Ehlers-Danlos syndrome type III and pregnancy: labor analgesia]

Conjoined twinning is the result of an abnormal developmental process of "twinning" in which two similar weighted and sized twins are partially conjoined and show a total symmetry independently from the pattern of conjunction. They are classified in three groups: Terata Catydidymus, Terata Anadidyma and Terata Anacatadidyma. Among Terata Catydidymus the dicephalus subtype is a rare abnormality with a severe prognosis compared to other subtypes as: diprosopus, pyophagus and ischiopagus. We report the case of a fetus at the 15th weeks of pregnancy. The external examination revealed severe diffuse somatic malformations consisting of dicephalia with a double neck in conjunction to a single chest, a single abdomen, a double spine conjoined distally near the sacrum, buds of ribs in between the two spines with mid clavicular and scapular fusion following the major axis of the two bones. Arms and legs revealed no abnormalities. Central nervous system structures were normally developed and the two hemispheres seemed completely separated and independent one to the other. We believe that the case described is interesting being Terata Catydidymus a rare phenomenon, being the dicephalus subtype still lesser frequent and its occurrence in males quite exceptional.     

The substitution of glycine 661 by arginine in type III collagen produces mutant molecules with different thermal stabilities and causes Ehlers-Danlos syndrome type IV

Previous studies have shown that Ehlers-Danlos syndrome type IV (EDS IV) is caused by mutations of type III collagen (COL3A1). Here we have characterised the most amino-terminal glycine substitution so far described in a patient with EDS IV. A combination of peptide mapping and chemical cleavage analysis of cDNA localised the mutation in cyanogen bromide peptide CB5. Sequence analysis showed a G to A mutation, converting glycine 661 to arginine, which was a new dominant mutation. Analysis of type III collagen secreted by cultured fibroblasts showed an overmodified mutant protein with normal thermal stability. However, the intracellularly retained form melted 2 degrees C lower than normal. This indicated that molecules resulting from the same mutation can differ in their thermal stabilities.     

Ehlers-Danlos syndrome type II in pregnancy

The Allen test was performed by four physician examiners on 200 hands of healthy volunteers. Positive results were found in 5.5% of hands. There was not a single case in which all four observers agreed. Considerable inter-observer disagreement is associated with the Allen test.     

Smith-Lemli-Opitz syndrome: a variable clinical and biochemical phenotype

We have reviewed all known UK cases of Smith-Lemli-Opitz syndrome. Among 49 cases with proven 7-dehydrocholesterol reductase deficiency, half had been terminated or had died in infancy. The minimum incidence is 1 in 60,000. The frequent occurrence of hypospadias may account for 71% of recognised cases being male. Important common features which emerged include short thumbs, severe photosensitivity, aggressive behaviour, and atrioventricular septal defect. The typical facial appearance becomes less obvious with age and 20% of cases did not have 2/3 toe syndactyly. Biochemical measurements of serum 7-dehydrocholesterol did not correlate with clinical severity.     

Ehlers-Danlos syndrome type I. Ultrastructural study

Ehlers-Danlos syndrome comprises a very heterogeneous group of collagen diseases characterised in clinical terms by fragility and cutaneous hyperextensability, ligamentous hyperlaxity, ecchymosis, scarring, visceral and neurological manifestations. Having been described in detail by Ehlers in 1899 and Danlos in 1908, it was subsequently classified into various clinical types. At present at least 11 forms are recognised on the basis of their clinical characteristics, methods of transmission and biochemical defect; the first four types of the syndrome account for approximately 95% of cases. Almost all forms are transmitted with a dominant autosomic character. Specific genetic mutations have been ascertained whereas the biochemical defect has been identified in numerous types. Ehlers-Danlos type 1 syndrome is the most frequent and most severe form. The biochemical anomaly underlying the altered deposition of collagen fibre is still unknown and this is responsible for the "storiform" appearance of collagen fibre on ultrastructural examination. The authors have described a typical case of "Ehlers-Danlos type 1 syndrome" in which the diagnosis was confirmed by comparing clinical data and the results of ultrastructural tests which revealed the characteristic "pattern" of collagen fibres.     

