Renal Presentation in Pediatric Acute Leukemia: Report of 2 Cases

Renal enlargement at time of diagnosis of acute leukemia is very unusual. We here in report 2 pediatric cases of acute leukemia who had their renal affection as the first presenting symptom with no evidences of blast cells in blood smear and none of classical presentation of acute leukemia.The first case is a 4-year-old girl who presented with pallor and abdominal enlargement. Magnetic resonance imaging showed bilateral symmetrical homogenous enlarged kidneys suggestive of infiltration. Complete blood picture (CBC) revealed white blood count 11 × 10⁹/L, hemoglobin 8.7 g/dL and platelet count 197 × 10⁹/L. Bone marrow aspiration was performed, and diagnosed precursor B-cell ALL was made. The child had an excellent response to modified CCG 1991 standard risk protocol of chemotherapy with sustained remission, but unfortunately relapsed 11 month after the end of therapy.The second child was 13-month old, presented with pallor, vomiting, abdominal enlargement, and oliguria 2 days before admission. Initial CBC showed bicytopenia, elevated blood urea, creatinine, and serum uric acid, while abdominal ultrasonography revealed bilateral renal enlargement. Bone marrow examination was done and showed 92% blast of biphenotypic nature. So, biphynotypic leukemia with bilateral renal enlargement and acute renal failure was subsequently diagnosed. The patients admitted to ICU and received supportive care and prednisolone. Renal function normalized and chemotherapy was started. The child achieved complete remission with marked reduction of kidney size but, unfortunately she died from sepsis in consolidation phase of therapy. This case demonstrates an unusual early renal enlargement in childhood acute leukemia.Renal involvement of acute leukemia should be considered in child presenting with unexplained bilateral renal enlargement with or without renal function abnormalities and bone marrow examination should be included in the workup.     

Down‐regulation of LPA receptor 5 contributes to aberrant LPA signalling in EBV‐associated nasopharyngeal carcinoma

Undifferentiated nasopharyngeal carcinoma (NPC) is a highly metastatic disease that is consistently associated with Epstein–Barr virus (EBV) infection. In this study, we have investigated the contribution of lysophosphatidic acid (LPA) signalling to the pathogenesis of NPC. Here we demonstrate two distinct functional roles for LPA in NPC. First, we show that LPA enhances the migration of NPC cells and second, that it can inhibit the activity of EBV‐specific cytotoxic T cells. Focusing on the first of these phenotypes, we show that one of the LPA receptors, LPA receptor 5 (LPAR5), is down‐regulated in primary NPC tissues and that this down‐regulation promotes the LPA‐induced migration of NPC cell lines. Furthermore, we found that EBV infection or ectopic expression of the EBV‐encoded LMP2A was sufficient to down‐regulate LPAR5 in NPC cell lines. Our data point to a central role for EBV in mediating the oncogenic effects of LPA in NPC and identify LPA signalling as a potential therapeutic target in this disease. Copyright © 2014 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.     

Epidemiology of needlestick and sharps injuries in a tertiary care center in Saudi Arabia

BACKGROUND: Health care workers (HCWs) are frequently exposed to the danger of infectious agents through needlestick and sharps injury (NSSI). In Saudi Arabia, the hepatitis B and C viruses pose a great threat to the HCW because of their high prevalence rate (8%-10% and 2%-6%, respectively). METHOD: A prospective study on the management of NSSI at King Fahad National Guard Hospital from 1996 to 2000. Data relating to the epidemiology of NSSI were collected with the Exposure Prevention Information Network (EPIN(et)) data collection tool, 1997. RESULTS: The results were compared with data as reported by EPIN(et) 1998. Consistency was demonstrated between King Fahad National Guard Hospital and EPIN(et) 1998 for the occupational categories, locations, and the devices involved. Three anomalies were noted: (1) housekeeping staff injuries ranked third at our facility and eighth as reported by EPIN(et) 1998; (2) injuries caused by devices discarded inappropriately commonly occurred at this facility but were not reported by EPIN(et); and (3) injuries due to unsafe practices ranked third at our hospital but ranked seventh in EPIN(et). To date, only 1 employee in our hospital had a seroconversion to hepatitis C. CONCLUSION: This surveillance highlighted risky practices and demonstrated employees and locations frequently involved in NSSIs. An education program was designed for all staff at risk of exposure, targeting higher-risk employees.     

Comparison Between Dexamethasone and Ibuprofen for Postoperative Pain Prevention and Control After Surgical Implant Placement: A Double‐Masked,Parallel‐Group,Placebo‐Controlled Randomized Clinical Trial

Background: Postoperative pain is a potential adverse side effect of oral surgeries, and attempts should be made to prevent or minimize it. This study compares efficacy of preemptive ibuprofen and dexamethasone protocols for pain prevention or control after surgical implant placement. Methods: This prospective, double‐masked, parallel‐group, placebo‐controlled, randomized clinical trial included 117 patients with planned dental implant placement. Patients were assigned to receive one of three different protocols: 1) 600 mg ibuprofen 1 hour before surgery and another 600 mg 6 hours after the first dose; 2) 4 mg dexamethasone 1 hour before surgery and another 4 mg 6 hours after the first dose; or 3) placebo. Rescue medication (1,000 mg acetaminophen) was made available to each patient, and they were instructed to take it as necessary. Pain intensity was evaluated via a 101‐point numeric rating scale and a visual analog scale, and discomfort was evaluated using a four‐point verbal rating scale hourly for the first 8 hours after surgery and three times daily for the following 3 days. Results: Ibuprofen and dexamethasone significantly reduced pain (Kruskal–Wallis; P <0.05) up to 3 days after surgery and discomfort (P <0.05) up to 2 days after surgery compared with placebo treatment. Both treatments reduced the number of painkillers taken and increased time before the first painkiller was taken (P <0.01). Conclusion: Steroidal dexamethasone is as effective as non‐steroidal ibuprofen for preventing or controlling postoperative pain and discomfort after surgical implant placement.     

