Long term disease burden post-transplantation: three decades of observations in 25 Hurler patients successfully treated with hematopoietic stem cell transplantation (HSCT).

BACKGROUND: Mucopolysaccharidosis type I-Hurler syndrome (MPSI-H) is a lysosomal storage disease characterized by severe physical symptoms and cognitive decline. Early treatment with hematopoietic cell transplant (HSCT) is critical to the survival of these patients. While survival rates and short-term outcomes are known to be improved by HSCT, the long-term cognitive, adaptive and psychosocial functional outcomes of children with (MPSI-H) post-HSCT are not well documented. This manuscript focuses on retrospective long-term follow-up (7-33 years) of 25 MPSI-H patients, transplanted between 1986 and 2011. RESULTS: The median age at transplantation was 21 months (range 12-57 months). Except for one death, all successfully transplanted MPSI-H patients surviving at least 1 year after HSCT are alive to-date, with a median age of 21 years (range 8-36 years) at the last follow-up evaluation. A majority of HSCT grafts were bone marrow transplants (BMT), resulting in durable full chimerism in 18 (72%). Pre-HSCT, the onset of first symptoms occurred very early, at a median age of 3 months (range birth-16 months). The most prevalent symptoms before MPSI-H diagnosis involved progressive dysostosis multiplex; almost all patients suffered from hip dysplasia and thoracolumbar spine Kyphosis. Despite HSCT, considerable residual disease burden and ensuing corrective surgical interventions were observed in all, and at every decade of follow-up post HSCT. Late-onset psychiatric manifestations were significant (n = 17 patients; 68%), including depression in 13 patients at a median onset age of 18 years (range 13-31 years), hyperactivity and attention deficit disorder (n = 4), and multiple acute psychotic episodes (APE), independent of depression observed (n = 3) at a median onset age of 18 years (range 17-31 years). The adult Welscher Intelligence Scale results (n = 16) were heterogenous across the four scale dimensions; overall lower scores were observed on both working memory index (median WMI = 69.5) and processing speed index (median PSI = 65), whereas verbal comprehension index (median VCI = 79) and perceptual reasoning index (median PRI = 74) were higher. CONCLUSION: With advanced treatment options, MPSI-H are living into 3rd and 4th decades of life, however not disease free and with poor adaptation. Residual disease (loss of mobility, limited gross and fine motor skills; low cognitive ability; suboptimal cardiopulmonary function, vision and hearing) negatively impacts the quality of life and psychosocial functioning of affected individuals.

Stability of tedizolid phosphate-sodium rifampicin and tedizolid phosphate-meropenem admixtures in intravenous infusion bags stored at different temperatures.

This is a report on the chemical stability and physical compatibility of intravenous tedizolid phosphate 0.8 mg/mL-sodium rifampicin 2.4 mg/mL and tedizolid phosphate 0.8 mg/mL-meropenem 4 mg/mL combinations in polypropylene 0.9% sodium chloride infusion bags stored at different storage conditions. Triplicate solutions of both admixtures were prepared in 0.9% sodium chloride polypropylene infusion bags and stored under light protection at room temperature (25±2 °C), refrigeration (2-8 °C) or freezing (-15 - -25 °C) conditions. The study was performed using a validated and stability-indicating liquid chromatography (LC) method. For both admixtures and for all storage conditions, at least 90% of the initial drug concentration of tedizolid phosphate remained unchanged throughout the entire study period. Stability of sodium rifampicin at 25±2 °C was determined to be seven hours and six days when it was stored at 2-8 °C. Under the same storage conditions, meropenem was stable for 12 h or 6 days, respectively. Under freezing conditions, sodium rifampicin was stable throughout all 28 days, while stability of meropenem was only 8 days. Solutions of 0.8 mg/mL tedizolid phosphate admixtured with 2.4 mg/mL rifampicin or 4 mg/mL meropenem, in polypropylene 0.9% sodium chloride infusion bags, are stable for at least 7 or 12 hours, respectively, when stored at 25±2 °C. When stored at 2-8 °C, stability was increased to 6 days for both admixtures.

