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Goehringer J, Kosmin A, Laible N, Romagnoli K. Assessing the Utility of a Patient-Facing Diagnostic Tool Among Individuals With Hypermobile Ehlers-Danlos Syndrome: Focus Group Study. JMIR Form Res 2024; 8:e49720. [PMID: 39325533 DOI: 10.2196/49720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/19/2024] [Accepted: 07/21/2024] [Indexed: 09/27/2024] Open
Abstract
BACKGROUND Hypermobile Ehlers-Danlos syndrome (hEDS), characterized by joint hypermobility, skin laxity, and tissue fragility, is thought to be the most common inherited connective tissue disorder, with millions affected worldwide. Diagnosing this condition remains a challenge that can impact quality of life for individuals with hEDS. Many with hEDS describe extended diagnostic odysseys involving exorbitant time and monetary investment. This delay is due to the complexity of diagnosis, symptom overlap with other conditions, and limited access to providers. Many primary care providers are unfamiliar with hEDS, compounded by genetics clinics that do not accept referrals for hEDS evaluation and long waits for genetics clinics that do evaluate for hEDS, leaving patients without sufficient options. OBJECTIVE This study explored the user experience, quality, and utility of a prototype of a patient-facing diagnostic tool intended to support clinician diagnosis for individuals with symptoms of hEDS. The questions included within the prototype are aligned with the 2017 international classification of Ehlers-Danlos syndromes. This study explored how this tool may help patients communicate information about hEDS to their physicians, influencing the diagnosis of hEDS and affecting patient experience. METHODS Participants clinically diagnosed with hEDS were recruited from either a medical center or private groups on a social media platform. Interested participants provided verbal consent, completed questionnaires about their diagnosis, and were invited to join an internet-based focus group to share their thoughts and opinions on a diagnostic tool prototype. Participants were invited to complete the Mobile App Rating Scale (MARS) to evaluate their experience viewing the diagnostic tool. The MARS is a framework for evaluating mobile health apps across 4 dimensions: engagement, functionality, esthetics, and information quality. Qualitative data were analyzed using affinity mapping to organize information and inductively create themes that were categorized within the MARS framework dimensions to help identify strengths and weaknesses of the diagnostic tool prototype. RESULTS In total, 15 individuals participated in the internet-based focus groups; 3 (20%) completed the MARS. Through affinity diagramming, 2 main categories of responses were identified, including responses related to the user interface and responses related to the application of the tool. Each category included several themes and subthemes that mapped well to the 4 MARS dimensions. The analysis showed that the tool held value and utility among the participants diagnosed with hEDS. The shareable ending summary sheet provided by the tool stood out as a strength for facilitating communication between patient and provider during the diagnostic evaluation. CONCLUSIONS The results provide insights on the perceived utility and value of the tool, including preferred phrasing, layout and design preferences, and tool accessibility. The participants expressed that the tool may improve the hEDS diagnostic odyssey and help educate providers about the diagnostic process.
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Affiliation(s)
| | - Abigail Kosmin
- Joan H. Marks Graduate Program in Human Genetics, Sarah Lawrence College, Bronxville, NY, United States
- Magee-Womens Hospital, Pittsburgh, PA, United States
| | - Natalie Laible
- Joan H. Marks Graduate Program in Human Genetics, Sarah Lawrence College, Bronxville, NY, United States
- GeneScreen Counseling, Bernardsville, NJ, United States
| | - Katrina Romagnoli
- Department of Population Health Sciences, Geisinger, Danville, PA, United States
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Neshatian M, Mittal N, Huang S, Ali A, Khattignavong E, Bozec L. Investigation of dermal collagen nanostructures in Ehlers-Danlos Syndrome (EDS) patients. PLoS One 2024; 19:e0307442. [PMID: 39172992 PMCID: PMC11341037 DOI: 10.1371/journal.pone.0307442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 07/04/2024] [Indexed: 08/24/2024] Open
Abstract
Ehlers-Danlos syndromes (EDS) represent a group of rare genetic disorders affecting connective tissues. Globally, approximately 1.5 million individuals suffer from EDS, with 10,000 reported cases in Canada alone. Understanding the histological properties of collagen in EDS has been challenging, but advanced techniques like atomic force microscopy (AFM) have opened up new possibilities for label-free skin imaging. This approach, which explores Type I collagen fibrils at the nanoscale, could potentially enhance EDS diagnosis and our knowledge of collagen type I-related connective tissue disorders. In the current study, we have employed AFM to examine ex-vivo skin biopsies from four individuals: one with classical EDS (cEDS), one with hypermobile EDS (hEDS), one with hEDS and Scleroderma (hEDS-Scleroderma), and one healthy control. Picrosirius red (PS) staining was used to highlight collagen differences in the samples. For each case, 14 images and 1400 force curves were obtained, with seven images and 700 force curves representing healthy collagen (PS-induced red staining) and the rest showcasing disrupted collagen (yellow staining). The results showed that PS staining was uniform throughout the control section, while cEDS and hEDS displayed localized areas of yellow staining. In the case of hEDS-Scleroderma, the yellow staining was widespread throughout the section. AFM images revealed irregular collagen fibrils in the disrupted, yellow-stained areas, contrasting with aligned and well-registered collagen fibrils in healthy, red-stained regions. Additionally, the study assessed the ability of non-AFM specialists to differentiate between healthy and disrupted collagen in AFM images, yielding substantial agreement among raters according to Fleiss's and Cohen's kappa scores (0.96 and 0.79±0.1, respectively). Biomechanical analysis revealed that normal healthy collagen exhibited a predominant population at 2.5 GPa. In contrast, EDS-affected collagen displayed subpopulations with lower compressive elastic modulus, indicating weaker collagen fibrils in EDS patients. Although these findings pertain to a limited number of cases, they offer valuable insights into the nanoscale collagen structure and biomechanics in individuals with EDS. Over time, these insights could be developed into specific biomarkers for the condition, improving diagnosis and treatment for EDS and related connective tissue disorders.
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Affiliation(s)
| | - Nimish Mittal
- Division of Physical Medicine and Rehabilitation, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sophia Huang
- Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
| | - Aiman Ali
- Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
| | - Emilie Khattignavong
- Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
- UMR 5513 Laboratoire de Tribologie et Dynamique des Systémes, École Centrale de Lyon - École Nationale d’Ingénieurs de Saint, Université de Lyon, Étienne, France
| | - Laurent Bozec
- Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
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Petrucci T, Barclay SJ, Gensemer C, Morningstar J, Daylor V, Byerly K, Bistran E, Griggs M, Elliot JM, Kelechi T, Phillips S, Nichols M, Shapiro S, Patel S, Bouatia-Naji N, Norris RA. Phenotypic Clusters and Multimorbidity in Hypermobile Ehlers-Danlos Syndrome. Mayo Clin Proc Innov Qual Outcomes 2024; 8:253-262. [PMID: 38779137 PMCID: PMC11109295 DOI: 10.1016/j.mayocpiqo.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024] Open
Abstract
Objective To perform a retrospective clinical study in order to investigate phenotypic penetrance within a large registry of patients with hypermobile Ehlers-Danlos syndrome (hEDS) to enhance diagnostic and treatment guidelines by understanding associated comorbidities and improving accuracy in diagnosis. Patients and Methods From May 1, 2021 to July 31, 2023, 2149 clinically diagnosed patients with hEDS completed a self-reported survey focusing on diagnostic and comorbid conditions prevalence. K-means clustering was applied to analyze survey responses, which were then compared across gender groups to identify variations and gain clinical insights. Results Analysis of clinical manifestations in this cross-sectional cohort revealed insights into multimorbidity patterns across organ systems, identifying 3 distinct patient groups. Differences among these phenotypic clusters provided insights into diversity within the population with hEDS and indicated that Beighton scores are unreliable for multimorbidity phenotyping. Conclusion Clinical data on the phenotypic presentation and prevalence of comorbidities in patients with hEDS have historically been limited. This study provides comprehensive data sets on phenotypic presentation and comorbidity prevalence in patients with hEDS, highlighting factors often overlooked in diagnosis. The identification of distinct patient groups emphasizes variations in hEDS manifestations beyond current guidelines and emphasizes the necessity of comprehensive multidisciplinary care for those with hEDS.
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Affiliation(s)
- Taylor Petrucci
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC
| | - S. Jade Barclay
- Kolling Institute of Medical Research, Faculty of Medicine and Health, the University of Sydney, Sydney, New South Wales, Australia
| | - Cortney Gensemer
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC
| | - Jordan Morningstar
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC
| | - Victoria Daylor
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC
| | - Kathryn Byerly
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC
| | - Erika Bistran
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC
| | - Molly Griggs
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC
| | - James M. Elliot
- Kolling Institute of Medical Research, Faculty of Medicine and Health, the University of Sydney, Sydney, New South Wales, Australia
| | - Teresa Kelechi
- College of Nursing, Medical University of South Carolina, Charleston, SC
| | - Shannon Phillips
- College of Nursing, Medical University of South Carolina, Charleston, SC
| | - Michelle Nichols
- College of Nursing, Medical University of South Carolina, Charleston, SC
| | - Steven Shapiro
- College of Dental Medicine, Medical University of South Carolina, Charleston, SC
| | - Sunil Patel
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC
| | | | - Russell A. Norris
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC
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Xu K, Li G, Wu Z, Zhang TJ, Wu N. Diagnosis and treatment of the Ehlers-Danlos syndromes in China: synopsis of the first guidelines. Orphanet J Rare Dis 2024; 19:194. [PMID: 38741208 DOI: 10.1186/s13023-024-03121-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/03/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND The Ehlers-Danlos syndromes (EDS) are a group of rare hereditary connective tissue disorders. EDS is clinically and genetically heterogeneous and usually involves multiple systems. There are 14 subtypes of EDS with hallmark features including joint hypermobility, skin hyperextensibility, and tissue fragility. The clinical manifestations and their severity differ among the subtypes, encompassing recurrent joint dislocations, scoliosis, arterial aneurysm and dissection, and organ rupture. Challenges in diagnosis and management arise from the complexity of the disease, which is further complicated by its rarity. The development of clinical guidelines and implementation of coordinated multi-disciplinary team (MDT) approaches have emerged as global priorities. MAIN BODY Chinese Multi-Disciplinary Working Group on the Ehlers-Danlos Syndromes was therefore established. Healthcare professionals were recruited from 25 top hospitals across China. The experts are specialized in 24 fields, including genetics, vascular surgery, dermatology, and orthopedics, as well as nursing care, rehabilitation, psychology, and nutrition. Based on GRADE methodology, the Guidelines were written by the Group supervised by methodologists, following a systemic review of all 4453 articles in PubMed published before August 9, 2023, using the search term "Ehlers Danlos". A coordinated MDT approach for the diagnosis and management of EDS is highly recommended by the Group, along with 29 specific recommendations addressing key clinical questions. In addition to the treatment plan, the Guidelines also emphasize integrating support from nursing care, rehabilitation, psychology, and nutrition. This integration not only facilitates recovery in hospital settings, but most importantly, the transition from an illness-defined life to a more "normalized" life. CONCLUSION The first guidelines on EDS will shorten the diagnostic odyssey and solve the unmet medical needs of the patients. This article is a synopsis of the full guidelines.
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Affiliation(s)
- Kexin Xu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Beijing, 100730, China
- Beijing Key Laboratory for Genetic Research of Skeletal Deformity, Beijing, 100730, China
- Key Laboratory of Big Data for Spinal Deformities, Chinese Academy of Medical Sciences, Beijing, 100730, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Guozhuang Li
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Beijing, 100730, China
- Beijing Key Laboratory for Genetic Research of Skeletal Deformity, Beijing, 100730, China
- Key Laboratory of Big Data for Spinal Deformities, Chinese Academy of Medical Sciences, Beijing, 100730, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Zhihong Wu
- Beijing Key Laboratory for Genetic Research of Skeletal Deformity, Beijing, 100730, China
- Key Laboratory of Big Data for Spinal Deformities, Chinese Academy of Medical Sciences, Beijing, 100730, China
- Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Terry Jianguo Zhang
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Beijing, 100730, China.
- Beijing Key Laboratory for Genetic Research of Skeletal Deformity, Beijing, 100730, China.
- Key Laboratory of Big Data for Spinal Deformities, Chinese Academy of Medical Sciences, Beijing, 100730, China.
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
| | - Nan Wu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Beijing, 100730, China.
- Beijing Key Laboratory for Genetic Research of Skeletal Deformity, Beijing, 100730, China.
- Key Laboratory of Big Data for Spinal Deformities, Chinese Academy of Medical Sciences, Beijing, 100730, China.
