Natural history of growth and anaemia in children with epidermolysis bullosa: a retrospective cohort study.

BACKGROUND: Impaired growth and anaemia are major extracutaneous complications of epidermolysis bullosa (EB), but data on their development are lacking. OBJECTIVES: To determine the clinical course of growth and anaemia in children with EB and clarify the impact of nutritional compromise, inflammation and genetic factors. METHODS: A retrospective study was conducted of 200 children, 157 with recessive dystrophic EB (RDEB) and 43 with junctional EB (JEB)-generalized intermediate, followed at the main referral centre in Germany. Growth charts were calculated using the modified LMS method and were correlated with parameters of anaemia, nutrition, inflammation and the molecular defect in a linear model. RESULTS: In our cohort of patients with RDEB, weight impairment started at 12-18 months old; by the age of 10 years, 50% showed wasting. The predicted median weight at age 20 years was 35·2 kg for men and 40·1 kg for women. In JEB, growth resembled that of healthy children. Anaemia was present from the second year of life onwards in RDEB and JEB. Low levels of haemoglobin, iron, vitamin D, zinc and albumin, high levels of C-reactive protein, and absence of collagen VII correlated significantly with low weight in RDEB. No correlation was observed in JEB. CONCLUSIONS: The results highlight that nutritional compromise occurs early in children with RDEB and therefore may require interventions as of the first year or two of life. What's already known about this topic? Children with epidermolysis bullosa (EB) suffer from failure to thrive and anaemia as major extracutaneous complications. The course of growth and the development of anaemia in EB are poorly characterized. What does this study add? A molecularly well characterized cohort of 200 children with EB was followed with regard to anthropometrics, anaemia and inflammation. We demonstrate early onset of growth failure and anaemia, most pronounced in the subset of recessive dystrophic EB. Awareness of early growth delay and nutritional deficiencies will improve EB care in daily practice.

[Visual analysis for an early detection of diabetic neuropathy]. / Visuelle Analyse zur Früherkennung einer diabetischen Neuropathie.

Diabetic neuropathy is the most common long-term complication of diabetes mellitus. It comes along with significant nerve dysfunction, which is not reversible. Hence, it is essential to detect nerve fibre abnormalities as early as possible. In this paper, we investigate markers describing degradation of corneal nerves. We apply statistical computations and visual analysis to identify those variables of two clinical studies that separate DN patients from a control group. In this way, the diagnosis of DN patients is supported. The visual analysis is based on different representations visualizing both the statistical results and the gathered multi-variate data. The user can interactively manipulate the views, or select data that will be shown by further displays. In this way, the understanding of the data and its classification is supported. Ambiguous categorisations can be identified and grouped into a so-called "fuzzy group". For this group, further investigations are needed to decide about diabetic neuropathy.

Droplet size distributions in turbulent emulsions: breakup criteria and surfactant effects from direct numerical simulations.

Lattice Boltzmann simulations of water-in-oil (W/O) type emulsions of moderate viscosity ratio (≃1/3) and with oil soluble amphiphilic surfactant were used to study the droplet size distribution in forced, steady, homogeneous turbulence, at a water volume fraction of 20%. The viscous stresses internal to the droplets were comparable to the interfacial stress (interfacial tension), and the droplet size distribution (DSD) equilibrated near the Kolmogorov scale with droplet populations in both the viscous and inertial subranges. These results were consistent with known breakup criteria for W/O and oil-in-water emulsions, showing that the maximum stable droplet diameter is proportional to the Kolmogorov scale when viscous stresses are important (in contrast to the inviscid Hinze-limit where energy loss by viscous deformation in the droplet is negligible). The droplet size distribution in the inertial subrange scaled with the known power law ~d(-10/3), as a consequence of breakup by turbulent stress fluctuations external to the droplets. When the turbulent kinetic energy was sufficiently large (with interfacial Péclet numbers above unity), we found that turbulence driven redistribution of surfactant on the interface inhibited the Marangoni effect that is otherwise induced by film draining during coalescence in more quiescent flow. The coalescence rates were therefore not sensitive to varying surfactant activity in the range we considered, and for the given turbulent kinetic energies. Furthermore, internal viscous stresses strongly influenced the breakup rates. These two effects resulted in a DSD that was insensitive to varying surfactant activity.

Phenotypic spectrum of epidermolysis bullosa associated with α6ß4 integrin mutations.