Fit-for-purpose chromatographic method for the determination of amikacin in human plasma for the dosage control of patients.

In this paper, a simple, rapid and sensitive method based on liquid chromatography with fluorimetric detection (HPLC-FLD) for the determination of amikacin (AMK) in human plasma is developed. Determination is performed by pre-column derivatization of AMK with ortho-phtalaldehyde (OPA) in presence of N-acetyl-L-cysteine (NAC) at pH 9.5 for 5 min at 80 °C. In our knowledge, this is the first time that NAC has been used in AMK derivatization. Derivatization conditions (pH, AMK/OPA/NAC molar ratios, temperature and reaction time) are optimized to obtain a single and stable, at room temperature, derivative. Separation of the derivative is achieved on a reversed phase LC column (Kromasil C18, 5 µm, 150 × 4.6 i.d. mm) with a mobile phase of 0.05 M phosphate buffer:acetonitrile (80:20, v/v) pumped at flow rate of 1.0 mL/min. Detection is performed using 337 and 439 nm for excitation and emission wavelengths, respectively. The method is fitted for the purpose of being a competitive alternative to the currently used method in many hospitals for AMK dosage control: fluorescence polarization immunoassay (FPIA). The method exhibits linearity in the 0.17-10 µg mL(-1) concentration range with a squared correlation coefficient higher than 0.995. Trueness and intermediate precision are estimated using spiked drug free plasma samples, which fulfill current UNE-EN ISO15189:2007 accreditation schemes. Finally, for the first time, statistical comparison against the FPIA method is demonstrated using plasma samples from 31 patients under treatment with AMK.

Evolution of adolescent idiopathic scoliosis: results of a multicenter study at 20 years' follow-up.

INTRODUCTION: To date there is no consensus on therapeutic indications in adolescent idiopathic scoliosis (AIS) with curvature between 30° and 60° at the end of growth. OBJECTIVE: The objective of this study was to assess outcome in patients with moderate AIS. MATERIAL AND METHODS: A multicenter retrospective study was conducted. Inclusion criteria were: Cobb angle, 30-60° at end of growth; and follow-up > 20 years. The data collected were angular values in adolescence and at last follow-up, and quality of life scores at follow-up. RESULTS: A total of 258 patients were enrolled: 100 operated on in adolescence, 116 never operated on, and 42 operated on in adulthood. Mean follow-up was 27.8 years. Cobb angle progression significantly differed between the 3 groups: 3.2° versus 8.8° versus 23.6°, respectively; P < 0.001. In lumbar scoliosis, the risk of progression to ≥ 20° was significantly higher for initial Cobb angle > 35° (OR=4.278, P=0.002). There were no significant differences in quality of life scores. DISCUSSION: Patients operated on in adolescence showed little radiological progression, demonstrating the efficacy of surgical treatment for curvature greater than 50°. Curvature greater than 40° was progressive and may require surgery in adulthood. Lumbar scoliosis showed greater potential progression than thoracic scoliosis in adulthood, requiring fusion as of 35° angulation. LEVEL OF EVIDENCE: IV, retrospective study.

[Bone dysplasia in mucopolysacchoridoses]. / Atteintes osseuses des mucopolysaccharidoses.

Mucopolysaccharidoses (MPS) are a group of disorders characterized by the accumulation of glycosaminoglycans. Skeletal abnormalities are early and prominent features of MPS. Cervical spine and atlantoaxial instability, thoracolumbar kyphosis, hip dysplasia and osteonecrosis, genu valgum, and carpal tunnel syndrome are frequently observed. MPS disease-awareness is important for pediatric healthcare providers who should be able to recognize the clinical presentation, musculoskeletal abnormalities, and radiographic findings associated with this group of disorders.

Perioperative medullary complications in spinal and extra-spinal surgery in mucopolysaccharidosis: a case series of three patients.

