Muscle-specific, liver-detargeted adeno-associated virus gene therapy rescues Pompe phenotype in adult and neonate Gaa-/- mice

Pompe disease (PD) is a neuromuscular disorder caused by acid α-glucosidase (GAA) deficiency. Reduced GAA activity leads to pathological glycogen accumulation in cardiac and skeletal muscles responsible for severe heart impairment, respiratory defects, and muscle weakness. Enzyme replacement therapy with recombinant human GAA (rhGAA) is the standard-of-care treatment for PD, however, its efficacy is limited due to poor uptake in muscle and the development of an immune response. Multiple clinical trials are ongoing in PD with adeno-associated virus (AAV) vectors based on liver- and muscle-targeting. Current gene therapy approaches are limited by liver proliferation, poor muscle targeting, and the potential immune response to the hGAA transgene. To generate a treatment tailored to infantile-onset PD, we took advantage of a novel AAV capsid able to increase skeletal muscle targeting compared to AAV9 while reducing liver overload. When combined with a liver-muscle tandem promoter (LiMP), and despite the extensive liver-detargeting, this vector had a limited immune response to the hGAA transgene. This combination of capsid and promoter with improved muscle expression and specificity allowed for glycogen clearance in cardiac and skeletal muscles of Gaa-/- adult mice. In neonate Gaa-/- , complete rescue of glycogen content and muscle strength was observed 6 months after AAV vector injection. Our work highlights the importance of residual liver expression to control the immune response toward a potentially immunogenic transgene expressed in muscle. In conclusion, the demonstration of the efficacy of a muscle-specific AAV capsid-promoter combination for the full rescue of PD manifestation in both neonate and adult Gaa-/- provides a potential therapeutic avenue for the infantile-onset form of this devastating disease.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Outcomes of nonagenarians with acute coronary syndrome

Background

Myocardial infarction (MI) in nonagenarians is associated with high morbidity and mortality. Nonetheless, this population has typically been underrepresented in cardiovascular clinical trials.

Objective

The aim of this study was to evaluate outcomes of nonagenarian patients presenting with MI who underwent either conservative or invasive management.

Methods

We retrospectively included all consecutive patients equal to or older than 90yo admitted with non-ST segment elevation (NSTEMI) or ST segment elevation MI (STEMI) in four tertiary care centers between 2005 and 2018. Patients with type 2 myocardial infarction were excluded. We collected patients' baseline characteristic and procedural data. In-hospital and at 1-year follow-up all-cause mortality and major adverse cardiovascular events were assessed.

Results

523 patients (mean age 92.6±2 years; 60% females) were analyzed. Overall, 184 patients (35.2%) underwent percutaneous coronary intervention (PCI), increasing over the years, mostly in STEMI group (from 16% of patients in 2005 to 75% in 2018). PCI was preferred in those subjects with less prevalence of disability for activities of daily living (p<0.01). The use of a radial access (76.6%) and bare metal stents (52.7%) was predominant. No significant differences were found in the incidence of major bleeding events or MI-related mechanical complications between both strategies. During index hospitalization, 99 (18.9%) patients died. Whereas no differences were found in the NSTEMI group (p=0.61), a significant lower in-hospital mortality was observed in STEMI group treated with PCI (p<0.01). At one-year follow up, 203 (38.8%) patients died, most of them due to a cardiovascular cause (60.6%). PCI was related to a lower all-cause mortality in either NSTEMI (p<0.01) or STEMI groups (p<0.01) however, lower cardiovascular mortality was only found in STEMI group (p=0.03).

Conclusion

An invasive approach was performed in over a third of nonagenarian patients, carrying prognostic implications and with a few numbers of complications. PCI seems to be the preferred strategy for STEMI in this high-risk population in spite of age.

Figure 1

Funding Acknowledgement

Type of funding source: None

Acute coronary syndromes in nonagenarians: do we have reliable risk scores?

Introduction

GRACE score is strongly validated to determine the probability of death in acute coronary syndrome (ACS), nevertheless its usefulness in nonagenarians, a population with frequently associated comorbidities, is less stablished. BARTHEL and CHARLSON scores might be useful tools to predict outcomes in this population.

Objective

The aim of this study was to evaluate the potential applicability of GRACE score and two comorbidity scores (CHARLSON and BARTHEL) to estimate prognosis in nonagenarians with ACS.

Material and methods

We retrospectively included all consecutive patients equal to or older than 90 years old admitted with non-ST (NSTEMI) or ST segment elevation myocardial infarction (STEMI) in four tertiary care centers between 2005 and 2018. Patients with type 2 myocardial infarction were excluded. We collected patients' baseline characteristics and procedural data. In-hospital and at 1-year follow-up all-cause and cardiovascular mortality were assessed. Risk score accuracy was evaluated by area under the curve ROC (AUC).

Results

A total of 444 patients (mean age 92.6±2.4 years, 60% females) were analyzed.

Approximately half of them (n=241, 54%) with STEMI and the remainder (n=203, 46%) with NSTEMI. Global GRACE-AUC for in-hospital and 1-year all-cause mortality were moderate (0.64; 95% CI: 0.59–0.69 and 0.62; 95% CI: 0.57–0.67, respectively). Only in the NSTEMI group, the GRACE-AUC was better to predict in-hospital mortality, 0.70 (95% CI: 0.63–0.77). Neither CHARLSON nor BARTHEL showed better predictive results than GRACE score (AUC ≤0.60).

Conclusion

GRACE score has moderate accuracy to estimate mortality in nonagenarian patients with ACS. BARTHEL and CHARLSON scores do not improve the predictive value of GRACE score. An individualized approach is required to make therapeutic decisions in this special population.

Figure 1. ROC-GRACE curves

Funding Acknowledgement

Type of funding source: None

474 Isolated pulmonary endocarditis

INTRODUCTION

Isolated pulmonary endocarditis is a rare entity, especially in patients without predisposing factors, being its current incidence less than 1% of the total cases of infectious endocarditis. This is due to the lower right heart pressures and a decrease of intravenous drug-consum, being most of the cases nowadays, related to congenital right-heart diseases or pacemakers and defibrillators implants.

