Midkine and chronic kidney disease-associated multisystem organ dysfunctions

Chronic kidney disease (CKD) is a progressive multisystem condition with yet undefined mechanistic drivers and multiple implicated soluble factors. If identified, these factors could be targeted for therapeutic intervention for a disease that currently lacks specific treatment. There is increasing preclinical evidence that the heparin/endothelial glycocalyx-binding molecule midkine (MK) has a pathological role in multiple CKD-related, organ-specific disease processes, including CKD progression, hypertension, vascular and cardiac disease, bone disease and CKD-related cancers. Concurrent with this are studies documenting increases in circulating and urine MK proportional to glomerular filtration rate (GFR) loss in CKD patients and evidence that administering soluble MK reverses the protective effects of MK deficiency in experimental kidney disease. This review summarizes the growing body of evidence supporting MK's potential role in driving CKD-related multisystem disease, including MK's relationship with the endothelial glycocalyx, the deranged MK levels and glycocalyx profile in CKD patients and a proposed model of MK organ interplay in CKD disease processes and highlights the importance of ongoing research into MK's potential as a therapeutic target.

The CD151-midkine pathway regulates the immune microenvironment in inflammatory breast cancer

The immune microenvironment in inflammatory breast cancer (IBC) is poorly characterised, and molecular and cellular pathways that control accumulation of various immune cells in IBC tissues remain largely unknown. Here, we discovered a novel pathway linking the expression of the tetraspanin protein CD151 in tumour cells with increased accumulation of macrophages in cancerous tissues. It is notable that elevated expression of CD151 and a higher number of tumour-infiltrating macrophages correlated with better patient responses to chemotherapy. Accordingly, CD151-expressing IBC xenografts were characterised by the increased infiltration of macrophages. In vitro migration experiments demonstrated that CD151 stimulates the chemoattractive potential of IBC cells for monocytes via mechanisms involving midkine (a heparin-binding growth factor), integrin α6β1, and production of extracellular vesicles (EVs). Profiling of chemokines secreted by IBC cells demonstrated that CD151 increases production of midkine. Purified midkine specifically stimulated migration of monocytes, but not other immune cells. Further experiments demonstrated that the chemoattractive potential of IBC-derived EVs is blocked by anti-midkine antibodies. These results demonstrate for the first time that changes in the expression of a tetraspanin protein by tumour cells can affect the formation of the immune microenvironment by modulating recruitment of effector cells to cancerous tissues. Therefore, a CD151-midkine pathway can be considered as a novel target for controlled changes of the immune landscape in IBC. © 2020 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Stratification of asthma phenotypes by airway proteomic signatures

BACKGROUND

Stratification by eosinophil and neutrophil counts increases our understanding of asthma and helps target therapy, but there is room for improvement in our accuracy in prediction of treatment responses and a need for better understanding of the underlying mechanisms.

OBJECTIVE

We sought to identify molecular subphenotypes of asthma defined by proteomic signatures for improved stratification.

METHODS

Unbiased label-free quantitative mass spectrometry and topological data analysis were used to analyze the proteomes of sputum supernatants from 246 participants (206 asthmatic patients) as a novel means of asthma stratification. Microarray analysis of sputum cells provided transcriptomics data additionally to inform on underlying mechanisms.

RESULTS

Analysis of the sputum proteome resulted in 10 clusters (ie, proteotypes) based on similarity in proteomic features, representing discrete molecular subphenotypes of asthma. Overlaying granulocyte counts onto the 10 clusters as metadata further defined 3 of these as highly eosinophilic, 3 as highly neutrophilic, and 2 as highly atopic with relatively low granulocytic inflammation. For each of these 3 phenotypes, logistic regression analysis identified candidate protein biomarkers, and matched transcriptomic data pointed to differentially activated underlying mechanisms.

CONCLUSION

This study provides further stratification of asthma currently classified based on quantification of granulocytic inflammation and provided additional insight into their underlying mechanisms, which could become targets for novel therapies.

