[NISCH syndrome, a rare cause of neonatal cholestasis: A case report]

NISCH syndrome is a rare autosomal recessive disease. It is characterized by scalp hypotrichosis, scarring alopecia, ichthyosis, and neonatal sclerosing cholangitis. It is caused by mutations in the CLDN1 gene encoding the claudin-1 protein, which is located at tight junctions. Fifteen cases have been reported to date and three different mutations have been identified. We report on the case of a 2-year-old boy from a consanguineous Moroccan family, presenting with NISCH syndrome and carrying the so-called Moroccan homozygous mutation (c.200-201delTT). The patient presented with the characteristic symptoms of the syndrome and a favorable progression with normalization of hepatic analyses under symptomatic treatment (vitamin supplementation and ursodeoxycholic acid). The currently limited availability of clinical and therapeutic data does not allow accurate prediction of the course of the disease and short- and long-term prognosis. Moreover, substantial interindividual variability has been reported. Description of new cases will provide new insights into the understanding and the overall management of this syndrome, the course of which remains elusive.

[Use of hyaluronidase to correct hyaluronic acid injections in aesthetic medicine]

Hyaluronic acid (HA) is the most commonly used filler in aesthetic medicine. However, overcorrections are frequent even with experienced practitioner. Hyaluronidase is an enzyme that hydrolyzes HA. Hyaluronidase has been recently proposed to correct unsatisfactory results of HA injections in aesthetic medicine (overcorrection, asymmetry, Tyndall effect) and to treat immediate complications such as arterial or venous thrombosis. The objective of this technical note was to summarize the literature data regarding the efficacy, safety and technique of use of hyaluronidase. Hyaluronidase may be responsible for allergies. The practitioner should take this risk and the possible drug interactions into account before using this antidote in order to weigh up the risk/benefit ratio.

Is there a justification for hysterectomy in patients with borderline ovarian tumors?

OBJECTIVE

To determine the frequency of uterine involvement in patients with borderline ovarian tumors (BOT) and to evaluate the recurrence risk and survival after hysterectomy.

MATERIALS AND METHODS

In two French hospitals: A tertiary referral centre (University hospital centre of Tours, France) and the Alliance community hospital of Tours (France), we reviewed data of consecutive women undergoing surgery for presumed stage I BOT between January 1997 and December 2012. Patients were divided into two groups: patients treated with fertility sparing surgery (group 1) and those treated with radical surgery (group 2).

RESULTS

A total of 135 patients were evaluated. 35 had fertility sparing surgery, 81 had radical surgery with hysterectomy and 19 had previous hysterectomy for other reasons. There were more recurrent borderline ovarian disease and more ovarian invasive disease developed in group 1 (p = 0.02, p = 0.04, respectively). Hysterectomy affected favorably borderline disease-free survival, OR = 0.09 95%CI (0.005-0.69), p = 0.04, but perceived benefits may be related to bilateral salpingo-oophorectomy and not hysterectomy directly.

Increased Susceptibility to Aphids of Flowering Wheat Plants Exposed to Low Temperatures

Frost is known to directly affect flowering wheat plants (Triticum aestivum L.) and lead to reduced grain yield. Additionally, it may increase wheat susceptibility to economically important pests, such as aphids (Hemiptera: Aphididae). Wheat plants at flowering stage were exposed to one of the three temperature treatments: ambient (11-12°C), 0°C, and -3°C for 60 min. Preference (3-choice) and performance (no-choice) bioassays with aphids (Rhopalosiphum padi L.) were conducted 1, 3, 6, and 12 d after temperature treatments to assess effects of temperature-induced stress over time. As an initial feasibility study of using remote sensing technologies to detect frost-induced stress in flowering wheat plants, hyperspectral imaging data were acquired from wheat plants used in preference bioassays. Element analysis of wheat plants was included to determine the effect of temperature-induced stress on the nutritional composition of flowering wheat plants. The results from this study support the following cause-effect scenario: a 60-min exposure to low temperatures caused a significant decrease in potassium and copper content of wheat plants 6 d after temperature exposure, and it coincided with a marked increase in preference by aphids of wheat plants. The preference exhibited by aphids correlated positively with performance of aphids, so the preference-performance hypothesis was confirmed and possibly driven by potassium and copper content of wheat plants. In addition, we demonstrated that hyperspectral imaging data can be used to detect frost-induced susceptibility to aphid infestation in flowering wheat plants. These findings justify further research into airborne remote sensing of frost-induced stress and the possible secondary effects on crop susceptibility to arthropod pests.

