Diagnosis and management of isolated neutropenia: A survey of pediatric hematologist oncologists.

BACKGROUND: Isolated neutropenia is a common referral to pediatric hematology oncology (PHO) physicians. There are no established consensus guidelines in the diagnosis and management of patients with isolated, asymptomatic, and incidentally discovered neutropenia. METHODS: A survey was distributed to PHO physicians on the American Society of Pediatric Hematology Oncology member discussion page to determine the common diagnostic and management decisions regarding patients with isolated neutropenia and to explore beliefs regarding the term "benign ethnic neutropenia." RESULTS: One hundred twenty-six PHO attending physicians completed the survey. The most common tests reportedly ordered for this patient population included complete blood cell count (CBC) (98%), peripheral smear (75%), antineutrophil antibody testing (29%), and immunoglobulins (24%). Providers were more likely to order an antineutrophil antibody in toddlers (p = .0085), and antinuclear antibody (ANA) panels in adolescents (p < .001). Half of providers do not request additional CBCs prior to their initial consultation, and most suggest referring patients with mild neutropenia after confirming a declining absolute neutrophil count (ANC) (51%). The three most important factors influencing ongoing follow-up included: history of recurrent/severe infections (98%), family history of blood disorders (98%), and more severe/progressively worsening neutropenia (97%). Seventy percent of respondents have diagnosed patients with "benign ethnic neutropenia," and 75% support replacement of the term to "typical neutrophil count with Fy(a-/b-) status," if confirmed with red cell phenotyping. CONCLUSION: We identified practice patterns of PHO physicians for the diagnosis and management of patients referred for asymptomatic and isolated neutropenia. These data provide the framework to conduct cost-effectiveness studies.

Thermal Conductivity of the Iron-Based Superconductor FeSe: Nodeless Gap with a Strong Two-Band Character.

The thermal conductivity κ of the iron-based superconductor FeSe was measured at temperatures down to 75 mK in magnetic fields up to 17 T. In a zero magnetic field, the electronic residual linear term in the T=0 K limit, κ_{0}/T, is vanishingly small. The application of a magnetic field B causes an exponential increase in κ_{0}/T initially. Those two observations show that there are no zero-energy quasiparticles that carry heat and therefore no nodes in the superconducting gap of FeSe. The full field dependence of κ_{0}/T has the classic two-step shape of a two-band superconductor: a first rise at very low field, with a characteristic field B^{⋆}≪B_{c2}, and then a second rise up to the upper critical field B_{c2}. This shows that the superconducting gap is very small (but finite) on one of the pockets in the Fermi surface of FeSe. We estimate that the minimum value of the gap, Δ_{min}, is an order of magnitude smaller than the maximum value, Δ_{max}.

Protein S antibody as an adjunct therapy for hemophilia B.

ABSTRACT: Hemophilia B (HB) is caused by an inherited deficiency of plasma coagulation factor IX (FIX). Approximately 60% of pediatric patients with HB possess a severe form of FIX deficiency (<1% FIX activity). Treatment typically requires replacement therapy through the administration of FIX. However, exogenous FIX has a limited functional half-life, and the natural anticoagulant protein S (PS) inhibits activated FIX (FIXa). PS ultimately limits thrombin formation, which limits plasma coagulation. This regulation of FIXa activity by PS led us to test whether inhibiting PS would extend the functional half-life of FIX and thereby prolong FIX-based HB therapy. We assayed clotting times and thrombin generation to measure the efficacy of a PS antibody for increasing FIX activity in commercially obtained plasma and plasma from pediatric patients with HB. We included 11 pediatric patients who lacked additional comorbidities and coagulopathies. In vivo, we assessed thrombus formation in HB mice in the presence of the FIXa ± PS antibody. We found an accelerated rate of clotting in the presence of PS antibody. Similarly, the peak thrombin formed was significantly greater in the presence of the PS antibody, even in plasma from patients with severe HB. Furthermore, HB mice injected with PS antibody and FIX had a 4.5-fold higher accumulation of fibrin at the thrombus induction site compared with mice injected with FIX alone. Our findings imply that a PS antibody would be a valuable adjunct to increase the effectiveness of FIX replacement therapy in pediatric patients who have mild, moderate, and severe HB.

