Ureteropelvic junction obstruction with primary lymphoedema associated with CELSR1 variants

BACKGROUND

Primary lymphoedema (PL) is a chronic, debilitating disease caused by developmental and functional defects of the lymphatic system. It is marked by an accumulation of interstitial fluid, fat and tissue fibrosis. There is no cure. More than 50 genes and genetic loci have been linked to PL. We sought to study systematically cell polarity signalling protein Cadherin Epidermal Growth Factor Laminin G Seven-pass G-type Receptor 1 (CELSR1) variants linked to PL.

METHODS

We investigated 742 index patients from our PL cohort using exome sequencing.

RESULTS

We identified nine variants predicted to cause CELSR1 loss of function. Four of them were tested for nonsense-mediated mRNA decay, but none was observed. Most of the truncated CELSR1 proteins would lack the transmembrane domain, if produced. The affected individuals had puberty/late-onset PL on lower extremities. The variants had a statistically significant difference in penetrance between female patients (87%) and male patients (20%). Eight variant carriers had a kidney anomaly, mostly in the form of ureteropelvic junction obstruction, which has not been associated with CELSR1 before. CELSR1 is located in the 22q13.3 deletion locus of the Phelan-McDermid syndrome. As variable renal defects are often seen in patients with the Phelan-McDermid syndrome, CELSR1 may be the long-sought gene for the renal defects.

CONCLUSION

PL associated with a renal anomaly suggests a CELSR1-related cause.

A severe case of PLOD1-related kyphoscoliotic Ehlers-Danlos syndrome associated with several arterial and venous complications: A case report

Kyphoscoliotic Ehlers-Danlos syndrome (kEDS) is a rare genetic disorder combining congenital hypotonia, congenital/early onset and progressive kyphoscoliosis, and generalized joint hypermobility. Vascular fragility is another characteristic of the disease rarely described. We report a severe case of kEDS-PLOD1 with several vascular complications leading to difficulties in disease management.

Assessment of arterial damage in vascular Ehlers-Danlos syndrome: a retrospective multicentric cohort

Background

Vascular Ehlers-Danlos syndrome (vEDS) is a rare inherited connective tissue disorder due to pathogenic variants in the COL3A1 gene, leading to medium-size artery (MSA) dissection, aneurysm, and rupture with a poor prognosis. Conversely, aortic lesions are rarer and less investigated.

Purpose

To describe the association between the distribution of MSA and aortic lesions and the type of COL3A1 variants in a multicentric cohort of vEDS patients.

Methods

Analysis of the 330 vEDS adult patients from the French RaDiCO SEDVASC registry. At the time of the study, 87% were alive, 60.3% were index cases and 60.0% females. Median age at molecular diagnosis was 36 years (IQR 24.3–46.8). COL3A1 variants were identified using NGS and/or Sanger sequencing and classified according to their functional consequences: 80.6% dominant-negative (DN) and 19.4% leading to haplo-insufficiency (HI). Computed tomography angiography (CTA) was systematically performed during the initial work-up of patients. Carotid mechanics was also assessed by echotracking in a subgroup of 133 patients.

Results

Arterial lesion history was reported in 82.4% of the patients (N=272), with 227/272 patients (83.5%) having MSA lesions alone, 9 (3.3%) aortic lesions alone and 36 (13.2%) both. DN variant was associated with higher prevalence of arterial lesions than HI variant (P 0.044), especially on supra-aortic trunks and renal arteries (P 0.018 and P 0.0003 respectively). Importantly, the higher prevalence of aortic lesions observed in HI patients with arterial lesions versus DN patients (P 0.027) was not significantly different when adjusted for age (P 0.559). Carotid Young's modulus was lower in DN than HI patients (P 0.014), in association with the higher incidence of MSA lesions in this genotype group.

Conclusion

The prevalence of aortic lesions is not influenced by the COL3A1 genotype when adjusted for age. vEDS patients with DN variants have a higher frequency of MSA lesions especially in supra-aortic trunks which is associated with a lower carotid stiffness, suggesting a need for an optimal care for this subgroup of patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): French National Research Agency under the specific programme “Investments for the Future”, cohort grant-agreement ANR-l0-COHO-03-01

Assessment of arterial damage in vascular Ehlers-Danlos syndrome: A retrospective multicentric cohort

Background

Vascular Ehlers-Danlos syndrome (vEDS) is a rare inherited connective tissue disorder due to pathogenic variants in COL3A1 leading to medium-size-artery (MSA) dissection, aneurysm, rupture. Aortic lesions are rarer and less investigated. The objective was to describe the distribution of MSA and aortic lesions and the type of COL3A1 variants in a multicentric cohort of 330 adult vEDS patients.

