Differential DNA methylation patterns of small B-cell lymphoma subclasses with different clinical behavior.

Non-Hodgkin's lymphoma (NHL) is a group of malignancies of the immune system with variable clinical behaviors and diverse molecular features. Despite the progress made in classification of NHLs based on classical methods, molecular classifications are a work in progress. Toward this goal, we used an array-based technique called differential methylation hybridization (DMH) to study small B-cell lymphoma (SBCL) subtypes. A total of 43 genomic DMH experiments were performed. From these results, several statistical methods were used to generate a set of differentially methylated genes for further validation. Methylation of LHX2, POU3F3, HOXC10, NRP2, PRKCE, RAMP, MLLT2, NKX6.1, LRP1B and ARF4 was validated in cell lines and patient samples and demonstrated subtype-related preferential methylation patterns. For LHX2 and LRP1B, bisulfite sequencing, real-time reverse transcriptase-polymerase chain reaction and induction of gene expression following treatment with the demethylating agent, 5'-aza-2'-deoxycytidine, were confirmed. This new epigenetic information is helping to define molecular portraits of distinct subtypes of SBCL that are not recognized by current classification systems and provides valuable potential insights into the biology of these tumors.

A novel treadmill protocol for exercise testing in children: the British Columbia Children's Hospital protocol.

BACKGROUND: Exercise testing in children is widely recommended for a number of clinical and prescriptive reasons. Many institutions continue to use the Bruce protocol for treadmill testing; however, with its incremental changes in speed and grade, it has challenges for practical application in children. We have developed a novel institutional protocol (British Columbia Children's Hospital (BCCH)), which may have better utility in paediatric populations. AIM: To determine if our institutional protocol yields similar peak responses in minute ventilation (VE), oxygen consumption (VO2), carbon dioxide production (VCO2), respiratory exchange ratio (RER), metabolic equivalents (METS) and heart rate (HR) when compared with the traditional Bruce protocol. METHODS: On two different occasions, 70 children (boys=33; girls=37) aged 10-18 years completed an exercise test on a treadmill using each of the protocols. During each test, metabolic gas exchange parameters were measured. HR was monitored continuously during exercise using an HR monitor. RESULTS: Physiological variables were similar between the two protocols (median (IQR); rs): VE (L/min) (BCCH=96.7 (72.0-110.2); Bruce=99.2 (75.6-120.0); rs=0.95), peak VO2 (mL/min) (BCCH=2897 (2342-3807); Bruce=2901 (2427-3654); rs=0.94) and METS (BCCH=16.2 (14.8-17.7); Bruce=16.4 (14.7-17.9); rs=0.89). RERs were similar (BCCH=1.00 (0.96-1.02); Bruce=1.03 (0.99-1.07); rs=0.48). Total exercise time (in seconds) was longer for the BCCH protocol: BCCH=915 (829-1005); Bruce=810 (750-919); rs=0.67. CONCLUSION: The BCCH protocol produces similar peak exercise responses to the Bruce protocol and provides an alternative for clinical exercise testing in children.

A Doppler Echocardiographic Study of the Myocardial Inotropic Response to Peak Semisupine Exercise in Healthy Children: Development of a Simplified Index of Myocardial Reserve.