Corrigendum to ' Recurrent venous thromboembolism in hospitalized children with a history of prior venous thromboembolism: a report from the Children's Hospital-Acquired Thrombosis Consortium' [Research and Practice in Thrombosis and Haemostasis Volume 7, Issue 5, July 2023, 102139].

[This corrects the article DOI: 10.1016/j.rpth.2023.102139.].

Chemometric analysis of targeted 3DLC-DAD data for accurate and precise quantification of phenytoin in wastewater samples.

A variety of pharmaceuticals have been found in various water systems, including wastewater treatment effluent. Due to the possible environmental and human health implications, it is important to be able to quickly and reliably quantify the amount of pharmaceuticals and personal care products that may be present in such samples. To this end, a new chromatographic analysis technique involving three dimensions of liquid chromatography, including selective comprehensive separations in the second and third dimensions, was applied to the analysis of a wastewater treatment plant effluent (WWTPE) sample using both standard addition and external calibrations. Iterative key set factor analysis alternating least squares with the application of both sample and spectral selectivity constraints was used to resolve the phenytoin peak at a concentration corresponding to about 40 parts-per-trillion using UV absorbance detection. Both the precision and accuracy of the method are investigated. We determined that the concentration of phenytoin in WWTPE using selective three dimensional liquid chromatography with diode array detection was 42 ± 1 ng/L, after resolution from an unknown interferent. The estimated concentration was not significantly different from that obtained by the reference 2DLC/MS/MS method, but was four and a half times more precise.

Secondary thrombosis prevention practice patterns in pediatrics: Results of an international survey.

Background: Pediatric venous thromboembolism (VTE) rates continue to increase. Although most children present with transient provoking factors, some have persistent prothrombotic risks beyond the initial treatment period warranting secondary anticoagulation. Current pediatric VTE guidelines provide limited recommendations in this regard. Objectives: Our primary objective was to identify key influences on pediatric thrombosis physicians' decisions to initiate secondary anticoagulation. Methods: We targeted pediatric hematologists/oncologists internationally using Duration of Therapy for Thrombosis in Children, Children's Hospital Acquired Thrombosis consortium, and Venous Thromboembolism Network US pediatric subgroup membership rosters, who self-identified as primary outpatient thrombosis providers. Of 124 total surveys distributed, 61 complete surveys were evaluable. We defined secondary anticoagulation as anticoagulant use beyond the initial treatment period, on a daily basis (extended) or limited to periods of superimposed clinical risk factors (episodic). Results: Pediatric thrombosis physicians surveyed indicated that they prescribe secondary anticoagulation in <25% of children despite persistent risks. Among those who indicated use of secondary anticoagulation, the preferred modality was extended anticoagulation in children with a history of recurrent unprovoked VTE (98%), chronic central venous catheter (74%), and potent thrombophilia (73%). Episodic anticoagulation was preferred in children with a history of mild thrombophilia (54%). Respondents were more likely to prescribe secondary anticoagulation for adolescents as opposed to children <12 years old. Conclusions: Among pediatric thrombosis physicians surveyed, they perceived the prevalence of persistent prothrombotic risks to be high in children who have completed a course of anticoagulation for provoked VTE; however, estimated use of secondary anticoagulation was low. Studies involving real-world data are needed to further evaluate use of secondary anticoagulation in this setting.

Enoxaparin Thromboprophylaxis in Children Hospitalized for COVID-19: A Phase 2 Trial.