The mucopolysaccharidoses (MPS) are genetic lysosomal storage diseases. Peripheral bone dysplasia and spinal involvement are the predominant orthopedic damage. The risk of spinal cord compression due to stenosis of the craniocervical junction is well known in these patients, whereas the thoracolumbar kyphosis is often well tolerated over a long period of time. Thus, signs of spinal cord compression at this level occur later and more insidiously. The authors describe three cases of patients with thoracolumbar kyphosis who suffered from postoperative spinal cord compression in the absence of direct surgical trauma. Analysis of these cases and review of the literature helped identify causal factors resulting in spinal cord ischemia. The risk of perioperative spinal cord complications related to a thoracolumbar kyphosis must be discussed with patients with MPS and their families prior to any surgery, including extra-spinal procedures.

Cervical spine alignment in the pediatric population: a radiographic normative study of 150 asymptomatic patients.

PURPOSE: To describe the normal cervical sagittal alignment of the pediatric spine in a normal population and to identify the changes during growth period. METHODS: We randomly selected in PACS database 150 full-spine standing views. Exclusion criteria were: age >18 years, spinal deformity and any disease affecting the spine (medical charts reviewing). For cervical alignment we measured: OC-angle according to Mc Gregor, C1C7 angle, upper cervical angle, inferior cervical angle and C7 tilt. Spino pelvic parameters were analyzed: T1 tilt, thoracic kyphosis, lumbar lordosis, pelvic incidence, sacral slope and pelvic tilt. We compared two age subgroups (juvenile and adolescent). Differences between age groups and gender were tested using Student's t test. Correlations between sagittal spinal parameters were evaluated using Pearson's test. RESULTS: Cervical spine shape was correlated to cranio cervical orientation to maintain horizontal gaze (r = 0.60) and to thoracic kyphosis (r = -0.46). Cervical spine alignment was significantly different between the two age groups except for the global C1C7 cervical lordosis, which remained stable. A significant gender difference was found for all the cervical sagittal angles (p < 0.01) whereas no differences were demonstrated for the spino pelvic parameters, except the lumbar lordosis (p = 0.047). CONCLUSIONS: This study is the first to report the cervical spinal alignment in a normal pediatric Caucasian population. Even though cervical lordosis is the common shape, our results showed variability in cervical sagittal alignment. Cervical spine is a junctional area that adjusts its alignment to the head position and to the underlying spinal alignment.

Intraoperative neurophysiologic monitoring in spine surgery. Developments and state of the art in France in 2011.

Intraoperative spinal cord monitoring consists in a subcontinuous evaluation of spinal cord sensory-motor functions and allows the reduction the incidence of neurological complications resulting from spinal surgery. A combination of techniques is used: somatosensory evoked potentials (SSEP), motor evoked potentials (MEP), neurogenic motor evoked potentials (NMEP), D waves, and pedicular screw testing. In absence of intraoperative neurophysiological testing, the intraoperative wake-up test is a true form of monitoring even if its latency long and its precision variable. A 2011 survey of 117 French spinal surgeons showed that only 36% had neurophysiological monitoring available (public healthcare facilities, 42%; private facilities, 27%). Monitoring can be performed by a neurophysiologist in the operating room, remotely using a network, or directly by the surgeon. Intraoperative alerts allow real-time diagnosis of impending neurological injury. Use of spinal electrodes, moved along the medullary canal, can determine the lesion level (NMEP, D waves). The response to a monitoring alert should take into account the phase of the surgical intervention and does not systematically lead to interruption of the intervention. Multimodal intraoperative monitoring, in presence of a neurophysiologist, in collaboration with the anesthesiologist, is the most reliable technique available. However, no monitoring technique can predict a delayed-onset paraplegia that appears after the end of surgery. In cases of preexisting neurological deficit, monitoring contributes little. Monitoring of the L1-L4 spinal roots also shows low reliability. Therefore, monitoring has no indication in discal and degenerative surgery of the spinal surgery. However, testing pedicular screws can be useful. All in all, thoracic and thoracolumbar vertebral deviations, with normal preoperative neurological examination are currently the essential indication for spinal cord monitoring. Its absence in this indication is a lost opportunity for the patient. If neurophysiological means are not available, intraoperative wake-up test is a minimal obligation.

