Susumu Inoue

Efficiency of skin sterilization for a venipuncture with the use of commercially available alcohol or iodine pads

Skin sterilization for a venipuncture is routinely done with commercially available alcohol or iodine pads. Selection of the antiseptics, alcohol or iodine, however, in most situations has been made on the basis of very little scientific data. With many patients with granulocytopenia who are undergoing venipunctures, the choice of antiseptic may be an important factor in preventing infections. We investigated two widely and commercially available disinfectant pads, alcohol and iodine, in the efficacy of skin sterilization. Seventy subjects (35 adults and 35 children) were randomly selected for this study. A designated area of the right and left forearm was sterilized either with alcohol or with an iodine pad in a predetermined uniform fashion. Specimens were obtained for cultures before and after sterilization. The bacterial cultures were performed with the use of blood agar plates and trypticase soy broth. For data analysis growth of any organisms on agar plates or trypticase soy broth after sterilization was interpreted as a sterilization failure. The iodine swab was significantly more efficient than the alcohol swab; the former yielded an 80% sterilization rate whereas the latter resulted in a rate of 61% (p less than 0.02). If, however, the growth only in agar plates was compared, the alcohol wipe yielded no growth in 83% and iodine in 84%, virtually identical success rates. Bacillus spp. predominated the residual organisms after either the alcohol or the iodine wipe. A variety of other organisms, however, including Staphylococcus and Corynebacterium spp., grew after alcohol but not after iodine sterilization.(ABSTRACT TRUNCATED AT 250 WORDS)

In Vitro Proliferation and Differentiation of Erythroid Progenitors of Cord Blood

Stem cell factor (SCF) is known to synergize with erythropoietin (EPO) for erythropoiesis in vitro. Clonogenic assay and suspension culture were used to assess the effect of EPO alone or its combination with SCF on the proliferation and differentiation of erythroid progenitors of cord blood. Colony formation, increase in cell count, and cell cycling status for the proliferation as well as expression of Glycophorin A (Gly A) and hemoglobinization as the marker of differentiation were determined with each stimulation. The cell cycle status of the cells in suspension cultures was determined using FACScan after labeling of cells with propidium iodide. Expression of Gly A and degree of hemoglobinization were determined by FACScan and spectrophotometer on the cells plucked from colonies in semisolid culture. Larger increases in cell counts in suspension culture were observed with EPO + SCF after 12 days of inoculation than with EPO alone. Mean doubling time was 14.2 h with EPO + SCF and 22.7 h with EPO alone. The proportion of cells in S and G2 + M phase in day 14 suspension culture was 48% with EPO + SCF and 43% with EPO alone (no significant difference). Mean colony counts per 105 nonadherent mononuclear cells were 76 ± 14 with EPO + SCF and 51 ± 15 with EPO at day 14 (p < 0.05). The number of macroscopic colonies with > 0.5 mm diameter was 10.7 ± 1.2 with EPO + SCF and 0.3 ± 0.5 with EPO (p < 0.05). Percent of Gly A+ cells was 75% for both EPO + SCF and EPO colonies at day 14. Hemoglobin concentration/105 cells at day 14 was 0.70 ± 0.17 μg with EPO + SCF, and 1.16 ± 0.32 μg with EPO alone (p < 0.05). In conclusion, SCF in the combination with EPO showed a synergistic effect for erythroid proliferation in colony number as well as colony size derived from cord blood, while SCF with EPO decreased hemoglobin synthesis but not Gly A expression at day 14.

Venorelbine and methotrexate for the treatment of Rosai-Dorfman disease.

