Non-oral manifestations in adults with a clinical and molecularly confirmed diagnosis of periodontal Ehlers-Danlos syndrome.

Introduction: Periodontal Ehlers-Danlos Syndrome (pEDS) is a rare autosomal dominant type of EDS characterised by severe early-onset periodontitis, lack of attached gingiva, pretibial plaques, joint hypermobility and skin hyperextensibility as per the 2017 International EDS Classification. In 2016, deleterious pathogenic heterozygous variants were identified in C1R and C1S, which encode components of the complement system. Materials and Methods: Individuals with a clinical suspicion of pEDS were clinically and molecularly assessed through the National EDS Service in London and Sheffield and in genetic services in Austria, Sweden and Australia. Transmission electron microscopy and fibroblast studies were performed in a small subset of patients. Results: A total of 21 adults from 12 families were clinically and molecularly diagnosed with pEDS, with C1R variants in all families. The age at molecular diagnosis ranged from 21-73 years (mean 45 years), male: female ratio 5:16. Features of easy bruising (90%), pretibial plaques (81%), skin fragility (71%), joint hypermobility (24%) and vocal changes (38%) were identified as well as leukodystrophy in 89% of those imaged. Discussion: This cohort highlights the clinical features of pEDS in adults and contributes several important additional clinical features as well as novel deleterious variants to current knowledge. Hypothetical pathogenic mechanisms which may help to progress understanding and management of pEDS are also discussed.

Electron microscopy in the diagnosis of Ehlers-Danlos syndromes: correlation with clinical and genetic investigations.

BACKGROUND: The Ehlers-Danlos syndromes (EDS) consist of 13 subtypes with overlapping features including joint hypermobility, skin and vascular fragility and generalized connective tissue friability. As DNA analysis has become the gold standard for investigation of EDS, transmission electron microscopy (TEM) in clinical practice is decreasing. However, owing to the use of next-generation sequencing, the frequency of variants of uncertain significance (VUS) identified using DNA analysis is increasing. We hypothesized that TEM can provide evidence for or against pathogenicity of VUS. OBJECTIVES: The aim of this study was to evaluate the role of TEM in the diagnosis of EDS subtypes. METHODS: Data were collected from patients who underwent a skin biopsy between October 2012 and March 2017 at the London EDS National Diagnostic Service. TEM biopsies were categorized as 'normal' or 'abnormal' according to the description and conclusion in the TEM reports. Definitive diagnoses were reached via a combination of clinical features, structural and functional studies and DNA investigations. RESULTS: The analysis included 177 patients, comprising 30 abnormal and 147 normal TEM reports. A definitive diagnosis of monogenic EDS subtypes was made in 24 patients. Overall, 17 of these 24 patients (71%) had an abnormal biopsy report and seven (29%) had a normal biopsy report. No TEM findings were specifically associated with any EDS subtype, although collagen flowers were present in most patients with a genetically confirmed diagnosis of classical EDS. CONCLUSIONS: TEM analysis of collagen structure may have the potential to provide evidence for or against the pathogenicity of a VUS, but more work is needed to establish a clear role for TEM in this process. What's already known about this topic? Collagen fibril abnormalities can be seen in several Ehlers-Danlos syndrome (EDS) subtypes. What does this study add? This study provides clinical data, transmission electron microscopy (TEM) data and molecular data of one of the largest groups of patients suspected to have a monogenetic EDS subtype. No TEM findings were specifically associated with an EDS subtype. There was a higher percentage (71%) of abnormal biopsy findings in patients with a definitive diagnosis of a monogenetic EDS subtype and where a class 4/5 genetic variant was present.

The West German Study Group Breast Cancer Intrinsic Subtype study: a prospective multicenter decision impact study utilizing the Prosigna assay for adjuvant treatment decision-making in estrogen-receptor-positive, HER2-negative early-stage breast cancer.