Sputum proteomic signature of gastro-oesophageal reflux in patients with severe asthma

Gastro-oesophageal reflux disease (GORD) has long been associated with poor asthma control without an established cause-effect relationship. 610 asthmatics (421 severe/88 mild-moderate) and 101 healthy controls were assessed clinically and a subset of 154 severe asthmatics underwent proteomic analysis of induced sputum using untargeted mass spectrometry, LC-IMS-MS^E. Univariate and multiple logistic regression analyses (MLR) were conducted to identify proteins associated with GORD in this cohort. When compared to mild/moderate asthmatics and healthy individuals, respectively, GORD was three- and ten-fold more prevalent in severe asthmatics and was associated with increased asthma symptoms and oral corticosteroid use, poorer quality of life, depression/anxiety, obesity and symptoms of sino-nasal disease. Comparison of sputum proteomes in severe asthmatics with and without active GORD showed five differentially abundant proteins with described roles in anti-microbial defences, systemic inflammation and epithelial integrity. Three of these were associated with active GORD by multiple linear regression analysis: Ig lambda variable 1-47 (p = 0·017) and plasma protease C1 inhibitor (p = 0·043), both in lower concentrations, and lipocalin-1 (p = 0·034) in higher concentrations in active GORD. This study provides evidence which suggests that reflux can cause subtle perturbation of proteins detectable in the airways lining fluid and that severe asthmatics with GORD may represent a distinct phenotype of asthma.

Large-Scale Label-Free Quantitative Mapping of the Sputum Proteome

Analysis of induced sputum supernatant is a minimally invasive approach to study the epithelial lining fluid and, thereby, provide insight into normal lung biology and the pathobiology of lung diseases. We present here a novel proteomics approach to sputum analysis developed within the U-BIOPRED (unbiased biomarkers predictive of respiratory disease outcomes) international project. We present practical and analytical techniques to optimize the detection of robust biomarkers in proteomic studies. The normal sputum proteome was derived using data-independent HDMS^E applied to 40 healthy nonsmoking participants, which provides an essential baseline from which to compare modulation of protein expression in respiratory diseases. The "core" sputum proteome (proteins detected in ≥40% of participants) was composed of 284 proteins, and the extended proteome (proteins detected in ≥3 participants) contained 1666 proteins. Quality control procedures were developed to optimize the accuracy and consistency of measurement of sputum proteins and analyze the distribution of sputum proteins in the healthy population. The analysis showed that quantitation of proteins by HDMS^E is influenced by several factors, with some proteins being measured in all participants' samples and with low measurement variance between samples from the same patient. The measurement of some proteins is highly variable between repeat analyses, susceptible to sample processing effects, or difficult to accurately quantify by mass spectrometry. Other proteins show high interindividual variance. We also highlight that the sputum proteome of healthy individuals is related to sputum neutrophil levels, but not gender or allergic sensitization. We illustrate the importance of design and interpretation of disease biomarker studies considering such protein population and technical measurement variance.

Urine and serum midkine levels in an Australian chronic kidney disease clinic population: an observational study

BACKGROUND AND OBJECTIVES

The cytokine midkine (MK) is pathologically implicated in progressive chronic kidney disease (CKD) and its systemic consequences and has potential as both a biomarker and therapeutic target. To date, there are no published data on MK levels in patients with different stages of CKD. This study aims to quantify MK levels in patients with CKD and to identify any correlation with CKD stage, cause, progression, comorbid disease or prescribed medication.

METHODS

In this observational, single-centre study, demographic data were collected, and serum and urine assayed from 197 patients with CKD and 19 healthy volunteers in an outpatient setting.