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
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Jin G, Zou M, Li L, Liu Z, Young C, Qi H, Zheng D. Corneal biomechanics and their association with severity of lens dislocation in Marfan syndrome. Int Ophthalmol 2024; 44:148. [PMID: 38502381 DOI: 10.1007/s10792-024-03079-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/16/2024] [Indexed: 03/21/2024]
Abstract
PURPOSE To investigate corneal biomechanical properties and its associations with the severity of lens dislocation in patients with Marfan syndrome. METHODS A total of 30 patients with Marfan syndrome and 30 age-, sex- and axial length (AL)-matched controls were recruited. Corneal biomechanical parameters of both groups were measured by CorVis ST and were compared between groups. Potential associations between corneal biomechanical parameters and severity of lens dislocation were also investigated. RESULTS Lower applanation 1 velocity (A1V) (0.13 ± 0.004 vs. 0.15 ± 0.003, P = 0.016), shorter applanation 2 time (A2T)(22.64 ± 0.11 vs. 22.94 ± 0.11, P = 0.013), longer peak distance (PD) (5.03 ± 0.07 vs. 4.81 ± 0.05, P = 0.008), longer radius (R) of highest concavity (7.44 ± 0.16 vs. 6.93 ± 0.14, P = 0.012), greater Ambrosio relational thickness horizontal (ARTh) (603 ± 20 vs. 498 ± 12, P < 0.001), and integrated radius (IR) (8.32 ± 0.25 vs. 8.95 ± 0.21, P = 0.033) were detected among Marfan eyes compared with controls (all P < 0.05). Marfan individuals with more severe lens dislocation tended to have increased stiffness parameter as longer A1T, slower A1V, shorter A2T, slower application 2 velocity (A2V), smaller PD and smaller Distance Amplitude (DA) (P < 0.05). CONCLUSION Marfan patients were detected to have increased corneal stiffness compared with normal subjects. Corneal biomechanical parameters were significantly associated with the severity of lens dislocation in Marfan patients.
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Affiliation(s)
- Guangming Jin
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Minjie Zou
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Longhui Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Zhenzhen Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Charlotte Young
- Albany Medical College, 49 New Scotland Ave, Albany, NY, USA
| | - Haotian Qi
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Danying Zheng
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China.
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Hsieh MT, Amalaseelan J, Mohd Tahir AR, Le T, Shakespeare TP. No Increase in Acute or Late Radiation Toxicities in Patients With Ehlers-Danlos Syndrome Receiving Adjuvant Breast Radiation Therapy: A Report of Four Cases With Extended Follow-Up. Cureus 2023; 15:e50346. [PMID: 38205452 PMCID: PMC10781429 DOI: 10.7759/cureus.50346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2023] [Indexed: 01/12/2024] Open
Abstract
Ehlers-Danlos syndrome (EDS) consists of a heterogeneous group of congenital collagen formation disorders characterised by skin hyperextensibility, atrophic scarring, and generalized joint hypermobility. Collagen vascular disorders have been implicated in increased incidence and severity of radiation toxicities; however, there are limited reports on the safety of radiation therapy with EDS. We identified all patients with EDS who received adjuvant conventional and hypofractionated breast radiation therapy at our institution and reviewed patient, treatment, and toxicity characteristics. Four patients were identified with a median follow-up of 13.2 months. Acute toxicities were limited to grade 1 dermatitis in all four patients. No late toxicities were seen. In this report, radiation therapy to the breast with conventional and hypofractionated regimens resulted in no significant acute or late toxicity.
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Affiliation(s)
- Michael T Hsieh
- Radiation Oncology, Coffs Harbour Health Campus, Mid North Coast Local Health District, Coffs Harbour, AUS
| | | | - Abdul Rahim Mohd Tahir
- Radiation Oncology, Coffs Harbour Health Campus, Mid North Coast Local Health District, Coffs Harbour, AUS
| | - Tue Le
- Radiation Oncology, Coffs Harbour Health Campus, Mid North Coast Local Health District, Coffs Harbour, AUS
| | - Thomas P Shakespeare
- Radiation Oncology, Coffs Harbour Health Campus, Mid North Coast Local Health District, Coffs Harbour, AUS
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Pearce G, Bell L, Pezaro S, Reinhold E. Childbearing with Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders: A Large International Survey of Outcomes and Complications. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6957. [PMID: 37887695 PMCID: PMC10606623 DOI: 10.3390/ijerph20206957] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/03/2023] [Accepted: 09/15/2023] [Indexed: 10/28/2023]
Abstract
One in 20 births could be affected by hypermobile Ehlers-Danlos syndrome or Hypermobility Spectrum Disorders (hEDS/HSD); however, these are under-diagnosed and lacking research. This study aimed to examine outcomes and complications in people childbearing with hEDS/HSD. A large online international survey was completed by women with experience in childbearing and a diagnosis of hEDS/HSD (N = 947, total pregnancies = 1338). Data were collected on demographics, pregnancy and birth outcomes and complications. Participants reported pregnancies in the UK (N = 771), USA (N = 364), Australia (N = 106), Canada (N = 60), New Zealand (N = 23) and Ireland (N = 14). Incidences were higher in people with hEDS/HSD than typically found in the general population for pre-eclampsia, eclampsia, pre-term rupture of membranes, pre-term birth, antepartum haemorrhage, postpartum haemorrhage, hyperemesis gravidarum, shoulder dystocia, caesarean wound infection, postpartum psychosis, post-traumatic stress disorder, precipitate labour and being born before arrival at place of birth. This potential for increased risk related to maternal and neonatal outcomes and complications highlights the importance of diagnosis and appropriate care considerations for childbearing people with hEDS/HSD. Recommendations include updating healthcare guidance to include awareness of these possible complications and outcomes and including hEDS/HSD in initial screening questionnaires of perinatal care to ensure appropriate consultation and monitoring can take place from the start.
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Affiliation(s)
- Gemma Pearce
- Research Centre for Healthcare and Communities, Coventry University, Coventry CV1 5FB, UK; (L.B.); (S.P.)
| | - Lauren Bell
- Research Centre for Healthcare and Communities, Coventry University, Coventry CV1 5FB, UK; (L.B.); (S.P.)
- Coventry City Council, Coventry CV1 2GN, UK
| | - Sally Pezaro
- Research Centre for Healthcare and Communities, Coventry University, Coventry CV1 5FB, UK; (L.B.); (S.P.)
| | - Emma Reinhold
- Patient and Public Involvement and Medical Advisor, Coventry University, Coventry CV1 5FB, UK;
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Drury AM, Landman MP, Billmire DF. Unusual Presentation of Vascular Ehlers Danlos Syndrome in a Pediatric Patient. Pediatrics 2023; 152:e2022057017. [PMID: 37593812 DOI: 10.1542/peds.2022-057017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/22/2023] [Indexed: 08/19/2023] Open
Affiliation(s)
- Allison M Drury
- Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | - Matthew P Landman
- Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | - Deborah F Billmire
- Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
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Yildiz M, Nucera M, Jungi S, Heinisch PP, Mosbahi S, Becker D, Siepe M, Schoenhoff F. Outcome of Stanford type B dissection in patients with Marfan syndrome. Eur J Cardiothorac Surg 2023; 64:ezad178. [PMID: 37129561 DOI: 10.1093/ejcts/ezad178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 04/19/2023] [Accepted: 04/28/2023] [Indexed: 05/03/2023] Open
Abstract
OBJECTIVES The aim of this study was to determine the outcome of Stanford type B aortic dissection in patients with Marfan syndrome (MFS) and to evaluate aortic diameters at time of dissection as well as the impact of previous aortic root replacement. METHODS Analysis of all patients with MFS fulfilling Ghent criteria seen at this institution since 1995 until 2022. RESULTS Thirty-six (19%) out of 188 patients with MFS suffered from Stanford type B aortic dissection during the study period. The Mean aortic diameter at the time of dissection was 39.0 mm [95% confidence interval (CI): 35.6-42.3]. The mean pre-dissection diameter (available in 25% of patients) was 32.1 mm (95% CI: 28.0-36.3) and the mean expansion was 19% (95% CI: 11.9-26.2). There was no correlation between age and diameter at the time of dissection (<20, 21-30, 31-40, 41-50, 51-60, <61 years; P = 0.78). Freedom from intervention after dissection was 53%, 44% and 33% at 1, 5 and 10 years. Aortic growth rate in those patients that had to undergo intervention within the 1st year after dissection was 10.2 mm/year (95% CI: 4.4-15.9) compared to 5.8 mm/year (95% CI: 3.3-8.3, P = 0.109) in those thereafter. The mean time between dissection and intervention was 1.8 years (95% CI: 0.6-3.0). While type B dissection seems more frequent after previous elective aortic repair (58% vs 42%), there was no difference between valve-sparing root replacement (VSRR) compared to Bentall procedures [Hazard ratio (HR) for VSRR 0.78, 95% CI: 0.31-2.0, P-value = 0.61]. The mean age of the entire population at the end of follow-up was 42 years (95% CI: 39.2-44.7). The mean follow-up time was 9 years (95% CI: 7.8-10.4). CONCLUSIONS Stanford type B dissection in patients with MFS occurs far below accepted thresholds for intervention. Risk for type B dissection is present throughout lifetime and two-thirds of patients need an intervention after dissection. There is no difference in freedom from type B dissection between a Bentall procedure and a VSRR.
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Affiliation(s)
- Murat Yildiz
- Department of Cardiac Surgery, Inselspital Bern, University Hospital Bern, Bern, Switzerland
| | - Maria Nucera
- Department of Cardiac Surgery, Inselspital Bern, University Hospital Bern, Bern, Switzerland
| | - Silvan Jungi
- Department of Cardiac Surgery, Inselspital Bern, University Hospital Bern, Bern, Switzerland
| | - Paul Philipp Heinisch
- Department of Cardiac Surgery, Inselspital Bern, University Hospital Bern, Bern, Switzerland
| | - Selim Mosbahi
- Department of Cardiac Surgery, Inselspital Bern, University Hospital Bern, Bern, Switzerland
| | - Daniel Becker
- Department of Cardiac Surgery, Inselspital Bern, University Hospital Bern, Bern, Switzerland
| | - Matthias Siepe
- Department of Cardiac Surgery, Inselspital Bern, University Hospital Bern, Bern, Switzerland
| | - Florian Schoenhoff
- Department of Cardiac Surgery, Inselspital Bern, University Hospital Bern, Bern, Switzerland
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Clarke JE, Reyes JM, Luther E, Govindarajan V, Leuchter JD, Niazi T, Ragheb J, Wang S. Chiari I malformation management in patients with heritable connective tissue disorders. World Neurosurg X 2023; 18:100173. [PMID: 36969375 PMCID: PMC10031113 DOI: 10.1016/j.wnsx.2023.100173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 02/16/2023] [Accepted: 02/23/2023] [Indexed: 03/08/2023] Open
Abstract
Background Chiari malformation type I (CMI) is relatively common neurosurgical condition typically treated with posterior fossa decompression. However, the management of CMI in patients with heritable connective tissue disorders (CTDs), such as Ehlers-Danlos Syndrome, Marfan Syndrome, or Osteogenesis Imperfecta, involves a unique set of perioperative challenges. Objective This study aims to define the demographic information, comorbidities, and perioperative course of patients with concomitant CMI and CTD. Methods Patients with CMI admitted for surgical decompression from 2008 to 2015 were captured using the National Inpatient Sample (NIS). Information was collected based on ICD-9 codes. Descriptive and regression analyses were performed in SPSS (version 26). Results 38,169 CMI patients, 353 of whom had CTD (0.92%), were identified. CMI patients with CTD were more likely to be female (p < 0.001) and present during teenage (p = 0.033) or young adult years (p < 0.001). They had more chronic issues (p < 0.001): systemic comorbidities include postural orthostatic tachycardia syndrome, cardiac dysrhythmias, and gastroparesis (all p < 0.001). CNS comorbidities include migraine, tethered spinal cord, and epilepsy (all p < 0.001). They have increased joint instability (both p < 0.001), as well as craniocervical instability (CCI). More posterior cervical fusion surgeries and application of cervical halo devices were seen during the same inpatient stay (both p < 0.001). Conclusions Patients with concurrent CTD and CMI were more likely to present with complex Chiari and associated CCI. They were also younger, more often female, and had more systemic, CNS, and joint abnormalities. As such, preoperative recognition of an underlying CTD is imperative to achieve optimal outcomes in this patient population.
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Love AN, Palmer B. Presentation and Management of a Novel Ehlers-Danlos COL5A1 Variant With Birt-Hogg-Dube Syndrome: A Case Study. Cureus 2023; 15:e35866. [PMID: 36895521 PMCID: PMC9990826 DOI: 10.7759/cureus.35866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2023] [Indexed: 03/09/2023] Open
Abstract
Ehlers-Danlos syndrome (EDS) is a hereditary disorder caused by a mutation in the COL gene, which leads to the faulty synthesis of the collagen protein. EDS can present with a wide array of manifestations depending upon which COL gene is mutated. Birt-Hogg-Dubé (BHD) syndrome is a rare hereditary disorder currently identified in 200 families worldwide. It presents clinically with cutaneous, renal, and pulmonary manifestations due to an autosomal dominant mutation in a tumor suppressor gene, FLCN, on chromosome 17p11.2. We present a case of a 22-year-old male with Birt-Hogg-Dubé syndrome, showing typical features consistent with the classical type of EDS, with genetic testing revealing a COL5A1 mutation of "uncertain clinical significance", not yet reported in clinical literature. We discuss the treatment of this patient and describe the presentations of the two pathologies. Lastly, we put forth guidelines for the management of a dilated ascending aorta, with which this patient presents, for future patients who may present with this novel EDS mutation.