BACKGROUND: Stress echocardiography has been advocated for the detection of abnormal myocardial function and unmasking diminished myocardial reserve in pediatric patients. The aim of this study was to create a simplified index of myocardial reserve, derived from the myocardial inotropic response to peak semisupine exercise in healthy children, and illustrate its applicability in a sample of pediatric oncology patients. METHODS: In this prospective analysis, children (7-18 years of age) with normal cardiac structure and function performed semisupine stress echocardiography to volitional fatigue. The quotient of wall stress at peak systole and heart rate-corrected velocity of circumferential fiber shortening were calculated at baseline and at peak exercise, the difference of which was termed the index of myocardial reserve (IMR). The IMR was also calculated in a retrospective sample of pediatric oncology patients with normal resting left ventricular function who had received anthracycline treatment and had performed the same exercise protocol to illustrate utility. RESULTS: Fifty healthy subjects (mean age, 13.2 ± 2.6 years) and 33 oncology patients (mean age, 12.7 ± 4.0 years) were assessed. In the healthy children at peak exercise, heart rate-corrected velocity of circumferential fiber shortening significantly increased (from 1.17 ± 0.17 to 1.58 ± 0.24 circ · sec-1, P < .001), while the quotient of wall stress at peak systole significantly decreased (from 75.3 ± 17.1 to 55.3 ± 13.8 g · cm-2, P < .001), shifting the plot of the relationship between the two parameters upward and to the left. The mean IMR was -30.8 ± 17.8, and the normal distribution ranged from -4.7 (fifth percentile) to -67.3 (95th percentile). The IMR was abnormal in 10 oncology patients who were treated with anthracyclines. CONCLUSIONS: The authors have developed a novel IMR. Relative to the normal distribution of this IMR in healthy subjects, it is possible to identify patients with abnormal myocardial reserve. Thus, this study demonstrates the application of the IMR to aid in clinical decision making in individual patients.

Guidelines for the medical management of Irish children and adolescents with Down syndrome.

Down syndrome (DS) is the most common chromosomal cause of developmental disability in Ireland. Children with DS have a high incidence of associated treatable medical disorders where early intervention carries a better outcome. Currently there are no agreed protocols for the screening and management of children and adults with DS in Ireland. A cross-sectional study of 394 children and adolescents was undertaken in the Eastern Regional Health Authority (ERHA) to assess the medical needs of children and adolescents with DS, in order to develop medical management guidelines. This study provides evidence-based data that children and adolescents with DS have a high incidence of treatable medical disorders, which supports the need for the medical management guidelines presented.

A new natriuretic peptide isolated from cardiac atria of trout, Oncorhynchus mykiss.

Atrial and brain natriuretic peptides (ANP and BNP, respectively) are two cardiac natriuretic peptides (NPs) found in tetrapods from amphibians to mammals, whereas ANP and ventricular NP (VNP) have been identified in eel hearts. Because VNP has also been found in the rainbow trout ventricle, we attempted to isolate NP from trout cardiac atria in order to determine whether ANP and VNP are common cardiac NPs in teleosts. In the present experiments, we isolated VNP and a novel atrial NP consisting of 29 amino acid residues from the atria. This new trout NP exhibited similar sequence identity to mammalian ANP and BNP (50-60%). Its homology to eel ANP was low (52%) compared with high homology of trout and eel VNP (78%). Based on yield, the content of this new NP in trout atria may be even smaller than that of VNP. The new trout atrial NP exhibited low relaxant activity in the chick rectum (only 1/10 of that of trout VNP), and extremely low vasorelaxant activity in the rat aortic strip (only 1/400 of that of human ANP). However, the new trout NP was equipotent with trout VNP and human ANP in relaxing trout epibranchial artery. Based on the sequence similarity with other NPs and on atrial content, the new NP isolated from trout atria cannot yet be assigned to a known member of the NP family.

Elective mapping and surgical division of the bundle of Kent in a patient with Ebstein's anomaly who required tricuspid valve replacement.

A 14 year old girl with Ebstein's anomaly and Wolff-Parkinson-White syndrome without supraventricular tachycardia underwent closure of an atrial septal defect and tricuspid valve commissurotomy. Her postoperative course was complicated by her first episodes of recurrent debilitating paroxysmal supraventricular tachycardia. Severe tricuspid insufficiency with low cardiac output necessitated a repeat intracardiac operation. At reoperation the patient underwent successful tricuspid valve replacement with concomitent cardiac mapping and division of the bundle of Kent. In patients with heart disease requiring intracardiac repair who also have Wolff-Parkinson-White syndrome, elective surgical division of the anomalous bundle is recommended whether or not preoperative attacks of tachycardia have occurred.

Hemodynamic effects of dobutamine in children.