Congenital scoliosis: a frontal plane evaluation of 251 operated patients 14 years old or older at follow-up.

INTRODUCTION: Congenital scoliosis, carrying an incidence between 0.5 and 1 per 1000 births, raise the problem of their evolutive potential. HYPOTHESIS: Some predictive factors for the evolution of scoliotic curvature due to congenital vertebral malformation (CVM) can be found. MATERIAL AND METHODS: This was a retrospective multicenter study of 251 patients, at least 14 years old when evaluated at end of follow-up, with CVM and spinal deformity predominating in the frontal plane. RESULTS: 38.8% of patients showed associated neurologic, visceral or orthopedic abnormalities. CVM was single in 60.6%, double in 20.3%, triple in 6.4% and multiple in 12.7% of cases. 34.1% of CVMs were thoracic. Congenital scoliosis curvature was single in 88.8% of patients, double in 10% and triple in 1.2%. Mean curvature angle was 31.7° at diagnosis (range, 0-105°) and 41.3° preoperatively (range, 10-105°). Sixty-one patients showed associated kyphosis. Mean change in postoperative curvature angle over follow-up was 1.6° (range, -20° to 38°) in the 73 patients managed by arthrodesis, -0.4° (-24° to 30°) in the 64 managed by epiphysiodesis, and 0.4° (-18° to 35°) in the 49 managed by hemivertebral (HV) resection. Results were found to correlate significantly with age at surgery for patients managed by epiphysiodesis, but not for those managed by HV resection or arthrodesis. DISCUSSION: More than 30% of congenital scolioses involve associated intraspinal abnormality. All CVM patients should therefore undergo medullary and spinal MRI to assess the CVM in all three planes, and the medullary canal and its content. The evolution of scoliotic curvature induced by CVM is hard to predict. Several factors are to be taken into account: CVM type, number and location, and patient age. Curvature progression may be slow or very fast. It accelerates during the peak of puberty, stabilizing with bone maturity. Surgery is mandatory in evolutive scoliosis. Four procedures may be recommended, according to type of CVM and especially to patient age: arthrodesis, convex epiphysiodesis, HV resection or rib distraction. Surgery seeks to correct the spinal deformity induced by the CVM and prevent compensatory curvature and neurologic complications, while conserving sagittal and frontal spinal balance and sparing as many levels as possible. In case of HV involvement, the procedure of choice is CVM resection, which provides 87.5% good results in this indication; the procedure is relatively safe, conservative of spinal levels, and without age limit. LEVEL OF EVIDENCE: Level IV. Retrospective study.

[Botulinum toxin for postoperative care after limb surgery in cerebral palsy children]. / Intérêt de la toxine botulique pour les suites opératoires en chirurgie des membres chez l'enfant infirme moteur cérébral.