RESULTS

The median serum and urine MK level in volunteers was 754 pg/mL (IQR: 554-1025) and 239 pg/mL (IQR: 154-568), respectively. Compared with serum MK in stage 1 CKD (660 pg/mL, IQR: 417-893), serum MK increased in stage 3 (1878 pg/mL, IQR: 1188-2756; p<0.001), 4 (2768 pg/mL, IQR: 2065-4735; p<0.001) and 5 (4816 pg/mL, IQ: 37477807; p<0.001). Urine MK levels increased from stage 1 CKD (343 pg/mL, IQR: 147-437) to stage 3 (1007 pg/mL, IQR: 465-2766; p=0.07), 4 (2961 pg/mL, IQR: 1368-5686; p=0.005) and 5 (6722 pg/mL, IQR: 3796-10 060; p=0.001). Fractional MK excretion (FeMK) increased from stage 1 CKD (0.159, IQR: 0.145-0.299) to stage 3 (1.024, IQR: 0.451-1.886, p=0.047), 4 (3.39, IQR: 2.10-5.82, p=0.004) and 5 (11.95, IQR: 5.36-24.41, p<0.001). When adjusted for estimated glomerular filtration rate, neither serum nor urine MK correlated with primary CKD diagnosis or CKD progression (small sample). There was a positive correlation between protein:creatinine ratio and FeMK (p=0.003). Angiotensin blockade (adjusted for proteinuria) was associated with lower urine MK (p=0.018) and FeMK (p=0.025).

CONCLUSION

MK levels sequentially rise with CKD stage beyond stage 2, and our data support existing animal evidence for an MK/renin angiotensin-system/proteinuria relationship. To what extent this is related to renal clearance versus pathology, or the consequences of chronically elevated MK levels requires further exploration.

Promotion of anagen, increased hair density and reduction of hair fall in a clinical setting following identification of FGF5-inhibiting compounds via a novel 2-stage process

Background

There are very few effective, scientifically validated treatments with known mechanisms of action for treatment of hair loss in both men and women. Fibroblast growth factor 5 (FGF5) is an important factor in the irreversible transition from anagen to catagen, and inhibition of FGF5 prolongs anagen phase and reduces hair loss.

Objective

We aimed to screen botanically derived molecules for FGF5 inhibitory activity in vitro and assess efficacy in a clinical setting.

Methods

We screened for FGF5 inhibitory efficacy via a novel 2-step in vitro pipeline consisting of an engineered FGF5 responsive cell line, followed by an activated dermal papillae (DP) cell method. Efficacy in a clinical setting was assessed in a randomized, single-blind, placebo-controlled trial against early- to mid-stage pattern hair loss in men and women.

Results

We observed FGF5 inhibitory activity for a number of compounds from the monoterpenoid family, many showing greater inhibitory efficacy than our previously reported crude plant extracts. Evaluation of a lead candidate in a clinical study over 112 days showed a significant improvement in anagen:telogen (AT) ratio (p = 0.002), reduced hair fall (p = 0.007) and improved visual grading (p = 0.004). Scientifically matched photography on a subgroup of randomly chosen participants highlighted significant improvement in hair density, with increases evident in all tested participants compared to baseline.

Conclusion

Isolates from the monoterpenoid family displayed efficacy in FGF5 inhibition in vitro. A topical formulation containing a leading isolate significantly improved AT ratio, reduced hair fall and increased apparent hair density in the tested population of men and women.

Application of 'omics technologies to biomarker discovery in inflammatory lung diseases

Inflammatory lung diseases are highly complex in respect of pathogenesis and relationships between inflammation, clinical disease and response to treatment. Sophisticated large-scale analytical methods to quantify gene expression (transcriptomics), proteins (proteomics), lipids (lipidomics) and metabolites (metabolomics) in the lungs, blood and urine are now available to identify biomarkers that define disease in terms of combined clinical, physiological and patho-biological abnormalities. The aspiration is that these approaches will improve diagnosis, i.e. define pathological phenotypes, and facilitate the monitoring of disease and therapy, and also, unravel underlying molecular pathways. Biomarker studies can either select predefined biomarker(s) measured by specific methods or apply an "unbiased" approach involving detection platforms that are indiscriminate in focus. This article reviews the technologies presently available to study biomarkers of lung disease within the 'omics field. The contributions of the individual 'omics analytical platforms to the field of respiratory diseases are summarised, with the goal of providing background on their respective abilities to contribute to systems medicine-based studies of lung disease.