BACKGROUND: Integrin α6ß4 is a transmembrane receptor and a key component of the hemidesmosome anchoring complex. It is involved in cell-matrix adhesion and signalling in various tissues. Mutations in the ITGA6 and ITGB4 genes coding for α6ß4 integrin compromise dermal-epidermal adhesion and are associated with skin blistering and pyloric atresia (PA), a disorder known as epidermolysis bullosa with PA (EB-PA). OBJECTIVES: To elucidate the molecular pathology of skin fragility in eight cases, disclose the underlying ITGA6 and ITGB4 mutations and study genotype-phenotype correlations. METHODS: DNA was isolated from ethylenediaminetetraacetic acid-blood samples, and the coding exons and exon-intron boundaries of ITGA6 and ITGB4 were amplified by polymerase chain reaction (PCR), and directly sequenced. Skin samples were submitted to immunofluorescence mapping with antibodies to adhesion proteins of the dermal-epidermal junction. Primary keratinocytes were isolated, and used for RNA and protein extraction, reverse transcription PCR and immunoblotting. Ultrastructural analysis of the skin was performed in one patient. RESULTS: We disclose 10 novel mutations, one in ITGA6 and nine in ITGB4. Skin cleavage was either intraepidermal or junctional. Lethal outcome and PA correlated with loss-of-function mutations in two cases. Solely mild skin involvement was associated with deletion of the C-terminus of ß4 integrin. Combinations of missense, nonsense or frameshift mutations caused severe urinary tract involvement in addition to skin fragility in five cases. CONCLUSIONS: The present study reveals novel ITGA6 and ITGB4 gene mutations and supports previous reports showing that the phenotype may lack PA and be limited to skin and nail involvement. In four out of six cases of EB-PA, life expectancy was not impaired. A high frequency of urinary tract involvement was found in this study, and represented the main cause of morbidity. Low levels of ß4 integrin expression were compatible with hemidesmosomal integrity and a mild skin phenotype.

Verrucous carcinoma in epidermolysis bullosa simplex is possibly associated with a novel mutation in the keratin 5 gene.

Epidermolysis bullosa simplex (EBS) is mainly caused by mutations in the KRT5 and KRT14 genes. Squamous cell carcinoma (SCC) represents the second most frequent skin neoplasia with complex aetiology. The molecular events disrupting the orchestrated interplay between the cytoskeleton, cell adhesion molecules and signalling proteins are ill understood in SCC. We describe the molecular background and the unusual course of the disease in a patient with EBS Dowling-Meara, severe keratoderma and a massive verrucous carcinoma. Skin and tumour samples from the patient were analysed using light microscopy, immunohistochemistry and immunofluorescence mapping. Mutation analysis of the KRT5 and KRT14 genes identified the novel KRT5 mutation p.E477D. Invasive tumour areas were characterized by downregulation of keratins 5 and 14, reduced and irregular desmocollin-2 expression and increased expression of keratins 6, 16 and 17. Levels of Ki-67 were increased and levels of E-cadherin strongly reduced in the tumour tissue. In this case a novel KRT5 mutation led to increased fragility of keratinocytes. Desmosome and adherens junctions were destabilized, which may trigger keratinocyte-mediated inflammation, possibly via p120-catenin-dependent signalling, suggesting a link between a keratin mutation and SCC, which adds weight to the hypothesis that disturbance of the cytoskeleton represents a major cause in the appearance of the malignant phenotype. Some individuals with EBS may be at risk of developing secondary SCC.

Stacking-Based Visualization of Trajectory Attribute Data.

Visualizing trajectory attribute data is challenging because it involves showing the trajectories in their spatio-temporal context as well as the attribute values associated with the individual points of trajectories. Previous work on trajectory visualization addresses selected aspects of this problem, but not all of them. We present a novel approach to visualizing trajectory attribute data. Our solution covers space, time, and attribute values. Based on an analysis of relevant visualization tasks, we designed the visualization solution around the principle of stacking trajectory bands. The core of our approach is a hybrid 2D/3D display. A 2D map serves as a reference for the spatial context, and the trajectories are visualized as stacked 3D trajectory bands along which attribute values are encoded by color. Time is integrated through appropriate ordering of bands and through a dynamic query mechanism that feeds temporally aggregated information to a circular time display. An additional 2D time graph shows temporal information in full detail by stacking 2D trajectory bands. Our solution is equipped with analytical and interactive mechanisms for selecting and ordering of trajectories, and adjusting the color mapping, as well as coordinated highlighting and dedicated 3D navigation. We demonstrate the usefulness of our novel visualization by three examples related to radiation surveillance, traffic analysis, and maritime navigation. User feedback obtained in a small experiment indicates that our hybrid 2D/3D solution can be operated quite well.

