Evidence for compound heterozygosity causing mild and severe forms of autosomal recessive spinal muscular atrophy

Spinal muscular atrophy is an autosomal recessive disease of motor neurone degeneration which shows a variable phenotype. Two candidate genes show deletions in affected subjects but with no distinction between different forms of the disease. We report an unusual family in which mild and severe SMA coexists and patients are deleted for the SMN gene. The father is affected with late onset SMA; therefore this family shows pseudodominant inheritance. When typed using closely linked flanking markers the severely affected son does not share the same haplotype as his sib, who is deleted for SMN but shows no signs yet of SMA. This supports the hypothesis that differences in SMA phenotype can be explained by a multiple allele model.

[Endoscopic hernia surgery (TAPP)--gold standard in management of recurrent hernias?]

From April 1993 to December 1995 210 TAPP procedures were performed because of recurrent hernia. With the TAPP method there is no difference between primary and recurrent repair. All procedures in this study were done with general anaesthesia by senior surgeons. The learning curve shows a reduction of operation time (60 to 55 min) with increasing experience and a reduction in complications as well (total 4.3%). Recurrence was observed in two cases. The reasons for these recurrences were technical failures during the previous repair. In both cases a second TAPP repair was carried out successfully. The main advantage of TAPP in recurrent hernia is that this method gives possibilities to avoid anterior scar tissue. Secondly tension-free repair can be combined with the benefit of the minimal access technique. For this reason, the TAPP procedure must be considered the method of choice in recurrent hernia repair.

Total gastrectomy. Updated operative mortality and long-term survival with particular reference to patients older than 70 years of age

OBJECTIVE

The authors conducted a study of patients who underwent total gastrectomy for gastric malignancy to elucidate contributing factors that lead to successful management of this disease in geriatric patients.

SUMMARY BACKGROUND DATA

The average mortality rate for patients undergoing stomach surgery due to carcinoma is 7.8% according to the literature overview, still relatively high. Even higher mortality rates are observed for geriatric patients after a total gastrectomy. Because of epidemiologic changes, a total gastrectomy is required with growing frequency in these high-risk patients.

METHODS

The study involved 380 patients with a gastric malignancy. Risks and benefits of a total gastrectomy with radical lymphadenectomy at an advanced age were analyzed retrospectively in 163 patients older than 70 years of age. The results achieved in these patients were compared with those observed in 217 younger patients.

RESULTS

The 30-day mortality and morbidity rates for the elderly patients were 3% and 33.7%, respectively; for the younger patients, they were 0.46% and 21.2%, respectively. A statistically significant correlation was found between the presence of risk factors, the occurrence of complications, and the mortality rate. No difference was seen between the two age groups when risk factors were absent. The 5-year survival rate was 30%, with no difference between young and elderly patients.

CONCLUSIONS

The data prove that a total gastrectomy with a radical lymphadenectomy can be carried out safely in older patients, with long-term results comparable to those achieved in younger patients.

Studies on nutritional status in general surgery patients by clinical, anthropometric, and laboratory parameters

We assessed the nutritional status of general surgery patients with and without cancer from a western European population in this prospective study. Anamnestic (weight development, abdominal complaints) and anthropometric (fat tissue measurements) data were collected on six groups of patients: cancer of the stomach (n = 13), pancreas (n = 13), colorectal (n = 23), breast (n = 12), and two control groups with benign diseases, ages 20-45 and 50-75 y. From these data, body mass index and ideal body weight were calculated. Concentrations of albumin, transferrin, retinol-binding protein, prealbumin, and creatinine height index were determined by biochemical tests. A weight loss of more than 10% was found in only 31% of gastric and 61% of pancreatic cancer patients. Significant values from anthropometric data were also found only in these groups. In biochemical tests, only the creatinine height index was reduced in all patients with pancreatic cancer. The remaining laboratory changes were so unspecific in all other parameters that no conclusions could be drawn as to the status of the patient's nutritional condition. For the evaluation of nutritional status, only relatively simple and inexpensive anamnestic and anthropometric measurements are necessary.

