The mitochondrial tRNA MT-TW m.5537_5538insT variant presents with significant intra-familial clinical variability

Mitochondrial disorders can present with a wide range of clinical and biochemical phenotypes. Mitochondrial DNA variants may be influenced by factors such as degree of heteroplasmy and tissue distribution. We present a four-generation family in which 10 individuals carry a pathogenic mitochondrial variant (m.5537_5538insT, MT-TW gene) with differing levels of heteroplasmy and clinical features. This genetic variant has been documented in two prior reports, both in individuals with Leigh syndrome. In the current family, three individuals have severe mitochondrial symptoms including Leigh syndrome (patient 1, 100% in blood), MELAS (patient 2, 97% heteroplasmy in muscle), and MELAS-like syndrome (patient 3, 50% heteroplasmy in blood and 100% in urine). Two individuals have mild mitochondrial symptoms (patient 4, 50% in blood and 67% in urine and patient 5, 50% heteroplasmy in blood and 30% in urine). We observe that this variant is associated with multiple mitochondrial presentations and phenotypes, including MELAS syndrome for which this variant has not previously been reported. We also demonstrate that the level of heteroplasmy of the mitochondrial DNA variant correlates with the severity of clinical presentation; however, not with the specific mitochondrial syndrome.

Brain Point of Care Ultrasound in Young Children Receiving Computed Tomography in the Emergency Department: A Proof of Concept Study

Background: Point of Care Ultrasound (POCUS) is an important tool in pediatric emergency medicine. In neonatal intensive care medicine ultrasound is often used to evaluate the brains of sick neonates. In theory, POCUS could be used in the ED in young children to evaluate the brain for abnormal pathology. Objectives: To examine the ability of PEM faculty to use brain POCUS to identify clinically significant brain injuries in children with head injuries and/or abnormal neurological exams, and generate sensitivity and specificity of brain POCUS in assessing such findings. Methods: This study used a convenience sample of patients seen in a tertiary care pediatric centre who required a CT head. A team of physicians who were trained at a workshop for brain POCUS were on call to perform the POCUS while being blinded to the results of the CT. Results: 21 children were enrolled in the study. Five (24%) of the patients had a CT that was positive for intracranial bleeds. Of the 5 patients with a positive CT, 3 had a brain POCUS scan that was also positive. The two false negative brain POCUS scans were on patients with small bleeds (no surgical intervention required) on CT, as reported by radiology. The sensitivity of brain POCUS was 60% (CI 15% - 95%) with a specificity of 94% (CI 70%-100%). The diagnostic accuracy of brain POCUS was 86% (CI 64% - 97%). Conclusion: This small proof of concept study shows that brain POCUS is an imaging modality with reasonable sensitivity and specificity in identifying intracranial pathologies that are present on CT. Its use may be most beneficial to expedite definitive imaging and subspeciality involvement.

MR Enterography Scores Correlate with Degree of Mucosal Healing in Pediatric Crohn's Disease: A Pilot Study

Objectives

MR enterography (MRE) Index of Activity (MaRIA) and Clermont are validated scores that correlate with Crohn's disease (CD) activity; however, the Clermont score has not been validated to correlate with the degree of change in mucosal inflammation post induction treatment in children. This pilot study evaluated if MaRIA and Clermont scores can serve as surrogates to ileocolonoscopy for assessing interval change in mucosal inflammation in pediatric CD post-induction treatment.

Methods

Children with known or newly diagnosed ileocolonic CD starting or changing therapy underwent ileocolonoscopy, scored with simple endoscopic score for Crohn's disease (SES-CD), and MRE on the same day at two time points (Week 0 and 12). Accuracy of global MaRIA and Clermont indices relative to ileocolonoscopy in detecting degree of post-treatment interval change in mucosal inflammation was assessed through correlational coefficients (r). Inter-reader agreement was calculated for imaging scores through intraclass correlation (ICC).

Results

Sixteen children (mean age 11.5 ± 2.8) were evaluated. Global MaRIA/Clermont correlated with SES-CD in detecting the degree of change in mucosal inflammation (r = 0.676 and r = 0.677, P < 0.005, respectively). Correlation for pooled timepoint assessments between SES-CD and global MaRIA/Clermont was moderate (r = 0.546, P < 0.001 and r = 0.582, P < 0.001, respectively). Inter-rater reliability for global MaRIA and Clermont was good (ICC = 0.809 and ICC = 0.768, respectively, P < 0.001).

Conclusions

MRE-based global scores correlate with endoscopic indices and may be used to monitor disease changes in children with CD undergoing induction treatment, which can advise the physician if treatment changes should be made.

The White Matter Rounds experience: The importance of a multidisciplinary network to accelerate the diagnostic process for adult patients with rare white matter disorders

Introduction

Adult genetic leukoencephalopathies are rare neurological disorders that present unique diagnostic challenges due to their clinical and radiological overlap with more common white matter diseases, notably multiple sclerosis (MS). In this context, a strong collaborative multidisciplinary network is beneficial for shortening the diagnostic odyssey of these patients and preventing misdiagnosis. The White Matter Rounds (WM Rounds) are multidisciplinary international online meetings attended by more than 30 physicians and scientists from 15 participating sites that gather every month to discuss patients with atypical white matter disorders. We aim to present the experience of the WM Rounds Network and demonstrate the value of collaborative multidisciplinary international case discussion meetings in differentiating and preventing misdiagnoses between genetic white matter diseases and atypical MS.

Methods

We retrospectively reviewed the demographic, clinical and radiological data of all the subjects presented at the WM Rounds since their creation in 2013.