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Affiliation(s)
- Avery N Love
- Osteopathic Medicine, Andrew Taylor (A.T. Still University School of Osteopathic Medicine, Mesa, USA
| | - Bruce Palmer
- Interventional Cardiology, United Regional, Wichita Falls, USA
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Igharo D, Thiel JC, Rolke R, Akkaya M, Weis J, Katona I, Schulz JB, Maier A. Skin biopsy reveals generalized small fibre neuropathy in hypermobile Ehlers-Danlos syndromes. Eur J Neurol 2023; 30:719-728. [PMID: 36437696 DOI: 10.1111/ene.15649] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/04/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Ehlers-Danlos syndromes are hereditary disorders of connective tissue that are characterized by joint hypermobility, skin hyperextensibility and tissue fragility. The most common subtype is the hypermobile type. In addition to symptoms of small fibre neuropathy (SFN) due to damage to the small peripheral nerve fibres, with degeneration of the distal nerve endings, autonomic disorders such as postural tachycardia syndrome (PoTS) are frequently reported features in patients with hypermobile Ehlers-Danlos syndrome (hEDS). To date, the underlying pathophysiological mechanisms are still not completely understood. STUDY PURPOSE To better understand pathophysiological mechanisms of small fiber neuropathy and autonomic neuropathy in hypermobile Ehlers-Danlos Syndromes. METHODS We prospectively investigated 31 patients with hEDS compared to 31 healthy controls by using skin biopsy, quantitative sensory testing, tilt-table testing, the painDetect, Small Fibre Neuropathy Screening List and the COMPASS-31 (Composite Autonomic Symptom Score 31) questionnaire. RESULTS Nineteen (61%) patients with hEDS were diagnosed with SFN, and 10 (32%) fulfilled the criteria for PoTS. Patients with hEDS had significantly higher heart rates than controls. According to quantitative sensory testing, these patients had generalized thermal and tactile hypesthesia. Skin biopsy revealed significantly reduced intraepithelial nerve fibre density proximally (thigh) and distally (lower leg) in patients compared to controls. This was consistent with various complaints of pain and sensory disturbances in both the proximal and distal body regions. CONCLUSION These results confirm histologically proven SFN as a common feature in patients with hEDS, revealing a generalized distribution of nerve fibre loss. Regarding the frequently reported autonomic and neuropathic dysfunctions, the findings support SFN as an important, but not the only, underlying pathomechanism.
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Affiliation(s)
- Denver Igharo
- Department of Neurology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Joana C Thiel
- Department of Neurology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Roman Rolke
- Department of Palliative Medicine, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Merve Akkaya
- Department of Neurology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Joachim Weis
- Institute of Neuropathology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Istvan Katona
- Institute of Neuropathology, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Jörg B Schulz
- Department of Neurology, Medical Faculty RWTH Aachen University, Aachen, Germany
- JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Andrea Maier
- Department of Neurology, Medical Faculty RWTH Aachen University, Aachen, Germany
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Balke J, Bohner L, Köppe J, Jackowski J, Oelerich O, Hanisch M. Oral Health-Related Quality of Life in Different Subtypes of Ehlers-Danlos Syndrome. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2218. [PMID: 36767586 PMCID: PMC9916345 DOI: 10.3390/ijerph20032218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 01/18/2023] [Accepted: 01/24/2023] [Indexed: 06/18/2023]
Abstract
This study assessed differences in the oral health-related quality of life (OHRQoL) between subtypes of Ehlers-Danlos syndrome (EDS). For statistical analysis, participants were divided according to their subtype: classical EDS (cEDS), hypermobile EDS (hEDS), and vascular EDS (vEDS). All other subtypes were descriptively analyzed. Free-text questions and the German short form of the Oral Health Impact Profile (OHIP-14) were used. Finally, 295 questionnaires were included, representing 10 different EDS subtypes. The mean OHIP score of all participants was 19.6 points (standard derivation (SD) ± 12.3). The most predominant subtypes showed similar reduced OHRQoL, with 18.0 (cEDS, ±12.9), 19.5 (hEDS, ±12.0), and 15.2 (vEDS, ±11.6) OHIP points. For all other subtypes, the OHIP values varied. Participants waited an average of 21.8 years (±12.8) for their diagnosis. However, within the predominant subtypes, vEDS patients waited a noticeably shorter period of 13.3 years (±13.0; p = 0.004) compared to participants with hEDS. Additionally, this study showed no difference in OHRQoL for the predominant subtypes regardless of whether a participant was a self-help group member (18.8, ±12.0) or not (19.4, ±12.1; p = 0.327).
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Affiliation(s)
- Julius Balke
- Department for Prosthodontics and Biomaterials, University Hospital Münster, D-48149 Münster, Germany
| | - Lauren Bohner
- Department of Oral and Maxillofacial Surgery, Hospital University Münster, 48149 Münster, Germany
| | - Jeanette Köppe
- Institute of Biostatistics and Clinical Research, University of Münster, Schmeddingstraße 56, D-48149 Münster, Germany
| | - Jochen Jackowski
- Department of Oral Surgery and Policlinical Ambulance, Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Str. 45, 58448 Witten, Germany
| | - Ole Oelerich
- Department for Prosthodontics and Biomaterials, University Hospital Münster, D-48149 Münster, Germany
| | - Marcel Hanisch
- Department of Oral and Maxillofacial Surgery, Hospital University Münster, 48149 Münster, Germany
- Department of Oral Surgery and Policlinical Ambulance, Faculty of Health, Witten/Herdecke University, Alfred-Herrhausen-Str. 45, 58448 Witten, Germany
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14
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Underhill LA, Barbarita C, Collis S, Tucker R, Lechner BE. Association of Maternal Versus Fetal Ehlers-Danlos Syndrome Status with Poor Pregnancy Outcomes. Reprod Sci 2022; 29:3459-3464. [PMID: 35676499 PMCID: PMC9734202 DOI: 10.1007/s43032-022-00992-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 05/29/2022] [Indexed: 12/14/2022]
Abstract
The majority of research papers published on obstetrical outcomes in Ehlers-Danlos syndrome (EDS) have focused on the contribution of maternal EDS to the risk of poor pregnancy outcomes. The purpose of our study was to further clarify the fetal versus maternal contribution of EDS to poor pregnancy outcomes. A web-based, anonymous questionnaire was developed to collect pregnancy histories of families with a member with EDS. The survey was disseminated via social media through the Ehlers Danlos National Foundation. Population descriptors (age, gender, EDS diagnosis, age of diagnosis) and pregnancy descriptors (number of pregnancies, live births, and birth complications) were collected. To identify fetal and maternal contribution of EDS to poor pregnancy outcomes, three groups were compared based on maternal or infant diagnosis (EDS versus non-EDS). The rate of birth complications, treatment for preterm birth, and occurrence of preterm birth, as well as gestational age at preterm birth, were different depending on maternal/ infant EDS status, and these differences were significant when comparing infant EDS status but not when comparing maternal EDS status. The occurrence of PPROM is increased in the non-EDS mother/EDS infant group compared to both EDS mother/non-EDS infant and EDS mother/EDS infant groups (38.9%, 12.5%, 14.8%, p = 0.025). This study identifies that poor outcomes in EDS pregnancies differ depending on the maternal and the fetal EDS status. These insights into maternal and fetal association with certain poor pregnancy outcomes in pregnancies complicated by EDS can further guide physicians in educating, managing, and treating these women during pregnancy.
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Affiliation(s)
- L A Underhill
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Kilguss Research Institute, The Warren Alpert Medical School of Brown University, 101 Dudley Street, Providence, RI, 02905, USA.
| | - C Barbarita
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Kilguss Research Institute, The Warren Alpert Medical School of Brown University, 101 Dudley Street, Providence, RI, 02905, USA
| | - S Collis
- Brown University, Providence, RI, USA
| | - R Tucker
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Kilguss Research Institute, The Warren Alpert Medical School of Brown University, 101 Dudley Street, Providence, RI, 02905, USA
| | - B E Lechner
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Kilguss Research Institute, The Warren Alpert Medical School of Brown University, 101 Dudley Street, Providence, RI, 02905, USA
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Lohkamp LN, Marathe N, Fehlings MG. Craniocervical Instability in Ehlers-Danlos Syndrome-A Systematic Review of Diagnostic and Surgical Treatment Criteria. Global Spine J 2022; 12:1862-1871. [PMID: 35195459 PMCID: PMC9609512 DOI: 10.1177/21925682211068520] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVE Ehlers-Danlos Syndrome (EDS) comprises a spectrum of connective tissue disorders, which may be associated with cranio-cervical instability (CCI). There is a lack of consensus on diagnostic imaging parameters, indications, and outcomes of surgical treatment. METHODS This systematic review analyses the literature on diagnostic methods and/or criteria for CCI, screening the databases Ovid Medline, Embase, Cochrane Library, and PubMed. Articles were included based on the PRISMA guidelines and assessed using the Newcastle-Ottawa Quality Assessment Scale (NOS) and according to their evidence level. RESULTS Sixteen articles, including 78 surgical patients, met the inclusion criteria. The main diagnostic measures for CCI were dynamic x-rays and CT imaging. Ten different radiographic parameters were reported, of which 4 were the most frequently applied for surgical decision-making: the clivo-axial angle (CXA), the Harris measurement, the Grabb-Mapstone-Oakes measurement, and the angular displacement of C1 to C2. The evidence level ranged between III and V and the article quality between 4 and 8 out of 9 stars on the NOS Scale. CONCLUSIONS There is a lack of high quality, prospective evidence regarding the evaluation of suspected CCI in patients with EDS. Based on our systematic review, we recommend that the CXA, Harris measurement, Grabb-Mapstone-Oakes measurement, and the angular displacement of C1 to C2 be used to evaluate suspected CCI in EDS patients. Surgical fixation of suspected CCI should only be performed in cases with clear radiographic presence of instability and concordant symptoms/signs. Consensus-based guidelines and care pathways are required.
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Affiliation(s)
- Laura-Nanna Lohkamp
- Division of Neurosurgery,
Department of Surgery, University of Toronto, Toronto, ON, Canada,Division of Neurosurgery, Spinal
Program, Krembil Nuroscience Centre, Toronto Western Hospital, University Health
Network, Toronto, ON, Canada
| | - Nandan Marathe
- Division of Neurosurgery,
Department of Surgery, University of Toronto, Toronto, ON, Canada,Division of Neurosurgery, Spinal
Program, Krembil Nuroscience Centre, Toronto Western Hospital, University Health
Network, Toronto, ON, Canada
| | - Michael G. Fehlings
- Division of Neurosurgery,
Department of Surgery, University of Toronto, Toronto, ON, Canada,Division of Neurosurgery, Spinal
Program, Krembil Nuroscience Centre, Toronto Western Hospital, University Health
Network, Toronto, ON, Canada,Michael G. Fehlings MD PhD, Division of
Neurosurgery and Spinal Program, Department of Surgery, University of Toronto,
Krembil Neuroscience Centre Toronto Western Hospital, 399 Bathurst Street, Suite
4W-449 Toronto, ON M5T 2S8, Canada.
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16
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Rationale and Feasibility of Resistance Training in hEDS/HSD: A Narrative Review. J Funct Morphol Kinesiol 2022; 7:jfmk7030061. [PMID: 35997377 PMCID: PMC9397026 DOI: 10.3390/jfmk7030061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/11/2022] [Accepted: 08/12/2022] [Indexed: 11/17/2022] Open
Abstract
Hypermobile Ehlers-Danlos Syndrome (hEDS) and hypermobility spectrum disorder (HSD) are genetic conditions characterized by increased joint hypermobility, often in the presence of other signs or symptoms if syndromic. This hypermobility can result in significant pain and ultimately decreased participation in recreational or competitive activity. Rehabilitation of patients with hEDS/HSD is not well understood, particularly since presentation can be relatively heterogenous. Regardless, more research is needed, particularly regarding resistance training, to allow patients with hEDS/HSD to participate in the activities they enjoy. The purpose of this narrative review is to provide an overview of the clinical features displayed by those with hEDS/HSD that have been found to be improved with resistance training in other populations, and to present the current evidence for resistance training in all types of study designs, ranging from case studies to randomized controlled trials.
