Renal insufficiency, a frequent complication with age in oral-facial-digital syndrome type I

The oral-facial-digital syndrome type I (OFD I) is characterized by multiple congenital malformations of the face, oral cavity and digits. A polycystic kidney disease (PKD) is found in about one-third of patients but long-term outcome and complications are not well described in the international literature. Renal findings have been retrospectively collected in a cohort of 34 females all carrying a pathogenic mutation in the OFD1 gene with ages ranging from 1 to 65 years. Twelve patients presented with PKD - 11/16 (69%) if only adults were considered -with a median age at diagnosis of 29 years [IQR (interquartile range) = (23.5-38)]. Among them, 10 also presented with renal impairment and 6 were grafted (median age = 38 years [IQR = (25-48)]. One grafted patient under immunosuppressive treatment died from a tumor originated from a native kidney. The probability to develop renal failure was estimated to be more than 50% after the age of 36 years. Besides, neither genotype-phenotype correlation nor clinical predictive association with renal failure could be evidenced. These data reveal an unsuspected high incidence rate of the renal impairment outcome in OFD I syndrome. A systematic ultrasound (US) and renal function follow-up is therefore highly recommended for all OFD I patients.

Precipitation of technetium by subsurface sulfate-reducing bacteria

To study the interaction between Tc and subsurface bacteria, we conducted batch experiments with soil and groundwater or sterilized deionized water. The system water/soil was amended with lactate and phosphate for bacterial growth. Nitrate and sulfate were added to stimulate the growth of indigenous denitrifying and sulfate-reducing bacteria. During denitrification Tc-concentration did not change with time. In the presence of sulfate-reducing bacteria, Tc-concentrations decreased in reacted waters which could be attributed to Tc(VII) reduction and precipitation of TcO2and/or TcS2. Coprecipitation with newly formed iron sulfide is expected to contribute to Tc removal. Additional experiments with U and Tc showed that these elements were simultaneously reduced by sulfate-reducing bacteria. This work shows that 1) subsurface mixed cultures of denitrifying bacteria do not remove Tc from solution, this is different from uranium and 2) sulfate-reducing bacteria reduce and remove Tc from aqueous solutions and thus in situ bioremediation of subsurface waters and soils may be possible with such ubiquitous bacteria.

Low reoperation rate with the Medoff sliding plate: 1 technical failure in 63 trochanteric hip fractures

The Medoff sliding plate was designed to treat unstable intertrochanteric and subtrochanteric fractures. This plate has a dual sliding capability along both the femoral shaft and neck in order to improve bone coaptation, interfragment compression and hence load-sharing between bone and implant in hip fractures. In a retrospective study of 63 patients (mean age 82 (51-98) years) with intertrochanteric (n 44) and high subtrochanteric fractures (n 19), we assessed the results with the Medoff sliding plate. All patients, except 1 lost to follow-up, were examined clinically and radiographically. 14 patients died within 1 year, and in the other, the mean follow-up was 15 (6-30) months. 1 technical failure occurred, leading to a single reoperation. The low technical failure rate suggests that the Medoff sliding plate with combined compression modus is suitable for treating intertrochanteric and high subtrochanteric fractures.

Clinical and mutation-type analysis from an international series of 198 probands with a pathogenic FBN1 exons 24-32 mutation

Mutations in the FBN1 gene cause Marfan syndrome (MFS) and a wide range of overlapping phenotypes. The severe end of the spectrum is represented by neonatal MFS, the vast majority of probands carrying a mutation within exons 24-32. We previously showed that a mutation in exons 24-32 is predictive of a severe cardiovascular phenotype even in non-neonatal cases, and that mutations leading to premature truncation codons are under-represented in this region. To describe patients carrying a mutation in this so-called 'neonatal' region, we studied the clinical and molecular characteristics of 198 probands with a mutation in exons 24-32 from a series of 1013 probands with a FBN1 mutation (20%). When comparing patients with mutations leading to a premature termination codon (PTC) within exons 24-32 to patients with an in-frame mutation within the same region, a significantly higher probability of developing ectopia lentis and mitral insufficiency were found in the second group. Patients with a PTC within exons 24-32 rarely displayed a neonatal or severe MFS presentation. We also found a higher probability of neonatal presentations associated with exon 25 mutations, as well as a higher probability of cardiovascular manifestations. A high phenotypic heterogeneity could be described for recurrent mutations, ranging from neonatal to classical MFS phenotype. In conclusion, even if the exons 24-32 location appears as a major cause of the severity of the phenotype in patients with a mutation in this region, other factors such as the type of mutation or modifier genes might also be relevant.