BACKGROUND: Evidence regarding the safety and efficacy of anticoagulant thromboprophylaxis among pediatric patients hospitalized for coronavirus disease 2019 (COVID-19) is limited. We sought to evaluate safety, dose-finding, and preliminary efficacy of twice-daily enoxaparin as primary thromboprophylaxis among children hospitalized for symptomatic COVID-19, including primary respiratory infection and multisystem inflammatory syndrome in children (MISC). METHODS: We performed a phase 2, multicenter, prospective, open-label, single-arm clinical trial of twice-daily enoxaparin (initial dose: 0.5mg/kg per dose; max: 60mg; target anti-Xa activity: 0.20-0.49IU/mL) as primary thromboprophylaxis for children <18 years of age hospitalized for symptomatic COVID-19. Study endpoints included: cumulative incidence of International Society of Thrombosis and Haemostasis-defined clinically relevant bleeding; enoxaparin dose-requirements; and cumulative incidence of venous thromboembolism within 30-days of hospital discharge. Descriptive statistics summarized endpoint estimates that were further evaluated by participant age (±12 years) and clinical presentation. RESULTS: Forty children were enrolled and 38 met analyses criteria. None experienced clinically relevant bleeding. Median (interquartile range) dose to achieve target anti-Xa levels was 0.5 mg/kg (0.48-0.54). Dose-requirement did not differ by age (0.5 [0.46-0.52] mg/kg for age ≥12 years versus 0.52 [0.49-0.55] mg/kg for age <12 years, P = .51) but was greater for participants with MISC (0.52 [0.5-0.61] mg/kg) as compared with primary COVID-19 (0.48 [0.39-0.51] mg/kg, P = .010). Two children (5.3%) developed central-venous catheter-related venous thromboembolism. No serious adverse events were related to trial intervention. CONCLUSIONS: Among children hospitalized for COVID-19, thromboprophylaxis with twice-daily enoxaparin appears safe and warrants further investigation to assess efficacy.

Chemometric Resolution and Quantification of Four-Way Data Arising from Comprehensive 2D-LC-DAD Analysis of Human Urine.

Two-dimensional liquid chromatography (LC×LC) is quickly becoming an important technique for the analysis of complex samples, owing largely to the relatively high peak capacities attainable by this analytical technique. With the increase in the complexity of the sample comes a corresponding increase in the complexity of the collected data. Thus the need for chemometric methods capable of resolving and quantifying such data is ever more urgent in order to obtain the maximum information available from the data. To this end, we have developed a chemometric method that combines iterative key set factor analysis and multivariate curve resolution-alternating least squares analysis with a spectral selectivity constraint that is shown to be capable of resolving chromatographically rank deficient, non-multilinear data. (Spectrally rank deficient compounds can only be quantified if the peaks having the same spectra are chromatographically resolved.) Over 50 chromatographic peaks were found in a relatively small section of a LC×LC-diode array data set of replicate urine samples (a four-way data set) using the developed method. The relative concentrations for 34 of the 50 peaks were determined with % RSD values ranging from 0.09 % to 16 %.

Outcomes of Isolated Neutropenia Referred to Pediatric Hematology-Oncology Clinic.

BACKGROUND: Children with isolated neutropenia (absolute neutrophil count [ANC] <1500/µL) are frequently referred to pediatric hematology and oncology clinics for further diagnostic evaluation. Scant literature exists on interventions and outcomes for isolated neutropenia. We hypothesized that children will have resolution of their neutropenia without the need for intervention(s) by a pediatric hematologist and oncologist. METHODS: We performed a 5.5-year institutional review board-approved retrospective chart review of children referred to our pediatric hematology and oncology clinics for isolated neutropenia. Neutropenia was categorized as mild (ANC of 1001-1500/µL), moderate (ANC of 500-1000 µL), severe (ANC of 201-500/µL), or very severe (ANC of ≤200/µL). RESULTS: Among 155 children referred with isolated neutropenia, 45 (29%) had mild neutropenia, 65 (42%) had moderate neutropenia, 30 (19%) had severe neutropenia, and 15 (10%) had very severe neutropenia. Only 29 (19%) children changed to an ANC category lower than their initial referral category. At a median follow-up of 12 months, 101 children had resolution of neutropenia, 40 children had mild neutropenia, 10 children had moderate neutropenia, 3 children had severe neutropenia, and 1 patient had very severe neutropenia. A specific diagnosis was not identified in most (54%) children. The most common etiologies were viral suppression (16%), autoimmune neutropenia (14%), and drug-induced neutropenia (8%). Black children had a 3.5 higher odds of having persistent mild neutropenia. Six (4%) children received granulocyte colony-stimulating factor therapy. CONCLUSIONS: Most children referred for isolated neutropenia do not progress in severity and do not require subspecialty interventions or hospitalizations.