PURPOSE: The West German Study Group (WSG) Breast Cancer Intrinsic Subtype (BCIST) study was designed to assess the influence of Prosigna gene signature assay results on physicians' adjuvant treatment recommendations by determining the extent of change in pre-test treatment recommendations following assay results. Secondary objectives were to assess the influence of Prosigna results on physicians' confidence in their therapeutic recommendations and on patients' decisional conflict status, anxiety levels, and functional status. METHODS: This prospective, observational, decision impact study enrolled consecutive postmenopausal patients with estrogen-receptor (ER)-positive, HER2-negative, lymph-node-negative early-stage breast cancer in 11 centers in Germany. Physicians based their pre-test adjuvant treatment recommendations on standard clinico-pathological parameters. Tumor specimens were assayed using the Prosigna test in a WSG central pathology laboratory following manufacturer's guidelines. An independent pathology laboratory performed subsequent Prosigna assays on tumor sections to assess assay result concordance with the central laboratory. Physicians completed treatment confidence questionnaires prior to and after receiving Prosigna test results. Patients completed standardized questionnaires on decisional conflict, anxiety, and health status both before and after Prosigna testing. RESULTS: The present study population consisted predominantly of low-to-intermediate risk patients (N = 198). Prosigna had 29.3% discordance in intrinsic subtyping with local immunohistochemistry test results. After Prosigna test results, a change in the adjuvant therapy recommendation occurred in 36 (18.2%) patients; 22 (11.1%) patients switched from no chemotherapy to chemotherapy. After Prosigna test results, physicians expressed increased confidence in their prognostic assessment in 87.9% of patients, and increased confidence in their treatment recommendation in 89.4%. Patients reported improved anxiety and emotional/functional well-being after receiving Prosigna test results. CONCLUSIONS: Use of the Prosigna assay led to a change in 18.2% of adjuvant treatment decisions. Prosigna testing was associated with increased patient and physician confidence in treatment decisions, and with decreased patient anxiety and improved well-being. Any comparison of the therapeutic decision-making impacts of different genomic assays must account for potential confounding factors.

A combined vascular surgical and clinical genetics approach to diffuse aneurysmal disease.

We report two patients who presented with extensive aneurysmal disease, in association with minimal external physical signs. Patient 1 remained genetically undiagnosed despite multiple structural, biochemical and genetic investigations. He made a good recovery following surgery for popliteal and left axillary artery aneurysms. Patient 2 was diagnosed with vascular type Ehlers-Danlos syndrome, associated with a high degree of tissue and blood vessel fragility, and is being managed conservatively. Early multidisciplinary assessment of such patients facilitates accurate diagnosis and management.

Conversion rate in 300 laparoscopic rectal resections and its influence on morbidity and oncological outcome.

INTRODUCTION: The negative influence of conversion from laparoscopic to open colorectal resection on early postoperative morbidity and outcome has been demonstrated several times. In this study, we analyzed the conversion rate and its influence on early postoperative morbidity and short-term oncological outcome following laparoscopic rectal resections. METHODS: From January 1998 to December 2006, 300 patients underwent laparoscopic resection due to rectal carcinoma at our institution. We compared the converted patient group with the non-converted patient group regarding demographical, clinical, surgical, and histological data, compounded with the early and late postoperative results. RESULTS: Two hundred seventy-four (91.3%) patients underwent laparoscopic rectal resection (LR), while conversion resection (CR) was necessary in 26 cases (8.6%). Conversion rate was 13% during the first 100 resections and decreased to 3% during the last 100 procedures (p = 0.035). Male gender, higher body mass index, and presence of T4-tumor were risk factors for conversion. Early postoperative complications were more frequent in the CR group than in the LR group. Concerning local tumor recurrence and overall survival, there was no significant difference between both groups (local recurrence, CR at 3.8% vs. LR at 4.5% and overall survival rate, CR at 76.9% vs. LR at 89.1%) after a median follow-up period of 22.5 months. CONCLUSION: Conversion to an open procedure during laparoscopic rectal resection correlates with an increased postoperative morbidity, however, without impairment of the short-term oncological outcome. The conversion rate is minimized by the growing experience of the operating surgeon and, therefore, is a marker of the learning curve.

