The characterization of toll-like receptor repertoire in Pinna nobilis after mass mortality events suggests adaptive introgression

The fan mussel Pinna nobilis is currently on the brink of extinction due to a multifactorial disease mainly caused to the highly pathogenic parasite Haplosporidium pinnae, meaning that the selection pressure outweighs the adaptive potential of the species. Hopefully, rare individuals have been observed somehow resistant to the parasite, stretching the need to identify the traits underlying this better fitness. Among the candidate to explore at first intention are fast-evolving immune genes, of which toll-like receptor (TLR). In this study, we examined the genetic diversity at 14 TLR loci across P. nobilis, Pinna rudis and P. nobilis × P. rudis hybrid genomes, collected at four physically distant regions, that were found to be either resistant or sensitive to the parasite H. pinnae. We report a high genetic diversity, mainly observed at cell surface TLRs compared with that of endosomal TLRs. However, the endosomal TLR-7 exhibited unexpected level of diversity and haplotype phylogeny. The lack of population structure, associated with a high genetic diversity and elevated dN/dS ratio, was interpreted as balancing selection, though both directional and purifying selection were detected. Interestingly, roughly 40% of the P. nobilis identified as resistant to H. pinnae were introgressed with P. rudis TLR. Specifically, they all carried a TLR-7 of P. rudis origin, whereas sensitive P. nobilis were not introgressed, at least at TLR loci. Small contributions of TLR-6 and TLR-4 single-nucleotide polymorphisms to the clustering of resistant and susceptible individuals could be detected, but their specific role in resistance remains highly speculative. This study provides new information on the diversity of TLR genes within the P. nobilis species after MME and additional insights into adaptation to H. pinnae that should contribute to the conservation of this Mediterranean endemic species.

Use of the parathyroid hormone assay at H6 post thyroidectomy: an early predictor of hypocalcemia

PURPOSE

Hypocalcemia linked to a diminished circulating intact parathormone (iPTH) is the most common complication after total thyroidectomy. The objective of this study was to evaluate iPTH as a predictor of post-thyroidectomy hypocalcemia.

METHODS

Hundred-and-eight patients who underwent total thyroidectomy were included. Blood samples (iPTH, calcium and albumin) were performed at different times: preoperatively (H₀), after removal of the gland (H_drop), 6 h (H₆) and one day (D₁) after the surgery. Hypocalcemia was defined by total calcium corrected by serum albumin ≤ 2.10 mmol/l. The area under the ROC curve (AUC) was used to determine the best cut-off value and predictability of iPTH for hypocalcemia in terms of absolute value (ng/L), decrease in the slope (ng/L) and decline (%) between two times.

RESULTS

The study included 101 patients. Among them, 39 had hypocalcemia (38.6%). At H₆, an iPTH absolute value less than 14.35 ng/L (Se = 0.706; Sp = 0.917) and a decline from the preoperative time of more than 59.5% (Se = 0.850; Sp = 0.820) were predictive of hypocalcemia. Other absolute values, decrease in the sloop and decline between preoperative and postoperative values were less relevant.

CONCLUSION

The iPTH 6 h after total thyroidectomy is predictive of hypocalcemia. It might be used to identify patients not at risk of hypocalcemia and earlier discharge could be considered.

[Elastic stable intramedullary nailing in Ilizarov bone lengthening]

PURPOSE OF THE STUDY

Bone lengthening with the Ilizarov technique gives good results but certain disadvantages are common: possible axial deviation during lengthening, long time to bone union, risk of fracture after removal of the external fixator. Associating the Ilizarov technique with elastic stable intramedullary nailing (ESIN) commonly used in traumatology has to be evaluated. We conducted an experimental study and report results of the first clinical application.