Water-filtered infrared A for the treatment of chronic venous stasis ulcers of the lower legs at home: a randomized controlled blinded study.

BACKGROUND: Water-filtered infrared A (wIRA) radiation can improve the healing of acute and chronic wounds both by thermal and thermic as well as by nonthermal and nonthermic effects. wIRA increases tissue temperature, oxygen partial pressure and perfusion. OBJECTIVES: Investigation of the influence of wIRA on chronic venous stasis ulcers in an investigator-initiated, randomized, controlled, blinded study. METHODS: Fifty-one patients with nonhealing chronic venous stasis ulcers of the lower legs were treated with compression therapy, wound cleansing, nonadhesive wound dressings and 30 min irradiation [wIRA + visible light (VIS) or VIS alone], predominantly at home, five times per week over 9 weeks and an additional 4 weeks without irradiation. RESULTS: Compared with the control group with VIS alone, the group with wIRA + VIS showed better wound healing [after 9 weeks 85 vs. 67·5 on a 0-100 visual analogue scale (VAS), median difference 15, 95% confidence interval (CI) 3-30, P = 0·012], a higher percentage of patients with a healing trend [after 9 weeks 21 of 25 (84%) vs. 13 of 26 (50%), P = 0·023], better granulation (after 9 weeks 90 vs. 80 on a 0-100 VAS, median difference 10, 95% CI 0-30, P = 0·036), a trend to less exudation (after 5 weeks 30 vs. 55 on a 0-100 VAS, P = 0·075) and to faster reduction of the wound area (after 7 weeks 39% vs. 19·5% reduction of wound area, median difference 20·5%, 95% CI -4-49%, P = 0·10; for wounds with an initial area < 10 cm(2): after 13 weeks 92% vs. 47% reduction of wound area, median difference 30%, 95% CI 0-68%, P = 0·11). The main variable 'Integral of relative ulcer area for each individual patient over time, standardized to an initial size of 1' did not reach significance. The application of wIRA at home was easily manageable. CONCLUSIONS: For the treatment of chronic venous stasis ulcers, the application of wIRA combined with phlebological therapy, compression therapy and wound dressing can be useful and can be recommended.

Late-onset inversa recessive dystrophic epidermolysis bullosa caused by glycine substitutions in collagen type VII.

Dystrophic epidermolysis bullosa (DEB) is a rare hereditary skin disorder caused by mutations in COL7A1, encoding collagen type VII.1 Clinical manifestations of COL7A1 mutations range from generalized skin blistering to mild localized blistering or nail dystrophy.2 The investigation of the molecular basis of DEB has revealed more than 540 different mutations that cannot entirely explain phenotypic variations (HGMD Professional 2010.3, https://portal.biobase-international. com/hgmd/). Inversa recessive DEB (RDEB-I) is a subtype characterized by generalized blistering in the neonatal period. The condition improves with age, and in adults blistering is restricted to intertriginous areas, and severe lesions of the oral and genital mucosa and nail changes occur in the majority of described patients.2 Recent data suggested that amino-acid substitutions affecting arginines or glycines at borders of collagenic subdomains might cause this phenotype.3 We report a German patient with an unusually mild RDEB-I harbouring compound heterozygous mutations in COL7A1.

Point-Based Visualization for Large Hierarchies.

Space-filling layout techniques for tree representations are frequently used when the available screen space is small or the data set is large. In this paper, we propose an efficient approach to space-filling tree representations that uses mechanisms from the point-based rendering paradigm. We present helpful interaction techniques and visual cues that tie in with our layout. Additionally, we relate this new layout approach to common layout mechanisms and evaluate the new layout along the lines of a numerical evaluation using the measures of the Ink-Paper Ratio and overplotted%, and in a preliminary user study. The flexibility of the general approach is illustrated by several enhancements of the basic layout, as well as its usage within the context of two software frameworks from different application fields.

The Design Space of Implicit Hierarchy Visualization: A Survey.

Apart from explicit node-link representations, implicit visualizations and especially the Treemap as their frontrunner have acquired a solid position among the available techniques to visualize hierarchies. Their advantage is a highly space-efficient graphical representation that does not require explicit drawing of edges. In this paper, we survey the design space for this class of visualization techniques. We establish the design space along the four axes of dimensionality, edge representation, node representation, and layout by examining existing implicit hierarchy visualization techniques. The survey is completed by casting some light into regions of the design space that have not yet been explored. Our design space is not a mere theoretical construct, but a practically usable tool for rapid visualization development. To that end, we discuss a software implementation of the introduced design space.

