Management of Children and Adolescents with Wilson Disease and Neurological Worsening Following D-Penicillamine Therapy: A Single Centre Experience

Background

Most centers in developing countries prefer chelation therapy with D-penicillamine for the management of Wilson's disease (WD) because of its easy availability and affordability. Neurological worsening following treatment with D-penicillamine is not uncommon. However, there is a paucity of Indian data on the incidence of neurological worsening in children and adolescents with WD following chelation therapy. Our study objectives were to identify the prevalence of neurological worsening in children and adolescents with WD following chelation with D-penicillamine therapy and to describe the management options and outcomes in these patients.

Materials and Methods

In this retrospective chart review, children and adolescents with an established diagnosis of WD from 2010 to 2020 were identified from the hospital electronic database. Among these patients, data of children and adolescents with neurological worsening following D-penicillamine therapy were extracted and analyzed.

Results

Neurological worsening was observed in 27/122 (22.1%) children and adolescents with WD on chelation therapy with D-penicillamine. Fifteen patients with neurological worsening following D-penicillamine therapy were managed with zinc monotherapy. Four patients were managed with a combination therapy of zinc and trientine. Five patients were treated with trientine monotherapy. Re-challenging with D-penicillamine at a lower dose followed by a slow dose escalation was attempted in three patients. Gradual clinical and functional status improvement was observed in 24 cases while one patient succumbed to pneumonia.

Conclusion

Children and adolescents with WD who had neurological worsening on D-penicillamine therapy may be managed with trientine. Zinc monotherapy with copper restricted diet was also found to be effective in non-affordable patients.

Oxidative Stress -a Phenotypic Hallmark of Fanconi Anemia and Down Syndrome: The Effect of Antioxidants

Background:

Oxidative stress plays a major role in the pathogenesis of leukemia-prone diseases such as Fanconi anemia (FA) and Down syndrome (DS)

Aim:

To explore the oxidative stress state in children with DS and FA by estimating the levels of antioxidants (e.g., malondialdehyde [MDA], total antioxidant capacity, and superoxide dismutase [SOD] activity) and DNA damage, and to evaluate of the effect of antioxidant treatment on these patients.

Subjects and methods

The study included 32 children clinically diagnosed with (15 patients) and FA (17 patients) in addition to 17 controls matched for age and sex. MDA, total antioxidant capacity, SOD activity, and DNA damage were measured. Antioxidants including Vitamin A, E, and C were given to the patients according to the recommended daily allowance for 6 months. Clinical follow-up and re-evaluation were conducted for all patients. Laboratory tests including complete blood count, karyotyping, DNA damage, and oxidative stress were re-evaluated. Statistical analysis was performed using statistical computer program Statistical Package for the Social Sciences version 14.0.

Results:

Children with FA and DS had elevated levels of oxidative stress and more DNA damage than controls. Oxidative stress parameters and DNA damage improved in FA and DS patients after antioxidant administration.

Conclusion:

Early administration of antioxidants to FA and DS patients is recommended for slowing of the disease course with symptoms amelioration and improvement of general health.

Terminal 2q deletion and partial trisomy chromosome 15q: a clinical and cytogenetic study

We report on a 5 years old female patient with a karyotype 46, XX, add (2), t(2;15) (q37;q22) associated with dysmorphic facial features, digital deformities, heart defect (mild mitral regurge) and severe mental retardation. This is the third reported case worldwide on the terminal 2q deletion and trisomy of chromosome 15q syndrome. The findings in this case and our literature review, delineates the pattern of malformations secondary to trisomy of 15q and deletion of 2q.