Parental source effect on inherited mutations in the dystrophin gene of mice and humans

Skewed X inactivation has been suspected as the genetic cause for some female carriers of Duchenne/Becker muscular dystrophy (DMD/BMD) presenting symptoms [1], as well as in manifesting females in other X-linked recessive diseases. No clear “parental source effect” – a difference in phenotype depending upon transmission of the mutated allele by either the father or the mother – has been observed [Cremer]. To date, most studies in this field have analysed the methylation status of flanking polymorphic sites (a measure of the maintenance of X inactivation and imprinting), not the expression of the causal gene itself.

To test the parental source effect on the protein expression of the dystrophin gene, we have set up crosses of mdx/mdx and mdx/y mice – the well-known DMD animal model [2] with the respective wild-type mice of the same strain (Table 1). The obligate heterozygous F1 females show a mosaic expression of dystrophin in skeletal and cardiac muscle upon immunehistological staining. Because the source of the mutation in the litters is well defined, the mosaic pattern should reflect a parental source effect, if any. Such an effect should also change the level of muscle enzymes in serum and may thus be easily testable in humans, too. Since DMD is genetically lethal in humans, one can test the hypothesis of a parental source effect in BMD families only.

[Quality assurance in goiter surgery by rate of recurrent nerve paralysis]

We analyzed the results of 1147 thyroid operations performed at a teaching hospital over a period of 3 years. These results were submitted to an internal quality control. We studied the factors that influenced the surgical complication rate and particularly the rate of a palsy of the recurrent laryngeal nerve. Operations of 'simple' goitres showed only a very low risk of post-operative complications whereas the risk for patients with Graves' disease, a carcinoma or a recurrent goitre was a markedly higher. The rate of a permanent palsy of the recurrent laryngeal nerve was just 0.5% for a simple goitre but as high as 7.8% for a relapse. Not just the underlying disease but the surgeon and his surgical technique play an important role in the incidence of a palsy of the recurrent laryngeal nerve. If a sophisticated surgical technique is applied without exposing the recurrent laryngeal nerve but leaving the fascial layer that covers the nerve and the vessels of the throat intact, there are no differences between the results of these operations and such where the nerve is routinely demonstrated. The follow-up of the patients with recurrent nerve palsy showed a medium recovery time of half a year. In one of six patients with temporary palsy the restitution was seen after more then one year.

Oxyradical damage and mitochondrial enzyme activities in the mdx mouse

A number of studies have already been undertaken to investigate involvement of oxyradicals in muscle diseases by means of measurements of oxyradical protective enzymes. We investigated o-tyrosine, which is a biomarker for OH radical damage in vivo, in 10 mdx and 10 control mice. We also measured mitochondrial enzymes in muscle homogenates of 10 mdx and 10 control mice. Mdx mice had significantly elevated values for o-tyrosine, succinat-phenacinmetosulfat oxidoreductase. NADH O2 oxidoreductase and cytochrome C oxidoreductase. Our findings confirm the suggestion that elevated oxyradical production occurs in muscular dystrophies with lack of dystrophin. Furthermore, our results demonstrate that OH radical damage does not impair mitochondrial enzyme activities in the mdx mouse.

[Standardized laparoscopic hernioplasty vs. Shouldice repair. Results of a randomized comparative study]

From 5/93 up to 12/93 a prospective randomized trial was performed. 102 patients with unilateral primary inguinal hernias were included. In 48 patients a Shouldice repair and in 54 patients a laparoscopic TAPP procedure was performed. The laparoscopic method is described. There were significantly less pain and quicker mobility in the laparoscopic group. In addition a shorter period of disability of work was seen (21 vs. 38 days) in the same group. The morbidity of the procedures was as low in the Shouldice as in the laparoscopic group. There was a regular control of all patients. The current follow-up period is 16 months (13-21) in median. In both groups there were no recurrences up to now. The efficiency of laparoscopic hernia repair is discussed.