Dobutamine is useful for augmenting cardiovasuclar function in adults. However, no information is available on the action of dobutamine in children. To determine its hemodynamic effects in children, we infused dobutamine into 12 children with congenital heart disease during diagnostic cardiac catheterization. We administered dobutamine in two doses: first 2 and then 7.75 microgram/kg per min for 10 minutes each. We meaured heart rate, cardiac output, systemic and pulmonary arterial, right atrial and pulmonary capillary blood pressures before and during the infusion of dobutamine. Systemic and pulmonary vascular resistances, cardiac index and stroke index were calculated. Cardiac output, cardiac index, stroke volume, stroke index and systemic arterial phasic and mean blood pressures increased sugnificantly (P less than 0.05) and pulmonary capillary mean blood pressure decreased significantly (P less than 0.05) during the infusion of each dose of dobutamine compared with control values. Heart rate, pulmonary and right atrial mean blood pressure and systemic and pulmonary vascular resistance were unchanged with either dose of dobutamine. We noted no adverse effect from the drug.

Mechanisms of cardiac arrhythmias after the Mustard operation for transposition of the great arteries.

To determine the mechanisms of the cardiac arrhythmias frequently seen after the Mustard operation for transposition of the great arteries, intracardiac electrophysiologic studies were performed in 52 children 1 to 8 years after the Mustard operation. Sinus nodal automaticity as judged from the response to rapid atrial pacing was abnormal in 28 of the 52 children. Sinoatrial conduction (conduction of the sinus impulse to the atrium) was found to be abnormal in three of nine patients studied with the atrial extrastimulus method. Conduction of the sinus impulse from the high right atrium to the atrioventricular (A-V) node was abnormally delayed in only 2 of 41 subjects. The low lateral wall of the right atrium was depolarized late in 3 of 11 subjects (including the preceding 2). Two subjects showed delayed A-V nodal conduction and one delayed His-Purkinje conduction. The mechanism of supraventricular tachycardia induced in the laboratory was determined to be sinoatrial nodal reentry in four subjects and atrial muscle reentry in four. Two of the four with atrial muscle reentry had prolonged high right atrium to low lateral right atrium intervals during sinus rhythm. Thus, damage to the sinus node remains the most common cause of arrhythmias after the Mustard operation. In addition, delayed atrial conduction may predispose to atrial muscle reentrant tachycardia.

The hemodynamic effect of dopamine in children.

Although dopamine is a useful therapeutic agent to augment cardiac function in adults, there is little information about the hemodynamic effects of dopamine in children. To delineate the hemodynamic effects of dopamine in children, we infused two doses of dopamine (2 and 7.75 micrograms/kg/min) into 10 children during diagnostic cardiac catheterization. We measured heart rate, systemic arterial, pulmonary arterial, right atrial, and pulmonary capillary blood pressure, and cardiac output. During infusion of 7.75 micrograms/kg/min of dopamine, cardiac index increased from 3.9 to 5.4 L/min/m2, stroke volume increased from 43 to 57 ml/stroke and systemic vascular resistance declined from 1,697 to 1,165 dynes-cm-5-sec-m2. These indices also were changed significantly from control during infusion of 2 micrograms/kg/min of dopamine. The ratio of mean pulmonary arterial blood pressure to mean systemic arterial blood pressure in one patient with pulmonary vascular obstructive disease increased from 0.73 to 1.15, and ventricular bigeminy occurred during infusion of 7.75 micrograms/kg/min of dopamine. Dopamine is a potentially useful inotropic agent in children, but the use of dopamine may be contraindicated in patients with elevated and fixed vascular resistance.

Ventricular septal defect with associated aortic valve insufficiency. Progression of insufficiency and operative results in young children.

Thirty-two children with both ventricular septal defect (VSD) and aortic insufficiency (AI) were evaluated for progression in degree of AI as well as effectiveness of operation in reducing or eliminating regurgitation. At the time of initial study. AI was mild in 21, moderate in eight, and severe in three patients. Twenty-one patients were followed medically over a 2 year to 19 year period, during which the degree of AI progressed in five. One death occurred during an episode of endocarditis. A total of 24 patients underwent operation at ages ranging from 1 year to 23 years. Postoperative evaluations continued from a minimum of 1 year to 24 years in 19 patients, with residual AI noted in 63% of these. Children less than 5 years of age, even with little valvular involvement, exhibited minimal benefit from attempted correction compared with those in the latter part of the first decade of life (p less than 0.05). Closure of the VSD with associated valvuloplasty resulted in a higher prevalence of elimination or improvement of AI compared with VSD closure alone (p less than 0.01). As AI can progress slowly without compromising the child's development, attempted surgical repair can safely be deferred in children less than 5 years of age with minimal valvular involvement unless careful medical management fails to prevent cardiac decompensation.

