Therapeutic plasma exchange in paediatric nephrology in Ireland

BACKGROUND

Therapeutic plasma exchange (TPE) is utilised in the management of a limited number of paediatric renal conditions. Despite its widespread acceptance and advancements in the practice of apheresis, there remains a paucity of data pertaining to paediatrics. We present a large retrospective review of our cohort of paediatric patients undergoing TPE for renal indications, outlining their outcomes and complications.

METHODS

A retrospective chart review was conducted for all patients (under 16 years) undergoing TPE for renal conditions between January 2002 and June 2019 in Ireland. Demographic and clinical data were extracted, with patients anonymised and stratified according to their pathology.

RESULTS

A total of 58 patients were identified. A total of 1137 exchanges were performed using heparin sodium anticoagulation. The median age was 35.5 months (IQR 18-110 months). The leading indication was neurological involvement in Shiga toxin-producing Escherichia coli haemolytic uraemic syndrome (STEC-HUS) (n = 29). Complications (minor or major) occurred in 65.5% (n = 38) of patients, with most experiencing minor complications 58.6% (n = 34). Asymptomatic hypocalcaemia was the most common complication in 43.1% (n = 25).

CONCLUSIONS

Our experience of TPE, spanning 1137 exchanges, proved a safe, well-tolerated therapy. Most complications were minor, and with therapy conducted in specialised centres, there are very low levels of adverse events.

Relationship Between Electroencephalography and Seizure Outcome in Typical Absence Seizures in Children

BACKGROUND

Typical absence seizures (TAS) are seen in idiopathic generalized epilepsy. Electroencephalography (EEG) contributes to syndrome characterization and counseling in an area where genetics does not currently play a significant role. Prominent interictal EEG findings are seen in juvenile absence epilepsy (JAE) and are thus thought to be associated with less favorable outcome in any TAS case despite lack of evidence. Our study evaluates EEG findings and their association with seizure outcomes in children with TAS.

METHODS

Retrospective cohort study of 123 children over 10 years with extensive EEG analysis and medical record review. Phone interviews ascertained longer-term outcomes. EEG reviewers were unaware of outcomes.

RESULTS

Total cohort included 123 children with phone review completed in 98. Median follow-up was 5 years 9 months. Seizure freedom was seen in 59% off antiseizure medicines (ASMs). Interictal findings included focal discharges in 29%, fragments of spike-wave (SW) discharges in 82.1%, and generalized interictal discharges in 63.4%. Interictal SW was more likely in those who slept (100%, 18 of 18) versus those who did not (57%, 60 of 105) (P < 0.001). Outcome analysis found no associations between focal or generalized interictal findings and seizure freedom, relapse off ASM, occurrence of other seizure types, or response to first ASM.

CONCLUSION

Focal and generalized interictal EEG discharges are common in children with TAS and are not associated with poorer outcomes. These interictal findings were traditionally associated with JAE rather than childhood absence epilepsy and were thus believed to be associated with potentially poorer outcome, which is probably not the case.

Uniparental disomy screen of Irish rare disorder cohort unmasks homozygous variants of clinical significance in the TMCO1 and PRKRA genes

A uniparental disomy (UPD) screen using whole genome sequencing (WGS) data from 164 trios with rare disorders in the Irish population was performed to identify large runs of homozygosity of uniparental origin that may harbour deleterious recessive variants. Three instances of whole chromosome uniparental isodisomy (UPiD) were identified: one case of maternal isodisomy of chromosome 1 and two cases of paternal isodisomy of chromosome 2. We identified deleterious homozygous variants on isodisomic chromosomes in two probands: a novel p (Glu59ValfsTer20) variant in TMCO1, and a p (Pro222Leu) variant in PRKRA, respectively. The overall prevalence of whole chromosome UPiD in our cohort was 1 in 55 births, compared to 1 in ∼7,500 births in the general population, suggesting a higher frequency of UPiD in rare disease cohorts. As a distinct mechanism underlying homozygosity compared to biallelic inheritance, the identification of UPiD has important implications for family planning and cascade testing. Our study demonstrates that UPD screening may improve diagnostic yields by prioritising UPiD chromosomes during WGS analysis.

Response to treatment and outcomes of infantile spasms in Down syndrome

AIM

To estimate the prevalence, and evaluate presentation, treatment response, treatment side effects, and long-term seizure outcomes in all known cases of children with Down syndrome and infantile spasms on the island of Ireland.

METHOD

This was a 10-year retrospective multicentre review of clinical records and investigations, focusing on treatment response, side effects, and long-term outcomes.

RESULTS

The prevalence of infantile spasms in Down syndrome was 3.0% during the study period. Fifty-four infants were identified with median age of spasm onset at 201 days (interquartile range [IQR] 156-242). Spasm cessation was achieved in 88% (n=46) at a median of 110 days (IQR 5-66). The most common first-line medications were prednisolone (n=20, 37%), vigabatrin (n=18, 33.3%), and sodium valproate (n=9, 16.7%). At follow-up (median age 23.7mo; IQR 13.4-40.6), 25% had ongoing seizures and 85% had developmental concerns. Treatment within 60 days did not correlate with spasm cessation. Seventeen children (31%) experienced medication side effects, with vigabatrin accounting for 52%.

