Cross-sectional characteristics of pediatric-onset discoid lupus erythematosus: Results of a multicenter, retrospective cohort study.

BACKGROUND: The incidence of systemic lupus in children with discoid lupus is unknown. OBJECTIVE: This study assessed the baseline characteristics of patients with pediatric discoid lupus erythematosus (pDLE). METHODS: Medical records at 17 sites were reviewed for pediatric dermatology and rheumatology patients with discoid lupus erythematosus. The inclusion criteria were clinical and/or histopathologic diagnosis of discoid lupus erythematosus with an age at onset of <18 years. Baseline data were collected at the first documented visit. Outcomes included diagnosis of systemic lupus erythematosus (SLE) at the baseline visit using the 1997 American College of Rheumatology (primary) and the 2012 Systemic Lupus International Collaborating Clinics (secondary) criteria. RESULTS: Of the >1500 charts reviewed, 438 patients met the inclusion criteria. The cohort was predominantly female (72%) and racially/ethnically diverse. A diagnosis of SLE at the baseline visit (pDLE + SLE) was rendered in 162 (37%) patients using the American College of Rheumatology and in 181 (41%) patients using the Systemic Lupus International Collaborating Clinics criteria. Patients with pDLE + SLE were older at the time of rash onset (median, 12.9 vs 8.9 years; P < .001), with shorter time from discoid lupus erythematosus onset to diagnosis, compared with patients with pDLE-only (median, 2 vs 7 months; P < .001). Patients with pDLE + SLE were more likely to be female (P = .004), with generalized discoid lupus erythematosus and clinically aggressive disease, including end-organ involvement, positive serologies, and higher- titer levels of antinuclear antibodies (P < .001). LIMITATIONS: Retrospective study. CONCLUSION: A diagnosis of discoid lupus erythematosus in adolescence should prompt thorough screening for SLE.

Skin-Related complications of Klippel-Trenaunay Syndrome: a retrospective review of 410 patients.

BACKGROUND: Little is known about skin-related complications in Klippel-Trenaunay syndrome (KTS), a complex vascular anomaly defined by capillary malformation (CM), venous malformation (VM) ± lymphatic malformation (LM) and limb overgrowth. Reported skin-related complications of KTS include ulceration, vascular ectasias (blebs), bleeding and infection. OBJECTIVE: To determine the spectrum, prevalence and predictors of skin-related complications in KTS. METHODS: A retrospective review of 410 patients fulfilling KTS criteria was performed to assess for the presence of skin-related complications. RESULTS: Skin-related complications were present in 45% of patients. Most prevalent were CM-related complications including blebs, bleeding, thickening (25%), cellulitis (22%) and ulceration (21%). Features positively associated with skin-related complications were presence of LM (OR 17.17; P < 0.001), VM on the buttocks/perineum/genitalia (OR 1.92; P = 0.009), CM on the feet (OR 1.77; P = 0.039) and male sex (OR 1.63; P = 0.034). Features negatively associated with skin-related complications were CM on the trunk (OR 0.59; P = 0.029) and tissue hypertrophy of the hands (OR 0.27; P = 0.025). CONCLUSION: Skin-related complications affect nearly half of patients with KTS. Those with lymphatic involvement or malformation presence in the undergarment area or feet are most at risk.

Orthopaedic diagnoses in patients with Klippel-Trenaunay syndrome.

PURPOSE: Klippel-Trenaunay syndrome (KTS) is a rare combined vascular malformation composed of capillary malformation, lymphatic and/or venous malformation and limb overgrowth, which commonly affects the extremities. Due to limb involvement, it is not uncommon for these patients to require referral to an orthopaedic surgeon. Herein we reviewed the prevalence of orthopaedic diagnoses in a large cohort of KTS patients and described the associated surgical interventions. METHODS: Between 1976 and 2012, 410 patients fulfilling strict criteria for KTS were evaluated at a single institution. Patient charts were reviewed for demographic information, details of the clinical evaluation, orthopaedic consultation and surgical interventions. RESULTS: A total of 264 of 410 patients (64%) with confirmed KTS required orthopaedic evaluation. Of these 264 patients, 84% had documented limb-length discrepancy. Other common diagnoses included: angular deformities (10%), scoliosis (9%), osteopenia/osteoporosis (7%), pathological fractures (6%), joint contracture (5%), degenerative joint disease (4%) and limb/joint pain (4%). Of the 264 patients evaluated by orthopaedic surgery, 133 patients (50.4%) underwent 169 surgeries. Surgery was most commonly performed for limb-length discrepancy (62%). Multivariable analysis confirmed an orthopaedic condition was more likely in patients with lymphatic malformation (odds ratio (OR) 3.78; p < 0.001), as well as in those with bone and/or soft-tissue hypertrophy of the lower extremity (OR 7.51; p < 0.001) or foot (OR 3.23; p < 0.001). CONCLUSION: Orthopaedic conditions are common in patients with KTS and approximately 50% require surgical intervention. Those with a lymphatic malformation and/or soft-tissue hypertrophy of the lower extremity are more likely to need surgery. LEVEL OF EVIDENCE: Level IV, Descriptive Case Series.