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17
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Kempers MJ, Wessels M, Van Berendoncks A, van de Laar IM, de Leeuw N, Loeys B. Phenotype of COL3A1/COL5A2 deletion patients. Eur J Med Genet 2022; 65:104593. [PMID: 35964930 DOI: 10.1016/j.ejmg.2022.104593] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 06/23/2022] [Accepted: 08/07/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION The diagnosis of Ehlers-Danlos syndrome is usually based on well-defined diagnostic criteria and the result of DNA investigation. Classical (cEDS) and vascular type (vEDS) are the most prevalent subtypes and are caused by heterozygous pathogenic variants in COL5A1, COL5A2, COL1A1 or, respectively, in COL3A1. We describe 3 cases with contiguous deletions resulting in haploinsufficiency of both genes with relative mild features of connective tissue disease. PATIENTS AND METHODS Information on medical history, physical information, genetic results (CNV-analysis) and imaging were obtained from the medical file. RESULTS The first patient was a 31 yr old female, diagnosed during pregnancy after the NIPT result showed an interstitial deletion of 2.3 Mb on chromosome 2q32.2, confirmed by XON array. She had normal aortic diameters. She had no signs of cEDS or vEDS except for a relatively thin skin with increased visibility of the veins. Her father died suddenly of a type A/B dissection at the age of 62 years. The second patient was diagnosed at the age of 10 years after she was referred because of her intellectual disability, autism and constipation. She was known with a thin and vulnerable skin and had a bleeding after tooth extraction. Array showed a 14,5 Mb deletion of 2q31.3q32.3 (de novo). Imaging (latest age 17 years) did not show any abnormalities. The third patient, aged 28 years, was diagnosed during pregnancy with an interstitial deletion of circa 6 Mb on chromosome 2q31.1q32.2 3, previously shown in the fetus with bilateral club feet and hydronephrosis. She had no vEDS facial features and the skin was relatively thin. She has thoracolumbar scoliosis and dural ectasia. Imaging did not reveal any vascular abnormalities. Her son, born at 37 weeks 3 days. had club feet but not other clinical signs suggestive of classical or vascular EDS. DISCUSSION Three patients are described with a contiguous deletion of varying size encompassing the COL3A1 and COL5A2 gene. Due to the mild phenotype a diagnosis of EDS was not suspected and was found coincidental. Since two of the patients were pregnant without major complications these patients may require a less defensive, approach to pregnancy/delivery.
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Affiliation(s)
- Marlies Je Kempers
- Department of Clinical Genetics, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Marja Wessels
- Department of Clinical Genetics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - An Van Berendoncks
- Department of Cardiology, Antwerp University Hospital/University of Antwerp, Antwerp, Belgium
| | - Ingrid Mbh van de Laar
- Department of Clinical Genetics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Nicole de Leeuw
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bart Loeys
- Department of Clinical Genetics, Radboud University Medical Center, Nijmegen, the Netherlands; Center for Medical Genetics, Antwerp University Hospital/University of Antwerp, Antwerp, Belgium
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Kallenbach K, Remes A, Müller OJ, Arif R, Zaradzki M, Wagner AH. Translational Medicine: Towards Gene Therapy of Marfan Syndrome. J Clin Med 2022; 11:jcm11143934. [PMID: 35887698 PMCID: PMC9319421 DOI: 10.3390/jcm11143934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/28/2022] [Accepted: 07/01/2022] [Indexed: 12/12/2022] Open
Abstract
Marfan syndrome (MFS) is one of the most common inherited disorders of connective tissue caused by mutations of the fibrillin-1 gene (FBN1). Vascular abnormalities, such as the enlargement of the aorta with the risk of life-threatening rupture are frequently observed. However, current treatment is limited and therapeutic options focus solely on symptomatic therapy. Gene therapy focuses on genetically modifying cells to produce a therapeutic effect and may be a promising treatment option for MFS. Here, we first provide an overview of the historical background and characterization of MFS. Subsequently, we summarise current gene therapy options and possible translational concepts for this inherited disorder that affects connective tissue.
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Affiliation(s)
- Klaus Kallenbach
- Institute for Cardiac Surgery and Interventional Cardiology (INCCI), Department of Cardiac Surgery, 1210 Luxembourg, Luxembourg;
- VASCERN HTAD European Reference Center, 1210 Luxembourg, Luxembourg
| | - Anca Remes
- Department of Internal Medicine III, University of Kiel and University Hospital Schleswig-Holstein, 24105 Kiel, Germany; (A.R.); (O.J.M.)
- German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, 20251 Hamburg, Germany
| | - Oliver J. Müller
- Department of Internal Medicine III, University of Kiel and University Hospital Schleswig-Holstein, 24105 Kiel, Germany; (A.R.); (O.J.M.)
- German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, 20251 Hamburg, Germany
| | - Rawa Arif
- Department of Cardiac Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany; (R.A.); (M.Z.)
| | - Marcin Zaradzki
- Department of Cardiac Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany; (R.A.); (M.Z.)
| | - Andreas H. Wagner
- Department of Cardiovascular Physiology, Heidelberg University, Im Neuenheimer Feld 326, 69120 Heidelberg, Germany
- Correspondence: ; Tel.: +49-6221-544062; Fax: +49-6221-544038
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Baeza-Velasco C, Hamonet C, Montalescot L, Courtet P. Suicidal Behaviors in Women With the Hypermobile Ehlers-Danlos Syndrome. Arch Suicide Res 2022; 26:1314-1326. [PMID: 33596399 DOI: 10.1080/13811118.2021.1885538] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Hypermobile Ehlers-Danlos syndrome (hEDS) is the most frequent heritable disorder of the connective tissue. This is characterized by a generalized fragility of tissues leading to chronic pain, disability and high levels of psychological distress. Suicidal behaviors in those affected are not uncommon but they have not been well studied. We aimed to explore aspects of suicidality and related factors in a group of patients with hEDS. METHOD Thirty-five women with hEDS were included in this cross-sectional study. They were assessed with the Mini-International Neuropsychiatric Interview for Axis 1 DSM-IV mental disorders and suicidality. They also responded to self-questionnaires assessing health (pain, BMI, and diagnosis delay) and psychosocial variables (social support, physical functioning, coping strategies, personality disturbances, and resilience). RESULTS Eleven patients (31.4%) had attempted suicide in the past. Fifteen patients (42.9%) had some degree of suicide risk at the time of evaluation, mainly mild risk (60%). Compared with patients without a history of suicide attempt, those who had attempted suicide were younger, scored higher on personality disturbances, especially on depressive, avoidant, antisocial, and borderline trait subscores, and had an increased prevalence of lifetime major depression, mania/hypomanic episodes, and anxiety disorders (p < .05). Binary logistic regression showed that personality disturbances and anxiety disorders increase the probability of belonging to the attempters group. CONCLUSIONS Consistent with previous reports, these data highlight the high frequency of suicidal behaviors in hEDS patients as well as the importance to explore psychopathology in those affected in order to identify vulnerable individuals and provide specific support.HIGHLIGHTSAttempted suicide in patients with hEDS is not uncommon.Age and the presence of psychopathology are associated with suicide attempt in hEDS patients.Personality disturbances and lifetime anxiety disorders predicted suicide attempted in this sample.
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Buryk-Iggers S, Mittal N, Santa Mina D, Adams SC, Englesakis M, Rachinsky M, Lopez-Hernandez L, Hussey L, McGillis L, McLean L, Laflamme C, Rozenberg D, Clarke H. Exercise and Rehabilitation in People With Ehlers-Danlos Syndrome: A Systematic Review. Arch Rehabil Res Clin Transl 2022; 4:100189. [PMID: 35756986 PMCID: PMC9214343 DOI: 10.1016/j.arrct.2022.100189] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Objective To conduct a systematic review examining the effect of exercise and rehabilitation in people with Ehlers-Danlos syndrome (EDS). Data Sources The following databases were systematically searched: MEDLINE, MEDLINE In-Process/ePubs, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, and Cumulative Index to Nursing and Allied Health. The final time point captured by the search is November 27, 2020. Study Selection Eligible study designs included case-control, case-series, prospective cohort, retrospective cohort, and intervention studies of structured exercise or rehabilitation interventions. Eligible populations included adults (18 years or older) with EDS (all subtypes) and hypermobility spectrum disorders. The search was restricted to articles published in English. Data Extraction Data were extracted by 2 independent reviewers. Risk of bias was assessed using the Physiotherapy Evidence Database (PEDro) scale for randomized controlled trials (RCTs) and Risk Of Bias In Nonrandomized Studies of Interventions (ROBINS-I) for non-RCTs. Reporting quality of RCTs was assessed using the Consolidated Standards for Reporting of Trials statement with the harms extension. Reporting was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Data Synthesis The search yielded 10 eligible studies including 330 participants. The study designs included 5 RCTs, 1 cohort, 2 single-arm interventions, 1 retrospective, and 1 feasibility study. All studies showed some improvement in a physical and/or psychological outcome after the intervention period. One adverse event (nonserious) potentially related to the intervention was reported. Of the 5 RCTs, 2 were rated as high quality with low risk of bias using PEDro, and the majority of non-RCTs were rated as critical risk of bias by ROBINS-I. Conclusions The results suggest that exercise and rehabilitation may be beneficial for various physical and psychological outcomes. Adequately powered and rigorous RCTs of exercise and rehabilitation interventions for people with EDS are needed.
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Key Words
- 6MWT, 6-minute walk test
- AIMS-2, Arthritis Impact Measurement Scales-2
- CONSORT, Consolidated Standards for Reporting of Trials
- EDS, Ehlers-Danlos syndrome
- Ehlers-Danlos Syndrome
- Exercise
- HADS, Hospital and Anxiety Depression Scale
- HSD, hypermobility spectrum disorders
- Joint instability
- PEDro, Physiotherapy Evidence Database
- PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- QOL, quality of life
- RCT, randomized control trial
- ROBINS-I, Risk Of Bias In Nonrandomized Studies of Interventions
- Rehabilitation
- SF-36, Short Form-36
- VAS, visual analog scale
- hEDS, hypermobile EDS
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Affiliation(s)
- Stephanie Buryk-Iggers
- Department of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada
| | - Nimish Mittal
- Department of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada
- Faculty of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Santa Mina
- Department of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Anaesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
| | - Scott C. Adams
- Department of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
- Department of Cardiology, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
- Ted Rogers Cardiotoxicity Prevention Program, Peter Munk Cardiac Centre, Toronto, Ontario, Canada
| | - Marina Englesakis
- Library and Information Services Toronto General Hospital, Toronto, Ontario, Canada
| | - Maxim Rachinsky
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Anaesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
| | - Laura Lopez-Hernandez
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada
| | - Laura Hussey
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada
| | - Laura McGillis
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada
| | - Lianne McLean
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada
| | - Camille Laflamme
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada
- Faculty of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Dmitry Rozenberg
- Faculty of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Respirology, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Hance Clarke
- GoodHope Ehlers Danlos Syndrome Clinic, Toronto General Hospital, Toronto, Ontario, Canada
- Faculty of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
- Department of Anaesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
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Zhou YY, Du YF, Lu Q, Zhai XZ, Shi MF, Chen DY, Liu SR, Zhong Y. Case Report: A Novel Mutation Identified in CHST14 Gene in a Fetus With Structural Abnormalities. Front Genet 2022; 13:853907. [PMID: 35464846 PMCID: PMC9024400 DOI: 10.3389/fgene.2022.853907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/03/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Musculocontractural Ehlers–Danlos syndrome (mcEDS) is a rare heritable connective tissue disease with various symptoms. The diagnosis of mcEDS is difficult because of the large overlap of clinical symptoms between different EDS subtypes.Methods: We performed karyotype analysis, gene copy number variation detection, whole-exome sequencing, and Sanger sequencing to reveal the underlying genetic etiology of a fetus with structural abnormalities in feet and kidneys.Results: A likely pathogenic mutation [NM_130468.3 c.958C>T (p.Arg320*)] and an uncertain significance mutation [NM_130468.3 c.896A>G (p.Tyr299Cys)] were identified in the carbohydrate sulfotransferase 14 (CHST14) gene by whole-exome sequencing and validated by Sanger sequencing.Conclusion: The two identified mutations appear highly likely to be the genetic causes of the fetal structural abnormalities.
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Slaoui A, Mahtate M, Lazhar H, Lakhdar A, Baydada A, Kharbach A. Spontaneous uterine rupture revealing vascular Ehlers-Danlos syndrome: An uncommon case report. Int J Surg Case Rep 2022; 92:106840. [PMID: 35202939 PMCID: PMC8881606 DOI: 10.1016/j.ijscr.2022.106840] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/10/2022] [Accepted: 02/13/2022] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Vascular Ehlers-Danlos syndrome also referred to as Ehlers-Danlos Type IV is an uncommon autosomal dominant genetic disorder linked to connective tissue abnormality. Its evolution is marked by the occurrence of severe vascular, digestive and obstetrical complications. The current case highlights the importance of early diagnosis and physician awareness about this disorder as it can improve the patient's prognosis. CASE PRESENTATION We present the case of a 34-year-old woman, who presented at 36 weeks of amenorrhea with labor pain. The labor evolution was marked by an increased fluctuating abdominal pain, a sudden loss of the fetal station detected during cervical examination and decelerations to 60 beats per min, leading to an emergency caesarean section. During the laparotomy, the patient presented a spontaneous bilateral extension of the cutaneous incision requiring the realization of stopping stitches. The fetus and placenta had been expelled via a 9 cm long uterine wall rupture also known as an open book uterine rupture. A live male infant weighting 2890 g was promptly delivered and transported to NICU for respiratory distress. Physical features typical of EDS-IV allowed us to suspect this disorder and genetic analysis identified the presence of COL3A1 gene mutation, confirming the diagnosis. CLINICAL DISCUSSION AND CONCLUSIONS Early recognition of Vascular Ehlers-Danlos syndrome is of paramount importance to improve the prognosis of affected patients, who often present themselves with life-threatening situations. Clinicians should maintain a high index of suspicion for the clinical signs of this inherited connective tissue disorder that is characterized by distinctive features.