INTERPRETATION

Prednisolone is an effective and well-tolerated medication for treating infantile spasms in Down syndrome. Despite the high percentage of spasm cessation, developmental concerns and ongoing seizures were common.

Disentanglement network data to characterize leatherback sea turtle Dermochelys coriacea bycatch in fixed-gear fisheries

To characterize sea turtle bycatch in fixed-gear fisheries in Massachusetts, USA, we analyzed a 15 yr dataset of entanglement reports and detailed documentation from disentanglement operations. Almost all (272) of the 280 confirmed entanglements involved leatherback turtles Dermochelys coriacea. The majority of turtles were entangled in actively fished (96%), commercial (94%) pot/trap gear with unbroken/untriggered weak links, specifically the buoy lines marking lobster, whelk, and fish traps. Most reports came from recreational boaters (62%) and other sources (26%), rather than commercial fishers (12%). Leatherback entanglements occurred from May to November, with peak reporting in August, and included adult males, adult females, and subadults. All entanglements involved the turtle’s neck and/or front flippers, with varying degrees of visible injuries; 47 entangled leatherbacks were dead in gear, 224 were alive at first sighting, and 1 case was unknown. Post-release monitoring suggested turtles can survive for days to years after disentanglement, but data were limited. While the observed entanglements in our study are low relative to global bycatch, these numbers should be considered a minimum. Our findings are comparable to observed numbers of leatherbacks taken in Canadian fixed-gear fisheries, and represent just one of multiple, cumulative threats in the North Atlantic. Managers should focus on strategies to reduce the co-occurrence of sea turtles and fixed-fishing gear, including reductions in the number of buoy lines allowed (e.g. replace single sets with trawls), seasonal and area closures targeted to reduce sea turtle-gear interaction, and encourage the development of emerging technologies such as ‘ropeless’ fishing.

Clinical features, investigations, and outcomes of pediatric limbic encephalitis: A multicenter study

OBJECTIVES

To describe the clinical presentation, investigations, management, and disease course in pediatric autoimmune limbic encephalitis (LE).

METHODS

In this retrospective observational study, from the UK Childhood Neuroinflammatory Disease network, we identified children from six tertiary centers with LE <18 years old between 2008 and 2021. Clinical and paraclinical data were retrieved from medical records.

RESULTS

Twenty-five children fulfilling LE criteria were identified, with median age of 11 years (IQR 8, 14) and median follow-up of 24 months (IQR 18, 48). All children presented with seizures; 15/25 (60%) were admitted to intensive care. Neuroimaging demonstrated asymmetric mesial temporal changes in 8/25 (32%), and extra-limbic changes with claustrum involvement in 9/25 (38%). None were positive for LGI1/CASPR2 antibodies (Abs), 2/25 were positive for serum anti-NMDAR Abs, and 2/15 positive for anti-Hu Abs; one died from relapsing neuroblastoma. Two children had serum and CSF anti-GAD antibodies. Initial immune therapy included steroids in 23/25 (92%), intravenous immunoglobulin (IVIg) in 14/25 (56%), and plasma exchange in 7/25 (28%). The commonest second-line treatment was rituximab in 15/25 (60%). Median duration of hospital admission was 21 days (IQR 11, 30). At last follow-up, 13/25 (52%) had refractory seizures and 16/25 (64%) had memory impairment. Six children (24%) had modified Rankin Scale (mRS) scores ≥3. There was no significant difference in mRS, or long-term cognitive and epilepsy outcomes in those who received rituximab versus those who did not.

INTERPRETATION

A diagnosis of autoimmune LE was associated with significant morbidity and adverse outcomes in this pediatric cohort.

Quality improvement project to decrease unnecessary investigations in infants with bronchiolitis in Cork University Hospital

Background

Bronchiolitis is a common reason for infants to present to the emergency department (ED). Clear evidence-based guidelines exist that recommend against routine radiological and laboratory investigations in this cohort. Despite this, preintervention audit showed that children below 12 months of age with bronchiolitis in the ED during November 2018–January 2019 were receiving unnecessary investigations. Our aim was to improve patient care by decreasing unnecessary investigations in bronchiolitis infants.

Methods

Baseline assessment comprised a preintervention audit of children less than 12 months of age with a diagnosis of bronchiolitis that presented to ED during November 2018–January 2019. The outcome measure was average weekly hospital length of stay (LOS), process measures were average weekly chest X-ray (CXR) and laboratory investigation rate. The balancing measure was the average weekly representation rate.

Intervention

A multimodal intervention was implemented comprising a locally agreed flowchart enhanced by regular feedback on performance using run charts and in-person sessions.