Results

Seventy-four patients (mean age 44.3) have been referred and discussed at the WM Rounds since 2013. Twenty-five (33.8%) of these patients were referred by an MS specialist for having an atypical presentation of MS, while in most of the remaining cases, the referring physician was a geneticist (23; 31.1%). Based on the WM Rounds recommendations, a definite diagnosis was made in 36/69 (52.2%) patients for which information was available for retrospective review. Of these diagnosed patients, 20 (55.6%) had a genetic disease, 8 (22.2%) had MS, 3 (8.3%) had both MS and a genetic disorder and 5 (13.9%) had other non-genetic conditions. Interestingly, among the patients initially referred by an MS specialist, 7/25 were definitively diagnosed with MS, 5/25 had a genetic condition (e.g., X-linked adrenoleukodystrophy and hereditary small vessel diseases like Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) and COL4A1-related disorder), and one had both MS and a genetic demyelinating neuropathy. Thanks to the WM Rounds collaborative efforts, the subjects who currently remain without a definite diagnosis, despite extensive investigations performed in the clinical setting, have been recruited in research studies aimed at identifying novel forms of genetic MS mimickers.

Conclusions

The experience of the WM Rounds Network demonstrates the benefit of collective discussions on complex cases to increase the diagnostic rate and decrease misdiagnosis in patients with rare or atypical white matter diseases. Networks of this nature allow physicians and scientists to compare and share information on challenging cases from across the world, provide a basis for future multicenter research studies, and serve as model for other rare diseases.

Development and Validation of a Pediatric MRI-Based Perianal Crohn Disease (PEMPAC) Index-A Report from the ImageKids Study

BACKGROUND

As part of the prospective multicenter ImageKids study, we aimed to develop and validate the pediatric MRI-based perianal Crohn disease (PEMPAC) index.

METHODS

Children with Crohn disease with any clinical perianal findings underwent pelvic magnetic resonance imaging at 21 sites globally. The site radiologist and 2 central radiologists provided a radiologist global assessment (RGA) on a 100 mm visual analog scale and scored the items selected by a Delphi group of 35 international radiologists and a review of the literature. Two weighted multivariable statistical models were constructed against the RGA.

RESULTS

Eighty children underwent 95 pelvic magnetic resonance imaging scans; 64 were used for derivation and 31 for validation. The following items were included: fistula number, location, length and T2 hyperintensity; abscesses; rectal wall involvement; and fistula branching. The last 2 items had negative beta scores and thus were excluded in a contending basic model. In the validation cohort, the full and the basic models had the same strong correlation with the RGA (r = 0.75; P < 0.01) and with the adult Van Assche index (VAI; r = 0.93 and 0.92; P < 0.001). The correlation of the VAI with the RGA was similar (r = 0.77; P < 0.01). The 2 models and the VAI had a similar ability to differentiate remission from active disease (area under the receiver operating characteristic curve, 0.91-0.94). The PEMPAC index had good responsiveness to change (area under the receiver operating characteristic curve, 0.89; 95% confidence interval, 0.69-1.00).

CONCLUSIONS

Using a blended judgmental and mathematical approach, we developed and validated an index for quantifying the severity of perianal disease in children with CD. The adult VAI may also be used with confidence in children.

Is horseshoe lung a component of VACTERL spectrum? Case report and review of literature

Horseshoe lung (HL) is a rare congenital anomaly that has been classically associated with Scimitar syndrome. Very few cases have been described in the context of the VACTERL spectrum. We present a case of a newborn girl with mesocardia, tracheoesophageal fistula, and imperforated anus, who required O2 support at birth and during hospitalization. A chest CT angiography revealed a HL as an incidental finding. We suspect that HL and the VACTERL spectrum, are not separated entities but likely a further expansion of VACTERL-associated symptoms. HL might be underdiagnosed in asymptomatic patients as Chest CT angiography is not part of the routine work up for patients with VACTERL association.

Whole genome sequencing identifies pathogenic RNU4ATAC variants in a child with recurrent encephalitis, microcephaly, and normal stature

Biallelic pathogenic variants in RNU4ATAC have been linked to microcephalic osteodysplastic primordial dwarfism type 1 (MOPD1). Although children with MOPD1 have been reported to show profound, life-limiting clinical decompensation at the time of a febrile illness, these episodes including magnetic resonance imaging (MRI) findings have not been well characterized. We present acute MRI brain findings for a 10-year-old girl with homozygous variants in RNU4ATAC (NR_023343.1) n.55G>A, who presented with two episodes of clinical decompensation associated with a febrile illness in early childhood. The pathogenic variants were identified by whole genome sequencing as RNU4ATAC is not captured in most exome products. Her MRI of the brain revealed symmetric, diffusion restriction of the deep gray nuclei that initially pointed to a mitochondrial disease or acute necrotizing encephalopathy. Her phenotype included microcephaly and profound cognitive impairment that can be seen with MOPD1. However, she did not demonstrate clinical or radiographic evidence of a spondyloepimetaphyseal dysplasia or "primordial dwarfism" that is characteristic of this disease. As such, the predominant neurological presentation of this child represents an atypical variant of RNU4ATAC-associated disease and should be a diagnostic consideration for geneticists and neurologists caring for children, particularly in the event of an acute clinical decline.