A 10-year-old African-American female developed right cervical lymph node enlargement about 2 months prior to a visit to our clinic onNovember 14, 1997. Shewas asymptomatic. She had several lymph nodes in the right side of the neck. The largest one measured 3 3 cm and was surgically removed. The histology showed sinus histiocytosis with massive lymphadenopathy (Rosai– Dorfman disease). The patient did well subsequently, but 4 years later in September of 2001 the lymphadenopathy recurred. At that time, she had progressively enlarging cervical lymph nodes, severe nasal obstruction with yellowish bloody nasal discharge of 8 months duration, and inability to breath well at night in the flat supine position.A computerized tomography (CT) showed pansinusitis, bilaterial partial blockage of osteomeatal complexes, and a posterior nasopharyngeal soft tissue mass. A posterior nasopharyngeal mass including the adenoid glandwas excised. The histology showedRosai–Dorfman disease. The difficulty in breathing and nasal obstruction resolved, but the enlarged cervical nodes persisted. Fivemonths later onMarch 4, 2002, she again developed difficulty in breathing and excessive fatigue that started 2–3 days prior to the visit. Multiple lymph nodes in the right neck were again noted. The enlarged lymph nodes collectively measured 16 11 cm. She was placed on prednisone 40 mg/m/day, and the symptoms rapidly subsided. The total area of the cervical swelling decreased to 12 8 cm in 4 days. Three weeks later, the dose was reduced to 25mg/m/day andwas continued at that dose for the next 2months, but no further reduction in the size of the mass occurred, and thick purulent nasal discharge continued. Because of this, 6-mercaptopurine (6MP) at 50 mg/m/ day by mouth (po) andmethotrxate (MTX) at 12mg/m po once a week as published by Horneff et al. [2] were started and continued for the next 2 months. There was no improvement. In fact lymph nodes increased in size. Prednisone was resumed at the dose of 40 mg/m/day The neck mass was partially surgically resected again on July 25, 2002, and prednisone was stopped. However, the nodes regrewwithin 6weeks and prednisonewas resumed, but this time no significant improvement occurred. In January 2003, she developed additional lymph node enlargement for the first time in the left neck. At this point, we started her on a combination of venorelbine 20 mg/m once a week, and methotrexate 30 mg/m IVonce a week in January 2003 according to the treatment protocol for fibromatosis [3]. Within 4 weeks, a clear reduction in the size of the lymph nodes was observed. A CT evaluation after 4 months of treatment showed a significant reduction in the size of the largest mass from 6.6 4.5 to 3.1 2.7 cm. Venorelbine and methotrexate were stopped after 24 weeks, though there were still residual enlarged nodes. Within the next month, therewas a rebound increase in the neck mass, and thus these two drugs were resumed on October 6, 2003 and continued for 9 more weeks. Again the lymph nodes decreased in size with the largest one being 1 1 cm. The patient has been off all medications for the last 12 months, and doing well. The natural history of SHML is that of spontaneous remissions and recurrences. Although, there have been some fatal cases [4], the disorder is regarded as a benign disease with eventual resolution in an overwhelming majority of cases. Thus the indications for interventions have been to manage symptoms, to remove compression of vital organs, or to correct severe disfigurement. In our case, an involvement of the retropharyngeal nodes and adenoids resulting in respiratory difficulty and sinusitis necessitated some formof treatment. The surgical removal gave the patient only temporary relief resulting in the subsequent steroid administration. Because of the side effects of long-term steroid administration and relative resistance to prednisone, we tried the combination of mercaptopurine and methotrexate, but this was totally ineffective. Other agents published to be effective are vincristine, or vinblastine and steroids [5,6]. In our clinic at that time, we were using a combination of venorelbine and methotrexate for a patient with desmoid tumor [2]. Venorelbine is pharmacologically very similar to vincristine and vinblastine, with much less neurotoxicity [2]. We were impressed by the lack of side effects.

Symptomatic Erythrocytosis Associated with a Compound Heterozygosity for Hb Lepore-Boston-Washington (δ87-β116) and Hb Johnstown [β109(G11)Val→Leu, GTG>TTG]

