Prevention of complications in glycogen storage disease type Ia with optimization of metabolic control.

Prior to 1971, type Ia glycogen storage disease was marked by life-threatening hypoglycemia, lactic acidosis, severe failure to thrive, and developmental delay. With the introduction of continuous feeds in the 1970s and cornstarch in the 1980s, the prognosis improved, but complications almost universally developed. Changes in the management of type Ia glycogen storage disease have resulted in improved metabolic control, and this manuscript reviews the increasing evidence that complications can be delayed or prevented with optimal metabolic control as previously was seen in diabetes.

Reversal of glycogen storage disease type IIIa-related cardiomyopathy with modification of diet.

Glycogen storage disease type III (GSD III) is caused by a deficiency in debranching enzyme, which leads to an accumulation of abnormal glycogen called limit dextrin in affected tissues. Muscle and liver involvement is present in GSD type IIIa, while the defect is limited to the liver only in GSD type IIIb. Besides skeletal muscle involvement, a cardiomyopathy resembling idiopathic hypertrophic cardiomyopathy is seen. Management consists of maintaining normoglycaemia by supplementation with cornstarch therapy and/or protein. While studies are lacking regarding the best treatment for skeletal muscle disease, a high-protein diet was previously reported to be beneficial. No cases of improvement in cardiomyopathy have been reported. Our patient presented in infancy with hypoglycaemia and hepatomegaly. His prescribed management consisted of cornstarch supplementation and a high-protein diet providing 20% of his total energy needs. At 16 years of age, he developed a severe cardiomyopathy with a left ventricular mass index of 209 g/m(2). The cardiomyopathy remained stable on a protein intake of 20-25% of total energy. At age 22 years, the diet was changed to increase his protein intake to 30% of total energy and minimize his cornstarch therapy to only what was required to maintain normoglycaemia. Dramatic improvement in the cardiomyopathy occurred. Over one year, his left ventricular mass index decreased from 159.7 g/m(2) to 78 g/m(2) (normal 50-86 g/m(2)) and the creatine kinase levels decreased from 455 U/L to 282 U/L. Avoidance of overtreatment with carbohydrate and a high-protein diet can reverse and may prevent cardiomyopathy.

Hyperlipidemia in glycogen storage disease type III: effect of age and metabolic control.

While the presence of hyperlipidaemia in glycogen storage disease (GSD) type Ia and Ib is generally accepted, few investigators have adequately assessed lipid profiles of GSD III in children, in whom the presence of hyperlipidaemia may be most prominent. We analysed the lipid profiles in 44 GSD III patients from 6 months to 30 years of age. Hypertriglyceridaemia and hypercholesterolaemia were common in children younger than 3 years of age. Hypertriglyceridaemia correlated negatively with age, and may reflect increased severity of hypoglycaemia in this younger population. The presence of hyperlipidaemia during childhood in these patients identifies another GSD population that could be at risk for early cardiovascular disease (CVD). Consequently, the outcome of clinical trials investigating the vascular effect of hyperlipidaemia in GSD applies to types other than GSD I.

Adalimumab for the treatment of Crohn-like colitis and enteritis in glycogen storage disease type Ib.

Glycogen storage disease (GSD) type Ib is a congenital disorder of glycogen metabolism that is associated with neutropenia, neutrophil dysfunction, and an inflammatory bowel disease that mimics a Crohn phenotype. Gastrointestinal inflammation in GSD Ib has been successfully treated with 5-aminosalicylic acid and granulocyte colony-stimulating factor (G-CSF). However, therapeutic options for patients not responding to traditional therapies have been limited owing to untoward effects of glucocorticoids and immunomodulators in this metabolic disorder. Adalimumab is a monoclonal antibody targeting tumour necrosis factor-α that has shown promise for the treatment of patients with Crohn disease. Due to the limited options for treating GSD-associated inflammatory bowel disease, use of adalimumab was attempted in a case unresponsive to aminosalicylate, G-CSF, and antibiotic therapy. Significant clinical and histological improvement was observed in our patient, and the medication was well tolerated.

Clinical evaluation of a portable lactate meter in type I glycogen storage disease.