MATERIAL AND METHODS

Eleven lengthenings of the tibia were conducted in dogs aged 1 to 4 years using an Ilizarov external fixator associated with ESIN. Lengthening started on day 1 and continued for 28 days. X-rays were obtained every week during lengthening, then at 15 and 30 days during the fixation period and 30 days after removal of the fixator. In two cases, arteriography was performed. In a pilot clinical trial, fourteen patients (8 males, 6 females) were treated with this method (1 humerus, 1 forearm, 7 femurs, 5 tibias). Mean patient age was 14 years.

RESULTS

In the experimental study, the x-rays showed rapid ossification of the regenerate which led to increased tibia length in 7 cases from 1.25 to 2 mm/day. Total bone union was observed in four dogs during the lengthening period. At day 15 of the fixation period, all tibia had fused with a good quality cortical bone and healing of the growth part of the regenerate. In three dogs, the external fixator was removed at day 15 of fixation and weight-bearing was total with the ESIN in place. No axial deviation and no skin problems were observed. The medullary artery was seen on the two arteriograms. In the clinical trial, bone union of the regenerate appeared earlier than in the Ilizarov series. The regenerate always displayed good density on the x-rays, proving intense bone activity. In three patients, the lengthening rate was increased to avoid premature bone fusion. The endosteal bone regenerate was obvious. Mean healing index was 18.6 days/cm (SD=6.2). Weight-bearing was allowed at six weeks. The desired correction was achieved in all patients and no complications were related to ESIN.

DISCUSSION

Bone lengthening may be obtained with an intramedullary locking nail which avoids the use of an external fixator but also destroys the endomedullary circulation. Our experimental and clinical study shows that use of an ESIN does not inhibit the endosteal regenerate and seems to improve new bone formation. In many patients, the lengthening rate had to be increased to avoid premature bone fusion. When used in optimal conditions, ESIN can stimulate new endosteal and periosteal bone formation. In addition, ESIN increases shaft stability avoiding the risk of axial deviation. ESIN plays an additional role of stabilization after early removal of the external fixation.

[Reduction of the period of treatment for leg lengthening. Technique and advantages]

PURPOSE OF THE STUDY

We assessed an adaptation of the Ilizarov method aimed at a considerable reduction in the period of treatment for leg lengthening in order to limit complications related to the duration of the external fixation. This technique associates multiple segment lengthening, automatic high-frequency lengthening, and stimulation of bone regeneration by extemporaneous compression at the end of traction.

MATERIAL AND METHODS

We analyzed 78 cases of automatic fémur lengthening in 40 patients and simultaneous fémur and tibia lengthening in 38 patients. There were 51 men and 27 women, mean age 13.2 years (6 - 43 years). Mean length deficiency was 4.3 cm for the fémur and 3.5 cm for the tibia. Femoral and/or tibial deformations were observed in 32 patients. Minimal follow-up was 1.5 years. The automatic traction device was composed of the conventional Ilizarov fixator and complementary elements. Different assemblies were used depending on the associated deformations allowing their progressive correction. For 17 patients, radioimmunoassay of thyrocalcitonin and parathormone was performed to compare the time courses.

RESULTS

Mean femoral lengthening achieved was 49 mm (8.5 to 20%). Mean tibial lengthening was 42 mm (7.2 to 18.8%). The consolidation index was 18.1 to 21.3 days/cm for single-segment lengthenings and 11.5 days/cm (mean) for two-segment lengthenings (taking into account both the femoral and tibial gain in length). The ideal moment of compression was 5.6 N/cm(2). Acceleration of the bone repairing process was evidenced by activation of the osteotrop hormone system. According to the SOFCOT classification of complications (1990), 60 patients (76.9%) were in category I, 15 (19.3%) in category II, and 3 (3.8%) in category III.

DISCUSSION

Improvement of lengthening procedures with external fixators remains an important issue. Treatment periods are often long with consolidation indices for the femur ranging from 39.6 d/cm to 45 d/cm, which can lead to many types of complications. Use of a high-frequency progressive lengthening procedure based on the Ilizarov method considerably reduces the rate of complications compared with progressive lengthening methods and has allowed achieving more satisfactory results in a shorter treatment period.