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Affiliation(s)
- Aziz Slaoui
- Gynaecology-Obstetrics and Endocrinology Department, Maternity Souissi, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco; Gynaecology-Obstetrics and Endoscopy Department, Maternity Souissi, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco.
| | - Mariam Mahtate
- Gynaecology-Obstetrics and Endocrinology Department, Maternity Souissi, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco
| | - Hanaa Lazhar
- Gynaecology-Obstetrics and Endocrinology Department, Maternity Souissi, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco
| | - Amina Lakhdar
- Gynaecology-Obstetrics and Endocrinology Department, Maternity Souissi, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco
| | - Aziz Baydada
- Gynaecology-Obstetrics and Endoscopy Department, Maternity Souissi, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco
| | - Aicha Kharbach
- Gynaecology-Obstetrics and Endocrinology Department, Maternity Souissi, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco
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The Ehlers–Danlos Syndromes against the Backdrop of Inborn Errors of Metabolism. Genes (Basel) 2022; 13:genes13020265. [PMID: 35205310 PMCID: PMC8872221 DOI: 10.3390/genes13020265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 01/26/2022] [Indexed: 02/04/2023] Open
Abstract
The Ehlers–Danlos syndromes are a group of multisystemic heritable connective tissue disorders with clinical presentations that range from multiple congenital malformations, over adolescent-onset debilitating or even life-threatening complications of connective tissue fragility, to mild conditions that remain undiagnosed in adulthood. To date, thirteen different EDS types have been recognized, stemming from genetic defects in 20 different genes. While initial biochemical and molecular analyses mainly discovered defects in genes coding for the fibrillar collagens type I, III and V or their modifying enzymes, recent discoveries have linked EDS to defects in non-collagenous matrix glycoproteins, in proteoglycan biosynthesis and in the complement pathway. This genetic heterogeneity explains the important clinical heterogeneity among and within the different EDS types. Generalized joint hypermobility and skin hyperextensibility with cutaneous fragility, atrophic scarring and easy bruising are defining manifestations of EDS; however, other signs and symptoms of connective tissue fragility, such as complications of vascular and internal organ fragility, orocraniofacial abnormalities, neuromuscular involvement and ophthalmological complications are variably present in the different types of EDS. These features may help to differentiate between the different EDS types but also evoke a wide differential diagnosis, including different inborn errors of metabolism. In this narrative review, we will discuss the clinical presentation of EDS within the context of inborn errors of metabolism, give a brief overview of their underlying genetic defects and pathophysiological mechanisms and provide a guide for the diagnostic approach.
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Curry TM, Esfandiarei M, Thomas TC, Rastogi RG. Case report: Lingering post-concussive symptoms in a pediatric patient with presumed Ehlers-Danlos syndrome. Front Pediatr 2022; 10:937223. [PMID: 36405827 PMCID: PMC9672464 DOI: 10.3389/fped.2022.937223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Connective tissue disorders such as Ehlers-Danlos Syndrome (EDS) can affect collagen and elastin content and structure, including weakening of tissues and vasculature, thus contributing to multiple systemic manifestations. Prior research has successfully focused on peripheral life-threatening manifestations resulting in increased life expectancy, yet clinical observations have warranted investigation of neurological vulnerability, where little is known. Compromised brain tissues and cerebrovasculature could leave these patients vulnerable to mild traumatic brain injury (TBI), with increased severity and duration of post-concussive symptoms and delayed recovery. Clinical reports in adults indicate that higher severity of symptoms after a mild TBI, such as a concussion, can unmask connective tissues disorders leading toward diagnosis. This clinical case report is an example of a pediatric patient with presumed Ehlers-Danlos syndrome who demonstrates increased vulnerability to mild TBI/concussion. PATIENT A pediatric female patient presents with unexplained lingering post-concussive symptoms, including trouble sleeping, nausea, frontal headaches, dizziness, visual changes, fatigue, and left-sided weakness more than 6 months post-mild concussion. Patient history of hypermobility, joint derangement, soft tissue mobility, and bruising suggests a potential diagnosis of Ehlers-Danlos syndrome, which may explain symptom severity and length of recovery. DISCUSSION This case is the first documented instance of increased vulnerability to TBI in a pediatric patient with presumed Ehlers-Danlos syndrome. It highlights the need for awareness and prevention of injury in this vulnerable patient population, suggests more targeted therapeutic intervention for recovery, and demonstrates the need for preclinical research evaluating the influence of genetic mutations associated with connective tissue disorders on the central nervous system.
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Affiliation(s)
- Tala Maris Curry
- Department of Child Health, College of Medicine-Phoenix, University of Arizona, Phoenix, AZ, United States.,Neurotrauma and Neurochemistry Research Laboratory, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Mitra Esfandiarei
- Department of Biomedical Sciences, College of Graduate Studies, Midwestern University, Glendale, AZ, United States.,Department of Basic Medical Sciences, College of Medicine-Phoenix, University of Arizona, Phoenix, AZ, United States
| | - Theresa Currier Thomas
- Department of Child Health, College of Medicine-Phoenix, University of Arizona, Phoenix, AZ, United States.,Neurotrauma and Neurochemistry Research Laboratory, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Reena Gogia Rastogi
- Department of Child Health, College of Medicine-Phoenix, University of Arizona, Phoenix, AZ, United States.,Pediatric Headache Program, Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States
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25
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Chizhonkova EA, Avetisov KS, Avetisov SE, Kharlap SI. [Ocular manifestations of Marfan syndrome]. Vestn Oftalmol 2022; 138:94-100. [PMID: 36004597 DOI: 10.17116/oftalma202213804194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Marfan syndrome is an orphan disease that is caused by a mutation in the FBN1 gene located on chromosome 15 (15q21.1) and is usually inherited in an autosomal dominant manner. The article reviews the results of studies concerning the potential ocular manifestations of Marfan syndrome.
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Affiliation(s)
| | - K S Avetisov
- Research Institute of Eye Diseases, Moscow, Russia
| | - S E Avetisov
- Research Institute of Eye Diseases, Moscow, Russia
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - S I Kharlap
- Research Institute of Eye Diseases, Moscow, Russia
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26
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Malfait F, Colman M, Vroman R, De Wandele I, Rombaut L, Miller RE, Malfait AM, Syx D. Pain in the Ehlers-Danlos syndromes: Mechanisms, models, and challenges. AMERICAN JOURNAL OF MEDICAL GENETICS. PART C, SEMINARS IN MEDICAL GENETICS 2021; 187:429-445. [PMID: 34797601 DOI: 10.1002/ajmg.c.31950] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/17/2021] [Accepted: 10/22/2021] [Indexed: 12/27/2022]
Abstract
Chronic pain is one of the most common, yet poorly studied, complaints in people suffering from Ehlers-Danlos syndromes (EDS). This heterogeneous group of heritable connective tissue disorders is typically characterized by skin hyperextensibility, joint hypermobility, and generalized connective tissue fragility. Most EDS types are caused by genetic defects that affect connective tissue biosynthesis, thereby compromising collagen biosynthesis or fibrillogenesis and resulting in a disorganized extracellular matrix. Even though chronic pain is a major source of disability, functional impairment, and psychosocial suffering in EDS, currently used analgesics and other treatment strategies provide inadequate pain relief and thus represents an important unmet medical need. An important contributor to this is the lack of knowledge about the underlying mechanisms. In this narrative review, we summarize the current understanding of pain and the associated mechanisms in EDS based on clinical studies focusing on questionnaires and experimental pain testing as well as studies in animal models of EDS. In addition, we highlight the challenges, gaps, and opportunities in EDS-pain research.
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Affiliation(s)
- Fransiska Malfait
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium.,Department of Biomolecular Medicine, Ghent University, Ghent, Belgium
| | - Marlies Colman
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium.,Department of Biomolecular Medicine, Ghent University, Ghent, Belgium
| | - Robin Vroman
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium.,Department of Biomolecular Medicine, Ghent University, Ghent, Belgium
| | - Inge De Wandele
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium.,Department of Biomolecular Medicine, Ghent University, Ghent, Belgium
| | - Lies Rombaut
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium.,Department of Biomolecular Medicine, Ghent University, Ghent, Belgium
| | - Rachel E Miller
- Division of Rheumatology, Rush University Medical Center, Chicago, Illinois, USA
| | - Anne-Marie Malfait
- Division of Rheumatology, Rush University Medical Center, Chicago, Illinois, USA
| | - Delfien Syx
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium.,Department of Biomolecular Medicine, Ghent University, Ghent, Belgium
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Pollock L, Ridout A, Teh J, Nnadi C, Stavroulias D, Pitcher A, Blair E, Wordsworth P, Vincent TL. The Musculoskeletal Manifestations of Marfan Syndrome: Diagnosis, Impact, and Management. Curr Rheumatol Rep 2021; 23:81. [PMID: 34825999 PMCID: PMC8626407 DOI: 10.1007/s11926-021-01045-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2021] [Indexed: 11/29/2022]
Abstract
Purpose of Review
Marfan syndrome (MFS) is an autosomal dominant heritable disorder of fibrillin-1 (FBN1) with predominantly ocular, cardiovascular, and musculoskeletal manifestations that has a population prevalence of approximately 1 in 5–10,000 (Chiu et al. Mayo Clin Proc. 89(1):34–42, 146, Dietz 3, Loeys et al. J Med Genet. 47(7):476–85, 4). Recent Findings The vascular complications of MFS still pose the greatest threat, but effective management options, such as regular cardiac monitoring and elective surgical intervention, have reduced the risk of life-threatening cardiovascular events, such as aortic dissection. Although cardiovascular morbidity and mortality remains high, these improvements in cardiovascular management have extended the life expectancy of those with MFS by perhaps 30–50 years from an estimated mean of 32 years in 1972 (Dietz 3, Gott et al. Eur J Cardio-thoracic Surg. 10(3):149–58, 147, Murdoch et al. N Engl J Med. 286(15):804–8, 148). The musculoskeletal manifestations of MFS, which to date have received less attention, can also have a significant impact on the quality of life and are likely to become more important as the age of the Marfan syndrome population increases (Hasan et al. Int J Clin Pract. 61(8):1308–1320, 127). In addition, musculoskeletal manifestations are often critically important in the diagnosis of MFS. Summary Here, we review the main clinically relevant and diagnostically useful musculoskeletal features of MFS, which together contribute to the “systemic features score” (referred to hereafter as systemic score), part of the revised Ghent nosology for MFS. We discuss current treatment strategies and highlight the need for a multidisciplinary approach to diagnosis and management. Finally, we review new pharmacological approaches that may be disease modifying and could help to improve the outcome for individuals with this syndrome.
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Affiliation(s)
- Lily Pollock
- Kennedy Institute of Rheumatology, NDORMS, University of Oxford, Oxford, UK
| | - Ashley Ridout
- Department of Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - James Teh
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, England, UK
| | - Colin Nnadi
- Department of Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Alex Pitcher
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Edward Blair
- Department of Clinical Genetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Paul Wordsworth
- Department of Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Tonia L Vincent
- Kennedy Institute of Rheumatology, NDORMS, University of Oxford, Oxford, UK. .,Department of Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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Ehlers Danlos Syndrome with Glycosaminoglycan Abnormalities. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1348:235-249. [PMID: 34807422 DOI: 10.1007/978-3-030-80614-9_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Ehlers-Danlos syndrome (EDS) is a genetically and clinically heterogeneous group of connective tissue disorders that typically present with skin hyperextensibility, joint hypermobility, and tissue fragility. The major cause of EDS appears to be impaired biosynthesis and enzymatic modification of collagen. In this chapter, we discuss two types of EDS that are associated with proteoglycan abnormalities: spondylodysplastic EDS and musculocontractural EDS. Spondylodysplastic EDS is caused by pathogenic variants in B4GALT7 or B3GALT6, both of which encode key enzymes that initiate glycosaminoglycan synthesis. Musculocontractural EDS is caused by mutations in CHST14 or DSE, both of which encode enzymes responsible for the post-translational biosynthesis of dermatan sulfate. The clinical and molecular characteristics of both types of EDS are described in this chapter.
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Micale L, Fusco C, Castori M. Ehlers-Danlos Syndromes, Joint Hypermobility and Hypermobility Spectrum Disorders. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1348:207-233. [PMID: 34807421 DOI: 10.1007/978-3-030-80614-9_9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Ehlers-Danlos syndrome is an umbrella term for a clinically and genetically heterogeneous group of hereditary soft connective tissue disorders mainly featuring abnormal cutaneous texture (doughy/velvety, soft, thin, and/or variably hyperextensible skin), easy bruising, and joint hypermobility. Currently, musculoskeletal manifestations related to joint hypermobility are perceived as the most prevalent determinants of the quality of life of affected individuals. The 2017 International Classification of Ehlers-Danlos syndromes and related disorders identifies 13 clinical types due to deleterious variants in 19 different genes. Recent publications point out the possibility of a wider spectrum of conditions that may be considered members of the Ehlers-Danlos syndrome community. Most Ehlers-Danlos syndromes are due to inherited abnormalities affecting the biogenesis of fibrillar collagens and other components of the extracellular matrix. The introduction of next-generation sequencing technologies in the diagnostic setting fastened patients' classification and improved our knowledge on the phenotypic variability of many Ehlers-Danlos syndromes. This is impacting significantly patients' management and family counseling. At the same time, most individuals presenting with joint hypermobility and associated musculoskeletal manifestations still remain without a firm diagnosis, due to a too vague clinical presentation and/or the lack of an identifiable molecular biomarker. These individuals are currently defined with the term "hypermobility spectrum disorders". Hence, in parallel with a continuous update of the International Classification of Ehlers-Danlos syndromes, the scientific community is investing efforts in offering a more efficient framework for classifying and, hopefully, managing individuals with joint hypermobility.