Results

A postintervention audit of November 2019–January 2020 was undertaken. There was a 57% reduction in the mean average weekly CXR rate (from 25% to 11%, p value 0.009974 significant at p<0.05); there was an improvement by 56% in the mean average weekly laboratory investigation rate (from 29% to 13%, p value 0.005475, significant at p<0.05) in the preintervention and postintervention periods, respectively. The mean average weekly representations remained at 4% preintervention and postintervention (p value 0.737). There was no significant difference in hospital LOS (from 25.3 hours to 20.7 hours, p value 0.270549).

Conclusion

An evidence-based protocol improved physicians’ ability in diagnosing and managing infants with bronchiolitis. This led to a reduction in unnecessary and potential harmful investigations, thereby improving patient quality of care. This improvement will contribute to decreased healthcare cost and appropriate use of resources during the high-pressured winter period.

Persistent sodium currents in SCN1A developmental and degenerative epileptic dyskinetic encephalopathy

Pathogenic variants in the voltage-gated sodium channel gene (SCN1A) are amongst the most common genetic causes of childhood epilepsies. There is considerable heterogeneity in both the types of causative variants and associated phenotypes; a recent expansion of the phenotypic spectrum of SCN1A associated epilepsies now includes an early onset severe developmental and epileptic encephalopathy with regression and a hyperkinetic movement disorder. Herein, we report a female with a developmental and degenerative epileptic-dyskinetic encephalopathy, distinct and more severe than classic Dravet syndrome. Clinical diagnostics indicated a paternally inherited c.5053G>T; p. A1685S variant of uncertain significance in SCN1A. Whole-exome sequencing detected a second de novo mosaic (18%) c.2345G>A; p. T782I likely pathogenic variant in SCN1A (maternal allele). Biophysical characterization of both mutant channels in a heterologous expression system identified gain-of-function effects in both, with a milder shift in fast inactivation of the p. A1685S channels; and a more severe persistent sodium current in the p. T782I. Using computational models, we show that large persistent sodium currents induce hyper-excitability in individual cortical neurons, thus relating the severe phenotype to the empirically quantified sodium channel dysfunction. These findings further broaden the phenotypic spectrum of SCN1A associated epilepsies and highlight the importance of testing for mosaicism in epileptic encephalopathies. Detailed biophysical evaluation and computational modelling further highlight the role of gain-of-function variants in the pathophysiology of the most severe phenotypes associated with SCN1A.

Single center analysis of patients with H1N1 vaccine-related narcolepsy and sporadic narcolepsy presenting over the same time period

STUDY OBJECTIVES

We aimed to describe the clinical features of narcolepsy in patients referred to our sleep center between 2009 and 2016, and to compare these features across age groups and between sporadic vs AS03-adjuvanted H1N1 influenza vaccine-related patients.

METHODS

This is a retrospective, consecutive study of adult and pediatric narcolepsy patients in the Republic of Ireland. All participants underwent structured assessments, including polysomnography and the Multiple Sleep Latency Test. Brain magnetic resonance imaging, hypocretin levels, and human leukocyte antigen typing were also carried out on the majority of patients. Patients were compared across age groups as well as etiology.

RESULTS

The conditions of 40 (74%) patients were vaccine-related. The median age was 13.5 years and time from symptom onset to diagnosis was 112 weeks. Median time from vaccination to symptom onset was 26 weeks. In children, hypnogogic hallucinations and sleep paralysis were less frequent than in adults (17% vs 67%, P = .018 and 0% vs 75%, P < .0005). Sleep latency determined by the Multiple Sleep Latency Test was shorter in children than adults (median 1.75 vs 4 minutes, P = .011). Patients with vaccine-related and sporadic narcolepsies had typical clinical presentations. Vaccine-related patients had longer polysomnography latency (median 10.5 vs 5 minutes, P = .043), longer stage N2 sleep (209.6 ± 44.6 vs 182.3 ± 34.2 minutes, P = .042), and a trend toward longer total sleep times (P = .09). No differences were noted in relation to Multiple Sleep Latency Test, hypocretin, human leukocyte antigen typing, and magnetic resonance imaging.

CONCLUSIONS

Results show that vaccine-related patients greatly outnumbered sporadic patients during the study period and suggest that sporadic and vaccine-related narcolepsy are clinically similar entities.