Characterization of C3dg binding to a recess formed between short consensus repeats 1 and 2 of complement receptor type 2 (CR2; CD21).

To allow for a better characterization of the ligand binding structures of human complement receptor type 2 (CR2; CD21), we have established an IgG1 kappa mouse mAb, FE8, that interferes efficiently with binding of C3dg and EBV to CR2. In contrast to mAb OKB7, the only well-characterized mAb with similar specificity, mAb FE8 blocked binding of soluble C3dg or particles carrying multiple copies of surface-bound C3dg to CR2 or induced complete removal of these ligands from the receptor. In vitro EBV infection of B lymphocytes, on the other hand, was abrogated by mAbs FE8 and OKB7 with similar dose-response characteristics. As FE8 was shown to recognize a discontinuous epitope, a series of overlapping peptides derived from SCR1 and -2 and immobilized on cellulose was screened with FE8. The results suggest that up to five discontinuous sequences contributed to the epitope. The sequence 63-EYFNKYS-69, located between the two SCR units, reacted most intensively. Two other sequences, 16-YYSTPI-21 and 105-NGNKSVWCQANN-116, are located between Cys1 and Cys2 of SCR1 and around Cys3 of SCR2, respectively. Based on the solution structure for two factor H SCRs, a three-dimensional model of SCR1 and -2 was generated. The FE8 binding peptide sequences were located in relative proximity to each other, bounding the recess formed between SCR1 and -2. This potential of mAb FE8 is currently unique and may be exploited for interfering with conditions of unwanted recognition of C3dg-coated structures by the immune system.

A novel mechanism of alternative pathway complement activation accounts for the deposition of C3 fragments on CR2-expressing homologous cells.

Complement receptor type 2 (CD21, CR2), the receptor for the C3 fragment C3dg, activates complement via the alternative pathway and also serves as a preferential acceptor site for C3 fragments. The molecular basis for this phenomenon, which has recently been demonstrated for B lymphocytes in vivo, is currently not understood. Here we present a model for this CR2-dependent complement activation. The inactive C3 (iC3), which forms spontaneously in serum in low amounts by reaction of native C3 with H2O, binds noncovalently to the N-terminal part of CR2. Subsequent association of properdin and factor B, and cleavage of factor B by factor D lead to formation of a C3 convertase associated with CR2, thus focussing covalent C3 deposition to CR2 itself. This model is supported by the following experimental findings. 1) By FACS analysis and radioreceptor assays we showed that iC3, properdin, and factor B bound to CR2 on Raji B cells, MT2 T cells, and peripheral blood B cells. 2) Both binding of these proteins and complement activation by CR2-expressing cells were reduced in parallel by Abs against CR2. 3) 125I-labeled C3b was covalently deposited on CR2, when hemolytically active 125I-labeled C3 was added to Raji cells preincubated with iC3, factor B, properdin, and factor D, thus proving functionality of CR2-bound C3 convertase. This model of C3 convertase activity formed on CR2 domains inaccessible for decay-accelerating factor offers an explanation for the deposition of C3 found on CR2-expressing cells.

Expression in insect cells of the functional domain of CD21 (complement receptor type two) as a truncated soluble molecule using a baculovirus vector.

We have made use of the plasmid vector pBSV-8His recently established for baculovirus-mediated expression of His-tagged proteins for the production of a truncated soluble complement regulator protein. The protein comprised the N-terminal part, i.e. short consensus repeats (SCRs) 1-4, of the B-cell membrane protein complement receptor type two (CR2; CD21) and contained the functional epitopes which mediate the binding of the complement component C3 fragments C3dg and iC3b. This recombinant protein, termed rsCR2.1-4, was furnished with a C-terminal histidine-tag for easy purification from insect cell supernatant. The yield of > 90% pure rsCR2.1-4 was 3 micrograms/ml supernatant at day eight p.i. RsCR2.1-4 was expressed as two proteins with a M(r) of 29 and 31 representing differentially glycosylated forms. Both reacted specifically with anti-CR2 mAb HB5 directed against SCRs 3-4, but not with anti-CR2 mAbs recognizing SCRs beyond SCR 4. RsCR2.1-4 was able to bind C3dg and to block binding of C3dg-coated beads to Raji cells. Used as antigen for immunization, it allowed the efficient and well-aimed generation of antisera which specifically blocked attachment of C3dg-coated beads to Raji B cells. Thus, insect cell derived rsCR2.1-4 has proved a valuable tool to study the functional domain of CR2 and its immunoregulatory capacity in B-lymphocytes.