Cri du chat syndrome: a series of five cases

The cri du chat syndrome (CdCS) is a chromosomal deletion syndrome associated with a partial deletion of the short (p) arm of chromosome 5. We describe five children who were diagnosed to have CdCS by conventional cytogenetic analysis. The deletion was at 5p15 in four patients, whereas the fifth had a larger, more proximal deletion at 5p14. Fluorescence in situ hybridization (FISH) analysis confirmed the deletion of the CdCS critical region at 5p15.2. All five children had global developmental delay and dysmorphism with microcephaly. The other clinical features were variable. Since the clinical diagnosis of CdCS may not always be evident because of the phenotypic heterogeneity, cytogenetic analysis is necessary to establish the diagnosis and confirm that the deletion involves the CdCS critical region. This will enable early intervention which plays an important role in improving the outcome.

Muscle fatigue and excitation-contraction coupling responses following a session of prolonged cycling

AIM

The mechanisms underlying the fatigue that occurs in human muscle following sustained activity are thought to reside in one or more of the excitation-contraction coupling (E-C coupling) processes. This study investigated the association between the changes in select E-C coupling properties and the impairment in force generation that occurs with prolonged cycling.

METHODS

Ten volunteers with a peak aerobic power (VO(2peak)) of 2.95 ± 0.27 L min(-1) (mean ± SE), exercised for 2 h at 62 ± 1.3%. Quadriceps function was assessed and tissue properties (vastus lateralis) were measured prior to (E1-pre) and following (E1-post) exercise and on three consecutive days of recovery (R1, R2 and R3).

RESULTS

While exercise failed to depress the maximal activity (V(max) ) of the Na(+) ,K(+) -ATPase (P = 0.10), reductions (P < 0.05) were found at E1-post in V(max) of sarcoplasmic reticulum Ca(2+) -ATPase (-22%), Ca(2+) -uptake (-26%) and phase 1(-33%) and 2 (-38%) Ca(2+) -release. Both V(max) and Ca(2+) -release (phase 2) recovered by R1, whereas Ca(2+) -uptake and Ca(2+) -release (phase 1) remained depressed (P < 0.05) at R1 and at R1 and R2 and possibly R3 (P < 0.06) respectively. Compared with E1-pre, fatigue was observed (P < 0.05) at 10 Hz electrical stimulation at E1-post (-56%), which persisted throughout recovery. The exercise increased (P < 0.05) overall content of the Na(+), K(+)-ATPase (R1, R2 and R3) and the isoforms β2 (R1, R2 and R3) and β3 (R3), but not β1 or the α-isoforms (α1, α2 and α3).

CONCLUSION

These results suggest a possible direct role for Ca(2+)-release in fatigue and demonstrate a single exercise session can induce overlapping perturbations and adaptations (particularly to the Na(+), K(+)-ATPase).

STUDIES ON X-RAY EFFECTS : II. STIMULATIVE ACTION ON THE LYMPHOCYTES

This study consists of blood counts on nine rabbits after an exposure to x-rays of a 7/8 inch spark-gap, milliamperage 25, distance from the target 8 inches, and time of exposure 20 minutes. In seven of the nine animals there resulted an increase of the circulating lymphocytes. In five of these the increase was marked and in two others definite but not striking. Of the two animals which showed no stimulation one showed marked fluctuation of counts both before and after x-rays and the other little or no change. The higher penetrating dose (6 inch spark-gap, milliamperage 5, distance from the target 10 inches, time 26 minutes and 57 seconds) given to two animals produced no appreciable stimulation.

Building capacity in local government for integrated planning to increase physical activity: evaluation of the VicHealth MetroACTIVE program

Integrated planning is a holistic approach to addressing the needs of local communities built on partnerships between those responsible for development, environmental quality and service provision. This study investigated the extent and key influences on the use of integrated planning to promote physical activity among six metropolitan councils in Melbourne Australia, which took part in the MetroACTIVE Project funded by the Victorian Health Promotion Foundation from 2005 to 2007. The evaluation entailed interviews conducted at the mid-term (N = 67) and completion (N = 50) of the project, and the review of relevant documents. Respondents included elected councillors, chief executive officers, officers from different council divisions and the project staff employed in each council. Three councils showed evidence of integrated planning for physical activity, whereas the remainder focused on the delivery of community participation programs. Leadership from senior management and an organizational culture that supported collaboration across council departments were prerequisites for integrated planning. Employment of a dedicated project officer with skills for engaging management and building partnerships within the organization was important. Barriers to integrated planning were a complex organization structure, high demands on the council due to a growing residential population and a poor climate among staff. Overall, integrated planning was found to be a viable approach for developing a coordinated approach to this issue involving the range of council services and functions. Ongoing strategies are needed to facilitate senior management commitment and organizational capacity for integrated planning, with leadership provided by departments responsible for infrastructure or corporate planning.