Comparison of Acute Effects of Neurotoxic Compounds on Network Activity in Human and Rodent Neural Cultures

Assessment of neuroactive effects of chemicals in cell-based assays remains challenging as complex functional tissue is required for biologically relevant readouts. Recent in vitro models using rodent primary neural cultures grown on multielectrode arrays allow quantitative measurements of neural network activity suitable for neurotoxicity screening. However, robust systems for testing effects on network function in human neural models are still lacking. The increasing number of differentiation protocols for generating neurons from human-induced pluripotent stem cells (hiPSCs) holds great potential to overcome the unavailability of human primary tissue and expedite cell-based assays. Yet, the variability in neuronal activity, prolonged ontogeny and rather immature stage of most neuronal cells derived by standard differentiation techniques greatly limit their utility for screening neurotoxic effects on human neural networks. Here, we used excitatory and inhibitory neurons, separately generated by direct reprogramming from hiPSCs, together with primary human astrocytes to establish highly functional cultures with defined cell ratios. Such neuron/glia cocultures exhibited pronounced neuronal activity and robust formation of synchronized network activity on multielectrode arrays, albeit with noticeable delay compared with primary rat cortical cultures. We further investigated acute changes of network activity in human neuron/glia cocultures and rat primary cortical cultures in response to compounds with known adverse neuroactive effects, including gamma amino butyric acid receptor antagonists and multiple pesticides. Importantly, we observed largely corresponding concentration-dependent effects on multiple neural network activity metrics using both neural culture types. These results demonstrate the utility of directly converted neuronal cells from hiPSCs for functional neurotoxicity screening of environmental chemicals.

Soft Tissue Lesions With High Vascular Density on Sonography in Pediatric Patients: Beyond Hemangiomas [Formula: see text]

Infantile hemangiomas are the most frequent vascular soft tissue lumps in the pediatric population. The clinical presentation and evolution of these lesions is characteristic, while the sonographic appearance is classic but not specific. This pictorial essay illustrates the different vascular soft tissue lumps on ultrasound that may mimic infantile hemangiomas. Awareness of these mimics is crucial to avoid misdiagnosis. Clinical and sonographic discriminators for each lesion are presented.

Whole-Body Diffusion-Weighted MRI Compared to 18 FFDG PET/CT in Initial Staging and Therapy Response Assessment of Hodgkin Lymphoma in Pediatric Patients

PURPOSE

The aim of our study was to compare whole-body diffusion-weighted MRI (WB-DWI-MRI) to fluoro-2-deoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) in the assessment of initial staging and treatment response in pediatric patients with Hodgkin lymphoma.

MATERIALS AND METHODS

This prospective study comprised 11 children with Hodgkin lymphoma. Whole-body DWI-MRI and FDG-PET/CT were obtained at baseline and after 2 cycles of chemotherapy. Two radiologists measured the apparent diffusion coefficient (ADC) values of the sites of involvement agreed upon in consensus and 1 nuclear medicine physician assessed the PET/CT. Reliability of radiologists' ratings was assessed by intraclass correlation coefficients (ICC_2,1). The sensitivity and positive predictive value (PPV) of DW-MRI relative to PET/CT were calculated for nodal and extranodal sites. The patients were staged according to both modalities. Association of treatment responses was assessed through the Pearson correlation between the ADC ratios and the change standardized uptake value (SUV) between baseline and follow-up.

RESULTS

There was good agreement between the raters for nodal and extranodal ADC measurements. The sensitivity and PPV of DW-MRI relative to PET/CT of nodal disease was 0.651 and 1.0, respectively, at baseline, and 0.697 and 0.885 at follow-up. The sensitivity and PPV of extranodal disease were 0.545 and 0.6 at baseline, and 0.167 and 0.333 at follow-up. Diffusion-weighted MRI determined correct tumor stage in 8 of 11 examinations. There was poor correlation between the ADC ratios and the absolute change in SUV between baseline and follow-up (0.348).

CONCLUSION

Our experience showed that WB-DWI-MRI is inferior to PET/CT for initial staging and assessment of treatment response of Hodgkin lymphoma in pediatric patients.

Clinical delineation of GTPBP2-associated neuro-ectodermal syndrome: Report of two new families and review of the literature

The GTPBP2 gene encodes a guanosine triphosphate (GTP)-binding protein of unknown function. Biallelic loss-of-function variants in the GTPBP2 gene have been previously reported in association with a neuro-ectodermal clinical presentation in six individuals from four unrelated families. Here, we provide detailed descriptions of three additional individuals from two unrelated families in the context of the previous literature. Both families carry nonsense variants in GTPBP2: homozygous p.(Arg470*) and compound heterozygous p.(Arg432*)/p.(Arg131*). Key features of this clinically recognizable condition include prenatal onset microcephaly, tone abnormalities, and movement disorders, epilepsy, dysmorphic features, retinal dysfunction, ectodermal dysplasia, and brain iron accumulation. Our findings suggest that some aspects of the clinical presentation appear to be age-related; brain iron accumulation may appear only after childhood, and the ectodermal findings and peripheral neuropathy are most prominent in older individuals. In addition, we present prenatal and neonatal findings as well as the first Caucasian and black African families with GTPBP2 biallelic variants. The individuals described herein provide valuable additional phenotypic information about this rare, novel, and progressive neuroectodermal condition.

Influence of timing of initiation of therapeutic hypothermia on brain MRI and neurodevelopment at 18 months in infants with HIE: a retrospective cohort study

OBJECTIVE

To examine the influence of timing of initiation of therapeutic hypothermia (TH) on brain injury on MRI and on neurodevelopmental outcomes at 18 months.

DESIGN

Retrospective cohort study.

SETTING

Tertiary neonatal intensive care unit in Ontario, Canada.

PATIENTS

Ninety-one patients with hypoxic ischaemic encephalopathy (HIE) were included, 54 in the early TH group and 37 in the late TH group.

INTERVENTION

Whole-body hypothermia administered for 72 hours, initiated either before 3 hours of life (early TH) or between 3 and 6 hours of life (late TH).

MAIN OUTCOME MEASURES

Brain injury on MRI after TH (assessed by two neuroradiologists), and neurodevelopmental outcomes at 18 months old.

RESULTS

TH was initiated at a median time of 1.4 hours (early TH) and 4.4 hours (late TH). Sixty-four neonates (early TH=36, late TH=28) survived and completed neurodevelopmental assessment at 18 months. Neonates in the early TH group received more extensive resuscitation than neonates in the late TH group (p=0.0008). No difference was observed between the two groups in the pattern or severity of brain injury on MRI, or in the neurodevelopmental outcomes at 18 months. The non-survivors (n=16) had lower Apgar scores at 10 min, more extensive resuscitation, suffered from more severe HIE and had significantly more abnormal cerebral function monitoring.

