[Screening of the SETX gene in sporadic amyotrophic lateral sclerosis patients of Chinese origin]

Objective: To investigate all coding regions of amyotrophic lateral sclerosis (ALS)-related gene Senataxin (SETX) in sporadic amyotrophic lateral sclerosis patients of Chinese origin. Methods: From January 2010 to December 2014, the peripheral venous blood samples and clinical data were collected from 311 patients with sporadic amyotrophic lateral sclerosis (SALS) and 311 healthy controls who were of Chinese ancestry from the Department of Neurology, Chinese PLA General Hospital.Genomic DNA was extracted from peripheral venous blood of all participants using standard methods. The coding regions of SETX were amplified by polymerase chain reaction (PCR) and screened for mutations using next-generation sequencing technology. The online software SIFT and PolyPhen-2 were used to analyze the conservation of an altered amino acid and predict the potential pathogenicity of identified mutations. The SPSS 22.0 software was used to analyze the clinical feature of all participants. Results: Tenkinds of rare and one novel nonsynonymous mutations were identified and were absent in 311 controls. Twelve (3.86%) patients carried one SETX gene mutation. Five (1.61%) out of above-mentioned 12 patients carried highly pathogenic mutations including p. Pro1868Leu (c.5603G>A), p. Pro1331Leu (c.3992G>A), p. Glu756Val (c.2267T>A), p. Leu564Val (c.1690A>C), and p. Asn144Ser (c.431T>C). Patients carried SETX mutations were not different from other patients in onset age. Conclusion: Mutations in SETX are likely to be a pathogenesis for Chinese sporadic amyotrophic lateral sclerosis.

[Prevalence of thyroid function in pregnant and lactating women in areas with different iodine levels of Shanxi province]

Objective: To investigate the effects of high iodine intake on thyroid function in pregnant and lactating women. Methods: A cross sectional epidemiological study was conducted among 130 pregnant women and 220 lactating women aged 19-40 years in areas with high environment iodine level (>300 μg/L) or proper environment iodine level (50-100 μg/L) in Shanxi in 2014. The general information, urine samples and blood samples of the women surveyed and water samples were collected. The water and urine iodine levels were detected with arsenic and cerium catalysis spectrophotometric method, the blood TSH level was detected with electrochemiluminescence immunoassay, and thyroid stimulating hormone (FT(4)), antithyroid peroxidase autoantibody (TPOAb) and anti-thyroglobulin antibodies (TGAb) were detected with chemiluminescence immunoassay. Results: The median urine iodine levels of the four groups were 221.9, 282.5, 814.1 and 818.6 μg/L, respectively. The median serum FT(4) of lactating women in high iodine area and proper iodine area were 12.96 and 13.22 pmol/L, and the median serum TSH was 2.45 and 2.17 mIU/L, respectively. The median serum FT(4) of pregnant women in high iodine area and proper iodine area were 14.66 and 16.16 pmol/L, and the median serum TSH was 2.13 and 1.82 mIU/L, respectively. The serum FT(4) levels were lower and the abnormal rates of serum TSH were higher in lactating women than in pregnant women in both high iodine area and proper iodine area, the difference was statistically significant (FT(4): Z=-6.677, -4.041, P<0.01; TSH: Z=8.797, 8.910, P<0.01). In high iodine area, the abnormal rate of serum FT(4) in lactating women was higher than that in pregnant women, the difference was statistically significant (Z=7.338, P=0.007). The serum FT(4) level of lactating women in high iodine area was lower than that in proper iodine area, the difference was statistically significant (Z=-4.687, P=0.000). In high iodine area, the median serum FT(4) in early pregnancy, mid-pregnancy and late pregnancy was 16.26, 14.22 and 14.80 pmol/L, respectively, and the median serum TSH was 1.74, 1.91 and 2.38 mIU/L, respectively. In high iodine area, the serum FT(4) level in early pregnancy was higher than that in mid-pregnancy and late pregnancy, and the serum TSH level was lower than that in mid-pregnancy and late pregnancy, the difference was statistically significant (FT(4): Z=-2.174, -2.238, P<0.05; TSH: Z=-2.985, -1.978, P<0.05). There were no significant differences in the positive rates of serum thyroid autoantibodies among the four groups of women and women in different periods of pregnancy (P>0.05). The morbidity rates of subclinical hyperthyroidism in pregnant women and lactating women in high iodine area were obviously higher than those in proper iodine areas, the difference was statistically significant (χ(2)=5.363, 5.007, P<0.05). Conclusions: Excessive iodine intake might increase the risk of subclinical hypothyroidism in pregnant women and lactating women. It is suggested to strengthen the iodine nutrition and thyroid function monitoring in women, pregnant women and lactating women in areas with high environmental iodine.