Rapid diagnosis of Mycobacterium tuberculosis meningitis by enumeration of cerebrospinal fluid antigen-specific T-cells

SETTING

Hospital in-patients with suspected tuberculous meningitis (TBM), predominantly in India.

OBJECTIVE

To determine whether interferon-gamma (IFN-gamma) secreting Mycobacterium tuberculosis antigen-specific T-cells are present in the cerebrospinal fluid (CSF) of patients with TBM and to evaluate the feasibility of CSF enzyme-linked immunospot (ELISpot) for the diagnosis of active TBM.

DESIGN

Prospective blinded hospital-based study.

RESULTS

The overnight ELISpot assay detected M. tuberculosis antigen-specific IFN-gamma secreting T-cells in CSF from nine of 10 prospectively recruited patients with TBM, and zero of seven control patients with meningitis of other aetiology. This corresponds to a diagnostic sensitivity of 90% (95%CI 56-100) and specificity of 100% (95%CI 59-100).

CONCLUSION

This pilot study demonstrates proof-of-principle for a new T-cell-based diagnostic test for TBM which is rapid, sensitive and specific.

On the perils of mycorrhizal status lists: the case of Buddleja davidii

One observation in a mycorrhizal check-list that Buddleja davidii is nonmycorrhizal has been perpetuated in subsequent citations and used in a number of analyses of mycorrhizal ecology and evolution. Direct observation of B. davidii from New Zealand and the UK shows extensive arbuscular mycorrhizal fungal structures inside B. davidii roots. The suggestion that B. davidii is nonmycorrhizal is therefore not supported. The use of mycorrhizal checklists for analysis of plant traits and evolution needs to be undertaken with care to ensure the validity of underlying data.

Reversal of muscle fatigue during 16 h of heavy intermittent cycle exercise

This study examined the effects of extended sessions of heavy intermittent exercise on quadriceps muscle fatigue and weakness. Twelve untrained volunteers (10 men and 2 women), with a peak oxygen consumption of 44.3 ± 2.3 ml·kg−1·min−1, exercised at ∼91% peak oxygen consumption for 6 min once per hour for 16 h. Muscle isometric properties assessed before and after selected repetitions (R1, R2, R4, R7, R12, and R15) were used to quantitate fatigue (before vs. after repetitions) and weakness (before vs. before repetitions). Muscle fatigue at R1 was indicated by reductions ( P < 0.05) in peak twitch force (135 ± 13 vs. 106 ± 11 N) and by a reduction ( P < 0.05) in the force-frequency response, which ranged between ∼53% at 10 Hz (113 ± 12 vs. 52.6 ± 7.4 N) and ∼17% at 50 Hz (324 ± 27 vs. 270 ± 30 N). No recovery of force, regardless of stimulation frequency, was observed during the 54 min between R1 and R2. At R2 and for all subsequent repetitions, no reduction in force, regardless of stimulation frequency, was generally found after the exercise. The only exception was for R2, where, at 20 Hz, force was reduced ( P < 0.05) by 18%. At R15, force before repetitions for high frequencies (i.e., 100 Hz) returned to R1 (333 ± 29 vs. 324 ± 27 N), whereas force at low frequency (i.e., 10 Hz) was only partially ( P < 0.05) recovered (113 ± 12 vs. 70 ± 6.6 N). It is concluded that multiple sessions of heavy exercise can reverse the fatigue noted early and reduce or eliminate weakness depending on the frequency of stimulation.