[Peritoneal carcinomatosis. Surgical treatment, including hyperthermal intraperitoneal chemotherapy]. / Peritonealkarzinose. Chirurgische Behandlungsmöglichkeiten einschliesslich hyperthermer intraperitonealer Chemotherapie.

Colorectal cancer is a common malignant disease with increasing incidence and a significant cause of death in cancer patients. More than 10% of patients with colorectal cancer show peritoneal carcinomatosis at initial diagnosis. Moreover, peritoneal metastasis is a common sign of recurrence. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are a new treatment strategy for highly selected patients with peritoneal carcinomatosis. Numerous studies show prolonged survival after CRS and HIPEC with acceptable morbidity and mortality rates. Accurate preoperative diagnostics and patient selection play a pivotal role in postoperative patient outcome. This promising treatment strategy is discussed regarding surgical technique, intraperitoneal chemotherapy, and patient outcome.

Multimodality treatment of peritoneal carcinomatosis from colorectal cancer: first results of a new German centre for peritoneal surface malignancies.

BACKGROUND: The presence of peritoneal carcinomatosis arising from colorectal cancer is associated with a poor prognosis. It was the purpose of this study to analyze morbidity, mortality, and survival after major cytoreductive surgery and intraperitoneal chemotherapy. MATERIALS AND METHODS: Thirty-two patients with peritoneal carcinomatosis were operated between April 2004 and June 2006 with the aim of complete macroscopical cytoreduction. All had a primary colorectal carcinoma. Surgery in these patients was followed by hyperthermic intraperitoneal chemotherapy (HIPEC) consisting of mitomycin C and doxorubicin. Data were analyzed retrospectively. RESULTS: Of all patients, 16 had appendix and 16 non-appendiceal colorectal carcinoma. A macroscopically complete cytoreduction was achieved in 24 patients by parietal and visceral peritonectomy procedures. All resections were combined with HIPEC. Overall morbidity was 34%. Most frequent surgical complications were intestinal obstruction (4/32), enteric fistula (2/32), pancreatitis (2/32), and bile leakage (2/32). One patient presented grade 4 renal toxicity. There was no hospital mortality. The median follow-up was 12 months. The 1-year overall survival rate is 96%. All patients after complete cytoreduction are still alive. CONCLUSIONS: Cytoreductive surgery combined with HIPEC is associated with an acceptable morbidity and low mortality. Complete cytoreduction may improve survival, particularly in well-selected patients having a low tumor volume and no extra-abdominal metastases.

[Surgical management of patients with peritoneal carcinomatosis of gastrointestinal origin]. / Chirurgische behandlung von peritoneal disseminierten gastrointestinalen tumoren.

Peritoneal carcinomatosis is found in approximately 15 % of patients with colorectal cancer during the course of their disease, and is associated with a poor prognosis. Even more patients with gastric cancer develop peritoneal seeding. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) have been introduced in the past decade and have led to 5-year survival rates of 30 to 40 % for selected patients with colorectal cancer and peritoneal carcinomatosis. These numbers have been demonstrated by many retrospective analyses and by prospective Phase II studies. The clinical assessment to select patients who will benefit from the combined therapy and achievement of complete macroscopic cytoreduction both play a crucial role. Less favourabale results have been achieved for patients suffering from stage IV gastric cancer with peritoneal seeding. Promising results were demonstrated for postoperative intraperitoneal chemotherapy following curative gastrectomy. Patients with hepatic, biliary and pancreatic cancers and peritoneal carcinomatosis do not benefit from cytoreductive surgery. There is a need for further multicentre, prospective trials analysing the use of hyperthermic intraperitoneal chemotherapy. They should be conducted in the specialised centres by interdisciplinary teams.

Autonomic innervation of the bovine testis.

