Nodular vasculitis in systemic lupus erythematosus

A 42-year-old man presented with fever, photosensitivity, headaches, myalgia, hyperhidrosis, muscle weakness, alopecia, nasal crustae, weight loss, painful nails, arthritis, oral ulcers, erythema, discoid cutaneous lesions, and painful subcutaneous nodes. We made a diagnosis of systemic lupus erythematosus (SLE), type II cryoglobulinemia, and nodular vasculitis. In the skin, different types of vasculitis may be observed. Typically, histology shows leukocytoclastic vasculitis of superficial vessels both in SLE and mixed cryoglobulinemia, which clinically results in palpable purpura. In our patient, however, histopathological examination of the subcutaneous nodes not only revealed leukocytoclastic vasculitis of the superficial vasculature but also showed even more extensive involvement of dermal and subdermal small and medium sized vessels, giving rise to a nodular vasculitis.

[Diagnostic image (365). A man with facial hyperpigmentation]

A 79-year-old man developed a blue-greyish facial hyperpigmentation after amiodarone administration over 4 years.

Regulation of adhesion molecule expression in human endothelial and smooth muscle cells by omega-3 fatty acids and conjugated linoleic acids: involvement of the transcription factor NF-kappaB?

We previously showed conjugated linoleic acids (CLA) inhibited TNF-alpha-induced monocyte (THP-1) adhesion to human umbilical vein endothelial cells (HUVEC) in vitro which involved an increase in platelet activating factor (PAF). Here we show adhesion molecule (ADM) regulation by fatty acids and the differing role of nuclear factor kappa B (NF-kappaB) activation in HUVEC and vascular smooth muscle cells (vSMC). CLA and omega-3 long-chain polyunsaturated fatty acids (PUFA) (FA) reduced TNF-alpha-induced expression of ADMs (intercellular adhesion molecule-1 (ICAM-1); vascular cell adhesion molecule-1 (VCAM-1) but not E-selectin) on HUVEC and vSMC to different extents depending on FA type and concentration, cell type and method of analysis. IkappaBalpha phosphorylation in HUVEC and vSMC and transient transfection with NF-kappaB-luciferase reporter plasmid (HUVEC only) indicated differential NF-kappaB involvement during FA modulation (cis-9, trans-11; trans-10, cis-12 and a 50:50 mix of both CLA isomers; eicosapentaenoic acid (EPA); docosahexaenoic acid (DHA)). TNF-alpha-induced ADM expression in both cell types by 2-10-fold. In HUVEC, CLA t10, c12 and CLA mix (50:50 mixture of CLA c9, t11 and t10, c12) and EPA and DHA reduced ICAM-1 expression (15-35%) at 12.5, 25 and/or 50 microM. VCAM-1 expression was reduced by 25 microM t10, c12 isomer and mix; omega-3 PUFA and other concentrations of CLA and TNF-alpha-induced E-selectin expression were unaffected. TNFalpha-induced inhibitor kappa B (IkappaB) phosphorylation was biphasic peaking at 5 min in both cell types and 60 and 120 min in HUVEC and SMC, respectively. IkappaBalpha phosphorylation and NF-kappaB activity was reduced (29% and 30%, respectively) by 25 microM CLA mix. n-3 PUFA did not reduce IkappaBalpha phosphorylation or NF-kappaB activity but reduced ADM expression. We show that n-3 PUFA and CLA reduce expression of ADM on HUVEC and vSMC. This reflected reduced adherence of monocytes to HUVEC previously reported by our group. Reduction of ICAM-1 and VCAM-1 protein expression by n-3 PUFA was less dependent on the NF-kappaB pathway than reduction by CLA which reflected the parallel attenuation of NF-kappaB activity. This indicated involvement of other transcription factors (i.e. AP-1) in the FA regulation of ADM expression and has, to our knowledge, not been previously reported.