[Surgical and drug therapy of metastatic gastrinoma. Successful palliation over the course of 2 1/2 years]

A midaged lady suffering from ulcer disease for about seven years had undergone several surgical and drug therapies without any satisfying success. Then the diagnosis of a gastrinoma was made. By this time there were already multiple liver metastases. First the large supposed primary tumor of the pancreas was resected and within six months later the resection of the progressing liver metastases became necessary because of local tumor complications. The additional drug therapy with octreotide (Sandostatin) given three times daily subcutaneously prevented further tumor progress. Until now this combination of surgical and medical treatment has proved to be a successful palliative method of treating the malignant gastrinoma for 2.5 years.

Clinical significance and management of pancreatic abscess and infected necrosis complicating acute pancreatitis

Secondary pancreatic infections are most serious and life threatening complications of acute necrotizing pancreatitis. The risk of secondary infection is to a large extend related to duration and extension of pancreatic or peripancreatic necrosis. The combination of abdominal CT-scan with guided percutaneous needle aspiration has been demonstrated to be highly reliable on differentiating between sterile and infected pancreatic necrosis. Previous results suggest a major role of enteric pathogens in this disease. Due to the type of microorganisms and the defence capacity of the patient, the pancreatic infection might result in either elimination of the microorganism, unlimited propagation within devitalized tissue (infected necrosis) or they may remain localized (abscess formation). Though the most fulminant course of acute pancreatitis is found in patients with early infected necrosis. In these cases an operation is usually necessary within 14 days after onset of symptoms. Persistence or new development of typical symptoms two to five weeks after initial improvement should raise the suspicion of abscess. The finding of infection is an absolute indication for surgical intervention. The intention of surgical treatment in combination with antibiotic therapy is to remove devitalized pancreatic and peripancreatic tissue, evacuate all purulent material and provide continuous drainage either by lavage or "open" abdominal treatment. In this article basic procedures of diagnosis and therapy are discussed.

[Juxtapapillary intraduodenal lipoma as a rare cause of jaundice and acute pancreatitis]

A 52-year-old man was admitted to hospital with acute pancreatitis and jaundice. The patient's medical history showed a case of hospitalization due to acute pancreatitis about three years before. Diagnostic examinations (abdomen sonography, CT, contrast medium radiography of the small intestine, ERCP) revealed a juxtapapillary lipoma, approximately 1 by 6 cm, obstructing the papilla Vateri. After the examinations had been completed and the pancreatitis had largely eased off, the lipoma was removed by transduodenal surgery. There were no postoperative complications.

[The lost gallstone--complication after laparoscopic cholecystectomy]

In this case report a persisting fistula between the right flexure of the colon and the abdominal wall was observed after a laparoscopic cholecystectomy. This was caused by a lost gallstone and eventually resulted in the resection of a colon segment. As a consequence of this case it can be said that intra-abdominally lost gallstones--especially larger ones--have to be recovered completely. In risky cholecystectomies we should consider the use of a laparoscopic bag or the installation of additional working cannulas.

Glucose homeostasis and endocrine pancreatic function in patients with chronic pancreatitis before and after surgical therapy

In a prospective clinical-experimental study, 15 consecutive patients with chronic pancreatitis, operated on because of severe pain, were examined for the effects of a duodenum-preserving resection of the pancreas head on endocrine pancreas function. This was done by means of oral and intravenous glucose tolerance testing before the operation, on the 10th or 11th day postoperatively, and 3 months after the operation. In addition to glucose levels in the peripheral venous blood, levels of insulin, C-peptide, glucagon, and pancreatic polypeptide were determined. As indicated by the k value, glucose tolerance improved postoperatively in 10 patients (66.6%); three patients (19.9%) showed no change, and one patient (6.6%) was worse. Only one patient (6.6%) developed evident diabetes mellitus immediately postoperatively. Pre- and postoperative levels of insulin and C-peptide showed no significant differences. The fasting levels of glucagon were significantly lower postoperatively than before the operation (p < 0.01). The stimulation of pancreatic polypeptide after oral glucose was significantly lower postoperatively (p < 0.01). Duodenum-preserving pancreas head resection does not lead to an impairment of glucose tolerance in the majority of patients; a deterioration was observed only in few cases (13.3%).

