The stressed bird in the hand: Influence of sampling design on the physiological stress response in a free-living songbird.

Despite the widely used application of standardized capture-handling protocols to collect blood and assess the physiological stress response, the actual sampling design (e.g., timing and the number of blood samples) often differs between studies, and the potential implications for the measured physiological endpoints remain understudied. We, therefore experimentally tested the effects of repeated handling and multiple blood sampling on the stress response in wintering free-living great tits (Parus major). We modified a well-established sampling protocol of avian studies by adding either an additional blood sample or a "sham-manipulation" (i.e., handling associated with the blood sampling procedure without venepuncture), to disentangle the effects of handling stress and blood loss. We combined three different stress metrics along the endocrine-immune interface to investigate the acute short-term stress response: total corticosterone concentrations (Cort), the heterophil/lymphocyte ratio (H:L), and the Leucocyte Coping Capacity (LCC). Our study provided three key results: i) no relationship between Cort levels, LCC and H:L, confirming that these three parameters represent different physiological endpoints within the stress response; ii) contrasting dynamics in response to stress by the measured parameters and iii) no difference in physiological stress levels 30 min after capture due to one additional blood sampling or handling event. By optimising the sampling design, our results provide implications for animal welfare and planning experimental procedures on stress physiology in passerine species.

CD4+ T-lymphopenia in HIV negative tuberculous patients at King Khalid University Hospital in Riyadh, Saudi Arabia.

Tuberculosis (Tb) is a chronic infectious disease in which the cellular immunity (specifically CD4+ and CD8 lymphocytes) provides the most important defense in controlling infection. CD4 lymphopenia is a well-defined risk factor for the development of active tuberculosis in patients infected with Human Immunodeficiency Virus. In HIV - negative patients, CD4 and CD8 cell count suppression has been associated with Tb infection. Our study was designed to determine the baseline and post-treatment values of CD4 and CD8 in HIV negative patients diagnosed with active Tb in Saudi Arabian patients. We recruited twenty-eight, non-HIV patients with tuberculosis for the study group comprising 16 males and 12 females with either disseminated or localized active Tb infection. Two control groups were selected one of twenty-one matched healthy controls and the second of forty-two subjects from pool of controls of an ongoing study in same population for normal CD4 and CD8 counts. The baseline pre-treatment CD4 and CD8 counts in the study group were significantly lower than either control group. Specifically the mean ± SD of CD4 counts were 556.79 ± 298.81 in the study group vs 1,132.38 ± 259.90 in control group 1 and 1,424.38 ± 870.98 in control group 2 (p 0.000). Likewise the CD8 counts in the study group were 1,136.00 ± 512.06 vs. 1,461.90 ± 367.02 in control group 1 and 1,495.90 ± 565.32 in control group 2 (p 0.000) respectively. After treatment of tuberculosis, the study patients experienced a significant increase in their mean ± SD CD4 and CD8 cell counts, from 556.79 ± 297.81 to 954.29 ± 210.90 for CD4 cells (p 0.005) and 1136.00 ± 512.06 to 1,316.54 ± 286.17 for CD8 cells (p 0.002). Analysis of study patients with disseminated disease found significantly lower CD4 cells (but not lower CD8 cells) compared to study patients with localized disease, both at baseline and after treatment. The mean ± SD baseline CD4 cells were 247.60 ± 187.80 with disseminated vs 728.56 ± 186.32 for localized disease (p = 0.000) which rose to 842.30 ± 93.55 vs 1016.50 ± 233.51 (p = 0.033) respectively. We conclude that tuberculosis may be associated with CD4 and CD8 lymphopenia even in patients without human immunodeficiency virus infection, there was the tendency of recovery towards normality especially of the CD4 and CD8 counts after treatment, and that disseminated disease is associated specifically with profound CD4 lymphopenia.

Ictal and interictal high frequency oscillations in patients with focal epilepsy.

OBJECTIVE: High frequency oscillations (HFOs) can be recorded with depth electrodes in focal epilepsy patients. They occur during seizures and interictally and seem important in seizure genesis. We investigated whether interictal and ictal HFOs occur in the same regions and how they relate to epileptiform spikes. METHODS: In 25 patients, spikes, ripples (80-250 Hz) and fast ripples (FR: 250-500 Hz) and their co-occurrences were marked during interictal slow wave sleep (5-10 min), during 10 pre-ictal seconds and 5s following seizure onset. We compared occurrence and spatial distribution between these periods. RESULTS: HFOs and spikes increased from interictal to ictal periods: the percentage of time occupied by ripples increased from 2.3% to 6.5%, FR from 0.2% to 0.8%, spikes from 1.1% to 4.8%. HFOs increased from interictal to pre-ictal periods in contrast to spikes. Spikes were in different channels in the interictal, pre-ictal and ictal periods whereas HFOs largely remained in the same channels. CONCLUSIONS: HFOs remain confined to the same, possibly epileptogenic, area, during interictal and ictal periods, while spikes are more widespread during seizures than interictally. SIGNIFICANCE: Ictal and interictal HFOs represent the same (epileptogenic) area and are probably similar phenomena.