Molecular heterogeneity of familial porphyria cutanea tarda in Spain: characterization of 10 novel mutations in the UROD gene

BACKGROUND

Porphyria cutanea tarda (PCT) results from decreased hepatic uroporphyrinogen decarboxylase (UROD) activity. In the majority of patients, the disease is sporadic (S-PCT or type I) and the enzyme deficiency is limited to the liver. Familial PCT (F-PCT or type II) is observed in 20-30% of patients in whom mutations on one allele of the UROD gene reduce UROD activity by approximately 50% in all tissues. Another variant of PCT (type III) is characterized by family history of the disease although it is biochemically indistinguishable from S-PCT.

OBJECTIVES

To investigate the molecular basis of PCT in Spain and to compare enzymatic and molecular analysis for the identification of patients with F-PCT.

METHODS

Erythrocyte UROD activity measurement and mutation analysis of the UROD gene were carried out in a cohort of 61 unrelated Spanish patients with PCT and 50 control individuals. Furthermore, each novel missense mutation identified was characterized by prokaryotic expression studies.

RESULTS

Of these 61 patients, 40 (66%) were classified as having S-PCT, 16 (26%) as having F-PCT and five (8%) as having type III PCT. Discordant results between enzymatic and molecular analysis were observed in two patients with F-PCT. In total, 14 distinct mutations were found, including 10 novel mutations: five missense, one nonsense, three deletions and an insertion. Prokaryotic expression of the novel missense mutations demonstrated that each results in decreased enzyme activity or stability.

CONCLUSIONS

These results confirm the high degree of molecular heterogeneity of F-PCT in Spain and emphasize the usefulness of molecular genetic analysis to distinguish between F-PCT and S-PCT.

18. The future of Canadian residency education: The core competency project

The Core Competency Project (CCP) is an initiative to reexamine fundamental recurring issues in Canadian medical education, including: (1) premature career decision making by medical students, (2) barriers to changing career disciplines by residents and practicing physicians, (3) lack of clarity on the role of “generalism” in medical training, and (4) the optimal structure and function of the PGME system. The CCP is a collaborative national endeavour of The Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada. From 2005 to 2007, the CCP employed four primary methods, including: (1) a systematic review of relevant literature, (2) a series of commentary papers by leaders in medicine and medical education, (3) a series of focus groups across Canada involving medical students, residents, and practicing physicians, and (4) a national survey of stakeholders. This was supplemented by consultations with key groups in the medical profession. We describe the findings of these studies and the implications for medical education policy in Canada and around the world. The CCP is an unprecedented national medical education policy initiative.

The histochemical profile of the rat extensor digitorum longus muscle differentiates after birth and dedifferentiates in senescence

Age dependent motor unit dedifferentiation is a key component of impaired muscle function in advanced age. Here, we tested the hypothesis that rat muscle histochemical profile during the lifespan of an individual has an age-specific pattern since comprehensive longitudinal studies of muscle differentiation after birth and dedifferentiation in advanced age are scarce. Our results show that extensor digitorum longus muscle (EDL) is comprised only of two fiber types after birth, type slow-oxidative (SO) and type SDH-intermediate (SDH-INT), the latter being indicative for the presence of polyneuronal innervation. In contrast to the constantly growing cross-sectional area of the muscle fibers, a dramatic decrease in SDH-INT proportion occurs between day 14 and 21 after birth resulting in a complete loss of fiber type SDH-INT at the age of 90 days (p<0.05). At the age of 270 days, the fiber type composition of rat EDL dedifferentiates as shown by the reappearance of the SDH-INT type with a further increase at the age of 540 days (p<0.05). These changes in histochemical fiber type spectra are brought about by fiber type conversion within the fast twich fibers. The findings of the present study provide further evidence that fiber type conversion is a basic mechanism leading to motor unit differentiation and dedifferentiation during ontogenesis. Fiber type conversion shows a distinct time specific pattern and is also characteristic for motor unit regeneration after peripheral nerve repair. Factors that influence fiber type conversion and thereby motor unit organization may provide a future therapeutic option to enhance the regenerative capacity of motor units.

