Jacques Maurice Birraux

A silicone-coated nylon dressing reduces healing time in burned paediatric patients in comparison with standard sulfadiazine treatment: a prospective randomized trial

Mepitel is a new grid like silicone coated nylon dressing containing no additional biological compounds. We describe a prospective randomized pilot study comparing Mepitel to the standard silver sulfadiazine cream (Flamazine) dressing for the topical treatment of paediatric burns. Seventy-six children presenting within 24 h of injury with a non previously treated burn were randomly assigned to Mepitel treatment (group M) or Flamazine treatment (group F). Age, sex, surface area of burn and causal agent were noted at admission. The depth of the burn, cumulative number of dressings, presence or absence of a complete epithelial cover, infection, bleeding and allergy were noted at each dressing change. There were 41 children in group M and 35 children in group F. Five children were subsequently withdrawn from each group because they required skin grafting. Analysis of the above mentioned criteria showed no statistical difference between the two groups except for the healing time (group M: 7.58+/-3.12, group F: 11.26+/-6.02, p < 0.01) and the number of dressings (group M: 3.64+/-1.5, group F: 5.13+/-2.9, p < 0.05). Mepitel has proved to be an easy-to-remove dressing, adhering only to intact skin. The faster healing time found in the Mepitel group may be related to a direct effect of silicone on epithelial growth or to a decrease in surface-cell damage compared to the silver sulfadiazine group. This attractive product will be further assessed on a larger scale trial to confirm our observations.

Ex vivo lentivirus transduction and immediate transplantation of uncultured hepatocytes for treating hyperbilirubinemic Gunn rat.

Background. Ex vivo liver gene therapy provides an attractive alternative to orthotopic liver transplantation for the treatment of liver diseases. We previously reported a protocol in which human primary hepatocytes are highly transduced in Suspension with Lentiviral vectors and Immediately Transplanted (SLIT). Here, we evaluated the SLIT approach in Gunn rats, the animal model for Crigler-Najjar syndrome type 1, a defect in bilirubin UDP-glucuronosyltransferase (BUGT). Methods. We constructed lentiviral vectors coding for BUGT under control of an ubiquitous promoter. Control vectors contained Green Fluorescent Protein (GFP) under control of the same promoter. Hepatocytes were isolated from jaundiced Gunn rats and transduced in suspension for four hr. After washing, 2×107 hepatocytes were immediately transplanted into syngeneic rats. Bilirubinemia and bile pigments were regularly assessed after cell transplantation. The percentage and presence of transduced hepatocytes was analyzed by immunohistochemistry in GFP-transplanted animals. Results. In rats receiving BUGT-transduced hepatocytes, bilirubinemia decreased by about 30%. The level of correction remained stable for up to 240 days. Bilirubin glucuronides were present in the bile of treated animals, indicating the metabolic activity of engrafted hepatocytes. In contrast, bilirubinemia in GFP-transplanted rats did not decline but rather increased. GFP-positive hepatocytes amounted to 0.5–1% of the liver, which is in agreement with the number of transplanted and genetically-modified hepatocytes (6×106). Conclusions. This work reports the first demonstration of long-term metabolic benefit after rapid transplantation of ex vivo lentivirally tranduced hepatocytes. Therefore, this study demonstrates the therapeutic proof-of-principle and potential of the SLIT approach for treating inherited metabolic liver diseases.

Uterocervicoplasty with a bladder mucosa layer for the treatment of complete cervical agenesis

OBJECTIVE To create an endocervical canal in a patient with a complete cervical agenesis. DESIGN Case report. SETTING University hospital. PATIENT(S) A 12-year-old girl presented with lower abdominal pain. On examination, complete vaginal agenesis was noted, with a 2-cm vaginal dimple. A pelvic magnetic resonance imaging scan disclosed an hematometra and absence of the cervix and vagina. INTERVENTION(S) Initial surgical therapy consisted of a vaginoplasty with a sigmoid bowel segment and opening of the uterus by puncture and stenting. The cervical permeation failed, with immediate complete stenosis. A new attempt was made through a low sagittal hysterotomy by removing a central muscular cylinder and lining the channel with a free tubularized bladder mucosa graft. A stent was left in place. MAIN OUTCOME MEASURE(S) Hysteroscopy, hysterography, and clinical follow-up evaluation. RESULT(S) The cervical stent was removed after 5 months. A hysterography and hysteroscopy confirmed the permeability of the cervix, which was lined by a well-vascularized longitudinally folded mucosa. Regular menses had been noted for more than 3 years as of this report. CONCLUSION(S) Cervicoplasty with mucosal lining permits the creation of a patent cervical canal, even in the reputedly unfavorable forms of congenital cervical agenesis.

