Fate of the micropenis and constitutional small penis: do they grow to normalcy in puberty?

INTRODUCTION

Penile length is an important indicator of male sexual development. Scarce data were reported on penile length measurements in children comparing changes between prepuberty and puberty for the small penile issue with long-term follow-up.

OBJECTIVE

The purpose of this study was to investigate the possibility of catch-up growth of the penile length of boys with a small penis in the long-term follow-up.

STUDY DESIGN

From April 2001 to December 2016, 27 boys who visited the outpatient clinic owing to a small penis, without any chromosomal anomalies and other genital disorder, were investigated retrospectively. Micropenis is defined as 2.5 standard deviations less than the mean stretched penile length (SPL) of age. Periodic penile length, testicular volume, hormonal levels (serum testosterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH)), and bone age were measured. Pubertal development was recorded by using the Tanner scale. The effect of hormonal therapy and the factors attributable to the increment of the penile length were evaluated.

RESULTS

The mean age at the first visit was 9.8 years (5-12 years) and that at puberty was 12.6 years (10-16 years). The length of the penis at the initial visit was 4.0 ± 0.8 cm (2.5-6.0) and at puberty, 7.3 ± 1.8 cm (4.0-12.0). Nine patients diagnosed with micropenis no longer had a micropenis in puberty. The less the age-matched SPL, the more the increment of SPL that was observed (rho = - 0.548, P = 0.003). The mean increment of SPL in the hormonal therapy group (11 boys) and the non-hormonal therapy group (16 boys) was not statistically different (43.5 ± 22. 9% vs 41.5 ± 21.6%, respectively, P = 0.497).

DISCUSSION

This study explains how much the growth of a small penis catches up in puberty. From the point of view of the increment of SPL, the increment was higher in boys who belonged to the smaller penis group. Hormonal therapy does not attribute to an increase in the length after long-term follow-up. Limitations of this study were its retrospective origin with a small number of patients in a single center.

CONCLUSION

Catch-up growth of the small penis at puberty was accomplished in most children with a small penis before puberty. Hormonal treatment was not significantly correlated with the penile length increment in the long-term follow-up.

Methotrexate hypersensitivity reactions in pediatrics: Evaluation and management

Reports of hypersensitivity reactions (HSRs) to MTX are limited to single case studies. We retrospectively reviewed HSRs to MTX during a 12-year period in our tertiary care pediatric center. Seven patients were evaluated for HSRs to MTX. Skin testing was positive in one of the four patients tested. One patient underwent successful graded challenge to MTX. Seventeen desensitizations to MTX were successfully performed in the other six patients. Skin testing, graded challenge, and desensitization were safe and effective procedures in the evaluation and management of patients with HSRs to MTX in our pediatric population.

A semiconductor photon-sorter

Obtaining substantial nonlinear effects at the single-photon level is a considerable challenge that holds great potential for quantum optical measurements and information processing. Of the progress that has been made in recent years one of the most promising methods is to scatter coherent light from quantum emitters, imprinting quantum correlations onto the photons. We report effective interactions between photons, controlled by a single semiconductor quantum dot that is weakly coupled to a monolithic cavity. We show that the nonlinearity of a transition modifies the counting statistics of a Poissonian beam, sorting the photons in number. This is used to create strong correlations between detection events and to create polarization-correlated photons from an uncorrelated stream using a single spin. These results pave the way for semiconductor optical switches operated by single quanta of light.

Rituximab Desensitization in Pediatric Patients: Results of a Case Series

Rituximab is a monoclonal antibody (mAb) primarily used to treat oncologic and autoinflammatory conditions. Although hypersensitivity reactions (HSRs) and desensitization protocols to mAbs have been well described in adults, the experience in the pediatric population is very limited. We sought to determine the safety and efficacy of desensitization to rituximab in the pediatric population at our institution. We retrospectively reviewed the experience with HSRs and desensitization to rituximab during a 5-year period in our tertiary care pediatric center, including reaction evaluation, premedication regimens, and desensitization procedures and protocols. A total of 17 desensitizations to rituximab were performed in three patients. A 14-year-old patient underwent successful desensitization to rituximab using a published adult protocol without incident. Two younger patients (ages 7 years and 23 months) experienced significant reactions during initial desensitization attempts. Therefore, we designed a modified desensitization protocol to rituximab, with particular attention to the rate of infusion as mg/kg/h. This new patient weight-based protocol was successfully used in a total of 13 desensitizations in these two patients. Desensitization to rituximab was a safe and effective procedure in our pediatric population. We present a new patient weight-based desensitization protocol for pediatric patients who develop HSRs to rituximab, with particular usefulness for younger pediatric patients and potential utility in pediatric patients with HSRs to other mAbs.

Ethnic Identity as a Moderator against Discrimination for Transracially and Transnationally Adopted Korean American Adolescents

Despite the growing practice of international adoption over the past 60 years, the racial and ethnic experiences of adopted youth are not well known. This study examined the moderating role of ethnic identity in the association between racial/ethnic discrimination and adjustment among transracially, transnationally adopted Korean American adolescents (N = 136). Building on self-categorization theory and past empirical research on Asian Americans, it was hypothesized that ethnic identity would exacerbate negative outcomes associated with discrimination. The moderating role of ethnic identity was found to vary by specific ethnic identity dimensions. For individuals with more pride in their ethnic group (affective dimension of ethnic identity), discrimination was positively associated with externalizing problems. For individuals with greater engagement with their ethnic group (behavioral dimension of ethnic identity), discrimination was positively associated with substance use. By contrast, clarity regarding the meaning and importance of one's ethnic group (cognitive dimension of ethnic identity) did not moderate the relationship between discrimination and negative outcomes.

Clinical outcomes in Asian elderly kidney transplant recipients: a multicenter cohort study

BACKGROUND

The kidney transplantation rate in elderly patients is increasing rapidly. However, the clinical outcomes of kidney transplantation in elderly patients have not yet been thoroughly evaluated.