PURPOSE OF THE STUDY: Spasticity can be the cause of pain in cerebral palsy (CP) children who may suffer increased postoperative pain after orthopedic surgery. Moreover, symptoms can be worsened by abnormal movements, cast immobilization or anxiety. Spasticity must therefore be treated after surgery in CP children. A randomized study has demonstrated that when these children undergo surgical tenotomy, preoperative injections of botulinum toxin have a beneficial effect in terms of pain relief. The aim of this study was to assess the benefit regarding pain and comfort provided by preoperative use of botulinum toxin in total-body CP children undergoing bone surgery. MATERIAL AND METHODS: Two successive groups of nine total-body CP children were compared in a retrospective study. All patients underwent an orthopedic surgery involving a bone or a multilevel procedure. The second group was treated before surgery with multisite injections of botulinum toxin. The main outcome criteria studied were: efficiency and adverse effects of botulinum toxin, duration of hospital stay and pain, length of level III analgesic treatment (morphine), sleep quality, and skin lesions under cast immobilization. The two groups were similar for mean age (8.7+/-2.04 versus 10.9+/-4.37 years) and mean body weight (20+/-5.6 versus 26+/-7.7 kg). Mean botulinum toxin (Botox/kg) in the second group was 11.6 U (range 9.7-14.8). Average time from preoperative botulinum toxin injections to surgery was 27 days (range 23-31). RESULTS: There was no significant difference between the two groups, except for the botulinum toxin treatment. The Aschworth scale confirmed the clinical efficiency of the preoperative injections, with no adverse effects. After the surgical procedure, all patients but two had cast immobilization (orthopedic traction, in botulinum group). The mean duration was six weeks in both groups. There was no significant difference in duration of the hospital stay: 7.33+/-1.5 versus 7.88+/-1.7 days and duration of level III analgesic treatment (4.33+/-1.9 versus 4.16+/-2.5 days). The duration of pain symptoms decreased significantly from 6.87+/-2.9 to 2.22+/-1.7 days and sleep quality improved from 7/9 to 1/9 patients with disturbed sleep. Four under-cast skin lesions were noted in the first group but none in the bolulinum group. DISCUSSION: We cannot confirm that botulinum toxin before bone surgery induces lesser consumption of analgesic drugs. Our results do however support the hypothesis that treatment of spasticity using preoperative injections of botulinum toxin decreases the duration of postoperative pain and improves the children's comfort. Moreover, postoperative under-cast skin lesions can be prevented. This work suggests that improved patient comfort and pain relief could be achieved by using multisite botulinum toxin injections before orthopedic surgery in spastic total-body CP children.

[Permanent, habitual dislocation and recurrent dislocation of the patella in children: surgical management by patellar ligamentous transfer in 50 knees]. / Traitement chirurgical des luxations et instabilités patellaires chez l'enfant et l'adolescent par transfert ligamento-périosté

PURPOSE OF THE STUDY: Appropriate treatment of patellar dislocation in children and adolescents remains a subject of debate. Ligamentous transfer or "soft rod" is a technique for realigning the extensor mechanism that can be adapted to children. We analyzed results obtained in our patients. MATERIAL AND METHODS: Between 1979 and 2000, 35 children (50 knees) underwent realignment which was combined in all cases with lateral retinacular release and medial reefing using the Insall procedure. Complementary procedures were needed in certain cases (quadriceps lengthening, femoral sulcus plasty, quadriceps release). Mean age at surgery was 11 years, range 5-15 years. All patients were reviewed at skeletal maturity with a mean follow-up of 7.5 years. The last review included a functional assessment using the IKDC form and standard x-rays (anteroposterior and lateral standing view and tangential view at 30 degrees flexion). A computed tomography scan and/or magnetic resonance imaging series were done preoperatively and at last follow-up. DISCUSSION: We distinguished two groups of patients, those with major (permanent or habitual) dislocation of the patella and those with recurrent dislocation. Functional outcome was good in 76% and 86% of knees respectively. There were eight cases of recurrent dislocation: five knees underwent revision surgery with good outcome. The femoral sulcus angle was improved in both groups, but especially in the congenital dislocation group. There was on case of reversed tibial slope (-2 degrees) ant to slopes at 0 degrees. Functional outcome was equivalent to results from earlier series (Grammont, Bensahel, Langeskiold), but comparison was hampered due to the heterogeneous nature of the different series. Femoral sulcus remodeling can enable good patellar stability if the surgery is performed early enough (before age 10 years). In teenagers with major instability, femoral sulcus plasty must be associated with the realignment procedure. We noted a small amplitude reduction of the tibial slope in eleven knees. The procedure appears to have an "epiphysiodesis effect" but with no functional consequence. CONCLUSION: Ligamentous transfer combined with different procedures is a method of choice for stabilizing the extensor system, enabling a normal femoral sulcus angle if the child is operated early. Remodeling of the tibial tuberosity could be related to a transient vascular disorder.

[Transverse sacral fracture in children: a case report presenting with neurological injury and review of the literature]. / Fracture transversale du sacrum chez l'enfant.