CLINICAL CASE

A 35 year-old man, tobacco smoker and intravenous cocaine consumer since he was 25, was admitted to our Emergency Department for fever up to 40ºC, cough and dyspnea started three days before admission. In the anamnesis he refereed intravenous consum of cocaine and sharing of syringes the last week. On physical examination he was tachycardic and signs of heart right failure were present such as jugular ingurgitation and peripheral edema. No murmurs were heard. No respiratory failure was detected at any time. Blood test analysis showed high levels of protein C reactive and leukocytosis. Blood cultures were positive for S. aureus (OXA-S) in the first 24h. Chest X-ray (image 1) showed a necrotizing bilateral pneumonia that was confirmed with the presence of cavitated images in the pulmonary CT (image 2). Antibiotic treatment was started with daptomicine + cloxaciline. With the suspicion of right endocarditis a transthoracic echocardiography was performed, showing the presence of a big vegetation (4x1cm) on the pulmonary valve that caused moderate pulmonary insufficiency (images 3, 4). Neither tricuspid nor left side valves were involved. Biventricular function was conserved and hyperdynamic. Endocarditis diagnosis was definitive and due to the presence of multiple right embolisms and the big size of the vegetation, the patient underwent cardiac surgery. Intra-surgical finding demonstrated a big vegetation of almost 5 cm (image 5) depending of the posterior pulmonary valve that was removed; the posterior valve needed to be repaired. Posterior clinical evolution was correct without complications, completing 17 days of i.v. antibiotics (cloxaciline) before discharge.

CONCLUSIONS

Right endocarditis is a rapidly progressive disease due to the fact that staphylococcus are the most frequent microorganisms involved. Valvular destruction and secondary embolic phenomena are the rule. Tricuspid valve is involved most of the times being the isolated pulmonary valve affection very uncommon.

Abstract 474 Figure. CT, Echo and surgical images

P1721 Reversible heart right failure. Pulmonary hypertension induced by Tyrosine Kinase Inhibitors

BACKGROUND

Pharmacologically induced pulmonary hypertension (PH) is infrequent nowadays and it is included in the type 1 of the classification of PH.

Tyrosine kinase inhibitors (TKI) are the cornerstone of the treatment of many haemotopoietic stem cell diseases. Dasatinib is a second-generation TKI used in chronic myeloid leukemia (CML) and as an infrequent cardiovascular side-effect (< 0,50%) could induce PH, usually reversible but life threatening. Only a few case series are published.

CASE DESCRIPTION: We present a 51-year-old woman who was diagnosed of a CML when she was 46. Initially, she underwent therapy with imatinib but after 5 years of treatment she developed resistance to this drug, and dasatinib was prescribed as a second line drug. After 3 months of continuous treatment, she started with dry cough and effort dyspnea. Blood analysis, EKG and Chest X-Ray were made but did not show outstanding findings. An unspecific viral infection was the final diagnosis. The patient clinical condition deteriorated with major dyspnea and edemas in the lower limbs. A TTE showed moderate tricuspid regurgitation and severe HP systolic pulmonary artery pressure (sPAP) of 80 mmHg. The pulmonary acceleration time was shortened and a mesosistolic knock was present. Systolic dysfunction of the right ventricle and pericardial effusion (image 1,2,3,4) were noted. The right atrium was not dilated. Cava vein was dilated but with inspiratory collapse >50%. The left ventricular function was preserved, but first degree diastolic dysfunction was found. Other causes of PH were excluded (types 2, 3, 4). A CT pulmonary angiogram did not show segmental perfusion defects. Finally, a right heart catheterization confirmed the TTE findings: severe precapillary PH without postcapillary component. After the diagnosis was confirmed, TKI was stopped and double targeted therapy with ambrisentan + tadalafil was started. After 6 months of treatment a new TTE was made with complete reversal of the secondary changes in the myocardium induced by the PH. No tricuspid regurgitation was detected nor any indirect sign of PH was found. (image 5,6).

CONCLUSIONS

Drug-induced PH is rare nowadays and most cases were described in the seventies in the USA related with the epidemic of anorexigenic drugs. Although the pathogenesis still remains unclear, treatment includes immediately stopping the offending agent.

Echocardiography due to its accessibility, reproducibility, consistence and low cost should be the first diagnostic tool to be considered, because as it is known, in the early stages of the disease, before developing right disfunction, clinical and conventional tests are non-specific.

Abstract P1721 Figure. Echo images: previous and afte treatment

Does Time Since Injury and Time Spent in Physical Therapy Treatment Affect Outcomes for Concussion Patients?

Purpose

To evaluate the effects of: 1) time between injury and physical therapy treatment and 2) time spent in physical therapy, on concussion symptom resolution.

Methods

Retrospective data was obtained for 202 patients who sustained a concussion and were referred for physical therapy. Subjects were assigned to groups based on type of injury (sport-related or not), time elapsed between concussion and therapy (0-14 days, 15–30, 31–60, 61–120, 121–365), and months spent in treatment (1 thru 4). Pre- and post- treatment scores were compared for the following measures: Sport Concussion Assessment Tool (SCAT), Convergence Insufficiency Symptom Survey (CISS), Dizziness Handicap Inventory (DHI), and Modified Clinical Test of Sensory Interaction on Balance (mCTSIB) using ANOVAs, with a Bonferroni-corrected p-value of p<.005.

Results

There was no significant difference in outcomes for athletes vs. non-athletes on SCAT Symptom (p=.74) or Severity Score (p=.18), CISS (p=.52), DHI (p=.05), or mCTSIB (p=.10); in outcomes for time elapsed since injury on SCAT Symptom Score (p=.80), SCAT Symptom Severity Score (p=.97), CISS (p=.61), DHI (p=.65), mCTSIB (p=.13); or in outcomes for months in treatment on SCAT Symptom Score (p=.23), SCAT Symptom Severity Score (p=.04), CISS (p=.41), DHI (p=.37), mCTSIB (p=.50).

Conclusion

Post-therapeutic improvements were noted for athletes receiving post-concussive physical therapy. Type of injury, time between injury and treatment, and time spent in treatment did not differentiate treatment outcomes for those receiving physical therapy post-concussion.

