Selenium depletion and its correction in a child with homocystinuria

A child of 10 months with proven homocystinuria was found to be selenium depleted and we report the serial monitoring of replacement therapy. Selenium, as an enriched yeast preparation, equivalent to 50 mug on alternate days was required for maintenance. Indices of selenium status returned to normal in varying times. The child initially demonstrated an abnormality of an in vitro challenge by hydrogen peroxide to her erythrocytes, that returned to within normal limits with selenium therapy alone, the serum vitamin E concentration being normal.     

Comparative effectiveness of biologics for the management of rheumatoid arthritis: systematic review and network meta-analysis

Our aim was to establish the comparative effectiveness of rheumatoid arthritis (RA) biologics, using a systematic review and network meta-analysis. The systematic review used randomized controlled trials (RCTs) in adults with RA who failed treatment with conventional disease-modifying agents for rheumatoid disease (cDMARDs). We compared the effectiveness of abatacept, adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, and rituximab to tocilizumab, a recent biologic with a different mechanism of action (anti-IL-6 receptor). A network meta-analysis (NMA) included the indirect and direct evidence previously selected. In total, 207 articles were included describing 68 RCTs. The NMA showed that tocilizumab monotherapy was superior to standard care (ACR20, OR 13.27, 95 % CrI [3.958, 43.98]; ACR50, 17.45 [10.18, 31.24]; ACR70, 37.77 [7.226, 216.3]; EULAR, 10.42 [1.963, 54.8]); and methotrexate (MTX; ACR50, OR 5.44 [4.142, 7.238]; ACR70, 7.364 [1.4, 30.83]; EULAR, 4.226 [1.184, 15.58]) at 26 weeks. Similarly, the combination of tocilizumab + MTX was significantly better than standard care/placebo and MTX alone for ACR20, ACR50, ACR70, and EULAR at 26 weeks (OR 18.63 [5.32, 66.81]; 24.27 [14.5, 41.91]; 46.13 [10.08, 277]; 14.23 [2.493, 84.02]; 4.169 [2.267, 7.871]; 5.44 [4.142, 7.238]; 8.731 [4.203, 19.29]; 7.306 [4.393, 13.04], respectively). At 52 weeks, compared to MTX alone, tocilizumab + MTX was significantly better for ACR20 and ACR50 response. Few significant differences were found between tocilizumab (alone or in combination) and any other biologics. Results must be considered in context with the limitations of the available evidence. This NMA suggests that tocilizumab was superior to cDMARDs and as effective as other biologics for RA.     

Distal hypospadias: which repair?

OBJECTIVE: To compare the function, complications and cosmesis after a modified Thiersch-Duplay and Mathieu unstented urethroplasty. PATIENTS AND METHODS: Over a 5-year period 381 consecutive patients (not randomized) with distal hypospadias were evaluated. A modified Thiersch-Duplay with dorsal incised urethral plate tubularization (group A) was undertaken in 170 (45%) and a parameatal based flip-flap Mathieu hypospadias repair (group B) in 211 (55%). No urinary diversion or stent was used in any of the 381 patients. RESULTS: In both groups the mean (sd) follow-up was 3.1 (1.4) years. All 381 patients voided spontaneously after surgery and none developed urinary retention needing catheterization. In groups A and B, respectively, the overall late complications were 12 (7.1%) and 32 (15.2%) (P=0.001), with urethrocutaneous fistula in six (3.5%) and 26 (12.3%; P=0.001); secondary surgery for fistula repair was successful in all boys in A and 89% in B. The glanular meatus was a vertical slit in all in group A and 86% in B (P=0.02). In both groups, 71% of the children who are now toilet-trained and standing to void have a good calibre, single and straight urinary stream in a forward direction. CONCLUSIONS: Stenting or urinary diversion is unnecessary after distal hypospadias surgery. The functional results were good in those standing to void. A more natural vertical slit-like glanular meatus was easily created using the modified Thiersch-Duplay urethroplasty, with a lower fistula rate.     

High-resolution computed tomographic characteristics in acute farmer's lung and in its follow-up.