Time course of the flash response of dark- and light-adapted human rod photoreceptors derived from the electroretinogram

1. The a-wave of the electroretinogram was recorded from human subjects with normal vision, using a corneal electrode and ganzfeld stimulation. We applied the paired-flash technique, in which an intense 'probe' flash was delivered at different times after a 'test' flash. The amplitude of the probe-flash response provided a measure of the circulating current remaining at the appropriate time after the test flash. 2. We extended previous methods by measuring not at a fixed time, but at a range of times after the probe flash, and then calculating the ratio of the 'test-plus-probe' response to the 'probe-alone' response, as a function of time. 3. Under dark-adapted conditions the rod response derived by the paired-flash technique (in response to a relatively dim test flash) peaked at ca 120 ms, with a fractional sensitivity at the peak of ca 0.1 Td(-1) s(-1). 4. As reported previously, background illumination reduced the maximal response, reflecting a reduction in rod circulating current. In addition, it shortened the time to peak (to ca 70 ms at an intensity of 170 Td), and reduced the flash sensitivity measured at the peak. The flash sensitivity declined approximately according to Weber's Law, with a 10-fold reduction occurring at an intensity of 100-200 Td. We could not reliably measure responses at significantly higher background intensities because the circulating current became so small. 5. In order to investigate the phototransduction process after correction for response compression, we expressed the derived response as a fraction of the maximal response that could be elicited in the presence of the background. The earliest rising phase of this 'fractional response per unit intensity' was little affected by background illumination, suggesting that the amplification constant of transduction was unaltered by light adaptation.

Light adaptation and dark adaptation of human rod photoreceptors measured from the a-wave of the electroretinogram

1. We recorded the a-wave of the human electroretinogram from subjects with normal vision, using a corneal electrode and ganzfeld (full-field) light stimulation. From analysis of the rising phase of rod-isolated flash responses we determined the maximum size (amax) of the a-wave, a measure of the massed circulating current of the rods, and the amplification constant (A) of transduction within the rod photoreceptors. 2. During light adaptation by steady backgrounds the maximal response was reduced, as reported previously. amax declined approximately as I0/(I0 + IB), where IB is retinal illuminance and I0 is a constant. In different subjects I0 ranged from 40 to 100 trolands, with a mean of 70 trolands, corresponding to about 600 photoisomerizations s-1 per rod. (1 troland is the retinal illuminance that results when a surface luminance of 1 cd m-2 is viewed through a pupil area of 1 mm2.) The amplification constant A decreased only slightly in the presence of steady backgrounds. 3. Following a full bleach amax recovered along an S-shaped curve over a period of 30 min. There was no detectable response for the first 5 min, and half-maximal recovery took 13-17 min. 4. The apparent amplification constant decreased at early times after large bleaches. However, upon correction for reduced light absorption due to loss of pigment, with regeneration of rhodopsin occurring with a time constant of 9-15 min in different subjects, it appeared that the true value of A was probably unchanged by bleaching. 5. The recovery of amax following a bleach could be converted into recovery of equivalent background intensity, using a 'Crawford transformation' derived from the light adaptation results. Following bleaches ranging from 10 to > 99 %, the equivalent background intensity decayed approximately exponentially, with a time constant of about 3 min. 6. The time taken for amax to recover to a fixed proportion of its original level increased approximately linearly (rather than logarithmically) with fractional bleach, with a slope of about 12 min per 100 % bleach. Similar behaviour has previously been seen in psychophysical dark adaptation experiments, for the dependence of the 'second component' of recovery on the level of bleaching.