A step toward liver gene therapy: efficient correction of the genetic defect of hepatocytes isolated from a patient with Crigler-Najjar syndrome type 1 with lentiviral vectors

Background. Ex vivo liver gene therapy may be a future alternative to orthotopic liver transplantation for the treatment of some liver diseases. We previously described the transduction in suspension with lentiviral vectors and immediate hepatocyte transplantation (SLIT) protocol and its high transduction rate with normal human hepatocytes. We also reported SLIT efficiency in the animal model of Crigler-Najjar type 1 syndrome (CN-1), the Gunn rat. Here, we evaluated SLIT efficiency with diseased human hepatocytes. Methods. Hepatocytes of the liver from a 4-year-old patient presenting CN-1 were isolated. They were transduced with liver-specific lentiviral vectors expressing uridine-diphosphate-glucuronosyltransferase (hUGT1A1) or green fluorescent protein, and then analyzed in vitro for transduction efficiency and hUGT1A1 expression, or transplanted in nonobese diabetic/severe combined immunodeficiency (SCID) mice to evaluate long-term survival of transplanted cells. Results. More than 90% of CN-1 hepatocytes were transduced. Hepatocytes produced hUGT1A1 protein after lentiviral transduction. After having been subjected to the SLIT, lentivirally transduced CN-1 hepatocytes engrafted long term (up to 26 weeks posttransplantation) in recipient livers and expressed green fluorescent protein or hUGT1A1 vector. Conclusion. The SLIT protocol allowed for a high transduction of CN-1 hepatocytes and restoration of the expression of the deficient protein. Furthermore, long-term survival of lentivirally transduced CN-1 hepatocytes in the liver of immunodeficient mice was demonstrated. This study is therefore an important step toward human application of lentiviral gene therapy.

Desafíos quirúrgicos de las anomalías del desarrollo sexual

Disorders of Sex Development (DSD) remain a fascinating challenge for the paediatricians, endocrinologists, biologists, psychiatrists, geneticists, radiologists, surgeons and for the whole society. This article aims at highlighting the current controversies and questions met with genital reconstruction in children born with abnormal genitalia. The main current techniques of masculinization and feminization are reviewed with their progress and their problems. The tools of decision used to assign a gender in some newborns with complex DSD are discussed showing that at the dawn of the third millenium, one still does not know why a boy is a boy, and a girl is a girl.

Long-term outcome of children with patent processus vaginalis incidentally diagnosed by laparoscopy.

INTRODUCTION Patent processus vaginalis (PPV) might be incidentally diagnosed during laparoscopy. The aims of this study were to determine the prevalence and the natural history of PPV, i.e. its possible development into symptomatic inguinal hernia. PATIENTS AND METHODS INCLUSION CRITERIA children <16years undergoing laparoscopy for pathologies other than processus vaginalis (PV) related, from 10/2000-10/2005. EXCLUSION CRITERIA past or present history of PV-related pathologies. The internal inguinal rings were documented during laparoscopy. Follow-up was provided by phone inquiry and clinical examination if needed. Median follow-up was 10.5years (range 7.1-12.8). RESULTS 416 patients were included. Median age at laparoscopy was 12.4years (range 3days-18.1years). Forty-three PPV (33 unilateral, 5 bilateral) were found in 38 patients (9.1%). Four children with PPV presented later with an ipsilateral inguinal hernia (10.5%, 95%CI [3%; 25%]), at a median age of 16.0years (range 11.8-17.3), at a median of 22.5months (range 12-50) after initial laparoscopy, as compared to no patient in the population with obliterated PV (0%, 95%CI [0%; 1%]). CONCLUSION 9.1% of the observed pediatric population showed an asymptomatic PPV, and 10.5% of these children later developed an inguinal hernia. None of the children with obliterated PV developed a hernia.

Ex vivo hepatocyte gene therapy: increased biosafety protocol for transduction in suspension with lentiviral vectors and immediate transplantation (SLIT).