Methods

At the time of the study, 87% were alive, 60.3% were index cases, and 60.0% were women. COL3A1 variants were identified using NGS and/or Sanger sequencing and classified according to functional consequences: 80.6% leading to dominant-negative (DN) and 19.4% leading to haploinsufficiency (HI). Imaging was systematically performed during the initial workup. Carotid mechanics were assessed by echo tracking in a subgroup of patients.

Results

Arterial lesions were reported in 82.4% of the patients (N = 272): 83.5% had MSA lesions alone, 3.3% had aortic lesions alone, and 13.2% both. DN variants were associated with a higher prevalence of arterial lesions (P < 0.044), especially in supra-aortic trunks and renal arteries. The prevalence of aortic lesions in HI patients with arterial lesions was higher than that in patients with DN (P 0.027), but not anymore when adjusted for age (P < 0.559). Carotid Young’s modulus was lower in patients with DN, in association with the higher incidence of MSA lesions in this group.

Conclusion

The prevalence of aortic lesions is not influenced by the COL3A1 genotype when adjusted for age. Patients with DN variant vEDS have a higher frequency of MSA lesions, especially in supra-aortic trunks associated with lower carotid stiffness. These results support optimized care and follow-up for these vulnerable patients.

Somatic TEK variant with intraarticular venous malformation and knee hemarthrosis treated with rapamycin

BACKGROUND

Venous malformations (VMs) are the most common vascular anomalies and have been associated with somatic variants in TEK. Current treatment of VM joint component might be challenging due to the size or location of some lesions or ineffective with recurrence of malformed veins. Targeted molecular therapies after identification of genetic defects might be an alternative.

METHODS

We report a case with intraarticular bleeding due to VM with a TEK pathogenic somatic variant treated with rapamycin.

RESULTS

A 26-year-old female patient was evaluated for right calf pain secondary to venous malformation of the right inferior limb with an intraarticular component in the right knee. Hemarthrosis and degenerative chondropathy of the knee were evidenced at MRA. Molecular diagnosis evidenced a pathogenic somatic TEK variant. Rapamycin was introduced to stop bleeding, with good tolerance and efficacy.

CONCLUSION

The TEK receptor signals through the PI3K/AKT/mTOR pathway and TEK mutations have been linked to AKT activation. As rapamycin acts against angiogenesis and reduces phosphorylated-AKT levels, targeted molecular therapy should be discussed as first-line therapy in patients with proven molecular diagnosis and diffuse VM inaccessible to conventional treatment.

Comparative therapeutic strategies for preventing aortic rupture in a mouse model of vascular Ehlers-Danlos syndrome

Vascular Ehlers-Danlos syndrome is a rare inherited disorder caused by genetic variants in type III collagen. Its prognosis is especially hampered by unpredictable arterial ruptures and there is no therapeutic consensus. We created a knock-in Col3a1^+/G182R mouse model and performed a complete genetic, molecular and biochemical characterization. Several therapeutic strategies were also tested. Col3a1^+/G182R mice showed a spontaneous mortality caused by thoracic aortic rupture that recapitulates the vascular Ehlers-Danlos syndrome with a lower survival rate in males, thin non-inflammatory arteries and an altered arterial collagen. Transcriptomic analysis of aortas showed upregulation of genes related to inflammation and cell stress response. Compared to water, survival rate of Col3a1^+/G182R mice was not affected by beta-blockers (propranolol or celiprolol). Two other vasodilating anti-hypertensive agents (hydralazine, amlodipine) gave opposite results on aortic rupture and mortality rate. There was a spectacular beneficial effect of losartan, reversed by the cessation of its administration, and a marked deleterious effect of exogenous angiotensin II. These results suggest that blockade of the renin angiotensin system should be tested as a first-line medical therapy in patients with vascular Ehlers-Danlos syndrome.