[Hepatic neoductules]. / Hepatische Neoductuli.

Proliferation of preexisting bile ducts, ductular metaplasia of hepatocytes and proliferation and differentiation of liver stem cells are discussed in the pathogenesis of neoductular structures in the liver. Under the condition of experimental bile duct obstruction and in extrahepatic bile duct stenosis neoductular structures are first the result of proliferation and sprouting of preexisting ducts and cholangioles. Especially in later stages of cholestasis but also in other chronic progredient liver diseases such as chronic alcoholic liver disease and chronic active hepatitis periportal hepatocytes may show a phenotypic shift towards ductular epithelia. In postnatal liver diseases hepatocytes first express keratin 7 and later keratin 19 during ductular transdifferentiation. This is in contrast to embryonal cholangiogenesis. In alpha-1-antitrypsin-deficiency, hemochromatosis, Wilson's disease, and chronic active hepatitis B cellular deposites typically located in hepatocytes such as alpha-1-AT, siderin, copper, HBs-Ag, and HBc-Ag can also be found in neoductular cells close to hepatocytes. These deposites seem to be retained during the ductular transdifferentiation of hepatocytes. Expression of bile duct-type integrin subtypes and TGF beta 1 in neoductular cells are involved in the changing parenchymal/mesenchymal interplay during neoductogenesis, resulting in periductular basal membrane and periductular fibrosis. In FNH the ductular transdifferentiation of hepatocytes is integrated in the histogenesis of micronodules and portal tract equivalents of these tumor-like lesions. Ductular structures in hepatoblastomas and especially in combined hepatocellular and cholangiocarcinomas (CHCC) may reflect the common embryologic derivation of hepatocytes and biliary epithelia. Non-neoplastic liver tissue in resection specimens of our CHCC showed a lower rate of cirrhosis, and a significantly higher Ki 67-LI of neoductular cells compared to liver tissue in resection specimens of HCC and liver metastases. 3 of 10 CHCC had developed in alpha-1-AT-deficiency, in which this protease-inhibitor was predominantly retained in periportal hepatocytes. These findings in non-neoplastic tumor-bearing liver tissue suggest that CHCC include a special histogenic type of primary liver carcinoma which in analogy to some experimental liver tumors might develop from periportal parenchymal cells.

Ca(2+)-dependent inactivation of P-type calcium channels in nerve terminals.

Rapid Ca2+ signals evoked by K+ depolarization of rat cerebral cortical synaptosomes were measured by dual-channel Ca2+ spectrofluorometry coupled to a stopped-flow device. Kinetic analysis of the signal rise phase at various extracellular Ca2+ concentrations revealed that the responsible voltage-dependent Ca2+ channels, previously identified as P-type Ca2+ channels, inactivate owing to the rise in intracellular Ca2+ levels. At millimolar extracellular Ca2+ concentrations the channels were inactivated very rapidly and the rate was dependent on the high influx rate of Ca2+, thus limiting the Ca2+ signal amplitudes to 500-600 nM. A slower, probably voltage-dependent regulation appears to be effective at lower Ca2+ influx rates, leading to submaximal Ca2+ signal amplitudes. The functional feedback regulation of calcium channels via a sensor for intracellular Ca2+ levels appears to be responsible for the different inhibition characteristics of Cd2+ versus omega-agatoxin IVa.

GABAB-receptor-mediated inhibition of calcium signals in isolated nerve terminals.

Time-resolved fluorometric monitoring of rapid changes in intracellular Ca(2+)-concentrations [Ca2+]i was employed to analyze the effect of gamma-aminobutyric acid (GABA) on evoked Ca(2+)-signals in rat hippocampal synaptosomes. The inhibitory action of GABA was mimicked by Baclofen, the selective agonist for GABAB-receptors, and also by the nonhydrolyzable GTP-derivative GTP-gamma-S. Preincubation of synaptosomes with GABA or baclofen for up to 250 ms before depolarization resulted in a maximal inhibition. The GABA-induced attenuation of the evoked rise in [Ca2+]i was maximal during the first milliseconds after depolarization. The inhibitory action of GABA apparently does not involve second messengers, such as cAMP or IP3/DAG; the GABA-induced inhibition of presynaptic voltage-dependent Ca(2+)-channels may be mediated directly by G-proteins.

Analysis of rapid calcium signals in synaptosomes.

