De novo facioscapulohumeral muscular dystrophy defined by DNA probe p13E-11 (D4F104S1)

Facioscapulohumeral muscular dystrophy (FSHD) is an autosomal dominant condition with variable age of onset and severity. Identification of a de novo DNA fragment by probe p13E-11 (D4F104S1) established the diagnosis of new mutation FSHD in 27 of 31 sporadic cases. The clinical data for these certain new mutation cases were as follows: 13 boys, 14 girls; mean age of onset 6.8 years; significant leg weakness in 19/27 (70%) (8/27 (30%) used wheelchairs at a mean age of 17.7 years); high tone sensorineural deafness in 10/27; visual acuity and direct ophthalmoscopy were normal. Congenital facial diplegia and sensorineural deafness in three children suggest that infantile FSHD is not a genetically separate disorder from FSHD. Ascertainment bias may explain the difference in severity between this group and typical familial cases. Molecular analysis for FSHD should be considered in children with either congenital or early onset facial weakness or diplegia.

Molecular analysis of British facioscapulohumeral dystrophy families for 4q DNA rearrangements

Facioscapulohumeral muscular dystrophy is an important autosomal dominant neuromuscular disorder that has been localised to 4q35. We have analysed our extensive panel of 45 families with a new DNA marker p13E-11. The findings, based on multiply informative individual meioses and multipoint mapping, suggest that probe p13E-11 is the closest marker for the disorder and it is likely to be located proximal to the disease locus as are all the other present markers. In nine of the ten new mutations studied, a new smaller EcoRI fragment which was not present in either of the parents was detected, indicating that a de novo DNA rearrangement is indeed associated with the development of the disease state. However, in view of the difficulty in defining the size of over 30kb alleles and the recombinant events observed with p13E-11, we suggest that it should be used in combination with another VNTR marker until a close distal flanking marker for this condition is identified or the gene itself is isolated.

Analysis of mutations at the neurofibromatosis 1 (NF1) locus

A panel of 200 unrelated NF1 individuals has been screened for mutations using a panel of specific clones for the entire gene. DNA analysis on conventional Southern blots indicated that (20) 10% of NF1 patients showed aberrant bands. Small lesions involving nucleotide alterations were detected in a further 10 patients; 5 of these alterations have been fully characterised and are the novel mutations in the NF1 gene. A number of mutations were identified in exon 2. Identical mutations in this exon in two unrelated individuals involved an insertion of cytosine into codon 5662 and resulted in an inappropriate stop codon. This mutation also created a new MnlI site. Another novel mutation in exon 2 resulted from the insertion of thymidine at nucleotide 5678, which also created an inappropriate stop codon. We have so far completed the screen of exons 1-9 of the NF1 gene for the identification of mutations and have found no evidence of clustering of such mutations in the gene.

Prioritising waiting lists

The 'top 22' patient conditions on the general surgical waiting list at Guy's Hospital were rated independently by five general surgeons. Each surgeon estimated the peri-operative mortality rates associated with each treatment; the proportion of patients who failed to benefit; the effect of successful treatment on life expectancy and on the patients' quality of life. the mean values were used to estimate the expected net benefits (in terms of quality-adjusted life-years) from treatment one year earlier than might otherwise have been the case. These benefits were then related to the operating times and length of stay associated with each treatment; this identified which treatments offered the greatest benefit per unit of each constrained resource. Of all conditions examined anal fissures where shown to be the least resource intensive in relation to the benefits generated, whilst varicose veins and epigastric hernias proved otherwise. For the full potential of this approach to be realised it needs to be repeated in other places and in other specialties. It nevertheless offers a more rational basis for interpreting waiting list data than presently exists and by using the short-cut methods is a relatively cheap way of generating much useful data.

An improved technique for in situ esophageal myotomy and proximal pouch mobilization in patients with esophageal atresia

The use of a modified endotracheal tube in the mobilization of the upper pouch in patients with esophageal atresia is described. While aiding mobilization in all patients the tube was particularly helpful in the performance of circular myotomy where this was necessary. The tube and the operative technique are described.

Hereditary xanthinuria in 2 Pakistani sisters: asymptomatic in one with beta-thalassemia but causing xanthine stone, obstructive uropathy and hypertension in the other

We describe a 3-year-old Pakistani girl who presented with recurrent urinary infections. She had a nonfunctioning hydronephrotic right kidney and hypertension. At operation a calculus was impacted in the right ureter with dilatation of the pelviocaliceal system. Nephrectomy was performed. Histology revealed end stage pyelonephritis. The calculus consisted of pure xanthine. Further investigations demonstrated low serum uric acid and absent urinary uric acid with increased excretion of xanthine. Eight months after nephrectomy blood pressure had decreased to normal. Her 5-year-old sister, who has beta-thalassemia, also has a low serum uric acid concentration and xanthinuria. The treatment of choice is to increase fluid intake so that the urine xanthine concentration remains below the level at which xanthine crystallizes. This may require adjustment of the urine pH.