Maple syrup urine disease: Clinical outcomes, metabolic control, and genotypes in a screened population after four decades of newborn bloodspot screening in the Republic of Ireland

Since 1972, 18 patients (10 females/8 males) have been detected by newborn bloodspot screening (NBS) with neonatal-onset maple syrup urine disease (MSUD) in Ireland. Patients were stratified into three clusters according to clinical outcome at the time of data collection, including developmental, clinical, and IQ data. A fourth cluster comprised of two early childhood deaths; a third patient died as an adult. We present neuroimaging and electroencephalography together with clinical and biochemical data. Incidence of MSUD (1972-2018) was 1 in 147 975. Overall good clinical outcomes were achieved with 15/18 patients alive and with essentially normal functioning (with only the lowest performing cluster lying beyond a single SD on their full scale intelligence quotient). Molecular genetic analysis revealed genotypes hitherto not reported, including a possible digenic inheritance state for the BCKDHA and DBT genes in one family. Treatment has been based on early implementation of emergency treatment, diet, close monitoring, and even dialysis in the setting of acute metabolic decompensation. A plasma leucine ≥400 μmol/L (outside therapeutic range) was more frequently observed in infancy or during adolescence, possibly due to infections, hormonal changes, or noncompliance. Children require careful management during metabolic decompensations in early childhood, and this represented a key risk period in our cohort. A high level of metabolic control can be achieved through diet with early implementation of a "sick day" regime and, in some cases, dialysis as a rescue therapy. The Irish cohort, despite largely classical phenotypes, achieved good outcomes in the NBS era, underlining the importance of early diagnosis and skilled multidisciplinary team management.

Narcolepsy in children and young people in Ireland: 2006-2017

AIM

To describe the population of young people in Ireland diagnosed with narcolepsy with regards to vaccine exposure, symptomatology, investigation results and experience of medical treatment.

METHOD

Retrospective review of medical records at the single tertiary referral centre for young people with narcolepsy in Ireland.

RESULTS

Sixty-seven patients were diagnosed with narcolepsy between July 2006 and July 2017. Sixty-one (91%) of these developed symptoms after receiving the Pandemrix vaccine. The population was largely homogeneous with low hypocretin (87.5%), HLA DQB1∗0602 positivity (95%) and unremarkable findings on MRI Brain (100%). 77.6% experienced cataplexy; we also measured high levels of obesity, school non-attendance and psychosocial complexity. Symptoms often continued despite treatment, with multiple medications prescribed in 76.1% of patients. Prescription of sodium oxybate was associated with a significant reduction in BMI standard deviation scores at 6 months, with improved IOTF obesity scores seen at 36 month follow-up.

CONCLUSIONS

This paper describes the experience of narcolepsy in children and young people in Ireland from 2006 - 2017 at the national tertiary referral centre. Narcolepsy in children and young people in Ireland carries a significant burden of illness, with impact on participation in education as well as physical and mental health. Symptoms can be refractory to medical treatment. Referral to tertiary centres for prompt treatment and multidisciplinary input is essential.

Moyamoya disease and moyamoya syndrome in Ireland: patient demographics, mode of presentation and outcomes of EC-IC bypass surgery

BACKGROUND

There are no previously published reports regarding the epidemiology and characteristics of moyamoya disease or syndrome in Ireland.

AIMS

To examine patient demographics, mode of presentation and the outcomes of extracranial-intracranial bypass surgery in the treatment of moyamoya disease and syndrome in Ireland.

METHODS

All patients with moyamoya disease and syndrome referred to the National Neurosurgical Centre during January 2012-January 2019 were identified through a prospective database. Demographics, clinical presentation, radiological findings, surgical procedures, postoperative complications and any strokes during follow-up were recorded.

RESULTS

Twenty-one patients were identified. Sixteen underwent surgery. Median age at diagnosis was 19 years. Fifteen were female. Mode of presentation was ischaemic stroke in nine, haemodynamic TIAs in eight, haemorrhage in three and incidental in one. Sixteen patients had Moyamoya disease, whereas five patients had moyamoya syndrome. Surgery was performed on 19 hemispheres in 16 patients. The surgical procedures consisted of ten direct (STA-MCA) bypasses, five indirect bypasses and four multiple burr holes. Postoperative complications included ischaemic stroke in one patient and subdural haematoma in one patient. The median follow-up period in the surgical group was 52 months; there was one new stroke during this period. Two patients required further revascularisation following recurrent TIAs. One patient died during follow-up secondary to tumour progression associated with neurofibromatosis type 1.

CONCLUSIONS

Moyamoya is rare but occurs in Caucasians in Ireland. It most commonly presents with ischaemic symptoms. Surgical intervention in the form of direct and indirect bypass is an effective treatment in the majority of cases.

OP0308-PARE PREGNANCY AND ARTHRITIS - A PATIENT EDUCATION PROGRAMME IN IRELAND

Background:

The relationship between pregnancy and arthritis is a complex one. Because of the variability of arthritic conditions, it is important for patients to get advice from their doctor or a specialist nurse before trying for a baby. There can be implications for medication regimes, while the pregnancy itself can also affect the inflammatory arthritis. In the postpartum period, other considerations include breastfeeding and the frequent return of flares.

Through this education programme, Arthritis Ireland developed information resources primarily targeting women of child-bearing age. The multichannel campaign provided information about the wide range of issues of concern to women with inflammatory arthritis who are planning a family or are pregnant.

