Efficacy and Safety of Vamorolone Over 48 Weeks in Boys With Duchenne Muscular Dystrophy: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Vamorolone is a dissociative agonist of the glucocorticoid receptor that has shown similar efficacy and reduced safety concerns in comparison with prednisone in Duchenne muscular dystrophy (DMD). This study was conducted to determine the efficacy and safety of vamorolone over 48 weeks and to study crossover participants (prednisone to vamorolone; placebo to vamorolone).

METHODS

A randomized, double-blind, placebo-controlled and prednisone-controlled clinical trial of 2 doses of vamorolone was conducted in participants with DMD, in the ages from 4 years to younger than 7 years at baseline. The interventions were 2 mg/kg/d of vamorolone and 6 mg/kg/d of vamorolone for 48 weeks (period 1: 24 weeks + period 2: 24 weeks) and 0.75 mg/kg/d of prednisone and placebo for the first 24 weeks (before crossover). Efficacy was evaluated through gross motor outcomes and safety through adverse events, growth velocity, body mass index (BMI), and bone turnover biomarkers. This analysis focused on period 2.

RESULTS

A total of 121 participants with DMD were randomized. Vamorolone at a dose of 6 mg/kg/d showed maintenance of improvement for all motor outcomes to week 48 (e.g., for primary outcome, time to stand from supine [TTSTAND] velocity, week 24 least squares mean [LSM] [SE] 0.052 [0.0130] rises/s vs week 48 LSM [SE] 0.0446 [0.0138]). After 48 weeks, vamorolone at a dose of 2 mg/kg/d showed similar improvements as 6 mg/kg/d for North Star Ambulatory Assessment (NSAA) (vamorolone 6 mg/kg/d-vamorolone 2 mg/kg/d LSM [SE] 0.49 [1.14]; 95% CI -1.80 to 2.78, p = 0.67), but less improvement for other motor outcomes. The placebo to vamorolone 6 mg/kg/d group showed rapid improvements after 20 weeks of treatment approaching benefit seen with 48-week 6 mg/kg/d of vamorolone treatment for TTSTAND, time to run/walk 10 m, and NSAA. There was significant improvement in linear growth after crossover in the prednisone to vamorolone 6 mg/kg/d group, and rapid reversal of prednisone-induced decline in bone turnover biomarkers in both crossover groups. There was an increase in BMI after 24 weeks of treatment that then stabilized for both vamorolone groups.

DISCUSSION

Improvements of motor outcomes seen with 6 mg/kg/d of vamorolone at 24 weeks of treatment were maintained to 48 weeks of treatment. Vamorolone at a dose of 6 mg/kg/d showed better maintenance of effect compared with vamorolone at a dose of 2 mg/kg/d for most (3/5) motor outcomes. Bone morbidities of prednisone (stunting of growth and declines in serum bone biomarkers) were reversed when treatment transitioned to vamorolone.

TRIAL REGISTRATION INFORMATION

ClinicalTrials.gov Identifier: NCT03439670.

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that for boys with DMD, the efficacy of vamorolone at a dose of 6 mg/kg/d was maintained over 48 weeks.

[Management strategy of femoral artery pseudoaneurysm combined with infectious wounds]

Objective: To investigate the surgical treatment methods of femoral artery pseudoaneurysm combined with infectious wounds and to evaluate the clinical effects. Methods: The retrospective observational research method was used. Twelve patients with femoral artery pseudoaneurysm combined with infectious wounds who met the inclusion criteria were admitted to Nanjing University of Chinese Medicine Wuxi Integrated Traditional Chinese and Western Medicine Hospital (Affiliated Hospital of Jiangnan University) from October 2014 to September 2022, including 6 males and 6 females, aged from 46 to 78 years. In the primary operation, debridement, tumor resection, and artery suture/venous grafting to repair the artery/artery ligation were performed, and the wound area after tumor resection ranged from 4.0 cm×1.5 cm to 12.0 cm×6.5 cm. Wounds that could be sutured were treated with tension reduction suture and extracutaneous continuous vacuum sealing drainage (VSD), while large wounds that could not be sutured were treated with VSD to control infection. In the secondary operation, tension reduction suture was performed to repair the wounds that could be sutured; large wounds were repaired with adjacent translocated flaps with area of 9.0 cm×5.0 cm to 15.0 cm×7.0 cm. Additionally, when the length of the exposed femoral artery was equal to or over 3.0 cm, the wounds were repaired with additional rectus femoris muscle flap with length of 15.0 to 18.0 cm. The donor areas of the flaps were directly sutured. The wound with artery ligation was treated with stamp skin grafting and continuous VSD. The bacterial culture results of the wound exudate samples on admission were recorded. The intraoperative blood loss, the location of femoral artery rupture, the artery treatment method, and the wound repair method in the primary operation were recorded, and the durations of catheter lavage, catheter drainage, and VSD treatment, and the drainage volume after the operation were recorded. The repair method of wounds in the secondary operation, the durations of catheter drainage and VSD treatment, and the total drainage volume after the operation were recorded. The survivals of flap/muscle flap/stamp skin grafts were observed, and the wound healing time was recorded. Follow-up after discharge was performed to evaluate the quality of wound healing and the walking function and to check whether the pulsatile mass disappeared. B-ultrasound or computed tomography angiography (CTA) was performed again to observe potential pseudoaneurysm recurrence and evaluate the patency of blood flow of the femoral artery. Results: The bacterial culture results of wound exudate samples of all the patients were positive on admission. The blood loss was 150 to 750 mL in the primary operation. The arterial ruptures were located in the femoral artery in 8 cases, in the external iliac artery in 2 cases, and in the femoral arteriovenous fistula in 2 cases. Six cases received direct artery suture, 4 cases received autologous great saphenous vein grafting to repair the artery, 1 case received autologous great saphenous vein bypass surgery, and 1 case received artery ligation. The primary wound suture was performed in 4 cases, along with catheter lavage for 3 to 5 days, catheter drainage for 4 to 6 days, VSD treatment for 5 to 7 days, and a total drainage volume of 80 to 450 mL after the surgery. In the secondary operation, the wounds were sutured directly in 3 cases along with catheter drainage for 2 to 3 days, the wound was repaired with scalp stamp skin graft and VSD treatment for 5 days in 1 case, the wounds were repaired with adjacent translocated flaps in 2 cases with catheter drainage for 2 to 3 days, and the wounds were repaired with rectus femoris muscle flaps+adjacent translocated flaps in 2 cases with catheter drainage for 3 to 5 days . The total drainage volume after the secondary operation ranged from 150 to 400 mL. All the skin flaps/muscle flaps/skin grafts survived after operation. The wound healing time ranged from 15 to 36 days after the primary operation. Follow-up of 2 to 8 months after discharge showed that the wounds of all patients healed well. One patient who underwent femoral artery ligation had calf amputation due to foot ischemic necrosis, and the rest of the patients regained normal walking ability. The pulsatile mass disappeared in inguinal region of all patients. B-ultrasound or CTA re-examination in 6 patients showed that the blood flow of femoral artery had good patency, and there was no pseudoaneurysm recurrence. Conclusions: Early debridement, tumor resection, and individualized artery treatment should be performed in patients with femoral artery pseudoaneurysm combined with infected wounds. Besides, proper drainage and personalized repair strategy should be conducted according to the wound condition to achieve a good outcome.

[Clinical features of 19 cases of lower respiratory papillomatosis]

Objective: To explore the clinical characteristics and prognosis of lower respiratory papilloma(LRP)and therefore to improve clinical diagnosis and treatment. Methods: We performed a retrospective analysis of patients who were diagnosed with LRP in our department from October 2008 to October 2020. Results: Nineteen patients were enrolled and 12 were male and 7 were female. The average age of the 7 adult patients was (41.3±17.5)years and that of the 12 pediatric patients was (5.5±3.5)years. Ten (83.3%)of the pediatric patients showed disease onset at an age of less than 5 years. The main symptoms were cough and sputum production (13/19), dyspnea (15/19), hoarseness (10/19) and signs of stridor or wheezing (7/19). Chest CT examination was performed in 9 patients, which showed nodules or masses (9/9), cystic thin-walled cavity (4/9), obstructive pneumonia (2/9), atelectasis (2/9), and spicule sign (1/9). The upper respiratory tract was affected in all the pediatric patients (12/12) and 3/7 of the adult patients. Eighteen cases (18/19) were diagnosed by bronchoscopy, 1 (1/9) by thoracoscopy. Eighteen cases (18/19) showed mulberry-like and papillary lesions under bronchoscopy. All the cases were histologically confirmed as squamous cell papilloma, with 17 cases(17/19)showing tissue HPV6/11(+), 2 negative (2/19). The positive rate of HPV6 was 36.8%, ant that of HPV11 was 21.1%, while the double positive rate of HPV6/11 was 31.6%, and HPV16/18 were negative in all the 19 cases. Isolated respiratory papillomatosis was found in 4 cases (4/19), and multiple papillomatosis in 15 cases (15/19). Seventeen cases (17/19) underwent endoscopic interventional therapy, and the result showed that 15 cases relapsed, and 2 cases had no recurrence. One patient was treated with thoracoscopic lobectomy, and died 4 months after surgery. One patient gave up treatment. Conclusions: LRP is a rare clinical disease with a chronic course, and isolated LRP is even rarer. Young patients often suffer from upper respiratory tract involvement, and the main symptoms are cough, sputum production, dyspnea and hoarseness. CT scanning showed nodules and masses, cystic thin-walled cavities or signs of airway obstruction. Bronchoscopy often demonstrates papillary lesions. The diagnosis depends on pathology, with squamous cell papilloma being the most common, and most tests are positive for HPV6/11. It is suggested that the incidence is associated with low-risk HPV infection. Endoscopic resection is the main treatment, which is prone to relapse. The treatment should take into account the pathological changes of upper respiratory tract, and the etiological treatment of HPV should be stressed.