The autonomic nerve supply of the bovine testis is investigated in animals of different ages by means of immunohistochemistry. Staining with antiserum to protein gene product 9.5 gives the most complete results for the study of the general innervation pattern. Autonomic nerves reach the testis by three different routes: with the blood vessels of the spermatic cord (funicular nervous contribution), by the mesorchium (mesorchial nervous contribution) and by the ligamentous bridge between epididymal tail and testis (caudal nervous contribution). The vessels of the spermatic cord are densely innervated. The large vessels of the vascular layer within the tunica albuginea display a discontinuous innervation pattern. In the interior of the testis, the caudal half of the gonad is completely free of any innervation. Slight differences in arrangement and fiber composition of testicular nerves in calves and bulls point to a reduction of the innervation with advancing age. The vast majority of bovine testicular nerves are dopamine-beta-hydroxylase-positive postganglionic sympathetic axons with vasomotor function. There is no evidence for a cholinergic innervation of the bovine testis. About half of the bovine testicular nerves are neuropeptide Y-immunoreactive. In the adult, solitary calcitonin gene-related peptide-immunoreactive fibers are the only ones independent of blood vessels. The absence of an innervation in the caudal half of the testis underlines the importance of local factors and blood-borne substances for the regulation of intratesticular blood flow in the bovine.

[Hepatic polycystic disease is not always associated with polycystic kidney: epidemiological data]. / La polykystose hépatique n'est pas toujours associée à la polykystose rénale: données épidémiologiques.

Adult polycystic disease of the liver (APLD) and of the kidney (ADPKD) is considered to represent one entity. In 75 ADPKD kindreds with 259 affected members, ultrasonography and/or CT were performed in 186 (71.8%) from 64 kindreds (85.3%). We demonstrated that ADPKD with or without APLD are two separate phenotypes and suggest genetic heterogeneity of these two entities.

[Continuous ambulatory peritoneal dialysis and renal transplantation]. / Dialyse péritonéale continue ambulatoire et transplantation rénale.

From 1981 to 1987, 792 renal transplantations were performed in our center: 60 (7.5%) patients were on continuous ambulatory peritoneal dialysis. Patient and graft survivals, are identical to those obtained in hemodialysis patients. Complications due to the technic of peritoneal dialysis (peritonitis, ascite, peritoneal breach) were rarely observed and without influence on the evolution of the transplant. The risk of arterial thrombosis could not be assumed. Our present experience confirm our previous results: CAPD may be regarded as the first choice method for young patients in whom rapid grafting is planned on account of their immune status.

Congenital vertical talus. The results of staged operative reduction.

Congenital vertical talus was diagnosed in 15 feet of 10 children, and was treated by operative reduction. Forefoot deformity was corrected first, using anterolateral soft-tissue release on 11 feet, and manipulation alone in four feet. After prolonged immobilisation in plaster the affected feet had posterior release at the ankle and elongation of the calcaneal tendon. Clinical and radiographic examination at follow-up 15 months to 21 years later showed that a satisfactory outcome had been achieved in 12 of the 15 feet.

Synthesis of [17,18-3H] trans-13-azaprostanoic acid. A labeled probe for the PGH2/TXA2 receptor.

Because of its highly unstable nature, TXA2, produced by platelet metabolism of arachidonic acid, does not lend itself to use as a receptor probe for its own receptor. As such, the stable TXA2/PGH2 antagonist, trans-13-azaprostanoic acid (trans-13-APA, 12b), was prepared as the [17, 18 3H] derivative [( 3H] trans-13-APA, 12c) to study this receptor and to better evaluate the mechanism of action of these azaprostanoids. Tritiated trans-13-APA, 12c, was prepared in nearly theoretical specific activity (57 Ci/mmole) from (17Z)-trans-13-azaprost-17-enoic acid (11b) by catalytic tritiation. The unsaturated 11b was prepared by condensation of cis-7-amino-3-heptene (8) with 2-(6-carboxyhexyl) cyclopentanone (9), NaBH4 reduction, chromatography, and hydrolysis of the trans isomer so isolated. The olefins 11a and b were also of biochemical interest because of the unsaturation in the lower side chain. The presence of similar unsaturation in PGH3(4) and TXA3 (3) renders these prostaglandins inactive as proaggregatory agents. Evaluation of the antiaggregatory activity of 11a and b indicated it to be about the same potency in inhibiting human platelet aggregation as the parent cis and trans-13-APAs, suggesting that introduction of a double bond at the 17 position in platelet prostaglandin antagonists is unlikely to result in enhanced antiplatelet activity.