Objectives:

•To provide information and increase awareness around inflammatory arthritis and pregnancy;

•To support women living with inflammatory arthritis through their illness and life journey;

•To increase awareness of the work of Arthritis Ireland as a patient organisation.

Methods:

In developing and executing this education programme, Arthritis Ireland worked extensively with a team of healthcare professionals, who are regarded internationally as leaders in this field.

A multi-channel approach was taken to the development, production and dissemination of information, with public information events, literature and a suite of videos developed

Up to this point, there had not been any Irish-produced material on this subject. he topic was seen to be an important one and an issue of significant public health interest.

The series of information talks on pregnancy and inflammatory arthritis was delivered by consultant rheumatologists and were held in cities around Ireland. The information booklet covered topics such as planning for a baby, medication and pregnancy, the role of the father, fertility, genetics, during the pregnancy, after the pregnancy and breastfeeding.

Video was seen to be central to the success of the campaign. Working with the expert healthcare team, six information videos were developed around obstetrics, rheumatology, physiotherapy and occupational therapy. The videos were published and promoted across Arthritis Ireland’s social media channels and website.

The capstone video featured a young mother who was diagnosed with JIA when she was two. Her story was an incredibly powerful testimony of overcoming and dealing with adversity and complex health issues.

Results:

This educational campaign was developed to meet a significant need in the health information landscape. While there are no little resources produced focusing on pregnancy and parenting, there wasn’t anything in Ireland which specifically addressed the needs of women and men with inflammatory arthritis who are looking to have a family. The materials produced are a valuable part of Arthritis Ireland’s canon of patient education materials.

Conclusion:

It is anticipated that the materials developed will have a long lifespan and will support prospective parents for several years to come. Central to the success of the project was the involvement of the expert healthcare teams. Their commitment to the project spoke volumes of its importance and the considerable need for the clearly communicated information, which the project provided.

Ultimately, Arthritis Ireland has produced a suite of resources which will be referenced and used by patients, and will hopefully make a considerable impact on their quality of life.

Acknowledgments:

This patient education programme was supported by a grant from UCB.

Disclosure of Interests:

Brian Lynch Grant/research support from: Arthritis Ireland received a grant from MSD to develop this patient education programme. Brian Lynch has not benefited personally in any way.

PARE0003 MY RA STORY - PERSONAL ACCOUNTS OF LIVING WITH RHEUMATOID ARTHRITIS

Background:

Over 2,000 people are diagnosed with rheumatoid arthritis (RA) in Ireland each year; three in four are of working age. In total, RA affects some 45,000 people in the country; 70 per cent of whom are women.

For someone newly diagnosed with RA, coming to terms with the news can seem overwhelming.

Such a dramatic shift in life circumstances can impact one’s physical and mental well-being. While there is no shortage of information available about the condition, it can be overwhelming trying to filter this, assess what is trustworthy and reliable.

Objectives:

•To provide information and hope to people newly diagnosed with RA, and to give a voice to those living with the condition;

•To increase awareness and understanding of RA – encourage engagement with HCPs, contributing to early diagnosis and better outcomes;

•To increase awareness of work of Arthritis Ireland as a patient organisation.

Methods:

Arthritis Ireland approached best-selling author and RA patient, Sinead Moriarty, to front an RA awareness campaign, called My RA Story.

The purpose of the campaign was to increase awareness and understanding of rheumatoid arthritis, of what it is like to live with this chronic condition with its invisible pain and life-changing impact. In so doing, Arthritis Ireland wanted to give a platform to people to tell their own story, so that they could be heard. We then wanted to publish these experiences in book form.

In April 2019, we launched a video on social media featuring Sinead Moriarty speaking about her experience of living with RA. The video generated lots of engagement across social media and also helped garner national and regional media coverage in print and broadcast.

The call for RA stories received a fantastic response from the public and the reading panel had a tough job in selecting the contributions which would feature in the published volume. Once the successful contributions were chosen, Arthritis Ireland proceeded to design a book, which could be sold in the book trade and online.

Results:

In September 2019, Arthritis Ireland published My RA Story: Personal accounts of living with rheumatoid arthritis. Launched in the National Library of Ireland by Sinead Moriarty, the 46 contributions touched upon themes of pain, fatigue, emotional impact, disability, surgery, education, career, family, goal-setting, self-management, connecting with others, hope, etc.

The contributors came from people who were living with RA for over 40 years, as well as from those who were more recently diagnosed.

The book is a hugely valuable contribution to health literature. Arthritis Ireland now plans to make the book available for sale internationally, through Amazon and other retail channels, as well as promoting it more extensively in rheumatology clinics.

In October, one of the contributors was interviewed on national television about her RA story, as part of a feature on World Arthritis Day.

Conclusion:

This campaign gave people living with RA a platform to write about and share about their condition. Fronted by an RA champion with significant name recognition and an enormous audience in her own right, best-selling author, Sinéad Moriarty, the book, My RA Story. Crucially, the book is a valuable resource for people who are newly diagnosed with the disease and uncertain of what the future holds.

