Characteristics Associated With Refractory Course, Blindness, and Treatment Strategy-Related Outcomes in Patients With Mucous Membrane Pemphigoid

Importance

Mucous membrane pemphigoid (MMP) is a rare and heterogeneous subepithelial autoimmune bullous disease with predominant mucosal involvement. Characteristics associated with the disease course and complications are yet to be delineated.

Objectives

To evaluate characteristics associated with refractory disease course and blindness among patients with MMP and to estimate the association of different treatment strategies with the prognostic outcome.

Design, Setting, and Participants

A retrospective cohort study of consecutive patients diagnosed with MMP and followed up for more than 1 year from 2007 to 2020 in 2 tertiary referral centers. Data were analyzed from January 1, 2009, to June 30, 2020.

Main Outcomes and Measures

Characteristics associated with refractory disease course and blindness were evaluated using multivariable logistic regression model.

Results

The study encompassed 121 patients with MMP (mean [SD] age, 66.0 [14.0] years; 78 (64.5%) were women), of whom 56 (46.3%) followed a refractory course and 13 (10.7%) developed blindness. Anti-LAD-1 IgA (odds ratio [OR], 3.42; 95% CI, 1.11-10.52; P = .03) and anti-dermal-epidermal/epithelial junction (DEJ) IgG (by indirect immunofluorescence on human salt-split skin; OR, 2.92; 95% CI, 1.26-6.78; P = .01) were significantly associated with refractory course. Development of blindness was associated with older age (≥68 years; OR, 6.38; 95% CI, 1.35-30.16; P = .009), initial presentation with bilateral ocular involvement (OR, 7.92; 95% CI, 2.04-30.68; P = .001), and scarring ocular lesions (OR, 5.11; 95% CI, 1.47-17.79; P = .006). However, 4 (30.8%) and 2 (15.4%) of those experiencing blindness had no ocular scarring lesions and unilateral ocular involvement at the onset of their disease, respectively. Patients progressing to blindness were more likely to be treated by 3 or more immunosuppressive/immunomodulatory drugs (OR, 4.07; 95% CI, 1.17-14.14; P = .02) and by cyclophosphamide (OR, 7.64; 95% CI, 2.24-26.09; P < .001). Patients developing blindness and refractory course were more frequently managed by intravenous immunoglobulin (OR, 7.64; 95% CI, 2.24-26.09; P < .001 and OR, 3.47; 95% CI, 1.42-8.45; P = .005, respectively).

Conclusions and Relevance

Findings of this cohort study support that patients with MMP with anti-LAD-1 IgA and anti-DEJ IgG reactivity should be carefully monitored. While initial bilateral ocular disease and scarring ocular lesions were associated with blindness, patients initially presenting with unilateral and nonscarring ocular disease may still develop severe vision impairment.

Evaluation of Site- and Autoantigen-Specific Characteristics of Mucous Membrane Pemphigoid

Importance

Mucous membrane pemphigoid (MMP) is a rare, heterogeneous subepithelial autoimmune bullous disease. The association between its clinical and immunological features is yet to be fully evaluated.

Objectives

To characterize the clinical, immunoserological, and immunopathological characteristics of patients with MMP and to identify site- and autoantigen-specific characteristics.

Design, Setting, and Participants

A retrospective cohort study encompassing all consecutive patients diagnosed with MMP from January 2007 through February 2020 in 2 tertiary referral centers in Germany.

Main Outcomes and Measures

The clinical, immunoserological, and immunopathological features of eligible patients were evaluated. Associations of different anatomical sites and autoantigens were assessed using a multivariable logistic regression model.