High lactate concentrations occur in type I glycogen storage disease (GSD) whenever glycogenolysis occurs. Not only does hyperlactataemia cause acute clinical deterioration, but chronic lactate elevations have also been associated with many of the long-term complications in GSD. A portable finger-stick blood lactate meter has recently been marketed as a training tool for high-performance athletes, but it has not been tested as a clinical diagnostic tool. This study was performed to assess the accuracy of the portable lactate meter in subjects with GSD I who are predisposed to high lactate concentrations. A total of 166 intravenous and 39 capillary samples from 13 subjects were tested concomitantly on three different lactate meters. The meter readings were compared with the lactate concentration determined by the laboratory gold-standard enzymatic colorimetric assay. Almost no inter-meter variability was found. The lactate meter values had outstanding correlation with the laboratory lactate determination, although the meters were found to run 0.5 mmol/L higher than the laboratory assay. The meter deviation was independent of lactate concentration. More variability was noted with finger-stick capillary lactate determinations, but monitoring of trends with capillary samples should prove valuable as a method for determining long-term control or acute deterioration. The portable lactate meter is a highly accurate tool for monitoring lactate concentrations, and should prove valuable for monitoring metabolic control in patients with GSD type I and other disorders associated with hyperlactataemia.

Hepatocellular carcinoma in glycogen storage disease type Ia: a case series.

We present a series of 8 patients (6 males, 2 females) with hepatocellular carcinoma (HCC) and glycogen storage disease type Ia (GSD Ia). In this group, the age at which treatment was initiated ranged from birth to 39 years (mean 9.9 years). All patients but one were noncompliant with treatment. Hepatic masses were first detected at an age range of 13-45 years (mean 28.1 years). Age at diagnosis of HCC ranged from 19 to 49 years (mean 36.9 years). Duration between the diagnosis of liver adenomas and the diagnosis of HCC ranged from 0 to 28 years (mean 8.8 years, SD = 11.5). Two patients had positive hepatitis serologies (one hepatitis B, one hepatitis C). Alpha-fetoprotein (AFP) was normal in 6 of the 8 patients. Carcinoembryonic antigen (CEA) was normal in the 5 patients in which it was measured. Current guidelines recommend abdominal ultrasonography with AFP and CEA levels every 3 months once patients develop hepatic lesions. Abdominal CT or MRI is advised when the lesions are large or poorly defined or are growing larger. We question the reliability of AFP and CEA as markers for HCC in GSD Ia. Aggressive interventional management of masses with rapid growth or poorly defined margins may be necessary to prevent the development of HCC in this patient population.

Decreased urinary citrate excretion in type 1a glycogen storage disease.

OBJECTIVES: To quantify urinary citrate and calcium excretion and systemic acid-base status in patients with type 1a glycogen storage disease (GSD1a) and to investigate their relationship to renal complications. STUDY DESIGN: Fifteen patients (7 male and 8 female; age range, 3--28 years) were studied during annual evaluations of metabolic control. All were treated with intermittent doses of uncooked cornstarch. Hourly blood sampling and a 24-hour urine collection were obtained while subjects followed their usual home dietary regimen. RESULTS: All but the youngest subject had low levels of citrate excretion (mean 2.4 +/- 1.8 mg/kg/d; 129 +/- 21 mg citrate/g creatinine). Normally, urinary citrate excretion increases with age; however, in patients with GSD1a, a strong inverse exponential relationship was found between age and citrate excretion (r = -0.84, P <.0001). Urinary citrate excretion was unrelated to markers of metabolic control. Hypercalciuria occurred in 9 of 15 patients (mean urinary calcium/creatinine ratio, 0.27 +/- 0.15) and was also inversely correlated with age (r = -0.62, P =.001). CONCLUSIONS: Hypocitraturia that worsens with age occurs in metabolically compensated patients with GSD1a. The combination of low citrate excretion and hypercalciuria appears to be important in the pathogenesis of nephrocalcinosis and nephrolithiasis. Citrate supplementation may be beneficial in preventing or ameliorating nephrocalcinosis and the development of urinary calculi in GSD1a.

Enrolling patients into clinical trials faster using RealTime Recuiting.