Acknowledgments:

This project was supported by an educational grant from MSD.

Disclosure of Interests:

Brian Lynch Grant/research support from: Arthritis Ireland received a grant from MSD to develop this patient education programme. Brian Lynch has not benefited personally in any way.

X-linked infantile spinal muscular atrophy (SMAX2) caused by novel c.1681G>A substitution in the UBA1 gene, expanding the phenotype

X-linked infantile spinal muscular atrophy (SMAX2), OMIM 301830, is a rare, severe form of spinal muscular atrophy, caused by variants in the Ubiquitin like modifier-activating enzyme 1 (UBA1) gene. Clinical features reported to date include marked hypotonia, areflexia, arthrogryposis, contractures, myopathic facies and tongue fibrillations. Previous reports have included a history of contractures. We report a male patient presenting following a normal pregnancy with typical symptoms of X-linked infantile spinal muscular atrophy including hypotonia, weakness, areflexia and respiratory insufficiency, however contractures were absent. There was a significant family history of neuromuscular disease on the maternal side, with several male relatives all dying before the age of six months. Creatine Kinase was mildly elevated, MRI Brain was normal and neurophysiological testing revealed a diffuse motor neuronopathy. Genetic testing for SMN1 gene was normal. UBA1 sequencing revealed a maternally inherited hemizygous familial variant [c.1681G>A p. (Asp561Asn)], which has not been previously reported.

Spectrum of KV 2.1 Dysfunction in KCNB1-Associated Neurodevelopmental Disorders

OBJECTIVE

Pathogenic variants in KCNB1, encoding the voltage-gated potassium channel K_V 2.1, are associated with developmental and epileptic encephalopathy (DEE). Previous functional studies on a limited number of KCNB1 variants indicated a range of molecular mechanisms by which variants affect channel function, including loss of voltage sensitivity, loss of ion selectivity, and reduced cell-surface expression.

METHODS

We evaluated a series of 17 KCNB1 variants associated with DEE or other neurodevelopmental disorders (NDDs) to rapidly ascertain channel dysfunction using high-throughput functional assays. Specifically, we investigated the biophysical properties and cell-surface expression of variant K_V 2.1 channels expressed in heterologous cells using high-throughput automated electrophysiology and immunocytochemistry-flow cytometry.

RESULTS

Pathogenic variants exhibited diverse functional defects, including altered current density and shifts in the voltage dependence of activation and/or inactivation, as homotetramers or when coexpressed with wild-type K_V 2.1. Quantification of protein expression also identified variants with reduced total K_V 2.1 expression or deficient cell-surface expression.

INTERPRETATION

Our study establishes a platform for rapid screening of K_V 2.1 functional defects caused by KCNB1 variants associated with DEE and other NDDs. This will aid in establishing KCNB1 variant pathogenicity and the mechanism of dysfunction, which will enable targeted strategies for therapeutic intervention based on molecular phenotype. ANN NEUROL 2019;86:899-912.

Initial experience with telemonitoring in left ventricular assist device patients

Background

Left ventricular assist devices (LVAD) are increasingly used in patients with end stage heart failure. The HeartAssist 5 and aVAD LVADs offer telemetric monitoring capabilities. Here we report our initial single centre experience with the largest telemonitoring cohort of LVAD patients.

Methods

Eleven patients (9 males) received a telemonitoring-capable LVAD and were included in our telemonitoring cohort. Waveforms and alarm data were obtained from the telemonitoring system and hospital records were reviewed for clinical data.

Results

Mean age at LVAD implantation was 59±5.1 years (mean ± standard deviation). Seven patients had non-ischemic cardiomyopathy and 4 patients had ischemic cardiomyopathy. Median LVEF at implant was 16% (IQR, 15-20%). The total follow-up time was 2,438 patient-days. A total of 6,216 alarm messages were generated in 11 patients. Most common were low flow alarms due to hypovolemia, followed by low flow alarms because of suspected pump thrombosis. One patient died during follow-up, one received a cardiac transplant and one had the LVAD explanted because of pump thrombosis. Pump thrombosis was suspected in 5 patients with 8 episodes of sudden flow decreases and laboratory signs of haemolysis.

Conclusions

Real-time telemonitoring of LVAD pump flow, motor speed and power consumption is a promising tool in the follow-up of LVAD recipients. Trending pump flow over hours or days can assist in the early detection of complications, especially flow reductions due to hypovolemia and LVAD thrombosis. Further studies are warranted to delineate the impact of remote monitoring on patients' prognosis.

A Case of Juvenile Onset Neuronal Intranuclear Inclusion Disease With a Negative Antemortem Skin Biopsy

Neuronal intranuclear (hyaline) inclusion disease (NIID) is a rare neurodegenerative disorder with a variable clinical presentation and multiple subtypes. We present the clinicopathologic details of a patient with juvenile-onset NIID and discuss the pathogenesis. We also discuss the utility of antemortem skin biopsy which was negative in our case.

