Electrical Impedance of Acupuncture Meridians: The Relevance of Subcutaneous Collagenous Bands

Background: The scientific basis for acupuncture meridians is unknown. Past studies have suggested that acupuncture meridians are physiologically characterized by low electrical impedance and anatomically associated with connective tissue planes. We are interested in seeing whether acupuncture meridians are associated with lower electrical impedance and whether ultrasound-derived measures – specifically echogenic collagenous bands- can account for these impedance differences. Methods/Results: In 28 healthy subjects, we assessed electrical impedance of skin and underlying subcutaneous connective tissue using a four needle-electrode approach. The impedances were obtained at 10 kHz and 100 kHz frequencies and at three body sites- upper arm (Large Intestine meridian), thigh (Liver), and lower leg (Bladder). Meridian locations were determined by acupuncturists. Ultrasound images were obtained to characterize the anatomical features at each measured site. We found significantly reduced electrical impedance at the Large Intestine meridian compared to adjacent control for both frequencies. No significant decrease in impedance was found at the Liver or Bladder meridian. Greater subcutaneous echogenic densities were significantly associated with reduced impedances in both within-site (meridian vs. adjacent control) and between-site (arm vs. thigh vs. lower leg) analyses. This relationship remained significant in multivariabl

An unusual association of deletion of SMARCB1 in a patient with intracranial yolk sac tumor: A case-report

Background: Deletion of SMARCB1/loss of INI is a well-known association in atypical rhabdoid teratoid tumors (ATRT) in the brain, rhabdoid tumors in the kidney, and less common tumors, including sinonasal INI1 deficient carcinoma, gastric undifferentiated carcinoma, undifferentiated uterine sarcomas, and poorly differentiated chordomas. Case report: We describe homozygous deletion of the SMARCB1 gene in a patient diagnosed with pineal yolk sac tumor, which is a rare entity. The association highlights the importance of INI1 staining when the clinical course is not progressing as expected and raises a critical management question: should this rare entity be treated aggressively, like ATRT, versus the conventional approach to intracranial yolk sac tumor? Conclusion: This case highlights the importance of INI1 staining in pediatric primitive central nervous system tumors as some germ cell markers are expressed in rhabdoid tumors at the stem cell level, implicating the germ cell origin of ATRT, which can complicate the diagnosis

Evaluation of Coagulation and Inflammatory Markers in Pediatric Patients on Extracorporeal Membrane Oxygenation (ECMO)