Results

The study encompassed 154 patients (96 [62.3%] women and 58 [37.7%] men; mean [SD] age at diagnosis, 66.2 [13.8] years) with MMP, of whom 125 (81.2%), 61 (39.6%), 34 (22.1%), and 16 (10.4%) presented with lesions involving the oral, ocular, nasal, and genital mucosae, respectively, and 35 (22.7%) presented with cutaneous involvement. Among the 154 patients, the most frequently targeted antigen was BP180 (90 patients [58.4%]), followed by laminin 332 (13 patients [8.4%]) and BP230 (3 patients [1.9%]). Ocular disease was inversely associated with oral (adjusted odds ratio [aOR], 0.02; 95% CI, 0.01-0.13) and nasal (aOR, 0.20; 95% CI, 0.04-0.91) involvement and was associated with a 13-fold increased risk of malignant neoplasm (aOR, 13.07; 95% CI, 1.56-109.36). Anti-laminin 332 reactivity was associated with malignant neoplasm (aOR, 23.27; 95% CI, 1.83-296.68), whereas anti-BP180 NC16A immunoglobulin G seropositivity was associated with absence of ocular lesions (aOR, 0.09; 95% CI, 0.01-0.99).

Conclusions and Relevance

In this cohort study of patients with MMP, malignant neoplasms were associated with ocular disease and anti-laminin 332 reactivity, suggesting potential benefit of malignant neoplasm screening in these patients.

Ethical and legal aspects of enteral nutrition

European ethical and legal positions with regard to EN vary slightly from country to country but are based on a common tradition derived from Graeco Roman ideas, religious thought and events of the 20th century. The Hippocratic tradition is based on 'beneficience' (do good) and 'non-maleficience' (do no harm). Religious thinking is based upon the presumption of providing food and drink by whatever means unless burden outweighs benefit. The concept of 'autonomy' (the patients right to decide) arose following in the decades after the Second World War and is enshrined in Human Rights law. The competent patient has the right to participate in decision making and to refuse treatment although the doctor is not obliged to give treatment which he or she considers futile or against the patient's interests. The incompetent patient is protected by law. The fourth principle is that of 'justice' i.e. equal access to healthcare for all. The law regards withholding and withdrawing treatment as the same. It also defines the provision of food and drink by mouth as basic care and feeding by artificial means as a medical treatment. It requires doctors to act in the best interests of the patient.

Concurrent quantification of cellular cholesterol, cholesteryl esters and triglycerides in small biological samples. Reevaluation of thin layer chromatography using laser densitometry

Absolute specificity and high accuracy is required for the quantitation of cholesterol, cholesteryl esters and triglycerides in small biological samples, particularly in a limited number of cells. Both can be achieved through thin-layer chromatography and molybdatophosphoric acid staining, while the shortcomings of traditional spot detection are overcome by laser densitometry. The major advantage of the proposed technique is the concurrent assay of nanogram quantities of cholesterol, cholesteryl esters and triglycerides. Our assay is at least ten-fold more sensitive than common thin-layer chromatography-based techniques and at least four-fold more sensitive than common enzymatic methods. The present low-cost assay is highly reproducible and may be particularly suitable for the routine lipid analysis of a 10% aliquot of relatively small tissue and cell samples, equivalent, for instance, to > or = 10(4) human monocytes.

Altered switch in lipid composition during T-cell blast transformation in the healthy elderly

Decreased mitogen responsiveness of lymphocytes during aging correlates inversely with membrane microviscosity, which reflects an altered lipid composition. Therefore, we addressed the question, whether age-related alterations of lipid metabolism affect the switch in lipid composition during formation of blasts. Membrane lipids and fatty acids of peripheral blood lymphocytes from SENIEUR protocol compatible ("healthy") elderly donors (66-77 yr) and young controls (18-30 yr) were quantified after incubation with or without the mitogen phytohaemagglutinin. The blastic change in membrane lipid composition was different for young controls with respect to cholesterol, phosphatidylethanolamine, total phospholipids, as well as several fatty acids. Moreover, the age-related alterations in the switch of membrane lipids and fatty acids were significantly correlated with a decreased mitogen response. Thus, the alterations in membrane reorganization during blast formation of lymphocytes from the elderly point to a disturbed cellular lipid homeostasis with possible impact on the age-related reduction in immune function.