METHODS

This multicenter cohort study included adult kidney transplant recipients (KTRs) admitted to five major tertiary hospitals in Korea between 1997 and 2012. A total of 3,565 adult participants were enrolled. Patient survival, allograft survival, and biopsy-proven acute rejection (BPAR) of 242 elderly recipients (≥ 60 years) were assessed and compared with those of a younger population.

RESULTS

Patients were divided into five groups according to age at time of transplantation. The proportion of elderly patients was 6.7 % (mean age, 63.1 ± 2.7 years; n = 242). The numbers of male patients (69.4%), those with diabetes mellitus history (36.3%), and those with pretransplantation ischemic heart disease history (17.7%) were significantly higher in the elderly group than in the younger age groups. Elderly patients were more likely to receive a cadaveric kidney, and overall mortality rates were significantly higher in the elderly patients (1-year survival 93.3%, 5-year survival 91.3%). However, death-censored allograft survival rate and BPAR were not affected by patient age (P = .104 and .501, respectively). Among the elderly, BPAR and female donors were independent risk factors for allograft loss.

CONCLUSION

The overall survival rate of the elderly KTRs was significantly lower than that of younger KTRs. However, the death-censored allograft survival rate did not differ between groups. Kidney transplantation should not be stagnated especially in elderly patients with end-stage renal disease.

Intrinsic rotation driven by non-Maxwellian equilibria in Tokamak plasmas

The effect of small deviations from a Maxwellian equilibrium on turbulent momentum transport in tokamak plasmas is considered. These non-Maxwellian features, arising from diamagnetic effects, introduce a strong dependence of the radial flux of cocurrent toroidal angular momentum on collisionality: As the plasma goes from nearly collisionless to weakly collisional, the flux reverses direction from radially inward to outward. This indicates a collisionality-dependent transition from peaked to hollow rotation profiles, consistent with experimental observations of intrinsic rotation.

Botulinum toxin injection into the superior rectus for treatment of strabismus

Botulinum toxin injected into the superior rectus (SR) has rarely been described in the literature. We conducted a database search to identify all cases of SR toxin from 1982 to 2010 at our institution. Out of a total of 7575 patients in the database, only eight cases of SR toxin were identified, all of which had residual hypertropia following previous ocular surgery. This surgery comprised: retinal surgery (3 patients), strabismus surgery for thyroid eye disease (2), and transposition for VI nerve palsy (2 patients). In seven out of eight cases, a long-lasting mean reduction of 10(Δ) was achieved from between two and three injections. Ptosis occurred in all but one case, but resolved. We conclude that SR toxin injection has very limited indications, but may be considered in residual hypertropia presumed secondary to a tight or overacting SR where the patient can tolerate the temporary iatrogenic ptosis.

Therapeutic effects of stem cells and substrate reduction in juvenile Sandhoff mice

Sandhoff Disease (SD) involves the CNS accumulation of ganglioside GM2 and asialo-GM2 (GA2) due to inherited defects in the β-subunit gene of β-hexosaminidase A and B (Hexb gene). Substrate reduction therapy, utilizing imino sugar N-butyldeoxygalactonojirimycin (NB-DGJ), reduces ganglioside biosynthesis and levels of stored GM2 in SD mice. Intracranial transplantation of Neural Stem Cells (NSCs) can provide enzymatic cross correction, to help reduce ganglioside storage and extend life. Here we tested the effect of NSCs and NB-DGJ, alone and together, on brain β-hexosaminidase activity, GM2, and GA2 content in juvenile SD mice. The SD mice received either cerebral NSC transplantation at post-natal day 0 (p-0), intraperitoneal injection of NB-DGJ (500 mg/kg/day) from p-9 to p-15, or received dual treatments. The brains were analyzed at p-15. β-galactosidase staining confirmed engraftment of lacZ-expressing NSCs in the cerebral cortex. Compared to untreated and sham-treated SD controls, NSC treatment alone provided a slight increase in Hex activity and significantly decreased GA2 content. However, NSCs had no effect on GM2 content when analyzed at p-15. NB-DGJ alone had no effect on Hex activity, but significantly reduced GM2 and GA2 content. Hex activity was slightly elevated in the NSC + drug-treated mice. GM2 and GA2 content in the dual treated mice were similar to that of the NB-DGJ treated mice. These data indicate that NB-DGJ alone was more effective in targeting storage in juvenile SD mice than were NSCs alone. No additive or synergistic effect between NSC and drug was found in these juvenile SD mice.

'Smoking': use of cigarettes, cigars and blunts among Southeast Asian American youth and young adults

Increased use of cigars has been noted among youth, as well as use of blunts (hollowed-out cigars filled with marijuana). Three types of relationships have been previously hypothesized between use of tobacco and marijuana in substance use progression. We aimed to assess these relationships for Southeast Asian American youth and adults in an urban population. We conducted in-person interviews with 164 Southeast Asians, smokers and non-smokers, in two low-income urban communities in Northern California, collecting both quantitative and qualitative data. Analysis of the quantitative data indicated distinct use patterns for blunts, cigars and other forms of marijuana in terms of associations with generation in the United States. The use of these items was also found to be related: ever having smoked cigarettes or blunts increased the risk of ever having smoked the other three items. Qualitative data found indications of all three hypothesized relationships between tobacco and marijuana for youths but not for older adults. For youths in the study, 'smoking' was found to constitute a social construct within which use of cigarettes, cigars and blunts were somewhat interchangeable. Youths in similar settings may initiate into and progress through smoking as an activity domain rather than any one of these items.

Baclofen for Patients with Congenital Periodic Alternating Nystagmus

PURPOSE

To describe the clinical effect of baclofen on a group of patients with congenital periodic alternating nystagmus.