Subclavian artery pseudoaneurysm in type IV Ehlers-Danlos syndrome

We report case of a subclavian artery pseudoaneurysm in a patient with type IV Ehlers-Danlos Syndrome. A 16-year-old boy underwent successful repair of a subclavian artery pseudoaneurysm that occurred after a cervical hyperextension injury. Subsequent workup included skin biopsy and fibroblast culture, which were consistent with a diagnosis of type IV Ehlers-Danlos Syndrome. This condition is a dominantly inherited connective tissue disorder, which in this patient was found to be caused by a spontaneous point mutation in the COL3A1 gene that encodes the chains of type III procollagen. The clinical, genetic, and molecular characteristics of type IV Ehlers-Danlos Syndrome are briefly reviewed.     

Immunohistochemical video-microdensitometry of myocardial collagen type I and type III

Collagen is an essential part of the cardiac interstitium. Collagen subtypes, their location, total amount and the architecture of the fibrillar network are of functional importance. Architecture in terms of density of the fibrillar network is assumed to be reflected by the intensity of immunohistochemical staining of collagen. The aim of this study was to evaluate a video-based microdensitometric method for quantifying density expressed as absorbance of collagen subtypes I and III stained with an indirect immunoperoxidase method in myectomy specimens of patients with hypertrophic obstructive cardiomyopathy. Various factors influencing the immunohistochemical staining product and the technical properties of the image analysis system were investigated. Linearity between collagen concentration and the absorbance of the immunohistochemical staining product was demonstrated for collagen I using a dot-blot technique. Immunohistochemical collagen staining and density measurement were easily reproducible. The cardiac disability of the patients was assessed according to the New York Heart Association (NYHA) criteria. There was a significant increase in collagen type I density with higher NYHA class, whereas no significant association was found for total collagen area fraction. Thus, video-based microdensitometry gives further insight into the structural remodelling of myocardial collagens and reveals their significance in the process of heart failure in hypertrophic cardiomyopathy.     

Leigh syndrome: clinical features and biochemical and DNA abnormalities

The morphology and number of cells in the trophectoderm (TE) and inner cell mass (ICM) of buffalo blastocysts derived from in vitro fertilization and cultured in the presence or absence of insulin-like growth factor-I (IGF-I) were analyzed by differential fluorochrome staining technique. The total cell number (TCN), TE number, and ICM cell number were significantly higher in blastocysts developed in vitro in the presence of IGF-I as compared to blastocysts developed without IGF-I (P < 0.01). It was observed that the buffalo blastocyst took 5-9 days postfertilization to develop in vitro. In order to correlate the time required for blastocyst development and the allocation of cells to TE and ICM, blastocysts were designated as fast (developing on or before day 7) or slow (developing after day 7). The TCN, TE, and ICM cells of fast-developing blastocysts cultured in the presence of IGF-I were significantly higher than slow-developing blastocysts (P < 0.01). The blastocysts developed on day 6 had a mean total cell number 118.6 +/- 21.4, which significantly decreased to 85.6 +/- 17.4, 62.0 +/- 14.5, and 17.0 +/- 4.0 on days 7, 8, and 9, respectively (P < 0.05). Normal development of buffalo embryo showed that, on average, embryos reached compact morula stage at the earliest between days 4.5-5.5. Blastocysts developed, at the earliest, between days 5.0-6.0, and it took them, on average, 6.5 days to hatch from the zona pellucida. TCN, TE, and ICM increased three times from morula to blastocyst; however, the proportion of ICM to TCN remained the same, in both embryonic stages. TE approximately doubled in hatched blastocysts, as compared to unhatched blastocysts (P < 0.05). However, ICM cells were decreased. The time required for development of parthenogenetic blastocysts was observed to be greater as compared to in vitro fertilized (IVF) blastocysts. The total cell number of parthenogenetic blastocysts was 100.8 +/- 11.3, including 59.2 +/- 8.4 cells of TE and 42.1 +/- 6.9 cells of ICM.     