Lung hypoplasia and severe pulmonary hypertension in an infant with double heterozygosity for spondyloepiphyseal dysplasia congenita and achondroplasia

A rare instance of double heterozygosity for spondyloepiphyseal dysplasia congenita and achondroplasia is presented. Despite midface hypoplasia, thorax deformity and lung hypoplasia, the child survived the neonatal period. Severe pulmonary hypertension, already present at birth, led to right heart failure and death at the age of 1 year.

Depletion of plasma vitamin C but not of vitamin E in response to cardiac operations

The whole-body inflammatory response produced by cardiopulmonary bypass is an important cause of perioperative morbidity after cardiac operations. This inflammatory response produces reactive oxygen species and other cytotoxic substances, such as the cytokines. The generation of reactive oxygen species might deplete principal antioxidant micronutrients, that is, vitamins C and E and the carotenoids. Therefore, we have investigated the time course of the plasma concentrations of vitamins C and E and the carotenoids in 18 patients undergoing coronary bypass operations after randomization for previous vitamin E supplementation (300 mg dl-alpha-acetyl-tocopherol 3 times daily for 4 weeks) or placebo. Supplementation with alpha-tocopherol doubled the lipid-standardized plasma vitamin E concentration to 63.7 +/- 14.5 mumol/L when compared with that of the control subjects (31.2 +/- 9.0 mumol/L) before the operation. The plasma concentrations of vitamin C (36.0 +/- 19.0 mumol/L and 44.0 +/- 21.7 mumol/L, respectively) and of the carotenoids were not statistically different between the two groups at baseline. The absolute plasma concentrations of both vitamin E and the carotenoids decreased during and after cardiopulmonary bypass, but after correction for hemodilution the plasma concentrations of vitamin E and the carotenoids showed no decrease. The vitamin E concentrations in the erythrocytes did not change either. In contrast, the plasma concentration of vitamin C decreased in all subjects within 24 hours after the operation by roughly 70%. Correction for hemodilution still revealed a significant decrease in plasma vitamin C that persisted in most patients up to 2 weeks. In conclusion, the vitamin E and the carotenoid plasma concentrations are of no major concern during and after cardiac operations. In contrast, the serious depletion of vitamin C may deteriorate the defense against reactive oxygen species-induced injury during cardiac operations.

A high-density-lipoprotein receptor appears to mediate the transfer of essential fatty acids from high-density lipoprotein to lymphocytes

It has been shown previously that a specific high-density lipoprotein (HDL) receptor exists on human lymphocytes that recognizes apoprotein (apo) A1 as its ligand, and may be responsible for utilization of HDL lipids to respond optimally to mitogenic stimulation when cultured in serum-free medium supplemented with HDL. To clarify further the relationship between various HDL lipids used by lymphocytes and HDL receptor activity, the lipid composition of the cells and the regulation of HDL and low-density lipoprotein (LDL) receptors on freshly isolated lymphocytes and mitogen-activated T-blasts after treatment with lipoproteins, liposomes or fatty acids were investigated. Our data show that the linear increase in cell proliferation correlates with the presence of HDL in fatty-acid-free culture medium in the concentration range of HDL receptor saturation. Decreased binding/uptake of dioctadecylindocarbocyanine (DiI)-fluorescence-labelled HDL by freshly isolated lymphocytes was observed in the presence of unlabelled HDL in 4-day culture, whereas T-blast binding/uptake was down-regulated by preincubation not only with HDL but also with LDL. T-blasts pretreated with HDL showed increased cellular contents of phosphatidylcholine, oleic acid (C18:1,n-9) and linoleic acid (C18:2,n-6), which are essential for optimal proliferation of mitogen-stimulated lymphocytes. Furthermore, DiI-HDL binding on lymphocytes was down-regulated by up to 20% (resting T cells) and 50% (T-blasts) when cultured in the presence of apoA1-phosphatidylcholine liposomes (T-blasts only), oleic acid or linoleic acid, but not by stearic acid (C18:0). The results indicate that HDL provide lymphocytes with essential fatty acids, which in turn regulate HDL receptor activity.