Identification of novel and known KRT5 and KRT14 mutations in 53 patients with epidermolysis bullosa simplex: correlation between genotype and phenotype.

BACKGROUND: Basal epidermolysis bullosa simplex (EBS) is a hereditary skin blistering disorder resulting in most cases from missense mutations in the keratin 5 (KRT5) or keratin 14 (KRT14) genes. OBJECTIVES: To identify the underlying mutations in different EBS subtypes and correlate genotype and phenotype. METHODS: Mutation analysis was performed in 53 patients with EBS and their families by direct sequencing of the KRT5 and KRT14 genes. RESULTS: We identified 39 different mutations, of which 15 have not been published previously. Three novel deletion/insertion mutations, among them one in-frame duplication, were associated with the rare phenotype of EBS with mottled pigmentation. We identified for the first time a patient with compound heterozygosity for KRT5 mutations causing Dowling-Degos disease and EBS. CONCLUSIONS: Identification of novel mutations and genotype-phenotype correlations in EBS allow improved understanding of disease pathogenesis as well as better patient management.

Forty-two novel COL7A1 mutations and the role of a frequent single nucleotide polymorphism in the MMP1 promoter in modulation of disease severity in a large European dystrophic epidermolysis bullosa cohort.

BACKGROUND: Dystrophic epidermolysis bullosa (DEB) is a severe genetic skin blistering disorder caused by mutations in the gene COL7A1, encoding collagen VII. Recently, the MMP1 promoter single nucleotide polymorphism (SNP) rs1799750, designated as 1G 2G, was shown to be involved in modulation of disease severity in patients with recessive DEB (RDEB), and was proposed as a genetic modifier. OBJECTIVES: To identify the molecular basis of DEB in 103 individuals and to replicate the results of the MMP1 promoter SNP analysis in an independent patient group, as verification is necessary in such a rare and heterogeneous disorder. METHODS: To determine the molecular basis of the disease, we performed COL7A1 mutation screening, reverse transcription-polymerase chain reaction (PCR) and real-time quantitative PCR. The status of the MMP1 SNP was analysed by PCR and restriction enzyme digestion and verified by sequencing. RESULTS: We disclosed 42 novel COL7A1 mutations, including the first large genomic deletion of 4 kb affecting only the COL7A1 gene, and three apparently silent mutations affecting splicing. Even though the frequency of the high-risk allele was increased in patients with RDEB, no statistically significant correlation between disease severity and genotype could be made. Also, no correlation was observed with development of squamous cell carcinoma, a severe complication of DEB. CONCLUSIONS: Taken together, the results suggest that the MMP1 SNP is not the sole disease modifier in different forms of DEB, and other genetic and environmental factors contribute to the clinical phenotype.

[Epidermolysis bullosa. An update]. / Epidermolysis bullosa. Ein Update.

Epidermolysis bullosa (EB) represents a group of diseases characterized by skin fragility usually developing blisters after minimal trauma. The clinical picture ranges from mild subtypes with minor skin reactions to severe forms with lethal outcome within the first months of life. In the severe generalized subtypes, complications such as aggressive squamous cell carcinoma of the skin, anemia, esophageal stenosis and cardiomyopathy can occur so that multidisciplinary patient care is necessary. EB can be divided in four types--EB simplex (EBS), junctional EB (JEB), dystrophic EB (DEB) and Kindler syndrome. All together 33 subtypes can be distinguished. In 2008 a revised EB classification was introduced. Several eponyms for EB subtypes were replaced by descriptive names. The review presents the EB subtypes based on the new EB classification system, the molecular background and new therapeutic options.

Load-induced cardiomyocyte apoptosis in cultured multicellular myocardial preparations is unaltered in presence of the beta-adrenoceptor antagonist nebivolol.

Overload-induced heart failure is associated with enhanced apoptosis of cardiomyocytes, and increased mechanical load is an inductor of this apoptosis. It is unknown whether nebivolol, a third generation beta(1)-adrenoceptor antagonist, possesses properties that can attenuate this apoptosis. Multicellular preparations from rabbit hearts were mounted in a culture system that allows for measurement of contractile parameters over several days. Culturing these muscles on a constant high preload induces apoptosis of the cardiomyocytes. Of each heart, 1 preloaded muscle preparation was treated with nebivolol (10(-6) mol/l), 1 preloaded without continuous exposure to nebivolol (positive control) and 1 unloaded (negative control). After 48 h of continuous loaded contractions, apoptosis was assessed by TUNEL-assay to confirm that nuclei of myocytes were affected, or by DNA-ladder intensity analysis for semiquantification. Maximal twitch force development was slightly, but significantly, lower in preparations contracting in presence of nebivolol (compared to solvent) while twitch-timing parameters were similar. After 48 h of continuous contractions, no additional differences were observed between the groups regarding contractile parameters. DNA-ladder analysis showed a similar rate of apoptosis in presence of nebivolol. Nebivolol does not increase, nor decrease, the rate of load-induced cardiomyocyte apoptosis.