METHODS

A retrospective review of case notes was carried out of all patients with congenital periodic alternating nystagmus (PAN) treated with baclofen between 1999 and 2004. Eight patients were identified, 6 males and 2 females with a mean age of 21 years (range 9 to 34 years). Clinical data were recorded for all patients pre- and post-treatment with the GABA agonist baclofen. Adverse effects of the treatment were recorded and a questionnaire was constructed to evaluate patient satisfaction with the treatment.

RESULTS

All 8 patients had an abnormal head posture (AHP) before treatment which improved following treatment in 4 patients, one of whom had recurrence following treatment withdrawal. Binocular Snellen visual acuity (VA) improved by one line in 4 cases, while none of the other 4 patients suffered any loss of vision from the treatment. Three of the eight patients have continued on treatment long-term, in one case for 6 years. In the other five, treatment was withdrawn due to side effects in 4 cases, and in the fifth due to a lack of effect. The most commonly reported side effect was drowsiness, which occurred in 3 patients. Using a patient-centered survey, complete responses were obtained from 6 of the 8 patients treated. Five patients were either pleased or very pleased that they had tried the treatment. The reasons given were: improved vision or head posture, an appreciation of slowing of ocular movements, improved cosmesis and improved confidence.

CONCLUSIONS

Baclofen may be effective in a select group of patients with congenital PAN and a trial of treatment may be worthwhile, prior to considering surgical intervention in this condition.

Does Botulinum toxin have a role in the treatment of small-angle esotropia?

A retrospective review of the Toxin Clinic database was carried out over an 18-year period. We identified 68 patients with esotropia of 20 prism dioptres and under who were treated with Botulinum toxin. There were 47 females and 21 males, with a mean age of 34 years (range 11-78 years). Thirty-two (47%) patients had residual esotropia, 20 (29%) had primary esotropia, 11 (16%) had consecutive esotropia, 4 (6%) had secondary esotropia and 1 (1.5%) had a decompensating esophoria. The mean pre-toxin angle was 16 prism dioptres (range 6-20). A total of 434 injections were given, with an average of 6 per patient (range 1-36). Forty-five (66%) patients underwent continued toxin treatment with an interval of 3 to 31 months. Thirteen (19%) patients achieved long-term benefit from only one injection. Seven were unable to demonstrate binocular vision pre-injection but demonstrated it post-injection. Following an initial injection, nine (13%) patients proceeded to surgery. Botulinum toxin was a successful treatment for these patients and was well tolerated, with no side effects. It appears to have a definite role in the treatment of small-angle esotropia.

Residual symptomatic superior oblique palsy

PURPOSE

To determine the outcome of patients treated for residual symptomatic hyperdeviations, in a tertiary referral centre, following a previous weakening procedure of the ipsilateral Inferior Oblique (IO) muscle in Superior Oblique (SO) palsy.

METHODS

A retrospective review of 37 patients seen over 6 years at one institution who had remained symptomatic from a SO palsy despite having had an initial weakening procedure to their ipsilateral IO (myectomy or recession). Median age was 19 years (range 3 to 56 years). Information recorded included pre- and postoperative deviation and ocular motility findings, preoperative symptoms, findings at the time of surgery, and outcome.

RESULTS

Nine patients underwent repeat weakening surgery (disinsertion) on the ipsilateral IO only. Thirteen patients underwent strengthening surgery on the ipsilateral SO only. Nine patients had surgery on both the ipsilateral IO and SO. Six patients had surgery on the ipsilateral IO with either horizontal or vertical rectus surgery. Nine (24%) patients remained symptomatic after their initial procedure and are regarded as initial failures. Four of these patients had masked bilateral IO weakness. Five patients required additional surgery. At final outcome, 84% were discharged with resolution of their symptoms.

CONCLUSIONS

In the light of these findings we suggest an approach for the management of these patients. This should always include exploring a previously operated ipsilateral IO. Despite this, patients should be warned that they have a 1 in 4 chance of needing further surgery to achieve adequate ocular motility.

RING-dependent tumor suppression and G2/M arrest induced by the TRC8 hereditary kidney cancer gene

TRC8/RNF139 and von Hippel-Lindau (VHL) both encode E3 ubiquitin (Ub) ligases mutated in clear-cell renal carcinomas (ccRCC). VHL, inactivated in nearly 70% of ccRCCs, is a tumor suppressor encoding the targeting subunit for a Ub ligase complex that downregulates hypoxia-inducible factor-alpha. TRC8/RNF139 is a putative tumor suppressor containing a sterol-sensing domain and a RING-H2 motif essential for Ub ligase activity. Here we report that human kidney cells are growth inhibited by TRC8. Inhibition is manifested by G2/M arrest, decreased DNA synthesis and increased apoptosis and is dependent upon the Ub ligase activity of the RING domain. Tumor formation in a nude mouse model is inhibited by TRC8 in a RING-dependent manner. Expression of TRC8 represses genes involved in cholesterol and fatty acid biosynthesis that are transcriptionally regulated by the sterol response element binding proteins (SREBPs). Expression of activated SREBP-1a partially restores the growth of TRC8-inhibited cells. These data suggest that TRC8 modulation of SREBP activity comprises a novel regulatory link between growth control and the cholesterol/lipid homeostasis pathway.

Sonographic findings of placental lacunae and the prediction of adherent placenta in women with placenta previa totalis and prior Cesarean section

OBJECTIVE

To investigate the value of transvaginal sonographic findings of intraplacental lacunae for predicting adherent placenta and clinical outcome in patients with placenta previa totalis and a history of Cesarean section.

METHODS

Fifty-one patients with placenta previa totalis diagnosed by transvaginal sonography and with a history of Cesarean section who delivered at our hospital were included in the study. The sonographic findings of intraplacental lacunae were classified into one of four grades. Pathological analysis of the placenta was performed for all patients who delivered, and in cases of hysterectomy, examination of the uterus was also performed. The placental findings and obstetric complications, including massive transfusion, intensive care unit admission and Cesarean hysterectomy, were compared with the grade of lacuna.