Vascular Ehlers-Danlos syndrome (vEDS) is a rare vascular genetic disease leading to life-threatening arterial and colonic fragility in young adulthood. We created a new mutant mouse with a typical disease-causing variant in the gene responsible for vEDS. This mouse recapitulates the vEDS vascular features with spontaneous mortality due to aortic rupture. We also tested several antihypertensive therapeutic strategies to improve the survival of this mouse. Only one of the 5 tested medications, losartan, which blocks the activity of angiotensin II, a vasoconstricting hormone, improves the survival of this mouse. Moreover, the deleterious effect of angiotensin II administration further highlights the role of angiotensin II on susceptibility to aortic rupture in this mouse. These results support the interest of a therapeutic trial in vEDS patients using angiotensin II receptor blockers.

Cardiovascular and connective tissue disorder features in FLNA-related PVNH patients: progress towards a refined delineation of this syndrome

BACKGROUND

FLNA Loss-of-Function (LoF) causes periventricular nodular heterotopia type 1 (PVNH1), an acknowledged cause of seizures of various types. Neurological symptoms are inconstant, and cardiovascular (CV) defects or connective tissue disorders (CTD) have regularly been associated. We aimed at refining the description of CV and CTD features in patients with FLNA LoF and depicting the multisystemic nature of this condition.

METHODS

We retrospectively evaluated FLNA variants and clinical presentations in FLNA LoF patient with at least one CV or CTD feature, from three cohorts: ten patients from the French Reference Center for Rare Vascular Diseases, 23 patients from the national reference diagnostic lab for filaminopathies-A, and 59 patients from literature review.

RESULTS

Half of patients did not present neurological symptoms. Most patients presented a syndromic association combining CV and CTD features. CV anomalies, mostly aortic aneurysm and/or dilation were present in 75% of patients. CTD features were present in 75%. Variants analysis demonstrated an enrichment of coding variants in the CH1 domain of FLNA protein.

CONCLUSION

In FLNA LoF patients, the absence of seizures should not be overlooked. When considering a diagnosis of PVNH1, the assessment for CV and CTD anomalies is of major interest as they represent interlinked features. We recommend systematic study of FLNA within CTD genes panels, regardless of the presence of neurological symptoms.

Pseudoxanthoma elasticum overlaps hereditary spastic paraplegia type 56

PURPOSE

Pseudoxanthoma elasticum (PXE) is a recessive disorder involving skin, eyes and arteries, mainly caused by ABCC6 pathogenic variants. However, almost one fifth of patients remain genetically unsolved despite extensive genetic screening of ABCC6, as illustrated in a large French PXE series of 220 cases. We searched for new PXE gene(s) to solve the ABCC6-negative patients.

METHODS

First, family-based exome sequencing was performed, in one ABCC6-negative PXE patient with additional neurological features, and her relatives. CYP2U1, involved in hereditary spastic paraplegia type 56 (SPG56), was selected based on this complex phenotype, and the presence of two candidate variants. Second, CYP2U1 sequencing was performed in a retrospective series of 46 additional ABCC6-negative PXE probands. Third, six additional SPG56 patients were evaluated for PXE skin and eye phenotype. Additionally, plasma pyrophosphate dosage and functional analyses were performed in some of these patients.

RESULTS

6.4% of ABCC6-negative PXE patients (n = 3) harboured biallelic pathogenic variants in CYP2U1. PXE skin lesions with histological confirmation, eye lesions including maculopathy or angioid streaks, and various neurological symptoms were present. CYP2U1 missense variants were confirmed to impair protein function. Plasma pyrophosphate levels were normal. Two SPG56 patients (33%) presented some phenotypic overlap with PXE.

CONCLUSION

CYP2U1 pathogenic variants are found in unsolved PXE patients with neurological findings, including spastic paraplegia, expanding the SPG56 phenotype and highlighting its overlap with PXE. The pathophysiology of ABCC6 and CYP2U1 should be explored to explain their respective role and potential interaction in ectopic mineralization.

