Literature Review and Comparison of Two Statistical Methods to Evaluate the Effect of Botulinum Toxin Treatment on Gait in Children with Cerebral Palsy

Aim

This study aimed at comparing two statistical approaches to analyze the effect of Botulinum Toxin A (BTX-A) treatment on gait in children with a diagnosis of spastic cerebral palsy (CP), based on three-dimensional gait analysis (3DGA) data. Through a literature review, the available expert knowledge on gait changes after BTX-A treatment in children with CP is summarized.

Methods

Part 1—Intervention studies on BTX-A treatment in children with CP between 4–18 years that used 3DGA data as an outcome measure and were written in English, were identified through a broad systematic literature search. Reported kinematic and kinetic gait features were extracted from the identified studies. Part 2—A retrospective sample of 53 children with CP (6.1 ± 2.3years, GMFCS I-III) received 3DGA before and after multilevel BTX-A injections. The effect of BTX-A on gait was interpreted by comparing the results of paired samples t-tests on the kinematic gait features that were identified from literature to the results of statistical parametric mapping analysis on the kinematic waveforms of the lower limb joints.

Results

Part 1–53 kinematic and 33 kinetic features were described in literature. Overall, there is no consensus on which features should be evaluated after BTX-A treatment as 49 features were reported only once or twice. Part 2—Post-BTX-A, both statistical approaches found increased ankle dorsiflexion throughout the gait cycle. Statistical parametric mapping analyses additionally found increased knee extension during terminal stance. In turn, feature analyses found increased outtoeing during stance after BTX-A.

Conclusion

This study confirms that BTX-A injections are a valuable treatment option to improve gait function in children with CP. However, different statistical approaches may lead to different interpretations of treatment outcome. We suggest that a clear, definite hypothesis should be stated a priori and a commensurate statistical approach should accompany this hypothesis.     

Monoclonal gammopathy in chronic myeloproliferative disorders

The incidence of monoclonal gammopathy in 61 patients with chronic myeloproliferative disorders (CMPD) was studied. The distribution of patients among the CMPD subgroups was: chronic myelocytic leukemia, 24 patients; myelofibrosis, 11; polycythemia vera, 15; essential thrombocythemia, 7; unclassified MPD, 4 patients. Monoclonal gammopathy was found in 5 patients (8.2%). Two of these patients (1 IgA/k and 1 IgM/k) had myelofibrosis and 3 (2 IgG/k and 1 IgG/lambda) polycythemia vera. The presence of monoclonal gammopathy indicates an involvement of the lymphoplasmatic system in CMPD.     

Intrauterine administration of prostaglandin by the extra-amniotic route

The present study was undertaken to explore whether abortion in the 13th-16th week of gestation could be induced by a single extra-amniotic injection of prostaglandin. A long acting prostaglandin analogue 15(S)-15-Methyl-PGF2alpha was utilized and different vehicles and injection techniques tried. The clinical results of the single injection method were compared with those using multiple injections of PGF2alpha as has been described earlier. It was found that approximately 80% of the patients aborted following a single injection of 750 mc 15-me-PGF2alpha and that the side effect rate was acceptable from a clinical point of view. The method seems to be an attractive alternative usable during the "difficult" period for induction of abortion, i.e., when the uterus is too large for vacuum aspiration but too small for abdominal puncture of the amniotic sac.     

Administration of 15-methyl-prostaglandin F2α as a pre-operative means of cervical dilatation

Pre-operative dilatation of the cervix prior to vacuum aspiration was accomplished in 67 volunteers by extra-amniotic or intra-muscular administration of 15(S)-15-methyl-PGF_2α (15-me-PGF_2α). Ninety-four per cent of the patients were in the 11th–13th week of gestation and 61% were nulliparae. A single extra-amniotic instillation (mean of 400 μg) or 3 intramuscular injections (300–800 μg per injection) of the compound induced a satisfactory outcome in terms of either abortion or sufficient dilatation of the cervix in 81% of the patients. In the remaining cases, the cervix was found at operation to be open for 7–9 mm which simplified the process of additional instrumental dilatation. In general the outcome of the trial turned the operation into an easy and safe procedure. Vacuum aspiration was performed in all cases after a mean time lag of 16 hours following the onset of the treatment. Extra-amniotic administration was associated with a low incidence of gastro-intestinal side-effects, but there was a transient and moderate degree of uterine pain reaction. The intramuscular route was technically more simple and caused less uterine pain but the high incidence of vomiting and diarrhoea constituted a clinical disadvantage. In late first trimester abortions, particularly cases where the uterus appears larger than expected, it is believed that dilatation of the cervix by PG prior to vacuum aspiration is a sound clinical indication. The method offers definite advantages that compensate for the price of some minor side-effects.     