The Basic Results on Reinitiation Processes in Diffracting Multifront Detonations. Part I

The basic results of experimental investigations on reinitiation processes in diffracting multifront detonation wave (DW) are discussed in connection with problem of practical application of new ecological technology for worn-out tire destruction, where the cooled worn-out tire destroys with the help of gaseous detonation. The experimental results for various fuel-oxygen and fuel-air mixtures are presented at wide range of mixture compositions, initial pressure and temperature, geometrical sizes of experimental equipment, symmetry types, dilution of inert gases, etc. Classical and nontraditional schema of DW-diffraction are investigated, such as multipointed initiation, DW-excitation by circular charge, initiation space-oriented longitudinal charges, initiation by circular charge, diffraction on concave boundary, diffraction on contact surface of different mixtures, flame diffraction, etc. The main characteristic parameters are identified for each diffraction schema. The physical processes taking place directly in the DW-front plays the governing role in reinitiation. The most important among these processes are collisions of transverse waves, which stick out as microscopic initiators. The optimization problem of DW-initiation from spatial and temporary distribution of energy is discussed carefully. This data can be used at hazard estimation also.

Post-surgical treatment of thyroid carcinoma in dogs with retinoic acid 9 cis improves patient outcome

The objective of the present study was to compare the effects of isotretinoin 9-cis (RA9-cis) as a post-surgery treatment of thyroid carcinoma to a traditional treatment (doxorubicin) and no treatment. Owners who did not want their dogs to receive treatment were placed into the control group A (GA; n=10). The remaining dogs were randomly placed into either group B (GB; n=12) and received doxorubicin at a dose of 30 mg/m² every three weeks, for six complete cycles or group C (GC; n=15) and treated with RA9-cis at a dose of 2 mg/kg/day for 6 months. The time of the recurrence was significantly shorter in the GA and GB compared to GC (P=0.0007; P=0.0015 respectively), while we did not detect differences between GA and GB. The hazard ratio of recurrence between GA and GB compared to GC were 7.25 and 5.60 times shorter, respectively. We did not detect any differences between the other groups. The risk ratio of recurrence was 2.0 times higher in GA compared to GC and 2.1 times higher in GB compared to GC. The type of carcinoma had an effect on time of survival with follicular carcinomas having an increased mean survival time than follicular-compact carcinomas (P<0.0001) and follicular-compact carcinomas had a longer mean survival time than compact carcinomas. The interaction among treatment and type was significant, but survival time in follicular carcinomas did not differ between treatments. In follicular-compact carcinomas the survival time of GC was greater than GB (P<0.05), but we did not detect a difference between GA and GB. In conclusion, this study shows that the use of surgery in combination with RA9-cis treatment significantly increases survival rate and decreases the time to tumor recurrence when compared to doxorubicin treated or untreated dogs. The histological type of carcinoma interacted with treatment for time to recurrence and survival time, with more undifferentiated carcinomas having a worse prognosis than differentiated carcinomas.

Airborne pollen levels and drug consumption for seasonal allergic rhinoconjunctivitis: a 10-year study in France

BACKGROUND

Few time-series studies, and none lasting longer than 4 years, have investigated the etiology of treated seasonal allergic rhinoconjunctivitis (SAR) on the basis of anti-allergic medication prescriptions. The aim of this article was to study the short-term relationship between pollen exposure and drug-treated SAR over 10 years in an urban area in central France.

METHODS

A SAR case was defined as the association between an oral antihistamine and a local anti-allergic drug on the same prescription. The relationship between daily changes in pollen concentrations and daily changes in the number of treated SAR cases was analysed using generalized additive models, taking into account confounding factors such as air pollution, weather and days of the week.

RESULTS

Between 2003 and 2012, the total yearly number of treated SAR cases rose from 7265 to 11 315. The relative risk of treated SAR associated with an interquartile increase in pollen concentration increased significantly for Fraxinus, Betula, Carpinus, Platanus, Poaceae and Urticaceae for the whole pollen season, and for Urticaceae in the first semester.

CONCLUSIONS

The prevalence of treated SAR cases rose by about 55% in 10 years. The study not only confirmed the highly allergenic role of Fraxinus, Betula and Poaceae pollens but also showed a relatively unknown association between treated SAR and Carpinus and Platanus pollens, despite their pollen counts being <1% of overall pollen concentration. It also showed robust correlations with Urticaceae pollens, especially during the first semester, suggesting a potential allergenic role of Parietaria pollination in this non-Mediterranean area.

[Type 2 diabetes and universal health care for low-income groups: a case-control study]

PURPOSE

In 2007 in France, type 2 diabetes involved 2.5 million people, and 4.5 million patients received free healthcare coverage under the universal healthcare coverage program (CMU) for low-income households. An optimal glycemic control and adequate diabetes monitoring can reduce the incidence of complications. The objective of this study was to compare the diabetes care of low-income patients (as defined by CMU coverage) with the rest of the population.

METHODS

A retrospective case-control study (non-CMU and CMU) over a one-year period of glycemic control for both populations through private laboratory data (number and values of HbA1c) and of individuals monitoring through data from the regional health insurance public institute.

RESULTS

Regarding glycemic control, 154 patients were included. The number of annual HbA1c tests was similar between CMU and non-CMU patients. The mean HbA1c value was higher for CMU patients (8.7% versus 8%; P<0.01). Regarding monitoring, 1254 patients were included. Over a one-year period, the number of HbA1c tests, lipid profile tests, serum creatinine measures and cardiology consultations were similar across groups. However, CMU patients benefited from less microalbuminuria testing (P<0.001), ophthalmologic monitoring visits (P<0.01), endocrinology consultations (P<0.01), and from more general physician consultations (P<0.001).

CONCLUSIONS

Receiving CMU health coverage was associated with a poorer glycemic control and lesser specialized monitoring than that was observed in control patients. Across the population, follow-up recommendations are far from being implemented satisfactorily.