Previous work has been done on both optimizing the clinical trials process, and on sending critical laboratory results and decision support through paging systems. We report the first integration of both these solution, focusing on improving the clinical trial recruitment process. We describe a clinical trial needing a real-time method of recruiting patients in an unbiased manner, quickly enough that study tests can be obtained before patients leave or samples discarded. The report describes how the ten currently recruited patients were found and how diagnoses of potentially life-threatening disorders are being made.

Use of a single-tree simulation model to predict effects of ozone and drought on growth of a white fir tree.

A physiologically based, single-tree simulation model, TREGRO, was parameterized with existing phenological, allometric, and growth data and used to predict effects of ozone and drought on growth of a 53-year-old white fir (Abies concolor (Gord. & Glend.) Lindl. ex Hildebr.) tree following a 3-year model simulation. Multiple experimental simulations were conducted to assess the individual and interactive effects of ozone (O(3)) exposure and drought on growth of white fir. The effects of O(3) were imposed as reductions in carbon (C) assimilation of 0, 2.5, 5, 10, and 20%. Drought was imposed as 0, 10, 25, and 50% reductions in total annual precipitation. The results of the simulations were compared with the effects of O(3) on white fir seedlings grown in the presence and absence of ozone in open-top chambers and with a field survey of white fir trees subjected to a gradient of O(3). In the O(3) simulations, an O(3)-induced reduction in C assimilation of 2.5% reduced total tree biomass and branch total nonstructural carbohydrate (TNC) content by < 7%. Although quantifiable in simulation experiments, such small reductions would probably not be detectable in the field. Results from both an open-top chamber experiment and a field survey indicated that reductions in C assimilation of white fir growing in elevated O(3) were much greater than 2.5%, but were not statistically different from control values. A simulated O(3) reduction in C assimilation of >/= 10% reduced total tree biomass by 7% and branch TNC by 55%. Results from the field survey indicated that branch elongation was reduced in response to increased O(3) concentration, corroborating the simulated response of reduced C allocation to the branches of white fir. Although simulated reductions in total annual precipitation of >/= 25% reduced final tree biomass, the simulated reductions also reduced O(3) uptake and therefore reduced the O(3) response of white fir. However, a combination of low amounts of O(3) (2.5% reduction in C assimilation) and drought (25% reduction in annual precipitation) synergistically reduced C gain of white fir more than either stress individually. Our simulations predict that moderate drought (no more than a 25% reduction in total annual precipitation) may not ameliorate the response of white fir to O(3) and that moderate amounts of atmospheric O(3) and drought could be more detrimental to white fir than either stress singly.

Glycogen storage diseases. Phenotypic, genetic, and biochemical characteristics, and therapy.

The glycogen storage diseases are caused by inherited deficiencies of enzymes that regulate the synthesis or degradation of glycogen. In the past decade, considerable progress has been made in identifying the precise genetic abnormalities that cause the specific impairments of enzyme function. Likewise, improved understanding of the pathophysiologic derangements resulting from individual enzyme defects has led to the development of effective nutritional therapies for each of these disorders. Meticulous adherence to dietary therapy prevents hypoglycemia, ameliorates the biochemical abnormalities, decreases the size of the liver, and results in normal or nearly normal physical growth and development. Nevertheless, serious long-term complications, including nephropathy that can cause renal failure and hepatic adenomata that can become malignant, are a major concern in GSD-I. In GSD-III, the risk for hypoglycemia diminishes with age, and the liver decreases in size during puberty. Cirrhosis develops in some adult patients, and progressive myopathy and cardiomyopathy occur in patients with absent GDE activity in muscle. It remains unclear whether these complications of glycogen storage disease can be prevented by dietary therapy. Glycogen storage diseases caused by lack of phosphorylase activity are milder disorders with a good prognosis. The liver decreases in size, and biochemical abnormalities disappear by puberty.

Simulated root dynamics of a 160-year-old sugar maple (Acer saccharum Marsh.) tree with and without ozone exposure using the TREGRO model.