Encephalopathy in pediatric patients after allogeneic hematopoietic stem cell transplantation is associated with a poor prognosis.

SUMMARY: Encephalopathy is a poorly characterized complication of hematopoietic stem cell transplantation (HSCT). No comprehensive report of encephalopathy exists for children, and the literature contains only a few for adults. We analyzed a large cohort of 405 pediatric patients who underwent allogeneic HSCT during a 10-year period and identified 26 patients (6.4%) who experienced encephalopathy. Identifiable causes of encephalopathy included infection (n=5), single or multiorgan failure (n=4), medication-related complications (n=3), nonconvulsive seizures (n=4), acute disseminated encephalomyelitis (n=2), thrombotic thrombocytopenic purpura (n=2), and stroke (n=1). We were unable to identify the etiology of encephalopathy in five (19%) patients. The prognosis for pediatric patients with encephalopathy was poor: only four (15%) experienced complete neurologic recovery, and 10 (38%) patients experienced partial recovery with residual neurologic deficits. Nine (35%) patients with complete or partial recovery survive long term. A total of 17 patients died; one died of progressive encephalopathy, and 16 died of either relapse of primary disease or toxicity. MRI, CSF analysis including molecular testing for infectious pathogens, and brain biopsy were helpful in obtaining a diagnosis in most of our patients. However, a standardized approach to accurate and timely diagnosis and treatment is needed to improve outcome in these patients.

Allogeneic bone marrow transplantation in children with myelodysplastic syndrome or juvenile myelomonocytic leukemia: the Seattle experience.

The purpose of this study was to evaluate the role of allogeneic bone marrow transplantation (BMT) in children with myelodysplastic syndrome (MDS). In total, 94 consecutive pediatric patients with MDS received an allogeneic BMT from 1976 to 2001 for refractory anemia (RA) (n=25), RA with ringed sideroblasts (RARS) (n=2), RA with excess blasts (RAEB) (n=20), RAEB in transformation (RAEB-T) (n=14), juvenile myelomonocytic leukemia (JMML) (n=32) or chronic myelomonocytic leukemia (CMML) (n=1). The estimated 3-year probabilities of survival, event-free survival (EFS), nonrelapse mortality and relapse were 50, 41, 28 and 29%, respectively. Patients with RA/RARS had an estimated 3-year survival of 74% compared to 68% in those with RAEB and 33% in patients with JMML/CMML. In multivariable analysis, patients with RAEB-T or JMML were 3.9 and 3.7 times more likely to die compared to those with RA/RARS and RAEB (P=0.005 and 0.004, respectively). Patients with RAEB-T were 5.5 times more likely to relapse (P=0.01). The median follow-up among the 43 surviving patients is 10 years (range 1-25). We conclude that allogeneic BMT for children with MDS is well tolerated and can be curative.

Effective donor lymphohematopoietic reconstitution after haploidentical CD34+-selected hematopoietic stem cell transplantation in children with refractory severe aplastic anemia.

Peritransplant toxicity and a delay in effective immune reconstitution have limited the utility of alternate donor transplantation for children with refractory severe aplastic anemia. We have assessed the effectiveness of infusing large numbers of highly purified haploidentical CD34+ cells after immunoablative conditioning in three patients who had failed intensive immunosuppression, lacked unrelated donors, and had active or recent serious infections. One patient rejected the first infusion, but engrafted after a second infusion from the same donor. This patient died 4 months after hematopoietic stem cell transplantation with no evidence of lymphoid reconstitution. Two patients experienced mixed chimerism requiring treatment with antibodies and/or donor lymphocyte infusion. Both currently survive more than 1 year after transplantation with normal blood counts, 100% donor engraftment, effective lymphoid reconstitution, and no chronic graft-versus-host disease. We observed functional thymopoiesis as measured by lymphocyte immunophenotyping, T cell receptor excision circles and T cell receptor Vbeta spectratyping complexity analysis. Further study is required to validate the initial promise of these preliminary observations.

Survival with combined modality therapy after intracerebral recurrence of pleuropulmonary blastoma.

