed (using monoclonal antibodies) in the mouse inner ear at the otocyst stage (13th gestational day), when organogenesis was largely completed (16th gestational day) and at birth (21st gestational day). Co-expression of vimentin and CKs occurred at the otocyst stage. On the 16th gestational day, most epithelial cells lacked immunoreactivity for vimentin and considerable variation in CK positivity was found between different regions of the epithelial lining. At birth, CK positivity was lacking in the developing organ of Corti but was present in other types of epithelium lining the scala media. In the vestibular half of the labyrinth, positivity for CKs was found at the apical surfaces of both sensory cells and supporting cells and in epithelia lining the membranous labyrinth. Vimentin positivity occurred in the greater epithelial ridge of the differentiating organ of Corti. Even at this stage the statoacoustic ganglion comprised two subpopulations of ganglion cells: those staining for NF proteins and those lacking this immunoreactivity. Thus, as the inner ear matures, a pattern of cytoskeletal reorganization occurs that is dependent on developmental stage.

The effect of digitalis on regional ischaemia of the rat small intestine.

Research in recent years has shown that under certain conditions digitalis has a strong vasoconstrictive effect in the splanchnic region. This may imply that in cases of mesenteric ischaemia, digitalization may inhibit a collateral circulation necessary for restoration of the intestinal function. In this investigation the effect of digitoxin on the exchange circulation of the small bowel mucosa was studied in rats with induced regional ischaemia of the intestine. On analysis 30 min after establishment of the ischaemia a statistically significant negative effect of digitoxin was observed.

Microsphere measurement of regional intestinal blood supply and cardiac output in the rat.

The regional blood supply to consecutive segments of the small intestine in the anaesthetized rat was investigated with a radioactive microsphere technique. A blood flow gradient with the lowest flow in the distal segments (0.85--0.89 ml/min.g) and the highest in the proximal segments (1.13--1.15 ml/min.g) was observed. Very few microspheres were found in the portal vein blood, indicating negligible arteriovenous shunting in the splanchnic area. The mean cardiac outputs in two consecutive measurements were 27.9 and 28.7 ml/min . 100 g, respectively. The cardiac output and regional blood flow values were in accordance with those obtained with other techniques.

Effects of transcutaneous nerve stimulation on the microcirculation in chronic leg ulcers.

The purpose of this study was to find out to what extent transcutaneous electrical nerve stimulation (TENS) affects the blood flow in and around chronic lower leg ulcers, as measured with a new technique, laser Doppler imaging (LDI). Fifteen patients, mean age 73 years (range 38-85) with chronic leg ulcers of various causes participated in the study. The duration of the ulcers ranged from 3 months to 16 years. Low-frequency (2 Hz; 10-45 mA) TENS was given for 60 minutes. The changes in blood flow were measured every 5 minutes by LDI. After 60 minutes, mean blood flow had increased in the ulcer by 35%, and in the intact skin surrounding the ulcer by 15%. Even 15 minutes after the TENS had finished there was still a mean blood flow increase of 29% in the ulcer and 9% in the skin. The present results show that TENS has a stimulating effect on local blood circulation in and around chronic ulcers.