High resolution computed tomography (HRCT) scans are increasingly used in hypersensitivity pneumonitis (HP). This study looked at HRCT findings at different phases of farmer's lung (FL), a common form of HP. A cross sectional analysis of 95 HRCT scans of FL cases (20 acute, 75 with a history of FL, 48 still in contact (Ex +) (dairy farm), and 27 who had ceased contact (Ex-)) was made. All scans were read independently by two, and if needed by three, radiologists blinded to the category. The lungs were divided into six regions (fives lobes + lingula), and read for attenuation/mosaic, ground-glass, micronodules, fibrosis, and emphysema. A score of 0-3 was given for each region and each variable: 0 = absence, 1 =<25% of the surface, 2 = 25-50%, 3 =>50%. Mediastinal lymphadenopathy was also noted. Ground glass, predominating in the lower lobes, was the most frequent feature in the acute and Ex+ cases. Other abnormalities had no preferential distribution. Ex+ had more ground-glass than the Ex- (p=0.0025). Emphysema was more frequently seen than interstitial fibrosis (p=0.004). Mediastinal lymphadenopathy was present in 26 cases (9 acute, 10 Ex+ and 7 Ex-). In conclusion, in farmer's lung: 1) ground-glass predominates in the lower lobes while the other abnormalities have no anatomic predilection; 2) contact avoidance allows a better resolution of computed tomography abnormalities than continued exposure; 3) emphysema is a more frequent finding than interstitial fibrosis; and 4) the presence of mediastinal lymphadenopathy has no negative diagnostic value.     

Megafaunal meiolaniid horned turtles survived until early human settlement in Vanuatu,Southwest Pacific

Meiolaniid or horned turtles are members of the extinct Pleistocene megafauna of Australia and the southwest Pacific. The timing and causes of their extinction have remained elusive. Here we report the remains of meiolaniid turtles from cemetery and midden layers dating 3,100/3,000 calibrated years before present to approximately 2,900/2,800 calibrated years before present in the Teouma Lapita archaeological site on Efate in Vanuatu. The remains are mainly leg bones; shell fragments are scant and there are no cranial or caudal elements, attesting to off-site butchering of the turtles. The new taxon differs markedly from other named insular terrestrial horned turtles. It is the only member of the family demonstrated to have survived into the Holocene and the first known to have become extinct after encountering humans.     

Hereditary Orotic Aciduria: Evidence for a Structural Gene Mutation

Orotic aciduria is a rare autosomal recessive disease in man due to a deficiency of orotate phosphoribosyltransferase (EC 2.4.2.10; orotidine-5′-phosphate:pyrophosphate phosphoribosyltransferase) and orotidine-5′-phosphate decarboxylase (EC 4.1.1.23; orotidine-5′-phosphate carboxy-lyase). We have compared certain physicochemical properties of orotidine-5′-phosphate decarboxylase from normal and mutant fibroblasts grown under identical conditions. Orotidine-5′-phosphate decarboxylase from homozygous mutant cells was more thermolabile and exhibited a different electrophoretic mobility when compared to the enzyme from normal cells; orotidine-5′-phosphate decarboxylase from one heterozygous cell strain exhibited an intermediate thermolability while the other heterozygote displayed a thermal inactivation curve indistinguishable from normal. The enzyme from both normal and mutant cells exhibited biphasic kinetics with the same apparent Michaelis constants. These data suggest that the molecular defect in the enzyme of this patient with orotic aciduria is due to a mutation in a gene that affects the structure of either orotate phosphoribosyltransferase or orotidine-5′-phosphate decarboxylase and cannot be attributed to a mutation in a regulatory gene, as previously suggested.     

Angiotensin II infused intrarenally causes preglomerular vascular changes and hypertension

The effects on the renal vasculature and on arterial blood pressure of chronic infusion of low doses of angiotensin II (Ang II) into the renal artery were studied. Sprague Dawley rats were infused continuously with Ang II (0.5, 1.5, or 4.5 ng. kg(-1). min(-1)) or vehicle into the right renal artery (contralateral nephrectomy). Intrarenal Ang II infusion for 25 days produced dose-dependent rises (P:<0.001) in awake mean arterial pressure (111+/-1, 119+/-5, and 130+/-3 mm Hg in rats receiving 0.5, 1.5, and 4.5 ng. kg(-1). min(-1) Ang II, respectively) compared with 105+/-1 mm Hg (vehicle). Renal vessel lumen characteristics were assessed with an established, maximally dilated, isosmotic perfused kidney preparation. This revealed a small dose-dependent right shift in the pressure-flow relation (P=0.05), as well as a dose-dependent right shift and a dose-dependent reduction in the slope of the pressure-glomerular filtration rate relation (P=0.04 and 0.03, respectively). The effects of Ang II infusion on arterial pressure were not affected by the timing of the contralateral nephrectomy but were reduced when the contralateral kidney remained in situ. Acute losartan administration (10 mg/kg IV bolus) produced similar effects on arterial pressure in rats infused with vehicle or Ang II (4.5 ng. kg(-1). min(-1)) for 14 days, P=0.89), indicating the lack of systemic spillover of Ang II. Intraperitoneal Ang II (0.5, 1.5, or 4.5 ng. kg(-1). min(-1) for 25 days) had no effect on arterial pressure. Thus, chronic intrarenal infusion of low doses of Ang II resulted in changes in the renal vasculature compatible with dose-related structural reductions in the lumen diameter of preglomerular vessels and produced dose-related increases in arterial pressure.