Quality and Safety Analysis of 2,999 Telemedicine Encounters During the COVID-19 Pandemic

Objective

To examine whether telemedicine remains safe and of high quality despite rapid expansion of services by comparing telemedicine encounters before and during the COVID-19 pandemic.

Methods

Pre-post study investigating 2,999 telemedicine encounters: February 1, 2020-May 15, 2020, was performed. A total of 2,919 completed visits before and after strict social distancing implementation were analyzed for patient and provider characteristics, encounter characteristics (e.g., history and physical examination), and quality and safety metrics (phone calls ≤ 7 days postvisit, visit-cause-specific hospital admission or mortality ≤ 30 days after visit). Stratified analysis of 3 groups for outcomes (young age, neuromuscular diagnosis, and new encounters) was performed.

Results

Patients ranging from 1 month to 33 years of age were seen. Rural patients were less likely to be seen during the pandemic compared with urban patients (8% vs 90%; p < 0.0001); teaching clinic and specialty clinic encounters increased significantly during the pandemic (8% vs 3%; p = 0.005), and documentation of at least 2 systems on examination was noted significantly more frequently during the pandemic (13% vs 7%; p = 0.009). No deaths were reported. There were no differences before/during the pandemic in safety or telemedicine failure metrics within the entire group and high-risk subgroups.

Conclusions

Despite a markedly and rapidly expanded scope of ambulatory telemedicine care during the COVID-19 pandemic, telemedicine remained a safe and high-quality option for pediatric neurology patients. In addition, populations perceived as high risk for telemedicine (the very young, new patients, and those with neuromuscular diagnoses) can benefit from telemedicine visits, particularly when access to in-person care is limited.

[Efficacy of hierarchical medical mode path management on the continuous treatment for chronic wound patients]

Objective: To explore the efficacy of hierarchical medical mode path management on the continuous treatment for chronic wound patients. Methods: From June 2017 to September 2018, the clinical data of 101 patients with chronic wounds who were just discharged from Department of Wound Repair of the Affiliated Hospital of Jiangnan University (hereafter referred to as the author's affiliation) and still needed continuous treatment, meeting the inclusion criteria, were analyzed with the method of retrospective cohort study. Based on the management method of continuous treatment after discharge, the patients were divided into path management group (52 patients, 27 males and 25 females, aged (44±6) years, 57 wounds) and conventional management group (49 patients, 26 males and 23 females, aged (45±6) years, 53 wounds). The patients in path management group were carried out with full-path management under hierarchical medical mode, and the patients in conventional management group were carried out with conventional continuous treatment management. The discharge time from the author's affiliation was the time before continuous treatment management (hereafter referred to as before management), and 12 weeks post discharge was the time after continuous treatment management (hereafter referred to as after management). The depression and anxiety of patients in two groups were assessed by Hamilton Depression Scale 24 item version (HAMD-24) and Self-rating Anxiety Scale (SAS), and the positive ratios of depression and anxiety were calculated. The effective rates of wound treatment, times of debridement and dressing change, and treatment cost during the continuous treatment management period were counted. Data were statistically analyzed with two independent sample t test, chi-square test, Fisher's exact probability test, and Wilcoxon rank-sum test. Results: (1) Before management, the HAMD-24 and SAS scores of patients in two groups were similar. After management, the HAMD-24 and SAS scores of patients in path management group were significantly lower than those of conventional management group (t=4.341, 3.840, P<0.01). Before and after management, the positive rates of depression and anxiety of patients in two groups were similar. (2) After management, the effective rate of wound treatment of patients in path management group was 98.25% (56/57), which was significantly higher than 86.79% (46/53) of conventional management group (χ(2)=5.341, P<0.05). (3) During the management, the times of debridement and dressing change in patients of path management group was 20±4, which was significantly less than 27±7 of conventional management group (t=5.833, P<0.01). (4) During the management, the treatment cost of patients in path management group was (2 479±213) yuan, which was significantly less than (5 215±326) yuan of conventional management group (t=50.185, P<0.01). Conclusions: In the continuous treatment of chronic wound patients, the full-path management under hierarchical medical mode can improve the effective rate of wound treatment, reduce the times of debridement and dressing change and treatment cost, and improve their psychological state.

[Normative application of negative-pressure wound therapy to improve the wound repair level]

In recent 20 years, the technology of negative-pressure wound therapy (NPWT) has been widely used in the field of wound repair. Basic research and clinical application have proved that NPWT plays a positive role in regulating wound repair in many aspects. Compared with the previous 10 years, NPWT has made great progress in the last 10 years in negative pressure materials or equipment, as well as in the use method, mechanism research, and clinical application strategy. Strict and accurate grasp of the clinical application indication of NPWT and scientific application of NPWT to regulate the microenvironment of wound healing, effective improvement of the healing quality of different types of wounds, and further improve the level of wound repair are the core principles of the normative use of NPWT.

Mortality and respiratory support in X-linked myotubular myopathy: a RECENSUS retrospective analysis

PURPOSE

Individuals with X-linked myotubular myopathy (XLMTM) who survive infancy require extensive supportive care, including ventilator assistance, wheelchairs and feeding tubes. Half die before 18 months of age. We explored respiratory support and associated mortality risk in RECENSUS, particularly among patients ≤5 years old who received respiratory support at birth; this subgroup closely matches patients in the ASPIRO trial of gene therapy for XLMTM.

DESIGN

RECENSUS is an international, retrospective study of patients with XLMTM. Descriptive and time-to-event analyses examined survival on the basis of age, respiratory support, tracheostomy use, predicted mutational effects and life-sustaining care.

RESULTS

Outcomes for 145 patients were evaluated. Among 126 patients with respiratory support at birth, mortality was 47% overall and 59% among those ≤5 years old. Median survival time was shorter for patients ≤5 years old than for those >5 years old (2.2 years (IQR 0.7-5.6) vs 30.2 years (IQR 19.4-30.2)). The most common cause of death was respiratory failure (66.7%). Median survival time was longer for patients with a tracheostomy than for those without (22.8 years (IQR 8.7-30.2) vs 1.8 years (IQR 0.2-not estimable)). The proportion of patients living without a tracheostomy was 50% at age 6 months and 28% at age 2 years. Median survival time was longer with provision of life-sustaining care than without (19.4 years (IQR 3.1-not estimable) vs 0.2 years (IQR 0.1-2.1)).

CONCLUSIONS

High mortality, principally due to respiratory failure, among patients with XLMTM ≤5 years old despite respiratory support underscores the need for early diagnosis, informed decision-making and disease-modifying therapies.

TRIAL REGISTRATION NUMBER

NCT02231697.

[Pelvic floor function of 5 143 women in early postpartum stage and analysis on the effect factors]

Objective: To describe the situation of early stage of pelvic floor function and investigate the effect factors in postpartum women. Methods: A retrospective survey was conducted, and women who did regular examination and gave birth in Peking University People's Hospital and had an annual pelvic floor examination at 6-12 weeks after delivery from Sep. 2012 to Dec. 2017 were interviewed. General information and pelvic floor electrical physiological indexes were collected and analyzed. Results: Totally 5 143 puerpera were included in the study. The normal strength of type Ⅰ muscle was 52.40% (2 695/5 143) and the normal strength of type Ⅱ muscle was 52.69% (2 710/5 143). The abnormal degree of fatigue of type Ⅰ muscle was 55.84% (2 872/5 143) and the abnormal degree of fatigue of typeⅡmuscle was 27.34% (1 406/5 143). Pelvic floor dynamic pressure was (93±37) cmH(2)O (1 cmH(2)O=0.098 kPa). The incidence of stress urinary incontinence (SUI) was 23.49% (1 208/5 143) after delivery and it was as high as 57.58% (95/165) for women who had family history of pelvic floor dysfunction. Family history of pelvic floor dysfunction was the risk factor of the fatigue index of type Ⅰ and type Ⅱ muscle (P<0.05). The incidence of SUI was associated with vaginal delivery and age (≥30 years old) and family history of pelvic floor dysfunction (P<0.01). Conclusions: Pelvic floor electrical physiological indicators are reduced in about half of women in early postpartum stage. Age (≥30 years old) and vaginal delivery and family history of pelvic floor dysfunction are the risk factors.

A pathogenic CtBP1 missense mutation causes altered cofactor binding and transcriptional activity

We previously reported a pathogenic de novo p.R342W mutation in the transcriptional corepressor CTBP1 in four independent patients with neurodevelopmental disabilities [1]. Here, we report the clinical phenotypes of seven additional individuals with the same recurrent de novo CTBP1 mutation. Within this cohort, we identified consistent CtBP1-related phenotypes of intellectual disability, ataxia, hypotonia, and tooth enamel defects present in most patients. The R342W mutation in CtBP1 is located within a region implicated in a high affinity-binding cleft for CtBP-interacting proteins. Unbiased proteomic analysis demonstrated reduced interaction of several chromatin-modifying factors with the CtBP1 W342 mutant. Genome-wide transcriptome analysis in human glioblastoma cell lines expressing -CtBP1 R342 (wt) or W342 mutation revealed changes in the expression profiles of genes controlling multiple cellular processes. Patient-derived dermal fibroblasts were found to be more sensitive to apoptosis during acute glucose deprivation compared to controls. Glucose deprivation strongly activated the BH3-only pro-apoptotic gene NOXA, suggesting a link between enhanced cell death and NOXA expression in patient fibroblasts. Our results suggest that context-dependent relief of transcriptional repression of the CtBP1 mutant W342 allele may contribute to deregulation of apoptosis in target tissues of patients leading to neurodevelopmental phenotypes.