CONCLUSION

Multiple-segment lengthening using an automatic lengthening procedure set at 1 mm per day in four times provides an important reduction in the treatment delays since distraction is performed more rapidly and fewer steps are needed. Automatic high-frequency lengthening with the Ilizarov method provides optimal conditions for tissue regeneration: Treatment periods are shorter and anatomic and functional outcome is very satisfactory. Stimulation by extemporaneous compression of the regeneration zone allows a significant reduction in the duration of consolidation. Shorter delays to consolidation help avoid device-related complications.

Treatment of Langerhans-cell histiocytosis in children. Experience at the Children's Hospital of Nancy

Forty children who had Langerhans-cell histiocytosis were followed for an average of six years (range, excluding patients who died of the disease, two to fifteen years). The patients were divided into two diagnostic groups: those who had localized disease (involving one bone or more only) and those who had multifocal disease (an osseous lesion and a soft-tissue mass, a skin rash, diabetes insipidus, or generalized disease). Methods of treatment included curettage, bone-grafting, chemotherapy, local or systemic corticosteroids, and radiotherapy. Nineteen of the thirty patients who had localized disease had a complete response to the therapy, four had a partial response, and seven had no response. Twenty-one of these thirty patients had not had a recurrence by the time of the latest follow-up examination; nine had a local recurrence within four years after the initial therapy but had no additional recurrences after treatment of the local recurrence. No recurrence occurred more than four years after the time that the initial diagnosis had been made. Five of the ten patients who had multifocal disease had a complete response to the therapy, two had a partial response, and three had no response. Six patients had a recurrence; four did not. Two patients died of the disease. As a result of this study, we recommend the avoidance of intensive measures of treatment, if possible, and we advise long-term follow-up of these patients.

Treatment of sternocostal wall malformations of the child. A series of 210 surgical corrections since 1975

Of 450 children examined for front chest wall malformations, 210 underwent a corrective operation: 190 funnel chests and 20 pigeon chests. A classification of the anatomic forms is presented which contains 6 groups: vertical cup-shaped (the most common), horizontal cup-shaped, vallecular, mixed, complex with sternal torsion or polymalformations. The operation has been programmed in 64% of the cases between 10 and 18 years, but 36% were operated under 6 years because of a severe functional disturbance. On the technical side, Ravitch's procedure is still used on young infants; for the other cases sternochondro-plasty is to be preferred. The fixation of the chest wall is realized with an original, light, solid elastic material taking little space, and easy to remove. This material is presented. The immediate results: 62% very good, 35% good and 3% mediocre, sometimes do present a pejorative evolution, so that after two years of follow-up we notice: 55% remained perfect, 35% very good, 10% moderate of which, 4% to be reoperated. This deterioration touches more particularly the older children operated between 16 and 18 years. Among the children between 3 and 6 years the results are usually very good and remain stable with growth.

[Villonodular synovitis of the wrist. Apropos of a case in an adolescent]

Pigmented villonodular synovitis of the wrist is an uncommon disease. It is also very rare in childhood and adolescence. The authors report a case with good outcome after surgery and review the literature concerning this.

Computerised tomography in non-treated congenital hip dislocation

Computerised tomography, carried out in 5 non-treated cases of congenital dislocation of the hip, shows that the femoral head can move in a large anteroposterior cavity. When the hip is extended the common position of dislocation is lateral superior and slightly anterior to the acetabulum. When the hip is flexed (at a right angle), the femoral head is located posterior and slightly superior to the acetabulum. Dislocation reduction has always been possible. When the hip is flexed a large "click" takes place; whereas if the hip is extended, the "click" is less noticeable, or even absent.