A combination of the stopped-flow technology with dual channel spectrofluorometry of Ca(2+)-indicators was utilized for the measurement of rapid Ca(2+)-signals in rat cerebral cortical synaptosomes evoked by K(+)-depolarization. There was no observable contribution of Ca(2+)-ions from intracellular stores to the rise in [Ca2+]i. The kinetics of the fast increase in intracellular Ca2+ concentration was analysed in relation to the depolarization strength. The maximal increase in [Ca2+]i and the time course of Ca(2+)-channel inactivation were determined for depolarizations obtained by different extracellular K(+)-concentrations ([K+]o). An apparent threshold was observed at about 18 mM [K+]o; a maximal Ca(2+)-signal amplitude was estimated at about 40 mM [K+]o. Pharmacological properties of the involved Ca(2+)-channels were determined using selective Ca(2+)-channel blockers (Dihydropyridines, omega-Conotoxin, omega-Agatoxins); the results suggest that a P-type voltage-dependent Ca(2+)-channel is the relevant channel type, generating the evoked Ca(2+)-signals in rat cerebral cortical synaptosomes.

[Postoperative analgesia for circumcision in children]. / Analgésie post-opératoire pour la circoncision chez l'enfant.

Circumcision in children is followed by severe pain. This study analysed retrospectively anesthetic techniques of 110 children from 17 months to 14 years old who had undergone ambulatory of 24 h stay circumcision. There were two groups of patients: one being operated on under locoregional techniques combined with general anesthesia (53.6%), the other one under general anesthesia alone (46.4%). Post operative analgesia was provided by the regional anesthesia (with or without additional analgesics via rectal route) for the former group whereas analgesic drugs were administered only rectally for the latter one. In this second group, pain relief assessment was insufficiently recorded and was considered poor. In the first group, dorsal nerves block of the penis (DNBP) was performed on 47 children (79.8% of the locoregional techniques), caudal block on 10 patients and ring block on 2 patients. Regional techniques offered a satisfactory, safe and reliably effective post circumcision analgesia. DNBP should be used systematically in order to shorten duration of day circumcision stay.

[Intramuscular methohexital. A simple and reliable means of sedation for cerebral computed tomography in children]. / Methohexital intra musculaire. Un protocole d'anesthésie simple et fiable pour scanner cérébral chez l'enfant.

Intramuscular methohexital sedation was retained as an easy and reliable method to sedate children for a C.T. scan. In this retrospective study of 50 cases of children aged from 2 months to 7 years all the children were administrated an oral premedication (diazepam: 1 drop/kg and atropine: 0.02 mg.kg-1) one hour before the scanner examination. Once in the operating room, they were administrated 10 mg.kg-1 methohexital saline 2.5% solution, intramuscularly deep in the buttock. E.C.G. was the main monitoring. Spontaneous breathing was evidenced by means of a simple device. At the end of the scan, the child was taken care for in the recovery room. The methohexital dose provided adequate sedation in most cases. Once the injection was given, a motionless state was reached in 4.20 minutes. The insertion of an intravenous catheter induced movements in 96% cases, which did not interfere with the successful intravenous puncture. In 33% cases, 1 to 2 mg.kg-1 ketamine was necessary because of a failed attempt at obtaining the required state, or of an awakening due to iodized injection. Among those cases, half the children were overweight for their ages. In this situation an adjusting dose should be considered. On average, a child under the influence of the drug slept for 35 minutes and the required time for a C.T. scan is 23.3 minutes. Time in the recovery room is on average 20 minutes. There was no episode of cardiovascular or respiration failure, or local reaction at the injection site. There was also no episode of seizure.(ABSTRACT TRUNCATED AT 250 WORDS)

[Oral premedication with diazepam]. / Prémédication orale au diazépam.

A double blind study has been carried out on patients scheduled for appendicectomy. They were divided into two groups who were given diazepam as premedication either orally or intramuscularly. The clinical effects were measured with regard to anxiolysis, gastric contents volume and acidity. Orally premedicated patients were not significantly less anxious. No significant differences between both groups concerning gastric contents (volume and pH) were found. Therefore, oral premedication did not increase the risk of inhalation. Taking into account the previous findings in the literature, the pharmacological advantages of the oral route and the lack of complications, a wider use of oral premedication for elective operations in adults is recommended.

A mathematical representation of the ovulatory cycle of the domestic hen.

The ovulatory cycle of the domestic hen (Gallus domesticus) was postulated to be the result of the interaction of two independent systems. A circadian system ws postulated to control the restriction of ovulation to an 8-h period of the day under conventional 14 h light: 10 h dark regimes. The final phase of follicular maturation was postulated to commence after ovulation of the preceding ovum in the hierarchy. Ovulation was postulated to occur when a mature follicle was present in the ovary during the appropriate phase of the circadian-linked system. The predicted times of oviposition were within the standard error of the observed times of oviposition under 21-, 24- and 28-h photoschedules. It was concluded that this hypothesis for the control of the ovulatory cycle of the hen is consistent with current knowledge.