CONCLUSION

In this retrospective cohort study, TH initiated early was associated neither with a difference in brain injury on MRI nor better neurodevelopmental outcomes at 18 months.

Current concepts in radiologic assessment of pediatric brain tumors during treatment, part 1

Pediatric brain tumors differ from those in adults by location, phenotype and genotype. In addition, they show dissimilar imaging characteristics before and after treatment. While adult brain tumor treatment effects are primarily assessed on MRI by measuring the contrast-enhancing components in addition to abnormalities on T2-weighted and fluid-attenuated inversion recovery images, these methods cannot be simply extrapolated to pediatric central nervous system tumors. A number of researchers have attempted to solve the problem of tumor assessment during treatment in pediatric neuro-oncology; specifically, the Response Assessment in Pediatric Neuro-Oncology (RAPNO) working group was recently established to deal with the distinct challenges in evaluating treatment-related changes on imaging, but no established criteria are available. In this article we review the current methods to evaluate brain tumor therapy and the numerous challenges that remain. In part 1, we examine the role of T2-weighted imaging and fluid-attenuated inversion recovery sequences, contrast enhancement, volumetrics and diffusion imaging techniques. We pay particular attention to several specific pediatric brain tumors, such as optic pathway glioma, diffuse midline glioma and medulloblastoma. Finally, we review the best means to assess leptomeningeal seeding.

Brief Review on Metabolic Bone Disease

Metabolic bone disease (MBD) is a broad term that describes a clinically heterogeneous group of diseases that are only united by a common denominator of an aberrant bone chemical milieu leading to a defective skeleton and bone abnormalities. From a forensic pathologist's perspective, MBDs create a challenging diagnostic dilemma in differentiating them from child abuse, particularly when the victim is an infant. Through this brief narrative review on MBD, bone pathophysiology and two relatively challenging pediatric MBDs will be discussed.

DOES THE TIMING OF INITIATION OF THERAPEUTIC HYPOTHERMIA INFLUENCE MRI FINDINGS AND OUTCOMES IN ENCEPHALOPATHIC BABIES?

BACKGROUND

Therapeutic hypothermia (TH), initiated < 6h of life, is the standard treatment for infants with moderate to severe hypoxic ischemic encephalopathy (HIE). While preclinical studies show that TH is more effective when started early, little clinical data exists.

OBJECTIVES

The objectives of our study are to examine the effect of early vs. late TH on the severity and pattern of brain injury on MRI and on the neurodevelopmental outcomes.

DESIGN/METHODS

This retrospective cohort included infants with HIE treated with TH at a level three neonatal intensive care unit between 2009 and 2016. Babies were grouped into: early cooling (TH started ≤ 180 minutes of life) or late cooling (TH started > 180 minutes of life). Two radiologists evaluated the severity and pattern of brain injury on MRI using both NICHD and Barkovich scoring system. Neurodevelopmental outcomes were evaluated at 4, 10, 18 and 48 months.

RESULTS

Ninety-four patients (median gestational age 39 weeks; median birth weight 3.3 kg) were included in the study, 55 in the early cooling and 39 in the late cooling group. The early cooling group included more patients with severe HIE (32.7% vs 10.3%, p=0.01). No difference was observed between the 2 groups in regard to the pattern and severity of brain injury. In the late cooling group, there was a trend toward more severe watershed (WS) injury (WS score ≥3) (30.6% vs 17%, p=0.19) and more moderate to severe brain injury (33.3% vs 23.4%, p=0.33). There was no difference in the neurodevelopmental outcomes between the 2 groups.

CONCLUSION

TH initiated early (before 180 minutes of life) was neither associated with a difference in brain injury on MRI nor better neurodevelopmental outcomes. Despite having more infants with severe HIE in the early cooling group, there was a trend toward less significant brain injury in this group.

Bilateral Piriform sinus fistulas: a case study and review of management options

BACKGROUND

Piriform sinus fistulas occur due to developmental abnormalities of the third and fourth branchial arches, and almost always occur unilaterally. They generally present as recurrent abscesses in the anterior-inferior neck, with concurrent thyroiditis. They have conventionally been managed with complete removal of the sinus tract, and thyroidectomy if required; however, endoscopic approaches have been increasingly favored. Herein we describe a case of bilateral piriform sinus fistulas, and present a review of the literature concerning their endoscopic management.

CASE PRESENTATION

Our patient was determined to have bilateral piriform sinus fistulas based on computer tomography, magnetic resonance imaging and microlaryngoscopy. We performed electrocauterization of the proximal fistula tracts, followed by injection of fibrin sealent. Our patient has not had a recurrence in the ten months since his procedure. There were no complications. Twenty-three articles describing an endoscopic approach to these fistulas were identified through PubMed, and a search through the references of related articles was completed.

CONCLUSION

Of one hundred and ninety-five patient cases we reviewed, an endoscopic procedure success rate of 82% and complication rate of 5.6% was determined. Piriform sinus fistulas that occur bilaterally are a rare congenital abnormality of the neck. Endoscopic approaches are an acceptable alternative option to open procedures, with similar success and a lower rate of complications.