[Incarcerated scar hernia in an adjacent channel after laparoscopic cholecystectomy--a rare complication?]

The rare case of a postoperatively incarcerated cicatricial hernia in an auxiliary instrument channel after laparoscopic cholecystectomy is reported. To avoid such a complication one should: 1. Oblique insertion through the abdominal wall of all operation trocars. 2. Placing the lateral auxiliary instrument channel through the straight abdominal muscle under consideration of the epigastric vessels instead of going through the white line.

Occurrence of Andermann syndrome out of French Canada--agenesis of the corpus callosum with neuronopathy

We report on two siblings, a boy and a girl, with agenesis of corpus callosum and neuronopathy. The children show diffuse hypotonia, delayed motor and mental development. Neurophysiological examinations revealed reduction of the motor nerve conduction velocity, absence of sensory nerve action potentials, abnormal somatosensory and visual evoked potentials. Nerve biopsies showed reduced density of myelinated and unmyelinated fibres in both children. We also found signs of hypomyelination and suggest this is secondary to degeneration of peripheral sensory and motor neurons. Our findings are consistent with the diagnosis of Andermann syndrome. This is the first report of the occurrence of Andermann syndrome out of French Canada.

The immune response to different doses of inactivated hepatitis A vaccine

The immunogenicity and reactogenicity of different doses of hepatitis A vaccine was studied in healthy adult volunteers. Vaccinees (105) were immunized with 6.25, 12.5 or 25 ng of HAV antigen, each dose administered at 0, 1 and 6 months (groups B, C and D); one group (group A) obtained three 6.25 ng doses at 0, 1 and 2 months. After one single dose high seroconversion rates ranging between 63 and 85% were observed in all four groups. All participants had seroconverted after the third dose, irrespective of the antigen content per dose and the vaccination schedule. Geometric mean titers after three doses were 439 IU/l (group A, month 3) and 1492, 963 and 2772 IU/l in groups B, C and D at month 7. One year after the first injection all vaccinees tested still showed antibody levels well above 10 IU/l. The vaccine was very well tolerated. Minor localized symptoms were observed mainly such as slight pain at the injection site. These symptoms were not dose related; no serious side effects occurred.

Time course of histomorphometric alterations in nerve grafts without connection to a muscle target organ: an experimental study in sheep

In 15 adult sheep, the saphenous nerve (28 +/- 1.8 cm) was used for ipsilateral or for cross-nerve grafting and was sutured to the proximal stump of the cut, motor-nerve branch of the vastus muscle. The distal end of the nerve graft was left without a target organ. Semi-thin cross sections of normal vastus nerves and saphenous grafts and of the distal ends of the grafts were analyzed by computer-assisted planimetry, 3, 6, 9, 12, and 18 months after the nerve-grafting procedure. Electronmicroscopy was also performed on specimens from the distal ends of the nerve grafts. Comparing the total number of myelinated nerve fibers in the distal end of the graft, the ipsilateral group showed an increase with time elapsed since nerve grafting, while the cross-over group showed a maximum after 3 and 6 months, and fewer fibers after longer periods of regeneration. Independent of the time passed since nerve grafting, the diameters of the myelinated nerve fibers were homogeneously thin in both experimental groups. Most interesting, the cross-nerve grafts did more poorly than the ipsilateral ones, even before they were influenced by the target muscle. With ultrastructural investigation, the ends of the grafts containing only a few myelinated fibers also showed a low number of unmyelinated fibers, but an increase of collagen fibers. The results have consequences for the clinical application of cross-nerve grafting.

[The effect of duodenum-preserving pancreatic head resection on the endocrine pancreas function in patients with chronic head pancreatitis]

In a prospective clinical-experimental study, 15 patients with chronic pancreatitis operated consecutively due to severe pain were examined for the effects of a duodenum-preserving resection of the pancreas head on endocrine pancreas function. This was done by means of oral and intravenous glucose tolerance testing before the operation, on the 10th or 11th postoperative day, and three months after the operation. In addition to glucose levels in the peripheral venous blood, levels of insulin, C-peptide, glucagon, somatostatin, and pancreatic polypeptide were determined. As indicated by the k-value, glucose tolerance improved postoperatively in 11 patients; two patients showed no change, and one patient was worse. Only one patient developed evident diabetes mellitus immediately postoperatively. The pre- and postoperative levels of insulin and C-peptide showed no significant differences. The fasting levels of glucagon were significantly lower postoperatively than before the operation (2p less than 0.01). Duodenum-preserving pancreas head resection led to improvement of the glucose tolerance in the majority of patients; a deterioration was observed only in two cases.