Neonatal carnitine palmitoyltransferase-2 deficiency: a case presenting with myopathy.

Mitochondria were isolated from liver, heart and skeletal muscle of a 34-day-old female infant who died from a myopathic illness. Muscle biopsy showed lipid accumulation and no obvious pathology in any other organ. Enzymatic analysis of skeletal muscle extracts revealed normal activities of the markers pyruvate dehydrogenase and citrate synthase. Malonyl-CoA-sensitive carnitine palmitoyltransferase (CPT1) was detected but malonyl-CoA-insensitive carnitine palmitoyltransferase (CPT2) appeared to be absent. Quantitative immunoblotting revealed the presence of a normal abundance of CPT2 protein in the patient's muscle. It is concluded that enzymically inactive CPT2 protein was present.

Microinjection of neuropeptide Y into the superficial dorsal horn reduces stimulus-evoked release of immunoreactive substance P in the anaesthetized cat.

In barbiturate anaesthetized spinal cats, antibody microprobes were used to measure release of immunoreactive substance P in the superficial dorsal horn following electrical stimulation of unmyelinated primary afferents of the ipsilateral tibial nerve. Prior microinjection of neuropeptide Y (0.2-0.6 microliters of 10(-5) mol/l solution) in the region of the substantia gelatinosa reduced the evoked release of immunoreactive substance P for up to 40 min. Microinjection of similar volumes of phosphate-buffered saline at similar sites was without effect. This action of neuropeptide Y could contribute to analgesia, particularly if this neuropeptide is co-released with noradrenaline from axon terminals in the superficial dorsal horn.

Release of immunoreactive galanin in the spinal cord of rats with ankle inflammation: studies with antibody microprobes.

Antibody microprobes bearing antibodies to the carboxy-terminus of rat galanin were inserted into the spinal cords of anaesthetized normal rats and those in which ankle inflammation had been induced by the unilateral subcutaneous injection of Freund's adjuvant four to six days previously. In normal rats, a basal presence of immunoreactive galanin was detected in the dorsal horn. Similar levels of immunoreactive galanin were found in the dorsal horn of both sides of the spinal cord in animals with unilateral ankle inflammation. Flexing the ankle or compressing the foot in normal rats failed to alter levels of immunoreactive galanin detected by microprobes. In animals with ankle inflammation, prolonged periods of ankle flexion did release immunoreactive galanin in the ipsilateral dorsal horn. Subsequent noxious ankle compression in these animals did not increase but rather decreased immunoreactive galanin in the dorsal horn to below basal levels. The reason for this decrease is unknown but it may represent an inhibition of release or a depletion of spinal stores of galanin.

Release, spread and persistence of immunoreactive neurokinin A in the dorsal horn of the cat following noxious cutaneous stimulation. Studies with antibody microprobes.

In barbiturate anaesthetized spinal cats antibody microprobes were used to examine release of immunoreactive neurokinin A following cutaneous thermal and mechanical stimulation. In the absence of peripheral stimuli, microprobes detected a diffuse basal presence of immunoreactive neurokinin A. Noxious mechanical and to a lesser extent noxious thermal stimuli increased the levels of immunoreactive neurokinin A diffusely throughout the dorsal horn which, in many cases, spread into the adjacent white matter. These diffuse stimulus-evoked increases contrast with previous experiments where the same stimuli produced discrete focal increases in levels of immunoreactive substance P. Evidence was obtained that released immunoreactive neurokinin A persisted in the spinal cord for at least 30 min beyond the period of stimulation. Neurokinin A needs consideration as the agent responsible for the long-lasting increases in excitability of some spinal neurons found by several laboratories to follow a brief input from unmyelinated primary afferents.