Role of S-100 staining in differentiating leprosy from other granulomatous diseases of the skin

Since Mycobacterium leprae are rarely demonstrable in the tuberculoid spectrum of leprosy, a confirmatory diagnosis of leprosy can be made on the basis of finding active destruction of cutaneous nerves by granulomatous inflammation in a skin biopsy. Immunoperoxidase staining for S-100 protein, which is a marker for Schwann cells, was used to delineate nerves in lesional skin biopsies of 25 patients with tuberculoid and borderline tuberculoid leprosy as well as 15 controls with nonleprous granulomatous inflammation. Four different patterns of nerve damage were observed: infiltrated, fragmented, absent, and intact. All of the nonleprous granulomatous dermatoses showed only intact nerves, either inside or outside the granuloma, and so S-100 staining can be used to rule out leprosy.

Amyotrophic lateral sclerosis immunoglobulins are ineffective in altering calcium influx through presynaptic voltage-sensitive calcium channels

Recent work has suggested that one factor in the etiology of the neuromuscular disease, amyotrophic lateral sclerosis (ALS), may be an autoimmune mechanism in which presynaptic voltage-sensitive calcium channels are an antigenic target. We have developed a fluorescence technique to measure rapid Ca2+ influx through presynaptic calcium channels in isolated nerve terminals (synaptosomes) from rat cerebral cortex. Depolarization of the synaptosomes by elevated external K+ concentration caused a rapid increase in cytoplasmic Ca2+, as measured by a change in fluorescence of the Ca2+ chelating dye, Fura-2, which was loaded inside the synaptosomes. Pharmacological characterization suggests that the P- and Q-subtypes of voltage-sensitive calcium channels mediate the majority of this Ca2+ influx. The synaptosome preparation has been used as a model system to investigate the effects of IgG, purified from eight ALS patients, on presynaptic calcium channel function. IgG (1 microgram ml-1 to 1 mg ml-1) was preincubated with the synaptosomes prior to depolarization. IgG, from these eight ALS patients, had no systematic effects on presynaptic Ca2+ influx. Thus, using this system, we find no evidence for an effect of ALS IgG on the function of presynaptic calcium channels.

Effects of calcium channel blockers on the kinetics of voltage-dependent changes in synaptosomal calcium concentrations

Synaptosomal preparations from rat cerebral cortex have been used in stopped-flow fluorescence studies to measure rapid changes in intrasynaptosomal calcium concentrations upon depolarization. Synaptosomes were loaded with the fluorescent calcium chelating dye, Fura-2, by incubation with the membrane permeant acetoxymethyl ester derivative. Depolarization by elevated external K+ concentration resulted in a rapid increase in cytoplasmic Ca2+ as measured by a quench in Fura-2 fluorescence when excited at 390 nm. The fluorescence change could be reasonably fit by a single exponential process with an apparent rate of 10-15 s-1 and the magnitude of the response was voltage-dependent, increasing with increasing external K+ over the range of 5-30 mM. The observed quench was blocked by micromolar concentrations of the inorganic calcium channel blockers, Cd2+, Co2+ and La3+. Nimodipine, a dihydropyridine which blocks L-type calcium channels, inhibited only 10-15% of the flux response while nitrendipine had no consistent effect. omega-Conotoxin GVIA, a blocker of N-type channels in many species, had only a small inhibitory effect at high (1-10 microM) concentrations. The response was, however, inhibited by pre-incubation of the synaptosomes with venom of the funnel web spider. Agelenopsis aperta (0.1-300 micrograms/ml). Inhibition was observed with both a purified polyamine fraction (FTX) from the venom (IC50 = 4 nl/ml) and a purified peptide toxin, omega-AgaIVA (IC50 = 30 nM). These results indicate that voltage-dependent Ca2+ uptake by mammalian nerve terminals is mediated primarily by channels that are insensitive to dihydropyridines and omega-conotoxin GVIA but are sensitive to components of funnel web spider venom.