[Respecting discipline laws and innovating leaping development]

Under the guidance of the predecessors and the efforts of the whole staff, Department of Burns and Plastic Surgery of Wuxi Third People's Hospital has grown into a well-known regional burn diagnosis and treatment center in China after about 30 years of development. Summarizing the experience, gain, and loss in the course of department growth, following and attaching importance to the discipline development law, consolidating the foundation, strengthening the skills, and being diligent in innovation are the most important. The future trend of discipline development is as follows: wound treatment is still fundamental, burn emergency treatment system should be further improved, interdisciplinary and multidisciplinary cooperation should be further strengthened, and basic scientific research should have the potential to transform to reality.

[The clinic experience of implantable diaphragm pacer in a patient with high cervical spinal cord injury and literature review]

Objective: To report the use of implantable diaphragm pacer (IDP) in a patient with high cervical spinal cord injury(HCSCI). Methods: A 14-year-old male patient, who suffered from a HCSCI at C2 neurological level and had been on a ventilator for 2 years, received IDP in August 2017 at China Rehabilitation Research Center. A systematic literature review was performed on IDP in patients with HCSCI in Pubmed, CNKI, and Wanfang databases, using the keywords: phrenic nerve and electrical stimulation and spinal cord injury; IDP and spinal cord injury; breathing pacemaker system and spinal cord injury. All fields were covered from 1970/01/01 to 2018/01/01 in Pubmed, from 1981/01/01 to 2018/01/01 in CNKI, and from 1900/01/01to 2018/01/01 in Wanfang. Results: No spontaneous breathing was observed preoperatively in the patient. The electrical response of phrenic nerves was intact on the right, but unresponsive on the left. We got started with the IDP at 4 weeks after surgery. The threshold voltage of the right hemidiaphragm pacing was 0.1 V and at the level of 0.7 V with an optimal effect. No significant diaphragmatic contraction was found at left side with the extent up till 0.7 V. The maximum tidal volume was 840 ml when electrical stimulation was given at an intensity of 0.7 V bilaterally. The bilateral stimulation voltage at 0.1-0.2 V, pacing frequencies at 9 beats/min in bed, or at 12 beats/min on wheelchair, were set to maintain the tidal volume at the level of (435±32) ml. After 2-week adaptive training, the patient could wean from the ventilator for 12 hours and had a normal blood gas analysis. At 6 week after surgery, with the aid of IDP, the patient could get out in wheelchair for outdoor activities. By literature review, we found 78 English papers, including 6 clinical trials, 10 reviews, and 11 Chinese papers, consisting of 8 reviews, 1 study in animal, and 2 news reports. Extensive contents, such as preoperative evaluation, preoperative preparation, surgical procedures, complications, surgical outcomes, and animal model studies of IDP were involved. The indications of IDP reported by literature were: (1) central alveolar hypoventilation; (2) Sleep apnea syndrome (Biot's respiration); (3) Respiratory failure induced by brainstem injury or disease; (4) Respiratory failure induced by spinal cord injury or disease above C3 level. Conclusion: Our case study confirmed the therapeutic effect of IDP on patients with respiratory failure caused by HCSCI.

Health Care Transition Experiences of Males with Childhood-onset Duchenne and Becker Muscular Dystrophy: Findings from the Muscular Dystrophy Surveillance Tracking and Research Network (MD STARnet) Health Care Transitions and Other Life Experiences Survey

Introduction:

As the proportion of males with Duchenne muscular dystrophy (DMD) surviving into adulthood increases, more information is needed regarding their health care transition planning, an essential process for adolescents and young adults with DMD. The objective of this study was to describe the health care transition experiences of a population of males living with Duchenne or Becker muscular dystrophy (DBMD).

Methods:

The eligible participants, identified through the Muscular Dystrophy Surveillance Tracking and Research Network (MD STARnet) surveillance project, were 16–31 years old and lived in Arizona, Colorado, Georgia, Iowa, or western New York (n=258). The MD STARnet Health Care Transitions and Other Life Experiences Survey was conducted in 2013 and administered online or in a telephone interview. Sixty-five males (25%) completed the survey. Among non-ambulatory males, response differences were compared by age group. Statistical comparisons were conducted using Fisher’s exact test, or when appropriate, the Chisquare test.

Results:

Twenty-one percent of non-ambulatory males aged 16–18 years, 28% of non-ambulatory males aged 19–23 years, 25% of non-ambulatory males aged 24–30 years, and 18 ambulatory males had a written transition plan. Nineteen percent of non-ambulatory males aged 24–30 years had delayed or gone without needed health care in the past 12 months. Among non-ambulatory males aged 24–30 years, 75% had cardiology providers and 69% had pulmonology providers involved in their care in the past 12 months. Twentyeight percent of non-ambulatory males aged 19–23 years and 25% of non-ambulatory males aged 24–30 years reported that they did not receive health care or other services at least once because they were unable to leave their home. Non-ambulatory males aged 16–18 years (29%) were less likely to have ever discussed how to obtain or keep health insurance as they get older compared to non-ambulatory males aged 24-30 years (69%) (p <0.01).

Discussion:

This study identified potential barriers to the successful health care transition of males with DBMD. The results of this study may indicate a lack of targeted informational resources and education focused on supporting the transition of young men with DBMD as they age from adolescence into adulthood within the healthcare system. Future studies could determine the reasons for the potential barriers to health care and identify the optimal transition programs for males with DBMD. There are a few online resources on transition available to adolescents and young adults with special health care needs.

[Ultrastructure of the lens anterior capsule in secondary cataract associated with uveitis under an electron microscope]

Objective: To observe the ultrastructure of lens epithelium cells in cataract associated with uveitis. Methods: A cross-sectional study. Seven patients(7 eyes) received phacoemulsification in Peking University First Hospital from August 2016 to March 2017 due to complicated cataract associated with uveitis[2 males and 5 females,with an average age of (49±20) years] and 3 patients of age-related cataract (3 eyes, females, aged 54, 71, 74 years) were enrolled. Anterior capsule samples were collected during surgery. Transmission electron microscopy was performed. The cell morphology, the proportion of cell nuclear and organelle changes and the proportion of apoptosis in cataract associated with uveitis were described statistically by x±s or median (range). Results: Spindle-shaped epithelial cells were observed in cataract associated with uveitis (100%), while 28.00%,16.67%,16.67% of spindle-shaped epithelial cells were observed in age-related cataract. The organelle changes included mitochondria swelling and damage to the tight cell junction in cataract associated with uveitis. The tight junction between two cells was damaged in different degrees, only 8.33% (0-16.67%)of the cell nuclei appeared normal, and increased chromatin density(47.07%±22.28%), nuclear pyknosis(38.02%±19.61%) and nuclear fragmentation (9.96%±8.10%) were observed in cataract secondary to uveitis. The apoptosis rate was (48.16%±26.66%) in cataract associated with uveitis and correlated to the duration of intraocular inflammation. While the apoptosis rate were 0, 8.33%, 0 in age-related cataract patients. No autophagosome was observed in cataract associated with uveitis. Conclusions: Ultrastructure changes existed in lens epithelium cells in cataract associated with uveitis. The increased rate of apoptosis and inhibition of autophagy could be the possible mechanism of cataract formation in uveitic eyes. (Chin J Ophthalmol, 2018, 54: 357-362).

[Effects of application of citrate anticoagulation in bedside continuous blood purification of severe burn patients with sepsis]

Objective: To investigate the effects of application of citrate anticoagulation in bedside continuous blood purification (CBP) of severe burn patients with sepsis, so as to provide reference for choosing anticoagulants in CBP of these patients. Methods: Thirty severe burn patients with sepsis, conforming to the study criteria, were admitted to our burn intensive care unit from January 2014 to July 2017. Patients were divided into heparin group and citrate group according to computer randomization method, with 15 cases in each group. Patients in two groups all received bedside CBP treatment. Patients in heparin group used local heparin anticoagulation, while patients in citrate group used local citrate anticoagulation. Time of predicted single-time CBP treatment, time of single-time CBP treatment, time of accumulative CBP treatment, and rate of reaching the standard of CBP treatment time were counted. Changes of prothrombin time (PT), activated partial thromboplastin time (APTT), international normalized ratio (INR), fibrinogen, serum procalcitonin, and C-reactive protein (CRP) of patients before and after treatment were monitored. Hemorrhage in wounds, incision on trachea, and arteriovenous intubation point, and other complications during and after CBP treatment were observed. Data were processed with independent sample t test and chi-square test. Results: (1) Time of predicted single-time CBP treatment of patients in the two groups was equal. Time of single-time CBP treatment and time of accumulative CBP treatment of patients in citrate group were longer than those in heparin group. Rate of reaching the standard of CBP treatment time of patients in citrate group was significantly higher than that in heparin group (χ(2)=16.655, P<0.01). (2) There was no statistically significant difference in PT, APTT, INR, fibrinogen, serum procalcitonin, and CRP of patients in the two groups before CBP treatment (t=0.203, -1.006, 0.203, 0.039, -1.591, -0.824, P>0.05). PT and APTT of patients in citrate group after CBP treatment were (14.2±1.6) and (45±7) s, respectively, significantly shorter than (15.5±1.4) and (53±6) s in heparin group (t=2.395, 3.321, P<0.05 or P<0.01). INR of patients in citrate group after CBP treatment was 1.13±0.12, significantly lower than 1.24±0.12 in heparin group (t=2.395, P<0.05). Fibrinogen of patients in citrate group after CBP treatment was (3.5±0.6) g/L, significantly higher than (3.0±0.6) g/L in heparin group (t=-2.427, P<0.05). Serum procalcitonin and CRP of patients in citrate group after CBP treatment were significantly lower than those in heparin group (t=2.520, 2.710, P<0.05). Decreased degree of serum procalcitonin and CRP of patients in citrate group after CBP treatment were (1.8±0.6) ng/mL and (143±69) mg/L, respectively, significantly higher than (0.9±0.6) ng/mL and (95±50) mg/L in heparin group (t=-4.033, -2.170, P<0.05 or P<0.01). (3) During CBP treatment, patients in heparin group experienced 21 times of exacerbation of wound hemorrhage and 10 times of new hemorrhage, including 2 times of hemorrhage at incision on trachea and 8 times of hemorrhage at arteriovenous intubation point. No exacerbation of hemorrhage or new hemorrhage happened in patients of citrate group. After CBP treatment, no electrolyte disturbance happened in patients of heparin group, but 1 patient in citrate group experienced hypocalcemia. Conclusions: Application of citrate anticoagulation in bedside CBP of severe burn patients with sepsis shows light impact on systematic coagulation status, and can effectively decrease inflammation reaction of burn sepsis with low rate of hemorrhage.