Degradation of Kraft Indulin Lignin by Streptomyces viridosporus and Streptomyces badius

Crawford and collaborators have studied extensively the solubilization of lignocellulose by two Streptomyces species, S. badius and S. viridosporus. Using a condensed industrial lignin essentially devoid of carbohydrates, Indulin AT, as the sole source of carbon, similar results were obtained: (i) the growths of the bacteria were optimum at pH 7.5 to 8.5; (ii) yeast extract was a better source of nitrogen than NH(4)Cl; (iii) the products of the depolymerization of Indulin were soluble, acid-precipitable polymers. When d-glucose was added as a secondary carbon source, it was used preferentially and the production of acid-precipitable polymers began only after the complete depletion of the sugar. On the assumption that the degradation of Indulin was catalyzed by enzymes, proteins found in the culture media and soluble and insoluble intracellular proteins were incubated with Indulin at pH 7.0 at 37 degrees C. Proteins in all fractions from S. badius had ligninolytic activities which, with the exception of those in the intracellular soluble fraction, were increased in the presence of H(2)O(2). In S. viridosporus, both extra- and intracellular soluble activities were found which were not increased by H(2)O(2). The extracellular activity of S. viridosporus was not affected by heat, resisted partially an exposure to pH 1.0, and was completely destroyed by proteolysis.

[Structured treatment interruption in HIV-infected adolescents]

Structured treatment interruption in HIV is now being debated. There are 2 cases in which it may be discussed: when the initial treatment was started early and when there is no compliance to treatment [Yeni P, et al. Les nouvelles recommandations de prise en charge des personnes infectées par le VIH 2006. Paris: Flammarion médecine-sciences; 2006]. Noncompliant behavior is one of the characteristics of chronic illness during adolescence. In HIV infection, however, the prognosis is negatively influenced because the resulting resistance to the antiretroviral therapy can further reduce therapeutic options. Therefore, it is important in such a critical period to consider both what is consciously and unconsciously at stake and what responsible action could be taken when a specialist is faced with spontaneous (unplanned) treatment interruption. We report here examples of follow-up care, interruption, and resumption of treatment in 4 female adolescents.

[Quality of life in HIV-infected children and adolescents under highly active antiretroviral therapy: change over time, effects of age and familial context]

OBJECTIVE

To evaluate Quality of life (QoL) of HIV-infected children under highly active antiretroviral therapies, and its change over 18 months.

MATERIALS AND METHODS

QoL was evaluated by self-administred questionnaires (french versions of AUQUEI, OK-ado, and compilation of both) in 23 young living with HIV/AIDS (6-15 yrs), under antiretroviral multitherapies, and re-evaluated 18 months later in 19 of them.

RESULTS

At baseline, QoL in HIV-infected children-adolescents was relatively good. The answers given to each items and the mean score from infected children were similar to those obtained in uninfected healthy children. Moreover, infected adolescents distinguished definitly from healthy adolescents, describing higher QoL. The mean satisfaction score from the whole group decreased between M0 and M18 (mainly in the youngests), and mainly concerned 3 fields (self-esteem, health and school) while their somatic health remained stable or improved. An effect of the familial context was also observed for these 3 fields.

CONCLUSION

The progressive decline of QoL in HIV-infected children, and the surprising high and steady level of satisfaction over-time provided by the adolescents, underlined the frailty of this population and the need for a psychologic management associated to the medical follow-up. Such a multidisciplinary approach should take into account the preoccupations and difficulties of each age-class, those linked to the diagnosis itself, and to the familial or scolar contexts, in order to preserve QoL of this pediatric population, as far as possible, in a long term.

A preliminary study of the occurrence of actidione-resistant fungi in sediments of Catalonian river mouths (Spain). I. Keratinolytic fungi and related Onygenales

Sediments from eight river mouths along the Catalonian coast (Spain) were surveyed for keratinolytic fungi and related Onygenales. The actidione plating technique was employed. Of 532 actidione-treated sediment samples, 268 (50.3%) were positive for the fungi. Altogether, 384 fungal strains from 35 species were isolated from the samples. Narasimhella marginospora, Aphanoascus fulvescens, Neoarachnotheca keratinophila with its anamorph Myriodontium keratinophilum, Narasimhella hyalinospora, Beauveria alba, Sporothrix schenckii, Chrysosporium lobatum and Gymnoascus littoralis were the predominant species in sediments. Abundance of N. marginospora was clearly correlated with the degree of water pollution with sewage.

Analgesic-antiinflammatory properties of Proustia pyrifolia

The antiinflammatory (per os and topic) and analgesic (per os) properties of the aerial part of Proustia pyrifolia a species in danger of extinction were investigated, and the major compounds of two of its active extracts were isolated. In addition, the evaluation of cytotoxicity in three tumoral cell lines and the acute toxicity of the crude methanol extract were also assayed, together with the antioxidant activity for the different extracts of this species. The results of the evaluation of the topic antiinflammatory activities induced by arachidonic acid, and phorbol 12-myristate 13-acetate of the different extracts showed that this species possesses active constituents that could diminish cyclo-oxygenase and lipoxygenases activities, the enzymes that allow the synthesis of proinflammatory endogenous substances as prostaglandin E(2) and leukotrienes, respectively. Our results corroborate the antiinflammatory and analgesic effects of Proustia pyrifolia, and could justify its use in folk medicine for the treatment of rheumatic and gout illnesses. From bio-active extracts beta-sitosterol, quercetin and dihydroquercetin were obtained, and these compounds could explain in part the antiinflammatory, analgesic and antioxidant activities of this species. The crude methanol extract did not present acute toxicity or cytotoxic activity, however only this extract exhibited antioxidant activity.

Major Degradation Product Identified in Several Pharmaceutical Formulations against the Common Cold

Different pharmaceutical preparations against the common cold containing acetaminophen, phenylephrine hydrochloride, and chlorpheniramine have been studied. An unidentified degradation product has been discovered in these preparations after short- and long-term stability studies, with increasing concentration at increasing storage temperatures and times. LC/MS was employed to identify and obtain molecular weights of the degradation products using an electrospray ionization interface. To obtain detailed structural information on the major degradation product, its isolation by SPE followed by HPLC was required. Final isolation was accomplished by using a new pentafluorophenyl stationary phase. Once the major degradation product was isolated, MS/MS, 1H NMR, 13C NMR, COSY, HMBC, and HSQC techniques permitted the complete characterization of this new compound formed under the usual stability conditions at climatic chambers. Its origin was also established as a result of the interaction between two of the components in the formulation. It is important to remark that this compound has not been described in the literature up to now and that, moreover, it has been identified in several commercial preparations containing phenylephrine hydrochloride and chlorpheniramine maleate.