C-terminally truncated kindlin-1 leads to abnormal adhesion and migration of keratinocytes.

BACKGROUND: The Kindler syndrome (KS) protein kindlin-1 is a member of a protein complex that links cortical actin to integrins on the surface of basal keratinocytes. Loss of kindlin-1 leads to abnormalities of cell adhesion and motility, and to skin blistering and progressive poikiloderma as clinical symptoms. OBJECTIVES: Here we investigated a severely affected patient, disclosed the mutation that caused the disease and delineated its biological consequences. METHODS: Mutation screening of the kindlin-1 gene, KIND1 (now called FERMT1), was performed with polymerase chain reaction (PCR) amplification of all exons and sequencing. Mutated kindlin-1 was characterized by reverse transcriptase (RT)-PCR and immunoblotting, and genotype-phenotype correlations were analysed using immunohistochemical staining of skin biopsies and keratinocytes from the patient's skin. Cell adhesion and motility were assessed with functional tests. RESULTS: We disclosed a splice site mutation in the first position of intron 13 of the FERMT1 gene, which caused skipping of exon 13. The short transcript partially escaped nonsense-mediated mRNA decay and was translated into a truncated protein. CONCLUSION: A C-terminally truncated kindlin-1 in keratinocytes could not function correctly even if it were expressed.

Dystrophic epidermolysis bullosa pruriginosa is not associated with frequent FLG gene mutations.

BACKGROUND: Dystrophic epidermolysis bullosa pruriginosa (DEB-Pr; OMIM 604129) is a rare manifestation of dystrophic epidermolysis bullosa (DEB), characterized by pruritus, nodular prurigo-like lesions and fragility of the skin mainly in the extremities. Fewer than 40 patients with autosomal dominant or recessive inheritance, or sporadic DEB-Pr, have been described in the literature. OBJECTIVES: To disclose mutations in DEB-Pr and to elucidate the role of other pathogenic factors which may influence the pruriginous phenotype. METHODS: Seven patients with typical clinical features of DEB-Pr were studied. RESULTS: In all patients, mutations in the gene encoding collagen VII (COL7A1) were disclosed, two of them novel (p.G2623V, p.E2736K). Three mutations were dominant, three recessive and one de novo. In the families with dominant DEB there were one or more members with DEB-Pr, but also at least one affected sibling who did not develop DEB-Pr. In six of seven patients, the clinical history revealed factors that initially induced pruritus, such as atopy, pregnancy, thyroid hormone imbalance, diabetes, infections and contact sensitization. Common filaggrin mutations were ruled out in all patients and normal filaggrin staining was found in the skin samples. CONCLUSIONS: DEB-Pr develops as a result of COL7A1 gene mutations and acquired phenotype-modifying factors. Filaggrin mutations did not contribute to the pruriginous phenotype in the present patient cohort.

Load-dependent induction of apoptosis in multicellular myocardial preparations.

Increased mechanical load has been proposed as an inductor of apoptosis, but it is unknown whether this can occur in the range of pre- and afterloads that prevail in the beating heart. We investigated apoptosis in cultured rabbit multicellular myocardial preparations over several days. Muscles contracted in absence of pre- and afterload (unloaded isotonic), in absence of preload but in presence of afterload (unloaded isometric), or in presence of both (loaded isometric). After up to 48 h of continuous contractions, apoptosis was assessed by TdT-mediated nick-end labeling (TUNEL) assay and DNA ladder analysis. In muscles that contracted loaded isometric, apoptosis was detected after 6-24 h. After 48 h, apoptosis was most prominent in this group, reflected by a high level of DNA ladder intensity (DLI; 27.8 +/- 11.5), whereas Bcl-xL (on RNA level) was significantly downregulated, and Fas remained unchanged. In unloaded isometric preparations, apoptosis was significantly less (6.9 +/- 5.9 DLI) and very similar to those contracting unloaded isotonic (6.1 +/- 5.1 DLI). We conclude that load-dependent apoptosis can occur at sarcomere lengths achievable in vivo and may mainly result from increased preload.