Isolation and cardiovascular activity of a second bradykinin-related peptide ([Arg0, Trp5, Leu8]bradykinin) from trout.

Previous work has shown that incubation of heat-denatured plasma from the rainbow trout Oncorhynchus mykiss with porcine pancreatic kallikrein generates [Lys0, Trp5, Leu8]bradykinin (trout [Lys0]BK). We have now isolated a second BK-related peptide from kallikrein-treated trout plasma with the primary structure: Arg-Arg-Pro-Gly-Trp-Ser-Pro-Leu-Arg (trout [Arg0]BK). Bolus injections of both trout [Arg0]BK and [Lys0]BK (> 100 pmol/kg) into the dorsal aorta of conscious trout produced multiphasic effects on arterial blood pressure. An initial pressor response of short duration (1-2 min) was followed by a fall in pressure (to below basal values in 11 out of 15 animals) and then by a sustained rise in pressure lasting up to 60 min. The maximum rise in pressure produced by trout [Arg0]BK (10 nmol/kg) was approximately one-fourth of the maximum rise produced by angiotensin II in the same animals. Intracerebroventricular injections of trout [Arg0]BK (500 pmol) into conscious trout had no effect on arterial blood pressure or heart rate. Trout [Arg0]BK did not affect the tension of vascular rings from trout efferent branchial and caeliacomesenteric arteries and anterior cardinal vein. Trout des [Arg9]BK had no effect on cardiovascular parameters, either in vivo or in vitro, indicating that the C-terminal arginine residue of the peptide is important in interaction with the trout kinin receptor(s).

Purification and cardiovascular activity of [Met1, Met5]-bradykinin from the plasma of a sturgeon (Acipenseriformes).

The sturgeons (Order Acipenseriformes) are extant representatives of a group of primitive Actinopterygian (ray-finned) fish that probably shared a common ancestor with present-day teleosts. Incubation of heat-denatured plasma from a sturgeon (a hybrid of the shovelnosed sturgeon Scaphirhynchus platorynchus and the pallid sturgeon Scaphirhynchus albus) with either trypsin or porcine pancreatic kallikrein generated bradykinin-like immunoreactivity. The primary structure of sturgeon bradykinin was established as Met-Pro-Pro-Gly-Met-Ser-Pro-Phe-Arg. This amino acid sequence contains two amino acid substitutions (Arg1 --> Met and Phe5 --> Met) compared with mammalian bradykinin. Bolus injections of synthetic sturgeon bradykinin in doses as low as 1 pmol/kg into the dorsal aorta of unanesthetized sturgeon resulted in an immediate and significant fall in arterial blood pressure with a maximum depressor response at 300 pmol/kg. Thus, the cardiovascular response of the sturgeon to bradykinin resembles more closely the response of mammals rather than the predominantly pressor response seen in teleost fish. Sturgeon bradykinin produced a strong and concentration-dependent (EC50 = 4.7 +/- 0.7 x 10(-10) M) relaxation of rings of vascular tissue from the sturgeon ventral aorta that had been pre-contracted with acetylcholine. The data indicate that sturgeon tissues are particularly responsive to native bradykinin and suggest that the kallikrein-kinin system may have evolved before the appearance of the neopterygians (gars, bowfin and teleosts).

An inexpensive microcomputer system for analysis of single channel currents.

A description is given of a system for rapidly measuring the durations of open times and closed times of single channel currents obtained by patch clamp techniques. The apparatus required, a BBC microcomputer and a Unilab interface, is inexpensive and easy to use. An outline of the software is given and measurements of the accuracy of timings presented. Examples of analyses of single channel currents obtained from spinal neurones in cultures are also presented.

Some neurobiological applications of the BBC Model B microcomputer and Unilab 8-bit interface.