Role of esophagogastroduodenoscopy in detecting distal duodenal lesions: A single-center pilot study in Southern China

OBJECTIVE

Esophagogastroduodenoscopy (EGD) is a standard instrument for detecting upper gastrointestinal lesions. However, the distal duodenum is often missed. This study aimed to clarify the diagnostic role of EGD in the distal duodenum.

METHODS

This retrospective study enrolled patients with distal duodenal lesions who underwent EGD between January 2004 and July 2016 at our center. The rate of missed diagnosis using EGD examination was calculated. Logistic regression analysis was performed to identify the factors associated with the missed diagnoses.

RESULTS

Sixty-three patients were included in the study. The overall diagnostic rate of distal duodenal lesions on EGD was 58.7%. After excluding the patients in whom the EGD did not reach the distal duodenum, this rate rose to 82.2%. In univariate analysis, intravenous sedation (26.8% vs 68.2%, odds ratio [OR] 0.171, P = 0.002), signs of lesions adjacent to the stomach (19.4% vs 62.5%, OR 0.099, P = 0.001), prior enteroscopy experience (15.0% vs 87.0%, OR 0.026, P < 0.001), and endoscopists with experiences of over 10 years (13.8% vs 64.7%, OR 0.087, P = 0.000) were associated with a decreased risk of missed diagnosis. In multivariate analysis, signs of lesions adjacent to the stomach (OR 0.167, P = 0.039) and prior enteroscopy experience (OR 0.035, P < 0.001) were significant independent protective factors.

CONCLUSION

EGD may be important in diagnosing distal duodenal lesions. Patients with gastric retention, blood in the stomach or erosion in the proximal duodenum may benefit from the deep insertion of EGD.

[Characteristics of repetitive nerve stimulation in 53 cases of amyotrophic lateral sclerosis]

Objective: To investigate the feature of repetitive nerve stimulation (RNS) in patients with amyotrophic lateral sclerosis (ALS) and correlation between RNS and clinical features and electromyography (EMG) findings of the corresponding muscle. Methods: Needle EMG and RNS were performed in 53 patients with ALS, who were recruited into Department of Neurology of Chinese PLA general hospital during April to December in 2016. Decrement of the compond muscle action potential (CMAP) in response to RNS of different nerves and stimulus frequencies was compared. The effects of gender, age of onset, disease duration, region of onset, ALS functional rating scale-revised (ALSFRS-R) and rate of disease progression (ΔFS) on the decrement were analyzed. Results: 49.1% of patients with ALS had decremental responses to low frequency RNS (LF-RNS) in accessory nerve, which was lower in ulnar nerve (4.3%) and common peroneal nerve (2.6%). Decremental responses of accessory nerve at 3 Hz were observed in 49.1% of patients with ALS, more frequent than 30.2% at 1 Hz. None of the patients had increased responses to high frequency RNS. Patients with upper-limb-onset, longer disease duration and lower ALSFRS-R tended to have more frequent decrement of CMAP in response to RNS. The decrement with LF-RNS of accessory nerve was in concert with neurogenic damage of sternocleidomastoid muscle with needle EMG (r=0.365, P=0.007). There were 3 patients who had decremental responses to LF-RNS in accessory nerve without clinical involvement and neurogenic damage of sternocleidomastoid muscle. Conclusions: There is significant decrement of CMAP in response to LF-RNS of accessory nerve in patients with ALS, which may reveal neuromuscular junction (NMJ) impairment. It may indicated a dying-back pattern of disease progression which derived from motor neuron terminal or NMJ to neuronal soma that some patients with ALS have decremental responses in RNS without clinical involvement and neurogenic damage of sternocleidomastoid muscle.