Hb Johnstown [β109(G11)Val→Leu, GTG>TTG] has previously been described as a high oxygen affinity variant in a heterozygous state and in combination with β0-thalassemia (β0-thal). Because the variant does not separate from Hb A by routine methods it may be easily missed unless clinical suspicion is high. Hb Lepore-Boston-Washington (Hb LBW; δ87-β116) is a δβ hybrid variant that clinically manifests similarly to a β+-thal. Hb LBW is not detected by routine polymerase chain reaction (PCR) sequencing but is easily detected by electrophoretic methods. We describe a 19-year-old African American male with a compound heterozygosity for Hb Johnstown and Hb LBW. The patient presented with progressively worsening chest pains, headaches and erythrocytosis. He was repeatedly phlebotomized with symptomatic improvement and subsequently was confirmed to have the high oxygen affinity hemoglobin (Hb) variant. The lowest Hb and hematocrit (packed cell volume, PCV) achieved by phlebotomy was 16.1 g/dL and 0.51 L/L, respectively. Currently, he is no longer being phlebotomized, and is feeling relatively well except for minor chest pain. It is unclear to what degree the phlebotomies contributed to his subjective improvement. The combination of Hbs Johnstown and LBW has not been heretofore described, and in this case, was associated with marked symptomatic erythrocytosis. This unique combination results in a more pronounced phenotype, similar to or slightly more severe than, compound Hb Johnstown/β0-thal. This compound hemoglobinopathy will likely not be correctly classified using a single method of Hb detection and underscores the need for multiple characterization methods when indicated by the clinical picture.

Clear cell sarcoma of the jaw: A case report and review of the literature

Clear cell sarcoma (CSS) is a unique malignant soft tissue tumor that mainly occurs from the aponeurotic tissue and tendons of extremities. It is rare in the pediatric population. The tumor does not respond well to chemotherapy or irradiation. Complete surgical resection offers the best chance for a cure. Most studies have demonstrated poor prognosis of this tumor, if it is >5 cm. The literature suggests that local recurrence and distant metastasis are not uncommon even with wide resection and that late recurrence and metastasis commonly occur. This case report discusses CSS in the jaw of a pediatric patient. To our knowledge, this is the only case of CSS of the jaw.

Bone marrow necrosis as a presenting feature of childhood acute lymphoblastic leukemia

the abdomen revealed the presence of two small, peripheral abscesses in spleen suggestive of Candida infection. One week after starting VRC, LAmB was added (5 mg/kg/day). Two weeks later the boy became afebrile but the follow-up CT demonstrated the same number of detectable lesions in the lungs while the follow-up ECHO scan showed disappearance of the two lesions of the spleen. The combined antifungal treatment with VRC and LAmB was replaced by caspofungin (1.6mg/kg/day i.v). Patient’s clinical condition improved. The follow-up CT of the chest on day 50 was normal as also the laboratory tests (Candida Ag test and blood culture were negative) (Fig. 1B). Caspofungin was continued at a dosage of 1.6 mg/kg/die i.v for a total of 78 days. For the last 22 days caspofungin was given daily on an outpatient basis during antifungal treatment. No severe clinical and laboratory side effects were noted. The patient is in an excellent condition and has completed consolidation treatment. Caspofungin represents a antifungal agent with in vitro activity against Candida and Aspergillus species. Although there are many data about its combination with VRC or LAmB for invasive fungal infections, there are only few reports about the use of caspofungin as monotherapy in pediatric patients [1,4]. We conclude from our case that caspofungin given as a single agent was likely able to overcome all mycotic lesions in comparison to the combined antifungal treatment (VRC plus LAmB). It is, therefore, suggested that caspofungin be studied further as a consideration as monotherapy for aggressive mycotic disease.

Rothmund-Thomson syndrome (RTS) with osteosarcoma due to RECQL4 mutation

Rothmund-Thomson syndrome (RTS) is a rare autosomal recessive disorder with clinical features consisting of poikiloderma, skeletal abnormalities, sparse hair, absent or scanty eyelashes and eyebrows and short stature. Patients with RTS due to genetic mutations of RECQL4 genes carry a high risk of developing osteosarcoma during childhood. Because of this, early genetic diagnosis is important. Here, we describe a 14-year-old white boy who developed an erythematous rash on both cheeks before the age of 3 months and was noted to have absent eyelashes and scanty eyebrows. He was found to have compound heterozygous mutations of the RECQL4 gene alleles at the age of 6 months and was diagnosed to have RTS type II. He subsequently developed osteosarcoma at age 10 which was successfully treated, and currently he has been tumour free for over 3 years.

