Long-term benefits and adverse effects of intermittent versus daily glucocorticoids in boys with Duchenne muscular dystrophy

OBJECTIVE

To assess the current use of glucocorticoids (GCs) in Duchenne muscular dystrophy in the UK, and compare the benefits and the adverse events of daily versus intermittent prednisolone regimens.

DESIGN

A prospective longitudinal observational study across 17 neuromuscular centres in the UK of 360 boys aged 3-15 years with confirmed Duchenne muscular dystrophy who were treated with daily or intermittent (10 days on/10 days off) prednisolone for a mean duration of treatment of 4 years.

RESULTS

The median loss of ambulation was 12 years in intermittent and 14.5 years in daily treatment; the HR for intermittent treatment was 1.57 (95% CI 0.87 to 2.82). A fitted multilevel model comparing the intermittent and daily regiments for the NorthStar Ambulatory Assessment demonstrated a divergence after 7 years of age, with boys on an intermittent regimen declining faster (p<0.001). Moderate to severe side effects were more commonly reported and observed in the daily regimen, including Cushingoid features, adverse behavioural events and hypertension. Body mass index mean z score was higher in the daily regimen (1.99, 95% CI 1.79 to 2.19) than in the intermittent regimen (1.51, 95% CI 1.27 to 1.75). Height restriction was more severe in the daily regimen (mean z score -1.77, 95% CI -1.79 to -2.19) than in the intermittent regimen (mean z score -0.70, 95% CI -0.90 to -0.49).

CONCLUSIONS

Our study provides a framework for providing information to patients with Duchenne muscular dystrophy and their families when introducing GC therapy. The study also highlights the importance of collecting longitudinal natural history data on patients treated according to standardised protocols, and clearly identifies the benefits and the side-effect profile of two treatment regimens, which will help with informed choices and implementation of targeted surveillance.

Stress in UK intensive care unit doctors

BACKGROUND

Doctors have long been considered at risk of occupational stress.

METHODS

A postal survey of all members of the Intensive Care Society using validated instruments.

RESULTS

Eight-five per cent of members returned questionnaires and 70% were eligible for the study. Twenty-nine per cent were suffering General Health Questionnaire-12 (GHQ-12) identified distress and 12% Symptom Checklist-Depression (SCL-D) defined depression. There were no significant age or sex differences between staff suffering distress or depression and those who did not. Dissatisfaction with career correlated highly with both distress and depression (P<0.01). Twenty doctors (3%) were bothered by suicidal thoughts. The most stressful aspects of work were bed allocation, being over-stretched, effect of hours of work and stress on personal/family life, and compromising standards when resources are short. Logistic regression revealed mental health problems were predicted by five stressors: 'lack of recognition of one's own contribution by others'; 'too much responsibility at times'; 'effect of stress on personal/family life'; 'keeping up to date with knowledge'; and 'making the right decision alone'.

CONCLUSIONS

Nearly one in three ICU doctors appeared distressed (GHQ), and one in 10 depressed (SCL-D); this is no greater than that reported in other specialities. Perceived stressors reveal some key areas of concern for the employer and the specialty.

Epidemiology of pyridoxine dependent and pyridoxine responsive seizures in the UK

OBJECTIVE

To study the epidemiology of pyridoxine dependent seizures and other forms of pyridoxine responsive seizures.

DESIGN

Monthly notifications to the British Paediatric Surveillance Unit over two years. Questionnaire follow up.

SETTING

UK and the Republic of Ireland.

PATIENTS

Children aged 15 years or younger whose seizures respond to pyridoxine.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Numbers of children with definite, probable, and possible pyridoxine dependent seizures or other seizures responsive to pyridoxine.

RESULTS

Point prevalence and birth incidence: 1/687 000 and 1/783 000, respectively (definite and probable cases); 1/317 000 and 1/157 000, respectively (all types of pyridoxine responsiveness). NOTIFICATIONS: Pyridoxine dependency: 14 definite, 9 probable, and 10 possible cases; neonatal seizures not meeting case definitions: 7; infantile spasms: 5. Eight of 18 families of definite/probable cases had 2 affected siblings. Just over a third had atypical presentations and just under a third had features and/or initial diagnoses of birth asphyxia and neonatal hypoxic ischaemic encephalopathy.