Arrangement of DYZ1 and DYZ2 repeats on the human Y-chromosome: a case with presence of DYZ1 and absence of DYZ2

The composition of Yq-heterochromatin is dominated by the two repetitive sequences DYZ1 (4000 copies) and DYZ2 (2000 copies). Probes derived from these sequences can be used for sex determination and the structural analysis of aberrant Y-chromosomes. Using such probes Schmid et al., have recently proposed a regular interspersion of the two sequences in a ratio of 2:1 over the entire Yq12 chromosome region. By Southern analysis we investigated the DNA of a normal male, cytogenetically negative for Yq-heterochromatin. Applying the same probes as used by Schmid et al., only a small amount of DYZ1 material could be detected. The case presented indicates the presence of DYZ1 only in the Yq11-Yq12 junction region and excludes DYZ2 from any function relevant for normal male development.

Correlation of lymphocyte lipid composition membrane microviscosity and mitogen response in the aged

Healthy aged and young blood donors were investigated for the role of membrane lipid composition in the age-related increase in membrane microviscosity and decline of mitogen responsiveness. Membrane microviscosity was shown to correlate positively with membrane cholesterol/phospholipid molar ratios, which were significantly elevated in the elderly. A positive correlation also was confirmed between lymphocyte membrane microviscosity, which was measured using the probe 1,6-diphenyl 1,3,5-hexatriene, and phytohemagglutinin responsiveness of cells from the same donor. Using stepwise regression statistical analysis, the variables age, cholesterol, cholesterol/total phospholipid and phosphatidyl ethanolamine/phosphatidyl choline molar ratios were all shown to have a significant positive influence on membrane microviscosity, whereas total phospholipids had a negative effect. No statistically significant difference was seen in content of any single saturated or unsaturated fatty acid between young and old donors. After pooling, however, the proportion of all unsaturated fatty acids was significantly higher in cells from the elderly as a consequence of an increase of n-6 and n-3 polyunsaturated fatty acids. Changes in lipid composition and physical properties of lymphocyte plasma membranes may, therefore, be responsible (at least partially) for the diminution of immune reactivity in old age.

Plasma vitamin E and beta-carotene concentrations during radiochemotherapy preceding bone marrow transplantation

Blood from 19 patients was examined for the essential antioxidants alpha-tocopherol and beta-carotene before, during, and after bone marrow transplantation (BMT). Marrow ablation and immunosuppression for BMT conditioning was achieved by treatment with high-dose chemotherapy, mostly combined with total body irradiation. All patients required total parenteral nutrition beginning 1 wk before BMT. After conditioning therapy the concentration of absolute and lipid-standardized alpha-tocopherol and beta-carotene in plasma decreased significantly, presumably as a result of an enhanced breakdown of these antioxidants. The loss of these lipid-soluble antioxidants has to be considered as a possible cause for early posttransplant organ toxicity.

Physical mapping of D8S7 and D8S11 to the band 8p23.1 of the short arm of chromosome 8

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[Fertility and Turner mosaicism syndrome]

Six patients with a Turner mosaicism are reported. All six women were investigated for sterility or infertility. Four of six patients had a total of nine pregnancies: six abortions, one stillbirth, two normal children. The literature contains reports of 17 pregnancies in 10 women with 45.X karyotype and 106 pregnancies in 48 women with mosaicism. Miscarriages, stillbirths and malformations were common. These women need special counselling and in case of a pregnancy amniocentesis is indicated. We discuss the pathogenesis of reduced fertility with Turner patients and explain the problems related to the cystogenetic diagnosis of the Turner-Mosaic Syndrome.

