Biomarkers for Ehlers-Danlos Syndromes: There Is a Role?

Joint Hypermobility Syndrome and Membrane Proteins: A Comprehensive Review

Ehlers-Danlos syndromes (EDSs) constitute a heterogeneous group of connective tissue disorders characterized by joint hypermobility, skin hyperextensibility, and tissue fragility. Asymptomatic EDSs, joint hypermobility without associated syndromes, EDSs, and hypermobility spectrum disorders are the commonest phenotypes associated with joint hypermobility. Joint hypermobility syndrome (JHS) is a connective tissue disorder characterized by extreme flexibility of the joints, along with pain and other symptoms. JHS can be a sign of a more serious underlying genetic condition, such as EDS, which affects the cartilage, bone, fat, and blood. The exact cause of JHS could be related to genetic changes in the proteins that add flexibility and strength to the joints, ligaments, and tendons, such as collagen. Membrane proteins are a class of proteins embedded in the cell membrane and play a crucial role in cell signaling, transport, and adhesion. Dysregulated membrane proteins have been implicated in a variety of diseases, including cancer, cardiovascular disease, and neurological disorders; recent studies have suggested that membrane proteins may also play a role in the pathogenesis of JHS. This article presents an exploration of the causative factors contributing to musculoskeletal pain in individuals with hypermobility, based on research findings. It aims to provide an understanding of JHS and its association with membrane proteins, addressing the clinical manifestations, pathogenesis, diagnosis, and management of JHS.

The Analgesic Mismanagement of a Patient With Ehlers-Danlos Syndrome (Hypermobility Variant): A Case Report

Ehlers-Danlos syndrome (EDS) is a rare disorder affecting the connective tissue, resulting in joint hypermobility, elastic skin, and often chronic pain, especially in the hypermobility variant. Although opioids are commonly prescribed for pain, they can lead to opioid use disorder (OUD) and overdose. A 67-year-old female with Ehlers-Danlos syndrome hypermobility type (EDS-HT), osteoarthritis (OA), and anxiety received opioid-based pain management for a decade before changing her primary care physician. Her medications included oxycodone and morphine sulfate extended-release (ER) at different dosages. To lower overdose risk, her morphine milligram equivalents (MME) were tracked, and a step-by-step opioid tapering process was started. Diagnosing EDS is difficult due to symptom overlap with other connective tissue disorders. Chronic pain in EDS involves both nociceptive and neuropathic pain, necessitating a comprehensive pain management approach. The essential components of pain management include non-opioid medications, physical therapy, and psychological support. Opioids should be used cautiously in EDS patients because of connective tissue vulnerabilities and potential side effects. Personalized plans for opioid tapering may be appropriate for those on long-term opioid therapy. Managing EDS-related chronic pain requires a tailored, multidisciplinary approach. Early and accurate diagnosis and specialized healthcare providers familiar with EDS are crucial for effective pain management. Ongoing research and evidence-based pain management approaches are vital to address the unique needs of EDS patients, promoting better pain relief and overall well-being. Through meticulous evaluation and personalized treatment plans, healthcare professionals can better support EDS patients in managing chronic pain and reducing opioid dependence and misuse risks. A comprehensive approach, incorporating non-opioid medications, physical therapy, and psychological support, can offer effective pain relief and improve the quality of life for those living with EDS.

Child Abuse, Misdiagnosed by an Expertise Center: Part I-Medico-Social Aspects

Child abuse is a dangerous situation for an infant. Professionals need to weigh the risk of failing to act when children are seriously harmed against the serious harm done by carrying out safeguarding interventions. In severe cases, foster care might be advisable. The negative effects for the child's psychosocial development requires that such placement must be based on very solid evidence. Our aim is to identify why Dutch parents whose child may have a medical condition that could mimic symptoms of child abuse have a significant chance of being erroneously convicted and losing custody of their child. As a method, we describe and analyze the following case. An Armenian-Dutch newborn (uncomplicated term vaginal delivery), starting at two weeks after birth, developed small bruises on varying body locations. At two months, a Well-Baby Clinic physician referred the girl to a university hospital, mentioning that there were no reasons to suspect child abuse and that her Armenian grandmother easily bruised as well. However, before consultation by a pediatrician of the hospital-located Expertise Center for Child Abuse, the parents were suspected of child abuse. Based on the expertise center's protocols, skeletal X-rays were made, which showed three healed, asymptomatic rib fractures, while invalid statistics suggested, incorrectly, a 10-100 times more likely non-accidental than accidental cause of the symptoms (discussed in Part II of this series). The expertise enter physician ignored any argument that could show parental innocence, including the positive parent-child relationship reported by the Well-Baby Clinic and the general practitioner. The girl and her older brother were placed in a family foster home and then in a secret home. The case radically resolved when a large bruise also developed there, and an independent tissue disease specialist diagnosed a hereditary connective tissue disorder in the mother, implying that the girl's bruises and rib fractures could well be disease-related. In conclusion, if child abuse is suspected, and foster care placement considered, the patient and the parents should be thoroughly investigated by an independent experienced pediatrician together with an experienced pediatric clinical psychologist or psychotherapist to produce an independent opinion. Children deserve this extra safeguard before being separated from their parents.