CONCLUSIONS

Pyridoxine dependency is rare. Atypical presentations are relatively frequent. A trial of pyridoxine is justified in all cases of early onset intractable seizures or status epilepticus, whatever the suspected cause.

Pyridoxine-dependent seizures: demographic, clinical, MRI and psychometric features, and effect of dose on intelligence quotient

A regional population-based survey identified six patients with pyridoxine dependency. Four presented on the first day of life and the other two at 1 and 8 months of age. Apart from multiple seizure types, other presenting features included jitteriness; encephalopathy, at first thought to be hypoxic-ischaemic; hepatomegaly, and abdominal distension with bilious vomiting. Later problems included break-through fits with fever; transient visual agnosia; squint; severe articulatory apraxia; motor delay with later dyspraxia; macrocephaly, and post-haemorrhagic hydrocephalus. Magnetic resonance imaging showed variable structural abnormalities in all the early onset cases. Psychometric assessment revealed a stereotyped pattern of intelligence scale subtest scores, with a specific impairment of expressive verbal ability. In a prospective open study over one year, an increased dose of pyridoxine was associated with an improvement in IQ, particularly in performance subtests. Pyridoxine dependency is more common than has been thought. It has a wider range of clinical features than the classical neonatal seizures and causes specific impairments of higher function, some of which may be reversible. The dosage of pyridoxine should be optimal for IQ as well as seizure control.

Investigation of tetrakis hydroxymethyl phosphonium chloride as an antioxidant for use in x-ray computed tomography polyacrylamide gel dosimetry

Of the antioxidants used to scavenge oxygen in polymer gel dosimeters, tetrakis (hydroxymethyl) phosphonium chloride (THPC) has been shown to hold great promise due to its rapid oxygen scavenging abilities. In this study we (a) investigate the use of THPC as an antioxidant for polyacrylamide gel (PAGAT) dosimeters used in conjunction with x-ray computed tomography (CT) and (b) work to establish the reaction mechanisms of THPC with the polymer gel constituents. We establish the dose response reproducibility of PAGAT dosimeters when imaged with CT and show that PAGAT dosimeters exhibit highly reproducible dose responses for a range of irradiation times post gel manufacture (2-6 h) and CT imaging times post gel irradiation (1-5 days). The THPC concentration within the gel leading to a maximized dose response and minimized O(2) inhibition of polymerization is found to be approximately 4.5 mM. We further assess the stability of PAGAT dosimeters by investigating the reactions of THPC with the individual gel constituents. The importance of utilizing deionized water in polymer gel manufacture is noted. We show that, while THPC remains unreactive with acrylamide and bis-acrylamide under unirradiated conditions, THPC can react with gelatin to increase the cross-linking of the gelatin matrix in unirradiated dosimeters. THPC reactions with gelatin can lead to the lower observed dose sensitivity of PAGAT (approximately 0.36 +/- 0.04 H Gy(-1)) as compared to polyacrylamide gels manufactured under anoxic conditions (approximately 0.83 +/- 0.03 H Gy(-1)). The reactions of THPC which lead to O(2) scavenging, and potential reactions of THPC with other gel constituents, are proposed.

Muscle fibre composition and glycogen depletion in horses competing in an endurance ride

An investigation into fibre composition and glycogen depletion pattern within the middle gluteal of 16 horses participating in an 80 km endurance ride was carried out. Although the proportion of slow twitch high oxidative (ST) fibres in the horses varied between 7 and 38 per cent, it was found that the horses with the highest proportion of these fibres usually had the best performance records. The cross-sectional area of the fast twitch low oxidative (FT) fibres was greatest, with the ST and fast twitch high oxidative (FTH) being similar in size. Most marked histological evidence of glycogen depletion after the ride was in the ST fibres, which were apparently totally depleted. A variable degree of depletion was found in both the FTH and FT fibres. Biochemical measurement of muscle glycogen showed a 56 +/- 7.2 per cent (mean +/- SEM) decrease in content.