Prevalence of sclerosing cholangitis in adults with autoimmune hepatitis: evaluating the role of routine magnetic resonance imaging

Large bile duct injury (that seen on cholangiography) is not usually considered a feature of autoimmune hepatitis (AIH) in adults but is present in up to 50% of children with AIH. The aim of this work was to study the prevalence of large bile duct abnormalities identified by magnetic resonance cholangiography (MRC) in adults given a diagnosis of AIH. Seventy-nine (n = 79) patients given a diagnosis of AIH (mean AIH score: 15.1 +/- 3.4) were screened with MRC for evidence of sclerosing cholangitis (SC). Results were reviewed by two radiologists. Clinical parameters were correlated with MRC findings. A histological review of available liver biopsies (n = 29) was performed. Of the 79 patients surveyed, 8 (10%) had MRC findings consistent with primary sclerosing cholangitis (PSC). The interrater variability was excellent (kappa = 0.87). Younger age at diagnosis (24.3 +/- 11.9), higher baseline alkaline phosphatase (186.4 +/- 98.3), higher bilirubin at time of MRC (45.8 +/- 37.2), and greater lobular activity on initial liver biopsy were significantly associated with the detection of this overlap of SC with AIH (P = 0.024, P = 0.037, P = 0.032, and P = 0.041, respectively), but not alkaline phosphatase/aspartate aminotransferase ratio, time between the initial diagnosis of AIH and the MRC, or the presence of cirrhosis on initial liver histology. Two cases with a normal MRC had histological lesions typical of small duct PSC. CONCLUSION: The presence of SC detected by MRC and from liver histology in adult patients with AIH may not be clinically overt, and thus the prevalence of this AIH/SC overlap may be higher than previously recognized. Our data suggest that routine radiological evaluation of the biliary tree should be performed in adults given a diagnosis of AIH, as in children the presence of this overlap negatively impacts on survival.     

Use of plasma DNA in detection of loss of heterozygosity in patients with multiple myeloma

BACKGROUND: Deletions or structural abnormalities in chromosomes 11 and 13 have been shown to be important in predicting clinical behavior in patients with multiple myeloma (MM). However, cytogenetic analysis in MM is frequently difficult because of poor yield of informative metaphases and the disease is frequently patchy, which complicates fluorescent in situ hybridization studies. OBJECTIVES: The purpose of this study was to explore the potential of using peripheral plasma DNA for the detection of loss of heterozygosity (LOH) in chromosomes 11 and 13 in patients with MM. METHODS: Peripheral blood (PB) plasma of 81 patients with MM, was used as a source of DNA for the detection of LOH at chromosomes 13q14 (D13S319 and D13AFMaw301wb5), and 11q21 (D11S2179) using polymerase chain reaction. RESULTS: Only 62 of the studied patients were informative for the two 13q microsatellite markers and 16 (26%) of these patients showed LOH. Only seven (11%) of 61 patients with informative D11S2179 microsatellite maker showed LOH. Purified plasma cells (PCs) from six bone marrow (BM) samples using anti-CD138-coated magnetic beads showed identical results to those detected in DNA isolated from PB plasma. Three patients with LOH underwent autologous BM transplantation, and two of three reverted to a normal state (no LOH) after transplantation. Seven of the patients with 13q LOH in PB plasma had <10% PCs (PCs) in their BM at the time of testing. CONCLUSION: PB plasma appears to be enriched by tumor-specific DNA and can be used to detect chromosomal abnormalities in patients with MM. Further studies are needed to establish the clinical relevance of this approach in comparison with other techniques.     

Effect of general inhalational anesthesia on intraocular pressure measurements in normal and glaucomatous children

Purpose

To investigate the agreement between the intraocular pressure (IOP) measurements in the awake condition and under different stages of general inhalational anesthesia using sevoflurane in both glaucomatous and normal children.

Methods

A prospective study was performed on 43 glaucomatous children and 30 age-matched controls. Baseline IOP of one eye was measured immediately before general anesthesia using Perkins tonometer and then re-measured under light, intermediate, and deep anesthesia, and then after intubation. Depth of anesthesia was determined using bispectral index pediatric sensor. The agreement between the IOP measurements before and during different stages of anesthesia was analyzed using Bland–Altman plots. Systematic and proportionate deviations between the IOP measurements were analyzed.

Results

The mean age was 58.6?±?41.99 months. The mean IOP was significantly lower at all stages of anesthesia in both groups. The coefficient of variation was over 20% in all measurements under anesthesia. For all IOP measurements during anesthesia, the limits of agreement were?>?7 mmHg difference in the control group and?>?20 mmHg in the glaucomatous group. The best agreement was with the IOP measurement after intubation (mean limit of agreement of -1.4 mmHg, 1.96 s range, ?8.8–6 mm Hg) in the control group and with the IOP measurement under intermediate anesthesia (mean limit of agreement of ?4.2 mmHg, 1.96 s range, ?15.1–6.8 mm Hg) in the glaucomatous group.

Conclusions

Inhalational anesthesia has variable effects on IOP measurement at all stages of anesthesia. Caution should be taken when extrapolating the true IOP from these measurements.