A new rat spinal cord injury model: a ventral compression technique

A new rat spinal cord injury model, which uses a modification of a DeBakey aortic aneurysm clamp to create the injury, is presented. The model produces a ventral persisting mass (bone and soft tissue) without the requirement of a prior decompressive operation (laminectomy). Modifications of the original technique have resulted in a nil surgical mortality rate. This technique has been applied to 138 animals. It has produced a consistent percentage of animals with complete myelopathies, as well as incomplete myelopathies and animals without apparent injury. The percent of baseline neurological function lost (change in degrees of the angle of tilt as measured by the inclined plane technique) in each group of surviving animals was 58, 36, and 9%, respectively. Sagittal postmortem sections confirmed mass lesions located ventral to the spinal cord. Histological sections confirmed neuronal loss consistent with the neurological findings.

Dose-dependent effects of naloxone and methylprednisolone in the ventral compression model of spinal cord injury

A study of the dose-response effects of naloxone and methylprednisolone after rat ventral spinal cord injury is presented. The spinal cord injury model used herein is unique in that it results in a ventral compression of the spinal cord without the need for a prior laminectomy. This allows for a close approximation of the human clinicopathological situation. There was a statistically significant positive effect on neurological outcome with a naloxone dose of 2.5 mg/kg, whereas higher and lower doses yielded little or no influence on outcome. Methylprednisolone was observed to offer similar results. These results, however, did not achieve statistical significance. The early administration of moderately high doses (45-60 mg/kg), however, offered the best results. The responses to the treatment regimens presented here offer hope for spinal cord injury victims. The observed dose-response relationships indicate that erroneous conclusions may arise from studies using inappropriate doses of narcotic antagonists, as well as other drugs.

Incidence of complications from coronary angiography in 463 USAF aviators

Over 600 fliers have had coronary angiography at the USAF School of Aerospace Medicine since 1971. This paper concerns the incidence of complications, long- and short-term, on the first 463. Information on short-term complications was compiled from computerized data storage and included all 463 patients. Mean age of patients was 40.5 with a range of 22-57 years. Information about long-term complications was obtained from 357 respondents to a three-page questionnaire (77% return rate). Most frequent indication for angiography was an abnormal treadmill stress test, and more than 90% of the patients were asymptomatic. There was no short-term mortality. Nine individuals reported some residual complaints involving the hand, but had no job or physical activity limitation from the procedure. The local arterial complications were more frequent with brachial cutdown than with the femoral percutaneous approach, but the difference in frequency was not statistically significant.

An experimental analysis of a program to reduce retail theft

A program for elementary school-aged youth, designed for and implemented by a retail business, was evaluated. The program included visual instructions to youth, tokens (exchangeable for special prizes) for appropriate verbal behavior, visual feedback to youth, and rewards for reducing merchandise loss, all continued to a criterion level. A 54% reduction in losses of popular youth merchandise was achieved.

Evaluation of outpatient client progress: time-series telephone interview data

A cost-efficient information system that allows for the continual monitoring of the verbal reports of mental health outpatient behavior was designed and implemented. Verbal descriptions of patients' problem behaviors were collected during baseline, therapy, and post-therapy periods using a telephone interview procedure. Descriptive data were presented for 25 patients, demonstrating that: (a) adequate baseline measures can be taken to evaluate therapy interventions, (b) there are wide differences among patients' reports as to the change in frequency of problems that occurs, and (c) patients' reported satisfaction with therapeutic services may be inconsistent with their verbal reports of behavioral change.

Care of patients after cardiac catheterization

In an effort to provide more definitive diagnosis for Air Force flyers referred to the USAF School of Aerospace Medicine, cardiac catherization has been performed, as indicated, on over 425 flyers since 1971. Since they are an apparently healthy and asymptomatic population, their recovery after cardiac catheterization is usually uneventful. However, the nurse must be able to recognize and interpret significant potential and/or existing post-catheterization complications. Nursing care of the patient after this procedure is essential to the successful completion of the test. Since any invasive procedure can lead to complications, quick and accurate nursing assessment and action are essential. The possible complications of cardiac catheterization which the nurse may encounter have been divided into possible causes, and a suggested plan of action. Reference tables are provided for each of the two main classifications, in an effort to provide quick guidance for the nurse responsible for care of the patients after catheterization.