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Affiliation(s)
- Lucia Micale
- Division of Medical Genetics, Fondazione IRCCS-Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Carmela Fusco
- Division of Medical Genetics, Fondazione IRCCS-Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Marco Castori
- Division of Medical Genetics, Fondazione IRCCS-Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy.
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30
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Zeigler SM, Sloan B, Jones JA. Pathophysiology and Pathogenesis of Marfan Syndrome. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1348:185-206. [PMID: 34807420 DOI: 10.1007/978-3-030-80614-9_8] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Marfan syndrome (MFS) is a systemic connective tissue disorder that is inherited in an autosomal dominant pattern with variable penetrance. While clinically this disease manifests in many different ways, the most life-threatening manifestations are related to cardiovascular complications including mitral valve prolapse, aortic insufficiency, dilatation of the aortic root, and aortic dissection. In the past 30 years, research efforts have not only identified the genetic locus responsible but have begun to elucidate the molecular pathogenesis underlying this disorder, allowing for the development of seemingly rational therapeutic strategies for treating affected individuals. In spite of these advancements, the cardiovascular complications still remain as the most life-threatening clinical manifestations. The present chapter will focus on the pathophysiology and clinical treatment of Marfan syndrome, providing an updated overview of the recent advancements in molecular genetics research and clinical trials, with an emphasis on how this information can focus future efforts toward finding betters ways to detect, diagnose, and treat this devastating condition.
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Affiliation(s)
- Sanford M Zeigler
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Brandon Sloan
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Jeffrey A Jones
- Division of Cardiothoracic Surgery, Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA.
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Abstract
Marfan syndrome (MFS) is an autosomal dominant, age-related but highly penetrant condition with substantial intrafamilial and interfamilial variability. MFS is caused by pathogenetic variants in FBN1, which encodes fibrillin-1, a major structural component of the extracellular matrix that provides support to connective tissues, particularly in arteries, the pericondrium and structures in the eye. Up to 25% of individuals with MFS have de novo variants. The most prominent manifestations of MFS are asymptomatic aortic root aneurysms, aortic dissections, dislocation of the ocular lens (ectopia lentis) and skeletal abnormalities that are characterized by overgrowth of the long bones. MFS is diagnosed based on the Ghent II nosology; genetic testing confirming the presence of a FBN1 pathogenetic variant is not always required for diagnosis but can help distinguish MFS from other heritable thoracic aortic disease syndromes that can present with skeletal features similar to those in MFS. Untreated aortic root aneurysms can progress to life-threatening acute aortic dissections. Management of MFS requires medical therapy to slow the rate of growth of aneurysms and decrease the risk of dissection. Routine surveillance with imaging techniques such as transthoracic echocardiography, CT or MRI is necessary to monitor aneurysm growth and determine when to perform prophylactic repair surgery to prevent an acute aortic dissection.
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Abstract
STUDY DESIGN A retrospective study of the prospective cohort. OBJECTIVE To demonstrate the accurate distribution of the severity of scoliosis in patients with Marfan syndrome, and to identify the predictive physical features for progression of scoliosis in Marfan syndrome. SUMMARY OF BACKGROUND DATA To date, no study has unveiled the risk factors for the progression of scoliosis in Marfan syndrome. METHODS We retrospectively obtained data from a prospective cohort of the Marfan syndrome clinic at our institute. We enrolled patients whose whole spine radiographs in the standing position were evaluated at the age of 15 or above, from January 2014 to March 2020. The collected variables were physical manifestations defined as in the systemic score of the revised Ghent nosology. We classified the degree of scoliosis into four categories: "not apparent," "mild" (10° ≤ Cobb < 25°), "moderate" (25° ≤ Cobb < 40°), and "severe" (40° ≤ Cobb or surgery conducted). To identify the risk factors for progression of scoliosis in Marfan syndrome, we conducted univariate and multivariate association analyses between severe scoliosis and each physical manifestation. RESULTS We identified 131 eligible patients (61 men and 70 women) with a mean age of 31.2 years. Scoliosis with a Cobb angle of ≥10° was identified in 116 patients (88.5%). Moderate scoliosis was identified in 33 patients (25.2%) and severe scoliosis in 53 patients (40.5%). The prevalence of each physical manifestation was equivalent to that reported in previous studies. Multivariate logistic regression analysis revealed that female sex (odds ratio, 3.27) and positive wrist sign (4.45) were predictive factors for progression of scoliosis into severe state in patients with Marfan syndrome. CONCLUSIONS The present study demonstrated the accurate distribution of the severity of scoliosis and identified the predictive factors for progression of scoliosis in patients with Marfan syndrome.Level of Evidence: 3.
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Scicluna K, Formosa MM, Farrugia R, Borg I. Hypermobile Ehlers-Danlos syndrome: A review and a critical appraisal of published genetic research to date. Clin Genet 2021; 101:20-31. [PMID: 34219226 DOI: 10.1111/cge.14026] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/08/2021] [Accepted: 07/02/2021] [Indexed: 12/15/2022]
Abstract
The Ehlers-Danlos syndromes (EDS) are a collection of rare hereditary connective tissue disorders with heterogeneous phenotypes, usually diagnosed following clinical examination and confirmatory genetic testing. Diagnosis of the commonest subtype, hypermobile Ehlers-Danlos Syndrome (hEDS), relies solely on a clinical diagnosis since its molecular aetiology remains unknown. We performed an up-to-date literature search and selected 11 out of 304 publications according to a set of established criteria. Studies reporting variants affecting collagen proteins were found to be hindered by cohort misclassification and subsequent lack of reproducibility of these genetic findings. The role of the described variants affecting Tenascin-X and LZTS1 is yet to be demonstrated in the majority of hEDS cases, while the functional implication of associated signaling pathways and genes requires further elucidation. The available literature on the genetics of hEDS is scant, dispersed and conflicting due to out-dated nosology terminology. Recent literature has suggested the role of several promising candidate mechanisms which may be linked to the underlying molecular aetiology. Knowledge of the molecular genetic basis of hEDS is expected to increase in the near future through the mainstream use of high-throughput sequencing combined with the updated classification of EDS, and the upcoming Hypermobile Ehlers-Danlos Genetic Evaluation (HEDGE) study.
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Affiliation(s)
- Kirsty Scicluna
- Department of Applied Biomedical Science, Faculty of Health Sciences, University of Malta, Msida, Malta
| | - Melissa M Formosa
- Department of Applied Biomedical Science, Faculty of Health Sciences, University of Malta, Msida, Malta.,Centre for Molecular Medicine and Biobanking, University of Malta, Msida, Malta
| | - Rosienne Farrugia
- Department of Applied Biomedical Science, Faculty of Health Sciences, University of Malta, Msida, Malta.,Centre for Molecular Medicine and Biobanking, University of Malta, Msida, Malta
| | - Isabella Borg
- Centre for Molecular Medicine and Biobanking, University of Malta, Msida, Malta.,Medical Genetics Unit, Department of Pathology, Mater Dei Hospital, Msida, Malta.,Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
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Rasmussen SA, Pomputius A, Amberger JS, Hamosh A. Viewing Victor McKusick's legacy through the lens of his bibliography. Am J Med Genet A 2021; 185:3212-3223. [PMID: 34159717 DOI: 10.1002/ajmg.a.62394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/13/2021] [Accepted: 05/22/2021] [Indexed: 11/09/2022]
Abstract
Victor McKusick's contributions to the field of medical genetics are legendary and include his contributions as a mentor, as creator of Mendelian Inheritance in Man (now Online Mendelian Inheritance in Man [OMIM®]), and as a leader in the field of medical genetics. McKusick's full bibliography includes 772 publications. Here we review the 453 papers authored by McKusick and indexed in PubMed, from his earliest paper published in the New England Journal of Medicine in 1949 to his last paper published in American Journal of Medical Genetics Part A in 2008. This review of his bibliography chronicles McKusick's evolution from an internist and cardiologist with an interest in genetics to an esteemed leader in the growing field of medical genetics. Review of his bibliography also provides a historical perspective of the development of the discipline of medical genetics. This field came into its own during his lifetime, transitioning from the study of interesting cases and families used to codify basic medical genetics principles to an accredited medical specialty that is expected to transform healthcare. Along the way, he helped to unite the fields of medical and human genetics to focus on mapping the human genome, culminating in completion of the Human Genome Project. This review confirms the critical role played by Victor McKusick as the founding father of medical genetics.
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Affiliation(s)
- Sonja A Rasmussen
- Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida, USA.,Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, Florida, USA.,Department of Epidemiology, University of Florida, College of Public Health and Health Professions and College of Medicine, Gainesville, Florida, USA
| | - Ariel Pomputius
- Health Science Center Libraries, University of Florida, Gainesville, Florida, USA
| | - Joanna S Amberger
- Department of Genetic Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ada Hamosh
- Department of Genetic Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Pain Management through Neurocognitive Therapeutic Exercises in Hypermobile Ehlers-Danlos Syndrome Patients with Chronic Low Back Pain. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6664864. [PMID: 34124258 PMCID: PMC8189767 DOI: 10.1155/2021/6664864] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 05/21/2021] [Indexed: 01/01/2023]
Abstract
Background The hypermobile type of Ehlers-Danlos syndrome (hEDS) is likely the most common hereditary disorder of connective tissue mainly characterized by joint hypermobility. Patients with hEDS suffer joint pain, in particular low back pain, commonly resistant to drug therapy. The aim of this research was to evaluate a neurocognitive rehabilitation approach based not only on the motion and function recovery but also on the pain management. Methods In this nonrandomized clinical trial, eighteen hEDS patients (4 males and 14 females) with mean age 21 years (range 13-55) were recruited and evaluated before and after three months of rehabilitation treatment. Results The outcome scores showed significant statistical results after treatment in reducing pain symptoms (numerical rating scale, P = 0.003; McGill (total score), P = 0.03), fatigue (fatigue severity scale, P = 0.03), fear of movement (Tampa scale, P = 0.003), and pain-associated disability (Oswestry disability index, P = 0.03). Conclusion The clinical results observed in our study seem to confirm the role of a specific neurocognitive rehabilitation program in the chronic pain management in the Ehlers-Danlos syndrome; the rehabilitation treatment should be tailored on patient problems and focused not only in the recovery of movement but also on pain perception.
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Hall JG. The contributions of careful clinical observations: A legacy. Am J Med Genet A 2021; 185:3202-3207. [PMID: 34015177 DOI: 10.1002/ajmg.a.62342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/28/2021] [Accepted: 05/03/2021] [Indexed: 11/06/2022]
Abstract
Clinical Medicine is an Art which is learned, together with hard work, as an apprentice-observing how a master works, and improving with experience and exposure. Clinicians are performing multiple things at the same time-trying to make a diagnosis, providing best therapies and preventative strategies, and looking for the underlying mechanism(s). Families want to know what to expect over time-the natural history of their disorder. Rare disease networks and parent support groups are helping in this effort. Information technologies and international collaborative efforts are changing the way clinical genetics is provided.
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Affiliation(s)
- Judith G Hall
- Department of Pediatrics and Medical Genetics, British Columbia Children's Hospital, Children's and Women's Health Centre of British Columbia, University of British Columbia, Vancouver, British Columbia, Canada
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Malek S, Köster DV. The Role of Cell Adhesion and Cytoskeleton Dynamics in the Pathogenesis of the Ehlers-Danlos Syndromes and Hypermobility Spectrum Disorders. Front Cell Dev Biol 2021; 9:649082. [PMID: 33968931 PMCID: PMC8097055 DOI: 10.3389/fcell.2021.649082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/22/2021] [Indexed: 12/26/2022] Open
Abstract
The Ehlers-Danlos syndromes (EDS) are a group of 13 disorders, clinically defined through features of joint hypermobility, skin hyperextensibility, and tissue fragility. Most subtypes are caused by mutations in genes affecting the structure or processing of the extracellular matrix (ECM) protein collagen. The Hypermobility Spectrum Disorders (HSDs) are clinically indistinguishable disorders, but are considered to lack a genetic basis. The pathogenesis of all these disorders, however, remains poorly understood. Genotype-phenotype correlations are limited, and findings of aberrant collagen fibrils are inconsistent and associate poorly with the subtype and severity of the disorder. The defective ECM, however, also has consequences for cellular processes. EDS/HSD fibroblasts exhibit a dysfunctional phenotype including impairments in cell adhesion and cytoskeleton organization, though the pathological significance of this has remained unclear. Recent advances in our understanding of fibroblast mechanobiology suggest these changes may actually reflect features of a pathomechanism we herein define. This review departs from the traditional view of EDS/HSD, where pathogenesis is mediated by the structurally defective ECM. Instead, we propose EDS/HSD may be a disorder of membrane-bound collagen, and consider how aberrations in cell adhesion and cytoskeleton dynamics could drive the abnormal properties of the connective tissue, and be responsible for the pathogenesis of EDS/HSD.