Prenatal exclusion of Ehlers-Danlos syndrome type VI by mutational analysis

Knowledge management provides a means for sharing data, lessons learned, and accumulated knowledge throughout an organization or within an entire industry. Gone are the days of hoarding knowledge to ensure job security; today's workers and managers must work together to find new and innovative ways to use what they know and optimize how that knowledge is accessed. Knowledge management's new approach to shared intellectual resources has implications for workers and managers in all fields and promises to redraw the management landscape. But are healthcare organizations setting the stage for reengineering themselves all over again?     

Evidence for a structural mutation of procollagen type I in a patient with the Ehlers-Danlos syndrome type VII

We have found that the collagen from a patient with the Ehlers-Danlos syndrome type VII contained a polypeptide chain, pN alpha 2, not present in collagen prepared from normal tissue. Fibroblasts cultured from the patient's skin produced type I procollagen in which the NH2-terminal propeptide of pro alpha 2 was cleaved to about half of normal values by chick procollagen neutral protease which removes the NH2-terminal propeptides from procollagen (N-protease). The NH2-terminal propeptide on the pro alpha 2 chain of the patient's procollagen was also more resistant than procollagen from control fibroblasts to digestion by pepsin or alpha-chymotrypsin. assays for procollagen N-protease indicated that the patient's fibroblsts contained about the same level of enzymic activity as normal fibroblasts. These results suggest that the patient's fibroblasts synthesize both an abnormal pro alpha 2 chain and a normal pro alpha 2 chain. The abnormality probably consists of a structural mutation in or near the site at which procollagen N-protease cleaves the pro alpha 2 chain. The results presented here appear to provide the first example of a mutation in a structural gene for collagen. Since equal amounts of pN alpha 2 and alpha 2 are found in the protein in neutral salt extracts of the patient's tissue, as well as in newly synthesized collagen produced by cultured skin fibroblasts, and since both parents are phenotypically normal and express exclusively normal collagen chains, the patient is likely to be a sporadic heterozygote, arisen by new mutation, with one normal and one abnormal gene coding for pro alpha 2.     

The scimitar syndrome: clinical spectrum and surgical treatment

The stretch-induced myogenic response (MR) of large-capacitance pulmonary arteries were studied in normal and pulmonary hypertensive fetuses as well as normal newborn and adult sheep. Pulmonary hypertension in the fetus was induced by ligation of the ductus arteriosus for 12 d. The MR was obtained by stretching the vessel segments in vitro from their resting diameter (no load) to the diameter at which the muscle fibers were at optimal length (Lo), and the response was measured as a percentage of force obtained after supramaximal electrical stimulation (Po). In five control and four pulmonary hypertensive fetuses, the MR was also obtained after a stretch of 140% of Lo. The pulmonary hypertensive fetal arteries had a lower stress (1.3 +/- 0.4 versus 4.0 +/- 0.5 mN/mm2; p < 0.001) and shortening capacity compared with the fetal control (5.1 +/- 1.6 versus 9.9 +/- 0.8% of Lo; p < 0.01). The MR was observed in 21% of the control and 30% of the experimental fetuses, and it was of greater magnitude in the latter (14.8 +/- 1.9 of Po versus 34.3 +/- 2.5%, respectively; p < 0.01). When stretched to 140% of Lo, the MR was also greater in the experimental (514 +/- 148% of Po) than the control fetuses (142 +/- 68; p < 0.05). Postnatally, the MR was present in 67% of the newborn and 15% of the adult pulmonary artery segments, and the response was greatest in the newborn (23.1 +/- 4.2% of Po) compared with the adult (2.3 +/- 0.8; p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Ehlers-Danlos syndrome type VIIB. Morphology of type I collagen fibrils formed in vivo and in vitro is determined by the conformation of the retained N-propeptide