Background: Bleeding and thrombosis remain the primary complications related to the use of extracorporeal membrane oxygenation (ECMO). To date, no single test or parameter has been identified to accurately predict the risk of these hemostatic complications. Thrombin generation may be the key marker for both thrombosis and bleeding, and may be influenced by inflammation. The aims of this study were to evaluate if novel laboratory tests including thrombin generation assay, neutrophil extracellular traps (NETs), microparticles (MPs), and red blood cell (RBC) membrane fragility/adhesion could better predict patients at risk for bleeding and/or thrombosis compared to routine laboratory tests. We hypothesized that ECMO related thrombosis is associated with increased thrombin generation and ECMO related bleeding is associated with decreased thrombin generation. Methods: An IRB approved prospective pilot study of patients requiring ECMO was conducted at Children's Hospital of Michigan. Patients were enrolled within 24 hours of ECMO cannulation after informed consent. Patients aged 0-17 years placed on venoarterial (VA) or venovenous (VV) ECMO were included. Patient demographics, baseline laboratory, clinical data, and novel assays were collected. Presented is the preliminary data of the first 16 patients enrolled. SPSS was used for data analysis. Results: Of the 16 patients, there were 9 males and 7 females with the majority being cannulated for primary respiratory etiologies. Median age was 8.5 months with 6 patients being neonates (38%). Twelve patients (75%) survived the ECMO run, and 11 patients (69%) survived to hospital discharge. Laboratory data was grouped based on "no event" (N=94), "bleeding event" (N=13) and "clotting event" (N=21) days. There were no differences in the number of RBC, fresh frozen plasma, or cryoprecipitate transfusions between events. Platelet transfusions were used at higher volumes in bleeding events, p=0.011. Platelet counts did not differ between groups, whereas fibrinogen levels were significantly lower on days of bleeding events, p≤0.001 (Figure 1A). There were no differences seen in the activated partial thromboplastin time (aPTT) or activated clotting time (ACT) which are routinely used for monitoring anticoagulation. However, the prothrombin time (PT) was significantly prolonged in bleeding events with a median of 16 seconds (p=0.001), which may be related to the lower fibrinogen levels (Figure 1B). Thrombin generation was assessed using the maximum rate of thrombin generation (MRTG) value from the thromboelastograph (TEG) generated velocity curve (Figure 1D). Bleeding events had a significantly lower median MRTG of 7.93 mm/min compared to 12.36 mm/min in the no event group and 12.14 mm/min in the clotting event group (p=0.004). The thrombin generation assay results are in process. NETs were analyzed using an ELISA to detect citrullinated histone-3 (CitH3) levels (ng/mL). There were no significant differences seen in our population, however there is a trend toward increased levels in thrombotic events (Figure 1E). Both absolute MPs and platelet MPs were significantly increased in clotting events compared to bleeding events, p=0.003 and p≤0.001 respectively (Figure 1C). In our population, there was no evidence that hemolysis played a role in thrombosis as assessed by flow based RBC mechanical fragility testing. Of note, flow based RBC adhesion showed a non-significant trend toward increased adhesion to P-selectin. This finding requires further investigation because P-selectin is a primary site for adhesion on endothelial cells and plays a crucial role in coagulation (Figure 1F). Conclusions: Bleeding events on ECMO are associated with increased mortality. Our findings suggest that lower fibrinogen levels, prolonged PT and decreased thrombin generation (as assessed by the TEG) are associated with an increased risk for major bleeding. Increased levels of NETs, MPs and RBC adhesion have a trend towards increased thrombotic events. Thus, although preliminary, our results suggest that novel laboratory tests were effective in identifying bleeding events, and the trends seen in thrombotic events may allow for the use of new medications to reduce clotting in ECMO. The results illustrate the challenges in monitoring ECMO anticoagulation and additional study of novel tests are needed to identify and avoid clinical complications. Disclosures Tarasev: Functional Fluidics:Current Employment, Current equity holder in private company.Hines:Functional Fluidics:Current equity holder in private company.Chitlur:Biovertiv:Honoraria;Pfizer:Honoraria;Novo Nordisk:Consultancy, Honoraria;Takeda:Honoraria;Agios Pharmaceuticals:Research Funding. </jats:sec

RUNX1 associated Familial Platelet Disorder with Myeloid Malignancy (FPD-MM) in Children: A Novel New Phenotype with Juvenile and Chronic Myelomonocytic Leukemia (JMML/CMML) Characteristics