Activation of thermogenesis in brown adipose tissue and dysregulated lipid metabolism associated with cancer cachexia in mice

Cancer cachexia/anorexia is a complex syndrome that involves profound metabolic imbalances and is directly implicated as a cause of death in at least 20% to 30% of all cancers. Brown adipose tissue (BAT) plays a key role in thermogenesis and energy balance and potentially contributes to the physiologic perturbations associated with cachexia. In this study, we investigated the impact of cachexia-inducing colorectal tumor on BAT in mice. We found that brown adipocytes were smaller and exhibited profound delipidation in cachectic tumor-bearing mice. Diurnal expression profiling of key regulators of lipid accumulation and fatty acid β-oxidation and their corresponding target genes revealed dramatic molecular changes indicative of active BAT. Increased Ucp1, Pbe, and Cpt1α expression at specific points coincided with higher BAT temperatures during the dark cycle, suggestive of a temporal stimulation of thermogenesis in cachexia. These changes persisted when cachectic mice were acclimatized to 28°C confirming inappropriate stimulation of BAT despite thermoneutrality. Evidence of inflammatory signaling also was observed in the BAT as an energetically wasteful and maladaptive response to anorexia during the development of cachexia.

Chaperonins from an Antarctic archaeon are predominantly monomeric: crystal structure of an open state monomer

Archaea are abundant in permanently cold environments. The Antarctic methanogen, Methanococcoides burtonii, has proven an excellent model for studying molecular mechanisms of cold adaptation. Methanococcoides burtonii contains three group II chaperonins that diverged prior to its closest orthologues from mesophilic Methanosarcina spp. The relative abundance of the three chaperonins shows little dependence on organism growth temperature, except at the highest temperatures, where the most thermally stable chaperonin increases in abundance. In vitro and in vivo, the M. burtonii chaperonins are predominantly monomeric, with only 23-33% oligomeric, thereby differing from other archaea where an oligomeric ring form is dominant. The crystal structure of an N-terminally truncated chaperonin reveals a monomeric protein with a fully open nucleotide binding site. When compared with closed state group II chaperonin structures, a large-scale ≈ 30° rotation between the equatorial and intermediate domains is observed resulting in an open nucleotide binding site. This is analogous to the transition observed between open and closed states of group I chaperonins but contrasts with recent archaeal group II chaperonin open state ring structures. The predominance of monomeric form and the ability to adopt a fully open nucleotide site appear to be unique features of the M. burtonii group II chaperonins.

A chemically modified alpha-amylase with a molten-globule state has entropically driven enhanced thermal stability

The thermostability properties of TAA were investigated by chemically modifying carboxyl groups on the surface of the enzyme with AMEs. The TAA(MOD) exhibited a 200% improvement in starch-hydrolyzing productivity at 60 degrees C. By studying the kinetic, thermodynamic and biophysical properties, we found that TAA(MOD) had formed a thermostable, MG state, in which the unfolding of the tertiary structure preceded that of the secondary structure by at least 20 degrees C. The X-ray crystal structure of TAA(MOD) revealed no new permanent interactions (electrostatic or other) resulting from the modification. By deriving thermodynamic activation parameters of TAA(MOD), we rationalised that thermostabilisation have been caused by a decrease in the entropy of the transition state, rather than being enthalpically driven. Far-UV CD shows that the origin of decreased entropy may have arisen from a higher helical content of TAA(MOD). This study provides new insight into the intriguing properties of an MG state resulting from the chemical modification of TAA.