Child Abuse, Misdiagnosed by an Expertise Center-Part II-Misuse of Bayes' Theorem

A newborn girl had, from two weeks on, small bruises on varying body locations, but not on her chest. Her Armenian grandmother easily bruised, too. Her mother was diagnosed with hypermobility-type Ehlers-Danlos-Syndrome (hEDS), an autosomal dominant connective tissue disorder, with a 50% inheritance probability. Referral to a University Medical Center located "Dutch Expertise Center for Child Abuse" resulted (prior to consultation) in physical abuse suspicion. Protocol-based skeletal X-rays showed three healed, asymptomatic rib fractures. A protocol-based Bayesian likelihood ratio guesstimation gave 10-100, erroneously used to suggest a 10-100 times likelier non-accidental-than-accidental cause. Foster care placement followed, even in a secret home, where she also bruised, suggesting hEDS inheritance. Correct non-accidental/accidental Bayes' probability of symptoms is (likelihood ratio) × (physical abuse incidence). From the literature, we derived an infant abuse incidence between about ≈0.0009 and ≈0.0026 and a likelihood ratio of <5 for bruises. For rib fractures, we used a zero likelihood ratio, arguing their cause was birth trauma from the extra delivery pressure on the chest, combined with fragile bones as the daughter of an hEDS-mother. We thus derived a negligible abuse/accidental probability between <5 × 0.0009 <0.005 and <5 × 0.0026 <0.013. The small abuse incidence implies that correctly using Bayes' theorem will also miss true infant physical abuse cases. Curiously, because likelihood ratios assess how more often symptoms develop if abuse did occur versus non-abuse, Bayes' theorem then implies a 100% infant abuse incidence (unwittingly) used by LECK. In conclusion, probabilities should never replace differential diagnostic procedures, the accepted medical method of care. Well-known from literature, supported by the present case, is that (child abuse pediatrics) physicians, child protection workers, and judges were unlikely to understand Bayesian statistics. Its use without statistics consultation should therefore not have occurred. Thus, Bayesian statistics, and certainly (misused) likelihood ratios, should never be applied in cases of physical child abuse suspicion. Finally, parental innocence follows from clarifying what could have caused the girl's bruises (inherited hEDS), and rib fractures (birth trauma from fragile bones).

Pain in Ehlers-Danlos Syndrome: A Non-Diagnostic Disabling Symptom?

BACKGROUND

Ehlers-Danlos syndrome (EDS) is a phenotypically and genetically heterogeneous group of connective tissue disorders. Currently, diagnosis of EDS is based on a series of clinical and genetic tools. On the other hand, the hypermobile form has not yet been characterized from a genetic point of view: it is considered a part of a continuous spectrum of phenotypes, ranging from isolated non syndromic joint hypermobility, through to the recently defined hypermobility spectrum disorders (HSD). The aim of this study is to characterize the pain symptom that is not considered among the diagnostic criteria but is relevant to what concerns the quality of life of patients with EDS. (2) Methods: A review of the literature was performed on two medical electronic databases (PubMed and Embase) on 20 December 2022. Study selection and data extraction were achieved independently by two authors and the following inclusion criteria were determined a priori: published in the English language and published between 2000 and 2022. (3) Results: There were fifty eligible studies obtained at the end of the search and screen process. Pain is one of the most common symptoms found in Ehlers-Danlos (ED) patients. Different causes seem to be recognized in different phases of the syndrome. (4) Conclusions: Pain is a nonspecific symptom and cannot be considered among the diagnostic criteria, but it is a negative predictive factor in the quality of life of patients with EDS. Therefore, proper evaluation and treatment is mandatory.

Pathological Background and Clinical Procedures in Oral Surgery Haemostasis Disorders: A Narrative Review

Haemostasis disorders are serious pathologies that could put dental and surgical procedures at risk as they are associated with postoperative bleeding, which in some circumstances could be prolonged and dangerous for the patient. In-depth knowledge of the problems associated with coagulation pathologies and the suitable specific procedures should be implemented in dental practice. A good awareness of the clinical protocols to be used in these circumstances may help reduce operator stress and increase patient compliance. Collaboration with the haematologist is always recommended to establish an adequate treatment plan, both regarding the administration of therapies that promote haemostasis and for assessing the operative risk. Hereby, we summarize the congenital and hereditary pathologies that lead to haemostasis disorders, which can be found in patients undergoing dental procedures. The purpose of this narrative review is to frame the diseases from a clinical, anamnestic, and etiopathological standpoint, as well as to evaluate an operative approach to the pathology under consideration, with particular attention to anaesthesia manoeuvres and post-surgical haemostasis, to avoid hematoma formation and uncontrolled bleeding which can lead procedure failure up and even death. Of note, it is likewise important to educate the patient about prevention, to keep the oral cavity healthy and avoid invasive procedures, limiting the number of operative sessions.

Biomarkers in Rare Diseases 2.0

It is estimated that there are over 7000 rare diseases, collectively affecting more than 350 million individuals worldwide [...].