Iron overload manifesting as apparent exacerbation of hepatic graft-versus-host disease after allogeneic hematopoietic stem cell transplantation.

Iron overload presenting as exacerbation of hepatic graft-versus-host disease (GVHD) after allogeneic hematopoietic stem cell transplantation has not been previously described. We report 6 patients with established hepatic GVHD in whom iron overload (median serum ferritin, 7231 mug/dL; median transferrin saturation, 77%) resulting from a lifetime median of 20 units of packed red blood cell transfusions was manifested by worsening of liver function. Liver biopsies performed in 4 patients confirmed severe iron overload and also hepatic GVHD. Analysis for the C282Y and H63D hemochromatosis gene mutation was negative for the homozygous state in all 6 patients. Erythropoietin-assisted phlebotomy resulted in normalization of liver function at a median of 7 months and of serum ferritin at a median of 11 months. Immunosuppressive therapy was successfully tapered in all 4 patients who completed the phlebotomy program, and this supported the impression that iron overload, rather than GVHD, was the principal cause of liver dysfunction. At a median follow-up of 50 months (range, 18-76 months) from the transplantation and 25 months (range, 5-36 months) from ferritin normalization, all 4 patients require maintenance phlebotomy. We conclude that iron overload can mimic GVHD exacerbation, thus resulting in unnecessary continuation or intensification of immunosuppressive therapy for GVHD, and that maintenance phlebotomy is necessary after successful iron-reduction therapy.     

Prenatal screening and diagnosis of handicaps: Current state of the art

Current medical procedures used in prenatal screening and diagnosis of handicapping conditions are reviewed. These strategies include ultrasound, amniocentesis, chorionic villus biopsy, restriction enzyme analysis, maternal serum analysis, fetoscopy, and fetal serum analysis. Along with an explanation of each method, advantages, disadvantages, and risks involved with each are provided. An understanding of these procedures by medical and educational personnel is encouraged, and the potential benefits of prenatal identification of handicapping conditions are emphasized.     

Lineage commitment and differentiation of T and natural killer lymphocytes in the fetal mouse

Summary: T cells and natural killer (NK) cells are presumed to share a common intrathymic precursor. The development of conventional a|3 T lymphocytes begins within the early fetal thymus, after the colonization of multipotent CDl1 71 precursors. Irrevocable commitment to the T lineage is marked by thymus-induced expression of CD25. However, the contribution of the fetal thymus to NK lineage commitment and differentiation remains largely unappreciated. Recently, we demonstrated that the development of functional mouse NK cells occurs first in the fetal thymus. Moreover, the appearance of mature fetal thymic NK cells (NK1.1⁺/CD 117^-) is preceded by a thymus-induced developmental stage (NKl.1⁺/CD1 17⁺) that marks lineage commitment of multipotent hematopoietic precursors to the T and NK-cell fates. Commitment to the T/NK bipotent stage is induced by fetal thymic stroma, but is not thymus dependent. Recent data indicate that CD90⁺/CD117^lo fetal blood prothymocytes exhibit NK lineage potential and are phenotypically and functionally identical to fetal thymic NK1,1⁺/CD1 17⁺ progenitors. This finding also indicates that full commitment of circulating precursors to the T-cell lineage occurs after thymus colonization. In this review, we discuss recent insights into the cellular and molecular events involved in fetal mouse T and NK lineage commitment and differentiation to unipotent progenitors.     

Touch-Screen Computerized Education for Patients with Brain Injuries

The use of computer technology for patient education has increased in recent years. This article describes a study that measures the attitudes and perceptions of healthcare professionals and laypeople regarding the effectiveness of a multimedia computer, the Brain Injury Resource Center? (BIRC), as an educational tool. The study focused on three major themes: (a) usefulness of the information presented, (b) effectiveness of the multimedia touch-screen computer methodology, and (c) the appropriate time for making this resource available. This prospective study, conducted in an acute care medical center, obtained healthcare professionals' evaluations using a written survey and responses from patients with brain injury and their families during interviews. The findings have yielded excellent ratings as to the ease of understanding and usefulness of the BIRC. By using sight, sound, and touch, such a multimedia learning center has the potential to simplify patient and family education.     

Patients with prosthetic joints: Are they at risk when receiving invasive dental procedures?

Most prosthetic joint infections (PJI) are due to wound contamination at the time of surgery. Some infections occur due to the hematogenous spread of bacteria from distant sites of infection. A review of the literature fails to associate PJI with transient bacteremias from invasive dental procedures. Several authors have described conditions which, they believe, render patients with prosthetic joints more at risk for infection. Prosthetic joint patients with these "high risk" conditions have the same types of infecting organisms as other patients with PJI. This indicates that the infecting bacteria are from wound contamination or distant sites of infection and not related to dental procedure bacteremias. Based on this review, antibiotic prophylaxis is not indicated for patients with prosthetic joints when receiving invasive dental procedures, since there is no proven benefit and there are known risks involved with the use of antibiotics. However, the American Dental Association (ADA) and the American Academy of Orthopaedic Surgeons (AAOS), in an advisory statement, suggest prophylaxis for "high risk" patients. The ADA and AAOS recommend a single dose of amoxicillin, cephradine, or clindamycin when prophylaxis is selected. The dentist is ultimately responsible for making treatment recommendations for his or her patients.     

Effect of a patellar realignment brace on patellofemoral relationships: Evaluation with kinematic MR imaging

The effect of a newly developed patellar realignment brace was evaluated in 21 patellofemoral joints (19 patients) with patellar subluxation (13 joints with lateral subluxation and eight with medial subluxation) by using active-movement, loaded kinematic magnetic resonance (MR) imaging. Sixteen patellofemoral joints (76%) demonstrated a qualitative correction of or improvement in patellar subluxation (ie, centralization of the patella or a decrease in the displacement of the patella) after application of the brace. Four of the five “failures” occurred in patellofemoral joints that had patella alta and/or dysplastic bone anatomy. These results indicate that the patellar realignment brace was able to counteract patellar subluxation in the majority of patellofemoral joints studied, as shown by active-movement, loaded kinematic MR imaging. This brace appears to be useful for conservative treatment of patients with patellofemoral joint pain secondary to patellar malalignment and maltracking.     

Cysteine proteases of parasites: A remarkable diversity of function

Summary Papain family cysteine proteases function primarily intracellularly in higher eukaryotes, but are often extracellular proteases in protozoan helminths. The utility of this class of enzymes is reflected in the diversity of functions they perform in both parasite life cycles and the pathogenesis of parasitic diseases. Examples include secretion of proteases into the gut of parasitic worms for hemoglobin degradation, release from the surface of nematodes to degrade cuticular proteins during molting, and facilitating excystment of protozoa.