Activity patterns of proteasome subunits reflect bortezomib sensitivity of hematologic malignancies and are variable in primary human leukemia cells

Proteasomal proteolysis relies on the activity of six catalytically active proteasomal subunits (beta1, beta2, beta5, beta1i, beta2i and beta5i). Applying a functional proteomics approach, we used a recently developed activity-based, cell-permeable proteasome-specific probe that for the first time allows differential visualization of individual active proteasomal subunits in intact primary cells. In primary leukemia samples, we observed remarkable variability in the amounts of active beta1/1i-, beta2/2i- and beta5/5i-type of subunits, contrasting with their constant protein expression. Bortezomib inhibited beta5- and beta1-type, but to a lesser extend beta2-type of subunits in live primary cells in vitro and in vivo. When we adapted the bortezomib-sensitive human acute myeloid leukemia cell line HL-60 to bortezomib 40 nM (HL-60a), proteasomal activity profiling revealed an upregulation of active subunits, and residual beta1/beta5-type of activity could be visualized in the presence of bortezomib 20 nM, in contrast to control cells. In a panel of cell lines from hematologic malignancies, the ratio between beta2-type and (beta1 + beta5)-type of active proteasomal polypeptides mirrored different degrees of bortezomib sensitivity. We thus conclude that the proteasomal activity profile varies in primary leukemia cells, and that the pattern of proteasomal subunit activity influences the sensitivity of hematologic malignancies toward bortezomib.

["True neurologic thoracic outlet syndrome" -- anatomical features and electrophysiological long-term follow-up of lateral thenar atrophy]

Atrophies of the intrinsic muscles of the hand are considered to be a typical symptom of the "true neurologic" form of thoracic outlet syndrome (TOS). The classical form of this entity was described as early as 1970, consisting of a cervical rib or a prolonged transverse process of C7, complete with a fibrous band to the first thoracic rib, resulting in atrophy of the intrinsic muscles of the hand. All our TOS patients presenting with such atrophy displayed anatomical findings consistent with this definition. Based on this observation, the TOS classification currently in clinical use, which differentiates between "disputed" and "true neurologic" subgroups of the neurologic form, is reviewed. In all cases of "true neurologic TOS" with atrophy of the intrinsic muscles of the hand, the lateral thenar muscles are affected first. We present the electrophysiological long-term results of such thenar atrophies of seven patients with eight operated extremities after brachial plexus decompression. The amplitude of the neurographically measured potential over the opponens pollicis and the abductor pollicis brevis muscle, respectively, was defined as quantitative parameter for muscles atrophy. Neither distinct reinnervation nor progressive denervation was evident in any of the cases after a follow-up period, on average, of more than five years post surgery. These findings are in conflict with clinical observations reporting a major postoperative improvement of the motor deficits.

Langzeitresultate nach operativer Therapie bei Thoracic-outlet-Syndrom (TOS)

This is a long-term follow-up analysis of patients who have been operated on for Thoracic Outlet Syndrome (TOS) at our clinic in order to evaluate the quality of therapy and the criteria of indications for surgery. 39 patients with a total of 45 surgical procedures were examined after a median follow-up of 8.8 years. The results in this study are based exclusively on the subjective outcome assessment by the patients themselves. Assessment of the long-term result in the "vascular TOS" group (13 cases = 29 %) was good in ten cases (77 %), fair in two cases (15 %) and poor in one case (8 %). In agreement with the literature, we were able to achieve the best results in this group. In the "true neurological TOS" group (28 cases = 62 %), assessment of the long-term result was good in 19 cases (68 %), fair in six cases (21 %) and poor in three cases (11 %). A clear tendency to a poor prognosis could be seen in women with a combination of cervical rib and fibrous band and a long delay between onset of symptoms and surgery. Assessment of long-term result in the "disputed TOS" group (four cases = 9 %) showed good results in three cases and a fair result in one case. In the absence of objective pathologies, only few and carefully selected patients were operated upon. The presented long-term results confirm the use of individual therapeutic concepts with special consideration of anatomy and clinical picture.