A multicenter, retrospective medical record review of X-linked myotubular myopathy: The recensus study

Introduction: X‐linked myotubular myopathy (XLMTM), characterized by severe hypotonia, weakness, respiratory distress, and early mortality, is rare and natural history studies are few. Methods: RECENSUS is a multicenter chart review of male XLMTM patients characterizing disease burden and unmet medical needs. Data were collected between September 2014 and June 2016. Results: Analysis included 112 patients at six clinical sites. Most recent patient age recorded was ≤18 months for 40 patients and >18 months for 72 patients. Mean (SD) age at diagnosis was 3.7 (3.7) months and 54.3 (77.1) months, respectively. Mortality was 44% (64% ≤18 months; 32% >18 months). Premature delivery occurred in 34/110 (31%) births. Nearly all patients (90%) required respiratory support at birth. In the first year of life, patients underwent an average of 3.7 surgeries and spent 35% of the year in the hospital. Discussion: XLMTM is associated with high mortality, disease burden, and healthcare utilization. Muscle Nerve57: 550–560, 2018

Outcomes of Colorado children with acute flaccid myelitis at 1 year

OBJECTIVE

We describe long-term functional, neurodiagnostic, and psychosocial outcomes of a cohort of 12 children from Colorado diagnosed with acute flaccid myelitis (AFM) in 2014.

METHODS

Children were assessed every 3 months for 1 year or until clinical resolution. Assessments included neurologic examination, MRI, EMG/nerve conduction studies (NCS), functional measures (Assisting Hand Assessment, Hammersmith Functional Motor Scale), and Patient-Reported Outcomes Measurement Information System questionnaires.

RESULTS

Eight of 12 children completed the study. Six of 8 had persistent motor deficits at 1 year; 2 demonstrated full recovery. Four were not enrolled, 2 of whom reported full recovery. The 6 affected were weakest in proximal muscles, showing minimal to no improvement and significant atrophy at 1 year. All patients improved in distal muscle groups. Cranial nerve dysfunction resolved in 2 of 5 and improved in all. Four of 5 showed progressive functional improvement at 6 and 12 months. Two of 8 reported pain at 1 year. Three of 8 reported depressive symptoms. Repeat MRI was performed in 7 of 8 children a median of 7 months after onset and showed significant improvement or normalization in all but one child. Repeat EMG/NCS was performed on 4 children a median of 8 months after onset and showed ongoing denervation and chronic reinnervation in 3 children with persistent deficits.

CONCLUSIONS

At 1 year, children with AFM demonstrated functional gains but weakness persisted. EMG changes correlated with persistent deficits better than imaging. Despite improvements, AFM had substantial long-term functional effects on affected children.

[Lay further emphasis on cause analysis and non-surgical treatment of chronic refractory wound]

There are many pathogenic correlation factors of chronic refractory wound. Due to the complexity and particularity of the causes of wounds and lack of a standard diagnosis guide, it is hard to treat this kind of wound. Based on our recent scientific research data and the relative research at home and abroad in the present, we systematically analyze and summarize the causes and non-surgical treatment of chronic refractory wound in this article.

[Effect of hydrocinnamoyl-L-valyl pyrrolidine on healing quality of deep partial-thickness scald wound in mice]

Objective: To observe the effect of Toll interleukin-1 recptor homology/BB-loop mimetic hydrocinnamoyl-L-valyl pyrrolidine (AS-1) on the healing quality of deep partial-thickness scald wound in mice. Methods: Forty-two adult C57BL/6 mice were divided into sham injury group (SI), scald group (S), early AS-1 treatment group (EAT), early dimethyl sulfoxide (DMSO) control group (EDC), late AS-1 treatment group (LAT), late DMSO control group (LDC) according to the random number table, with 7 mice in each group. Mice in group SI were sham injured without other treatment. Deep partial-thickness scald model with 10% total body surface area was reproduced on the back of the other mice, and the wound was treated by daily wound cleaning with saline and dressing changing with vaseline gauze after injury. Mice in group EAT and those in group LAT were intraperitoneally injected with 20 mg/mL AS-1 50 mg/kg each day respectively from post scald hour (PSH) 8 and post scald day (PSD) 15 on. Mice in group EDC and those in group LDC were intraperitoneally injected with 20 mg/mL DMSO 50 mg/kg each day respectively from PSH 8 and PSD 15 on. On PSD 21, the gross condition of wound healing of mice with scald was observed, and the wound healing rate was calculated. Tissue samples of healed wound were collected and stained with HE and Masson respectively to observe the histomorphological change and fibrosis of collagen, and the percentage of fibrosis of collagen was calculated. The mRNA expressions of interleukin-1β (IL-1β), tumor necrosis factor α (TNF-α), transforming growth factor β₁ (TGF-β₁), matrix metalloproteinase-1 (MMP-1), tissue inhibitors of metalloproteinase 1 (TIMP-1), connective tissue growth factor (CTGF), type Ⅰ collagen and type Ⅲ collagen in healed wound tissue were detected by real time fluorescent quantitive reverse transcription polymerase chain reaction. The protein expressions of type Ⅰ collagen and type Ⅲ collagen in healed wound tissue were detected by Western blotting. Skin tissue of mice in group SI at the same area as that observed and collected in mice with scald was performed with the same observation and detection as mentioned above at the same time. Data were processed with one-way analysis of variance and Tukey test. Results: On PSD 21, no abnormal appearance was found in skin tissue of mice in group SI. Wounds of mice in group EAT were healed completely without scar formation, while those in the other four groups were not completely healed with scars formed in different degree. The wound healing rate of mice in group EAT was (97±4)%, close to that of group SI (100%, q=1.753, P>0.05), and both of them were obviously higher than those of groups S, EDC, LAT, and LDC [respectively (83±8)%, (87±6)%, (85±9)%, and (85±7)%, with q values from 4.819 to 6.803, P<0.05 or P<0.01]. On PSD 21, no abnormal appearance was found in morphology of skin tissue of mice in group SI. The morphology of healed wound tissue of mice in group EAT was close to that in group SI, with little epidermis hyalinosis and few newly formed collagen fibers arranged orderly. Epidermis hyalinosis in band- or flake-shape and obvious proliferation of collagen fibers arranged disorderly were observed in healed wound tissue of mice in the other four groups. Much infiltration of inflammatory cells was found in group S. The percentage of fibrosis of collagen in healed wound tissue of mice in group EAT was (30±3)%, close to that of group SI [(30±4)%, q=0.159, P>0.05], and both of them were obviously lower than those of groups S, EDC, LAT, and LDC [respectively (86±9)%, (74±5)%, (82±4)%, and (82±7)%, with q values from 12.080 to 15.530, P values below 0.01]. On PSD 21, compared with those of group SI, the mRNA expressions of IL-1β, TNF-α, TGF-β₁, MMP-1, and CTGF in healed wound tissue of mice in group S, the mRNA expressions of TGF-β₁ in healed wound tissue of mice in groups EDC and LDC, and the mRNA expression of MMP-1 in healed wound tissue of mice in group LAT were significantly increased (with q values from 4.039 to 5.232, P values below 0.05), while the mRNA expression of TIMP-1 in healed wound tissue of mice in group S was significantly decreased (q=4.921, P<0.05). Compared with those of group S, the mRNA expressions of IL-1β, TNF-α, TGF-β₁, MMP-1, and CTGF in healed wound tissue of mice in group EAT and the mRNA expressions of IL-1β and CTGF in healed wound tissue of mice in group LAT were significantly decreased (with q values from 4.418 to 6.402, P<0.05 or P<0.01), while the mRNA expressions of TIMP-1 in healed wound tissue of mice in groups EAT and LAT were significantly increased (with q values respectively 3.929 and 8.299, P<0.05 or P<0.01). Compared with those of group SI, the mRNA and protein expressions of type Ⅲ collagen in healed wound tissue of mice in the other groups and the mRNA and protein expressions of type Ⅰ collagen in healed wound tissue of mice in groups S, EDC, LAT, and LDC were significantly increased (with q values from 7.054 to 11.650, P values below 0.01). Compared with those of group EAT, the mRNA and protein expressions of type Ⅰ collagen in healed wound tissue of mice in groups S, EDC, LAT, and LDC were significantly increased (with q values from 5.156 to 7.451, P<0.05 or P<0.01). Conclusions: AS-1 can effectively promote wound healing and reduce fibrosis degree in the early stage of inflammation response after deep partial-thickness scald in mice, which may be related to its effect in decreasing the expression of inflammation related factors IL-1β and TNF-α and fibrosis related factors TGF-β₁, MMP-1, CTGF, and type Ⅰ collagen.