Worsening anemia associated with volvulus in a stable neonate with intestinal obstruction

Intrauterine intestinal obstruction complicated by midgut volvulus is a serious life-threatening diagnosis. Immediate surgical intervention is generally the course of action upon diagnosis to prevent morbidity and mortality. We report a case of intrauterine intestinal obstruction where the neonate then presented with an unusual onset of volvulus within the first 12 hours of life. The patient was born with generalized edema, a distended abdomen, and pallor. Unlike many cases, the patient did not present with typical signs of volvulus. Diagnostic imaging preceding delivery and the stable postnatal clinical course did not offer a justification for immediate laparotomy. Less than 24 hours later, the patient's hemoglobin significantly dropped leading to an emergent laparotomy. Findings included a volvulus of the terminal ileum and large amounts of intraluminal blood. Our case report includes an analysis of clinical observations that should be considered so that patients presenting with similar signs receive earlier surgical intervention.

Broad spectrum of neuropsychiatric phenotypes associated with white matter disease in PTEN hamartoma tumor syndrome

White matter lesions have been described in patients with PTEN hamartoma tumor syndrome (PHTS). How these lesions correlate with the neurocognitive features associated with PTEN mutations, such as autism spectrum disorder (ASD) or developmental delay, has not been well established. We report nine patients with PTEN mutations and white matter changes on brain magnetic resonance imaging (MRI), eight of whom were referred for reasons other than developmental delay or ASD. Their clinical presentations ranged from asymptomatic macrocephaly with normal development/intellect, to obsessive compulsive disorder, and debilitating neurological disease. To our knowledge, this report constitutes the first detailed description of PTEN-related white matter changes in adult patients and in children with normal development and intelligence. We present a detailed assessment of the neuropsychological phenotype of our patients and discuss the relationship between the wide array of neuropsychiatric features and observed white matter findings in the context of these individuals.

Rickets: Historical, Epidemiological, Pathophysiological, and Pathological Perspectives

Rickets was a common metabolic disease of bone a century ago in Europe, North America, and East Asia (mainly due to vitamin D deficiency) but was largely eradicated in growing children by use of cod liver oil and the introduction of vitamin D fortification of milk in the 1930s in the United States. Vitamin D deficiency (VDD) remains the most common form of metabolic bone disease that is entirely preventable and treatable. Historically, rickets has appeared in sporadic epidemics and, despite the introduction of numerous preventive strategies, VDD has remained a global health problem amongst children. Moreover, developed countries such as Canada, Australia, the United Kingdom, and the United States have not been exempt from this. The radiological and histological features of rickets are both distinctive and characteristic and they reflect the underlying pathophysiological issue of decreased mineralization of bone as a result of VDD. The radiological features include 1) metaphyseal cupping and fraying, 2) poor mineralization of epiphyseal centers, 3) irregular and widened epiphyseal plates, 4) increased distance between the end of shaft and epiphyseal center, 5) cortical spurs at right angles to the metaphysis, 6) coarse trabeculation, and 7) periosteal reactions. Fractures may also be evident. The histological features of rickets reflect the failure of cartilage to mineralize and undergo resorption. This results in 1) disordered proliferation of chondrocytes in the hypertrophic zone secondary to a lack of apoptosis, 2) loss of the columnar arrangement of chondrocytes that results in thickening and disorganization of the hypertrophic zone, 3) tongue-like projections of cartilage that extend into the spongiosa, 4) irregularity of the limit between the proliferative and hypertrophic zones, and 5) penetration of blood vessels into the hypertrophic zone. The case of a premature 3-month-old female infant, born in the winter months in the arctic region of Canada who died from a lobar pneumonia with an incidental finding of radiological and pathological evidence of rickets, is presented. The case is used to review the entity of rickets from historical, pathophysiological, radiological, and histological perspectives.

Prevalence and risk factors for non-alcoholic fatty liver in children and youth with obesity

Background

Non- Alcoholic Fatty Liver (NAFL) is a spectrum of liver diseases (LD) that ranges from benign fatty infiltration of the liver to cirrhosis and hepatic failure. Hepatic ultrasound (US) and serum alanine aminotransferase (ALT) are often used as markers of NAFL. Our aim is to describe prevalence of NAFL and associated findings on ultrasound (US) and biochemical parameters in a population of children and adolescents with obesity at the Children’s Hospital of Eastern Ontario.

Methods

Children with Obesity (BMI >95th percentile) ages 8–17 years presenting to the Endocrinology and Gastroenterology clinics, without underlying LD were prospectively recruited from 2009 to 2012. Fasting lipid profile, HOMA IR) and serum adiponectin levels were measured. NAFL was defined as ALT > 25 and >22 IU/mL (males and females respectively) and/or evidence of fatty infiltration by US. Logistic regression was performed to assess associations.

Results

97 children with obesity included in the study (Male 43%). Mean age was 12.9 ± 3.2 years (84% were older than 10 y). Mean BMI-Z score was 3.8 ± 1.4. NAFL was identified in 85%(82/97) of participants. ALT was elevated in 61% of patients. Median triglyceride (TG) level was higher in children with NAFL(1.5 ± 0.9 vs. 1.1 ± 0.5 mmol/L, p = 0.01). Total cholesterol, HDL, LDL and Non HDL cholesterol were similar in both groups(p = 0.63, p = 0.98, p = 0.72 and p = 0.37 respectively). HOMA IR was ≥3.16 in 53% of children(55% in those with NAFL and 40% in those without NAFL). Median serum adiponectin was 11.2 μg/ml(IQR 7.3–18.3) in children with NAFL vs. 16.1 μg/ml(IQR 9.0–21.9) in those without NAFL(p = 0.23). Liver US was reported as normal in 30%, mild fatty infiltration in 38%, moderate in 20% and severe in 12%. TG were significantly higher(1.5 mmol/L vs. 1.0 mmol/L, p < 0.01) and HDL-C was lower(1.0 mmol/L vs. 1.1 mmol/L, p = 0.05) in children with moderate and severe NAFL by US. BMI-Z score, HOMA IR, serum adiponectin and HDL levels were not associated with NAFL, however TG were significantly associated(OR = 3.22 (95% CI: 1.01–10.25, p = 0.04)).