[Verification of thumb-specific muscles in a triphalangeal thumb with magnetic resonance imaging]

The presence of three phalanges in the first digit is considered to be a relatively rare congenital hand malformation. Six groups of this deformity can be distinguished: some digits are opposable, others resemble a non-opposable five-fingered hand. In cases of a hypoplastic thenar region with a restrained opposition, a clear verification of thumb-specific musculature has been hardly possible. We report of the possibility of a non-invasive identification of thumb-specific muscles by means of magnetic resonance imaging.

Compression neuropathy of the radial palmar thumb nerve

Compression neuropathy of a single digital nerve is a rare entity. We report the case of a patient with numbness in the distribution of the radial digital nerve of the thumb caused by the use of a walking stick. The nerve was compressed between the handle of the stick, the loop and the radial sesamoid bone of the first metacarpophalangeal joint. The site of the lesion was confirmed by electrophysiologic examination. Orthodromic recording of the sensory response from the radial palmar digital nerve of the thumb documented a complete absence of nerve action potential whereas the ulnar digital thumb nerve showed a normal response. Sensory function was restored when a padded ski glove was used to protect the area of the metacarpophalangeal joint whilst using the stick.

[Wartenberg's Sign of Ulnar Nerve Lesion. A Contribution to Pathophysiology and to the Differential Diagnosis]

The abduction stance of the small finger is frequently, but not necessarily due to ulnar nerve paresis. Five cases suffering from bothersome permanent abduction of the small finger and referred under the diagnosis of ulnar nerve paresis are presented. Clinical, electrodiagnostic and imaging evaluation revealed different causes. While partial paresis with the function of the abductor digiti minimi muscle preserved usually results in a disturbing abduction stance, complete paresis of the ulnar nerve causes a less severe abduction posture of the small finger. Operative measures are indicated when the stance of the small finger is disturbing and when sufficient time has passed to make sure that spontaneous recovery cannot be presumed. Clinical, electrodiagnostic and imaging evaluation of three neurogenic cases disclosed a lesion of the ramus profundus distal to the branches innervating hypothenar muscles in one case, ulnar nerve injury with neuromuscular hyperactivity of the abductor digiti minimi muscle following split repair in another case and syringomyelia in the third case. Two patients revealed an abduction posture of the little finger of non-neurogenic origin. One of them showed closed ligament injuries. The other patient revealed necrosis, scarring and contracture of hypothenar muscles and atrophy of the third palmar interosseous muscle following compression in a tight cast.

[Methods, indications and validation of intraoperative nerve conductivity testing]

During nerve surgery, electrodiagnostic methods are applied to assess the availability and viability of nerve fibers and to adjust operative measures accordingly. The validity of this procedure is verified by histology and by the outcome of the operation. This paper explains the techniques of intraoperative nerve action potential (NAP) and somatosensory evoked potential (SEP) recording, how to interpret the electrodiagnostic results, and describes both the special features and the limitations of the methods. We found reliable results of neurography, detecting the presence or absence of spontaneous nerve regeneration across a lesion in continuity months before the reinnervation reached its final target. Based on our results, we suggest that NAP recording of the exposed nerve can widely prevent unnecessary nerve or fascicle resection. Besides this important indication, the nerve function evaluation was successfully used in nerve surgery whenever the quality of the nerve parenchyma was crucial to the operative management. Further indications such as evaluating brachial plexus lesions and the condition of nerve roots, judging the proximal coaptation site in nerve reconstruction, tracing the site of a nerve lesion and identifying the pathophysiology of nerve malfunction are exemplified. Intraoperative nerve conductivity testing should not be considered as a replacement of but rather as a complement to preoperative clinical, electrophysiological and imaging evaluations and a thorough intraoperative morphological examination.