[HPV type determination and clinical characteristics in juvenile onset recurrent respiratory papillomatosis]

Objective:To investigate the relationship between different subtypes of human papillomavirus(HPV) infection and clinical features in juvenile onset recurrent respiratory papillomatosis(JORRP) patients. Method:Two hundred and forty cases with JORRP from 2010 to 2014 were retrospectively analyzed. HPV tpye were determined using tumor specimens taken from surgery, and all patients were divided into different groups based on HPV type. Clinical characteristics of patients from each groups were analyzed. Result:Except for HPV11 single infection or HPV6 single infection, some HPV11 and 6 co-infections were found in children with JORRP. Compared with patients with HPV6 single infection, HPV11 positive patients present an earlier age of onset, more times of operation and higher derkay score during surgery.Conclusion:JORRP in patients infected with HPV11 is more severe than that in patients with HPV6 infection in children.

Clinical course of growth in patients with congenital neuromuscular disease in a single multidisciplinary neuromuscular clinic

OBJECTIVE

To assess the effect of nutritional interventions on growth and on respiratory status in patients with congenital myopathy (CM), congenital muscular dystrophy (CMD), and congenital myasthenic syndrome (CMS).

METHODS

Retrospective cohort study based on case-note review of 18 patients affected by CM, CMD, and CMS, followed at a single pediatric neuromuscular center, between 2006 and 2014.

RESULTS

Seventy-two percent of patients required placement of a gastrostomy tube for bulbar weakness or for growth failure. Of those patients, 10 had 1 year follow up anthropometric data and 6 had 2 year follow up anthropometric data. Height percentiles and z-scores were significantly improved in patients after 1 year, while weight and BMI percentiles and z-scores were not. Weight and height percentiles and z-scores were significantly improved in patients at 2 year follow up, while BMI percentiles and z-scores were not. The number of respiratory illnesses was not significantly different before or after placement of the feeding tube. Of the patients who did not have placement of a gastrostomy tube, 4 had 1 year follow up anthropometric data and 3 had 2 year follow up anthropometric data. Gastrostomy tube fed patients had significantly higher mean weight percentiles and z-scores compared to orally fed patients. There was no significant difference in height or BMI between the gastrostomy fed and orally fed groups. Individual growth curves highlight the effect of intervention on weight and height.

CONCLUSIONS

This is a single multidisciplinary center experience describing the effect of nutritional interventions on growth in patients with congenital neuromuscular disorders. While the number of patients and their data in this report are limited, it highlights that the growth in this group of patients is unique but that the low weight and short stature respond to nutritional interventions with changes typically seen after 2 years of intervention.

TPM3 deletions cause a hypercontractile congenital muscle stiffness phenotype

OBJECTIVE

Mutations in TPM3, encoding Tpm3.12, cause a clinically and histopathologically diverse group of myopathies characterized by muscle weakness. We report two patients with novel de novo Tpm3.12 single glutamic acid deletions at positions ΔE218 and ΔE224, resulting in a significant hypercontractile phenotype with congenital muscle stiffness, rather than weakness, and respiratory failure in one patient.

METHODS

The effect of the Tpm3.12 deletions on the contractile properties in dissected patient myofibers was measured. We used quantitative in vitro motility assay to measure Ca(2+) sensitivity of thin filaments reconstituted with recombinant Tpm3.12 ΔE218 and ΔE224.

RESULTS

Contractility studies on permeabilized myofibers demonstrated reduced maximal active tension from both patients with increased Ca(2+) sensitivity and altered cross-bridge cycling kinetics in ΔE224 fibers. In vitro motility studies showed a two-fold increase in Ca(2+) sensitivity of the fraction of filaments motile and the filament sliding velocity concentrations for both mutations.

INTERPRETATION

These data indicate that Tpm3.12 deletions ΔE218 and ΔE224 result in increased Ca(2+) sensitivity of the troponin-tropomyosin complex, resulting in abnormally active interaction of the actin and myosin complex. Both mutations are located in the charged motifs of the actin-binding residues of tropomyosin 3, thus disrupting the electrostatic interactions that facilitate accurate tropomyosin binding with actin necessary to prevent the on-state. The mutations destabilize the off-state and result in excessively sensitized excitation-contraction coupling of the contractile apparatus. This work expands the phenotypic spectrum of TPM3-related disease and provides insights into the pathophysiological mechanisms of the actin-tropomyosin complex.

Association of a Novel ACTA1 Mutation With a Dominant Progressive Scapuloperoneal Myopathy in an Extended Family

IMPORTANCE

New genomic strategies can now be applied to identify a diagnosis in patients and families with previously undiagnosed rare genetic conditions. The large family evaluated in the present study was described in 1966 and now expands the phenotype of a known neuromuscular gene.

OBJECTIVE

To determine the genetic cause of a slowly progressive, autosomal dominant, scapuloperoneal neuromuscular disorder by using linkage and exome sequencing.

DESIGN, SETTING, AND PARTICIPANTS

Fourteen affected individuals in a 6-generation family with a progressive scapuloperoneal disorder were evaluated. Participants were examined at pediatric, neuromuscular, and research clinics from March 1, 2005, to May 31, 2014. Exome and linkage were performed in genetics laboratories of research institutions.

MAIN OUTCOMES AND MEASURES

Examination and evaluation by magnetic resonance imaging, ultrasonography, electrodiagnostic studies, and muscle biopsies (n = 3). Genetic analysis included linkage analysis (n = 17) with exome sequencing (n = 7).

RESULTS

Clinical findings included progressive muscle weakness in an initially scapuloperoneal and distal distribution, including wrist extensor weakness, finger and foot drop, scapular winging, mild facial weakness, Achilles tendon contractures, and diminished or absent deep tendon reflexes. Both age at onset and progression of the disease showed clinical variability within the family. Muscle biopsy specimens demonstrated type I fiber atrophy and trabeculated fibers without nemaline rods. Analysis of exome sequences within the linkage region (4.8 megabases) revealed missense mutation c.591C>A p.Glu197Asp in a highly conserved residue in exon 4 of ACTA1. The mutation cosegregated with disease in all tested individuals and was not present in unaffected individuals.

CONCLUSIONS AND RELEVANCE

This family defines a new scapuloperoneal phenotype associated with an ACTA1 mutation. A highly conserved protein, ACTA1 is implicated in multiple muscle diseases, including nemaline myopathy, actin aggregate myopathy, fiber-type disproportion, and rod-core myopathy. To our knowledge, mutations in Glu197 have not been reported previously. This residue is highly conserved and located in an exposed position in the protein; the mutation affects the intermolecular and intramolecular electrostatic interactions as shown by structural modeling. The mutation in this residue does not appear to lead to rod formation or actin accumulation in vitro or in vivo, suggesting a different molecular mechanism from that of other ACTA1 diseases.

CNS myelination requires cytoplasmic dynein function

BACKGROUND

Cytoplasmic dynein provides the main motor force for minus-end-directed transport of cargo on microtubules. Within the vertebrate central nervous system (CNS), proliferation, neuronal migration, and retrograde axon transport are among the cellular functions known to require dynein. Accordingly, mutations of DYNC1H1, which encodes the heavy chain subunit of cytoplasmic dynein, have been linked to developmental brain malformations and axonal pathologies. Oligodendrocytes, the myelinating glial cell type of the CNS, migrate from their origins to their target axons and subsequently extend multiple long processes that ensheath axons with specialized insulating membrane. These processes are filled with microtubules, which facilitate molecular transport of myelin components. However, whether oligodendrocytes require cytoplasmic dynein to ensheath axons with myelin is not known.

RESULTS

We identified a mutation of zebrafish dync1h1 in a forward genetic screen that caused a deficit of oligodendrocytes. Using in vivo imaging and gene expression analyses, we additionally found evidence that dync1h1 promotes axon ensheathment and myelin gene expression.

CONCLUSIONS

In addition to its well known roles in axon transport and neuronal migration, cytoplasmic dynein contributes to neural development by promoting myelination.

Spectrum and features of congenital heart disease in Xi'an, China as detected using fetal echocardiography

This study aimed to investigate the spectrum and features of congenital heart disease (CHD) in Xi'an, China using fetal echocardiography. All pregnant women referred for fetal echocardiography underwent a systematic fetal echocardiographic examination. Each case of complex defects was diagnosed according to the predominant pathophysiology, and the overall frequency of each defect was recorded and classified according to its location in the fetal heart. CHD was diagnosed in 195 fetuses. The top 5 types of CHD were, in order, single ventricle (15.9%, 31/195), atrioventricular septal defect (12.3%, 24/195), ventricular septal defect (VSD) (11.8%, 23/195), tetralogy of Fallot (10.8%, 21/195), and double-outlet right ventricle (8.2%, 16/195). The 195 cases of CHD comprised 316 defects in total. The most common defect was ventricular malformation (40.5%, 128/316), followed by great artery anomalies (38.0%, 120/316), endocardial cushion abnormalities (11.7%, 37/316), atrial abnormalities (6.6%, 21/316), and semilunar valve abnormalities (3.2%, 10/316). VSD accounted for the largest proportion (24.4%, 77/316) of the ventricular malformations. The total proportion of obstructive lesions in this group was much higher for the right than for the left side of the heart (18.4% (58/316) vs 9.5% (30/316), respectively). The spectrum of fetal CHD detected by echocardiography was much different compared to that accepted in the past. Complex defects were more common prenatally. Ventricular malformations were the largest constituent of all of the defects associated with fetal CHD, and VSD was the most common component of complex defects. Chinese fetal CHD encompassed more right-sided than left-sided obstructive lesions.

The motor neuron response to SMN1 deficiency in spinal muscular atrophy

INTRODUCTION

The purpose of this study was to measure and analyze motor unit number estimation (MUNE) values longitudinally in spinal muscular atrophy (SMA).