RESULTS

Lacunae were classified as Grade 1+ in 10 cases, Grade 2+ in 11 cases, Grade 3+ in five cases and as Grade 0 (i.e. lacunae were absent) in the remaining 25 cases. When lacunae of > or = Grade 1+ were considered, the sensitivity, specificity, positive predictive value and negative predictive value of diagnosing adherent placenta were 86.9%, 78.6%, 76.9% and 88.0%, respectively. When lacunae of > or = Grade 2+ were considered, the sensitivity, specificity, positive predictive value and negative predictive value of diagnosing placenta increta or percreta were 100%, 97.2%, 93.8% and 100%, respectively. Hysterectomy was performed in 18 cases, among whom two cases showed Grade 1+ lacunae, 11 cases showed Grade 2+ lacunae, and five cases showed Grade 3+ lacunae. No hysterectomy was performed in any case in which lacunae were absent. Compared to those without lacunae, the number of massive transfusions and intensive care unit admissions and cases of disseminated intravascular coagulopathy and Cesarean hysterectomy were significantly greater in those with lacunae (P < 0.0001).

CONCLUSION

Transvaginal sonographic findings of intraplacental lacunae in patients with placenta previa totalis and a history of Cesarean section are useful in the prediction of adherent placenta and may have a role in the prediction of clinical outcome.

Causes and outcomes for patients presenting with diplopia to an eye casualty department

PURPOSE

To evaluate the causes and outcomes for patients presenting with diplopia to an eye casualty department.

METHODS

Patients presenting with diplopia as a principal symptom, who were referred to the Orthoptic Department from Moorfields Eye Casualty over a 12-month period, were retrospectively investigated.

RESULTS

One hundred and seventy-one patients were identified with complete records in 165 cases. There were 99 men and 66 women with an age range of 5-88 years. Monocular diplopia accounted for 19 cases (11.5%), whereas 146 patients (88.5%) had binocular diplopia. Cranial nerve palsies were the most common cause of binocular diplopia accounting for 98 (67%) of cases. Isolated sixth nerve palsy was the largest diagnostic group (n=45). Microvascular disease (hypertension or diabetes mellitus, or both) was present in 59% of patients with cranial nerve palsies, and of this group, 87% resolved spontaneously by 5 months rising to 95% by 12 months.

CONCLUSION

Patients with clinically isolated single cranial nerve palsies associated with diabetes or hypertension are likely to recover spontaneously within 5 months and initially require observation only. However, patients with unexplained binocular diplopia and those who progress or fail to recover should be investigated to establish the underlying aetiology and managed as appropriate.

Hearing voices and seeing pictures

I have been living with a psychiatric disorder, schizophrenia, for 2 decades. I will relate how important medication is to the treatment of this illness. I will also relate how important the assessment of the level of medication to be used is to recovery. Specifically, I will explain how I learned to manage hallucinations and delusions and also how I acquired an experience which I refer to as spiritual, mystical and psychic.

The incidence of strabismus and refractive error in patients with blepharophimosis, ptosis and epicanthus inversus syndrome (BPES)

A retrospective review was carried out of 204 patients with blepharophimosis, (blepharo) ptosis and epicanthus inversus syndrome (BPES). Of these, 94 (46%) had an autosomal dominant family history of BPES. Forty (20%) had manifest strabismus. Of these, 28 (70%) had esotropia, 10 (25%) had exotropia and 2 (5%) had hypertropia. Twelve (6%) patients had nystagmus. Seventy (34%) patients had a significant refractive error requiring spectacles. Twenty-one (30%) of these patients had anisometropic hypermetropia and 24 (34%) had anisometropic myopia. Forty-three patients had bilateral amblyopia and 40 had unilateral amblyopia, with 26 (65%) of these undergoing occlusion treatment. Of these, 14 had strabismus and refractive error, 7 refractive error only, 2 strabismus only and 3 neither refractive error nor strabismus. We conclude that there is a higher incidence of strabismus and refractive error in patients with BPES than in the normal population.

No correlation between aggregates of Cu/Zn superoxide dismutase and cell death in familial amyotrophic lateral sclerosis

Aggregates of Cu/Zn superoxide dismutase (SOD) have been demonstrated in familial amyotrophic lateral sclerosis (FALS) and other neurodegenerative diseases; however, their role in disease pathogenesis is unclear. In this study, we investigated the presence of SOD aggregates in nerve growth factor (NGF)-differentiated PC12 cells and cell viability following: (i) transduction with replication-deficient recombinant adenoviruses (AdVs) expressing wild-type SOD (SODWT) or mutant SOD (SODMT, V148G or A4V); (ii) transfection of yellow fluorescent protein-tagged SODWT (SODWT-YFP) or SODMT (SODA4V-YFP, SODV148G-YFP). SOD aggregates were more prominent in cells following transduction of AdSODMT than AdSODWT and following treatment with H2O2, suggesting that mutant SOD leads to oxidation of cellular components. In addition, cells expressing SODMT-YFP yielded SOD aggregates that were significantly larger and more frequent than SOD aggregates in cells expressing SODWT-YFP. Proteasome inhibitors, but not cathepsin B inhibitors, increased aggregate formation but did not increase cell death. In addition, treatments that increased cell viability did not significantly decrease SOD aggregates. Taken together, our data demonstrate that there is no association between SOD aggregates and cell death in FALS.

Regulation of pancreatic beta-cell growth and survival by the serine/threonine protein kinase Akt1/PKBalpha

The physiological performance of an organ depends on an interplay between changes in cellular function and organ size, determined by cell growth, proliferation and death. Nowhere is this more evident than in the endocrine pancreas, where disturbances in function or mass result in severe disease. Recently, the insulin signal-transduction pathway has been implicated in both the regulation of hormone secretion from beta cells in mammals as well as the determination of cell and organ size in Drosophila melanogaster. A prominent mediator of the actions of insulin and insulin-like growth factor 1 (IGF-1) is the 3'-phosphoinositide-dependent protein kinase Akt, also known as protein kinase B (PKB). Here we report that overexpression of active Akt1 in the mouse beta cell substantially affects compartment size and function. There was a significant increase in both beta-cell size and total islet mass, accompanied by improved glucose tolerance and complete resistance to experimental diabetes.