Detection of damage to the mitochondrial genome in the oncocytic cells of Warthin's tumour

Warthin's tumour of the salivary glands is composed of oncocytic cells containing excessive numbers of mitochondria which show frequent structural abnormalities and reduced metabolic function. Recent evidence of a strong association between cigarette smoking and the occurrence of Warthin's tumour prompted this study, to look for evidence of damage to mitochondrial DNA (mtDNA) that could be the result of an increase in oxidative stress; two-colour fluorescence in situ hybridization (FISH) was developed to show the distribution of mitochondria with deleted mtDNA in paraffin wax-embedded material. Approximately 10% of mtDNA bears the 'common' 4977 bp deletion. Using the polymerase chain reaction (PCR), the 4977 bp deletion was further quantified, in Warthin's tumour and age-matched normal parotid control tissue. Whilst the deletion was present in all parotid tissue, its presence was significantly higher in oncocytic tumour cells. In a small number of controls, there was a trend towards higher concentrations of the deletion in smokers.

Tethering of the vertebral artery in the congenital arcuate foramen of the atlas vertebra: a possible cause of vertebral artery dissection in children

Twelve children with vertebrobasilar artery stroke are reported (seven males, five females; aged 6 months to 15 years). Patient 1 showed an arcuate foramen in the posterior arch of the atlas, an anatomical variant occurring in 3 to 15% of the population. It was hypothesized that the presence of the arcuate foramen might cause tethering of the vertebral artery and lead to its dissection by repetitive trauma. Lateral plain films of the cervical spine in cases of posterior circulation stroke were taken. Eight of 11 patients showed aberrant arcuate foramina. Of the remaining three patients, one had normal cervical spine X-rays, one had an absent right posterior arch of the atlas following previous surgery for a cervical meningocele, and one patient had incomplete ossification of the vertebrae. Seven of the nine patients with arcuate foramina had vertebral angiograms. In all cases this showed the vertebral artery passing through the arcuate foramen before entering the brain and an appearance consistent with arterial dissection and occlusion at the same site below the foramen. Most documented cases of posterior circulation stroke in children follow trauma, which may be minimal or repetitive, with thrombotic occlusion of the artery at C1-C2 level. The association with an arcuate foramen and its possible causative role in the genesis of posterior circulation stroke in children has not been previously recognized. There may be a causal association between the presence of an arcuate foramen, tethering of the vertebral artery in the foramen, and dissection from repetitive trauma with movement of the neck.

Enhanced intestinal glucose and alanine transport in cystic fibrosis

The rise in short-circuit current associated with the active transport of glucose and alanine was measured in intestinal biopsy samples from children with cystic fibrosis. The glucose-induced increase in the short-circuit current was greater in the cystic fibrosis tissues than in control samples over the whole range of concentrations tested (2.5-35 mM), a reflection of an increased maximum rate of transport. Similar results were obtained with alanine. These findings suggest that active Na(+)-linked nutrient transport is enhanced in cystic fibrosis.

Effect of feeding on the fate of orally administered phenylbutazone, trimethoprim and sulphadiazine in the horse

Phenylbutazone, sulphadiazine and trimethoprim were administered to three horses on two occasions, recently fed and unfed, and the effect of feeding on the pharmacokinetics of the three drugs assessed. The mean peak concentrations of phenylbutazone and trimethoprim were reduced by feeding by 34 and 75 per cent, respectively. The pharmacokinetics of sulphadiazine were not significantly affected.

A randomized controlled trial of laparoscopic extraperitoneal hernia repair as a day surgical procedure

BACKGROUND

A randomized controlled trial was conducted in a day surgery setting comparing a standardized variant of the Shouldice hernioplasty with extraperitoneal laparoscopic herniorrhaphy.

METHODS

The laparoscopic repair was technically challenging, evidenced by conversion from extraperitoneal to transabdominal repairs in 6.25% of patients. It was free from the inherent dangers of intraperitoneal laparoscopy. Surgical morbidity was low and comparable to that for patients randomized to the open repair.

RESULTS

Outcome following laparoscopic extraperitoneal herniorrhaphy varied depending on the parameter measured. It was comparable to the open repair with respect to postoperative activity levels and the number of days required for return to work but inferior to the open repair in terms of operation time and time to hospital discharge. The extraperitoneal approach was superior to the open repair with respect to postoperative pain levels and analgesic requirements. No attempt was made to compare recurrence rates due to the short follow-up period.

CONCLUSIONS

Laparoscopic extraperitoneal herniorrhaphy should not supercede conventional hernia repair until subjected to further trials with the aid of larger study populations and greater technical expertise; the results of long-term recurrence rates are awaited.