BACKGROUND: We present and discuss the successful treatment of pleuropulmonary blastoma metastatic to the brain using a multimodality regimen with surgery, high-dose chemotherapy and radiation therapy. PROCEDURE: A 3-year-old boy referred to our institution with bilateral pulmonary cysts was diagnosed with pleuropulmonary blastoma (PPB). Initial treatment included surgery and multiagent chemotherapy with vincristine, dactinomycin, cyclophosphamide, cisplatin, and doxorubicin. One year after the completion of therapy, his PPB recurred as an intracerebral metastasis, and required further treatment with a multimodality salvage regimen. The child was successfully treated with a subtotal surgical resection, followed by high-dose cyclophosphamide, and radiation therapy. He is now disease-free 24 months later. RESULTS: Intracerebral metastases of PPB have been a uniformly fatal complication of this tumor. Postsurgical chemotherapy and radiation therapy appear to have contributed to the prolonged survival and potential for cure in our patient. CONCLUSIONS: The use of this multimodality regimen may be warranted in other patients with recurrent PPB metastatic to the brain.

Successful treatment of relapsed infant acute lymphoblastic leukemia with intensive antimetabolite-based chemotherapy.

PURPOSE: The treatment of infant acute lymphoblastic leukemia (ALL) continues to be a significant challenge for pediatric oncologists due to the high incidence of early relapses. Salvage regimens used to date have met limited success. We describe two cases of relapsed infant ALL who have achieved long-term survival with an intensive antimetabolite-based salvage regimen. PATIENTS AND METHODS: Two consecutive infants with relapsed ALL presented at our institution and were treated with an antimetabolite-based regimen. Both cases exhibited clinical and biological phenotypes previously associated with infantile ALL. RESULTS: Both patients have achieved prolonged and sustained remissions 48 and 30 months EFS respectively following therapy with intensive antimetabolite-based salvage regimen. CONCLUSIONS: An intensive multiagent antimetabolite based salvage regimen resulted in prolonged EFS in two cases of relapsed infant ALL. Dose intensification was achieved by administering repeated cycles of the same treatment schema using high dose chemotherapy throughout therapy. These infants were spared prophylactic cranial irradiation without a negative impact on outcome. The use of L-asparaginase, timed after high-dose Cytarabine (ARA-C) throughout therapy, might have contributed to their cure.

Transient therapy-related myelodysplastic syndrome associated with monosomy 7 and 11q23 translocation.

Secondary acute myelocytic leukemia (AML) and myelodysplastic syndromes (MDS) are known to develop in patients previously treated with different chemotherapeutic regimens. Nonrandom chromosomal abnormalities have been demonstrated in these therapy-related myeloid disorders which often evolve into refractory AML. The prognosis of these patients with conventional chemotherapy has been dismal and only allogeneic bone marrow transplantation offers a potential cure. We describe two patients who developed MDS after chemo/radiotherapy and had a spontaneous recovery. One patient was treated with MOPP-ABVD hybrid therapy for Hodgkin's disease, developed pancytopenia, marrow hypoplasia and dyserythropoiesis associated with monosomy 7. The other was treated with a combination of chemotherapy including VP-16 for Ewing's sarcoma, developed thrombocytopenia, marrow hypoplasia and dyserythropoiesis associated with an 11q23 translocation. Both patients received rhG-CSF after their cycles of chemotherapy and were considered for a bone marrow transplant. Marrow aspirates at frequent intervals showed gradual disappearance of the abnormal clone with parallel normalization of the peripheral count. In both patients G-CSF might have played a role in the development of the abnormal clone. We suggest that patients with therapy-related MDS without excess of blasts could be closely monitored for karyotypic and hematological improvement rather than transplanted immediately.

Progressive autologous graft-versus-host disease induced by cyclosporin A.

The development of graft-versus-host disease (GVHD) in patients undergoing allogeneic bone marrow transplantation for leukemias and lymphomas has been associated with a lower incidence of relapse. This phenomenon is thought to be secondary to the anti-tumor effect of adoptively transferred cells. Cyclosporin A (CsA) therapy is known to cause autologous and syngeneic GVHD in experimental models and humans, and has been used in patients undergoing autologous bone marrow transplantation. It has been the consensus to date that CsA-induced autologous GVHD is generally mild, confined to the skin, self-limiting and non-life-threatening. We report by case of severe and progressive GVHD induced by CsA in a child following autologous bone marrow transplantation for acute lymphoblastic leukemia in second remission.

Congenital heart disease masking pulmonary tuberculosis in children.

A report on 2 patients in whom coexisting pulmonary tuberculosis (PTB) was partially masked by signs of congenital heart disease is presented. The cases illustrate the difficulties in making a diagnosis of PTB in such situation and highlight the need for a high index of suspicion.