The burst-like firing of spinal neurons in rats with peripheral inflammation is reduced by an antagonist of N-methyl-D-aspartate.

Ankle inflammation was induced in rats by subcutaneous injection of complete Freund's adjuvant and the firing properties of spinal neurons receiving afferent input from the inflamed areas were studied four to six days later. Comparable neurons in normal rats were also studied. In normal animals the response of neurons to ankle compression consisted of a brief burst of action potentials followed by sustained firing during stimulus application. On cessation of the stimulus there was no prolonged afterdischarge. In rats with an inflamed ankle, compression of the ankle produced firing while the stimulus was applied, but with 17 of 22 neurons there was a prolonged (219 +/- 55 s) post-stimulus afterdischarge. All neurons studied in rats with peripheral inflammation fired with intermittent bursts of action potentials, particularly during the afterdischarge and spontaneous firing. The N-methyl-D-aspartate receptor antagonist DL-2-amino-5-phosphonopentanoate was ejected microiontophoretically near the cells studied. The major effect was a near abolition of bursts present in spontaneous firing and post-stimulus afterdischarges with a lesser reduction in firing during stimulus application. Effects on afterdischarge duration were variable. Since firing in bursts is known to increase transmitter release at some sites in the brain, it is proposed that when the relevant spinal neurons fire in bursts, additional intraspinal pathways are recruited and this contributes to the expanded receptive fields of neurons and possibly to the enhanced pain experienced by manipulation of inflamed peripheral tissues.

Spatially localized magnetic resonance spectroscopy of the brains of normal and asphyxiated newborns.

Phase-modulated rotating frame imaging is a modification of magnetic resonance spectroscopy, which uses a linear radiofrequency field gradient to obtain spatially localized biochemical information. Phase-modulated rotating frame imaging was used to study regional cerebral energy metabolism in the brains of 9 normal newborns and 25 newborns after birth asphyxia. Relative concentrations of phosphorus-containing metabolites and intracellular pH were determined for brain tissue at three specified depths below the brain surface for all neonates. Wide variations in metabolite ratios were seen among normal neonates, and considerable metabolic heterogeneity was demonstrated in individual neonates by depth-resolved spectroscopy. Asphyxiated neonates with severe hypoxic-ischemic encephalopathy and a poor neurodevelopmental outcome showed the expected rise in inorganic orthophosphate and fall in phosphocreatine concentrations in both global and spatially localized spectra. Phase-modulated rotating frame imaging showed that metabolic derangement was less in superficial than in deeper brain tissue. The inorganic orthophosphate-adenosine triphosphate ratio from 1 to 2 cm below the brain surface was more accurate than any global metabolite ratio for the identification of neonates with a poor short-term outcome. These data are consistent with the known vulnerability of subcortical brain tissue to hypoxic-ischemic injury in the full-term neonate.

Analgesic doses of morphine do not reduce noxious stimulus-evoked release of immunoreactive neurokinins in the dorsal horn of the spinal cat.

1. Antibody microprobes were used to detect immunoreactive neurokinin A release in the dorsal spinal cord of barbiturate-anaesthetized spinal cats. 2. Noxious mechanical stimulation of the ipsilateral hind paw and electrical stimulation (suprathreshold for unmyelinated primary afferent fibres) of the ipsilateral tibial nerve evoked immunoreactive neurokinin A release. 3. Systemic morphine, 5 mg kg-1, i.v., did not block immunoreactive neurokinin A release in response to these stimuli. 4. Subsequent naloxone administration, 0.5 mg kg-1, i.v., did not alter this stimulus-evoked release. 5. Basal levels of immunoreactive neurokinin A were unaltered by morphine or naloxone. 6. These results suggest that the analgesic effects of morphine at the spinal cord level are not brought about by activation of presynaptic opiate receptors on neurokinin A containing afferent terminals.