Antithrombotic therapy is associated with better survival in patients with severe heart failure and left ventricular systolic dysfunction (EPICAL study)

BACKGROUND

In patients with congestive heart failure (CHF), clinical trials have demonstrated the benefit of a number of drugs on morbidity and mortality. Nevertheless so far, there is no published controlled study of long-term antithrombotic therapy in patients with CHF. The aim of this work was to identify the relationship between cardiovascular drug use, especially antithrombotic therapy, and survival of CHF patients in current clinical practice, using an observational, population-based database.

METHODS

The EPICAL study (Epidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine) has identified prospectively all patients with severe CHF in the community of Lorraine. Inclusion criteria were age 20-80 years in 1994, at least one hospitalisation for cardiac decompensation, NYHA III/IV HF, ventricular ejection fraction < or =30% or cardiothoracic index > or =60% and arterial hypotension or peripheral and/or pulmonary oedema. A total of 417 consecutive patients surviving at hospital discharge were included in the database. The average follow-up period was 5 years. Univariate Cox models were used to test the relationship of baseline biological and clinical factors to survival. Cardiovascular drug prescriptions were tested in a multivariate Cox model adjusted by other known predictive factors.

RESULTS

Duration of disease >1 year, renal failure, serum sodium > or =138 mmol/l, old age, serious comorbidity, previous decompensation, high doses of furosemide and vasodilators use were independently associated with poor prognosis at 1 and 5 years. Oral anticoagulants, aspirin, lipid lowering drugs and beta-blockers use were associated with better survival. There was no interaction between aspirin and angiotensin converting enzyme inhibitor use on survival.

CONCLUSION

Antithrombotic therapy was associated with a better long-term survival in our study population of severe CHF. These results together with other previously published circumstantial evidence urge for a prospective, controlled and randomised trial specifically designed to evaluate optimal oral anticoagulants and aspirin in patients with congestive heart failure.

Multicenter study on spreading of the tet(M) gene in tetracycline-resistant Streptococcus group G and C isolates in Argentina

A prospective multicenter study on invasive infections caused by beta-hemolytic streptococci was performed over 6 months and involved 42 centers from 16 cities in Argentina. Among 33 isolates recovered, 9 group G Streptococcus isolates (39.1%) and 2 group C Streptococcus isolates (20%) exhibited resistance to tetracycline and harbored the tet(M) gene. Genealogical analysis revealed that tetracycline resistance has a polyclonal origin in Argentina.

A paleoepidemiologic study of diffuse idiopathic skeletal hyperostosis

OBJECTIVE

To investigate the prevalence of diffuse idiopathic skeletal hyperostosis (DISH) in ancient populations.

MATERIAL AND METHODS

We studied 38 women and 61 men aged at least 30 years at death, whose remains were recovered from four cemeteries of the High Middle Ages (VIth to VIIIth century) located in Lorraine (eastern France). Criteria previously developed by Crubézy and Crubézy-Ibanez for paleopathological studies were used to determine whether the skeletal remains exhibited definite, possible, probable, or no DISH.

RESULTS

Definite DISH with flowing ossification along the thoracic spine and ossification of peripheral enthesopathies was seen in 2.8 to 3.7% of the subjects from two cemeteries and in none from the other two cemeteries. Identical figures were found for possible DISH. The prevalence and male predominance s (nine of 13 subjects in any DISH category were males) were similar to those reported in contemporary studies and in other paleopathological studies.

CONCLUSION

In the absence of clinical data on the metabolic status of the study subjects, our results suggest that DISH in our subjects was a marker for older age at death.

[Streptococcus pyogenes: penicillin and erythromycin susceptibility in the cities of Neuquen and Cipolletti]

Penicillin resistance has not yet been detected in Streptococcus pyogenes. However macrolide-resistant streptococci have emerged in several countries. Only low rates of erythromycin-resistant S. pyogenes were reported in Argentina, with the exception of a 11.1% observed in Mendoza. The aim of the present study was to determine the susceptibility to penicillin and to erythromycin of 251 consecutive clinically-significant isolates of S. pyogenes obtained from four centers of Cipolletti and Neuquén during the period April-December 1998. The double disk test with erythromycin and clindamycin disks was employed as a screening method to detect ERY-resistant streptococci and to determine the phenotype of macrolide resistance. Disk diffusion was also employed for determining penicillin susceptibility. Macrolide-resistant isolates were also tested for penicillin, ceftriaxone, erythromycin, clindamycin and azithromycin susceptibility by the agar dilution method. Additionally they were also tested for erythromycin susceptibility by E-test (AB Biodisk, Solna, Sweden). All streptococci studied were susceptible to penicillin and thirty of them (12.0%) were resistant to erythromycin. All these resistant isolates were also resistant to azithromycin but susceptible to ceftriaxone and clindamycin. They showed the phenotype M (probably efflux-mediated mechanism) and the MICs of erythromycin ranged between 8 and 16 micrograms/ml. According to these results we conclude that in spite of universal susceptibility to penicillin in S. pyogenes, macrolide resistance is a matter of concern in Neuquén and Cipolletti. At least in those cities it appears to be necessary to routinely perform macrolide susceptibility tests in beta-hemolytic streptococci.

[Infection of ascending aortic graft: treatment with surgical cleaning, graft preservation and transposition of muscle flaps. Report of two cases]

Mediastinitis with graft infection is a serious complication of ascending aorta replacement. We report two cases of graft infection, treated with surgical cleaning, graft preservation and transposition of muscle flaps. A 62 years old male was admitted 34 days after an ascending aortic grafting due to a sternal dehiscence and mediastinitis. Antimicrobial treatment was started and a surgical cleaning performed, leaving an open sternotomy. Three days later, the thoracic cavity was closed with a rectus abdominis muscle flap. After 23 months of follow up, the patient is well and without evidence of infection. A 74 years old male was subjected to an aortic valve and ascending aorta replacement and a myocardial revascularization. In the postoperative period, the patient developed septic signs, and a purulent drainage. A CAT scan showed a liquid collection surrounding the aortic graft. On tW Sixteenth postoperative day, a surgical cleaning was performed and the thorax was closed with the pectoralis major muscle. After 10 months of follow up, the patient is in Good condition and without evidence of infection.