Previously we showed that fibrils generated from collagen and pNcollagen-ex6 from fibroblasts of an individual with Ehlers-Danlos syndrome (EDS) type VIIB were hieroglyphic in cross-section and all N-propeptides were located at the fibril surface. Hieroglyphs were resolved to near-cylindrical fibrils (that were similar in appearance to the fibrils seen in the tissues of individuals with EDS type VIIB) by treatment with N-proteinase which cleaved the pN alpha 1(I) chains but not the pN alpha 2(I)-ex6 chains (Watson, R. B., Wallis, G. A., Holmes, D. F., Viljoen, D., Byers, P. H., and Kadler, K. E. (1992) J. Biol. Chem. 267, 9093-9100). Here, quantitative scanning transmission electron microscopy (STEM) showed that N-propeptides in hieroglyphs were in a "bent-back" conformation and thus located exclusively in the overlap zone of the fibril D-period (D = 67 nm). In contrast, STEM of fibrils from the dermis of an individual with EDS type VIIB showed that partially cleaved N-propeptides (in which cleaved pN alpha 1(I) remained in noncovalent association with pN alpha 2(I)-ex6 chains) were distributed equally between the gap and overlap zones of the fibrils. Comparison of experimental data with theoretical mass distributions of the fibril based on amino acid sequence data gave a consistent value of 33 nm for the total axial extent for the N-propeptides in hieroglyphic and tissue fibrils irrespective of the location of N-propeptides to the gap or overlap zone. These data exclude the possibility that N-propeptides adopt a random configuration, but rather, that they locate to specific sites in the gap and overlap zones. The results demonstrated that cleavage of pN alpha 1(I) chains in vivo releases the N-propeptides from the constraints of the bent-back conformation. Co-distribution of partially cleaved N-propeptides between gap and overlap zones allows a higher surface packing density of N-propeptides and explains how circularity of large diameter fibrils can be achieved despite the retention of N-propeptides in tissues of individuals with EDS type VIIB.     

Giant bladder diverticulum in Ehlers-Danlos syndrome type I causing outflow obstruction

A series of 33 patients with juvenile dermatomyositis was reviewed in terms of their prognosis in relation to their drug therapy. This retrospective study was intended to help clarify the use of various therapies in this rare, heterogeneous disease from our hospital's experience in the last 24 years. The results confirmed that oral corticosteroids should remain the undisputed first line of treatment. For more refractory, chronic patients, the results suggest that azathioprine should be the favored drug of first choice (in addition to corticosteroids). There may be a role for cyclosporine as a "rescue" treatment, but this needs to be further defined.     

Gly-Gly-containing triplets of low stability adjacent to a type III collagen epitope

Collagens, in addition to their structural role in the extracellular matrix, possess a number of functional binding domains. In this study, the binding to collagen of a monoclonal antibody is used as a model to define the molecular features involved in triple-helix interactions with other proteins. Here we report the thermal stability of an overlapping set of triple-helical peptides that includes the epitope recognized by a monoclonal antibody to type III collagen. Although the sequences of these peptides are very closely related, by a translation of a single triplet along the collagen chain, substantial variations in the melting temperatures were observed. These variations in thermal stability could not be readily explained by differences in imino acid content, or in numbers of charged or hydrophobic residues. The results indicate that Gly-Gly-Y triplets, which are adjacent to the epitope, have a strong influence in reducing the thermal stability of triple-helical peptides. Further studies, which were carried out on a set of "host-guest" triple-helical peptides containing different Gly-Gly-Y guest triplets, confirm the destabilizing effect of such tripeptides. The presence of Gly-Gly-Y triplets may play an important role in specific functions of type III collagen by modulating the local triple-helical structure or dynamics.     

