Significance of hypoalbuminemia in pediatric oncology patients--malnutrition or infection?

Nutritional status was evaluated on 210 occasions in 90 pediatric oncology inpatients during a 7-month period; 39 had solid tumors and 51 leukemia. Ages ranged from 3 months to 20 yr. Nutritional parameters were defined as normal, "at risk," or "probably malnourished." Fifty-seven and 29% of assessments revealed at least one parameter "at risk" or "probably malnourished," respectively. Prognosis was negatively related to the number of abnormal nutritional parameters. Serum albumin was most frequently abnormal. However, on most occasions, hypoalbuminemia was associated with weight/height, arm muscle area, and triceps skinfold measurements in the normal range. In order to further identify determinants of serum albumin, we analyzed dietary, chemotherapy, and temperature data in 10 prospectively studied leukemia patients, half of whom received parenteral nutrition. In these patients there was little relationship of serum albumin to chemotherapy or dietary intake. In all of these patients, especially those receiving total parenteral nutrition, low serum albumin was highly associated with fever (p less than 0.0005). We concluded that febrile illness is an important determinant of abnormal serum albumin concentrations. In pediatric cancer patients, abnormal serum albumin may more often reflect the acute metabolic response to fever and infection than depletion of body mass.     

Chronic neurogenic quadriceps amyotrophies

Summary Two cases of quadriceps amyotrophy, probably of chronic neurogenic origin are reported. Only the knee jerks were diminished, the calves hypertrophic, and the serum creatine kinase level very high in one case, and there were neurogenic electromyographic abnormalities in the quadriceps. In the first case, biopsy of the quadriceps muscle revealed a neurogenic origin with hyalinized hypertrophic fibres. CT scan showed abnormalities not only in the quadriceps but also in the sartorius, gracilis and gastrocnemius muscles. A second biopsy specimen from the gastrocnemius muscle showed histological findings similar to those of the quadriceps. In the second case, the EMG and biopsy findings suggested a myogenic origin, but 6 years later they were compatible with neurogenic atrophy. Differentiation from Becker dystrophy is very difficult in the first case and the second case is more a focal spinal amyotrophy. Further, in spite of their localization, the extension of the affected muscles changes the diagnosis. The same applies to chronic quadriceps amyotrophy in general, which cannot be regarded as an entity, but which suggests muscular dystrophy, spinal atrophy, polymyositis or a metabolic disorder. These cases can be compared with the four cases reported in the literature, which were regarded as a forme fruste of chronic spinal amyotrophy.     

Auditory evoked responses and their modifications during conditioning paradigm in autistic children

Auditory evoked responses (AERs) were recorded from 16 autistic children (ages 2–10 years) and age-matched normal and retarded controls. In order to test the ability to form auditory-visual cross-modal associations, often impaired in autism, the effects on AERs of coupling sound and light were studied with a paradigm that did not require the cooperation of the subject. Several differences between groups were found concerning the frequency and the amplitudes of present AERs. The pattern characterizing the effects on AERs of coupling sound and light (conditioning phenomenon) was observed for both autistic and normal controls, and not for retarded children. Results suggest that autistic children may have a real but slow learning ability.This study was supported by C.N.R.S. (UA 596), Biology and Neuropsychiatry, Sécurité Sociale, 1982. We wish to thank M. Barre, A. Lardeux, and L. Crespin for their technical work.     

Multi-drug therapy trials for leprosy in Senegal: first observations relative to liver tolerance of multibacillary patients. Therapeutic consequences