[Leg ulcer associated with type I cryoglobulinaemia due to incipient B-cell lymphoma]

BACKGROUND

Skin lesions are frequent in monoclonal cryoglobulinaemia and may be the first sign of B-cell lymphoma, especially multiple myeloma, Waldenström's macroglobulinaemia and B-cell chronic lymphocytic leukaemia.

PATIENTS AND METHODS

A 74-year-old woman with no prior medical history presented with necrotic leg ulcer. Skin biopsy showed dermal angiomatosis with numerous PAS+ thromboses, associated with monoclonal intravascular deposits of IgM kappa, indicating monoclonal cryoglobulin, which was confirmed by laboratory tests. Subsequent blood immunophenotyping revealed an inconspicuous circulating monoclonal CD5(+) B-cell population and small B-cell clusters in the bone marrow, while the B-cell count was normal and no lymphadenopathy or splenomegaly were present. Overall, these findings indicated a small B-cell lymphoma, classed as non-MALT marginal zone lymphoma on the WHO classification, at a very early stage of development. The patient was first treated by cyclophosphamide and oral steroids without success. Subsequent administration of six cycles of rituximab, cyclophosphamide, vincristine and prednisone (RCVP) led to remission of her leg ulcer, cryoglobulinaemia and lymphoma.

CONCLUSION

Skin biopsies of necrotic ulcers should undergo routine screening for intravascular deposits of type 1 cryoglobulin. Leg ulcers due to monoclonal cryoglobulinaemia may reveal incipient marginal zone B-cell lymphoma at the stage of circulating monoclonal lymphocytosis.

Molecular screening of MECP2 gene in a cohort of Lebanese patients suspected with Rett syndrome: report on a mild case with a novel indel mutation

BACKGROUND

Rett syndrome (RTT), an X-linked, dominant, neurodevelopment disorder represents 10% of female subjects with profound intellectual disability. Mutations in the MECP2 gene are responsible for up to 95% of the classical RTT cases, and nearly 500 different mutations distributed throughout the gene have been reported.

METHODS

We report here the molecular study of two isoforms, MECP2_e1 and MECP2_e2, in 45 Lebanese girls presenting developmental delay and at least one of the following features: microcephaly, neurodegeneration, abnormal behaviour, stereotypical hand movements, teeth grinding and difficulty in walking. Mutation screening was performed by denaturating high-performance liquid chromatography combined with direct sequencing.

RESULTS

Sixteen variants were noted, of which 14 have been previously reported: five suspected polymorphisms and nine mutations. Two variants were novel mutations in exon 4: c.1093_1095delGAG (p.E365del) and c.1164_1184delACCTCCACCTGAGCCCGAGAGinsCTGAGCCCCAGGACTTGAGCA (p.P388PfsX389). The deletion was found in an 8-year-old girl with typical clinical features of RTT. The indel was found in a 6-year-old girl with a very mild phenotype.

CONCLUSION

Genotype/phenotype correlation is discussed and the importance of a molecular study of MECP2 gene in patients with very mild features or a regression after the age of 2 is raised.

Reliability of a simple fluoroscopic method to study sagittal plane femorotibial contact changes in total knee arthroplasties during flexion

Clinical interest in sagittal plane kinematic analysis of the knee undergoing total knee replacement fosters the development of simple, reliable methods to estimate femorotibial contact in a regular clinical setting. In this study, the sagittal femorotibial contact was analysed in lateral X-rays and lateral fluoroscopic views, from extension to knee flexion. Quantitative and categorical data were obtained from these views by two different observers, and compared with data from direct views of the components. Interobserver and intermethod errors for quantitative and categorical data were evaluated based on correlation, kappa coefficient, and Bland-Altman graphs. Interobserver reproducibility of quantitative measurement from fluoroscopic views was r=0.96 while categorical assignment exhibited a kappa coefficient of 0.95. Reproducibility from plain radiographs was not so high, with a kappa coefficient of 0.64. High concordance was also obtained when the method was compared with the direct view of the implant, supporting these measurement techniques. Bland-Altman graphs confirmed the absence of bias in the intermethod comparison. Therefore, with the obvious limitation of rotational assessment, lateral fluoroscopic evaluation enhanced by a simple fitting technique can be used as a valuable tool for clinical evaluation of knee kinematics in the sagittal plane.