Familial ureteral abnormalities syndrome: genomic mapping, clinical findings

Macrophage inflammatory protein-1 alpha (MIP-1alpha) has been shown to have a role in the control of myeloid stem and progenitor cell proliferation. Recent evidence suggests that MIP-1alpha also has a stimulatory effect on proliferation of mature progenitors as well as an inhibitory effect on immature progenitors in vitro. We have compared the effect of MIP-1alpha on myeloid and erythroid colony formation of CD34+ cells isolated from bone marrow and cord blood. In the presence of MIP-1alpha, bone marrow granulocyte-macrophage-colony forming cells (GM-CFC) were inhibited over a dose range of 15 ng/ml to 500 ng/ml, and GM-CFC from cord blood CD34+ cells were stimulated over the same dose range. MIP-1alpha suppressed BFU-E colonies in both bone marrow and cord blood. Using thymidine suicide assays, the influence of MIP-1alpha on the cycling status of the cells was assessed. A good correlation between the effect of MIP-1alpha on colony formation and cell cycle progression was observed. These results suggest that there is a differential response to MIP-1alpha when bone marrow and cord blood CD34+ cells are compared. Using flow cytometry and a biotinylated human MIP-1alpha/avidin fluorescein conjugate, the expression of MIP-1alpha receptors on CD34+ cells was assessed. The data indicated that there was little quantitative difference in overall expression of receptors (82.9% versus 93%) from bone marrow or cord blood, respectively. However, when Northern blot analysis was used, mRNA for two different MIP-1alpha receptors CCR1 and CCR5 could be detected in bone marrow, but only CCR1 mRNA was seen in cord blood CD34+ samples. Therefore, the expression of different receptor subtypes on CD34+ cells may be responsible for the difference in MIP-1alpha responsiveness observed.     

Ehlers-Danlos syndrome and congenital heart anomalies

OBJECTIVE: To study the effects of octreotide on portal pressure and the relationship between the portal pressure and portal hemodynamics measured by color Doppler. METHODS: A high portal resistance model by injecting bletilla hyacinthina was established in 6 dogs. The portal pressure and portal hemodynamics studied by color Doppler were measured respectively by two investigators before and after injecting octreotide into the peripheral vein. RESULTS: Portal hypertension was caused by injecting bletilla hyacinthina into the portal vein. The portal pressure was reduced and portal venous velocity increased after injecting octreotide into the peripheral vein. There was a significant negative correlation between the portal pressure and portal venous velocity. CONCLUSION: Color Doppler is helpful in evaluating the effects of octreotide on the portal pressure.     

Mechanical properties of skin in Ehlers-Danlos syndrome, types I, II, and III

Mechanical properties of skin were evaluated in vivo in 17 children suffering from Ehlers-Danlos syndrome (EDS) types I, II, and III. These were compared with normal values from 63 healthy children. Noninvasive measurements were performed under suction of 500 mbar using a Cutometer equipped with a 4-mm probe. Prominent increases in skin extensibility and elasticity were the most distinctive and diagnostic features of all three EDS types. Differences in the average values of biomechanical variables were present among the three types. Patients with EDS-I were the most affected, whereas those with EDS-III had virtually normal skin. However, interindividual differences in the severity of rheological alterations were found within each type, illustrating a continuum in the variation of mechanical properties of EDS skin rather than yielding step differences among the types.     

Parental mosaicism and autosomal dominant mutations causing structural abnormalities of collagen I are frequent in families with osteogenesis imperfecta type III/IV

Protein-chemical and molecular studies were conducted on all osteogenesis imperfecta (OI) type III/IV patients referred to our hospital during the last 15 y. Of a total of 16 OI type III/IV patients studied, 15 patients were heterozygous for a mutation in one of the two genes coding for collagen I, COL1A1 or COL1A2. Cultured fibroblasts from these 15 patients produced both normal and abnormal collagen I molecules, pointing to a dominant-negative effect of the mutation. Nine mutations had not been described previously. Parental mosaicism was demonstrated in three families. In the 16th child the causative mutation was not found. In conclusion, OI type III/IV in most patients of Western European ancestry is caused by dominant mutations in the genes for collagen I, and recurrence of OI is caused in most cases by parental gonadal mosaicism.