Calpains play a role in insulin secretion and action

Studies of the genetic basis of type 2 diabetes suggest that variation in the calpain-10 gene affects susceptibility to this common disorder, raising the possibility that calpain-sensitive pathways may play a role in regulating insulin secretion and/or action. Calpains are ubiquitously expressed cysteine proteases that are thought to regulate a variety of normal cellular functions. Here, we report that short-term (4-h) exposure to the cell-permeable calpain inhibitors calpain inhibitor II and E-64-d increases the insulin secretory response to glucose in mouse pancreatic islets. This dose-dependent effect is observed at glucose concentrations above 8 mmol/l. This effect was also seen with other calpain inhibitors with different mechanisms of action but not with cathepsin inhibitors or other protease inhibitors. Enhancement of insulin secretion with short-term exposure to calpain inhibitors is not mediated by increased responses in intracellular Ca2+ or increased glucose metabolism in islets but by accelerated exocytosis of insulin granules. In muscle strips and adipocytes, exposure to both calpain inhibitor II and E-64-d reduced insulin-mediated glucose transport. Incorporation of glucose into glycogen in muscle also was reduced. These results are consistent with a role for calpains in the regulation of insulin secretion and insulin action.

Prenatal diagnosis of der(11)t(11;18)(q24;q21.3) due to paternal balanced translocation and both parents are carriers of alpha-thalassemia-1--a case report

A couple were identified as alpha-thalassemia-1 carriers (father: alpha-thal-1 of Filipino type, mother: alpha-thal-1 of SEA type). Amniocentesis was done at 19 weeks of gestation by a local obstetrician. Molecular study of amniotic fluid presented a non-thalassemia fetus, but the cytogenetic study revealed a karyotype of 46,XX,der(11)t(11;18)(q24;q21.3), resulting from a paternal balanced reciprocal translocation and unbalanced adjacent 1 segregation. The pregnancy was terminated at 23 weeks of gestation. The gross of fetus revealed bilateral cleft lip and palate, hypertelorism, flat nasal bridge, frontal bossing, micrognathia, low set ears, short neck with cystic hygroma, overlapping fingers, prominent heels, and limited hip abduction. The chromosome complement of the present case was partial monosomy for 11q24-qter and partial trisomy for 18q21.3-qter. This is the first prenatal diagnosis of unbalanced translocation with der(11)t(11;18)(q24;q21.3) pat due to paternal balanced translocation and both parents being carriers of alpha-thalassemia-1.

Strabismus surgery in congenital third nerve palsy

BACKGROUND

Congenital third nerve palsy is a rare condition that usually presents with a large-angle incomitant strabismus and is often associated with ptosis and amblyopia.

METHODS

We present the results of strabismus surgery in seven consecutive patients. RESULTS; All the palsies developed before the age of 6 months and the age at surgery ranged from 3 to 24 years. The operations performed included horizontal recti resection/recession (7), supra-placement of the insertions (6), superior oblique weakening (4) and traction sutures (4). The preoperative and postoperative horizontal deviations consisted of seven exotropias and one esotropia due to a combined sixth and partial third nerve palsy. The preoperative vertical deviation consisted of 7 hypotropias and one hypertropia; postoperatively, 5 remained hypotropic and 2 were hypertropic. All patients underwent ptosis surgery.

CONCLUSION

Patients with congenital third nerve palsy often achieve reasonable cosmesis with strabismus and ptosis surgery.

Intensive occlusion therapy for amblyopia

AIM

To study the effects of supervised inpatient occlusion treatment for amblyopia in children who had failed to respond to outpatient treatment.

METHODS

A retrospective study of 39 children admitted to a paediatric ophthalmic ward for 5 days of supervised intensive occlusion therapy having previously failed to respond to outpatient occlusion. Visual acuity of amblyopic and fellow eyes was recorded at each clinic visit before admission, daily during admission, and at each outpatient visit after discharge.

RESULTS

There was no significant overall improvement in visual acuity during a mean of 9 months of attempted outpatient occlusion before admission. During the 5 days of admission 26 children (67%) gained at least one line of acuity in their amblyopic eye and five (13%) gained three or more lines (mean gain 1.03 Snellen lines). The acuities of both the amblyopic and fellow eyes subsequently improved with continuing part time patching as an outpatient, including in nine of the children who did not respond during admission. At the last recorded visit, at a median time of 14 months after discharge, 13 (33%) of the patients had an acuity of at least 6/12 in their amblyopic eye.

CONCLUSIONS

The acuity of amblyopic eyes did not improve without effective treatment. Subsequent supervised inpatient occlusion therapy was effective in the majority of the children.

Active management in patients with ocular manifestations of myasthenia gravis

PURPOSE

Myasthenia gravis can cause variable strabismus with disabling diplopia and/or poor cosmesis. A retrospective study of a group of patients with myasthenia gravis or 'myasthenia gravis like' syndromes was made.

METHODS

The study group consisted of patients who had undergone botulinum toxin treatment and/or surgery for disabling diplopia, poor cosmesis or both. Surgical treatment was by conventional techniques including recess/resect, posterior fixation, superior oblique tenotomy and adjustable sutures.

RESULTS

There were 9 patients in the study group (8 female, 1 male). Age at surgery ranged from 21 to 59 years (mean 46 years). Six were symptom-free following treatment. Two, although symptomatically improved, had occasional diplopia. One patient failed treatment and required an occlusive contact lens.