Experimental study of electrolysis-induced hepatic necrosis

BACKGROUND

One of the most promising but unexplored methods for treating patients with irresectable liver tumours is electrolysis. This study examined the effect of increasing 'current dose' on the volume of the lesion induced in normal rat liver.

METHODS

A direct current generator, connected to platinum electrodes implanted in the rat liver, was used to examine the effect of (1) varying current doses from 1 to 5 coulombs and (2) electrode separation (2 or 20 mm), on the volume of liver necrosis.

RESULTS

There was a significant correlation (P < 0.001) between the current dose and the volume of necrosis produced for each electrode separation. Placing the electrodes 2 mm apart resulted in smaller total volumes of necrosis than placing them 20 mm apart when anode lesions were significantly larger than cathode lesions (P< 0.05). Liver enzymes (aspartate aminotransferase, alanine aminotransferase) were significantly raised 1 day after treatment (P < 0.001) and predicted the total volume of hepatic necrosis (P < 0.001).

CONCLUSION

Predictable and reproducible areas of liver necrosis are produced with electrolysis. If these results extrapolate to larger animal models, this technique has potential for patients with irresectable primary and secondary liver tumours.

Acute renal failure following cardiopulmonary bypass in children: results of treatment

Following open heart surgery using cardiopulmonary bypass, 18 (4%) of 441 operated children required treatment with peritoneal dialysis for acute renal failure or refractory oliguria. Nine recovered renal function (50%) and 5 (28%) survived. Only 2 died from renal causes. Despite both adequate symptomatic treatment of renal failure and few complications of dialysis itself, the prognosis remains poor, even with early treatment, but an aggressive approach is justified because some survivors can be expected.

X-ray CT dose in normoxic polyacrylamide gel dosimetry

This study reports on the effects of x-ray CT dose in CT imaged normoxic polyacrylamide (nPAG) gel dosimeters. The investigation is partitioned into three sections. First, the CT dose absorbed in nPAG is quantified under a range of typical gel CT imaging protocols. It is found that the maximum absorbed CT dose occurs for volumetric imaging and is in the range of 4.6 +/- 0.2 cGy/image. This does scales linearly with image averaging. Second, using Raman spectroscopy, the response of nPAG to CT imaging photon energies (i.e., 120-140 kVp) is established and compared to the well known dose response of nPAG exposed to 6 MV photons. It is found that nPAG exhibits a weaker response (per unit dose) to 140-kVp incident photons as compared to 6 MV incident photons (slopes m6 mv = -0.0374 +/- 0.0006 Gy(-1) and m140 kVp = -0.016 +/- 0.001 Gy(-1)). Finally, using the above data, an induced change in CT number (deltaN(CT)) is calculated for nPAG imaged using a range of gel imaging protocols. It is found that under typical imaging protocols (120-140 kVp, 200 mAs, approximately 16-32 image averages) a deltaN(CT) < 0.2 H is induced in active nPAG dosimeters. This deltaN(CT) is below the current limit of detectability of CT nPAG polymer gel dosimetry. Under expanded imaging protocols (e.g., very high number of image averages) an induced deltaN(CT) of approximately 0.5 H is possible. In these situations the additional polymerization occurring in nPAG due to the imaging process may need to be accounted for.

Utrophin abundance is reduced at neuromuscular junctions of patients with both inherited and acquired acetylcholine receptor deficiencies

Congenital myasthenic syndromes are a heterogeneous group of conditions in which muscle weakness resulting from impaired neuromuscular transmission is often present from infancy. One form of congenital myasthenic syndrome is due to a reduction of the number of acetylcholine receptors (AChRs) at the neuromuscular junction. We describe four new cases of AChR deficiency, characterized by a reduction in both miniature endplate potential amplitude and AChR abundance accompanied by elongation of the neuromuscular junction and some decrease in postsynaptic folding. A number of cytoplasmic proteins are normally associated with the postsynaptic membrane and may contribute to the clustering of AChRs at the neuromuscular junction. We therefore investigated the expression of several of these proteins in these AChR-deficiency patients. In each patient, immunolabelling of the neuromuscular junction for rapsyn, dystrophin, beta-dystroglycan and a form of beta-spectrin was strong but that for utrophin was markedly reduced or absent. This suggested that a defect in utrophin expression might underlie the congenital AChR deficiency. However, a reduction in utrophin labelling was also seen in three patients with adult acquired autoimmune myasthenia gravis in whom AChR loss results directly from the extracellular binding of autoantibodies. We conclude that the loss of AChRs in AChR deficiency does not result from the absence of rapsyn or beta-dystroglycan and that reduction of utrophin is probably secondary to the loss of AChRs. The possible role of AChRs and/or utrophin in determining the extent of postsynaptic folding is discussed.