METHODS

Sixty-two children with SMA types 2 and 3 were observed prospectively for up to 42 months. Longitudinal electrophysiological data were collected, including compound motor action potential (CMAP), single motor unit action potential (SMUP), and MUNE.

RESULTS

Significant motor neuron loss and compensatory collateral reinnervation were noted at baseline. Over time, there was a significant mean increase in MUNE (4.92 units/year, P = 0.009), a mean decrease in SMUP amplitude (-6.32 μV/year, P = 0.10), and stable CMAP amplitude.

CONCLUSIONS

The unexpected longitudinal results differ from findings in amyotrophic lateral sclerosis studies, perhaps indicating that compensatory processes in SMA involve new motor unit development. A better understanding of the mechanisms of motor unit decline and compensation in SMA is important for assessing novel therapeutic strategies and for providing key insights into disease pathophysiology.

Patterns of growth in ambulatory males with Duchenne muscular dystrophy

OBJECTIVE

To provide weight-for-age, height-for-age, and body mass index-for-age growth reference standards for ambulatory, steroid-naïve males, ages 2-12 years, with Duchenne muscular dystrophy (DMD) and to compare these growth curves to the 2000 Centers for Disease Control and Prevention growth charts for boys, which serve as references of physical size and growth for the general male pediatric population in the US.

STUDY DESIGN

Through a multi-state population-based surveillance of individuals with muscular dystrophy, a total of 1877 weight and 1544 height measurements ascertained during 1985-2010 from 513 males with DMD were obtained retrospectively from medical record review. Cases were classified as DMD if loss of ambulation occurred before the 12th birthday or, if younger than 12 years and still ambulating, the earliest symptoms of dystrophinopathy occurred before the 6th birthday. Each growth chart was constructed using 5 percentiles: 10th, 25th, 50th, 75th, and 90th. Smoothing procedures were applied in 2 stages to the irregular plots of the empirical percentile values.

RESULTS

A set of growth curves, derived from a large cohort of male youth with DMD, are presented. These curves demonstrate that DMD males are shorter and tend to the extremes of weight and body mass index compared with the general male pediatric population in the US.

CONCLUSION

Charts representing the pattern of growth in ambulatory, steroid-naïve males with DMD can facilitate monitoring of growth and early detection of unusual growth patterns. Use of these growth standards also will assist in monitoring responses to corticosteroid treatment.

Prospective cohort study of spinal muscular atrophy types 2 and 3

OBJECTIVE

To characterize the natural history of spinal muscular atrophy type 2 and type 3 (SMA 2/3) beyond 1 year and to report data on clinical and biological outcomes for use in trial planning.

METHODS

We conducted a prospective observational cohort study of 79 children and young adults with SMA 2/3 who participated in evaluations for up to 48 months. Clinically, we evaluated motor and pulmonary function, quality of life, and muscle strength. We also measured SMN2 copy number, hematologic and biochemical profiles, muscle mass by dual x-ray absorptiometry (DXA), and the compound motor action potential (CMAP) in a hand muscle. Data were analyzed for associations between clinical and biological/laboratory characteristics cross-sectionally, and for change over time in outcomes using all available data.

RESULTS

In cross-sectional analyses, certain biological measures (specifically, CMAP, DXA fat-free mass index, and SMN2 copy number) and muscle strength measures were associated with motor function. Motor and pulmonary function declined over time, particularly at time points beyond 12 months of follow-up.

CONCLUSION

The intermediate and mild phenotypes of SMA show slow functional declines when observation periods exceed 1 year. Whole body muscle mass, hand muscle compound motor action potentials, and muscle strength are associated with clinical measures of motor function. The data from this study will be useful for clinical trial planning and suggest that CMAP and DXA warrant further evaluation as potential biomarkers.

Changes in serum runt-related transcription factor 2 levels after a 6-month treatment with recombinant human parathyroid hormone in patients with osteoporosis

BACKGROUND

The mechanisms regulating the anabolic response of the skeleton for recombinant human PTH (1- 34) [rhPTH (1-34)] administration has not been fully elucidated.

AIM

The aim of this study was to evaluate the effect of rhPTH (1-34) on serum levels of runt-related transcription factor 2 (Runx2) in women with osteoporosis.

METHODS

Sixty post-menopausal women with osteoporosis (EO group) and 45 control subjects (NC group) were enrolled in this study. The EO group received daily injection of 20 μg rhPTH (1-34) plus oral 500 mg elemental calcium and 400 IU vitamin D3 for 6 months. Runx2 and Matrix metalloproteinase 13 (MMP-13) were measured with commercially available enzyme-linked immunosorbent assay kits. Bone mineral density (BMD) was also measured before and 6 months after rhPTH (1-34) treatment.

RESULTS

Serum total Ca2+, phosphate, and bone-specific alkaline phosphatase were significantly increased (p<0.05 or p<0.01), and the lumbar spine BMD (LS-BMD) was also increased by 4% in patients with osteoporosis after treatment with rhPTH (1-34) (p<0.05). On the contrary, serum Runx2 and MMP-13 were significantly decreased at post treatment (13.1% and 36.6%, respectively, p<0.05 and p<0.01). At baseline, serum Runx2 positively correlated with MMP-13 (r=0.74, p<0.01), the correction remained after adjusting for age and body mass index.

CONCLUSION

The daily injection of rhPTH (1-34) was able to stimulate bone formation. The therapy of 20 μg rhPTH (1- 34) for 6 months resulted in decrease of serum Runx2 and MMP-13. These changes might reflect the increase of active osteoblasts and the better bone homeostasis.

The expression of angiopoietin-1 and -2 in the endometrium of women with abnormal bleeding induced by an intra-uterine device

This study identified differences in expression of angiopoietin-1 (Ang-1) and angiopoietin-2 (Ang-2) in the endometrium of 33 women with abnormal bleeding induced by an intra-uterine device (IUD; 23 proliferative phase, 10 secretory phase) compared with 28 control samples from normal endometria in women without an IUD fitted (12 proliferative phase, 16 secretory phase). Expression of Ang-1, Ang-2 and endothelial cell-specific tyrosine kinase receptor-2 (Tie-2) mRNA was detected by reverse transcription-polymerase chain reaction (RT-PCR), and Ang-1 and Ang-2 protein levels were detected by immunohistochemistry. The RT-PCR results showed significantly decreased Ang-1 expression in the endometrium from IUD patients during both phases compared with the control women. Expression of Tie-2 mRNA and the Ang-1:Ang-2 mRNA ratio were also significantly decreased in endometria from IUD patients in the secretory phase compared with the control women. Immunohistochemical analysis showed elevated Ang-2 protein levels in secretory phase endometrium from IUD patients compared with the control women. These results suggest that the angiopoietin/Tie-2 system promotes vascular remodelling in the endometrium and that changes in the expression of Ang-1, Ang-2 and Tie-2 may contribute to abnormal uterine bleeding in some IUD users.

Overview of paediatric neuromuscular disorders and related pulmonary issues: diagnostic and therapeutic considerations

Pulmonary compromise is common in neuromuscular disease. Respiratory failure may be a presenting feature of neuromuscular disease and remains a major cause of morbidity and mortality. This article will review the current understanding of the more commonly encountered neuromuscular disorders in childhood and emphasize related pulmonary issues.

Mechanisms of organophosphate resistance in a field population of oriental migratory locust, Locusta migratoria manilensis (Meyen)

The susceptibilities to three organophosphate (OP) insecticides (malathion, chlorpyrifos, and phoxim), responses to three metabolic synergists [triphenyl phosphate (TPP), piperonyl butoxide (PBO), and diethyl maleate (DEM)], activities of major detoxification enzymes [general esterases (ESTs), glutathione S-transferases (GSTs), and cytochrome P450 monooxygenases (P450s)], and sensitivity of the target enzyme acetylcholinesterase (AChE) were compared between a laboratory-susceptible strain (LS) and a field-resistant population (FR) of the oriental migratory locust, Locusta migratoria manilensis (Meyen). The FR was significantly resistant to malathion (57.5-fold), but marginally resistant to chlorpyrifos (5.4) and phoxim (2.9). The malathion resistance of the FR was significantly diminished by TPP (synergism ratio: 16.2) and DEM (3.3), but was unchanged by PBO. In contrast, none of these synergists significantly affected the toxicity of malathion in the LS. Biochemical studies indicated that EST and GST activities in the FR were 2.1- to 3.2-fold and 1.2- to 2.0-fold, respectively, higher than those in the LS, but there was no significant difference in P450 activity between the LS and FR. Furthermore, AChE from the FR showed 4.0-fold higher activity but was 3.2-, 2.2-, and 1.1-fold less sensitive to inhibition by malaoxon, chlorpyrifos-oxon, and phoxim, respectively, than that from the LS. All these results clearly indicated that the observed malathion resistance in the FR was conferred by multiple mechanisms, including increased detoxification by ESTs and GSTs, and increased activity and reduced sensitivity of AChE to OP inhibition.

Psoriatic arthritis-associated polyneuropathy: a report of three cases

Psoriatic arthritis (PA) occurs in about 30% of patients with psoriasis. Although polyneuropathy is described in association with many connective tissue diseases, it is rarely reported in the autoimmune dermatoses. We describe 3 patients with polyneuropathy associated with PA. The clinical and electrophysiologic features are consistent with a chronic distal symmetric sensorimotor axonal process. PA-associated neuropathy should be considered in the differential diagnosis of chronic length-dependent axonal polyneuropathies.