The management of metatarsus adductus et supinatus.

Forty-three patients with 69 feet affected by isolated metatarsus adductus et supinatus were reviewed. Of these, 20 patients (with 31 involved feet) had been treated expectantly and spontaneous resolution had occurred with time. The remaining 23 patients (with 38 feet) had required anteromedial release; the operative technique is described. Excellent results were uniformly achieved in both groups, with neither recurrence nor complications in the operatively treated feet. There was a consistent correlation between good clinical results and a naviculo -metatarsal angle of less than 100 degrees. The timing of soft-tissue release did not influence the final outcome.

2-(6-carboxyhexyl)cyclopentanone hexylhydrazone: a potent inhibitor of the blood platelet cyclo-oxygenase.

Previous studies have demonstrated that 13-azaprostanoic acid (13-APA) is a potent and specific antagonist of thromboxane A2/prostaglandin H2 (TXA2/PGH2) at the platelet receptor level. In the present study we evaluated the effects of a new azaprostanoid , 2-(6- carboxyhexyl ) cyclopentanone hexylhydrazone (CPH), on human platelet function. This hydrazone was found to completely inhibit arachidonic acid (AA)-induced platelet aggregation at 1 microM CPH. On the other hand, CPH was not an effective inhibitor of PGH2-induced aggregation. Furthermore, 100 microM CPH was completely ineffective in blocking platelet aggregation stimulated by adenosine diphosphate (ADP) or the stable prostaglandin endoperoxide analog U46619 (which presumably acts at the TXA2/PGH2 receptor). Measurement of platelet thromboxane B2 (TXB2) production demonstrated tha the primary site-of-action of CPH is at the cyclo-oxygenase level. Thus, CP inhibited TXB2 formation from AA in a dose-dependent manner (0.1 microM-100 microM CPH)2. In contrast, CPH blocked TXB2 production from PGH2 only at the highest CPH concentration tested, i.e., 100 microM. These results indicate that relative to 13-APA, addition of a second nitrogen at C14 and a double bond between the 12- and 13- positions results in a loss of receptor activity but produces a high affinity for the platelet cyclo-oxygenase.

2-(6-carboxyhexyl)cyclopentanone hexylhydrazone. A potent and time-dependent inhibitor of platelet aggregation.

Two new azaprostanoids, a hydrazone (3) and hydrazide (4), have been prepared by the condensation of 2-(6-carboxyhexyl)cyclopentanone with n-hexylhydrazine and caproic acid hydrazide. Preliminary results with the stable hydrazide 4 indicate that it inhibits arachidonic acid (AA) induced human platelet aggregation and that, unlike 13-azaprostanoic acid (1), its site of action is at the cyclooxygenase level. Results with the unstable hydrazone derivative 3 indicate it to be a potent and time-dependent inhibitor of AA-induced human platelet aggregation, with its site of action also at the cyclooxygenase level.

Specific binding of the thromboxane A2 antagonist 13-azaprostanoic acid to human platelet membranes.

In the present study we characterized the interaction between the thromboxane A2/prostaglandin H2 antagonist, trans-13-azaprostanoic acid (13-APA), and isolated human platelet membranes. In these studies, we developed a binding assay using trans [3H] 13-APA as the ligand. It was found that trans [3H] 13-APA specific binding was rapid, reversible, saturable and temperature dependent. Scatchard analysis of the binding data yielded a curvilinear plot which indicated the existence of two classes of binding sites: a high-affinity binding site with an estimated dissociation constant (Kd) of 100 nM; and a low-affinity binding site with an estimated Kd of 3.5 microM. At saturation, approximately 1 pmol/mg protein of [3H] 13-APA was bound to the high affinity site. In order to further characterize the nature of the [3H] 13-APA binding site, we evaluated competitive binding by cis 13-APA, cis 15-APA, prostaglandin F2 alpha, U46619, 6-ketoprostaglandin F1 alpha and thromboxane B2. It was found that the [3H] 13-APA binding site was stereospecific and structurally specific. Thus, the cis isomer of 13-APA exhibited substantially reduced affinity for binding. Furthermore, the prostaglandin derivatives, thromboxane B2 and 6-ketoprostaglandin F1 alpha, which do not possess biological activity, also did not compete for [3H] 13-APA binding. On the other hand, U46619 which acts as a thromboxane A2/prostaglandin H2 mimetic, and prostaglandin F2 alpha which acts as a thromboxane A2/prostaglandin H2 antagonist, both effectively competed for [3H] 13-APA binding. These findings indicate that trans 13-APA binds to a specific site on the platelet membrane which presumably represents the thromboxane A2/prostaglandin H2 receptor.