Chronic myelomonocytic leukemia (CMML) as a second malignancy following Ewing sarcoma

To the Editor: Le Deley et al. [1], in Pediatric Blood & Cancer, reported a high frequency of secondary leukemia, including MDS and AML, following treatments with high cumulative doses of etoposide. Recently we cared for a child who developed CMML following etoposide-containing chemotherapy for Ewing sarcoma/ primitive neuroectodermal tumor (PNET). A 5-year-old African-American male developed an occipitoparietal mass. The tumorwas located in the scalp, and did not invade the calvarium. Excisional biopsy of the mass was read as Ewing sarcoma/PNET. There were no metastases. Cytogenetic analysis of the tumor cells was normal [no t(11;22) or t(21;22)]. Awide margin resection of the tumor was done and he was treated with chemotherapy on the COG AEWS 0031 protocol consisting of vincristine, doxorubicin, cyclophosphamide, and etoposide (total cumulative dose of etoposide, 3.55 g/m). About three years later, the patient developed leukocytosis (18,200/mL), monocytosis (12,078/mL), and mild anemia (Hb of 11 g/dL). Bone marrow revealed increased cellularity and myeloid hyperplasia with occasional myeloblasts. The chromosomal study demonstrated 100% of the cells to have 45, XY,-7. Chromosome 11 was intact. Flow cytometry showed CD13þ, CD 14þ, CD 15þ, and CD 33þ cells. Fetal hemoglobin was less than 1%. The diagnosis of chronic myelomonocytic leukemia (CMML) was made. The subsequent course over the next 2 years was a decrease of the platelet count to 60,000/mL and monocytosis (5,664/mL) and leukocytosis (23,600/mL). The patient remains asymptomatic and is awaiting a suitable unrelated stem cell donor. CMML is rare as a second neoplasm. Dose intense use of etoposide has been linked to an increased incidence of AML with translocation of the MLL gene [1]. On the other hand, a monosomy 7 or 7qabnormality has also been commonly found in treatment-associated leukemias [2]. The cause of the secondary myeloproliferative syndrome in our patient remains unclear.

Cord Blood Transplant : Current and Future Issues

Cord blood as the source of hematopoietic stem cells has several advantages over bone marrow cells for transplant purpose. It is readily available, and causes no physical harm or inconveniences to the donor in the processing of harvesting cells. Waiting time between initiating the search and the time to transplant from an unrelated donor is much shorter with cord blood than with unrelated donor bone marrow. The incidence of graft-versus-host diseases is much less. Because of these advantages, cord blood has been increasingly used as the source of stem cells. As of this writing, more than 200 cord blood transplants have been done in patients with hematological malignancies, solid tumors, hematological diseases, immunodeficiency syndromes, and metabolic diseases. One of the limitations inherent in the cord blood is its limited number of hematopoietic stem cells. Thus it has been primarily used for pediatric patients, though more recently, adult patients also have been transplanted with cord blood as people have become more experienced in harvesting cord blood thus yielding a large number of stem cells in a given specimen. Efforts have been made to amplify stem cellsin vitro following harvesting cord blood stem cells, so that adult recipients also would routinely benefit from this resource. Cord blood lymphocytes are functionally “naive”, do not generate vigorous mixed lymphocyte culture reactivities. The low incidence of graft-versus-host disease in the recipients of cord blood is due to this particular property. It is highly desirable that the world wide cord blood registry, similar to the international bone marrow registry would be instituted, but there are logistic, ethical and financial problems that need to be resolved. Cord blood is one of the best stem cell sources, and its application is quite wide.

Mean Platelet Volume in Thrombocytopenic, Preterm Infants.

We evaluated the use of mean platelet volume (MPV) as a reliable indicator of bacteremia in neonates. We first established normal MPV values in very low birth weight neonates (< 1 kg and ≥ 1 kg < 1.8 kg, respectively) in the first 47 days of life. We conclude that MPV is not a reliable predictor of sepsis. However, one subset of thrombocytopenic neonates, with birth weights ≥ 1 kg < 1.8 kg was identified with significantly increased MPV (P < 0.05) compared to the age-matched control. In this group, the thrombocytopenia was not associated with sepsis, and the etiology of the decreased platelet count remained to be determined.