Conclusion

NAFL is highly prevalent in obese children and youth. Elevated TG levels are associated with NAFL; these findings may serve as a noninvasive screening tool to help clinicians identify children with obesity needing liver biopsy and/or more aggressive therapeutic interventions.

Social support buffers the effect of interpersonal life stress on suicidal ideation and self-injury during adolescence

BACKGROUND

The effect of life stress on suicidal symptoms during adolescence is well documented. Stressful life events can trigger suicidality, but most adolescents are resilient and it is unclear which factors protect against the deleterious impact of stress. Social support is thought to be one such factor. Therefore, we investigated the buffering effect of specific sources of social support (parental and peer) on life stress (interpersonal and non-interpersonal) in predicting suicidal symptoms during adolescence. In order to test the specificity of this stress buffering, we also examined it with regard to dysphoric mood.

METHOD

Data come from the Adolescent Development of Emotions and Personality Traits (ADEPT) Project, a cohort of 550 adolescent females aged 13.5-15.5 recruited from Long Island. Self-reported social support, suicidality, and dysphoria were assessed at baseline and suicidality and dysphoria were assessed again at 9-month follow-up. Life stress was assessed by interview at the follow-up.

RESULTS

High levels of parental support protected adolescent girls from developing suicidal symptoms following a stressor. This effect was less pronounced for peer support. Also, social support did not buffer the pathogenic effects of non-interpersonal stress. Finally, social support did not buffer the effect of life stress on dysphoric symptoms.

CONCLUSIONS

Altogether, our results highlight a distinct developmental pathway for the development of suicidal symptoms involving parental support that differs from the development of dysphoria, and signifies the importance and specificity of social support in protecting against suicidality in adolescent girls.

Late diagnosis of cerebral folate deficiency: Fewer seizures with folinic acid in adult siblings

Cerebral folate deficiency is a genetically heterogeneous condition.(1) Mutations in FOLR1 are responsible for a rare but treatable form of cerebral folate deficiency (OMIM #613068).(1) The gene codes for folate receptor alpha (FRα), a specific CNS folate transporter. Individuals with FOLR1-related folate deficiency present with ataxia, dyskinesia, spasticity, seizures, and regression in cognitive abilities and motor skills during early childhood.(2) Seizures commonly observed include generalized tonic-clonic, atonic, and myoclonic.(3) To date, there have been 18 individuals with FOLR1-related cerebral folate deficiency diagnosed in childhood and reported in the literature.(3-5) Early diagnosis is crucial, as high-dose folinic acid (2-5 mg/kg/day) has been reported to be an effective treatment that can ameliorate or even prevent further neurodegeneration, although no long-term treatment studies have been performed.(1,3,5,6) We present the late diagnosis of adult siblings with cerebral folate deficiency due to FOLR1 mutations and their subsequent treatment.

Homozygous mutation in the eukaryotic translation initiation factor 2alpha phosphatase gene, PPP1R15B, is associated with severe microcephaly, short stature and intellectual disability

Protein translation is an essential cellular process initiated by the association of a methionyl-tRNA with the translation initiation factor eIF2. The Met-tRNA/eIF2 complex then associates with the small ribosomal subunit, other translation factors and mRNA, which together comprise the translational initiation complex. This process is regulated by the phosphorylation status of the α subunit of eIF2 (eIF2α); phosphorylated eIF2α attenuates protein translation. Here, we report a consanguineous family with severe microcephaly, short stature, hypoplastic brainstem and cord, delayed myelination and intellectual disability in two siblings. Whole-exome sequencing identified a homozygous missense mutation, c.1972G>A; p.Arg658Cys, in protein phosphatase 1, regulatory subunit 15b (PPP1R15B), a protein which functions with the PPP1C phosphatase to maintain dephosphorylated eIF2α in unstressed cells. The p.R658C PPP1R15B mutation is located within the PPP1C binding site. We show that patient cells have greatly diminished levels of PPP1R15B-PPP1C interaction, which results in increased eIF2α phosphorylation and resistance to cellular stress. Finally, we find that patient cells have elevated levels of PPP1R15B mRNA and protein, suggesting activation of a compensatory program aimed at restoring cellular homeostasis which is ineffective due to PPP1R15B alteration. PPP1R15B now joins the expanding list of translation-associated proteins which when mutated cause rare genetic diseases.

Brain malformations in a patient with deletion 2p16.1: A refinement of the phenotype to BCL11A

Microdeletions of 2p15-16.1 have been reported in 15 patients with a recognizable syndrome of dysmorphic features, intellectual disability and microcephaly. Facial features include telecanthus, short palpebral fissures, epicanthal folds, a broad nasal root, smooth and long philtrum and large ears. Brain malformations can be observed in this syndrome and include hypoplasia of the corpus callosum and a simplified cortical gyral pattern. Case reports have narrowed the critical region of the neurodevelopmental phenotype to a region that spans the B-cell CLL/lymphoma 11A (BCL11A) gene. Here we present a 3-year-old normocephalic girl with moderate development delay and dysmorphic features including a prominent forehead, telecanthus, depressed nasal bridge, thin upper vermilion and a small chin. Magnetic resonance imaging shows enlargement of the lateral, third and fourth ventricles and hypoplastic corpus callosum, cerebellar vermis and pons. Array CGH revealed a 0.875 Mb de novo deletion at 2p16.1 that includes only BCL11A. The moderate delays, hypoplastic and dysmorphic corpus callosum and hippocampi and the facial features are in keeping with the previously described 2p15-16.1 microdeletion syndrome. However, hypoplasia of the pons and cerebellum are not commonly recognized features and are reminiscent of the brain malformations observed in individuals with a mutation in CASK. CASK is known to interact with BCL11A in the normal growth of axons. This case report highlights the role of BCL11A in 2p15-16.1 microdeletion syndrome and the unique phenotype suggests a common pathway for BCL11A and other genes in neurodevelopment.