Fibrinogen adsorption and platelet lysis characterization of fluorinated surface-modified polyetherurethanes

A polyetherurethane (PU) was modified using fluorinated surface-modifying macromolecules (SMMs). A double radiolabel method was used simultaneously to measure the number of adhered platelets ((51)Cr) and the quantity of adsorbed Fg ((125)I), in a cone-and-plate instrument. The objectives were to determine if adsorbed Fg levels correlated to platelet adhesion on the surfaces, and to assess if any reductions in platelet adhesion for the SMM-treated surfaces resulted from surface-induced platelet lysis, rather than changes directly related to lower platelet activation and attachment on the novel surfaces. Platelet lysis was determined from lactate dehydrogenase (LDH) and unbound (51)Cr released into plasma isolated from whole blood exposed to test materials. The corresponding Fg adsorption, evaluated under the same platelet adhesion conditions, did not account for the reduced platelet adhesion on the treated surfaces. LDH and (51)Cr platelet release were very low and indicated no statistically significant differences between the materials. It was therefore concluded that platelet lysis did not contribute to the reduction in platelet adhesion characteristic observed on the SMM-treated surfaces. More importantly, the work emphasizes that the platelet activation cannot be inferred to by assessing the quantity of fibrinogen as is commonly done in the literature. The finding suggests a much more complex mechanism of action for the SMM surface modifiers. On-going work is investigating other Fg parameters such as protein binding affinity and protein conformational state in order to establish the mechanism by which the fluorinated surface modifiers may be reducing platelet adhesion via intermediary changes in initial protein adsorption.

Masturbation in infancy and early childhood presenting as a movement disorder: 12 cases and a review of the literature

PURPOSE

Infantile masturbation (gratification behavior) is not commonly identified as a cause of recurrent paroxysmal movements. Extensive and fruitless investigations may be pursued before establishing this diagnosis. Sparse literature is available regarding masturbatory behavior as a whole, but literature available as case reports describes common features. The purpose of this case series is to describe consistent features in young children with posturing accompanying masturbation.

METHODS

Twelve patients presenting to a pediatric movement disorders clinic with a suspected movement disorder were determined to have postures and movements associated with masturbation. We reviewed the clinical history, examination, and home videotapes of these patients.

RESULTS

Our patients had several features in common: (1) onset after the age of 3 months and before 3 years; (2) stereotyped episodes of variable duration; (3) vocalizations with quiet grunting; (4) facial flushing with diaphoresis; (5) pressure on the perineum with characteristic posturing of the lower extremities; (6) no alteration of consciousness; (7) cessation with distraction; (8) normal examination; and (9) normal laboratory studies.

CONCLUSIONS

The identification of these common features by primary care providers should assist in making this diagnosis and eliminate the need for extensive, unnecessary testing. Direct observation of the events is crucial, and the video camera is a useful tool that may help in the identification of masturbatory behavior.

Fibrinogen surface distribution correlates to platelet adhesion pattern on fluorinated surface-modified polyetherurethane

In previous work, it had been shown that platelet adhesion could be reduced by fluorinating surfaces with oligomeric fluoropolymers, referred to as surface-modifying macromolecules (SMMs). In the current study, two in vitro blood-contacting experiments were carried out on a polyetherurethane modified with three different SMMs in order to determine if altered platelet adhesion levels could be related to the pattern of adsorbed protein and more specifically to the manner in which fibrinogen (Fg) distribution occurs at the surface. In the first experiment, the materials were placed in whole human blood and the adherent platelets were viewed with high-resolution scanning electron microscopy (SEM). In a second experiment, the materials were incubated with human plasma with the absence of platelets. The plasma contained 5% fluorescent-Fg. The materials were then viewed with a fluorescence microscope and images were collected to define the distribution of high-density fluorescent-Fg areas. The SEM and fluorescent-Fg images were imported to Image Pro Plus imaging software to measure the area, length and circularity and a bivariate correlation test was conducted between the two sets of data. For area and length morphology parameters, there were high and significant correlations (r > 0.9, p < 0.05) between the platelets and Fg aggregates. The data suggest that the Fg distribution may serve as a predictor of platelet morphology/activation and provides insight into the non-thrombogenic character of biomaterials containing the fluorinated SMMs.

Biological characterization of a novel biodegradable antimicrobial polymer synthesized with fluoroquinolones

Biomaterial-related infections continue to represent a significant challenge to the medical community. Several approaches have been utilized to incorporate antimicrobial agents at the surface of implant devices in attempts to delay or eliminate the formation of biofilms. To date, most of these strategies have focused on drug conjugation or diffusion-limited systems for the delivery of such pharmaceutical agents. More recently, work has been presented on the feasibility of incorporating drugs into the backbone of polymers as a main-chain monomer. When sequenced into the backbone of the polymer with other monomers that are hydrolytically sensitive to enzyme-catalyzed breakdown, it is thought that drugs may be able to be selectively released. Specifically, degradable polyurethanes have been synthesized with fluoroquinolone antibiotics and have shown an ability to kill bacteria when released following degradation of the polymer chains by the macrophage-derived enzyme cholesterol esterase. However, specificity of the cleavage sites in the polymer was difficult to control. Since cholesterol esterase has specificity for hydrophobic moieties, it is desirable to alter the formulation of the polyurethanes to incorporate long hydrophobic monomers immediately adjacent to the ciprofloxacin molecule. Hence, the current study focuses on evaluating the enzyme-catalyzed degradation of a degradable polyurethane synthesized with 1,12 diisocyanatododecane as a substitute for 1,6 diisocyanatohexane, which was used in previous work. Validation of specific ciprofloxacin release and the generation of antimicrobial are shown. A preliminary cell study to assess the cytotoxicity of this biodegradable antibiotic polymer shows that the material has no observable effects on cell proliferation or cell membrane structure.

[Clinical observation on effect of xuejie jiawei decoction on vaginal hemorrhagic amount and duration in patients after drug-abortion]

OBJECTIVE

To observe the effect of Xuejie Jiawei Decoction (XJJWD) in reducing vaginal hemorrhagic amount, shortening hemorrhagic duration and lowering the curettage rate of incomplete abortion in patients after drug-abortion.

METHODS

Group A was treated with XJJWD No. I from the 2nd day after abortion, one dose per day for 7 days. Group B was treated with XJJWD No. II from the 11th day after abortion, one dose per day for 5 days. The therapeutic effect of the two groups was compared with that of the untreated control group.

RESULTS

In the Group A, the total score on vaginal hemorrhagic amount was markedly less than that in the control group (P < 0.01), and the vaginal hemorrhagic duration in patients with menostasis less than 45 days was shorter than that in the control group (P < 0.01). In the Group B, the total score on vaginal hemorrhagic amount in patients with menostasis less than 45 days was lower than that in the control group (P < 0.05).

CONCLUSION

XJJWD could reduce the vaginal hemorrhagic amount and duration in patients after drug-abortion. It should be applied early after abortion, the less the duration of menostasis, the more effective the treatment.

Humic acid induced growth retardation in a sertoli cell line, TM4

Humic acid (HA) is a fluorescent deep brown organic, polymeric compound composed of phenolic acid. Intraperitoneal injection of HA in rats induced testicular morphological changes including degeneration of the seminiferous tubule, reduction in the number of Sertoli cells and spermatogonia, and a loss of spermatids. It was suggested that Sertoli cells may be involved in the progression of testicular atrophy. In this study, we used a mouse Sertoli cell Line, TM4, to investigate the effect of HA on Sertoli cells and the mechanism of the testicular atrophy induced by HA. We found that the cell growth of TM4 cells were reduced in 1 to 4 days of HA exposure. FACScan analysis of the DNA content of HA-treated TM4 cells revealed that there was no sub-G1 peak, indicating that the TM4 cells did not commit to the programmed cell death. However, a large proportion of TM4 cells were arrested at the G1 phase. The percentage of TM4 cells at the G1 phase increased from 36% to 84% after HA treatment for 4 days. Western blot assay of HA-treated TM4 cells showed that the expression of cyclin D1 protein decreased while the expression of p27kiP1 protein increased. These results suggest that HA-induced testicular atrophy is linked in part to an inhibitory effect on the growth of Sertoli cells. This model may be useful in investigation of environmental agents inducing testicular atrophy.

[Mast cell in the gingival cancer: histochemical and electron microscopical study]

OBJECTIVE

To observe the relation between mast cells and gingival cancer.

METHODS

The gingival cancer tissue of 24 cases and normal gingival tissue of 7 cases were studied with histochemical and electron microscopical methods.

RESULTS

The results showed that the number of mast cells around the periphery of gingival cancer tissue increased significantly. The histochemical properties of these mast cells differed from the normal gingival tissue. The former did not contain heparin which was present normally. Under electron microscope, according to the characteristic ultrastructure, the mast cells around the gingival cancer were TC mast cells. Some of them showed the appearance of degranulation, and contacted intimately with cancer cells, lymphocytes and macrophages.

CONCLUSION

These results suggested that together with lymphocytes, macrophages, the mast cell contributed to the defense reaction to the cancer tissue.

Review of pre-eclampsia in Taiwan: a multi-institutional study

BACKGROUND

Because the reported frequency of pre-eclampsia in Taiwan varies significantly, the aims of this study were to measure the current incidence of pre-eclampsia and its correlated morbidity and mortality for both mothers and fetuses in Taiwan.

METHODS

We retrospectively studied all reported cases of pre-eclampsia and eclampsia from January 1, 1993 to December 31, 1997 in the 14 tertiary medical centers and regional hospitals in Taiwan. Recruiting criteria were pregnancy-induced hypertension (systolic blood pressure > or = 140 mmHg or diastolic blood pressure > or = 90 mmHg) with proteinuria (> or = 300 mg of urinary protein per 24 hours) and independent part edema.