CONCLUSIONS

The ocular manifestations of myasthenia gravis or 'myasthenia gravis like' syndromes may respond to surgery and/or botulinum toxin injection. Active intervention should be considered when deviations become stable. To our knowledge this is the first report of the use of botulinum toxin in such patients.

Review of the inverse Knapp procedure: indications, effectiveness and results

PURPOSE

To evaluate the indications and results of inverse Knapp procedures performed at one institution over a 10 year period between 1987 and 1996.

METHODS

The records of patients who had undergone inverse Knapp procedures were retrospectively reviewed. Demographic data were collected, pre- and post-operative orthoptic assessments were evaluated, and pre- and post-operative binocular single vision (BSV) charts and Hess charts were scored.

RESULTS

Twenty-one patients were identified and records were available in 17. The main indication for the operation was orbital trauma. The mean vertical deviation in primary position and downgaze improved from 16.06 prism dioptres (PD) to 7.35 PD and 26.45 PD to 6.66 PD respectively. The pre-operative average score for BSV was 42%, increasing to 62% post-operatively. The Hess chart error scores improved on average from 848.8 pre-operatively to 296.4 post-operatively. Further operations were required for 8 patients.

CONCLUSIONS

Inverse Knapp procedure is an uncommon strabismus operation but an extremely useful one in selected cases. We recommend it for the treatment of marked inferior rectus weakness, congenital or acquired, for post-traumatic inferior rectus underaction with or without orbital blow-out fracture and for residual large hypertropia in patients with poor binocular functions. The extent of inferior rectus underaction should be assessed very carefully to avoid overcorrecting.

Simulation study of the structure and dynamics of the Alzheimer's amyloid peptide congener in solution

The amyloid Abeta(10-35)-NH2 peptide is simulated in an aqueous environment on the nanosecond time scale. One focus of the study is on the validation of the computational model through a direct comparison of simulated statistical averages with experimental observations of the peptide's structure and dynamics. These measures include (1) nuclear magnetic resonance spectroscopy-derived amide bond order parameters and temperature-dependent H(alpha) proton chemical shifts, (2) the peptide's radius of gyration and end-to-end distance, (3) the rates of peptide self-diffusion in water, and (4) the peptide's hydrodynamic radius as measured by quasielastic light scattering experiments. A second focus of the study is the identification of key intrapeptide interactions that stabilize the central structural motif of the peptide. Particular attention is paid to the structure and fluctuation of the central LVFFA hydrophobic cluster (17-21) region and the VGSN turn (24-27) region. There is a strong correlation between preservation of the structure of these elements and interactions between the cluster and turn regions in imposing structure on the peptide monomer. The specific role of these interactions in relation to proposed mechanisms of amyloidosis is discussed.

Enzyme production of Trichoderma reesei Rut C-30 on various lignocellulosic substrates

Economical production of cellulase enzyme is key for feasible bio-ethanol production from lignocellulosics using an enzyme-based process. On-site cellulase production can be more feasible with the process of separate hydrolysis and fermentation (SHF) than with simultaneous saccharification and fermentation, since the cost of enzyme is more important and a variety of substrates are available for the SHF process. Cellulase production using various biomass substrates available for SHF, including paper sludge, pretreated wood (steam exploded), and their hydrolysis residues, was investigated in shake flasks and a fermenter for their productivities and titers. Among the newspaper sludge, office paper sludge, and steam-exploded woods treated in various ways, the steam-exploded wood showed the best properties for substrate in cellulase production. The best titer of 4.29 IU/mL was obtained using exploded wood of 2% (w/v) slurry in the shake flask, and the titer with the same substrate was duplicated to about 4.30 IU/mL in a 3.7-L fermenter. Also, the yield of enzyme reached 215 IU/g of substrate or 363 IU/g of cellulose. Despite various pretreatment attempts, newspaper and office paper substrate was inferior to the exploded-wood substrate for cellulase production. However, hydrolysis residues of papers showed quite promising results. The hydrolysis residue of office paper produced 2.48 IU/mL of cellulase in 7 d. Hence, the utilization of hydrolysis residues for cellulase production will be further investigated in the future.

Phacoemulsification and opaque intraocular lens implantation for the treatment of intractable diplopia

Intractable diplopia secondary to paralytic strabismus may be treated with the occlusion of the affected eye. Established treatments include occlusion with a patch, opaque spectacles or contact lenses, and performing upper lid lowering procedures or tarsorrhaphies. Two cases are presented in which intractable diplopia was resolved by performing clear lens phacoemulsification and the insertion of an opaque intraocular lens. Both patients reported a resolution of their diplopia having been dissatisfied with other forms of treatment. Although opaque intraocular lens insertion is not recommended as the initial treatment of choice in such cases, it offers a valuable treatment option for those patients in whom other forms of therapy have failed.

Disinsertion of the inferior oblique muscle for treatment of superior oblique paresis

PURPOSE

To examine the safety and efficacy of disinsertion of the inferior oblique muscle in the treatment of long-standing ipsilateral superior oblique paresis.

METHODS

This retrospective study included 52 patients who underwent disinsertion of the inferior oblique muscle over a 5-year period. Mean age at presentation was 30.8 years (range: 1-70 years). All patients had long-standing unilateral superior oblique paresis and overaction of the ipsilateral inferior oblique muscle. Information recorded included pre- and postoperative vertical deviation, pre- and postoperative Hess chart error scores, reoperation rate, and symptom relief.

RESULTS

Following surgery, mean vertical deviation was reduced from 12.9 to 4 prism diopters, while mean Hess chart error score decreased from 596 to 258. This procedure alone resulted in satisfactory symptom relief in 84.6% of patients. The only complication was significant undercorrection requiring further surgery in 13.6% of patients and prisms in 1.8%. When further surgery was needed, the procedure of choice was tucking of the affected superior oblique. Recession of the contralateral inferior rectus was carried out when superior oblique tucking was believed to be unsuitable.