[An analysis of characteristics of nerve conduction in 154 cases of amyotrophic lateral sclerosis]

Objective: To analyze the features of nerve conduction in patients with amyotrophic lateral sclerosis (ALS), and explore the correlation between compound muscle action potential (CMAP) amplitude and disease duration and revised amyotrophic lateral sclerosis functional rating scale (ALSFRS-R). Methods: Standard motor and sensory nerve conduction studies were performed in 154 patients with ALS. The following parameters were collected including CMAP amplitude, distal motor latency (DML), motor conduction velocity, sensory conduction velocity and sensory nerve action potential amplitude. Regression study was done to explore the correlation between CMAP amplitude and disease duration and ALSFRS-R. Results: Motor nerve conduction abnormalities were presented in a majority of the patients with prolonged DML in the tibial nerve, median nerve and ulnar nerve as the most common form (61.06%-81.42%), followed by decreased CMAP amplitude (30.12%-53.98%), decreased MCV (12.05%-16.81%) and absence of CMAP (2.65%-9.73%). Sensory nerve conduction abnormalities were detected in a small proportion of patients and the decreased SCV, decreased SNAP amplitude and absence of SNAP in the sural nerve, median nerve and ulnar nerve were found in 1.22%-2.73%, 0-1.82% and 0-1.22% patients respectively. No correlation was found between CMAP of the common peroneal nerve, tibial nerve, median nerve and ulnar nerve and the disease duration (P>0.05), while significant positive correlation was established between CMAP amplitude of the median nerve and ulnar nerve and ALSFRS-R (r=0.273, P=0.016; r=0.357, P=0.001). Conclusions: Motor nerve conduction is abnormal in a majority of ALS patients with prolonged DML as the most common form, while abnormal sensory nerve conduction is only found in a few of ALS patients. CMAP amplitude of the median nerve and ulnar nerve might be of certain clinical value in evaluating the severity of ALS.

[Needle electromyography features and values of paraspinal muscle parameters in assessment of respiratory function of patients with amyotrophic lateral sclerosis]

Objective: To analyze the features of needle electromyography (EMG) in patients with amyotrophic lateral sclerosis (ALS), and explore the correlation between EMG parameters of the tenth thoracic paraspinal muscle and disease duration, rate of disease progression, forced vital capacity (FVC) and revised Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-R). Methods: Standard EMG was recorded from unilateral sternocleidomastoid muscle and/or tongue muscles, upper and lower limbs muscles and the tenth thoracic paraspinal muscle in 112 patients with definite ALS between March 2012 and June 2013 in the Department of Neurology at Chinese PLA General Hospital. Parameters studies included spontaneous potentials, duration and amplitude of motor unit potentials (MUP), pattern of recruitment. Results: EMG revealed diffuse neurogenic changes in each case. Fibrillation potential or positive sharp waves were found in some muscles in all of patients, and both of them were found in most of the cases. Fasciculation potentials (FPs) were found in 8 patients and accompanied with fibrillation potential and positive sharp waves in 5 of them. Complex repetitive discharges (CRDs) were found in only 1 patient. Duration and amplitude of MUP was prolonged and increased in ALS patients, and the rate of high amplitude and decreased recruitment pattern were 35.71% and 72.32%, respectively. Logistic regression analysis revealed an association of the FVC loss with the drop of ALSFRS-R and peak amplitude of the tenth thoracic paraspinal muscle. Conclusions: The abnormal spontaneous activity with high frequency are fibrillation potentials and/or positive sharp waves. However, FPs is observed in a small number of patients and CRDs is rarely seen in ALS. The ALSFRS-R and peak amplitude of thetenth thoracic paraspinal muscle may be of certain clinical value in estimating the severity of disease especially the respiratory dysfunction in ALS patients.

Cap-aspiration lumpectomy for small submucosal tumors originating from the muscularis propria of the gastric fundus: a preliminary study (with videos)

OBJECTIVE

Small fundal submucosal tumors (SMTs) originated from the muscularis propria pose great difficulties to conventional therapies. We aimed to evaluate the feasibility and safety of endoscopic cap-aspiration lumpectomy (CASL) as a new and simple full-thickness resection for the treatment of small fundal SMTs.

METHODS

From July 2013 to February 2014, patients with small fundal SMTs of ≤10 mm in diameter that were originated from muscularis propria were included in the study. CASL was performed by suctioning SMTs into a transparent cap, ligating with a metal snare and resecting the tumors. The wall deficit was closed by using endoclips.

RESULTS

Altogether 28 patients were included in the study. CASL achieved an en bloc resection rate of 100%, with a mean total procedure time of 23.9 min. Active perforation was found in 20 (71.4%) patients, and endoclips closed the wall defect in all 20 cases. One patient developed pneumoperitoneum and self-limited peritonitis was found in two patients, all of whom were managed successfully. Pathological examination showed that 71.4% (20/28) of the tumors were gastrointestinal stromal tumors. No tumor recurrence was observed during the follow-up.

CONCLUSIONS

CASL may be a feasible and safe full-thickness resection modality for the treatment of small fundal SMTs arising from the muscularis propria. Further randomized studies are needed to confirm the results.