The Temple Star Transitional Model of Care for epilepsy; the outcome of a quality improvement project

OBJECTIVE

The aim and objective of this study was to assess the knowledge and views of parents on transitional and adolescent care in young adults with epilepsy, and to develop a transitional and adolescent program for epilepsy.

METHODS

Data were collected from questionnaires completed by parents during focus groups exploring transitional care and inherent issues for young adults, aged 12-18years, with epilepsy. The questionnaire assessed the current knowledge and views of parents of children with epilepsy on transitional care, and following a presentation on "Transition in Epilepsy" (including themes such as self-advocacy, independent healthcare behavior, sexual health, psychosocial support, educational and vocational planning, health and lifestyle issues) assessed feedback on the proposed model of care in transitional and adolescent care.

RESULTS

Data were collected from 34 parents; the majority of parents, 74% (n=25), wish their children to be transitioned and transferred over to the adult epilepsy sites at the age of 18years. Over 82% (n=28) of parents believe the concept of transition should be introduced between the ages of 12-16years.

CONCLUSION

This quality improvement initiative identified the need for transitional care to begin at an early age. This study engaged parents in a process to improve adolescent and transitional care for adolescents with epilepsy. This study also highlights the importance of introducing a detailed preparatory phase for a transitional and adolescent care in epilepsy.

Novel COL4A2 variant in a large pedigree: Consequences and dilemmas

Pathogenic COL4A2 variants cause abnormalities in collagen production and can have serious implications for a range of organ systems, most notably the brain. Herein, we describe a large family of first-degree relatives affected by a novel heterozygous variant in COL4A2 (c.3490G.A). A wide disease spectrum is described, from asymptomatic to symptomatic, including 2 children with porencephaly and co-existing juvenile idiopathic polyarthritis. During a subsequent pregnancy, antenatal testing identified a positive fetus. In view of the literature, we review management and genetic counselling dilemmas.

MELAS (Mitochondrial Encephalomyopathy, Lactic Acidosis, Stroke) - a Diagnosis Not to be Missed

MELAS is a rare mitochondrial disorder. We report two cases in Irish males where the characteristics were evident, but the diagnosis not made for a considerable period of time. In one of the cases the symptoms were presumed secondary to prematurity. In the other the symptoms were presumed secondary to epilepsy and he had three respiratory arrests secondary to benzodiazepine administration. This report wishes to highlight MELAS as a differential diagnosis in paediatric patients who present with stroke.

Climatic Conditions and the Reporting of Sun-Protective Behavior Survey Data: A Brief Report

Two hundred thirty-one spectators at a Cricket match in Brisbane, Australia, were interviewed and observed to determine their sun protective behaviors, and these behaviors were compared to the temperature and amount of cloud cover at the time of the study. People tended to protect themselves from the sun when there was less cloud cover and temperatures were higher.

Anti-N-Methyl-D-Aspartate Receptor Antibody Mediated Neurologic Relapse Post Herpes Simplex Encephalitis: A Case Series

Despite the advent of antiviral therapy, herpes simplex encephalitis (HSE) remains a devastating condition with significant morbidity and mortality. Neurologic relapse after initial improvement is generally attributed to herpes simplex virus reactivation. In 2013, inflammation caused by anti-N-methyl-D-aspartate receptor antibodies was reported in association with cases of neurologic relapse after herpes simplex encephalitis. We present 3 such cases and discuss diagnostic and management dilemmas.

Rapid identification and antimicrobial susceptibility testing of positive blood cultures using MALDI-TOF MS and a modification of the standardised disc diffusion test: a pilot study

AIMS

In an era when clinical microbiology laboratories are under increasing financial pressure, there is a need for inexpensive, yet effective, rapid microbiology tests. The aim of this study was to evaluate a novel modification of standard methodology for the identification and antimicrobial susceptibility testing (AST) of pathogens in positive blood cultures, reducing the turnaround time of laboratory results by 24 h.

METHODS

277 positive blood cultures had a Gram stain performed and were subcultured and incubated at 37°C in a CO2 atmosphere for 4-6 h. Identification of the visible growth was performed using matrix-assisted laser desorption time of flight mass spectrometry (MALDI-TOF MS). Taking a modified approach to the Clinical and Laboratory Standards Institute-standardised AST methodology, an inoculum density of 0.5 McFarland was prepared from the early growth for disc diffusion testing. The standard AST method was also performed on the 18-24 h culture.

RESULTS

96% (n=73/76) of gram-negative organisms were correctly identified by MALDI-TOF MS. Comparative analysis of the rapid and standard AST results showed an overall interpretive category error rate of 7.7% (6.7% minor errors, 0.6% major errors and 0.4% very major errors). 100% of Staphylococcus aureus (n=41) and enterococcus isolates (n=9) were correctly identified after 4-6 h incubation. The overall AST categorical agreement was also 100% for these isolates.