Four computer programs written for the BBC Model B microcomputer (coupled to a Unilab 8-bit interface) are discussed. These programs enable the system to be used as (1) a transient recorder, (2) a rapid signal averager, (3) a spike-train analyser and (4) an instrument for measuring the amplitude of single channel currents. Flow-charts illustrating the operation of each program are given along with a detailed discussion of how the programs may be used in the laboratory. The discussion is illustrated using recordings taken from experiments conducted on a range of neurobiological preparations.

Repeat replacement of aortic valve bioprosthesis.

We describe a safe and simple technique for replacing an aortic valve bioprosthesis in a patient who also had a previously implanted ascending aortic graft and multiple coronary artery bypass grafts. This method allows for isolated valve replacement without removal of the ascending aortic graft or alteration of the coronary artery bypass graft attachments.

Tissue and whole-body extracellular, red blood cell and albumin spaces in the rainbow trout as a function of time: a reappraisal of the volume of the secondary circulation

[58Co]EDTA, [51Cr]RBC and [125I]albumin spaces in the whole body and 28 tissue samples were examined at timed intervals over 16 h in rainbow trout Oncorhynchus mykiss. [58Co]EDTA space (which approximates extracellular fluid volume; ECF) in fins, skin, gallbladder and eye are reported for the first time. After a 16 h equilibration, ECF volume was large (376-726 microl g-1 wet tissue mass) in kidney, swimbladder, skin and fins, moderate (219-313 microl g-1 wet tissue mass) in stomach, skull, spleen, liver, intestine, gills, eye and cecum, and small (53-181 microl g-1 wet tissue mass) in red muscle, fat, brain, gallbladder and white muscle. Whole-body ECF was 387+/-10.6 microl g-1 (mean +/- s.e.m.; N=11). [51Cr]RBC space relative to [58Co]EDTA space was large in spleen, liver, intestine and gill, and low in skin, fins, stomach and skull. Whole-body [51Cr]RBC space was 9.9+/-0.6 microl g-1 body mass (N=17). Blood volume calculated from [51Cr]RBC space at 16 h and a dorsal aortic hematocrit of 24.5 % was 40.4 microl g-1 body mass. Whole-body [125I]albumin space at 16 h was 118.0+/-7.4 microl g-1 body mass (N=6), which resulted in an estimated blood volume of 156. 6 microl g-1 body mass, nearly four times that estimated from the [51Cr]RBC space. Tissue hematocrits, calculated from [125I]albumin and [51Cr]RBC spaces, were significantly lower than dorsal aortic hematocrit in all tissues except spleen, kidney and liver. [58Co]EDTA and [51Cr]RBC spaces reached equilibrium in nearly all tissues within 1 h, whereas [125I]albumin continued to accumulate in many tissues up 24 h. The disparity between [125I]albumin distribution kinetics compared with the kinetics of [58Co]EDTA and [51Cr]RBC distribution, as well as the accumulation of [125I]albumin in tissues not known to have a secondary circulation, indicates that [125I]albumin is a poor marker of plasma volume in trout and that previous studies based on [125I]albumin clearance from the plasma have overestimated both the volume and the turnover rate of the secondary system. Revised estimates of secondary circulation volume, based on [58Co]EDTA distribution rate, indicate that it is no more than 10-20 % of the volume of the primary circulation.

Cardiovascular effects of arginine vasotocin in the rainbow trout Oncorhynchus mykiss.