The authors have studied tolerance of multibacillary patients to 4 MDT regimens. These 4 regimens consist of: One supervised part in which RMP-ETH combination in once-monthly administered; furthermore, in 2 of these regimens, is included one "starter phase" with daily doses of that combination for 2 months. One self-administered part during which CLO is associated either to DDS for new cases, or to ETH for relapses. Clinical Supervision: Out to 310 multibacillary patients, 7 cases of hepatitis with or without icterus, but no death due to the treatment. Interruptions of MDT have been temporary and have been observed in 0.9 to 5.6% of the patients according to the therapeutic regimen. Checking SGOT: The SGOT were abnormally high in 16.3% of the patients before treatment. These pre-existing liver damages do not favour the appearance of intolerance disorders. During MDT, abnormal increases in SGOT are observed in 27% of the patients but there is no exact correlation between the absorbed doses of ETH and the frequency in SGOT increases. The clinical or biological evidence of liver damages occur rather early (1st, 2nd month) in regimens with "starter phase", and later (4th-8th month) in those without "starter phase". But introduction of "Starter phase" does not increase the global frequency of such intolerance accidents. ETH combined with RMP, must be used under steady clinical and biological supervision. Recalling the results of a previous survey, the authors consider that a long duration of MDT is not necessary. For the multibacillary leprosy treatment, they propose a diphasic regimen, more easily applicable in the field than the WHO protocols. In this diphasic regimen, the only part which must be supervised is the initial "starter phase" of 2 month. It consists of daily administration of 3 antibacillary drug among which RMP and ETH. The second phase is a relay treatment using 2 drugs, CLO combined with DDS or ETH, self-administered until smear negativity.     

Do Gut Hormones Contribute to Weight Loss and Glycaemic Outcomes after Bariatric Surgery?

Bariatric surgery is an effective intervention for management of obesity through treating dysregulated appetite and achieving long-term weight loss maintenance. Moreover, significant changes in glucose homeostasis are observed after bariatric surgery including, in some cases, type 2 diabetes remission from the early postoperative period and postprandial hypoglycaemia. Levels of a number of gut hormones are dramatically increased from the early period after Roux-en-Y gastric bypass and sleeve gastrectomy—the two most commonly performed bariatric procedures—and they have been suggested as important mediators of the observed changes in eating behaviour and glucose homeostasis postoperatively. In this review, we summarise the current evidence from human studies on the alterations of gut hormones after bariatric surgery and their impact on clinical outcomes postoperatively. Studies which assess the role of gut hormones after bariatric surgery on food intake, hunger, satiety and glucose homeostasis through octreotide use (a non-specific inhibitor of gut hormone secretion) as well as with exendin 9–39 (a specific glucagon-like peptide-1 receptor antagonist) are reviewed. The potential use of gut hormones as biomarkers of successful outcomes of bariatric surgery is also evaluated.     

TB prevention cascade at a district hospital in rural Eastern Cape,South Africa

SETTING:Rural Eastern Cape, South Africa.OBJECTIVE:To identify steps in the TB preventive care cascade from routinely collected data among TB patients at a district hospital prior to the implementation of a novel TB program.DESIGN:This was a retrospective study. We adapted the TB prevention cascade to measure indicators routinely collected at district hospitals for TB using a cascade framework to evaluate outcomes in the cohort of close contacts.RESULTS:A total of 1,722 charts of TB patients were reviewed. The majority of patients (87%) were newly diagnosed with no previous episodes of TB. A total of 1,548 (90%) patients identified at least one close contact. A total of 7,548 contacts were identified with a median of 4.9 (range 1–16) contacts per patient. Among all contacts identified, 2,913 (39%) were screened for TB. Only 15 (0.5%) started TB preventive therapy and 122 (4.4%) started TB treatment. Nearly 25% of all medical history and clinical information was left unanswered among the 1,722 TB charts reviewed.CONCLUSION:Few close contacts were screened or started on TB preventive therapy in this cohort. Primary care providers for TB care in district health facilities should be informed of best practices for screening and treating TB infection and disease.     

Fecal Excretion of Mycobacterium leprae,Burkina Faso

Mycobacterium leprae was detected by optical microscopy, fluorescent in situ hybridization, and molecular detection in feces collected for the diagnosis of Entamoeba coli enteritis in a leprosy patient in Burkina Faso. This observation raises questions about the role of fecal excretion of M. leprae in the natural history and diagnosis of leprosy.     