tions (2.5 1.1 ng/mL/mg before vs. 3.8 2.5 ng/mL/mg after omega-3 PUFA; P 0.001). Intrapatient and interpatient variability of SRL trough levels was not affected by omega-3 PUFA administration (data not shown). Pharmacokinetic studies—performed every 6 months after surgery— demonstrated that the concomitant administration of omega-3 PUFA also increased doseadjusted SRL area under curve (AUC0–24) values compared with untreated patients (98 38 vs. 79 23 ng hr/mL/ mg; P 0.007). Interestingly, the major differences in the pharmacokinetic profiles between patients given or not omega-3 PUFA were found from 240 to 480 min after SRL administration, namely during the phase of drug metabolism. Nearly 25% reduction in the SRL dose was required to reach SRL trough concentrations and AUC0 –24 values comparable with those found in patients not given these agents (3.2 1.3 vs. 4.2 1.5 mg SRL, P 0.001). To assess whether higher lipid concentrations observed in patients given omega-3 PUFA could have biased the results, doseadjusted SRL AUC0–24 values were stratified according to total cholesterol and triglyceride concentrations. No significant differences were observed on dosenormalized AUC0 –24, when dividing data according to total cholesterol less than or equal to or more than 200 mg/dL (87 31 vs. 86 32 ng hr/mL/mg; P NS) or to triglyceride levels less than or equal to or more than 170 mg/dL (87 32 vs. 88 37 ng hr/mL/mg; P NS). Similarly, no impact of statin treatment on SRL pharmacokinetics was observed (data not shown). To further confirm the predictive role of omega-3 PUFA administration on SRL exposure, a multivariate regression analysis was performed considering dose-adjusted SRL AUC0 –24 as the dependent variable and the patient demographic and biometric characteristics as the independent covariates. According to the multivariate regression analysis, the use of omega-3 PUFA and red blood cell count (RBC) were the only independent factors significantly associated to SRL exposure. Altogether, these clinical data suggest that daily SRL exposure was significantly increased by the concomitant administration of omega-3 PUFA and extend previous in vitro and in vivo experimental observations showing the inhibitory activity of omega-3 PUFA on CYP3A4, the main enzyme involved in SRL metabolism (2, 3). Multivariate analysis showed that in addition to omega-3 PUFA, SRL exposure was also independently associated to RBC. In particular, low RBC was related to lower SRL AUC0–24 values. This finding could be explained considering that in the blood, SRL is mainly partitioned in erythrocytes (5); thus, as RBC decrease, there will be an increase in the drug-free concentration, namely the fraction available for metabolism by the cytochromial system. In conclusion, we have provided evidence that concomitant administration of omega-3 PUFA significantly increases SRL exposure in kidney transplant recipients on calcineurin inhibitor-free immunosuppression, ultimately requiring a 25% reduction of SRL dose to keep patients in the expected SRL trough concentration-based window. These findings may help transplant physicians to better individualize SRL therapy in kidney allograft recipients.

Laparoscopic-assisted vaginal pull-through: A new approach for congenital adrenal hyperplasia patients with high urogenital sinus

Background: To open vaginal cavity to the pelvic floor is part of surgical treatment for urogenital sinus (UGS) in girls with congenital adrenal hyperplasia (CAH). For high UGS, this operative procedure can be challenging and may jeopardise urinary continence. Combined perineal and laparoscopic approaches could be useful to minimise perineal dissection and to facilitate the vaginal lowering. Patients and Methods: We report the procedure of a laparoscopic-assisted vaginal pull-through for supra-sphincteric UGS in a 5-year-old girl with CAH. Laparoscopic dissection of the vagina from the posterior wall of the bladder and urethra, division of the confluence and vaginal pull-through to the perineum are described. Discussion: The technique is derived from laparoscopic-assisted treatment for high ano-rectal malformations. Compared with current procedures for treatment for high UGS, laparoscopic-assisted approach allows mobilising vagina with minimal dissection of perineum and complete preservation of urethra. Another major advantage is to provide a direct vision for dissection of the space between rectum and urethra prior to vaginal pull-through. Conclusion: Laparoscopic-assisted vaginal pull-through appears to be an interesting approach for high UGS in CAH patients, reducing dissection and risk of urinary incontinence. This new approach needs to be strengthened by other cases.

A novel SRY mutation leads to asymmetric SOX9 activation and is responsible for mixed 46,XY gonadal dysgenesis.

Background: SRY, located on the Y chromosome, is one of the key genes involved in human sex determination. SRY mutations are responsible for 10–15% of all cases of 46,XY gonadal dysgenesis (GD) but are rarely implicated in the pathogenesis of mixed GD. Methods: SRY was analyzed by sequence analysis of DNA extracted from blood leukocytes. SRY activity was evaluated by SOX9 immunostaining, one of the targets of SRY. Results: We report a case of mixed GD due to a novel SRY point mutation in a patient with a 46,XY karyotype, without mosaicism or submicroscopic genomic imbalances. Hormonal studies showed low anti-müllerian hormone and histological examination of the gonads showed a streak gonad on the right side and a left dysgenetic testis, thus permitting the diagnosis of mixed GD. Immunostaining for SOX9, a target of SRY, was positive in nuclei of Sertoli and epididymal cells in the left gonad and negative on the right, thus indicating asymmetric activation of SRY. Conclusion: Mixed GD can result from SRY mutations without mosaicism, neither in peripheral blood, nor within the gonads. The asymmetric effect of the point mutation implies the presence of local factors modulating SRY expression or action.

Urethral duplication in a 12-year-old child

Urethral duplication is a rare congenital malformation affecting mainly boys. The authors report a case in a Cameroonian child who was diagnosed and managed at the Gynaeco-Obstetric and Paediatric Hospital, Yaounde. The malformation was characterized by the presence of an incontinent epispadic urethra and a normal apical urethra. We describe the difficulties faced in the management of this disorder in a developing country.