Long-term renal risk factors in children with meningomyelocele

We studied renal function and structure in 42 patients with meningomyelocele, 28 treated with intermittent catheterization and 14 with ileal loop diversion. Patients were observed for a minimum of 60 months. Nine of the 28 patients who underwent intermittent catheterization had evidence of unilateral or bilateral reflux, and all patients with ileal loop diversion had free ureteral reflux. Bacteriuria was present in 38% +/- 5% of cultures obtained from patients with catheterization and in 70% +/- 7% of cultures from those with diversion (P less than 0.001). Four (14%) of 28 patients with catheterization had worsening renal function or anatomic appearance by intravenous pyelogram, and required a diversion. Three (28%) of 14 patients with diversion had changes in renal structure or function. Eight of 31 patients from both groups studied with voiding cystourethrography before the onset of therapy had small, noncompliant, trabeculated bladders; all seven patients who had worsening in function or anatomic appearance were from this subset (P less than 0.01). None of the patients with flaccid or distensible bladders demonstrated these changes. Renal disease was unrelated to the level of neurologic function. A small, noncompliant, trabeculated bladder is a risk factor associated with loss of renal function in patients with meningomyelocele.

Ultrastructural evaluation of biochemical events of bone resorption in human chronic otitis media

Bone resorption is a significant component of chronic inflammatory ear disease. Bone is a unique tissue requiring both demineralization and collagen degradation for breakdown. Mineral removal probably occurs prior to collagen destruction. A localized change in pH may be one of the mechanisms that induces demineralization. Localized accumulations of lysosomal acid hydrolases could provide the acidic environment necessary for mineral removal. The present study utilizes the electron microscope to localize the lysosomal enzyme acid phosphatase in specimens removed from patients with chronic otitis media. Areas of localized bone resorption exhibited mononuclear inflammatory cells attached to the resorption margin. These cells contained abundant acid phosphatase, as did isolated fibroblasts within the zone of inflammation at the resorption margin. Extra cellular acid phosphatase was seen in these areas. Within the bone, osteocytes adjacent to resorption displayed increased cytoplasmic organelle patterns and contained the acid phosphatase reaction. The localization of destructive enzymes in mononuclear inflammatory cells and osteocytes explains the bony destructive changes observed in human chronic otitis media in the absence of multinucleated osteoclasts.

Lymphangitis carcinomatosa

A case of lymphangitis carcinomatosa secondary to a primary gastric adenocarcinoma is reported. Diagnosis was suspected clinically and radiologically, but was established only at autopsy. The condition is reviewed. When suspected, transbronchial lung biopsy would allow histological confirmation of the diagnosis.

Bone resorption in chronic otitis media

Bone resorption is an important aspect of chronic otitis media contributing to many complications of this disease. It is postulated that the mechanism of this localized destructive process is chemical in origin. Collagenase, lysosomal enzymes, prostaglandins, and other cell mediators are thought to induce bone resorption, but the site of action and cellular origin of these substances remains unclear. In this report, we demonstrate the location and attempt to delineate the cellular origin of two enzymes, collagenase and the lysosomal enzyme acid phosphatase in guinea pig temporal bones and human ossicles from ears containing chronic otitis media. Tissue localization of these enzymes identifies sites of active bone resorption and demonstrates the cells initiating this process. Using immunohistochemical and immunocytochemical techniques, collagenase was seen surrounding mononuclear inflammatory cells of granulation tissue at bone resorbing margins and at the periphery of osteocyte lacunae adjacent to resorbing areas. Electron microscopic data suggests that collagenase is an extracellular enzyme foun at the periphery of osteocytes. In addition, abundant acid phosphatase activity was seen in the same cells that exhibited collagenase staining, lending credence to the destructive function of these cells. The chronic inflammatory reaction found in chronic otitis media appears to activate bone destruction through the dynamic activity of mononuclear inflammatory cells and stimulates bone cells to increase their destructive biochemical functions.

Recurrent swellings of the parotid gland, sialectasis and Mikulicz's syndrome

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Visual and automated differential leukocyte counts. A comparison study of three instruments

The authors compared referee (senior author) microscopic counts, microscopic counts by several technologists, and counts obtained with two pattern-recognition leukocyte classifiers, (1) Larc and (2) Hematrak, and a cytochemical automated method for leukocyte counting, (3) Hermalog D, using samples from (1) a random patient population, (2) a selected abnormal patient population, and (3) healthy individuals. All instruments showed good accuracy and flagged abnormal results for review. Variability in pattern-recognition counts was found to be due mainly to the distribution of the cells on prepared blood smears. The Larc classifier was found to be very sensitive to minor alterations in the cytoplasm or nucleus, and rejected a number of slides. The Hemalog D showed the greatest precision. The method of preparation of slides would be a major decision factor in selecting one pattern-recognition instrument over another.

Third component, HBeAg/3, of hepatitis B e antigen system, identified by three different double-diffusion techniques

A third component, HB(e)AG/3, of the hepatitis B e antigen system has been detected, and it was consistently detected in three variations of the double-diffusion technique.