Doxorubicin-peptide conjugates overcome multidrug resistance

A well-known mechanism leading to the emergence of multidrug-resistant tumor cells is the overexpression of P-glycoprotein (P-gp), which is capable of lowering intracellular drug concentrations. To overcome this problem, we tested the capability of two peptide vectors that are able to cross cellular membranes to deliver doxorubicin in P-gp-expressing cells. The antitumor effect of peptide-conjugated doxorubicin was tested in human erythroleukemic (K562/ ADR) resistant cells. The conjugate showed potent dose-dependent inhibition of cell growth against K562/ADR cells as compared with doxorubicin alone. Doxorubicin exhibited IC50 concentrations of 65 microM in the resistant cells, whereas vectorized doxorubicin was more effective with IC50 concentrations of 3 microM. After treatment of the resistant cells with verapamil, the intracellular levels of doxorubicin were markedly increased and consequent cytotoxicity was improved. In contrast, treatment of resistant cells with verapamil did not cause any further enhancement in the cell uptake nor in the cytotoxic effect of the conjugated doxorubicin, indicating that the conjugate bypasses the P-gp. Finally, we show by the in situ brain perfusion method in P-gp-deficient and competent mice that vectorized doxorubicin bypasses the P-gp present at the luminal site of the blood-brain barrier. These results indicate that vectorization of doxorubicin with peptide vectors is effective in overcoming multidrug resistance.

Ebola and Marburg virus antibody prevalence in selected populations of the Central African Republic

With the natural history of the filovirus family seemingly unknown, filovirus ecology in its natural environment remains a rudimentary field of research. In order to investigate the maintenance cycle of filovirus in Central Africa, a study was conducted within the rain forest of the Central African Republic. The epidemiological study determines the frequency and distribution of filovirus seroprevalence in a selected human population. Using an ELISA, serum samples from Pygmy and non-Pygmy populations were tested for Ebola-Zaire virus and Marburg (MBG) virus antibody. Filovirus antibody reacting sera were found in all zones investigated, and in all populations studied (Ebola virus IgG 5.3%; Marburg virus IgG 2.4%). Pygmies appeared to have a significantly higher seroprevalence (P < 0.03) against Ebola-Zaire virus (7.02%) than non-Pygmies (4.2%). MBG virus or related unknown filovirus strains also seem to be present in the western part of Central Africa. MBG virus antibodies were present in different Pygmy groups (ranging from 0.7 to 5.6%, mean 2.05%) and in several non-Pygmy populations (ranging from 0.0 to 3.9%, mean 3.4%) without an overall significant difference between the two groups (P = 0.14). The potentialities of nonpathogenic filovirus strains circulating in the Central African Republic are discussed.

Antiphospholipid antibodies and retinal thrombosis in patients without risk factors: a prospective case-control study

PURPOSE

To determine the prevalence of antiphospholipid antibodies and other immunologic abnormalities in patients with occlusive retinal vascular events, exempt from conventional risk factors of retinal thrombosis.

METHODS

Forty patients with retinal vascular occlusion (26 with retinal vein occlusions, eight with arterial occlusions, two with combined venous and arterial occlusions, and four with venous occlusions plus vasculitis), free of main accepted risk factors for retinal thrombosis, were prospectively screened for antiphospholipid antibodies (anticardiolipin-antibodies and lupus anticoagulant) and other immunologic abnormalities. Fourteen patients were younger than 50 years. Prevalence and mean values of antiphospholipid antibodies (aPL) were compared with those in a homogeneous control group of 40 patients.

RESULTS

The prevalence of antiphospholipid antibodies in the study group was 22.5% (nine of 40). Comparison with control group prevalence (5% [two of 40]) showed a statistically significant difference (P = .04). Six patients in the study group disclosed positivity for IgG-anticardiolipin antibodies, one patient for IgM anticardiolipin antibodies, and two patients for both isotypes IgG and IgM anticardiolipin antibodies. The antibody assay for lupus anticoagulant was negative for all patients. Three patients were diagnosed as having primary antiphospholipid antibody syndrome and are undergoing systemic anticoagulant therapy. Relevant immunologic abnormalities were also found (27.5% with antinuclear antibodies, 35% with elevation of circulating immune complexes, 35% with complement deficiency, 30% with positive rheumatoid factor, and 17.5% with positive C-reactive protein). Thirteen patients (32.5%) had more than four parameters altered. No significant association was found between prevalence or mean values of anticardiolipin antibody and patients younger than 50 years.

CONCLUSIONS

The high prevalence of anticardiolipin antibodies in patients with vaso-occlusive retinopathy exempt from conventional risk factors, and the relevant diagnostic and therapeutic implications, lead us to recommend a systematic search for specific antiphospholipid antibodies in such patients.

Studies on keratinophilic fungi. XI. Chrysosporium undulatum sp. nov

Chrysosporium undulatum sp. nov., showing intermediate characteristics between Chrysosporium and Malbranchea, is described and illustrated. This taxon is characterised by long and curved to loosely coiled hyphal appendages, deflected to wavy fertile hyphae forming dense tufts and small, subglobose, frequently intercalary, verrucose conidia. Restriction enzyme analysis and comparison of sequences of the ITS1-5.8S-ITS2 ribosomal DNA region of the most similar species strongly support this proposal.

Immunohistochemical localization of nephrocalcin, a kidney-specific glycoprotein, to renal cell carcinoma

OBJECTIVES

Nephrocalcin (NC), an acidic glycoprotein produced by renal proximal tubule cells and functioning as an inhibitor of calcium oxalate monohydrate crystalization, has been previously shown to have increased urinary excretion in patients with renal cell carcinoma (RCC). The current study uses immunohistochemical techniques to localize NC to cells of primary RCC.

METHODS

We studied 29 kidneys removed because of RCC. Slides were deparaffinized and stained after incubating with anti-NC antibody by using the avidin-biotin-peroxidase complex techniques. Uptake of stain by tumor cells and adjacent normal renal cells was compared.

RESULTS

Twenty-seven kidneys (93%) showed positive staining for RCC tumor cells; 2 kidneys staining positive for normal proximal tubule cells failed to stain adjacent RCC tumor cells (7%).

CONCLUSIONS

The data suggest that enhanced production of urinary NC in patients with RCC derives from cells of the primary tumor.