[Laboratory tests and therapeutic strategies for the porphyrias]

The porphyrias are a heterogeneous group of predominantly hereditary metabolic diseases resulting from a dysfunction of heme biosynthesis. Most of the porphyrias can manifest with a broad range of cutaneous symptoms on the sun-exposed areas of the body, whereas other variants reveal life-threatening acute neurological attacks. Further, mixed types of porphyrias exist. Besides the skin, other organs can be affected, such as the liver and the central nervous system. Therefore, interdisciplinary supervision of these patients is mandatory. In this review we will first present the clinical picture and diagnosis of the porphyrias, including the specific biochemical laboratory tests and a diagnostic algorithm. Thereafter, the current therapeutic concepts will be briefly addressed. Finally, we introduce the European Porphyria Initiative (EPI), an association of various European porphyria centers that is aiming at gathering the broad experience of internationally renowned porphyria experts for the development of European consensus guidelines for diagnosis and treatment of these metabolic disorders.

Hereditäre Photodermatosen

Hereditary photodermatoses are characterized by an increased photosensitivity caused by an inherited single gene defect. With few exceptions, they manifest in early childhood, reveal heterogeneous clinical symptoms, and are difficult to treat. Although these diseases are rare, it is very important to make an accurate diagnosis on the basis of clinical symptoms, specific diagnostic tests, and direct DNA analysis. We review the spectrum of inherited photodermatoses, including porphyria cutanea tarda, erythropoietic protoporphyria, actinic prurigo, Kindler syndrome, and disorders associated with a defect in DNA repair, including xeroderma pigmentosum, trichothiodystrophy, Cockayne syndrome, and Bloom syndrome. Early diagnosis may prevent complications associated with prolonged unprotected exposure to sunlight and makes it possible to offer genetic counseling and, when indicated, prenatal diagnosis to families at risk for these rare heritable disorders.

Mutations in the gene encoding the Wnt-signaling component R-spondin 4 (RSPO4) cause autosomal recessive anonychia

Anonychia is an autosomal recessive disorder characterized by the congenital absence of finger- and toenails. In a large German nonconsanguineous family with four affected and five unaffected siblings with isolated total congenital anonychia, we performed genomewide mapping and showed linkage to 20p13. Analysis of the RSPO4 gene within this interval revealed a frameshift and a nonconservative missense mutation in exon 2 affecting the highly conserved first furin-like cysteine-rich domain. Both mutations were not present among controls and were shown to segregate with the disease phenotype. RSPO4 is a member of the recently described R-spondin family of secreted proteins that play a major role in activating the Wnt/ beta -catenin signaling pathway. Wnt signaling is evolutionarily conserved and plays a pivotal role in embryonic development, growth regulation of multiple tissues, and cancer development. Our findings add to the increasing body of evidence indicating that mesenchymal-epithelial interactions are crucial in nail development and put anonychia on the growing list of congenital malformation syndromes caused by Wnt-signaling-pathway defects. To the best of our knowledge, this is the first gene known to be responsible for an isolated, nonsyndromic nail disorder.

The effect of voluntary arm abduction on balance recovery following multidirectional stance perturbations

The goal of this study was to investigate how voluntarily abducting one arm, 90 degrees at onset of a rotational perturbation of the support surface, influences the recovery of upright stance. Young adults were tested under four stance conditions: abducting one arm to the horizontal only (AO); perturbation of stance using a support surface rotation only (PO); combined support surface rotation and abduction of the downhill arm, ipsilateral to tilt (IPS); and fourth abduction of the uphill, contralateral arm (CON). Simultaneous auditory and visual trigger cues were used for arm raising. Perturbations consisted of six directions of combined support surface roll and pitch rotation (7.5 degrees and 60 degrees/s). Outcome measures were whole body centre of mass (COM) movements and body segment angular displacements recorded with a motion analysis system, as well as leg, trunk, and arm EMG responses. Arm raises contralateral and ipsilateral to the direction of support surface roll were more rapid than in the AO condition and significantly reduced or increased, respectively, COM lateral displacements relative to the PO condition. The changes in COM displacements and velocities during combined CON arm raise and perturbation were greater than expected from the sum of displacements for AO and PO conditions alone, but less for the IPS condition. Arm raising increased trunk roll in a direction opposite arm raising was more than for the AO and PO conditions. Robust effects were also observed for hip abduction but not for leg flexion. Early balance correcting activity was enhanced on the side opposite arm raising and later stabilising activity reduced bilaterally in lower trunk muscles compared to summed activity for the AO and PO conditions. Similar effects were observed in gluteus medius muscles but effects were weak in ankle muscles. EMG onsets in muscles of the raised arm were earlier than in the AO conditions. We conclude that triggered arm abduction, contralateral to the direction of support surface rotation, had significant stabilization benefits for young adults and ipsilateral arm movements had destabilizing effects. The arm raises could be simultaneously executed with balance corrections. These results provide insights into the integration of balance corrections and voluntary commands into one automatic reaction that may be useful in training fall avoidance.