CONCLUSIONS

Disinsertion of the inferior oblique muscle is a safe and effective treatment for the majority of long-standing idiopathic unilateral superior oblique pareses.

New antimicrobial flavanones from Physena madagascariensis

Two new flavanones (1 and 2) with antibacterial activity were isolated from the methanolic extract of the dried leaves of Physena madagascariensis using activity against Staphylococcus aureus to guide the isolation. A third flavonoid, a flavanone dimer linked by a methylene group (3) was also isolated and proved to be inactive. The structures of 1 and 2 were established primarily from NMR studies, while that of 3 required more extensive mass spectrometric analysis. All three flavanones had lavandulyl units in the limonene form. Flavanones 1 and 2 were active against several bacteria at concentrations as low as 4 microM.

Morphological effects of ArF excimer laser irradiation on enamel and dentin

BACKGROUND AND OBJECTIVE

The aim of this investigation to determine the range of morphological and ablative effects that can be achieved on dental enamel and dentin using ArF excimer laser irradiation at a wavelength of 193nm.

STUDY DESIGN/MATERIALS AND METHODS

Caries-free coronal enamel and dentin surfaces of 20 extracted human teeth were subjected to irradiation at 193nm using a Lamda-Physik model EMG 103 MSC and ArF fill. Morphology of cavity floors and walls were assessed by light microscopy and SEM.

RESULTS

Morphological surface effects and ablation could be controlled effectively and reliably by choice of parameter combination, allowing the operator to achieve either a smooth, flat, or increasingly rough surface with differing degrees of selective ablation. No signs of thermal damage were apparent.

CONCLUSION

Excimer laser irradiation at 193nm provided clinically useful cavity preparations and surface morphological effects.

Activation barriers to structural transition determine deposition rates of Alzheimer's disease a beta amyloid

Brain amyloid composed of the approximately 40-amino-acid human beta-amyloid peptide A beta is integral to Alzheimer's disease pathology. To probe the importance of a conformational transition in Abeta during amyloid growth, we synthesized and examined the solution conformation and amyloid deposition activity of A beta congeners designed to have similar solution structures but to vary substantially in their barriers to conformational transition. Although all these peptides adopt similar solution conformations, a covalently restricted Abeta congener designed to have a very high barrier to conformational rearrangement was inactive, while a peptide designed to have a reduced barrier to conformational transition displayed an enhanced deposition rate relative to wild-type A beta. The hyperactive peptide, which is linked to a heritable A beta amyloidosis characterized by massive amyloid deposition at an early age, displayed a reduced activation barrier to deposition consistent with a larger difference in activation entropy than in activation enthalpy relative to wild-type A beta. These results suggest that in Alzheimer's disease, as in the prion diseases, a conformational transition in the depositing peptide is essential for the conversion of soluble monomer to insoluble amyloid, and alterations in the activation barrier to this transition affect amyloidogenicity and directly contribute to human disease.

The Alzheimer's peptide a beta adopts a collapsed coil structure in water

The self-assembly of the soluble peptide Abeta into Alzheimer's disease amyloid is believed to involve a conformational change. Hence the solution conformation of Abeta is of significant interest. In contrast to studies in other solvents, in water Abeta is collapsed into a compact series of loops, strands, and turns and has no alpha-helical or beta-sheet structure. Conformational stabilization is primarily attributed to van der Waals and electrostatic forces. A large conspicuous uninterrupted hydrophobic patch covers approximately 25% of the surface. The compact coil structure appears meta-stable, and because fibrillization leads to formation of intermolecular beta-sheet secondary structure, a global conformational rearrangement is highly likely. A molecular hypothesis for amyloidosis includes at least two primary driving forces, changes in solvation thermodynamics during formation of amyloid deposits and relief of internal conformational stress within the soluble precursor during formation of lower-energy amyloid fibrils.

Alzheimer's disease amyloid propagation by a template-dependent dock-lock mechanism

Amyloid plaques composed of the peptide Abeta are an integral part of Alzheimer's disease (AD) pathogenesis. We have modeled the process of amyloid plaque growth by monitoring the deposition of soluble Abeta onto amyloid in AD brain tissue or synthetic amyloid fibrils and show that it is mediated by two distinct kinetic processes. In the first phase, "dock", Abeta addition to the amyloid template is fully reversible (dissociation t(1/2) approximately 10 min), while in the second phase, "lock", the deposited peptide becomes irreversibly associated (dissociation t(1/2) >> 1000 min) with the template in a time-dependent manner. The most recently deposited peptide dissociates first while Abeta previously deposited becomes irreversibly "locked" onto the template. Thus, the transition from monomer to neurotoxic amyloid is mediated by interaction with the template, a mechanism that has also been proposed for the prion diseases. Interestingly, two Abeta peptides bearing primary sequence alterations implicated in heritable Abeta amyloidoses displayed faster lock-phase kinetics than wild-type Abeta. Inhibiting the initial weak docking interaction between depositing Abeta and the template is a viable therapeutic target to prevent the critical conformational transition in the conversion of Abeta((solution)) to Abeta((amyloid)) and thus prevent stable amyloid accumulation. While thermodynamics suggest that inhibiting amyloid assembly would be difficult, the present study illustrates that the protein misfolding diseases are kinetically vulnerable to intervention.