Periodontal (formerly type VIII) Ehlers-Danlos syndrome: Description of 13 novel cases and expansion of the clinical phenotype

Periodontal Ehlers-Danlos syndrome (pEDS) is a rare condition caused by pathogenic variants in the C1R and C1S genes, encoding subunits C1r and C1s of the first component of the classical complement pathway. It is characterized by early-onset periodontitis with premature tooth loss, pretibial hyperpigmentation and skin fragility. Rare arterial complications have been reported, but venous insufficiency is rarely described. Here we report 13 novel patients carrying heterozygous pathogenic variants in C1R and C1S including three novel C1S variants (c.962G > C, c.961 T > G and c.961 T > A). In addition to the pEDS phenotype, three patients and one relative displayed widespread venous insufficiency leading to persistent varicose leg ulcers. One patient suffered an intracranial aneurysm with familial vascular complications including thoracic and abdominal aortic aneurysm and dissection and intracranial aneurysm rupture. This work confirms that vascular complications can occur, although they are not frequent, which leads us to propose to carry out a first complete non-invasive vascular evaluation at the time of the diagnosis in pEDS patients. However, larger case series are needed to improve our understanding of the link between complement pathway activation and connective tissue alterations observed in these patients, and to better assess the frequency, type and consequences of the vascular complications.

Spontaneous Cervical Artery Dissection in Vascular Ehlers-Danlos Syndrome: A Cohort Study

BACKGROUND AND PURPOSE

Vascular Ehlers-Danlos syndrome is a rare inherited connective tissue disorder because of pathogenic variants in the COL3A1 gene. Arterial complications can affect all anatomic areas and about 25% involve supra-aortic trunks (SATs) but no systematic assessment of cervical artery lesions has been made. The primary objective was to determine an accurate prevalence of spontaneous SAT lesions in a large series of patients with vascular Ehlers-Danlos syndrome at diagnosis and during follow-up. Secondary objectives were to study their neurological consequences (transient ischemic attack or stroke) and the possible relationships with sex, genotype, ascertainment status.

METHODS

A retrospective review of a monocentric cohort of patients with molecularly proven vascular Ehlers-Danlos syndrome followed in a tertiary referral center from 2000 to 2017.

RESULTS

One hundred forty-four patients were analyzed, 56.9% (n=82) had SAT lesions: 64.6% females, 74.4% index-case patients. Most lesions were identified in early arterial assessment (48% at first work-up, mean age of 35.7±13.0 years). Cumulative incidence of a first identification of a SAT lesion was 41.7% at 40 years old. On the complete period of survey, 183 SAT lesions (with 132 dissections and 33 aneurysms) were identified, mainly in internal carotid arteries (56.3%) and vertebral arteries (28.9%), more rarely in patients with COL3A1 null mutations (P=0.008). Transient ischemic attack or stroke were reported in n=16 (19.5%) of the 82 patients with SAT lesions without relation with age, sex, treatment, or hypertension.

CONCLUSIONS

Cervical artery lesions are frequent and mostly asymptomatic in patients with vascular Ehlers-Danlos syndrome. Local dissections and aneurysms are the most frequent type of lesions, but transient ischemic attack or stroke seem rare.

Osmotic pressure estimation using the Pitzer equation for forward osmosis modelling

Forward osmosis (FO) has received widespread recognition in the past decade due to its potential low energy production of water. This study presents a new model analysis for predicting the water flux in FO systems when inorganic-based draw solutions are used under variable experimental conditions for using a laboratory scale cross-flow single cell unit. The new model accounts for the adverse impact of concentration polarization (both ICP and ECP) incorporating the water activity by Pitzer to calculate the bulk osmotic pressures. Using the water activity provides a better correlation of experimental data than the classical van't Hoff equation. The nonlinear model also gave a better estimate for the structural parameter factor (S) of the membrane in its solution. Furthermore, the temperature and concentration of both the draw and feed solutions played a significant role in increasing the water flux, which could be interpreted in terms of the mass transfer coefficient representing ECP; a factor sensitive to the hydraulics of the system. The model provides greatly improved correlations for the experimental water fluxes.