Decreased essential antioxidants and increased lipid hydroperoxides following high-dose radiochemotherapy

The blood from 19 patients having bone marrow transplantation was examined for the essential antioxidants alpha-tocopherol and beta-carotene as well as lipid hydroperoxides before, at and after bone marrow transplantation (BMT). Conditioning therapy, preceding BMT in order to achieve marrow ablation and immunosuppression, consists of high-dose chemotherapy which is mostly combined with total body irradiation (TBI). In order to see a possible difference between patients with and without additional TBI, we divided the patients up into two groups; patients receiving TBI (RT+) and patients without TBI (RT-). All patients required total parenteral nutrition beginning one week prior to BMT. After conditioning therapy plasma levels of absolute and lipid-standardized alpha-tocopherol and beta-carotene decreased in both groups, presumably as a result of an enhanced breakdown of these antioxidants. The loss of these lipid-soluble antioxidants has to be considered as a possible cause for early post-transplant toxicity. Lipid hydroperoxides increase significantly in the group of patients with additional TBI, whereas the other group, receiving no additional TBI, showed no significant change. We suggest high-dose supplementation of essential antioxidants for patients undergoing BMT.

Linkage relationships and allelic associations of the cystic fibrosis locus and four marker loci

The linkage relationships between the cystic fibrosis (CF) locus and four marker loci (MET-H, MET-D, D7S8 and D7S16), allelic associations between these loci and the extent of informativity at these marker loci were investigated in a sample of 206 families with at least one child affected by CF. The data were contributed by 11 laboratories from Europe and Israel. The maximum lod scores and recombination frequency estimates (luminal diameter) (and confidence limits of luminal diameter) were: 18.3 at luminal diameter = 0.007 (0.001-0.038) for CF vs. MET, 11.0 at luminal diameter = 0.016 (0.001-0.068) for CF vs. D7S8, and 5.7 at luminal diameter = 0.0 (0.0-0.064) for CF vs. D7S16. A gene order of CF-MET-D7S8 was best supported by the data, but its preference to the order D7S8-CF-MET is mainly based on one single family. There are significant allelic associations between CF, MET, D7S8 and D7S16; these allelic associations affect the risk of random individuals to be carriers of CF.

[Significance of the medical anthropology work of Dieter Wyss for modern psychiatry and psychotherapy]

In the first part the decrease of the psychopathological research was described and the impact on the practical psychopathology was deplored, which in its existential tendencies could be very productive for a patient-orientated psychiatrist. The writings of D. Wyss stand in contrast to that disappearance of psychopathology. The author stressed the historical development of the patient an the importance of conflict which yields the dynamics of that development. The conception of psychosis has as its basic concept that of perspective which is a fundamental union of the "interior" and "exterior" of the human person. The essay ends with a discussion of the importance of the author for a humane psychotherapy which exists in a symmetric relation to the patient.

Deficiency, transposition, and duplication of one 15q region may be alternatively associated with Prader-Willi (or a similar) syndrome. Analysis of seven cases after varying ascertainment

Seven patients are described who have some or all of the symptoms of Prader-Willi syndrome. They were ascertained by varying criteria starting either from the clinical picture or from the identification of a chromosome abnormality involving the proximal portion of the long arm of chromosome 15. The chromosome abnormalities consisted of two balanced translocations (15;18 and 8;15), three unbalanced ones (15;18, 15;19, and 9;15), and one interstitial deletion of bands 15q11 and q12. The seventh case had an unidentified extra chromosome. These data and a review of the literature led to the conclusion that deficiency, transposition, and even duplication of the region(s) 15q11-q13 may all result in a syndrome which is identifiable with or similar to the Prader-Willi syndrome.