Clinical characteristics of ovarian cancer classified by BRCA1, BRCA2, and RAD51C status

We evaluated homologous recombination deficient (HRD) phenotypes in epithelial ovarian cancer (EOC) considering BRCA1, BRCA2, and RAD51C in a large well-annotated patient set. We evaluated EOC patients for germline deleterious mutations (n = 899), somatic mutations (n = 279) and epigenetic alterations (n = 482) in these genes using NGS and genome-wide methylation arrays. Deleterious germline mutations were identified in 32 (3.6%) patients for BRCA1, in 28 (3.1%) for BRCA2 and in 26 (2.9%) for RAD51C. Ten somatically sequenced patients had deleterious alterations, six (2.1%) in BRCA1 and four (1.4%) in BRCA2. Fifty two patients (10.8%) had methylated BRCA1 or RAD51C. HRD patients with germline or somatic alterations in any gene were more likely to be high grade serous, have an earlier diagnosis age and have ovarian and/or breast cancer family history. The HRD phenotype was most common in high grade serous EOC. Identification of EOC patients with an HRD phenotype may help tailor specific therapies.

Output feedback trajectory stabilization of the uncertainty DC servomechanism system

This work proposes a solution for the output feedback trajectory-tracking problem in the case of an uncertain DC servomechanism system. The system consists of a pendulum actuated by a DC motor and subject to a time-varying bounded disturbance. The control law consists of a Proportional Derivative controller and an uncertain estimator that allows compensating the effects of the unknown bounded perturbation. Because the motor velocity state is not available from measurements, a second-order sliding-mode observer permits the estimation of this variable in finite time. This last feature allows applying the Separation Principle. The convergence analysis is carried out by means of the Lyapunov method. Results obtained from numerical simulations and experiments in a laboratory prototype show the performance of the closed loop system.

Nasogastric tubes and videofluoroscopic swallowing studies in children

BACKGROUND

Videofluoroscopic swallowing study (VFSS) is considered to be the gold standard method in assessing the risk of aspiration. Not infrequently, children who undergo VFSS are on tube feeds.

OBJECTIVE

To investigate the reliability of the findings of VFSS when a nasogastric tube is in place at the time of the study.

MATERIALS AND METHODS

A retrospective review of VFSS covered a 6.5-year period. This review included only patients who had studies performed both with and without a nasogastric tube in place. Ninety-two studies (46 with and 46 without a nasogastric tube) were assessed in 46 children (30 boys, 16 girls) with a mean age of 6.7 months. The VFSS checklist of findings included weak sucking, incoordination, nasopharyngeal reflux, valecular and pyriform sinus pooling, penetration, aspiration and associated cough or respiratory compromise. We compared the occurrence rates of these events between studies with and without a nasogastric tube.

RESULTS

No significant statistical difference was found in the occurrence of the different swallowing events during VFSS in the two groups. The presence of a nasogastric tube does not significantly alter the association of cough; however, it shows a moderately significant (P=0.06) higher incidence of clinical respiratory compromise if aspiration does occur (8.5% of aspiration events).

CONCLUSION

The presence of a nasogastric tube does not alter the findings of VFSS; however, it might increase the incidence of respiratory compromise when aspiration is present.

Effect of broccoli (Brassica oleracea) and its phytochemical sulforaphane in balanced diets on the detoxification enzymes levels of tilapia (Oreochromis niloticus) exposed to a carcinogenic and mutagenic pollutant

Tilapia fish (Oreochromis niloticus) were fed with enriched diets containing broccoli and its phytochemical sulforaphane over 30 d. The levels of cytochrome P450, superoxide dismutase, catalase, lipid peroxidation and glutathione-S-transferase activities were measured. Basal value of cytochrome P450 activity was significantly increased as consequence of the broccoli and sulforaphane enriched diets, while no statistically significant changes were found on catalase and lipid peroxidation activities. After benzo(a)pyrene exposure, the cytochrome P450 activity increased to higher levels in the fish feed with broccoli and sulforaphane when compared with the control fish. Activities of antioxidant enzymes also varied but without significant difference with the control fish. Supported by the lower concentrations of BaP metabolites in bile from fish fed with broccoli or with sulforaphane enriched diets (indicating a better xenobiotic elimination) the cytochrome P450 induction could be considered beneficial for the detoxification because this transformation is the first step for PAH elimination by the phase II system. The protection of aquaculture organism against pollution effects by designing special diets able to modulate the enzymes involved in the phase-I and phase-II detoxification mechanism are discussed.

Supracondylar distal femoral nonunions treated with a megaprosthesis in elderly patients: a report of two cases

The purpose of this paper is to report the use of total knee arthroplasty, a megaprosthesis, as a treatment in elderly patients who have a persistent nonunion of a supracondylar femur fracture. This case report includes two elderly patients who sustained supracondylar femur fractures that failed to unite with standard operative fixation methods. Despite multiple procedures during a long period, patients had a persistent nonunion. Both patients underwent total arthroplasty with a cemented kinematic rotating hinge and had significant clinical improvement. The Hospital for Special Surgery (HSS) knee scores increased from fifty-four points to seventy points in one patient and forty-two points to seventy-three points after surgery in the other patient. Both patients had excellent range of motion after surgery. A cemented megaprosthesis appears to be a viable treatment option for persistent nonunions of supracondylar femur fractures in elderly patients. It is well tolerated and permits early ambulation and return to activities of daily living.