[cRNA probes (riboprobes) synthesized in vitro for detecting enterovirus by molecular hybridization]

Radioactively labelled RNA transcripts made in vitro of various fragments from cDNA clones of poliovirus type 1 and of hepatitis A virus under the control of bacteriophage T7 or SP6 promoters have been evaluated for diagnostic purposes. The RNA transcripts were 2 orders of magnitude more sensitive as hybridization probes than corresponding cDNA preparations labelled by the nick translation procedure. A combination of hybridization analysis and sequence comparison showed that some regions of the genome of a number of enteroviruses are highly conserved, while others show very little homology; the general order of conservation is: 5'-non-coding greater than 3'-terminal greater than central (2C) greater than VP3 greater than VP1. The 350 bases of the poliovirus VP1 region were highly specific for that virus, while the 450-bases of the 5'NC region showed extensive cross-reaction with other enteroviruses. However, these probes did not hybridize with HAV, which was detected only by HAV-specific riboprobes. The transcripts have been successfully applied as hybridization probes in diagnostic tests on supernatants of infected cell culture lysates and in clinical samples, mainly in stool extracts.

Elastic stable intramedullary nailing of femoral shaft fractures in children

We report the use of elastic stable intramedullary nailing (ESIN) in 123 fractures of the femoral shaft in children. Flexible rods are introduced through the distal metaphyseal area, and the aim is to develop bridging callus. Early weight-bearing is possible and is recommended. There was one case of bone infection and no delayed union. Complications were minimal, the most common being minor skin ulceration caused by the ends of the rods. A surprising feature was the low incidence of growth changes, with a mean lengthening of only 1.2 mm after an average follow-up of 22 months. Compared with conservative treatment, ESIN obviates the need for prolonged bed rest and is thus particularly advantageous for treating children.

The history of pediatric surgery in France

In 1741, Nicolas Andry, counsellor of King Louis XV, published a book about "orthopedics," inventing this word. The book is interesting as the author refers to beliefs and habits of the time. In 1864, Guersant published Notes About Pediatric Surgery, a real textbook which was translated into English and German and dealt with the importance of children's psychological training, anesthesia, and water or mother's milk after the operation, and also described tracheotomy, draining of cervical adenitis, and lithotrity. The classification of bone affections was still very confused. Tuberculosis and syphilis have an important place; hypospadias is not treated by surgery. In 1905, Froehlich published Pediatric Surgery Studies dealing exclusively with visceral surgery and demonstrating progress compared to Guersant's study. In 1906, Kirmisson published Pediatric Surgical Textbook, containing the first discussion of radiology and the description of the pathology of the omphalomesenteric duct and of other congenital malformations. Osteomyelitis was given its proper name, and cervical fistulas were explained. In 1914, A. Broca achieved further progress describing treatments of megacolon, intussusception, and the operation of Fredet Ramstedt. The book by Ombredanne, already out of date at the time of its publication, showed that he was not aware of the wartime, progress achieved by Ladd and Gross in the USA. French publications have diminished since then, and French pediatric surgery is still trying to find a precise identity.

Elastic stable intramedullary pinning of long bone shaft fractures in children

Stable intramedullary pinning is an excellent method for treating shaft fractures in children when there is an indication for operative management. It is a new biomechanical concept which aims at developing the bridging external callus. This closed pinning uses flexible rods which are introduced into a metaphysial area. Technique, results and indications are described particularly in regard to shaft fractures of the femur and the forearm. This closed surgical procedure can always be performed; complication rates are slight (no sepsis, no delayed union). Early mobilisation is possible, and use of a cast is unnecessary.

Preliminary evaluation of the ELISA as a tool for the detection of rotaviruses in activated sewage sludge

Samples of activated sludge were taken in three different treatment plants near Nancy (France) and in West Berlin (F.R.G.), and were investigated for their content of rotaviruses. After elution with beef extract (0.25%, pH 7.3) and ultrasonication, the samples were concentrated by protamine flocculation and, in a few cases, in parallel by ultracentrifugation. A commercially available ELISA test kit (Rotazyme, Abbott Diagnostics) was routinely used for rotavirus detection. Although both the Rotazyme and a laboratory-designed ELISA gave positive results for the suldge concentrates, confirmation with a blocking test and electron microscope (EM) was negative in all cases so far investigated. Therefore, the exclusive use of ELISA cannot be recommended for similar investigations as it may lead to false positive results. In this light, an additional verification step with neutralizing antibodies should be included by the ELISA kits' manufacturers to enable a quick confirmation of the user's results.