Distinct antinociceptive actions mediated by different opioid receptors in the region of lamina I and laminae III-V of the dorsal horn of the rat.

1. In view of the presence of mu, delta and kappa opioid receptors in the spinal dorsal horn and their apparent involvement in behavioural analgesia, the present experiments addressed the action of selective agonists ionophoresed in the vicinity of rat dorsal horn neurones which were located either in lamina I or in laminae III-V. 2. In laminae III-V, kappa agonists (U50488H and dynorphin A) caused a selective inhibition of the nociceptive responses of multireceptive cells, whilst mu and delta agonists [( D-Ala2, MePhe4, Gly-ol]enkephalin and [D-Pen2, D-Pen5]enkephalin respectively) failed to alter either the spontaneous activity or the response to noxious and innocuous cutaneous stimuli and to D,L-homocysteic acid or glutamate. Nocispecific neurones were encountered too rarely in laminae III-V to study their properties. 3. In lamina I, agonists had no effects on either nocispecific or multireceptive neurones. In contrast, the mu agonist [D-Ala2, MePhe4, Gly-ol]enkephalin consistently inhibited nociceptive responses of both multireceptive and nocispecific lamina I cells. The delta agonist [D-Pen2, D-Pen5]enkephalin consistently caused selective inhibition of the nociceptive responses of multireceptive cells but had a mixed profile of action on nocispecific cells. 4. These results suggest that mu, delta and kappa opioid receptors mediate different antinociceptive actions in both laminae III-V and lamina I. The study reveals a distinct physiological role for delta receptors in modulating nociceptive inputs to lamina I neurones. In contrast to mu and kappa receptor actions, delta receptors heterogeneously influence subpopulations of neurones.

Lack of effect of microinjection of noradrenaline or medetomidine on stimulus-evoked release of substance P in the spinal cord of the cat: a study with antibody microprobes.

1. Experiments were performed on barbiturate anaesthetized, spinalized cats to investigate the effect of microinjected noradrenaline or medetomidine on the release of immunoreactive substance P in the dorsal spinal cord following peripheral nerve stimulation. The presence of immunoreactive substance P was assessed with microprobes bearing C-terminus-directed antibodies to substance P. 2. Noradrenaline or medetomidine were microinjected into the grey matter of the spinal cord, near microprobe insertion sites, at depths of 2.5, 2.0, 1.5 and 1.0 mm below the spinal cord surface with volumes of approximately 0.125 microliters and a concentration of 10(-3) M. 3. In the untreated spinal cord, electrical stimulation of the ipsilateral tibial nerve (suprathreshold for C-fibres) elicited release of immunoreactive substance P which was centred in and around lamina II. Neither noradrenaline nor medetomidine administration in the manner described produced significant alterations in this pattern of nerve stimulus-evoked release. 4. In agreement with recent ultrastructural studies these results do not support a control of substance P release by catecholamines released from sites near to the central terminals of small diameter primary afferent fibres.

Peripheral administration of CRF and urocortin: effects on food intake and the HPA axis in the marsupial Sminthopsis crassicaudata.

The hypothalamic peptides corticotrophin releasing factor (CRF) and urocortin (UCN) decrease food intake and increase energy expenditure when administered either centrally or peripherally to rodents. The effects of CRF and UCN on food intake in other mammals (for example marsupials), however, are not known. Peripherally administered CRF induced cortisol release in the marsupial Sminthopsis crassicaudata via the CRF1 receptor, and central CRF administration potently decreased food intake, as in rodents. When peripherally administered, both CRF and UCN decreased food intake in S. crassicaudata, but UCN was considerably more potent ( approximately 50 fold) in this regard. The anorectic effects of CRF and UCN were not blocked by the CRF1 receptor antagonist antalarmin, suggesting that the peripheral effects of CRF and UCN on food intake are mediated primarily by the CRF2 receptor.