Contribution of molecular analyses in diagnosing Marfan syndrome and type I fibrillinopathies: an international study of 1009 probands

BACKGROUND

The diagnosis of Marfan syndrome (MFS) is usually initially based on clinical criteria according to the number of major and minor systems affected following international nosology. The number of FBN1 mutation carriers, at risk of aortic complications who would not be properly diagnosed based only on clinical grounds, is of growing importance owing to the increased availability of molecular screening. The aim of the study was to identify patients who should be considered for FBN1 mutation screening.

METHODS

Our international series included 1009 probands with a known FBN1 mutation. Patients were classified as either fulfilling or not fulfilling "clinical" criteria. In patients with unfulfilled "clinical" criteria, we evaluated the percentage of additional patients who became positive for international criteria when the FBN1 mutation was considered. The aortic risk was evaluated and compared in patients fulfilling or not fulfilling the "clinical" international criteria.

RESULTS

Diagnosis of MFS was possible on clinical grounds in 79% of the adults, whereas 90% fulfilled the international criteria when including the FBN1 mutation. Corresponding figures for children were 56% and 85%, respectively. Aortic dilatation occurred later in adults with unfulfilled "clinical criteria" when compared to the Marfan syndrome group (44% vs 73% at 40 years, p<0.001), but the lifelong risk for ascending aortic dissection or surgery was not significantly different in both groups.

CONCLUSIONS

Because of its implications for aortic follow-up, FBN1 molecular analysis is recommended in newly suspected MFS when two systems are involved with at least one major system affected. This is of utmost importance in patients without aortic dilatation and in children.

Effect of mutation type and location on clinical outcome in 1,013 probands with Marfan syndrome or related phenotypes and FBN1 mutations: an international study

Mutations in the fibrillin-1 (FBN1) gene cause Marfan syndrome (MFS) and have been associated with a wide range of overlapping phenotypes. Clinical care is complicated by variable age at onset and the wide range of severity of aortic features. The factors that modulate phenotypical severity, both among and within families, remain to be determined. The availability of international FBN1 mutation Universal Mutation Database (UMD-FBN1) has allowed us to perform the largest collaborative study ever reported, to investigate the correlation between the FBN1 genotype and the nature and severity of the clinical phenotype. A range of qualitative and quantitative clinical parameters (skeletal, cardiovascular, ophthalmologic, skin, pulmonary, and dural) was compared for different classes of mutation (types and locations) in 1,013 probands with a pathogenic FBN1 mutation. A higher probability of ectopia lentis was found for patients with a missense mutation substituting or producing a cysteine, when compared with other missense mutations. Patients with an FBN1 premature termination codon had a more severe skeletal and skin phenotype than did patients with an inframe mutation. Mutations in exons 24-32 were associated with a more severe and complete phenotype, including younger age at diagnosis of type I fibrillinopathy and higher probability of developing ectopia lentis, ascending aortic dilatation, aortic surgery, mitral valve abnormalities, scoliosis, and shorter survival; the majority of these results were replicated even when cases of neonatal MFS were excluded. These correlations, found between different mutation types and clinical manifestations, might be explained by different underlying genetic mechanisms (dominant negative versus haploinsufficiency) and by consideration of the two main physiological functions of fibrillin-1 (structural versus mediator of TGF beta signalling). Exon 24-32 mutations define a high-risk group for cardiac manifestations associated with severe prognosis at all ages.

Trochanteric flip osteotomy for cranial extension and muscle protection in acetabular fracture fixation using a Kocher-Langenbeck approach

OBJECTIVE

To describe the advantages and surgical technique of a trochanteric flip osteotomy in combination with a Kocher-Langenbeck approach for the treatment of selected acetabular fractures.

DESIGN

Consecutive series, teaching hospital.

METHODS

Through mobilization of the vastus lateralis muscle, a slice of the greater trochanter with the attached gluteus medius muscle can be flipped anteriorly. The gluteus minimus muscle can then be easily mobilized, giving free access to the posterosuperior and superior acetabular wall area. Damage to the abductor muscles by vigorous retraction can be avoided, potentially resulting in less ectopic ossification. Ten consecutive cases of acetabular fractures treated with this approach are reported. In eight cases, an anatomic reduction was achieved; in the remaining two cases with severe comminution, the reduction was within one to three millimeters. The trochanteric fragment was fixed with two 3.5-millimeter cortical screws.