Interactions of primary amphipathic vector peptides with membranes. Conformational consequences and influence on cellular localization

The conformations of two peptides produced by the combinations of a nuclear localization sequence and a sequence issued from the fusion protein gp41 of HIV 1 have been analyzed both in solution and in membranes or in membrane mimicking environments. Both are shown to be nonordered in water, alpha-helical when incorporated into SDS micelles where the helical domain concerns the hydrophobic part of the peptides. Interactions with lipids induce the formation of beta-sheet and the lipid-peptide interactions are governed by the nature of the lipid polar headgroups. A monolayer study shows that replacement of the sequence separating the two sequences with an arginine favors the lipid-peptide interactions which may contribute to the understanding of the different, nuclear and membrane associated, cellular localizations of the peptides.

Design of carrier peptide-oligonucleotide conjugates with rapid membrane translocation and nuclear localization properties

Peptides containing a hydrophobic motif associated with a nuclear localization signal separated by various linkers were synthesized in solid phase. The hydrophobic sequence corresponds either to a signal peptide sequence or to a fragment of the fusion peptide of GP41 while the hydrophilic sequence is that of a nuclear localization signal. The C-termini of these peptides bear a cysteamide group that was linked to a fluorescent probe. This allowed the cellular localization of the probe to be determined as a function of the peptide sequences. The labeled peptides were then incubated with fibroblasts. Using N-biotinylated derivatives we confirmed by indirect immunofluorescence that the observed localizations corresponds to those of the peptides. The presence of a linker appears to play a role in the cellular localization. One of these peptides was successfully used to target fluorescent oligodeoxynucleotides into living cells demonstrating improved cell delivery of peptide-oligodeoxynucleotide conjugates.

Transvaginal sonography in endometrial carcinoma: preoperative assessment of the depth of myometrial invasion in 50 cases

OBJECTIVE

A prospective study was designed for patients previously diagnosed of endometrial carcinoma to evaluate the accuracy of transvaginal sonography (TVS) in determining both the presence and the depth of myometrial invasion. Patients with advanced stage disease (III and IV) were specifically excluded from the analysis.

SUBJECTS AND METHODS

Sixty patients with endometrial carcinoma underwent transvaginal ultrasonography. Ten of these patients were ruled out due to various reasons. In the remaining 50 cases, TVS findings were compared with those obtained after total abdominal hysterectomy and bilateral salpingo-oophorectomy (AHT).

RESULTS

The sensitivity of TVS in detecting deep invasion, i.e. more than 50% of the myometrial thickness was 94.1%, while the specificity was 84.8% and the overall accuracy was 88%. Following the classification of the International Federation of Obstetrics and Gynecology, stage I, which divides myometrial invasion into three categories (none, superficial involvement and deep invasion) sensitivity was 66.2%, specificity was 83.1% and overall accuracy was 77.2%.

CONCLUSION

These findings are consistent with those reported in literature with regard to overall accuracy of TVS. Results are similar to those obtained with magnetic resonance imaging (MRI) without contrast and slightly lower than MRI plus contrast.

Effects on mollicutes (wall-less bacteria) of synthetic peptides comprising a signal peptide or a membrane fusion peptide, and a nuclear localization sequence (NLS) -- a comparison with melittin

In order to investigate the effect of primary amphipathic peptides on mollicutes (wall-less bacteria), we have synthesised five molecules (P1, P2, P3, JM123, and JM133) comprising a 16 to 18-residue hydrophobic sequence and the nuclear localization sequence (NLS) PKKKRKV of simian virus 40 large-T antigen, C-terminated by a cysteamide group. The hydrophobic cluster was in P1 the signal sequence of the heavy chain of Caiman crocodilus immunoglobulin G and in JM123 the fusion peptide of human immunodeficiency virus 1 glycoprotein gp41 in which phenylalanine7 was replaced by a tryptophan residue. The homologues P2, P3, and JM133 were obtained by slight alterations of these sequences. Circular dichroism spectroscopy revealed that, in liposomes, P-series peptides were mainly under the form of beta-sheets whereas JM-series peptides displayed a high proportion of turns. These peptides proved to be bactericidal for some mollicutes, notably Acholeplasma laidlawii, but were much less potent than melittin. Furthermore, their antibiotic activity was independent of the average thickness of the plasma membrane hydrophobic core whilst that of melittin was inversely related to the thickness. Melittin and the synthetic peptides abolished spiroplasma cell motility and helicity, but only melittin and P-series peptides split the cells into globular forms displaying an average diameter of ca. 1 microm. In contrast to melittin, the synthetic peptides agglutinated spiroplasmas, suggesting that their polycationic NLS was exposed on the cell surface. P-series peptides decreased, though less efficiently than melittin, A. laidlawii and Spiroplasma melliferum membrane potential (delta psi) and transmembrane pH gradient (delta pH), at concentrations much lower than their minimal inhibitory concentrations whilst JM-series peptides had no effect on delta psi and delta pH in the same conditions. Actually, the bactericidal activity of these peptides towards mollicutes was proportional to their ability to collapse the electrochemical transmembrane potential.

Conformations of primary amphipathic carrier peptides in membrane mimicking environments

Two peptides designed for drug delivery were generated by the combination of a signal peptide with a nuclear localization sequence and are shown to facilitate the cellular internalization of small molecules which are covalently linked to these peptides. In order to understand the mechanism of internalization, the conformations of the peptides were investigated through different approaches both in solution and in membrane-mimicking environments. These peptides are highly versatile and adopt different conformational states depending on their environment. While in a disordered form in water, they adopt an alpha-helical structure in TFE and in the presence of micelles of SDS or DPC. The structured domain encompasses the hydrophobic part of the peptides, whereas the charged C-termini remain unstructured. In contrast, in the presence of lipids and whatever the nature of the phosphate headgroup, the two peptides mainly adopt an antiparallel beta-sheet form and embed in the lipidic cores. This result suggests that the beta-sheet is responsible for the translocation through the cellular membranes but also questions the conformational state of signal peptides when associated to hydrophilic sequences.