Because of difficulties in directly assessing root responses of mature forest trees exposed to atmospheric pollutants, we have used the model TREGRO to analyze the effects of a 3- and a 10-year exposure to ozone (O(3)) on root dynamics of a simulated 160-year-old sugar maple (Acer saccharum Marsh.) tree. We used existing phenological, allometric, and growth data to parameterize TREGRO to produce a simulated 160-year-old tree. Simulations were based on literature values for sugar maple fine root production and senescence and the photosynthetic responses of sugar maple seedlings exposed to O(3) in open-top chambers. In the simulated 3-year exposure to O(3), 2 x ambient atmospheric O(3) concentrations reduced net carbon (C) gain of the 160-year-old tree. This reduction occurred in the C storage pools (total nonstructural carbohydrate, TNC), with most of the reduction occurring in coarse (woody) roots. Total fine root production and senescence were unaffected by the simulated 3-year exposure to O(3). However, extending the simulated O(3) exposure period to 10 years depleted the TNC pools of the coarse roots and reduced total fine root production. Similar reductions in TNC pools have been observed in forest-grown sugar maple trees exhibiting symptoms of stress. We conclude that modeling can aid in evaluating the belowground response of mature forest trees to atmospheric pollution stress and could indicate the potential for gradual deterioration of tree health under conditions of long-term stress, a situation similar to that underlying the decline of sugar maple trees.

Response of sugar maple to multiple year exposures to ozone and simulated acidic precipitation.

Potted sugar maple seedlings were exposed to ozone and acidic precipitation in open-top chambers for three consecutive growing seasons. Periodic measurements of photosynthesis, dark respiration, through-fall and soil solution chemistry, and annual measurements of the weight of plant parts were made. Experimental treatments caused few and minor effects on above- or below-ground growth of the seedlings, even after three growing seasons. There were trends for reduced photosynthesis in trees exposed to elevated concentrations of ozone and increased photosynthesis in those exposed to the lowest pH simulated rain treatment. The chemistries of soil-solutions and through-fall were not altered significantly by treatment. Although major effects were not observed, sugar maple may respond to exposures that take place over a significant part of its life cycle.

Osteoporosis after spinal cord injury.

Dual-photon absorptiometry characterized bone loss in males aged less than 40 years after complete traumatic paraplegic and quadriplegic spinal cord injury. Total bone mass of various regions and bone mineral density (BMD) of the knee were measured in 55 subjects. Three different populations were partitioned into four groups: 10 controls (healthy, age matched); 25 acutely injured (114 days after injury), with 12 reexamined 16 months after injury; and 20 chronic (greater than 5 years after injury). Significant differences (p less than 0.0001) in bone mass mineral between groups at the arms, pelvis, legs, distal femur, and proximal tibia were found, with no differences for the head or trunk. Post hoc analyses indicated no differences between the acutely injured at 16 months and the chronically injured. Paraplegic and quadriplegic subjects were significantly different only at the arms and trunk, but were highly similar at the pelvis and below. In the acutely injured, a slight but statistically insignificant rebound was noted above the pelvis. Regression techniques demonstrated early, rapid, linear (p less than 0.0001) decline of bone below the pelvis. Bone mineral loss occurs throughout the entire skeleton, except the skull. Most bone loss occurs rapidly and below the pelvis. Homeostasis is reached by 16 months at two thirds of original bone mass, near fracture threshold.

Loss of high-affinity agonist binding to M1 muscarinic receptors in Alzheimer's disease: implications for the failure of cholinergic replacement therapies.

Cholinergic replacement therapies have yielded little or no clinical improvement in Alzheimer's disease (AD). Since the number of postsynaptic muscarinic receptors remains unchanged in the cerebral cortex, the involvement of other neurotransmitter systems may account for this limited efficacy. Alternatively, there may be a defective coupling of the muscarinic receptor with its nucleotide-binding protein in AD, which would severely limit the ability of cholinergic agonists to activate intracortical second messengers. To address this possibility, we assessed the ability of the putative M1 muscarinic receptor to form high-affinity agonist-receptor complexes with guanine nucleotide regulatory proteins in postmortem frontal cortex. Agonist affinity states of the M1 muscarinic receptor were measured by carbachol/[3H]-pirenzepine competition. M1 muscarinic receptors exhibited both high (KH) and low (KL) affinities for the agonist carbachol. High-affinity agonist binding to M1 receptors in postmortem frontal cortex samples from subjects with AD was reduced, demonstrated by an increase in the KH value. Low-affinity agonist binding (KL value) was unchanged in AD and was not significantly different from the KL value for the uncoupled receptor determined in the presence of guanine nucleotides. The increase in the KH value resulted in a 70% decrease in the average KL/KH ratio for AD as compared to control samples. Choline acetyltransferase activities correlated significantly with the KL/KH ratios (r = 0.73, p less than 0.001). These data suggest that the KL/KH ratio for muscarinic agonists may serve as a neurochemical marker of disease severity. The reduced ability of the M1 receptor subtype to form a high-affinity agonist state in AD may account for the failure of cholinergic replacement therapies to improve specific features of memory and cognition.