Small bowel esophagoplasty with vascular microanastomoses in the neck for treatment of esophageal burns in childhood

Replacement of the esophagus may become mandatory in esophageal burns if dilatation treatment is unsuccessful. Normally, the isoperistaltic transverse colon placed in the neck is used for this purpose. The use of the major curvature of the stomach, according to Gavriliu, may also be considered. In two of our patients, these techniques could not be applied, and we transplanted a portion of the small bowel into the neck, with the blood supply to the pedicule being provided by vascular microanastomosis in the cervical region. The functional results were very satisfying in both cases, despite of the bent appearance of the grafts. At long-term follow-up, there have been no major, particularly peptic, complications. The two cases and the technique applied are described.

Resection followed by vascularized bone autograft in patients with possible recurrence of malignant bone tumors after conservative treatment

In conservative treatment of malignant bone tumors, assessment of the local condition is difficult. The radiological changes seen in the irradiated tumor and the frequent occurrence of pathological fractures at this site may give rise to the fear that the tumor has relapsed. Resection of the whole of the involved bone is the best way to assure adequate local control but the extent of the bone defect and the bad local conditions secondary to irradiation make reconstruction hazardous. In two patients (one with Ewing's sarcoma of the femur and one with osteogenic sarcoma of the humerus) the authors used a free, vascularized fibular graft for the reconstruction having obtained consolidation of the limb after resection of the irradiated tumor, with preservation of its function. The encouraging results obtained have suggested a conservative attitude as primary treatment of specific malignant bone tumors.

[Closed flexible medullary nailing in pediatric traumatology]

Flexible Medullary Nailing is an excellent method in children when operative management is indicated. It is a new biomechanical concept using prebent flexible rods introduced in a metaphyseal area. In femoral shaft fractures, closed percutaneous nailing permits stabilization using wires inserted by a medial and a lateral approach. In severely displaced humeral fractures of the upper end, two Kirschner wires are inserted under X-ray control through a epicondyl hole. Pinning can be indicated in others fractures : tibia, radial neck (original procedure), fore arm, humeral supracondylar original procedure and shaft fractures. This closed surgical procedure can always be done; the complication rate is light (no sepsis, no delayed union). Early mobilisation is often possible and cast is not necessary.

[Surgical treatment of portal hypertension in children (author's transl)]

Various operative techniques are employed for the surgical treatment of portal hypertension in children. Operations to reduce oxygen supply are briefly described, followed by a more detailed study of procedures for azygoportal disconnection which include endoscopic sclerosis, direct varices ligature, transection of the oesophagus and stomach, or gastro-oesophageal resection. Operations to obtain a portal vein blood shunt by portosystemic anastomosis are described more fully, these including radicular shunts involving capillary anastomoses between the portal and systemic systems, radicular shunts and more particularly splenorenal and mesentericocaval anastomoses, and those employing an interposed graft. Truncal shunts have also been employed in the different types of portocaval anastomoses, and those employing an interposed graft. Truncal shunts have also been employed in the different types of portocaval anastomosis. So-called mixed operations concern either oesophageal devascularisation procedures or radicular anastomosis, the prototype for the latter being Warren's operation.

[The effects of innominate ostèotomy on the opposite acetabulum (author's transl)]

The study on dissected pelvis shows that after innominate osteotomy, the acetabulum still faces too much anteriorly. Its anterior wall remains deficient. The innominate osteotomy is able to diminish the excessive antetorsion of the acetabulum by rotating the distal fragment outwards. But this movement seems to increase the antetorsion of the opposite acetabulum. Axial X. Rays of the pelvis authors think that in case of great anterior defect, and in case of bilateral hip dysplasia, a triple pelvic osteotomy will be preferred to Salter's osteotomy.

