A case of familial popliteal pterygium syndrome: early surgical intervention for successful treatment

A 2-year-old boy presented at our hospital with severe familial popliteal pterygium syndrome with extensive skin webbing from thigh to heel and severely reduced range of motion of the knee and ankle joints. For accomplishment of knee extension, the patient underwent surgery with resection of the fibrous bands, freeing of the sciatic nerve, Z-lengthening of the Achilles tendon and multiple Z-plasties. One year after surgery, the patient can put his heel on the ground and has almost complete range of motion in the knee and ankle joints.

Pre-emptive surgery and increasing demands for technical perfection

Challenging times for surgeons

Hereditary gingival fibromatosis: a case report

BACKGROUND/AIMS

Hereditary gingival fibromatosis is characterized by various degrees of attached gingival overgrowth. It usually develops as an isolated disorder but can be one feature of a syndrome. A case of a 38-year-old female is reported who presented a generalized severe gingival overgrowth, involving the maxillary and mandibular arches and covering almost all teeth. The clinical differential diagnosis included drug-induced overgrowth as well as idiopathic gingival fibromatosis.

TREATMENT

Excess gingival tissue was removed by conventional gingivectomy. As the gingival enlargement was generalized to all quadrants, on both sides, the surgery was carried out under general anaesthesia. The postoperative course was uneventful and the patient's appearance improved considerably. Post-surgical follow-up after 20 months demonstrated a slight recurrence

CONCLUSIONS

Hereditary gingival fibromatosis is a rare disorder characterized by the proliferative fibrous overgrowth of the gingival tissue. Resective surgery of the excess tissue is the treatment available. However, recurrence is a common feature.

Congenital diaphragmatic hernia in 120 infants treated consecutively with permissive hypercapnea/spontaneous respiration/elective repair

BACKGROUND/PURPOSE

Poor prognosis (approximately 50% survival rate and significant morbidity) traditionally has been associated with congenital diaphragmatic hernia (CDH). The authors reviewed a single institution experience and challenged conventional wisdom in the context of a care strategy based on permissive hypercapnea/spontaneous respiration/elective repair.

METHODS

From August 1992 through February 2000, all infants with CDH and (1) respiratory distress requiring mechanical ventilation, (2) in-born or (3) transferred preoperatively within hours of birth are reported. All respiratory care strategy used permissive hypercapnea/spontaneous respiration and combined with elective repair. Arterial blood gas values and concomitant ventilator support were recorded. Outcome markers were (1) need for extracorporeal membrane oxygenation ECMO, (2) discharge to home, (3) supplemental oxygen need at discharge, and (4) influence of non-ECMO ancillary therapies (surfactant, nitric oxide, high-frequency oscillatory ventilation).

RESULTS

One hundred twenty consecutive infants were reviewed. Overall survival rate was 75.8%, but, excluding 18 of 120 not treated (6 lethal anomalies, 10 overwhelming pulmonary hypoplasia, 3 prerepair ECMO-related neurocomplications), 84.4% survived to discharge. A total of 67/120 were inborn. Non-ECMO ancillary treatments had no impact on survival rate. ECMO was used in 13.3%. Surgery was transabdominal; prosthetics were used in 7%. Tube thoracostomy was rare. Every inborn patient (n = 11) requiring a chest tube for pneumothorax died. Respiratory support before surgery was peak inspiratory pressure (PIP), 22, FIO(2),.43 with PaO(2), 66 torr; PaCO(2), 41 torr; and pH, 7.32. The survivors discharged on oxygen (n = 2) died at 4 and 7 months.

CONCLUSIONS

The majority of infants with life-threatening CDH treated with permissive hypercapnea/spontaneous respiration/elective surgery survive to discharge with minimal pulmonary morbidity.