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Affiliation(s)
- Sabeeha Malek
- Division of Biomedical Sciences, Centre for Mechanochemical Cell Biology, Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Darius V Köster
- Division of Biomedical Sciences, Centre for Mechanochemical Cell Biology, Warwick Medical School, University of Warwick, Coventry, United Kingdom
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Clapp IM, Paul KM, Beck EC, Nho SJ. Hypermobile Disorders and Their Effects on the Hip Joint. Front Surg 2021; 8:596971. [PMID: 33842528 PMCID: PMC8027473 DOI: 10.3389/fsurg.2021.596971] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 01/25/2021] [Indexed: 11/15/2022] Open
Abstract
Hypermobility, or joint hyperlaxity, can result from inherited connective tissue disorders or from micro- or macrotrauma to a joint. The supraphysiologic motion of the hip joint results in capsuloligamentous damage, and these patients have a propensity to develop femoroacetabular impingement syndrome (FAIS) and labral injury. In this review, the recent literature evaluating the definitions, history, incidence, genetics, and histology of hypermobile disorders is investigated. We then review the clinical evaluation, natural history, and resulting instability for patients presenting with a hypermobile hip. Lastly, treatment options and outcomes will be highlighted.
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Affiliation(s)
- Ian M Clapp
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, United States
| | - Katlynn M Paul
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, United States
| | - Edward C Beck
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, NC, United States
| | - Shane J Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, United States
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Gensemer C, Burks R, Kautz S, Judge DP, Lavallee M, Norris RA. Hypermobile Ehlers-Danlos syndromes: Complex phenotypes, challenging diagnoses, and poorly understood causes. Dev Dyn 2021; 250:318-344. [PMID: 32629534 PMCID: PMC7785693 DOI: 10.1002/dvdy.220] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/24/2020] [Accepted: 06/28/2020] [Indexed: 12/14/2022] Open
Abstract
The Ehlers-Danlos syndromes (EDS) are a group of heritable, connective tissue disorders characterized by joint hypermobility, skin hyperextensibility, and tissue fragility. There is phenotypic and genetic variation among the 13 subtypes. The initial genetic findings on EDS were related to alterations in fibrillar collagen, but the elucidation of the molecular basis of many of the subtypes revealed several genes not involved in collagen biosynthesis or structure. However, the genetic basis of the hypermobile type of EDS (hEDS) is still unknown. hEDS is the most common type of EDS and involves generalized joint hypermobility, musculoskeletal manifestations, and mild skin involvement along with the presence of several comorbid conditions. Variability in the spectrum and severity of symptoms and progression of patient phenotype likely depend on age, gender, lifestyle, and expression domains of the EDS genes during development and postnatal life. In this review, we summarize the current molecular, genetic, epidemiologic, and pathogenetic findings related to EDS with a focus on the hypermobile type.
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Affiliation(s)
- Cortney Gensemer
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, South Carolina
| | - Randall Burks
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, South Carolina
| | - Steven Kautz
- Department of Health Sciences and Research, Medical University of South Carolina, Charleston, South Carolina
| | - Daniel P. Judge
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Mark Lavallee
- Department of Family Medicine, Wellspan Health, York, Pennsylvania
| | - Russell A. Norris
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, South Carolina
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Prepubertal Periodontitis in a Patient with Combined Classical and Periodontal Ehlers-Danlos Syndrome. Biomolecules 2021; 11:biom11020149. [PMID: 33498938 PMCID: PMC7912441 DOI: 10.3390/biom11020149] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 01/18/2023] Open
Abstract
We report an extremely rare case of combined classical and periodontal Ehlers−Danlos syndrome (EDS) with early severe periodontitis and a generalized lack of attached gingiva. A German family with classical EDS was investigated by physical and dental evaluation and exome and Sanger sequencing. Due to the specific periodontal phenotype in the affected child, an additional diagnosis of periodontal EDS was suspected. Physical and genetic examination of two affected and three unaffected family members revealed a family diagnosis of classical EDS with a heterozygous mutation in COL5A1 (c.1502del; p.Pro501Leufs*57). Additional to the major clinical criteria for classical EDS—generalized joint hypermobility, hyperelastic skin, and atrophic scarring —the child aged four years presented with generalized alveolar bone loss up to 80%, early loss of two lower incisors, severe gingival recession, and generalized lack of attached gingiva. Due to these clinical findings, an additional diagnosis of periodontal EDS was suspected. Further genetic analysis revealed the novel missense mutation c.658T>G (p.Cys220Gly) in C1R in a heterozygous state. Early severe periodontitis in association with generalized lack of attached gingiva is pathognomonic for periodontal EDS and led to the right clinical and genetic diagnosis in the present case.
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Ehlers-Danlos Syndrome: Immunologic contrasts and connective tissue comparisons. J Transl Autoimmun 2021; 4:100077. [PMID: 33437956 PMCID: PMC7786113 DOI: 10.1016/j.jtauto.2020.100077] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/12/2020] [Accepted: 12/17/2020] [Indexed: 11/21/2022] Open
Abstract
Ehlers-Danlos Syndrome (EDS) is a family of multisystemic hereditary connective tissue disorders now comprised of 13 recognized subtypes, classical, classical-like, cardiac-valvular, vascular, hypermobile, arthrochlasia, dermosparaxis, kyphoscoliotic, brittle cornea syndrome, spondylodysplastic, musculocontractural, myopathic, and periodontal, as designated by the most recent 2017 International classification system. Clinical presentation of this disease can range from mild manifestations including skin hyperextensibility and joint hypermobility, to more severe complications such as vascular and organ rupture. While there may be accompanying inflammation in some of the subtypes of EDS, the pathogenic mechanisms have not been clearly defined. Thorough evaluation incorporates clinical examination, family history, laboratory testing, and imaging. In recent years, studies have identified multiple gene variants involved in the pathogenesis of specific EDS subtypes as well as elaborate clinical diagnostic criteria and classification models used to differentiate overlapping conditions. The differential diagnosis of EDS includes hypermobility spectrum disorders, Marfan syndrome, Loey-Dietz syndrome, Cutis laxa syndromes, autosomal dominant polycystic kidney disease, osteogenesis Imperfecta Type 1, fibromyalgia, depression, and chronic fatigue syndrome. Surgical treatment is reserved for complications, or emergencies involving vascular or orthopedic injury because of the risk of poor wound healing. Management techniques each have their own consequences and benefits, which will also be discussed in this review article. Patients affected by this spectrum of disorders are impacted both phenotypically and psychosocially, diminishing their quality of life. There are 13 of EDS as defined by the International EDS Consortium, some with an identified genetic etiology. Skin hyperextensibility, joint hypermobility, easy bruising, and organ rupture are common features of EDS. Hypermobile EDS is a poorly defined entity that has been associated with MCAS and POTs. The association of hEDS, MCAS and POTS has not been confirmed. There is a paucity of evidence for an immunological mechanism for EDS.
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Prevalence of joint hypermobility syndromes in pediatric postural orthostatic tachycardia syndrome. Auton Neurosci 2021; 231:102770. [PMID: 33388686 DOI: 10.1016/j.autneu.2020.102770] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/12/2020] [Accepted: 12/23/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Patients with postural orthostatic tachycardia syndrome (POTS) have been shown to exhibit comorbid joint hypermobility manifested as Ehlers-Danlos syndrome (EDS) or hypermobility spectrum disorder (HSD). The prevalence of EDS and HSD in POTS has been demonstrated in smaller studies combining adult and pediatric patients. We examined a large series of pediatric patients to determine their prevalence in children with POTS. MATERIALS AND METHODS Patients 18 years old, or less, at initial evaluation at our clinic were included. POTS was diagnosed based on at least six months of frequent debilitating symptoms of orthostatic intolerance, plus a consistent heart rate increase of at least 40 beats per minute without orthostatic hypotension on standing test. Patients with a Beighton score of at least 5/9 plus other systemic findings suggestive of EDS were further evaluated in Connective Tissue Disorders clinics. RESULTS There were 362 patients meeting inclusion criteria, of which 82 patients had EDS (22.7%) and 141 patients had HSD (39.0%). Patients with EDS had an earlier median age at symptom onset (12.1 vs. 13.5 years, p=0.004) and longer median symptom duration (2.5 vs. 1.5 years, p=0.0008) compared to patients without hypermobility. CONCLUSIONS Our evaluation of a large series of pediatric patients with POTS revealed that over one-fifth of patients had EDS and over one-third of patients had HSD. The awareness of the prevalence of comorbidities such as hypermobility disorders may help inform providers diagnosing and caring for these patients.
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Jianping XMS, Faping CMS, Shuixiu DMS, Jiafu OMD. Echocardiography of Marfan's Syndrome Patient with New Gene Mutation of FBN1 with 13-year Follow-up. ADVANCED ULTRASOUND IN DIAGNOSIS AND THERAPY 2021. [DOI: 10.37015/audt.2021.200070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Oelerich O, Kleinheinz J, Reissmann DR, Köppe J, Hanisch M. Correlation between Oral Health-Related Quality of Life and Objectively Measured Oral Health in People with Ehlers-Danlos Syndromes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17218243. [PMID: 33171578 PMCID: PMC7664661 DOI: 10.3390/ijerph17218243] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 10/26/2020] [Accepted: 11/06/2020] [Indexed: 11/18/2022]
Abstract
It is a well-known fact that people with Ehlers–Danlos syndromes (EDS) report a worse oral health-related quality of life (OHRQoL) than the general population. The aim of this study was to examine whether there is a correlation between the subjective OHRQoL and the objectively measured oral health in people with EDS. To determine the subjective OHRQoL, the German version of the 14-item Oral Health Impact Profile (OHIP-14) questionnaire was used. Furthermore, all participants in the study were clinically examined, and the measured parameters were recorded using the Physical Oral Health Index (PhOX). Altogether, records of 46 participants were collected. The median (interquartile range (IQR)) of the OHIP-14 was 17 (23) points and the median of the PhOX was 73 (16) points. However, a statistically significant correlation could not be demonstrated (r = −0.240, p = 0.108). In the observed cohort, for participants who reported having pain often or very often, the OHIP score (median = 24, IQR = 18, p < 0.01) was higher than the score of the group given by participants who never or intermittently experienced pain (median = 8, IQR = 18). In conclusion, patients with EDS showed a reduced OHRQoL, although it was not possible to observe an association between the subjective OHRQoL and the objective oral health. However, participants who often or very often suffer from pain in their tooth, mouth, and jaw areas showed a reduced OHRQoL.
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Affiliation(s)
- Ole Oelerich
- Department of Cranio-Maxillofacial Surgery, Research Unit Rare Diseases with Orofacial Manifestations (RDOM), University Hospital Münster, D-48149 Münster, Germany; (O.O.); (J.K.)
| | - Johannes Kleinheinz
- Department of Cranio-Maxillofacial Surgery, Research Unit Rare Diseases with Orofacial Manifestations (RDOM), University Hospital Münster, D-48149 Münster, Germany; (O.O.); (J.K.)
| | - Daniel R. Reissmann
- Department of Prosthetic Dentistry, Center for Dental and Oral Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, D-20251 Hamburg, Germany;
| | - Jeanette Köppe
- Institute of Biostatistics and Clinical Research, University of Münster, D-48149 Münster, Germany;
| | - Marcel Hanisch
- Department of Cranio-Maxillofacial Surgery, Research Unit Rare Diseases with Orofacial Manifestations (RDOM), University Hospital Münster, D-48149 Münster, Germany; (O.O.); (J.K.)
- Correspondence:
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Abstract
PURPOSE OF REVIEW Vascular Ehlers-Danlos syndrome (vEDS) is the most severe form of EDS, affecting the synthesis of type III collagen. It is notable for decreased life expectancy and morbidity, including spontaneous vessel rupture. The present review summarizes recent findings that have improved the ability to manage and delineate the natural history of vEDS. RECENT FINDINGS Recent EDS consortium guidelines for the diagnosis of vEDS have emerged and outlined clinical features and molecular diagnostic tools to help facilitate rapid diagnosis. Although medical interventions to help halt the disease progression remain limited, improved awareness of vEDS by patients and practitioners have resulted in increased average life expectancy. Early excitement with celiprolol has been tempered by a lack of high-quality studies. Likewise, the creation of multidisciplinary care teams and tertiary referral centers is helping improve outcomes. Unfortunately, there remain limitations in terms of the surgical management (including more advanced endovascular techniques) of these patients and the morbidity associated with these interventions. SUMMARY Although new consensus guidelines have emerged to facilitate the diagnosis of those with vEDS, there remain limitations in terms of interventions and medical therapy that can be provided for these patients. Life expectancy does appear to be improving however with increased awareness and coordinated multidisciplinary efforts among medical geneticists, general practitioners, and interventionalists alike.