Abstract Introduction: RUNX1 (aka AML1; 21q22.12) is indispensable in the establishment of definitive hematopoiesis in humans. Activating RUNX1 mutations are associated with both Acute Myeloid and Lymphoblastic Leukemias (AML, ALL). On the other hand, hypofunctioning RUNX1 mutations cause dominantly inherited Familial Platelet Disorder (FPD). RUNX1 FPD has a high risk for progression to pancytopenia, myeloproliferative disorders (MPD) or AML, hence the new WHO category FPD with myeloid malignancy (FPD-MM). Those with MM carry mutations in other genes seen in AML, MDS. It is a relatively rare disorder with ~75 affected kindreds reported worldwide (Sood, et al. Blood 2017). Detailed reviews of pediatric cases are few. Case Histories: We encountered two children with RUNX1 associated thrombocytopenia; the mutations are novel. The first family is that of 14 yr old AAF, presenting with fainting- blood counts are shown in Table 1; fetal hemoglobin (HbF) was elevated; bone marrow was hypercellular with 6% type 1 blasts, extreme paucity of megakaryocytes, erythroid hyperplasia and large numbers of sea blue histiocytes. The high HbF suggested JMML while the monocyte CD16;14 profile (95.6% CD14+ cells) was similar to that seen in the adult type Chronic Myelomonocytic Leukemia (CMML). Her mother has pancytopenia without excess blasts in the marrow. The second case presented with neonatal thrombocytopenia; father has history of excessive bruising. Results: Blood counts and values for HbF are listed in Table 1. Molecular testing: Case1: A Myeloid gene panel showed RUNX1 - NM_001754.4:c.501delT, p.Ser167Argfs*9; PHF6 - NM_032458.2:c.902dupA, p.Tyr301*; CUX1- NM_001202543.1:c.2378delC, p.Pro793Argfs*26. No mutations were noted in PTPN11, CBL or RAS genes, the latter confirmed by JMML panel done at University of California, San Francisco. UCSF panel identified a mutation in SH2B3, a gene linked to erythrocytosis not caused by JAK2 mutations. Her mother has the same RUNX1 mutation, thus identifying a germline mutation of RUNX1 in her and her child but not the PHF6, CUX1 or the SH2B3 mutations seen in her daughter. A half sibling is unaffected and is a potential transplant donor for the mother. Case2: No coding sequence mutations were detected in genes associated with familial thrombocytopenia including ETV6, GATA1 and RUNX1. Array Comparative Genomic Hybridization studies (Prevention Genetics) identified a heterozygous deletion of the entire exon 5 of RUNX1. To understand the complex findings in family 1 additional studies were done- DRAQ5, CD71, Fetal Hb staining showed that NRBC in Case 1 contained predominantly high HBF cells. LIN28B was markedly elevated in the proband but not the mother (HbF- normal); LIN28B expression was normal in Case 2. Treatment/Outcome: In Case 1, low dose decitabine therapy resulted in the control of MPD features with good Hb recovery and normalization of the monocyte CD16;14 profiles. There was no platelet response to decitabine nor to a course of valproic acid. The child died of fulminant acute graft vs host disease affecting the liver following a 4/6 cord mismatch transplantation. Mother continues to show moderately severe pancytopenia requiring frequent transfusion support. The second child is symptom free with mild thrombocytopenia. Discussion: The hybrid JMML/CMML features in the index child are likely caused by the concurrent CUX1/PHF6/SH2B3 mutations. We are unable to establish if these are true de novo mutations as the father was not available for study; she had no full siblings. Neither high HbF nor high LIN28B are known feature of FPD by itself nor CMML or Polycythemia Vera (p Vera). Recently, the high HbF in JMML has been linked to high expression of LIN28B. SH2B3 mutation may have contributed to the high erythroid proliferation observed in our case. Induced CUX1 haploinsufficiency in mice causes MPD akin to CMML and megakaryocytic (Meg) proliferation (An N, et al. Blood 2018). The virtual absence of Megs in our case indicates that the CUX1 mutation was unable to overcome the Meg ploidization defect caused by the RUNX1 mutation. PHF6 mutations occur in T-ALL and AML but have not been linked to high HbF. Conclusions: Normal HbF and normal LIN28B expression in the mother of Case1 and in Case2 indicate that increased LIN28B is linked to the high HbF in Case 1 and that high LIN28B itself is a consequence of the malignant transformation caused by the concurrent CUX1/PHF6/SH2B3 mutations. Disclosures Chitlur: Baxter, Bayer, Biogen Idec, and Pfizer: Honoraria; Novo Nordisk Inc: Consultancy. Ravindranath:AGIOS: Other: Site Investigator for Pyruvate Kinase Deficiency. </jats:sec