Transverse fractures of the sacrum are exceptional in children. We report a case in a 10-year-old girl. The patient presented an isolated flexion fracture of the sacrum in Denis zone III (transverse "U" fracture) of S1-S2 with neurological signs at the initial examination: sensorial deficit in the perineum and sphincter dysfunction. Treatment consisted in laminectomy and bone resection to relieve compression causing the neurological injury. Orthopedic treatment led to correct bone healing. Outcome was favorable with complete resolution of the neurological deficit and stability at three years. Eight cases of transverse sacral fracture before the age of 18 years have been reported in the literature. The diagnostic elements are similar to those in adults, but can be missed in children who rarely present sacral fracture. The therapeutic approach has varied, both for children and adults. We advocate surgical treatment in the event of neurological complications and orthopedic treatment of stable bone lesions.

Outcome of 27 patients with Hurler's syndrome transplanted from either related or unrelated haematopoietic stem cell sources.

Over the last 15 years, we have performed a total of 30 haematopoietic stem cell transplants on 27 children suffering from Hurler's syndrome. These children were of median age 11 months at the time of diagnosis and 25 months at the time of transplantation. The phenotype was severe in 21 cases (78%). The donor was familial in 13 cases: nine genotypically identical, one phenotypically identical father and three HLA-mismatched donors. Unrelated donors were selected in 17 cases: four phenotypically identical and 13 with 1-4 HLA mismatches. The conditioning regimen generally consisted of busulphan 600 mg/m(2) plus cyclophosphamide (Endoxan) 260 mg/kg and cyclosporin with methotrexate for GvHD prophylaxis. Rabbit anti-thymocyte globulin (Thymoglobuline) was given for all unrelated or familial mismatched transplantations. The median nucleated cell dose infused was 6.00 x 10(8) TNC/kg. No bone marrow (apart from one) was T cell depleted. For first transplants, engraftment was observed in 23/27 patients (pts) (85%). Primary graft failure was observed in 4/27 patients (16%), two were retransplanted from an unrelated donor, one with success. Four patients have died. The primary cause of death was infection in three cases (TRM : 11%) and disease progression in one case, after primary graft failure. Of the 23 living patients, two have disease progression after graft failure and 21 (78%) have functional grafts with a favourable long-term outcome after a median follow-up of 4.7 years, having either full or mixed chimaerism. Among surviving patients with functional grafts, 13 (62%) were transplanted from unrelated donors of whom 10 (77 %) had HLA disparities. There was a remarkably low incidence of GvHD. In our experience, haematopoietic stem cell transplantation using an HLA-matched familial donor or an HLA-matched or -mismatched unrelated donor without T cell depletion or irradiation can achieve a favourable outcome in Hurler's syndrome, with improved cognitive function, but with a limited effect on the corneas and skeleton.

Factors and motives associated with drop-out in an ambulatory service for patients with psychotic disorders.

The aim is to study motives and factors associated with treatment drop-out in an ambulatory psychiatric service, which integrates medical, social, familial and rehabilitation treatments. Only 9% of the psychotic patients dropped out, whose motives were non-compliance with medication and unawareness of illness, and the associated factors were comorbidity of substance abuse, social isolation and male gender.

[Scoliosis and congenital diaphragmatic agenesis]. / Scolioses associées aux aplasies de coupole diaphragmatique.

PURPOSE OF THE STUDY: Diaphragmatic agenesis is the most extreme anatomic form of congenital diaphragmatic defects. Clinically this pathology is not different from posterolateral diaphragmatic hernia described by Bochdalek. We describe our observations of scoliosis in 16 neonates with diaphragmatic agenesis. MATERIAL AND METHODS: Between 1987 and 1996, 69 neonates underwent surgery for a congenital diaphragmatic hernia (CDH) at our institution. Sixteen of these patients had the most extreme form of CDH. Ten of these 16 patients survived. Spinal and/or chest wall deformities were observed in nine patients, including isolated scoliosis in two patients, scoliosis associated with a chest wall deformity in three, and isolated chest wall deformity (pectus excavatum or pectus carnium) in four. These deformities developed between 13 months and three and a half years of age (mean: two years). RESULTS: For two patients the deformity was mild (Cobb angle<15 degrees ) and required only observation. A Milwaukee brace was used in three patients that had severe kyphoscoliosis. Isolated chest wall deformities were treated with observation. No patient required operative treatment for these skeletal deformities. DISCUSSION: The preliminary results of this study indicate that chest wall deformities and scoliosis frequently occur during surgery for diaphragmatic agenesis. Nonoperative treatment is usually sufficient, however, follow-up of these patients until adulthood is recommended.