Communication of genetic information to at-risk relatives during the multidisciplinary monitoring of vascular Ehlers-Danlos syndrome in a French referral clinic

Vascular Ehlers-Danlos syndrome (vEDS) is a rare inherited disorder leading to arterial, digestive, and uterine complications due to pathogenic COL3A1 variants. Identification of causal variants allows family screening, provided that relatives have previously been informed, according to a 2013 French Decree. The aims of our study were to assess the communication of genetic information to at-risk relatives, the impact of diagnosis disclosure and to highlight a possible link between the experience of vEDS patients and ability to communicate about genetic information. A total of n = 51 vEDS adult probands answered a questionnaire during a clinical visit. Communication to relatives was considered effective if the proband gave information to some or all first-degree relatives and considered easily achieved if it was disclosed to all relatives less than a month after the diagnosis and without difficulty. Personal and family vEDS experiences of probands were also assessed. Effective communication of information to relatives was remarkably high (98%). Siblings were the most frequently informed relatives (82%). Women informed their at-risk relatives of genetic family screening faster (p = .006) and easier (p = .004) than men. There was no difference in the disclosure of information to relatives before and after 2013 in our multidisciplinary clinic. Regarding the lived experience of vEDS patients, they felt anxious (78%) at diagnosis disclosure but also considered this diagnosis as an opportunity to start a medical follow-up (82%) putting an end to diagnosis delay. Our findings highlight for the first time that the ability to easily inform at-risk first-degree relatives is related to the relief felt during vEDS-positive diagnosis disclosure (p = .04). In order to improve the communication of genetic information to relatives, we believe that psychological support should systematically be part of the multidisciplinary monitoring, just as medical follow-up and genetic counseling.

443Natural history of arterial morbidity in vascular ehlers-danlos syndrome

Background

Vascular Ehlers-Danlos syndrome (vascular EDS) is a rare inherited connective tissue disorder, responsible of exceptional organ fragility. The disease is caused by pathogenic COL3A1 variants with a dominant negative effect, except for variants leading to haploinsufficiency. The course of the disease is characterized by the occurrence of recurrent spontaneous arterial accidents (dissections, aneurysm formation, spontaneous ruptures), typically of medium size arteries.

Purpose

To describe the natural history of arterial accidents in a molecularly characterized population of patients with vascular EDS, that benefited from repeated standardized vascular monitoring in a tertiary referral centre.

Methods

All patients from the French natural reference centre for vascular EDS were included in a retrospective cohort study. Standardized monitoring of arterial beds was performed at molecular diagnosis (baseline) and every 15 months thereafter in clinically silent patients, by CT-angiogram or MRA, and by vascular Doppler Ultrasound. In case of symptomatic arterial accidents, diagnostic imaging was also reviewed for arterial defects. Arterial lesions were sorted by date of diagnosis and staged by anatomical location and by type of defect.

Results

Between January 2000 and March 2017, n=144 patients (n=91 index, Sex Ratio 0.68) were diagnosed with vascular EDS at a mean age of 34.0 [25.0; 41.0] years, and regularly followed-up in our centre for a median 5.80 [3.45; 8.80] years. Types of COLA3A1 variants were glycine substitutions (68%), splice-site (31.8%) and those leading to haplosufficiency (8.3%). During follow-up a median 1.57 [0.9; 3.0] arterial accidents per 5 years occurred and n=17 (11.8%) patients died. At first referral, a majority of patients (68.8%) had already presented a disease-related event, predominantly arterial ones, totalling 232 arterial defects (dissections, 72%; aneurysms, 11.2%; ruptures, 9%; carotid cavernous fistula, 4.3% and arteriovenous fistula, 0.9%). Vascular assessment at baseline identified another 255 arterial defects in the same patients that had not been reported previously. At each further vascular monitoring, one third (36%) of patients presented with new arterial defects, a majority of which (66%) were clinically silent. Moreover, 15% of patients at each vascular assessment had evolved on previously diagnosed arterial lesions (healing or aggravation). Notably, neither symptomatic arterial event nor silent evolutivity occurred in haploinsufficient patients.

Conclusion

This study gives an extensive insight into distribution, nature and timeline of arterial defects in patients with vascular EDS in a large patient cohort. Besides known and expected arterial morbidity and mortality, a consistent proportion of clinically silent patients developed new arterial lesions, suggesting that progression of arterial pathology in vascular EDS is not limited to symptomatic arterial events.

Natural history of gastrointestinal manifestations in vascular Ehlers-Danlos syndrome: A 17-year retrospective review

BACKGROUND AND AIM

Vascular Ehlers-Danlos syndrome (vEDS) is a rare connective tissue disorder due to heterozygous mutations in the COL3A1 gene with a dominant negative effect. Spontaneous bowel perforation and intra-abdominal organ rupture are common complications of vEDS. Other gastrointestinal (GI) manifestations may occur but have not been extensively characterized. We herein describe the natural history of GI events and surgery-related complications in patients with vEDS.