Distinct immunopathological mechanisms of EBV-positive and EBV-negative posttransplant lymphoproliferative disorders

EBV-positive and EBV-negative posttransplant lymphoproliferative disorders (PTLDs) arise in different immunovirological contexts and might have distinct pathophysiologies. To examine this hypothesis, we conducted a multicentric prospective study with 56 EBV-positive and 39 EBV-negative PTLD patients of the K-VIROGREF cohort, recruited at PTLD diagnosis and before treatment (2013–2019), and compared them to PTLD-free Transplant Controls (TC, n = 21). We measured absolute lymphocyte counts (n = 108), analyzed NK- and T cell phenotypes (n = 49 and 94), and performed EBV-specific functional assays (n = 16 and 42) by multiparameter flow cytometry and ELISpot-IFNγ assays (n = 50). EBV-negative PTLD patients, NK cells overexpressed Tim-3; the 2-year progression-free survival (PFS) was poorer in patients with a CD4 lymphopenia (CD4⁺<300 cells/mm³, p <  .001). EBV-positive PTLD patients presented a profound NK-cell lymphopenia (median = 60 cells/mm³) and a high proportion of NK cells expressing PD-1 (vs. TC, p = .029) and apoptosis markers (vs. TC, p < .001). EBV-specific T cells of EBV-positive PTLD patients circulated in low proportions, showed immune exhaustion (p = .013 vs. TC) and poorly recognized the N-terminal portion of EBNA-3A viral protein. Altogether, this broad comparison of EBV-positive and EBV-negative PTLDs highlight distinct patterns of immunopathological mechanisms between these two diseases and provide new clues for immunotherapeutic strategies and PTLD prognosis.     

Tuberculosis infection and disease in South African adolescents with perinatally acquired HIV on antiretroviral therapy: a cohort study

IntroductionThere are limited data on Tuberculosis (TB) in adolescents with perinatally acquired HIV (APHIV). We examined the incidence and determinants of TB infection and disease in the Cape Town Adolescent Antiretroviral Cohort (CTAAC).MethodsYouth between nine and fourteen years on antiretroviral therapy (ART) for more than six months in public sector care, and age‐matched HIV‐negative adolescents, were enrolled between July 2013 through March 2015 and followed six‐monthly. Data were censored on 31 October 2018. Symptom screening, chest radiograph, viral load, CD4 count, QuantiFERON (QFT) and sputum for Xpert MTB/RIF, microscopy, culture and sensitivity were performed annually. TB infection was defined by a QFT of >0.35 IU/mL. TB diagnosis was defined as confirmed (culture or Xpert MTB/RIF positive) or unconfirmed (clinical diagnosis and started on TB treatment). Analyses examined the incidence and determinants of TB infection and disease.ResultsOverall 496 HIV+ and 103 HIV‐negative participants (median age at enrolment 12 years (interquartile range, IQR 10.6 to 13.3) were followed for a median of 3.1 years (IQR 3.0 to 3.4); 50% (298/599) were male. APHIV initiated ART at median age 4.4 years (IQR 2.1 to 7.6). At enrolment, 376/496 (76%) had HIV viral load <40 copies/mL, median CD4 count was 713 cells/mm³ and 179/559 (32%) were QFT+, with no difference by HIV status (APHIV 154/468, 33%; HIV negative 25/91, 27%; p = 0.31). The cumulative QFT+ prevalence was similar (APHIV 225/492, 46%; 95%CI 41% to 50%; HIV negative 44/98, 45%; 95% CI 35% to 55%; p = 0.88). APHIV had a higher incidence of all TB disease than HIV‐negative adolescents (2.2/100PY, 95% CI 1.6 to 3.1 vs. 0.3/100PY, 95% CI 0.04 to 2.2; IRR 7.36, 95% CI 1.01 to 53.55). The rate of bacteriologically confirmed TB in APHIV was 1.3/100 PY compared to 0.3/100PY for HIV‐negative adolescents, suggesting a fourfold increased risk of developing TB disease in APHIV despite access to ART. In addition, a positive QFT at enrolment was not predictive of TB in this population.ConclusionsHigh incidence rates of TB disease occur in APHIV despite similar QFT conversion rates to HIV‐negative adolescents. Strategies to prevent TB in this vulnerable group must be strengthened.