The results of pantalar reduction in the management of congenital talipes equinovarus.

One hundred and twenty-five patients with 194 feet affected by congenital talipes equinovarus were treated by the senior author during the period 1959 to 1980. Of these, 70 patients presented either at birth or in the early neonatal period, and 55 were seen later, having been referred from other centres. Seventy-five patients were subsequently reviewed by two of us; the remaining 50 were assessed from records and research files. Patients seen within four weeks of birth were termed "early", the remainder "late". Of the early group of 70 patients, 44 (with 68 affected feet) were reviewed and 26 (with 41 affected feet) were assessed from records. Excellent or good results were achieved in 94 per cent of feet treated conservatively and in 82 per cent of feet which required pantalar release. Of the 55 late referrals 32 patients (with 55 affected feet) were reviewed and 23 (with 30 affected feet) were assessed from records. Satisfactory results were slightly less frequent, but were achieved in 75 per cent of cases. There was no statistical correlation between early soft-tissue release and a good final outcome, but there was a positive statistical correlation between good clinical results and a high talocalcaneal index. Osseous correction (a laterally based wedge tarsectomy or a triple arthrodesis) was necessary at a later date in four feet (four per cent) of those who presented early and in 13 feet (15 per cent) of late referrals.

Prostaglandin F2 alpha antagonizes thromboxane A2-induced human platelet aggregation.

The effects of prostaglandin F2 alpha on human blood platelet function were investigated. PGF2 alpha at 15 muM completely blocked platelet aggregation induced by 500 muM arachidonic acid or 3 muM U46619 but had no effect on aggregation induced by 7.5 muM ADP. A similar specificity of action was not obtained with either PGI2 or PGE2. Thus concentrations of PGI2 (3 nM) or PGE2 (20 muM) which inhibited U46619- induced aggregation by 100% also blocked ADP-stimulated aggregation. The inhibitory properties of PGF2 alpha were not related to increases in platelet cAMP, since direct measurement of intracellular cAMP revealed that 15 muM PGF2 alpha produced no substantial change in cAMP levels. This finding was in direct contrast to results obtained using induced significant increases in platelet cAMP levels. The possibility that PGF2 alpha directly interacts at the platelet TXA2/PGH2 receptor was investigated by measuring [3H]PGF2 alpha binding to isolated platelet membranes. It was found that [3H] PGF2 alpha binding reached equilibrium within 30 min at room temperature and could be 90% displaced by addition of 1000 fold excess of unlabelled PGF2 alpha. Furthermore, when 1000 fold excess of either the TXA2/PGH2 "mimetic' U46619 or the TXA2/PGH2 antagonist displaced by 95% and 85% respectively. In contrast, the same molar excess of 6-keto-PFG1 alpha, azo analog 2, or TXB2, caused displacement of only 15%, 20% or 25% of the [3H] PHF2 alpha binding. Scatchard analysis indicated that [3H] PGF2 alpha has two binding sites; i.e., a high affinity binding site with an apparent Kd of 50 nM and a low affinity binding site with apparent Kd of 320 nM. These results suggest that the selective inhibition by PGF2 alpha of AA or U46619- induced aggregation may be mediated through interaction at the platelet TXA2/PGH2 receptor.