RESULTS

There were 4,193 patients with pre-eclampsia and eclampsia for a frequency of 2.03% of 206,551 deliveries during the study period. Of these, 58.9% of patients were classified as having mild pre-eclampsia while 38.4% had severe pre-eclampsia. Advanced maternal age (> 35 years) (odds ratio [OR] = 4.56; 95% confidence interval [CI] = 4.23-4.90; p < 0.001), primiparity (OR = 1.71; 95% CI = 1.61-1.82; p = 0.02) and twin pregnancy (OR = 1.92; 95% CI = 1.64-2.25; p = 0.01) were significant risk factors for developing pre-eclampsia. However, multivariate analysis showed that only advanced maternal age was a significant risk factor for pre-eclampsia (OR = 3.21; 95% CI = 2.95-3.50; p < 0.001). In contrast to mild pre-eclampsia, severe pre-eclampsia resulted in significantly worse outcomes for both mothers and fetuses. Complications in patients with severe pre-eclampsia included placental abruption, acute renal failure, pulmonary edema, postpartum hemorrhage, pleural effusion, preterm labor, intrauterine growth retardation, stillbirth, neonatal mortality and low birth weight infants, all of which occurred significantly more frequently than in patients with mild pre-eclampsia (p < 0.001).

CONCLUSIONS

Pre-eclampsia remains a big challenge in modern obstetrics in Taiwan. Early diagnosis and management of patients with pre-eclampsia to prevent progression would significantly improve outcomes for mothers and fetuses.

Brain-damaged survivors after intrauterine death of a monochorionic twin

BACKGROUND

Potential risks for a surviving twin after fetal death of a co-twin in twin-to-twin transfusion syndrome (TTTS) has been documented. Although some studies suggest ending a twin pregnancy after a single fetal death as soon as possible in order to minimize the risks of thromboembolic complications in the surviving twin, we are more concerned about the risks of a premature birth. In this study, we searched for a potential marker to predict thromboembolic complications in the surviving twin.

METHODS

From 1993 to 1998, nine women in two teaching hospitals had pregnancies complicated by TTTS and the death of one fetus. In addition to routine ultrasound examinations and obstetric monitoring, all patients had disseminated intravascular coagulation tests. The outcome of the surviving fetus was recorded.

RESULTS

Three patients had silent and minimal coagulopathy (33%) that revealed only the presence of D-dimer. Among these three patients, two had a disappearance of serum D-dimer, but the other one had persistent D-dimer levels for more than 5 weeks and delivered a fetus with a cerebral infarction. Except for the above-mentioned fetus, all surviving fetuses were normal and healthy and were delivered at the median gestational age of 33 (range, 31-36) weeks. Of the nine surviving children, the mean interval between fetal death of one twin and delivery of the healthy twin was 22.7 days, ranging from 3 days to 47 days.

CONCLUSIONS

All patients having TTTS associated with one fetal death should be carefully monitored for coagulopathy; the appropriate time for delivery might depend on the duration of persistent D-dimer in the maternal blood. The long-term presence of D-dimer in the maternal serum may indicate a severe underlying thromboembolic complication in the surviving twin after intrauterine death of a monochorionic twin. Due to the increased risks of morbidity in premature births, the benefit of early termination of pregnancy in order to protect against subsequent sequelae in the surviving twin is minor and remains an area for future research.

Prenatal diagnosis and management of congenital cystic adenomatoid malformation

Congenital cystic adenomatoid malformation (CCAM) is a rare pulmonary malformation resulting from excessive overgrowth of the terminal bronchioles. We present two CCAM case studies: type I (macrocystic) and type III (microcystic), diagnosed by antenatal ultrasonography at 31 and 21 weeks' gestation, respectively. In the former, multiple dilated cystic masses in the fetal left lung, with polyhydramnios, were identified during the antepartum examination. A postnatal thoracotomy with lobectomy was performed due to persistent cyanosis and resulted in a good outcome. In the latter case, an echogenic mass with multiple cysts in the fetal right lung was detected by prenatal sonography. The parents decided to terminate the pregnancy after prenatal counseling.

Role of the Janus kinase (JAK)/signal transducters and activators of transcription (STAT) cascade in advanced glycation end-product-induced cellular mitogenesis in NRK-49F cells

Advanced glycation end product (AGE) is important in the pathogenesis of diabetic nephropathy, which is characterized by cellular hypertrophy/hyperplasia leading to renal fibrosis. However, the signal transduction pathways of AGE remain poorly understood. The Janus kinase (JAK)/signal transducers and activators of transcription (STAT) pathway has been associated with cellular proliferation in some extra-renal cells. Because interstitial fibroblast proliferation might be important in renal fibrosis, we studied the role of the JAK/STAT pathway in NRK-49F (normal rat kidney fibroblast) cells cultured in AGE/BSA and non-glycated BSA. We showed that AGE dose-dependently (10-200 microgram/ml) increased cellular mitogenesis in NRK-49F cells at 5 and 7 days. However, cellular mitogenesis was unaffected by the simultaneous presence of BSA. Regarding the JAK/STAT pathway, AGE (100 microgram/ml) induced tyrosine phosphorylation of JAK2 (but not JAK1, JAK3 or TYK2) at 15-60 min; it also induced the tyrosine phosphorylation of STAT1 and STAT3 at 1-2 h and 0.5-4 h respectively. Being a transcription factor, AGE also increased the DNA-binding activities of STAT1 and STAT3 AG-490 (a specific JAK2 inhibitor) (5 microM) inhibited tyrosine phosphorylation of JAK2 and the DNA-binding activities of STAT1 and STAT3. The same results were obtained by using specific 'decoy' oligodeoxynucleotides (ODNs) that prevented STAT1 and STAT3 from binding to DNA. Meanwhile, the STAT1 or STAT3 decoy ODN and AG-490 were effective in reversing AGE-induced cellular mitogenesis. We concluded that the JAK2-STAT1/STAT3 signal transduction pathway is necessary for AGE-induced cellular mitogenesis in NRK-49F cells.

Peroxisome proliferation, adipocyte determination and differentiation of C3H10T1/2 fibroblast cells induced by humic acid: induction of PPAR in diverse cells

Humic acid, a high-molecular-weight polyphenolic compound, exists abundantly in soil, natural water, and various terrestrial and aquatic environments. Humic acid causes peroxisome proliferation in mouse liver and induces the expression of peroxisome proliferator activated receptor (PPAR) in BNL CL.2 cells. Both cytotoxicity and flow cytometry show that humic acid inhibits the growth of C3H10T1/2 cells at G1 phase. C3H10T1/2 fibroblast cells express PPARgamma and the adipocyte P2 (aP2) genes which convert into adipocytes after being treated with humic acid. Our findings may provide a unique model for studying the molecular control of determination and differentiation of mesodermal cell lineages.

Borderline ovarian tumors complicating pregnancy: a case report

Although the majority of ovarian tumors complicating pregnancy are benign, they still pose a challenge because of the difficulty in differentiating between benign and malignant tumors during pregnancy. To our knowledge, the value of color Doppler ultrasound in the diagnosis of borderline malignant tumors complicating pregnancy remains unclear. We present the case of a 29-year-old pregnant woman with an ovarian tumor of low malignant potential. Preoperative ultrasound revealed a well-encapsulated cystic complex on the left ovary measuring 16 x 18 x 12 cm with an internally smooth surface, multiple septa ranging from 2 to 4 mm in thickness and a small solid component 2 cm in diameter, with a resistance index of 0.42. The differential diagnosis preoperatively was a borderline tumor. The patient underwent a left oophorectomy at 18 weeks of gestation. Frozen pathology indicated a mucinous cystadenocarcinoma of low malignant potential. A thorough surgical staging was completed. The final pathology confirmed mucinous cystadenocarcinoma of low malignant potential, stage IA. Postoperatively, the patient had an uneventful course and did not receive any adjuvant therapy. She delivered a normal male fetus weighing 3,450 g at 38 weeks of gestation. We conclude that color Doppler ultrasound is helpful for the preoperative diagnosis of borderline tumors of the ovaries but its usefulness for making an accurate diagnosis may require further evaluation.

Ovarian surgery during pregnancy and puerperium: twelve-year experience at the Veterans General Hospital-Taipei

BACKGROUND

This study was performed in order to assess the surgical effects and characteristics of ovarian tumors during pregnancy and analyze their prognosis.

METHODS

Between 1982 and 1993, 121 patients who had undergone ovarian surgery during pregnancy or puerperium were reviewed at the Veterans General Hospital-Taipei. These patients were analyzed with particular emphasis on the length of gestation at the time of surgery, complications related to the stage of pregnancy, surgical and pathologic findings and the outcome of pregnancy.

RESULTS

Ovarian tumors were commonly detected during the second trimester (54.5%) and most of them (79.3%) were asymptomatic. The pathologic review found 38 patients (31.4%) with benign teratoma, 16 patients (13.1%) with corpus luteum and four patients (3.3%) with malignancy. There was a significant difference between emergent ovarian surgery and elective ovarian surgery in the spontaneous fetal wastage rate (14.1% vs 1%, p = 0.009). Compared with elective surgery, cases necessitating oophorectomy, with or without salpingectomy, increased significantly during emergency surgery (57% vs 36%, p = 0.03). All ovarian surgeries performed before a gestational age of seven weeks resulted in spontaneous fetal wastage.

CONCLUSIONS

Although the majority of the ovarian tumors detected during pregnancy were benign, emergency laparotomy was sometimes required, which led to an increase in the risk of a fetal wastage. Preconception counseling should be emphasized because early removal of non-functional ovarian tumor before conception, especially teratoma, would decrease the incidence of ovarian surgery during pregnancy. Furthermore, elective and well-prepared surgical intervention appears to be a crucial factor for favorable pregnancy outcome.