METHODS

A retrospective review of GI events in a large cohort of molecularly proven vEDS patients was conducted, after exclusion of mild forms of the disease.

RESULTS

Of 133 patients, 41% had a history of GI manifestations with 112 events, mean 2.0 ± 1.3 events per patient. There was an earlier occurrence of GI events in men (P 0.008). Cumulative incidence was 58% for all patients, higher in men and in patients with splice-site variants. Recurrence of GI events was reported in more than 50% of patients. Colonic perforation was the first digestive event for 47% of patients. Of 85 GI surgeries, 37 (43%) were complicated with 43 events. Nine deaths were reported in this population.

CONCLUSIONS

Vascular Ehlers-Danlos syndrome is characterized not only by bowel perforation but also by a wide variety of GI complications that occur in close to half (41%) of patients. The pattern of GI fragility seems more severe in males and splice-site variants. Complications of GI surgery are common and are related with tissue fragility/friability.

Accuracy of Clinical Diagnostic Criteria for Patients With Vascular Ehlers-Danlos Syndrome in a Tertiary Referral Centre

Background:

Vascular Ehlers-Danlos syndrome is a rare inherited connective tissue disease secondary to mutations within the COL3A1 gene. The diagnosis of vascular Ehlers-Danlos syndrome is challenging, and patient selection for genetic testing relies on diagnostic criteria, which have never been evaluated.

Methods:

All patients seen at a dedicated tertiary referral center for a suspicion of vascular Ehlers-Danlos syndrome between January 2001 and March 2016 were retrospectively included in a diagnostic accuracy study. Major and minor diagnostic criteria of the Villefranche classification were tested for sensitivity, specificity, positive and negative predictive values, according to results of genetic testing.

Results:

N=519 patients were eligible for analysis dividing into n=384 probands and n=135 relatives. A pathogenic COL3A1 variant was identified in n=165 (31.8%) patients. The Villefranche criteria were met for n=248 patients with a sensitivity of 79% (95% CI, 0.72–0.85) and a negative predictive value of 87% (95% CI, 0.83–0.91). Diagnostic accuracy was highest for symptomatic probands (sensitivity 92%; negative predictive value 95%) with limited specificity (60%). Probands ≤25 years had the worst diagnostic performance. The revised diagnostic Criteria (2017) were less accurate than the Villefranche classification (overall diagnostic odds-ratio, 4.17 versus 7.8; probands diagnostic odds-ratio, 4.04 versus 18.1; and probands ≤25 years diagnostic odds-ratio, 2.36 versus 5.1) mainly due to a lack of sensitivity.

Conclusions:

The Villefranche criteria provide accurate detection of symptomatic probands in specialized practice but have limited specificity. The revised diagnostic criteria for vascular Ehlers-Danlos syndrome have increased specificity, but its overall performance is poorer. The early clinical diagnosis of probands without family history is not addressed by both diagnostic classifications.

Accuracy of Clinical Diagnostic Criteria for Patients with Vascular Ehlers-Danlos Syndrome in a Tertiary Referral Centre

BACKGROUND

Vascular Ehlers-Danlos syndrome (vEDS) is a rare inherited connective tissue disease secondary to mutations within the COL3A1 gene. The diagnosis of vEDS is challenging and patient selection for genetic testing relies on diagnostic criteria, which have never been evaluated.

METHODS

All patients seen at a dedicated tertiary referral centre for a suspicion of vEDS between January 2001 and March 2016 were retrospectively included in a diagnostic accuracy study. Major and minor diagnostic criteria of the Villefranche classification were tested for sensitivity (Se), specificity (Sp), positive and negative predictive values (PPV, NPV), according to results of genetic testing.