RESULTS

All osteotomies healed in anatomic position within six to eight weeks postoperatively. Abductor strength was symmetric in eight patients and mildly reduced in two patients. Heterotopic ossification was limited to Brooker classes 1 and 2 without functional impairment at an average follow-up of twenty months. No femoral head necrosis was observed.

CONCLUSION

This technique allows better visualization, more accurate reduction, and easier fixation of cranial acetabular fragments. Cranial migration of the greater trochanter after fixation with two screws is unlikely to occur because of the distal pull of the vastus lateralis muscle, balancing the cranial pull of the gluteus medius muscle.

The oxygen concentrator: an appropriate technology for treating hypoxaemic children in developing countries

The World Health Organization (WHO) recommends supplying oxygen in developing countries by concentrators because cylinders pose considerable logistic and financial problems. This technology was employed to treat children in a hospital in Ndioum, Senegal, who met the WHO oxygenation criteria. There were clear clinical and financial benefits, but neither the nurses' knowledge of the various techniques of oxygen supply nor the maintenance service were satisfactory. The use of concentrators should be encouraged in developing countries. A strategy including technical training, maintenance and monitoring should be adopted. Corrective actions were undertaken in Ndioum, and several concentrators are now being used on a regular basis.

Analyse génétique du fœtus à partir du sang maternel

Circulating fetal DNA in maternal plasma and serum was first demonstrated by Lo et al. in 1997 and has become a useful tool for prenatal diagnosis less than five years later. There is more and more evidence that the trophoblastic cells act as the major source of this circulating fetal DNA. Contrary to fetal cells analysis in maternal blood which requires isolation and enrichment procedures, fetal DNA analysis is relatively easy to perform with the use of real-time PCR. Non-invasive fetal sex and fetal RHD genotype determination are, to date, the two main clinical indications. Those newly offered possibilities have changed the management of pregnant women who are carriers for X-linked genetic disorders; prenatal diagnosis by choriovillous sampling could only be performed for male fetuses avoiding an unnecessary risk of fetal loss for female fetuses. Moreover, fetal RHD genotyping by maternal blood analysis could be useful in RhD-negative women at risk of immunization in order to adapt prophylactic anti-D injection.

Circulating cell-free fetal DNA in maternal serum appears to originate from cyto- and syncytio-trophoblastic cells. Case report

Circulating cell-free fetal DNA in maternal serum offers an early and non-invasive method for prenatal diagnosis, but the origin of this DNA is still unknown. We report the absence of the SRY gene in maternal serum of a pregnant woman despite male genitalia at ultrasound. The karyotype was 45,X after direct trophoblast analysis and 45,X/46,Xidic(Yp) after culture and in all fetal tissues studied. Due to the absence of the SRY sequence in maternal blood and in the cytotrophoblast, we presume that free fetal DNA in this case originates from trophoblastic cells. As the case presented here is exceptional, it only has a minor impact on the accuracy of fetal sex determination by maternal serum analysis, but highlights the importance of and the necessity for the complementary ultrasonographic control.

Stellenwert und Vorteil neuer winkelstabiler Implantate bei Schaftfrakturen (LCP vs. Nagel)

Der goldene Standard zur Behandlung von Schaftfrakturen langer Röhrenknochen des Erwachsenen bleibt nach wie vor die Marknagelosteosynthese. Das operative Verfahren ist standardisiert und meist minimal-invasiv, die primäre Heilungsrate ist hoch, und Komplikationen treten selten auf. Für Problemzonen (metadiaphysärer Übergang), bei schlechter Knochenqualität und bei anderen relativen Kontraindikationen für den Marknagel (enger Markkanal, Frakturen beim Adoleszenten und beim Polytrauma) bieten die neuen winkelstabilen Schrauben-Platten-Systeme (LISS, LCP) eine ausgezeichnete Alternative für die operative Stabilisierung. Die damit erreichte sehr hohe Primärstabilität in Kombination mit neu entwickelten, weichteilschonenden Operationstechniken (MIPO = Minimalinvasive Plattenosteosynthese) bieten die Grundlagen für eine funktionelle Nachbehandlung und eine möglichst rasche und komplikationsarme Knochenheilung.

Biologische Osteosynthese – was bedeutet das für den Hausarzt?