Mutations in PHD-like domain of the ATRX gene correlate with severe psychomotor impairment and severe urogenital abnormalities in patients with ATRX syndrome

Mutations in ATRX are associated with a wide and clinically heterogeneous spectrum of X-linked mental retardation syndromes. The ATRX protein, involved in chromatin remodelling, belongs to the family of SWI/SNF DNA helicases and contains a plant homeodomain (PHD)-like domain. To date, more than 60 different mutations have been reported in ATRX. One of them is recurrent and accounts for 20% of all the reported mutations, whereas all others are private. Most mutations are clustered in the two major functional domains, the helicase and the PHD-like domain. So far, no clear genotype-phenotype correlation has been established, with exception to the rare truncating mutations located at the C-terminal part of the protein, which are consistently associated with severe urogenital defects. In this study, we report the molecular analysis performed in 16 families positive for ATRX. Our findings indicate that, in addition to the previously described mutation 'hotspot' in the PHD-like domain, two other protein sections emerge as minor 'hotspots' in the helicase region encoded by exons 18-20 and 26-29, respectively, gathering 33% of all described mutations. Additionally, based on the clinical data collected for 22 patients from the 16 families, we observe that mutations in the PHD-like domain produce severe and permanent psychomotor deficiency, usually preventing patients from walking, as well as constant urogenital abnormalities, while mutations in the helicase domain lead to delayed but correct psychomotor acquisitions together with mild or absent urogenital abnormalities. In summary, mutations in the helicase domain are associated with milder phenotypes than mutations in the PHD-like domain.

[Segmental rehabilitation in cardiac failure: short and long-term results]

Many patients with chronic cardiac failure may benefit from exercise rehabilitation. However, the usual protocols, which may lead to haemodynamic disturbances or induce arrhythmias, are rarely applicable in the most severe cases. Therefore, the authors developed a protocol of segmental rehabilitation where the same muscle groups as in global readaptation are involved, but successively and not simultaneously. This study included 25 patients in the NYHA class III. Many parameters were analysed before and after forty sessions. Although the resting isotopic ejection fraction (0.26 +/- 0.1 vs 0.27 +/- 0.11; p = NS), oxygen consumption at the ventilatory threshold (14.3 +/- 3.5 vs 18.3 +/- 5.2 ml/kg/min; p = NS) or at peak effort (17.4 +/- 4.7 versus 18.3 +/- 5.2 ml/kg/min, p = NS) were unchanged, three other parameters were significantly improved: the duration of exercise (9.2 +/- 2.4 vs 10.4 +/- 3.4 min; p < 0.02) maximum work load (3 046 +/- 1 510 vs 3 992 +/- 2 482; p < 0.01) and muscular force (151 +/- 35 versus 220 +/- 41 kg; p < 0.0001). In addition, after a follow-up period of 43 +/- 18 months, a close inverse relationship was observed between the gains obtained in terms of duration of exercise and maximum work load and the number of hospital readmissions. Similarly, the 10 patients having undergone rehabilitation with this protocol had 11.7 times fewer hospital readmissions than the other 15. Segmental rehabilitation would therefore seem to be a safe technique for patients with severe cardiac for significantly increasing exercise capacity and lowering the number of readmissions to hospital.

Vitreous fluorescein accumulation determined by in vivo fluorophotometry and by vitreous extraction in normal and diabetic rats

Vitreous fluorophotometry was performed on pigmented male rats (Piebald strain) 2 weeks after induction of diabetes by streptozotocin. In vivo fluorophotometry data were compared with measurements obtained by direct extraction of the vitreous 60 min after an intravenous injection of sodium fluorescein. In addition, the rate of fluorescein disappearance from blood plasma, plasma protein binding of fluorescein and the effect of insulin treatment of diabetic animals were investigated. Age-matched nondiabetic animals served as controls. In vivo fluorophotometric measurements showed a good correlation with fluorescein determinations after direct extraction of the vitreous. Vitreous fluorescein concentrations were similar in diabetic and normal rats and were strongly related to the dye plasma levels within each group of animals. In the diabetic rats, however, the elimination of plasma fluorescein was accelerated and the percentage of free fluorescein, as determined by ultrafiltration and equilibrium dialysis, was consistently higher (130-150% of controls). The ratios of vitreous to total or free plasma fluorescein levels were elevated in diabetic rats. Experimental data indicate that plasma concentration of free fluorescein is crucial for vitreous dye accumulation. Insulin treatment of diabetic rats markedly improved their metabolic state and normalized the plasma fluorescein elimination and the vitreous to plasma fluorescein concentration ratios. It is concluded that vitreous fluorophotometry can be adequately applied to pigmented rats, provided that plasma fluorescein elimination rate and protein binding are considered in the interpretation of the results, since both influence the vitreous fluorescein accumulation and both may be altered by disease and drug treatment.