[Ground force in relation to the activity of various leg muscles in the supporting foot phase of human gait]

By means of using biomechanical methods we investigated the relations between muscle activity and ground forces that are produced during walking. Our special attention was directed forwards the touching phase of the foot which was registered via integrated electromyogram (surface electrodes) and force plateform (Kistler). The initial spike of vertical force and its dependence of m. tibialis anterior activity was examined. In addition we observed connections between m. tibialis anterior activity and surface condition of the ground. Further, our results documented a damped movement of the touching fore foot and a steady take over of weight during pressing which was caused by increased tibialis activity. The pressure phase (first part of the vertical force component) was separated in two curves and defined by means of two angles. More data was given for interpretation the activities of m. gastrocnemius, m. peroneus longus and vertical and transversal force components. In further experiments we intend to analyse pathologic conditions.

Correlation between the number of sex chromosomes and the H-Y antigen titer

H-Y antigen was studied serologically on blood cells and cultured fibroblasts of patients with numerical aberrations of the sex chromosomes. As compared with normal males, patients with the karyotypes 48,XXXY and 49,XXXXY have reduced H-Y antigen titers; a tendency toward reduced titers can also be detected in the 47,XXY Klinefelter syndrome. The existence of an intermediary titer was further substantiated by a quantitative absorption test applied to cells with the 49,XXXXY karyotype. It appears that in the presence of one Y chromosome, the H-Y antigen titer decreases with an increasing number of X chromosomes. In contrast, the H-Y antigen titer is increased if, at a given number of X chromosomes, the number of Y chromosomes is increased, as in the 47,XYY male. Consequently, patients with 48,XXYY chromosomes are in the male control range. The findings are interpreted under the hypothesis of a controlling or modifying influence of the sex chromosomes on the titer of H-Y antigen.

The gingivitis iron test

Mixed saliva stimulated by mastication was sampled under standardized conditions in 50 recruits before and after a 10-day period of intensified oral hygiene. The degree of gingivitis was assessed (1) with the Sulcus Bleeding Index and (2) with the spectrophotometric determination of blood iron in the saliva samples. Oral hygiene reduced (1) the SBI from 1.1+/-0.6 to 0.6+/-0.4 and (2) salivary iron from 0.6+/-0.5 to 0.3+/-0.4 mug, both differences being highly significant (PF is less than 0.001). SBI and iron data were significantly but not strongly correlated (r=51).

Irregular phenotypic expression of ring chromosomes

2 patients with 13- and C9-rings are reported. On reviewing the phenotypical features of the published ring carriers and comparing them with our results we do not find any characteristic similarities. This can be explained by cytogenetical and biological findings. We are therefore inclined to reject the existence of clear-cut ring chromosome syndromes.

Siblings with different types of chromosal aberrations due to D-E-translocation of the mother

A woman of normal appearance had an abortion and gave birth to two mentally defective children with different malformations. A fourth pregnancy was interrupted legally. Features of the first child resemble those of the D trisomy syndrome and the second child has some characteristics in common with cases of E trisomy syndrome. The common symptoms are mental deficiency, short stature, flexion of the fingers and a mild scrotal abnormality. The chromosomes were examined in some members of the family. In the mother, it is presumed that one part of a chromosome of group D has been translocated to a chromosome 17, giving a large chromosome in the group C size range. The other fragment of the broken chromosome resembles the chromosomes of group G. The mother presumably has the normal, although rearranged, genetic material in each cell. The two children reflect the two possible types of partial D trisomy derivable from the mother’s karyotype. Child 1 has the large D/E translocation chromosome with only one chromosome 17. Child 2 has 47 chromosomes since the proximal part of the involved maternal chromosome D has been inherited as an extra chromosome. Since a reciprocal translocation is possibly involved, then child 2 may be trisomic not only for part of a D chromosome but also for a region of chromosome 17. The clinical picture supports this possibility. The karyotypes of the embryo and the mother are identical. The chromosomes are normal in the maternal grandmother and in the father of children 1 and 2. The chromosome number is 46 in a maternal aunt, but two out of 18 mitoses examined have an abnormal karyotype.