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Affiliation(s)
- Ehsan Benrashid
- Section of Vascular and Endovascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Hopping GC, Somani AN, Vaidyanathan U, Liu H, Barnes JR, Ronquillo YC, Hoopes PC, Moshirfar M. Myopic regression and recurrent Salzmann nodule degeneration after laser in situ keratomileusis in Ehlers Danlos Syndrome. Am J Ophthalmol Case Rep 2020; 19:100729. [PMID: 32426553 PMCID: PMC7225616 DOI: 10.1016/j.ajoc.2020.100729] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 12/18/2019] [Accepted: 04/27/2020] [Indexed: 11/18/2022] Open
Abstract
PURPOSE We describe the first case of Ehlers Danlos Syndrome (EDS) reported in the English language ophthalmic literature to have undergone Laser In Situ Keratomileusis (LASIK) surgery. OBSERVATIONS We review our patient's specific postoperative complications of myopic regression, Salzmann nodular degeneration, and dry eye syndrome, as well as the risks and consequences of performing LASIK on patients with this collagen disorder. CONCLUSIONS AND IMPORTANCE Refractive errors may prompt EDS patients to seek laser vision correction, placing them at increased risk for complications such as myopic regression, keratectasia, and dry eye syndrome. Aberrant wound healing and collagen dysfunction may have influenced our patient's myopic regression and Salzmann nodule degeneration post-LASIK. Currently, EDS is considered a relative contraindication in LASIK due to a presumed higher risk of postoperative keratectasia; however, we believe it is possible that not all forms of EDS need to be an absolute contraindication to LASIK. More research is warranted to determine preoperative risk stratification for laser vision surgery in each subtype of EDS.
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Affiliation(s)
- Grant C. Hopping
- McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin St, Houston, TX, 77030, USA
| | - Anisha N. Somani
- McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin St, Houston, TX, 77030, USA
| | - Uma Vaidyanathan
- McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin St, Houston, TX, 77030, USA
| | - Harry Liu
- McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin St, Houston, TX, 77030, USA
| | - James R. Barnes
- Virginia Commonwealth University School of Medicine, VCU Medical Center, 1201 E, Marshall St #4-100, Richmond, VA, 23298, USA
| | - Yasmyne C. Ronquillo
- Hoopes Durrie Rivera Research Center, Hoopes Vision; 11820 State St, Draper, UT, 84020, USA
| | - Phillip C. Hoopes
- Hoopes Durrie Rivera Research Center, Hoopes Vision; 11820 State St, Draper, UT, 84020, USA
| | - Majid Moshirfar
- Hoopes Durrie Rivera Research Center, Hoopes Vision; 11820 State St, Draper, UT, 84020, USA
- Utah Lions Eye Bank; 6056 Fashionsquare Drive Suite 200, Murray, UT, 84107, USA
- John A. Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah School of Medicine; 65 Mario Capecchi Drive Salt Lake City, UT, 84132, USA
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Suwal R, Khadka S, Joshi P. <p>Ocular Manifestations and Biometrics in Marfan’s Syndrome from Eastern Nepal</p>. Clin Ophthalmol 2020; 14:2463-2472. [PMID: 32904572 PMCID: PMC7457576 DOI: 10.2147/opth.s269364] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 08/10/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To evaluate the ocular characteristics of Marfan’s syndrome (MFS) fulfilling the revised Ghent-2 nosology in Eastern Nepal. Materials and Methods A hospital-based observational and cross-sectional study was conducted. Ocular manifestations and biometrics were incorporated. Patients were subdivided into adults (16 years or older) and children (5–15 years). Ocular biometric parameters consisted of values of refractive error, keratometry readings, anterior chamber depth (ACD), central corneal thickness (CCT), lens thickness (LT) and axial length (AL). Results A total of 34 eyes of 17 patients with MFS were included, where 32 eyes were phakic. Mean age of the study participants was 14.5 ± 9.1 years. The mean best corrected visual acuity (BCVA) of phakic eyes was 0.99 ± 0.82 LogMAR. Myopia greater than −3 diopters (D) was present in 28/34 (82.35%) eyes. The average spherical equivalent was −12.34 ± 8.85 D. Ectopia lentis (EL) was present in 24/32 (75%) eyes where superonasal was the most common subluxation in 10/24 (41.7%) eyes. AL was longer in adults 26.54 ± 4.42 mm compared to 25.21 ± 1.93 mm in children. Likewise, LT in adults was 4.9 ± 0.70 mm and 4.40 ± 0.59 mm in pediatric participants. Flat corneas were noted in both the groups with an average of 41.53 ± 2.21 D. The mean CCT and ACD were 524.62 ± 21.74 μm and 3.64 ± 0.80 mm, respectively. There was a negative association between the AL and the average corneal curvature (Kmed, correlation coefficient −0.11, p=0.54). Conclusion Myopia is the foremost ocular involvement with significant visual disability in MFS. Though, AL and corneal curvature are not included in the revised Ghent-2 nosology, we strongly recommend these parameters to be considered during ophthalmic evaluation in suspected and diagnosed cases of MFS in the absence of genetic testing.
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Affiliation(s)
- Rinkal Suwal
- Department of Optometry, BP Eye Foundation, Hospital for Children, Eye, ENT and Rehabilitation Service (CHEERS), Bhaktapur, Nepal
| | - Simanta Khadka
- Department of Vitreo-Retina, Bharatpur Eye Hospital, Bharatpur, Chitwan, Nepal
- Correspondence: Simanta Khadka Department of Vitreo-Retina, Bharatpur Eye Hospital, Bharatpur, Chitwan, NepalTel +977-9841572286Fax +977-056-523333 Email
| | - Purushottam Joshi
- Department of Vitreo-Retina, Mechi Eye Hospital, Birtamod, Jhapa, Nepal
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Malfait F, Castori M, Francomano CA, Giunta C, Kosho T, Byers PH. The Ehlers-Danlos syndromes. Nat Rev Dis Primers 2020; 6:64. [PMID: 32732924 DOI: 10.1038/s41572-020-0194-9] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/15/2020] [Indexed: 12/16/2022]
Abstract
The Ehlers-Danlos syndromes (EDS) are a heterogeneous group of hereditary disorders of connective tissue, with common features including joint hypermobility, soft and hyperextensible skin, abnormal wound healing and easy bruising. Fourteen different types of EDS are recognized, of which the molecular cause is known for 13 types. These types are caused by variants in 20 different genes, the majority of which encode the fibrillar collagen types I, III and V, modifying or processing enzymes for those proteins, and enzymes that can modify glycosaminoglycan chains of proteoglycans. For the hypermobile type of EDS, the molecular underpinnings remain unknown. As connective tissue is ubiquitously distributed throughout the body, manifestations of the different types of EDS are present, to varying degrees, in virtually every organ system. This can make these disorders particularly challenging to diagnose and manage. Management consists of a care team responsible for surveillance of major and organ-specific complications (for example, arterial aneurysm and dissection), integrated physical medicine and rehabilitation. No specific medical or genetic therapies are available for any type of EDS.
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Affiliation(s)
- Fransiska Malfait
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium.
| | - Marco Castori
- Division of Medical Genetics, Fondazione IRCCS-Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Clair A Francomano
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Cecilia Giunta
- Connective Tissue Unit, Division of Metabolism and Children's Research Centre, University Children's Hospital, Zurich, Switzerland
| | - Tomoki Kosho
- Department of Medical Genetics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Peter H Byers
- Department of Pathology and Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, WA, USA
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Stark VC, Hensen F, Kutsche K, Kortüm F, Olfe J, Wiegand P, von Kodolitsch Y, Kozlik-Feldmann R, Müller GC, Mir TS. Genotype-Phenotype Correlation in Children: The Impact of FBN1 Variants on Pediatric Marfan Care. Genes (Basel) 2020; 11:genes11070799. [PMID: 32679894 PMCID: PMC7397236 DOI: 10.3390/genes11070799] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/08/2020] [Accepted: 07/13/2020] [Indexed: 12/21/2022] Open
Abstract
Currently, no reliable genotype–phenotype correlation is available for pediatric Marfan patients in everyday clinical practice. We investigated correlations of FBN1 variants with the prevalence and age of onset of Marfan manifestations in childhood and differentiated three groups: missense/in-frame, splice, and nonsense/frameshift variants. In addition, we differentiated missense variants destroying or generating a cysteine (cys-missense) and alterations not affecting cysteine. We categorized 105 FBN1-positive pediatric patients. Patients with cys-missense more frequently developed aortic dilatation (p = 0.03) requiring medication (p = 0.003), tricuspid valve prolapse (p = 0.03), and earlier onset of myopia (p = 0.02) than those with other missense variants. Missense variants correlated with a higher prevalence of ectopia lentis (p = 0.002) and earlier onset of pulmonary artery dilatation (p = 0.03) than nonsense/frameshift, and dural ectasia was more common in the latter (p = 0.005). Pectus excavatum (p = 0.007) appeared more often in patients with splice compared with missense/in-frame variants, while hernia (p = 0.04) appeared earlier in the latter. Findings on genotype–phenotype correlations in Marfan-affected children can improve interdisciplinary therapy. In patients with cys-missense variants, early medical treatment of aortic dilatation seems reasonable and early regular ophthalmologic follow-up essential. Patients with nonsense/frameshift and splice variants require early involvement of orthopedic specialists to support the growing child.
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Affiliation(s)
- Veronika C. Stark
- Pediatric Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany; (F.H.); (J.O.); (P.W.); (R.K.-F.); (G.C.M.); (T.S.M.)
- Correspondence:
| | - Flemming Hensen
- Pediatric Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany; (F.H.); (J.O.); (P.W.); (R.K.-F.); (G.C.M.); (T.S.M.)
| | - Kerstin Kutsche
- Institute of Human Genetics, University Medical Center Hamburg-Eppendorf, Hamburg, Martinistrasse 52, 20246 Hamburg, Germany; (K.K.); (F.K.)
| | - Fanny Kortüm
- Institute of Human Genetics, University Medical Center Hamburg-Eppendorf, Hamburg, Martinistrasse 52, 20246 Hamburg, Germany; (K.K.); (F.K.)
| | - Jakob Olfe
- Pediatric Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany; (F.H.); (J.O.); (P.W.); (R.K.-F.); (G.C.M.); (T.S.M.)
| | - Peter Wiegand
- Pediatric Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany; (F.H.); (J.O.); (P.W.); (R.K.-F.); (G.C.M.); (T.S.M.)
| | - Yskert von Kodolitsch
- Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany;
| | - Rainer Kozlik-Feldmann
- Pediatric Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany; (F.H.); (J.O.); (P.W.); (R.K.-F.); (G.C.M.); (T.S.M.)
| | - Götz C. Müller
- Pediatric Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany; (F.H.); (J.O.); (P.W.); (R.K.-F.); (G.C.M.); (T.S.M.)
| | - Thomas S. Mir
- Pediatric Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, 20246 Hamburg, Germany; (F.H.); (J.O.); (P.W.); (R.K.-F.); (G.C.M.); (T.S.M.)
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Paige SL, Lechich KM, Tierney ESS, Collins RT. Cardiac involvement in classical or hypermobile Ehlers-Danlos syndrome is uncommon. Genet Med 2020; 22:1583-1588. [PMID: 32518415 DOI: 10.1038/s41436-020-0856-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/22/2020] [Accepted: 05/22/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Cardiac-valvular and vascular Ehlers-Danlos syndrome (EDS) have significant cardiovascular issues. The prevalence and significance of such abnormalities in classical (cEDS) or hypermobile EDS (hEDS) remain unclear. We report the prevalence of cardiac abnormalities in patients with cEDS and hEDS. METHODS We identified 532 pediatric patients with potential EDS evaluated at our institution from January 2014 through April 2019 by retrospective chart review. Ninety-five patients (12 cEDS and 83 hEDS patients) met 2017 EDS diagnostic criteria and had an echocardiogram. One patient was excluded due to complex congenital heart disease, and two were excluded due to lack of images. We reviewed echocardiograms for all structural abnormalities. RESULTS Of these 95 patients, 1 had mild aortic root dilation, and 1 had mild ascending aorta dilation in the setting of a bicuspid aortic valve. Eleven patients (11.6%) had a cardiac valve abnormality, all of which were trivial to mild. None of the patients required cardiac intervention. CONCLUSION Our results demonstrate that aortic dilation and valvular anomalies are uncommon in cEDS or hEDS patients. Given the lack of evidence, we do not recommend echocardiographic evaluation and surveillance in patients with cEDS and hEDS in the absence of clinical findings or positive family history.
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Affiliation(s)
- Sharon L Paige
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, CA, USA. .,Cardiovascular Institute, Stanford University, Stanford, CA, USA.
| | - Kirstie M Lechich
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Elif Seda Selamet Tierney
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, CA, USA.,Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - R Thomas Collins
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, CA, USA.,Cardiovascular Institute, Stanford University, Stanford, CA, USA.,Division of Cardiovascular Medicine, Department of Internal Medicine, Stanford University School of Medicine, Stanford, CA, USA
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