Splenic size and function in adult coeliac disease

Splenic scintigraphy was performed after measurement of 99Tcm-labelled heat-damaged red cell clearance in 29 patients with treated coeliac disease. Good correlation was found between splenic size and function using these techniques. 99Tcm-labelled sulphur colloid scintiscans were also performed in 24 coeliacs. Splenic volumes computed from colloid scans correlated well with those computed from red cell scans. Almost 50% of adult patients with treated coeliac disease have impaired splenic function, the incidence rising with increasing age of starting treatment. Sulphur colloid scintigraphgy provides a simple quantitative method of assessing splenic function in treated coeliac disease which can be used in exploring the possibilities of avoidance of the adverse effects of hyposplenism.

Fecundity of anthelmintic resistant adult Haemonchus contortus after exposure to ivermectin or benzimidazoles in vivo

A strain of Haemonchus contortus resistant to the benzimidazoles, ivermectin and salicylanilides was used to study the effect of exposure to ivermectin or oxfendazole on the number of eggs produced by adult female parasites. After anthelmintic administration there was a reduction in the faecal egg count of the infected lambs. Ivermectin caused a reduction in the number of eggs within adult parasites for up to 72 hours but this returned to higher than pre-treatment levels at 168 hours after treatment. After oxfendazole treatment there was an increase in the number of eggs stored in the adult parasites at 24 hours and then a significant reduction in the number of eggs for over 168 hours. This suggested that both ivermectin and oxfendazole have a deleterious effect on the reproductive potential of female H contortus although the parasites are resistant to these drugs. These results confirm the importance of allowing up to 10 days to elapse between the time of administration of an anthelmintic and the collecting of faecal samples when using the faecal egg count reduction test to identify anthelmintic resistance, especially when using benzimidazoles. The more prolonged effect on fecundity produced by oxfendazole may reflect the antimitotic action of the benzimidazole anthelmintics.

Oral absorption and bioavailability of fenbendazole in the dog and the effect of concurrent ingestion of food

Fenbendazole was administered orally without food to six beagle dogs at 2.5, 5.0, 10, 20, 40 and 80 mg/kg of body weight. Increasing the dose rate did not significantly increase the amount of fenbendazole absorbed. In a separate study fenbendazole was administered to the same six beagle dogs at a dose rate of 20 mg/kg of bodyweight in food with high, medium and low fat content. The food provided 1.52, 0.70 or 0.34 g of fat per kg of body weight. Administration of fenbendazole in food with different fat contents did not affect its relative bioavailability. Administration of fenbendazole at a dose rate of 20 mg/kg in food, irrespective of fat content, did however significantly increase its bioavailability when compared to administration of the same dose as a bolus on an empty stomach.

Pallidal stimulation for pantothenate kinase-associated neurodegeneration dystonia

Pantothenate kinase-associated neurodegeneration is associated with generalised dystonia and cognitive deterioration. Limited evidence suggests that pallidal deep brain stimulation improves physical functioning. This is a report of the assessment and treatment of a severely affected patient in whom pallidal deep brain stimulation improved both physical and psychosocial functioning. Implications for treatment are briefly discussed.

Surgery for scoliosis in Duchenne muscular dystrophy

BACKGROUND

Scoliosis in people with Duchenne muscular dystrophy is usually progressive and treated with surgery. However, it is unclear whether the existing evidence is sufficiently scientifically rigorous to support a recommendation for spinal surgery for most people with Duchenne muscular dystrophy and scoliosis.

OBJECTIVES

The objectives of this systematic review were to determine the effectiveness and safety of spinal surgery in Duchenne muscular dystrophy patients with scoliosis. We intended to test whether spinal surgery is effective in increasing life expectancy, improving respiratory function, improving quality of life and overall functioning; and whether spinal surgery is associated with severe adverse effects.