Attachment insecurity and the distinction between unhappy spouses who do and do not divorce

The hypothesis that attachment insecurity would be associated with remaining in an unhappy marriage was tested. One hundred seventy-two newly married couples participated in a 4-year longitudinal study with multiple assessment points. Hierarchical linear models revealed that compared with spouses in happy marriages and divorced spouses, spouses who were in stable but unhappy marriages showed the highest levels of insecurity initially and over time. Spouses in stable, unhappy marriages also had lower levels of marital satisfaction than divorced spouses and showed relatively high levels of depressive symptoms initially and over time. Results suggest that spouses at risk for stable, unhappy marriages can be identified early and may benefit from interventions that increase the security of spouses' attachment to each other.

Attachment change processes in the early years of marriage

The authors examined 4 models of attachment change: a contextual model, a social-cognitive model, an individual-difference model, and a diathesis-stress model. Models were examined in a sample of newlyweds over the first 2 years of marriage, using growth curve analyses. Reciprocal processes, whereby attachment representations and interpersonal life circumstances affect one another over time, also were studied. On average, newlyweds became more secure over time. However, there was significant within-subject variability on attachment change that was predicted by intra- and interpersonal factors. Attachment representations changed in response to contextual, social-cognitive, and individual-difference factors. Reciprocal processes between attachment representations and marital variables emerged, suggesting that these factors influence one another in an ongoing way.

Depression and Axis II symptomatology in an adolescent community sample: concurrent and longitudinal associations

The relationship between personality pathology and depression has been the focus of increasing attention, but few investigators have examined this issue prospectively or in adolescent community samples. The present study used both self report and interviewer assessments of personality disorder symptomatology and depression in a sample of 155 late adolescent women followed over three years. Personality pathology cluster and total scores demonstrated moderate to fairly high degrees of stability, indicating endurance of these traits in late adolescence. As predicted, Axis II symptoms were associated with concurrent depressive symptomatology. Overall, self-reported personality disorder symptoms, as well as those specifically in Clusters A and B, predicted interviewer-rated depression over two years beyond the contribution of initial depression, indicating that subclinical Axis II symptoms are a risk factor for subsequent depressive symptomatology.

Attachment change processes in the early years of marriage

The authors examined 4 models of attachment change: a contextual model, a social-cognitive model, an individual-difference model, and a diathesis-stress model. Models were examined in a sample of newlyweds over the first 2 years of marriage, using growth curve analyses. Reciprocal processes, whereby attachment representations and interpersonal life circumstances affect one another over time, also were studied. On average, newlyweds became more secure over time. However, there was significant within-subject variability on attachment change that was predicted by intra- and interpersonal factors. Attachment representations changed in response to contextual, social-cognitive, and individual-difference factors. Reciprocal processes between attachment representations and marital variables emerged, suggesting that these factors influence one another in an ongoing way.

Axis II symptomatology, depression, and life stress during the transition from adolescence to adulthood

This study examined 2 models of the relationship between personality disorder symptomatology and depression, incorporating life stress as an intervening variable. In a community sample of late adolescent women, symptoms of Cluster B disorders predicted interpersonal chronic stress and self-generated episodic stress over 2 years, controlling for initial depression. Cluster A symptoms also predicted subsequent chronic interpersonal stress, over initial depression. Cluster C pathology did not predict subsequent stress. Personality disorder symptomatology was also associated with partner-reported relationship dissatisfaction. Support was found for a mediation model whereby women with higher levels of initial personality disturbance in Clusters A and B generated excessive amounts of episodic stress and interpersonal chronic stress in the next 2 years, which, in turn, increased vulnerability for depressive symptoms. A moderation model, whereby the presence of greater personality disorder symptoms would increase the likelihood of depression in response to stress, was not supported.

Axis II symptomatology, depression, and life stress during the transition from adolescence to adulthood

This study examined 2 models of the relationship between personality disorder symptomatology and depression, incorporating life stress as an intervening variable. In a community sample of late adolescent women, symptoms of Cluster B disorders predicted interpersonal chronic stress and self-generated episodic stress over 2 years, controlling for initial depression. Cluster A symptoms also predicted subsequent chronic interpersonal stress, over initial depression. Cluster C pathology did not predict subsequent stress. Personality disorder symptomatology was also associated with partner-reported relationship dissatisfaction. Support was found for a mediation model whereby women with higher levels of initial personality disturbance in Clusters A and B generated excessive amounts of episodic stress and interpersonal chronic stress in the next 2 years, which, in turn, increased vulnerability for depressive symptoms. A moderation model, whereby the presence of greater personality disorder symptoms would increase the likelihood of depression in response to stress, was not supported.

Marital functioning and depressive symptoms: evidence for a stress generation model

The present study applied C.L. Hammen's (1991) stress generation model to depressive symptoms in the context of marriage. The authors predicted that depressive symptoms would lead to increased marital stress, which would in turn lead to increased depressive symptoms. Social support processes were hypothesized to function as a mechanism by which dysphoric spouses generate stress. Hypotheses were tested in a sample of 154 newlywed couples. Depressive symptoms, marital stress, support perceptions, and support behavior (assessed using observational procedures) were assessed initially and 1 year later. Results provided evidence of marital stress generation among wives, and social support processes functioned as a mechanism of stress generation for wives. Results highlight the cyclical course of dysphoria and stress among wives.

Marital functioning and depressive symptoms: evidence for a stress generation model

The present study applied C.L. Hammen's (1991) stress generation model to depressive symptoms in the context of marriage. The authors predicted that depressive symptoms would lead to increased marital stress, which would in turn lead to increased depressive symptoms. Social support processes were hypothesized to function as a mechanism by which dysphoric spouses generate stress. Hypotheses were tested in a sample of 154 newlywed couples. Depressive symptoms, marital stress, support perceptions, and support behavior (assessed using observational procedures) were assessed initially and 1 year later. Results provided evidence of marital stress generation among wives, and social support processes functioned as a mechanism of stress generation for wives. Results highlight the cyclical course of dysphoria and stress among wives.