Argentinian collaborative study on prevalence of erythromycin and penicillin susceptibility in Streptococcus pyogenes. The Argentinian Streptococcus Study Group

Two monthly studies on the prevalence of penicillin and erythromycin susceptibility of Streptococcus pyogenes were performed in May and October of 1994 in Argentina. A total of 58 centers from 27 cities participated in these studies. A total of 1072 isolates were tested by a diffusion method, although 595 isolates were tested both by the diffusion and an agar dilution method (n = 1767 isolates). No penicillin-resistant streptococci were found in our study (MIC100 = 0.03 microgram/ml). Only four isolates were confirmed as erythromycin resistant S. pyogenes (prevalence 0.14 and 0.28% in May and October 1994, respectively). Resistance in three isolates was due to an inducible mechanism, although in one strain a different phenotype was observed.

Studies on keratinophilic fungi. IX: Neoarachnotheca gen. nov. and a new species of Nannizziopsis

Neoarachnotheca is proposed as a new genus of Onygenales. The outstanding generic characteristics are white, spherical ascomata with a wall formed by a network of hyphae and spherical, subhyaline ascospores with an irregular sheath. Nt. keratinophila, the type species, characterized by wavy peridial hyphae has been isolated from marine and river sediments and Myriodontium keratinophilum is its anamorph. Nannizziopsis tropicalis is proposed as a new species based on a strain isolated from soil in Burundi. RFLPs analysis of ITS and 5.8S rDNA support these proposals. The differences with related genera are discussed.

A new peptide vector for efficient delivery of oligonucleotides into mammalian cells

The development of antisense and gene therapy has focused mainly on improving methods for oligonucleotide and gene delivery into cells. In the present work, we describe a potent new strategy for oligonucleotide delivery based on the use of a short peptide vector, termed MPG (27 residues), which contains a hydrophobic domain derived from the fusion sequence of HIV gp41 and a hydrophilic domain derived from the nuclear localization sequence of SV40 T-antigen. The formation of peptide vector/oligonucleotide complexes was investigated by measuring changes in intrinsic tryptophan fluorescence of peptide and of mansyl-labelled oligonucleotides. MPG exhibits relatively high affinity for both single- and double-stranded DNA in a nanomolar range. Based on both intrinsic and extrinsic fluorescence titrations, it appears that the main binding between MPG and oligonucleotides occurs through electrostatic interactions, which involve the basic-residues of the peptide vector. Further peptide/peptide interactions also occur, leading to a higher MPG/oligonucleotide ratio (in the region of 20/1), which suggests that oligonucleotides are most likely coated with several molecules of MPG. Premixed complexes of peptide vector with single or double stranded oligonucleotides are delivered into cultured mammalian cells in less than 1 h with relatively high efficiency (90%). This new strategy of oligonucleotide delivery into cultured cells based on a peptide vector offers several advantages compared to other commonly used approaches of delivery including efficiency, stability and absence of cytotoxicity. The interaction with MPG strongly increases both the stability of the oligonucleotide to nuclease and crossing of the plasma membrane. The mechanism of cell delivery of oligonucleotides by MPG does not follow the endosomal pathway, which explains the rapid and efficient delivery of oligonucleotides in the nucleus. As such, we propose this peptide vector as a powerful tool for potential development in gene and antisense therapy.

[New strategy for RNA vectorization in mammalian cells. Use of a peptide vector]

A major barrier for gene delivery is the low permeability of nucleic acids to cellular membranes. The development of antisenses and gene therapy has focused mainly on improving methods of oligonucleotide or gene delivery to the cell. In this report we described a new strategy for RNA cell delivery, based on a short single peptide. This peptide vector is derived from both the fusion domain of the gp41 protein of HIV and the nuclear localization sequence of the SV40 large T antigen. This peptide vector localizes rapidly to the cytoplasm then to the nucleus of human fibroblasts (HS-68) within a few minutes and exhibits a high affinity for a single-stranded mRNA encoding the p66 subunit of the HIV-1 reverse transcriptase (in a 100 nM range). The peptide/RNA complex formation involves mainly electrostatic interactions between the basic residues of the peptide and the charges on the phosphate group of the RNA. In the presence of the peptide-vector fluorescently-labelled mRNA is delivered into the cytoplasm of mammalian cells (HS68 human fibroblasts) in less than 1 h with a relatively high efficiency (80%). This new concept based on a peptide-derived vector offers several advantages compared to other compounds commonly used in gene delivery. This vector is highly soluble and exhibits no cytotoxicity at the concentrations used for optimal gene delivery. This result clearly supports the fact that this peptide vector is a powerful tool and that it can be used widely, as much for laboratory research as for new applications and development in gene and/or antisense therapy.

[Lower extremity salvage in diabetics: microsurgical muscle transplantation with and without previous vascular reconstruction]

Soft tissues wounds with or without bony involvement are a common problem and a cause of limb loss in diabetics. Usually local care, antibiotics, minor debridement and skin grafting are enough for successful handling of these lesions. When there is associated limb ischemia, revascularization is indicated. In patients with large ulcers, proximal bony involvement and tendon exposure, the incidence of primary amputation rises, frequently being considered the only alternative. Two cases of diabetic patients with indication of primary amputation of a lower limb for large infected ulcers are reported. A microvascularized muscle transplant was used to cover large defects of soft tissue, tendons and infected bone. One patient presented also critical ischaemia of the limb, requiring iliac angioplasty and a femoro-distal by-pass with in situ greater saphenous vein previous to the muscle graft. Both patients had no postoperative complications, being able to walk two months after the operation with their useful limb. Microvascularized muscle transplant with or without revascularization is a very useful alternative to amputation in the management of complex wounds of selected diabetic patients.

An unreported cause of rupture of the extensor pollicis longus tendon

Avulsion fractures of the index metacarpal at the insertion of extensor carpi radialis longus are rare. We report such a fracture and the resulting complication of division of the extensor pollicus longus tendon, by the avulsed bony fragment. Careful clinical assessment and appropriate radiological examination is needed to diagnose this rare fracture and internal fixation is recommended.

The problem of bilateral foot reconstruction after severe burns

Reconstruction of bilateral, distal lower limb defects presents a major reconstructive challenge. In the patient with a major burn injury, however, the problem of bilateral foot reconstruction is compounded by both the limited availability of normal unscarred donor sites and by the limited availability of recipient vessels. A case is presented where bilateral dorsum of foot defects in a patient with a 50% surface area burn were successfully reconstructed using a single parascapular free flap. The problems presented by this case are discussed.