A morphogen gradient model for pattern regulation. I. Formation of non-repetitive and repetitive structures

A model for pattern formation is proposed based on two concentration gradients S and Sigma. S is a local morphogen generated by a reaction-diffusion mechanism while Sigma is a by-product of the S-decomposition. Under certain conditions S is well approximated by S(x,L) = alpha(L)f(x L ), where alpha(L) is a scaling function of the length L and f(x L ) is a monotonie function of the relative distance x L from the origin. Sigma degradates and diffuses in the field, reaching a stable L-dependent homogeneous distribution. An allosteric protein P with several active sites reacts with S and Sigma and separates the field into segments. To every segment a corresponding active state of P is dominant. Pattern regulation is automatically achieved since the compartmerttal separation depends explicitly only on x L . For the case of repetitive patterns, a supplementary Gierer-Meinhardt mechanism is introduced for activator X and inhibitor Y. The level of Sigma can affect the decomposition rate of X or Y, e.g. via a second order degradation reaction, hence making the chemical wavelength lambda size-dependent. For a particular decay scheme of Y, a variation of L induces a change of lambda so that finally the number of repetitive structures becomes independent of the field size.     

Types of supernumerary outgrowths produced after inverting the dorsoventral limb axis of the anuranBufo bufo

Summary Contralateral grafts were performed on the larval limb buds of the anuranBufo bufo. The dorsoventral axis of 80 buds at stages IV or V was inverted. Ten tadpoles were used as controls. Fifty-two supernumerary structures developed, all of them in dorsal or ventral locations on the host stump. The majority (32 out of the 44 outgrowths with more than 3 toes) were normal limbs of stump handedness. However, the following abnormal structures were also observed: 2 double-posterior, 3 mixed-symmetric, and 7 undetermined cases. These results are in agreement with the predictions of a hierarchical polar coordinate model for epimorphic regeneration.     

Pyridoxal phosphate site in glycogen phosphorylase b: structure in native enzyme and in three derivatives with modified cofactors

The detailed environment of the essential cofactor pyridoxal 5'-phosphate in glycogen phosphorylase b, resulting from crystallographic refinement at 1.9-A resolution, is described. The pyridoxal ring is buried in a nonpolar site containing three aromatic rings while the 5'-phosphate group is highly solvated and makes only three direct contacts to the protein. The pyridine nitrogen interacts via a water with protein atoms [main chain carbonyl oxygen (Asn-133) and OH of tyrosine (Tyr-90)]. The crystal structures of three active derivatives of phosphorylase reconstituted with 5'-deoxypyridoxal 5'-methylenephosphonate (PDMP), 6-fluoropyridoxal 5'-phosphate (6-FPLP), and pyridoxal (PL) in place of the natural cofactor have been determined at 2.5-A resolution. The results for PDMP-phosphorylase show a closer proximity of the phosphonate group to the NZ atom of a lysine (Lys-574) than that observed in the native enzyme, consistent with 31P NMR studies that have shown a change in ionization state of the phosphonate group compared to the native cofactor phosphate. The replacement of the polar 5'-ester linkage by a CH2 group results in a small shift of a water and its hydrogen-bonded tyrosine (Tyr-648). In 6-FPLP-phosphorylase the fluorine is accommodated with no significant change in structure. It is suggested that substitution of the electronegative fluorine at the 6-position may result in lower activity of 6-FPLP-phosphorylase through a strengthening of hydrogen-bonded interactions to the pyridine nitrogen N1.(ABSTRACT TRUNCATED AT 250 WORDS)     

Migration inhibitory factor (MIF) production by skin fibroblast cultures from patients with severe combined immunodeficiency

The supernatants of fibroblast cultures derived from skin biopsies of each of two patients with severe combined immunodeficiency were studied for the presence of migration inhibitory activity (MIF). The supernatants of both of these fibroblast cultures were found to contain inhibitory activity for the migration of cultured human lymphoid cells (PGLC-33H). This MIF activity was found to share chromatographic similarities with the MIF contained in the supernatants of a lymphoid cell line (PGLC-33H) and phytohemagglutinin (PHA) and tuberculin (PPD) stimulated human peripheral lymphocytes. These data suggest that MIF is not solely a lymphoid product and that severe combined immunodeficiency does not represent a gene deletion for MIF production.     

Immobilization of photosynthetically active cyanobacteria in glutaraldehyde-crosslinked albumin matrix

Summary Cryoprotection was afforded to cells ofPhormidium luridum andAnacystis nidulans by preloading them with dimethyl sulphoxide and then performing the immobilization reaction in dimethyl sulphoxide-free medium. Compared with free cyanobacteria cells, matrix-immobilized cyanobacteria exhibit superior temperature tolerance and storage longevity of photoinduced electron transport, while their phycobiliproteins are better protected against thermal denaturation. Photosynthetically activePhormidium spheroplasts capable of interacting with ionic Hill cofactors, were immobilized in crosslinked albumin matrix, with cryoprotection provided by sorbitol.