Vaccination against hepatitis A: comparison of different short-term immunization schedules

A total of 114 healthy young adults were immunized with hepatitis A vaccine using different vaccination schedules. Individuals received either a single dose (group 1), two doses given simultaneously (group 2), two doses at days 0 and 14 (group 3) or at days 0 and 28 (group 4), or three doses at days 0, 7 and 21 (group 5). Two weeks after a single dose, seroconversion rates between 77 and 85% were achieved (groups 1, 3, 4). All individuals immunized with two doses within two weeks (groups 2, 3, 5) had antibodies to hepatitis A vaccine (anti-HAV positive) by week 3; these participants also showed clearly higher mean anti-HAV values (geometric mean titres, GMTs) at this time than those individuals vaccinated only once. GMTs at week 8 were 560 IU/l in group 5, 236, 339 and 428 IU/l in groups 2-4 and 102 IU/l in group 1. Of participants with anti-HAV at week 8, 82 were again tested 4 months later; all were still seropositive. Ten individuals were tested during the first three weeks at 3-4 day intervals for anti-HAV immunoglobulin M (IgM); specific IgM responses were not detectable before day 10 but were present in eight of 10 vaccinees by day 14.

Lyme borreliosis as a cause of myocarditis and heart muscle disease

Lyme borreliosis (LB) is a multisystem disorder that may cause self-limiting or chronic diseases of the skin, the nervous system, the joints, heart and other organs. The aetiological agent is the recently discovered Borrelia burgdorferi. In 1980, cardiac manifestations of LB were first described, including acute conduction disorders, atrioventricular block, transient left ventricular dysfunction and even cardiomegaly. Pathohistological examination showed spirochaetes in cases of acute perimyocarditis. Recently, we were able to cultivate Borrelia burgdorferi from the myocardium of a patient with long-standing dilated cardiomyopathy. In this study, we have examined 54 consecutive patients suffering from chronic heart failure for antibodies to Borrelia burgdorferi. On ELISA, 32.7% were clearly seropositive. The endomyocardial biopsy of another patient also revealed spirochaetes in the myocardium by a modified Steiner's silver stain technique. These findings give further evidence that LB is associated with chronic heart muscle disease.

Total biliary protein, mucus glycoproteins, cyclic-AMP, and apolipoproteins in the gallbladder bile of patients with cholesterol stones and stone-free controls

The concentrations of total protein, mucus glycoprotein, cyclic-AMP, and apolipoproteins A-I, A-II, and B were determined in the gallbladder bile of patients with cholesterol gallbladder stones and in stone-free controls. The total protein content was significantly increased in gallstone patients (2.03 +/- 0.6 versus 1.31 +/- 0.67 mg/ml; p less than 0.05), as was the mucus glycoprotein concentration (380 +/- 88.5 versus 128 +/- 57.2 micrograms/ml; p less than 0.05). The cyclic-AMP concentration in the gallbladder fluid was increased up to 91 +/- 20 pmol/100 microliters in the gallstone subjects, as compared with 46 +/- 26 pmol/100 microliters (p less than 0.01) in stone-free controls. Cyclic-AMP concentrations correlated positively with the glycoprotein content of the bile in cholesterol gallstone patients (r = 0.66; p less than 0.05). The apolipoprotein concentrations were determined by the radial immundiffusion technique. The corresponding values for patients with stones and controls were 7.5 +/- 0.8 versus 3.0 +/- 0.8 for Apo A-I (p less than 0.025), 10.4 +/- 0.6 versus 6.3 +/- 1.3 for Apo A-II (p less than 0.02), and 1.9 +/- 0.5 versus 1.6 +/- 0.2 mg/dl for Apo B (NS), respectively. Biliary proteins probably play an important role in the nucleation process during the pathogenesis of cholesterol gallbladder stones.