Tattooing agents for nerve marking in experimental surgery

Experimental nerve surgery involves test procedures, including those for nerve lesions in continuity, that leave no visible traces of impairment after surgery. In such cases, non-resorbable sutures are usually used to mark the lesion sites on the nerves. However, this method has two drawbacks: it is not completely atraumatic, and may be frustrating due to displacement of the suture material. The authors demonstrate the use of carbon tattoo pigment to mark nerve lesions permanently, thus allowing their identification reliably at any later date. Following successful preliminary experiments, the tattooing procedure was used in 12 New Zealand White rabbits that had been operated on for a specific nerve regeneration problem. Altogether, 56 tattoo marks were set. The small pigment spots were well-preserved and clearly visible during a second and third operation 4 and 15 weeks later. Histologic examination identified the carbon granules in the outer epineurium; there were no signs of inflammation. This simple, atraumatic, inert, and permanent method for nerve markings in the experimental animal is recommended.

Cervical outlet syndrome due to an accessory part of the trapezius muscle in the posterior triangle of the neck

A 48-year-old man presented with pain and sensory impairment radiating from the neck to the thumb and forefinger of the right hand when lifting weights and turning or tilting the head. The symptoms were due to an anomalous accessory part of the trapezius muscle crossing the upper part of the brachial plexus. Excision of the anomalous muscle and release of the clavicular part of the sternocleidomastoid muscle abolished the complaints.

[Effective treatment of a large muscle hernia by local botulinum toxin administration]

A 53-year-old patient developed an impairing muscle hernia when a fascia lata graft was harvested as a substitute for a cruciate ligament of the knee and closure of the defect was not possible. The fascial defect enlarged with time, extending along the whole upper leg. The large muscle protrusion and incarceration in the distal fascial slit was extremely painful during walking and getting up from a chair. Since autologous grafts were disregarded because of the high tissue pressure and alloplastic substitutes seemed problematic, the large hernia was successfully reduced by local muscle denervation with injections of botulinum-A toxin into the protruding vastus lateralis muscle. This procedure achieved relief of pain and enabled the patient to walk without complaints. Side effects were not observed.

[Skin symptoms in neurological diseases]

The considerable variety of diseases involving both the skin and the peripheral or central nervous system is due to the developmental relationship between skin and nervous system. Diseases of the nervous system resulting in skin changes comprise disorders of nails, hair, sweat and sebaceous glands as well as neuropathic ulcers in various manifestations. Neurocutaneous syndromes (phacomatoses) are nevoid systemic diseases comprising neurofibromatoses, tuberose sclerosis, ataxia telangiectasia, nevoid angiomatoses and other neurocutaneous disorders. Polytopic disorders of the skin and nervous system may be due to infectious diseases, diseases of the connective tissue, fat, inflammatory vascular and granulomatous disorders.

[Nerve compression syndromes of the extremities]

Peripheral entrapment neuropathies occur in high frequency and present clinically with a wide range of variations. They need to be recognized early enough in order to initiate correct therapy and so to obviate serious nerve lesions and possible neurological sequelae. This paper overviews the essentials of the compression neuropathies as they are encountered in both upper and lower extremities. Pathomechanisms , pathogenesis, evaluation considerations as well as differential diagnosis and basic treatment algorithms are emphasized.

[Mucopolysaccharidosis I-S (Scheie's disease) (author's transl)]

Mucopolysaccharidosis I-S in two encygotic twin sisters. The disease is characterised by opacification of the cornea, hepatospenomegaly, carpal tunnel syndrome, flexion contractures of the fingers and toes, valvar heart disease, normal intelligence and essentially normal behaviour. The biochemical defect consists of deficiency of the lysosomal hydrolase alpha-L-iduronidase. Urinary dermatan-sulphate excretion is raised. The muscles are also involved:the electron microscopic revelas interstitial storage of glycosaminoglycan-like substance. There is no specific treatment.