Energy flow and the persistence of a human population: a simulation analysis.

The authors describe "a human ecosystem model, NUNOA, [which] simulates the yearly energy balance of individuals, families, and extended families in a hypothetical farming and herding community of Quechua Indians in the high Andes. The yearly energy demand of each family, based on the caloric requirements of its members, is computed by simulation of agricultural and herding activities in response to stochastic environmental conditions. The family energy balance is used in determining births, deaths, marriages, and resource sharing." The model can be used "to investigate the effect of changes in marriage patterns, resource sharing patterns, or subsistence activities on the ability of the human population to survive in the harsh Andean environment. Results from the model suggest that the substructuring of a population into extended families provides a mechanism for sheltering the population from control by exogenous influences. A population without substructures for resource sharing is shown to be unstable in such an unpredictable environment."

Differential thermal analysis of dipalmitoylphosphatidylcholine--fatty acid mixtures.

Mixtures of dipalmitoylphosphatidylcholine (DPPC) with palmitic, stearic, and myristic acids and the sodium salts of these acids were analyzed by differential thermal analysis (DTA) over a wide range of lipid compositions, all in excess water. All three fatty acids raise the liquid-crystal phase transition temperature and form sharp-melting complexes, with 1:2 DPPC--fatty acid stoichiometry observed for palmitic and stearic acids and suggested for myristic acid. Phase diagrams of the peritectic type, indicating nonideal mixing, was fitted to the DPPC--palmitic acid and DPPC--stearic acid data. In contrast, DPPC forms nearly ideal mixtures with the putative DPPC--myristic acid complex. At levels of only a few mole percent, both sodium stearate and myristate remove the pretransition and main transition and produce new peaks at approximately 30 and approximately 48 degrees C; the relative areas of the new peaks were unreproducible for the DPPC--myristate system. Sodium palmitate is the least disruptive of any of the sodium soaps or fatty acids; up to 80 mol % palmitate, the transition is lowered 3 degrees C and approximately doubled in width. The pretransition is detectable up to 36 mol %, and the main transition persists up to 88 mol % palmitate. The apparent pK of palmitic acid (12 mol %) in DPPC bilayers was determined to be 10.2 by direct pH measurement of ternary DPPC mixtures with known palmitic acid/sodium palmitate ratios; the intrinsic pK is estimated to be less than or approximately 8.5.

Metabolism of Radiolabeled beta-Guaiacyl Ether-Linked Lignin Dimeric Compounds by Phanerochaete chrysosporium.

Phanerochaete chrysosporium metabolized the radiolabeled lignin model compounds [gamma-C]guaiacylglycerol-beta-guaiacyl ether and [4-methoxy-C]veratrylglycerol-beta-guaiacyl ether (VI) to CO(2) in stationary and in shaking cultures. CO(2) evolution was greater in stationary culture. CO(2) evolution from [gamma-C]guaiacyl-glycerol-beta-guaiacyl ether and [4-methoxy-C]veratrylglycerol-beta-guaiacyl ether in stationary cultures was two- to threefold greater when 100% O(2) rather than air (21% O(2)) was the gas phase above the cultures. CO(2) evolution from the metabolism of the substrates occurred only as the culture entered the stationary phase of growth. The presence of substrate levels of nitrogen in the medium suppressed CO(2) evolution from both substrates in stationary cultures. [C]veratryl alcohol and 4-ethoxy-3-methoxybenzyl alcohol were formed as products of the metabolism of VI and 4-ethoxy-3-methoxyphenylglycerol-beta-guaiacyl ether, respectively.