Genome-wide association study of serious blistering skin rash caused by drugs

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but severe, potentially life threatening adverse drug reactions characterized by skin blistering. Previous studies have identified drug-specific and population-specific genetic risk factors with large effects. In this study, we report the first genome-wide association study (GWAS) of SJS/TEN induced by a variety of drugs. Our aim was to identify common genetic risk factors with large effects on SJS/TEN risk. We conducted a genome-wide analysis of 96 retrospective cases and 198 controls with a panel of over one million single-nucleotide polymorphisms (SNPs). We further improved power with about 4000 additional controls from publicly available datasets. No genome-wide significant associations with SNPs or copy number variants were observed, although several genomic regions were suggested that may have a role in predisposing to drug-induced SJS/TEN. Our GWAS did not find common, highly penetrant genetic risk factors responsible for SJS/TEN events in the cases selected.

Breast cancer and the stromal factor. The "prometastatic healing process" hypothesis

The correlation between axillary status and several histological features of breast carcinomas has been well established, however stromal changes have rarely been analyzed. Detailed clinicopathological review of 1803 patients with infiltrating breast carcinoma was performed. Stromal myxoid changes (SMC), size (T2-T3: > 2 cm, T1c: 1-2 cm, T1 a-b: < 1cm), fibrotic focus, age, lymphovascular embolizations, tumor infiltrating lymphocytes (TIL), multifocality, histological grade (G), estrogen receptors (ER), progesterone receptors (PR) and HER2 were semi-quantitated in two or three grades and correlated to axillary status. SMC3 followed by T2-T3, G3, fibrotic focus, T1c, embolizations, SMC2, TIL2, G2 and multifocality were strongly associated with positive axillary nodes; an inverse association was found with ER+++ and PR+++. Our findings support a critical role of the peritumoral stroma in the development of metastases. These stromal alterations should be remarked in routine pathology reports as they can be easily assessed and provide important information about tumor biology and aggressiveness. They could also become, in a future, the target of novel therapeutics.

Adherence to extracolonic cancer screening in Lynch syndrome kindreds

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Introduction: In addition to colorectal cancer (CRC), Lynch syndrome (LS) patients are at increased risk of extracolonic malignancies including endometrial (EC), ovarian (OC), upper gastrointestinal and urothelial tract cancers. Although the efficacy of extracolonic cancer screening in LS has not been clearly demonstrated, multi-organ screening is routinely recommended for LS patients (Lindor et al., JAMA 2006). Anecdotal evidence suggests that adherence to such screening may be inferior to CRC screening. Methods: 35 adults, identified in the context of genetic counseling and testing (GCT) as being from LS kindreds, were given recommendations for multi-organ screening and enrolled on a prospective follow-up study. For participants with relevant organs at risk, these included colonoscopy, urine cytology, transvaginal ultrasound (TVUS), CA-125 level and endometrial sampling all to be performed at least annually. Adherence with screening, perceived risk of cancer subtype and future intentions regarding screening were evaluated at least 12 months after GCT. Results: Median age at time of GCT was 44, 66% were female and 69% were diagnosed with a LS- related cancer prior to GCT (15 CRC; 9 EC). At time of follow-up, 89% of patients without CRC had a colonoscopy within the year. Among women at-risk for OC, 25% had TVUS and 38% had CA-125 level within the year. Among women at risk for EC, 22% had TVUS and 22% had endometrial sampling within the year. Of all participants, 40% had urine cytology within the year. Of participants with relevant organs at-risk, 72%, 33%, 75% and 12% reported their risk of developing CRC, EC, OC, and urothelial tract cancer, respectively, as “moderately”, “very” or “extremely” high. Of patients with previous colonoscopy, 93% had definitive intentions to continue on schedule screening. However, only 68%, 50%, 60% and 50% of patients who underwent previous urine cytology, TVUS, CA-125 or endometrial sampling, respectively, had definitive intentions of continuing on schedule screening. Conclusions: Adherence with extracolonic cancer screening in LS kindreds is poor and patients persistently underestimate their extracolonic risk despite GCT. Possible interventions should be aimed at better educating patients about extracolonic cancer risk and importance of on-going surveillance.

No significant financial relationships to disclose.

Platelet-derived hyaluronidase 2 cleaves hyaluronan into fragments that trigger monocyte-mediated production of proinflammatory cytokines

Hyaluronan (HA) occurs in the body as a large, hydrating, space-filling, carbohydrate polymer in the extracellular matrix; it has both anti-angiogenic and immunosuppressive properties. Cleavage of HA results in the generation of variably sized fragments that stimulate multiple angiogenic and inflammatory responses in a size-specific manner. In this study, we report that platelets, as well as their megakaryocyte precursors, are unusual among somatic cells in that they contain only hyaluronidase 2 (HYAL2) but not HYAL1. Platelet HYAL2 is sufficient to cleave HA into fragments that are specific for inflammatory and angiogenic signaling; this process occurs in the absence of HYAL1, which is necessary in all other tissues to perform further HA degradation. Platelets can bind to HA, some of which derives from the stressed microvessel endothelial cell surface. Platelet-derived HYAL2 cleaves HA into fragments that stimulate mononuclear leukocytes in the immediate microenvironment to produce proinflammatory cytokines, including interleukin-6 and interleukin-8. Platelets, thus, are not only involved in hemostasis, the earliest step in wound healing, but are also important in the signaling of subsequent inflammatory and angiogenic steps. We hypothesize that aberrations in these sequential steps can promote chronic inflammation, as found in inflammatory bowel disease. The platelet may thus provide an interface between acute and chronic inflammation, wound healing, and their subsequent fibrotic responses.

[Prehospital care of acute coronary syndrome by anaesthetists. Prospective comparison with the care standards of cardiologists]

BACKGROUND

Prehospital treatment of acute coronary syndrome (ACS) by anaesthetists acting in physician staffed emergency medical service (EMS) was compared with that of the gold standard of cardiologists.

METHODS

Prospectively 599 patients with assumed ACS were traced. Prehospital diagnosis and therapy were compared with re-evaluation of ECGs and diagnosis on hospital discharge.

RESULTS

In the case of ST-segment elevating myocardial infarction (STEMI) anaesthetists diagnosed 84% of cases correctly and cardiologists in 94% (p=0.048). False positive diagnoses were given in 11% by anaesthetists versus 5% by cardiologists (p=0.31). Anaesthetists accompanied all patients with instable angina versus 94% by cardiologists (p=0.06). Anaesthetists achieved 82% of patients to be pain-free versus 73% of cardiologists (p=0.01). Mortality until discharge was identical for the two groups (8.2%).

CONCLUSION

In prehospital management of ACS cardiologists showed higher diagnostic competence, whereas anaesthetists revealed a greater degree of therapeutic caution. Patient mortality was not influenced.