[Sturge-Weber syndrome. Diagnostic imaging relative to neuropathology]

Clinical presentation of a child with port-wine stain and seizures leads to the suspicion of Sturge-Weber disease (SWD). This diagnosis can be confirmed by the detection of a meningeal angiomatosis. In rare cases, early detection of meningeal pathology by ultrasound has been reported. Key findings are brain atrophy, gyriform cortical calcifications demonstrated by skull radiographs after the first year of life or earlier by cranial CT, and dys- or aplasia of the deep cerebral veins on angiography. Radionuclide imaging shows focal or diffuse tracer accumulation over the affected brain regions. MR demonstrates an abnormal appearance of the affected meninges, especially thickening and pathologically increased signal intensity after Gd-DTPA application. This, in association with the demonstration of abnormal enhancement in deep medullary veins, is the most characteristic finding. Contrast-enhanced MR allows early and non-invasive diagnosis of SWD, mainly by revealing leptomeningeal angiomatosis and abnormal venous vessels.

Neuromuscular diseases: evaluation with high-frequency sonography

Forty-four patients with clinically suspected neuromuscular disease and 12 healthy volunteers underwent high-frequency ultrasound examination of the rectus femoris, vastus medialis, vastus lateralis, and biceps brachii muscles, and the number of perimysial septa was determined. These numbers and muscle/soft-tissue ratios of the lower extremity were compared. Findings were correlated with results of muscle biopsy in all patients with suspected disease. Using the number of perimysial septa in the lower extremity, the authors found significant differences between the muscles of healthy volunteers and those of patients with Duchenne muscular dystrophies, other muscular dystrophies, and spinal muscular atrophies: The receiver operating characteristic curve showed that an average of 12 perimysial septa within 1 cm of muscle is the ideal cutoff value to differentiate subjects without morphologic changes from those with pathologic findings. The authors conclude that this measurement is useful for differentiation of neuromuscular diseases and may be a noninvasive, reproducible means with which to evaluate disease progression.

[Effect of enteral and parenteral nutrition on glucose tolerance in the early postoperative phase]

In a randomized clinical trial in 24 patients with colorectal resections the different behaviour of glucose tolerance (GT) in the early post-operative period was investigated. Especially, we were concerned with the way nutritional substrate were applicated. Therefore 2 groups were randomly formed for a six day period of enteral versus parenteral nutrition. To check the GT enteral tolerance-tests were done preoperatively, and on day 1, 3 and 6 postoperatively. Our results show a significant improvement of GT in the enteral group on 3, and 6, postoperative days, as well as a significantly higher insulin secretion on 3, postoperative day. C-Peptide displays similar high concentrations as a sign of elevated insulin secretion. These results prove, that enteral glucose application is superior to the parenteral way in early postoperative nutrition.

MR-imaging findings in children with Sturge-Weber syndrome

Intracranial extent and distribution of leptomeningeal angiomatosis, visualized by magnetic resonance imaging (MRI) with Gadolinium-DTPA (Gd-DTPA) enhancement, is demonstrated in four children with Sturge-Weber syndrome (SWS). Aged 7, 9, 11 and 19 months, they presented with cutaneous, neurologic and ocular symptoms at the time of MRI examination. Angiomatous alteration of the skull, atypically located and congested intracerebral and basal veins as well as intracerebral changes secondary to the leptomeningeal angiomatosis are demonstrated with T2 weighted images. Gd-DTPA enhanced T1 weighted images exhibit clearly the regional distribution of angiomatosis in the skull, meninges and within the brain. Before calcifications in children with SWS are detectable by CT, MRI is the method of choice to detect intracranial involvement. Enhancement with Gd-DTPA improves the diagnostic value of MRI, before neurological symptoms appear. Follow-up studies with Gd-DTPA enhanced MRI can be applied to recognize thrombotic changes of leptomeningeal angiomatosis as well as subsequent intracerebral impairment.