SEARCH STRATEGY

We searched the specialized registers of the Cochrane Neuromuscular Disease Group and Cochrane Back Group, the Cochrane Central Register of Controlled Trials (January 2006), MEDLINE (January 1966 to January 2006), EMBASE (January 1980 to January 2006), Dissertation Abstracts International (1861 to Jan 2006), CINAHL (January 1982 to January 2006), and the National Institute of Health Clinical Trials Database (January 2006). No language restrictions were imposed.

SELECTION CRITERIA

Controlled clinical trials using random or quasi-random allocation of treatment evaluating all forms of spinal surgery for scoliosis in patients with Duchenne muscular dystrophy were to be included in the review. The control interventions would have been no treatment, non-operative treatment, or a different form of spinal surgery.

DATA COLLECTION AND ANALYSIS

Two authors examined the search results and evaluated the study characteristics against inclusion criteria to decide which ones would be included in the review.

MAIN RESULTS

A total of 402 studies were identified from electronic searching. Thirty-six studies were relevant but none met the inclusion criteria for the review, because they were not clinical trials but prospective or retrospective reviews of case series.

AUTHORS' CONCLUSIONS

Since there were no randomized controlled clinical trials available to evaluate the effectiveness of scoliosis surgery in people with Duchenne muscular dystrophy, no evidence-based recommendation can be made for clinical practice. Patients should be informed about the uncertainty of benefits and potential risks of surgery for scoliosis. Randomized controlled trials are needed to investigate the effectiveness of scoliosis surgery, in terms of patients' quality of life, functional status, respiratory function and life expectancy.

The pharmacokinetics of meclofenamic acid in the horse

The pharmacokinetics of meclofenamic acid were studied in Thoroughbred horses and in ponies. After intravenous (i.v.) administration of either 2 mg/kg or 4 mg/kg sodium meclofenamate the elimination half-life was of the order of 0.9 h while the volume of distribution was found to be 0.128 litre/kg. Elimination was in accordance with a one-compartment model. Following oral administration of either meclofenamic acid (4 mg/kg) or sodium meclofenamate (4 mg/kg) a much longer terminal half-life than that calculated for Kel from i.v. data was found. This anomaly indicated that the 'flip-flop' phenomenon was present, i.e. Ka exceeded Kel. More rapid and higher peak levels occurred following sodium meclofenamate than meclofenamic acid, although total bioavailability was similar. Studies in ponies with meclofenamic acid showed a lower absorption than that found in Thoroughbreds. Overnight fasting before meclofenamic acid administration did not alter the rate or extent of absorption. Intramuscular administration of sodium meclofenamate resulted in low plasma concentrations and after 25 h only 46% of the drug had been absorbed.

The laryngeal mask airway in experimental pig anaesthesia

The pig is used as a large animal model in many research projects. Standard practice for airway maintenance under general anaesthesia is using endotracheal (ET) intubation after intravenous induction to a near surgical plane. This is a technically demanding skill, requiring the assistance of an experienced technician. A technique is required which simplifies pig anaesthesia. This study examined the feasibility and potential advantages of using the laryngeal mask airway (LMA) in 10 pigs during laparotomy under spontaneous breathing anaesthesia. The results show that the LMA can be inserted rapidly, with minimal time for airway control by researchers relatively inexperienced in anaesthesia and is associated with few complications. By removing the need for intravenous induction, an entire step in the anaesthetic process is removed. The LMA designed for humans fits well in the pig hypopharynx; all pigs could be manually ventilated with no detectable gas leak. Although the pigs in this study were spontaneously breathing it is proposed that the LMA should be further investigated in studies of artificially ventilated pigs.

Pharmacokinetics of carprofen administered intravenously to sheep

Carprofen was administered intravenously to sheep at two dose rates (0.7 and 4.0 mg kg-1), and the pharmacokinetics of the drug studied. Plasma concentrations of the drug were measured by high performance liquid chromatography. Carprofen had a small volume of distribution (Vd[area], 95.5 and 118.4 ml kg-1), a prolonged elimination half-life (t1/2 beta, 26.1 and 33.7 hours) and a slow body clearance rate (Clb, 2.5 ml kg-1 h-1) in sheep.