RESULTS

N=519 patients were eligible for analysis dividing into n=384 probands and n=135 relatives. A pathogenic COL3A1 variant was identified in n=165 (31.8%) patients. The Villefranche criteria were met for n=248 patients with a Se of 79% (95%CI: 0.72-0.85) and a NPV of 87% (95%CI: 0.83-0.91). Diagnostic accuracy was highest for symptomatic probands (Se 92%; NPV 95%) with limited Sp (60%). Probands {less than or equal to}25 years had the worst diagnostic performance. The revised diagnostic Criteria (2017) were less accurate than the Villefranche classification (overall Diagnostic odds-ratio (DOR) 4.17 vs. 7.8, probands DOR 4.04 vs. 18.1; probands {less than or equal to}25 years DOR 2.36 vs. 5.1), mainly due to a lack of Se.

CONCLUSIONS

The Villefranche criteria provide accurate detection of symptomatic probands in specialized practice, but have limited Sp. The revised diagnostic criteria for vEDS have increased Sp, but its overall performance is poorer. The early clinical diagnosis of probands without family history is not addressed by both diagnostic classifications.

Pathophysiology of carotid-cavernous fistulas in vascular Ehlers-Danlos syndrome: a retrospective cohort and comprehensive review

Background

Vascular Ehlers-Danlos syndrome (vEDS) is a rare condition characterized by connective tissue fragility. Direct spontaneous carotid-cavernous fistula (sCCF) is reportedly pathognomonic of vEDS. We conducted this study to understand the possible mechanisms of occurrence of sCCF in this subset of patients.

Methods

We conducted a retrospective analysis of a monocentric vEDS cohort along with a literature review regarding sCCF in this condition.

Results

Of 133 patients regularly followed in our centre between 2000 and 2017, 13 (9.8%) had a diagnosis of direct sCCF (92.3% female, median age 33.0 years, interquartile range (IQR) [26.0–39.5]). There were 7 Glycine missense and 6 splice-site variants but no variant leading to haploinsufficiency. The literature search identified 97 vEDS patients with direct sCCF (79.4% female, 7.2% sex not reported, median age 31.0 years, IQR [24.0–39.0]). Increased carotid circumferential wall stress, higher carotid distensibility and lower carotid intima-media thickness could contribute to a higher risk for direct sCCF in vEDS. There is no predictive factor for the occurrence of sCCF apart from female sex in vEDS.

Conclusions

In vEDS, anatomical and pathophysiological features of the intra-cavernous internal carotid artery make it prone to shunting in the cavernous sinus, due either to a spontaneous rupture or to a spontaneous dissection with pseudoaneurysm formation. Direct sCCF in seemingly healthy young individuals should be highly suggestive of vEDS and prompt further investigation.

[Statins in primary prevention of cardiovascular disease]

Cardiovascular events are the second leading cause of death in France. The assessment of overall cardiovascular risk using a personalized assessment with weighting risk factors can predict the risk of cardiovascular events in ten years. The validated treatments to reduce cardiovascular mortality in primary prevention are few. The use of statins in primary prevention is discussed. We report in this review the updated conclusions from clinical trials regarding the treatment with statins in primary prevention.

Feasibility of the membrane bioreactor process for water reclamation

The feasibility of the membrane bioreactor (MBR) process for water reclamation was studied. Process evaluation was based on the following: literature review of MBRs, worldwide survey of MBRs, and preliminary costs estimates. The literature review and the survey have shown that the MBR process offers several benefits over the conventional activated sludge process, including: smaller space and reactor requirements, better effluent water quality, disinfection, increased volumetric loading, and less sludge production. The MBR process can exist in two different configurations, one with the low-pressure membrane modules replacing the clarifier downstream the bioreactor (in series), and the second with the membranes submerged within the bioreactor. Four major companies are currently marketing MBRs while many other companies are also in the process of developing new MBRs. The MBR process operates in a considerably different range of parameters than the conventional activated sludge process. The preliminary cost evaluation has shown that the MBR process is cost competitive with other conventional wastewater treatment processes.

Evaluation of an integrated membrane system for water repurification

An integrated membrane system was evaluated for water repurification. Performance evaluation of the membrane system was based on three criteria: flux and fouling, disinfection capability, and rejection of pollutants. Minimal membrane fouling was observed for all of the membranes employed in the study. Significant contaminant rejection was also achieved by the membrane system purifying the reclaimed water to meet and exceed drinking water standards. Wide range of virus rejection was observed for the membranes, which was dependent on the membrane type, manufacturer, and the fouling status. Overall, the results of this study demonstrated that the integrated membrane system is a very effective and reliable process for water repurification.