Cellular and molecular neurosurgery: pathways from concept to reality--part I: target disorders and concept approaches to gene therapy of the central nervous system

Recent advances in cellular and molecular biology and better understanding of genetic and biochemical bases of different central nervous system (CNS) disorders have made gene therapy of the CNS a realistic goal. Concept approaches for gene therapy of CNS disorders are reviewed and include the following: 1) gene replacement with a single normal allele to correct the inherited global neurodegenerative disorders, such as enzyme deficiencies; 2) brain repair to restore the function of a particular subset of cells that were lost because of a neurodegenerative process; 3) gene therapy of brain tumors; and 4) gene therapy of stroke. Techniques of viral vector-mediated CNS transfer of a therapeutic gene, transplantation of genetically modified cells, fetal embryonic implantation and/or implantation of genetically engineered neural progenitor cells, and production of a specific enzyme, neurotransmitter, and/or growth factor are discussed with respect to the therapeutic potential for global and localized CNS neurodegenerative disorders and stroke. Transfection of the CNS tumor cells with the drug susceptibility ("suicide") gene and/or "toxic" gene and antisense strategies and a concept of adoptive immunotherapy of brain tumors are also discussed. Other approaches, such as transfer of drug-resistant genes and monoclonal antibody gene transfer, are briefly discussed. In addition to summarizing current principles of gene therapy for several groups of CNS disorders, the issues that remain to be resolved in clinical reality, such as delivery of the genetic material and regulation of the cellular expression of the transgene, and the negatives associated with the concepts of gene therapy, such as transient gene expression, toxicity of viral proteins, drawbacks of antisense therapy, and the problem of immune response to the transfected protein, have been also identified.

[Current problems in pediatric bone marrow transplantation]

Bone marrow transplantation (BMT) has been increasingly applied to a variety of potentially fatal diseases in childhood. However, trends of indication of BMT are changing because chemotherapy in leukemia and immunosuppressive therapy with/without colony stimulating factor in aplastic anemia are improving. Several progresses have been noted in matched unrelated BMT and peripheral blood stem cell transplantation as well as in sibling BMT or autologous BMT. Many efforts are being made to decrease rejection rate or leukemia relapse and to improve quality of life by new conditioning regimens. Attempts to induce GVL effects or syngeneic GVHD are currently under progress. The quality of life in long term surviving children are generally good and acceptable, although delay in growth, infertility, cataract and obstructive lung disease are seen in a few patients.

Recent developments in experimental bone marrow transplantation

Animal models have been a mainstay for the preclinical evaluation of the principles of bone marrow transplantation. In addition to evaluation of the therapeutic effectiveness of bone marrow transplantation in oncologic, hematologic, immunologic, and genetic diseases, experimental animal models provide insights into the immunobiology of bone marrow transplantation, including engraftment kinetics, tolerance, immune reconstitution, and graft-versus-host and graft-versus-tumor reactions. Many recent developments in experimental bone marrow transplantation resulted from not only the discovery of new spontaneously occurring models of human diseases but also the induction of neoplastic diseases, eg, chronic myelogenous leukemia, by transplantation of syngeneic marrow cells into which foreign genes were introduced and expressed. Murine bone marrow transplantation systems are an exemplary format for the study of clinically relevant basic aspects of hematopoiesis, including identification and elucidation of the biology of hematopoietic stem cells. Finally, the application of molecular biologic techniques in animal bone marrow transplantation models provides the preclinical foundations of gene-insertion therapy by transplantation of syngeneic or autologous marrow-derived stem cells into which functional genes were inserted.

Results of bone marrow transplants from human leukocyte antigen-identical sibling donors for treatment of childhood leukemias. A report from the International Bone Marrow Transplant Registry

PURPOSE

Bone marrow transplantation is an effective treatment for leukemia. Cures are possible in 20-80% of transplant recipients depending on the stage of leukemia at the time of transplant. The antileukemia efficacy of transplants result from high-dose chemotherapy and/or radiation given pretransplant and from immune-mediated effects of the graft.

RESULTS

Success of the procedure is limited by transplant-related complications, including graft rejection, graft-vs.-host disease and interstitial pneumonia. Five-year leukemia-free survival ranges from approximately 25% for children transplanted with advanced leukemia, to > 60% in those transplanted in first remission of acute leukemia or first chronic phase of chronic myeloid leukemia.

CONCLUSIONS

Candidates for transplant include children failing conventional therapy and, possibly, those with early leukemia characterized by features predicting a poor response to conventional therapy.