Die biologische Osteosynthese ist durch mehrere Faktoren gekennzeichnet: schonungsvolle Operationstechnik, Reduktion des Repositionszieles auf das funktionell Notwendige und Verwendung neuer Verankerungsprinzipien und Implantatdesigns, welche die Vitalität des Knochens wenig beeinflussen. Die Reposition einer Fraktur im Schaftbereich erfolgt meist indirekt, die Exposition der Frakturzone wird vermieden, und die Fragmente bleiben in ihrem Weichteilverbund integriert, so dass der natürliche Knochenheilungsprozess so wenig wie möglich gestört wird. In diesem Zusammenhang hat sich insbesondere die Technik der Plattenosteosynthese gewandelt. In Analogie zu einer Marknagel-Osteosynthese wird die Fraktur mit der Platte langstreckig überbrückt unter korrekter Einstellung von Länge, Achsen und Torsion des Knochens. Der chirurgische Zugang ist oft minimal und dient lediglich noch dem Einschieben des Implantates, die Inzisionslänge entspricht dabei eher dem Plattenquerschnitt als der Plattenlänge. Die mechanische Leistungsfähigkeit der Platte wird durch den Gebrauch langer Implantate und die Möglichkeit, neben Standardschrauben auch winkelstabile Schrauben einzusetzen, optimiert. Durch die Vergrößerung des mechanisch wirksamen Hebelarms der Platte nimmt die Belastung der Schrauben ab, was die Gefahr des Ausreissens von Schrauben oder eines Schraubenbruchs vermindert. Die Platte selbst erfährt bei gegebener Belastung eine geringere elastische Deformation und damit eine bessere Resistenz gegen einen Ermüdungsbruch. Die vorsichtige funktionelle Nachbehandlung bis zur radiologisch gesicherten Konsolidation des Knochens bleibt wichtiges Element des Behandlungserfolgs.

Ten-year patient and prosthesis survival after unipolar hip hemiarthroplasty in female patients over 70 years old

We found that 162 unipolar hemiarthroplastics of the hip were performed between 1989 and 1995 on women over 70 years of age in our institution. The mean age was 84 years (70 to 99). Cumulative survival of the prostheses was 98% at 1 year and 94% after 5 and 10 years. Of the original patients, 137 have died. Survival rate for patients was 73% at 1 year, 23% at 5 years, and 6% at 10 years. Eighteen patients could be accounted for, with a mean follow-up time of 7.7 years (5.5-11.3 years). The mean Harris hip score was 80 points (55-100). Protrusion was observed in 3 patients. The treatment of cervical neck fracture with unipolar hip prostheses is a valuable method, with a low complication rate, particularly in women over 70 years for whom life expectancy may be short.

Recombinant adenovirus shedding after intratumoral gene transfer in lung cancer patients

We conducted two phase 1 trials of direct intratumoral injection of a recombinant E1E3-deleted adenovirus (AdR) encoding either the bacterial enzyme beta-galactosidase (Ad.RSVbetagal) or interleukin 2 (IL2, AdTG5327) into primary nonsmall-cell lung cancers of 21 patients. We report here virus shedding and the duration of virus expression in the tumor after intrabronchial injection of 10(7), 10(8) or 10(9) PFU of adenovirus. The infectious AdR and the viral DNA were detected in PBL, plasma, stool and aerodigestive samples in a dose-dependent manner, since cell cultures and PCRs were found to be positive mainly for samples from patients who received the highest AdR dose (10(9) PFU). We detected beta-galactosidase activity in the tumor biopsy samples of 66% of the patients, seemingly dose related, and only low levels of IL2 mRNA could be detected in tumor biopsy samples. E1 sequences were not detected by PCR in any of the PBL and bronchial samples collected after virus delivery, except in one patient. In this patient, E1 sequences were detected in PBL as well as in tumor biopsy samples collected at days 8, 30 and 60 and were correlated with longer beta-galactosidase expression in tumor samples. PBL tested before and after virus delivery contained both E1 sequences indicating that they did not result from replication-competent adenovirus (RCA) E1 sequences present in the inoculum. In addition, only on the day of the injection was Ad.RSVbetagal also detected in E1-positive PBL, indicating that virus replication in blood was very unlikely.

The relationship between cup design and the radiological signs of aseptic loosening in total hip arthroplasty

We assessed differences in the incidence and appearance of the radiological signs of loosening of the cup for various types of design. This was an observational study based on hip registry data of 15,340 patients with 17,951 total hip arthroplasties collected over a period of 33 years in 49 hospitals in Central Europe. The threaded and the press-fit titanium cups showed significantly less aseptic loosening than the other systems. The direction of migration and the frequency of the radiological signs of loosening differed between the cup systems and were time-dependent. Our findings indicate the superiority of uncemented threaded cups and press-fit titanium cups over other designs of cup.