Synthesis, distribution, and levels of an egg lipoprotein from the apple snail Pomacea canaliculata (Mollusca: Gastropoda).

The site of synthesis of mollusc lipoproteins is hitherto unknown and was investigated for perivitellin 2 (PV2), an egg lipoprotein found in the freshwater snail Pomacea canaliculata. Tissues (albumen gland, gonad-digestive gland complex, and muscle) from vitellogenic females were incubated in vitro with 14C-leucine at 25 degrees C for 12 hr. At the end of incubation, soluble proteins from tissue homogenates and medium were analyzed for de novo protein synthesis by electrophoresis and HPLC, and radiolabeled proteins were quantified by liquid scintillation. Two albumen gland radiolabeled proteins (67 and 31 kDa) co-migrated with the subunits of PV2, and they represented 6.0% of the total labeled protein in that tissue. Western blot analysis confirmed the presence of PV2 only in the albumen gland. In vivo experiments where adult females were injected with 3H-leucine revealed that PV2 was not present in hemolymph. ELISA analysis in all tissues of the snail confirmed the PV2 presence only in the albumen gland and developing eggs with levels of 26 and 98 mg/g protein, respectively. Therefore, the albumen gland is the only site for PV2 synthesis, and no extra-gland synthesis, circulation, or accumulation could be found. PV2 subunits were further characterized analyzing N-terminal sequences which showed no homology with other proteins.

Mitochondrial DNA phylogeny and the evolution of host-plant use in palearctic Chrysolina (Coleoptera, Chrysomelidae) leaf beetles.

The genus Chrysolina consists of specialized phytophagous leaf-beetles (Coleoptera, Chrysomelidae) with feed on several plant families. There is no explicit phylogenetic hypothesis available for this genus, which includes 65 subgenera and more than 400 species with a wide distribution. We obtained 839-bp sequence data from the 16S rDNA and cytochrome oxidase subunit I (COI) mitochondrial genes. Thirty Chrysolina taxa representing eight host-plant affiliations, two species of the closely related genus Oreina, and two outgroups were sampled. These data sets were used separately and combined to obtain the mitochondrial cladogram of the group using maximum-parsimony and maximum-likelihood criteria. The results were compared to current proposals for Chrysolina systematics that are based on morphological, ecological, and karyological data. The trees obtained were in the most part congruent with the proposed ancestral association of Chrysolina to Lamiaceae based on chromosome number in several lineages. A minimum of five host-plant switches from the ancestral state inferred at the family level and two at the subclass level suggests the absence of parallel evolution of beetles and their host plants. Another switch leading to oligophagy at the family level was deduced to have occurred in the lineage of the subgenus Chrysolina s.str.

Blount's disease: classification and treatment.

Forty-three tibia vara in 27 patients were analyzed retrospectively in two centers. The criteria for diagnosis of the child form are discussed. A simple classification is suggested to facilitate the choice of treatment. In stage 0 (possible Blount's disease), the patient is younger than 2 1/2 years, and an observation period is indicated for gathering data. In stage 1 (confirmed Blount's disease and absence of medial metaphyseal bony bridge), known as physis+, a valgization osteotomy is proposed. In stage 2 (evidence of a medial metaphysoepiphyseal bony bridge) known as physis-, valgization osteotomy with lateral epiphysiodesis and treatment of the lower limb discrepancy is proposed. For stages 1 and 2, there are two possibilities: normal medial tibial plateau or sloping of the medial tibial plateau, indicating a transphyseal elevation osteotomy. When one-step correction is proposed for stage 2 disorder, external fixators such as Orthofix or Ilizarov devices are useful.