Autoantibodies after bone marrow transplantation in children with genetic disorders: relation to chronic graft-versus-host disease

The occurrence of autoantibodies and their relation to chronic graft-versus-host disease (GVHD) have been studied in children, 100 days or more following allogenic bone marrow transplantation (BMT), mainly performed for a variety of genetic disorder. Seventeen of 40 patients had autoantibodies to thyroid microsomes, compared with none of 46 control children of similar age (p less than 0.001). The presence of these antibodies was strongly associated with chronic GVHD (14 of 20 patients), p = 0.001. IgG antibodies to the cytoplasm of squamous epithelial cells were demonstrated in 15 of 36 children following transplantation (p less than 0.001), none being found in 46 normal children. The incidence and titre of these antibodies were significantly higher in patients with chronic GVHD (p = 0.041 and p = 0.019 respectively). Despite there being a significant number of patients with antibodies to nuclei, smooth muscle and gastric parietal cells, these autoantibodies were not related to the presence of chronic GVHD. Although the mechanism of production is not known, antibodies to thyroid antigens and the cytoplasm of squamous epithelial cells may be useful markers for GVHD.

Enzymes as agents for the treatment of disease

The replacement of genetically deficient enzymes in patients with inherited metabolic disorders by infusion of purified enzymes or by organ transplantation has had very limited success, although good results with bone marrow transplantation have been obtained in some patients with mucopolysaccharidosis, Gaucher disease and inherited immunodeficiency diseases. Genetic engineering of the patient's lymphocytes may ultimately render these approaches redundant, at least for some of these diseases. Treatment of chronic pancreatic insufficiency and of disaccharidase deficiency with oral enzymes can be very effective; therapy can be monitored in the latter by measuring the breath hydrogen excretion and in the former by a range of tests of which stool chymotrypsin assay is the most convenient. Treatment of acute myocardial infarction by intracoronary perfusion of thrombolytic enzymes can improve both cardiac function and long-term survival if given early enough. Successful reperfusion can be identified by changes in the kinetics of serum enzyme release and clearance, especially for the isoenzymes and isoforms of creatine kinase. In cancer chemotherapy, L-asparaginase has long been a useful adjunct in the treatment of acute lymphoblastic leukemia, but recent experience suggests a role in acute nonlymphoblastic leukemia as well.

The child conceived to give life. The point of view of the hematologist

The different modalities of stem cell transplantation and the indication of each of them are briefly discussed. Transplantation can be successfully applied in hematologic diseases or in congenital disorders.

Bone marrow transplantation for the treatment of genetic diseases

Consideration of a bone marrow transplant (BMT) for a child with a genetic disease depends upon many factors including the pathophysiology of the disorder, the natural history of the disease, whether an alternative therapy exists and whether a donor is available. Children with disorders such as severe combined immunodeficiency disease (SCID), in which life expectancy is minimal, are obviously candidates for a BMT, even with less than optimal donors, while those with disorders such as beta-thalassemia major, in which an alternative therapy exists, must be considered more carefully and only with an optimal donor. The risks of conditioning therapy, graft-versus-host disease (GVHD), and early death as well as the cost are critical to this decision and must be viewed in light of the potential outcome of a successful BMT and the life expectancy and quality of life with a BMT. For some genetic diseases with multisystem involvement (e.g., Hurler's mucopolysaccharidosis), the efficacy of a BMT has been reasonably demonstrated, providing significant brain damage has not occurred previously. For some other storage-related diseases, there is no place for BMT. Further studies are essential to increase our knowledge as to its potential role in other types of genetic-associated diseases.

Bone marrow transplantation for genetic disorders

In 1967, a congenital disorder, severe combined immune deficiency disease, (SCID), was the first condition to be successfully corrected by bone marrow transplantation (BMT) from a histocompatible matched sibling donor. Since then the number of inherited disorders in which BMT has been used has been greatly extended. In preface, it should be stressed that BMT represents only one aspect of the management of genetic disorders which includes first and foremost detection and prevention by antenatal screening. Enzyme replacement treatment and the development of genetic engineering techniques to correct the underlying fault are being actively explored. However, reliable screening programmes are only feasible in a minority of disorders, of which thalassaemia is an example. Enzyme replacement treatment has been largely unsuccessful, and despite considerable advances in the understanding of gene regulation, at present BMT represents the only practice capable of correcting genetic disorders and improving the quality of life of affected individuals.

Bone marrow transplantation for genetic diseases

Bone marrow transplantation is the treatment of choice for a number of genetic diseases. Recently, bone marrow transplantation has been increasingly used for erythroid disorders, such as thalassemia and sickle cell anemia. A number of inherited metabolic disorders (i.e., storage diseases, leukodystrophies, and the like) may be corrected with a marrow transplant. Successful correction of genetic diseases with allogeneic bone marrow transplantation lays the groundwork for the use of specific gene therapy.