Intestinal strangulation between two vertebra following an axial dislocation of L1/L2

An exceptional cause of intestinal obstruction is reported. Ileus is an 8-yr-old boy persisted for 9 days after successful reduction of an axial dislocation of L1 on L2. At laparotomy, a paraduodenal hernia with bowel strangulated between the bodies of L1 and L2 was discovered. The successful treatment consisted of cleaning out the intervertebral space, resection of the necrotic bowel with anastomosis, antibiotic therapy, and a plaster jacket worn for 3 mo.

[Reduction and fixation of fractures of the neck of the radious be centro-medullary pinning. Original technic]

Fractures of the neck of the radius may cause considerable permanent limitation of elbow and forearm movement. This complications resulted from failure to achieve adequate reduction or from vascular disturbance. The authors make use of a Kirschner wire introduced in the medullary canal by its lower end. It is possible to reduce and stabilise the head of the radius without open reduction.

[Congenital "cardio-esophageal" syndromes. Congenital cardiopathies and multiple abnormalities syndromes in the child with esophageal abnormalities]

A case of esophageal stenosis and tracheo-esophageal fistula associated with dextrocardia due to dextrorotation, ventricular septal defect and complete double arotic arch is reported. In 116 cases of esophageal atresia and tracheo-esophageal fistula 9 had an associated cardiac malformation (4 right-sided aortic arch and 4 ventricular septal defects). The possible individualization of multiple abnormality syndromes in which these two types of malformations are associated with others such as vertebral arch defects, limb anomalies, imperforate anus, etc. is discussed. These are so-called "Vater" or "Vactel" syndromes.

[Solid-phase enzyme immunoassay for specific immunoglobulin G and immunoglobulin M antibodies of rubella virus (author's transl)]

A sensitive solid-phase enzyme-immunoassay for the detection of rubella virus specific IgG and IgM antibodies has been developed. Wells of polystyrene trays were sensitized with purified rubella antigen. A substrate employed in enzyme-histochemistry, which gives a stable staining, was used to allow direct determination of titre values. One hundred and thirty-five human sera were tested. Antibodies titres, detected using this glucose oxidase immunoassay, correlated well with those obtained using a virus haemagglutination inhibition test. With this procedure sera can be tested without any pretreatment and evaluated within one day. Moreover, TIE is more sensitive and specific antibodies are detected earlier.

A case of EMG (exomphalos, macroglossia, and gigantism) syndrome with associated renal tumor

This is a brief report of a patient with Wiedemann-Beckwith syndrome and nephroblastoma with metastases, apparently cured by surgery, chemotherapy, and radiation.

[Periostitis or, rather, periosteal appositions in paediatrics (author's transl)]

In relation to a case of multiple fatigue fractures definitely diagnosed by scintigraphy and xerography, the authors report two other previous cases of spontaneous fractures at a single site in which the diagnosis was made only after surgical biopsy and histological examination. Recalling the frequent confusion arising in children between periosteal appositions and osteomyelitis or Ewing's sarcoma, and the different radiological phases of this type of fracture, they stress the necessity for a maximum effort to demonstrate the key element in the diagnosis: the cortical fissure. The latter is often minimal, at the limit of visibility and developing late. Thus repeated examinations and the use of special radiological techniques are necessary.

[A rare tumour of the right hypochondrium in the child (author's transl)]

Pancreatic pathology in the child is rare and usually limited to necrotic or traumatic pseudo-cysts. The authors report a case of multicystic dysplasis localised in the pancreas in a one-year old infant. The preoperative diagnosis of a traumatic cyst was made in error as the result of the discovery of a fracture of the skull. At operation, the "tumour" was seen to be a multicystic mass within the duodenal loop but pediculated under the inferior surface of the pancreas. Histological examination confirmed its dysplasic nature. The presence, as a result of vascular compression, together with the post-operative resolution of hypertension lend further originality to this case.