The physiological functions of the neurohypophyseal hormone arginine vasotocin (AVT) in teleosts are not clear. In the present studies, the sites and mechanisms of action of AVT on the rainbow trout Oncorhynchus mykiss cardiovascular system were examined in unanesthetized instrumented fish, perfused organs and isolated vessels. Injection of AVT (1, 10 or 100 pmol kg-1 body mass) into trout with dorsal aortic cannulas produced a modest, but dose-dependent, increase in dorsal aortic pressure (PDA). Bolus injection of AVT (100 pmol kg-1 body mass), or continuous infusion (6.7 pmol kg-1 min-1), into trout instrumented with dorsal aortic, ventral aortic and central venous cannulas and a ventral aortic flow probe significantly increased PDA as well as ventral aortic (PVA) and central venous (PVEN) blood pressure. Bradycardia accompanied the rapid rise in PVA while gill resistance (RG) increased. Maximum response to the AVT bolus was reached within 13­21 min and the response decayed slowly over the ensuing 90 min. AVT infusion (6.7 pmol kg-1 min-1) significantly increased PVEN and mean circulatory filling pressure and decreased unstressed blood volume, whereas venous compliance was unaffected. These in vivo studies indicate that AVT increases venous tone, thereby mobilizing blood from the unstressed compartment into the stressed compartment. This increases PVEN, which increases venous return and helps maintain, or slightly elevate, cardiac output. This, combined with an elevated RG and slightly elevated systemic resistance (RS), increases both PVA and PDA; however, the rise in PDA is mitigated by a disproportionate increase in RG relative to RS. In vitro, the effects of AVT are consistent with in vivo responses. AVT increased vascular resistance in the perfused gill and perfused trunk and contracted isolated vascular rings from both rainbow and steelhead trout. The general order of sensitivity of isolated vessels to AVT was (in decreasing order): anterior cardinal vein, celiacomesenteric artery, ductus Cuvier, efferent branchial artery, ventral aorta and coronary artery. Extracellular Ca2+ accounted for over 70 % of the tension in the AVT-contracted efferent branchial artery, but only 57 % of the tension in the anterior cardinal vein. Vascular AVT receptor sensitivity (EC50) in vitro ranged from 0.3 to 6 nmol l-1 and was similar to the estimated ED50 for the dose-dependent increase in PDA in vivo (approximately 1 nmol l-1). AVT was not inotropic in paced ventricular rings nor did it exhibit vasorelaxant activity in perfused organs or vascular rings. These results show that AVT is a potent vasoconstrictor in trout and that its two primary cardiovascular targets are the systemic veins and the branchial vasculature.

Comparative study of endralazine and hydralazine for the treatment of hypertension uncontrolled by a beta-blocker and diuretic.

Endralazine and hydralazine were compared in a randomized double-blind, parallel group study lasting 1 year in 30 patients with essential hypertension inadequately controlled by a beta-blocker and a diuretic. Dosage ranged from 10 mg to 30 mg endralazine per day and from 75 mg to 200 mg hydralazine per day according to patient response. The results showed that endralazine was at least as effective as hydralazine in reducing blood pressure. Patients' tolerance, assessed by drop-out rate, was significantly better (p less than 0.05) in the endralazine group. No cases were found of drug-induced lupus-like syndrome on endralazine as opposed to 2 cases with hydralazine. The dose of endralazine required much less adjustment than that of hydralazine.

Directiveness in teachers' language input to toddlers and preschoolers in day care.

Five subtypes of directiveness were examined in the interactions of day care teachers with toddler and preschooler groups. The instructional context (book reading, play dough) yielded significant differences across all five subtypes of directiveness, indicating that these two activities elicited different types of teacher-child discourse. Book reading was characterized by significantly more behavior and response control and less conversation control in comparison with the play-dough activity. Correlations between teachers' directiveness and child language productivity indicated that behavior control and turn-taking control were associated with low levels of productivity, whereas conversation control was associated with the highest levels of productivity. The results of this study confirm that instructional context is an important mediator of teachers' directiveness and suggest that subtypes of directiveness have differential effects on child language output.

The vocal athlete and endotracheal intubation: a management protocol.

Endotracheal intubation is associated with significant laryngeal sequelae that range in severity from mild hoarseness to life-threatening tracheal stenosis. Although the most severe trauma appears to be related to prolonged intubation, even short-term intubation (< 1 day) can adversely affect laryngeal and vocal function. Concern is warranted for all intubated patients, but particularly for the vocal athlete whose livelihood and identity depend on optimal vocal function. It is proposed that the vocal athlete faced with endotracheal intubation risk warrants careful multidisciplinary management. A number of intubation risk factors have been identified in the literature; however, clinical management of vocal athletes who undergo intubation has not been addressed. In medical settings where adverse intubation outcomes can lead to litigation, this clinical management protocol is expected to improve the probability of favorable voice outcome following endotracheal intubation.