Genetic association of the human corticotropin releasing hormone receptor 1 (CRHR1) with binge drinking and alcohol intake patterns in two independent samples

To investigate the role of the corticotropin releasing hormone receptor 1 (CRHR1) in patterns of human alcohol drinking and its potential contribution to alcohol dependence, we analysed two independent samples: a sample of adolescents, which consisted of individuals from the 'Mannheim Study of Risk Children' (MARC), who had little previous exposure to alcohol, and a sample of alcohol-dependent adults, who met DSM-IV criteria of alcohol dependence. Following determination of allelic frequencies of 14 polymorphisms of the CRHR1 gene, two haplotype tagging (ht)SNPs discriminating between haplotypes with a frequency of > or =0.7% were identified. Both samples were genotyped and systematically examined for association with the htSNPs of CRHR1. In the adolescent sample, significant group differences between genotypes were observed in binge drinking, lifetime prevalence of alcohol intake and lifetime prevalence of drunkenness. The sample of adult alcohol-dependent patients showed association of CRHR1 with high amount of drinking. This is the first time that an association of CRHR1 with specific patterns of alcohol consumption has been reported. Our findings support results from animal models, suggesting an importance of CRHR1 in integrating gene-environment effects in alcohol use disorders.

The porphyrias: clinical presentation, diagnosis and treatment

The porphyrias comprise a clinically and genetically heterogeneous group of diseases mostly arising from a genetically determined dysfunction of specific enzymes along the pathway of heme biosynthesis. Based on the occurrence or absence of cutaneous symptoms and life-threatening acute neurological attacks, the different types of porphyrias can either be classified into cutaneous and non-cutaneous forms or acute and non-acute forms. Establishing an accurate diagnosis might be difficult for two reasons: i) the porphyrias can manifest with a broad but unspecific spectrum of clinical symptoms mimicking several other disorders, and ii) biochemical examination of urine, feces, and blood can reveal overlapping findings. Fortunately, however, the advances in the fields of molecular genetics during recent years have provided us with the possibility of overcoming these diagnostic pitfalls. Therefore, in controversial cases the correct diagnosis can finally be made using molecular biological techniques. Due to the various facets of the porphyrias, diagnosis and treatment should always imply a close interdisciplinary collaboration to counsel and help patients and their families most efficiently.

Focused ion beam milling of vitreous water: prospects for an alternative to cryo-ultramicrotomy of frozen-hydrated biological samples

The feasibility of using a focused ion beam (FIB) for the purpose of thinning vitreously frozen biological specimens for transmission electron microscopy (TEM) was explored. A concern was whether heat transfer beyond the direct ion interaction layer might devitrify the ice. To test this possibility, we milled vitreously frozen water on a standard TEM grid with a 30-keV Ga(+) beam, and cryo-transferred the grid to a TEM for examination. Following FIB milling of the vitreous ice from a thickness of approximately 1200 nm to 200-150 nm, changes characteristic of heat-induced devitrification were not observed by TEM, in either images or diffraction patterns. Although numerous technical challenges remain, it is anticipated that 'cryo-FIB thinning' of bulk frozen-hydratred material will be capable of producing specimens for TEM cryo-tomography with much greater efficiency than cryo-ultramicrotomy, and without the specimen distortions and handling difficulties of the latter.