APP carboxyl-terminal fragment without or with abeta domain equally induces cytotoxicity in differentiated PC12 cells and cortical neurons

Mutations in the beta-amyloid precursor protein (APP) gene cause familial Alzheimer's disease (AD). Although amyloid beta peptide (Abeta) is the principal constituent of senile plaques in AD, other cleavage products of APP are also implicated in playing a role in the pathogenesis of AD. C-terminal fragments of APP (APP-CTs), that contain complete Abeta sequence, are found in neuritic plaques, neurofibrillary tangles and the cytosol of lymphoblastoid cells obtained from AD patients. Our previous report demonstrated that APP-CT105 causes death of differentiated PC12 cells and cultured rat cortical neurons (Kim and Suh [1996] J. Neurochem. 67:1172-1182) and induces strong inward currents in Xenopus oocyte (Fraser et al., [1996] J. Neurochem. 66:2034-2040). In the present study, to investigate which domain of APP-CT105 is responsible for the neurotoxicity, we have made deletion mutants of APP-CT105 without Abeta and transmembrane domain (TM) or without NPTY domain, a putative endocytosis signaling sequence, using the PCR-amplified strategy and the recombinant GST-fusion protein strategy. The effect on cell survival of the deletion mutants of APP-CT105 (8 microM) was then determined by the LDH and MTT assay. We found that C-terminal fragment without NPTY significantly causes cell death in NGF-differentiated PC12 cells and cultured rat cortical neurons. This finding suggests that NPTY may not play an important role in APP-CT105 mediated neurotoxicity. We found, however, that C-terminal fragment without Abeta and TM significantly induces neuronal cell death. Our results suggest that in addition to Abeta, C-terminal fragment of APP without Abeta and TM domain itself may also participate in the neuronal degeneration in AD.

Functional role of caspase-1 and caspase-3 in an ALS transgenic mouse model

Mutations in the copper/zinc superoxide dismutase (SOD1) gene produce an animal model of familial amyotrophic lateral sclerosis (ALS), a fatal neurodegenerative disorder. To test a new therapeutic strategy for ALS, we examined the effect of caspase inhibition in transgenic mice expressing mutant human SOD1 with a substitution of glycine to alanine in position 93 (mSOD1(G93A)). Intracerebroventricular administration of zVAD-fmk, a broad caspase inhibitor, delays disease onset and mortality. Moreover, zVAD-fmk inhibits caspase-1 activity as well as caspase-1 and caspase-3 mRNA up-regulation, providing evidence for a non-cell-autonomous pathway regulating caspase expression. Caspases play an instrumental role in neurodegeneration in transgenic mSOD1(G93A) mice, which suggests that caspase inhibition may have a protective role in ALS.

Cytotoxic triterpenes from Crataegus pinnatifida

Bioassay-guided fractionation of Crataegus pinnatifida (Rosaceae) gave two cytotoxic ursane-type triterpenes which were identified as uvaol (1) and ursolic acid (2) by physicochemical and spectroscopic methods. 3-Oxo-ursolic acid (3) was synthesized from ursolic acid (2) by Jones method. The cytotoxic activities of these compounds were tested against murine L1210 and human cancer cell lines (A549, SK-OV-3, SK-MEL-2, XF498, and HCT15) in vitro. Compounds 1 and 2 showed moderate cytotoxicities against L1210, whereas they showed weak activities against human cancer cell lines. However, compound 3 exhibited potent cytotoxic activities both in murine and in human cancer cell lines.

Mutation analysis of PTEN/MMAC1 in acute myeloid leukemia

Recently, a putative tumor suppressor gene, PTEN/MMAC1, has been identified at chromosome 10q23.3, which encodes a 403 amino acid dual-specificity phosphatase containing a region of homology to tensin and auxillin. Somatic mutations of the PTEN/MMAC1 gene have been identified in a number of cancer cell lines and primary cancers. Mutations in PTEN/MMAC1 are most frequently found in advanced cancers. To evaluate the role of the PTEN/MMAC1 gene in leukemia, bone marrow and/or peripheral blood from 62 acute myeloid leukemia (AML) patients, 5 hemopoietic cell lines (HL60, U937, Raji, KG-1, K562), and 30 normal controls were analyzed. The results showed aberrant PTEN/MMAC1 transcripts in 15 of the 62 (24%) AML patients, 4 of the 5 cell lines (80%), and 4 of the 30 (13%) normal controls. As in our previous study of TSG101, the abnormal transcripts may result from aberrant RNA splicing as evidenced by the presence of both these aberrant transcripts and normal full length transcripts in all specimens examined. Loss of heterozygosity (LOH) analysis and PCR-SSCP of the entire coding region showed that none of the AML cases had LOH or mutation. Only one frameshift mutation at codon 130 (insertion of CCCG) with premature termination of coding sequence was observed in the U937 cell line. Our results indicate that the PTEN/MMAC1 gene may play a role in a small percentage of AML, but its significance needs to be further evaluated.

Congenital anomalies in patients with Duane retraction syndrome and their relatives

PURPOSE

Although the high incidence of skeletal, neural, and other ocular problems has been identified in previous reports of large cohorts of patients with Duane syndrome, there has not been any documentation of anomalies in close relatives. Patients with Duane syndrome have a greater than 50% incidence of associated abnormalities that include deafness, other ocular anomalies, cranial nerve palsies, and skeletal abnormalities. This study was undertaken to review the experience of our strabismus service with patients who have Duane retraction syndrome (DRS) and to delineate the associated anomalies in them and their first-degree relatives.

METHODS

A prospective study of all patients with Duane syndrome who were seen at the strabismus service at Moorfields Eye Hospital has been ongoing for the last 4 years. All patients were assessed for the presence of ophthalmologic features of DRS and then referred to the pediatric service for a physical and neurologic examination. First-degree relatives were also examined, and a family pedigree was generated.

RESULTS

We have evaluated 68 patients with DRS, of which 60.2% were female patients. The left eye was involved at a ratio of 4:1 in unilateral cases. The number of bilateral cases was 57.3%. Among the patients with DRS, 46% had first-degree relatives with associated abnormalities.

CONCLUSIONS

The high incidence of associated anomalies in patients and first-degree relatives may suggest that a common genetic defect is responsible. This has to be confirmed with molecular genetic studies, which were not performed on these families because of a lack of available resources. However, our findings may indicate that the inheritance of Duane syndrome is much higher than the 10% previously reported, if any congenital abnormality is accepted as DRS associated. Children with Duane syndrome may benefit from a full medical assessment, in view of the frequency of other abnormalities, and so may their siblings.