CONCLUSIONS

An incubation of 4-6 h directly from positive blood cultures allowed for both a rapid species identification and an antimicrobial susceptibility result approximately 24 h earlier than is possible using standard methodology.

Reporting of Acute Flaccid Paralysis in Children under 15 years of age: Improving Surveillance, January 2009 - December 2014

Acute Flaccid Paralysis (AFP) surveillance, including case investigation and specimen collection is a gold standard method for poliomyelitis surveillance. The expected annual non-polio AFP rate <15 years of age in Ireland is = 1/100 000 population. This study reviewed all cases of AFP reported to the Irish Paediatric Surveillance Unit and the Health Protection Surveillance Centre between January 2009 and December 2014 and compared reporting rates with the expected incidence rate annually. We assessed quality of surveillance data in terms of completeness of investigation for each case reported. Forty-three AFP cases in children <15 years were notified; 35 of which were confirmed. Guillain-Barre Syndrome (GBS) accounted for 48.6% (n=17) of AFP notifications. In 2014, the expected annual AFP target rate was reached. This study identified possible under-reporting of AFP paediatric cases in Ireland between 2009-2013. Completeness of investigations has improved over time, but requires further work.

The FIKK kinase of Toxoplasma gondii is not essential for the parasite's lytic cycle

FIKK kinases are a novel family of kinases unique to the Apicomplexa. While most apicomplexans encode a single FIKK kinase, Plasmodium falciparum expresses 21 and piroplasms do not encode a FIKK kinase. FIKK kinases share a conserved C-terminal catalytic domain, but the N-terminal region is highly variable and contains no known functional domains. To date, FIKK kinases have been primarily studied in P. falciparum and Plasmodium berghei. Those that have been studied are exported from the parasite and associate with diverse locations in the infected erythrocyte cytosol or membrane. Deletion of individual P. falciparum FIKK kinases indicates that they may play a role in modification of the infected erythrocyte. The current study characterises the single FIKK gene in Toxoplasma gondii to evaluate the importance of the FIKK kinase in an apicomplexan that has a single FIKK kinase. The TgFIKK gene encoded a protein of approximately 280kDa. Endogenous tagging of the FIKK protein with Yellow Fluorescent Protein showed that the FIKK protein exclusively localised to the posterior end of tachyzoites. A Yellow Fluorescent Protein-tagged FIKK and a Ty-tagged FIKK both co-localised with T. gondii membrane occupation and recognition nexus protein to the basal complex and were localised apical to inner membrane complex protein-5 and Centrin2. Deletion of TgFIKK, surprisingly, had no detectable effect on the parasite's lytic cycle in vitro in human fibroblast cells or in acute virulence in vivo. Thus, our results clearly show that while the FIKK kinase is expressed in tachyzoites, it is not essential for the lytic cycle of T. gondii.

117 DEVELOPMENT OF A NONINVASIVE, FECAL PROTEIN PREGNANCY TEST FOR POLAR BEARS

Differentiating between pregnancy and nonpregnancy noninvasively is difficult in species that experience pseudopregnancy, including polar bears (Ursus maritimus). These bears usually breed in the spring, undergo delayed implantation until late summer or early fall, and give birth in late fall. In other species, the placental protein transthyretin (TTR) has been shown to be essential for early fetal growth, responsible for transporting thyroid hormone from the mother to the fetus during early pregnancy. Preliminary data obtained via 2D-DIGE indicated that fecal TTR is elevated during polar bear pregnancy, but further research is needed to validate its use as an accurate biomarker of pregnancy. The aim of this study was to develop a bench-side assay to characterize TTR in longitudinal fecal samples from pregnant and nonpregnant polar bears. Specific objectives were to 1) develop an effective method for total fecal protein extraction; 2) identify antibodies that cross-react with polar bear fecal TTR; 3) validate an EIA for measuring fecal TTR; and, for proof of concept, 4) compare fecal TTR concentrations among pregnant, pseudopregnant, and nonpregnant polar bears. Fecal samples (n = 205) were collected from females that produced cubs (pregnant; n = 2), did not breed but exhibited a prolonged increase in progesterone (P4; pseudopregnant; n = 2), or did not breed and did not exhibit an increase in P4 (nonpregnant; n = 2). Total protein of each sample was extracted using a modified ammonium sulfate method. Protein concentrations were quantified using the Bradford assay. Western blot was used to determine commercial antibody compatibility with polar bear fecal TTR. A sandwich EIA was optimized using a standard curve ranging from 12.5 to 400 pg of human TTR/well. A parallelism was performed using two-fold serial dilutions of pooled fecal protein. Fecal TTR concentrations were measured in duplicate and are reported as femtograms of TTR per micrograms of total protein. Mean TTR concentrations in samples collected from July–December were compared among groups. Values are reported as mean ± standard error of the mean. Total fecal protein yield was 459.38 ± 284.38 µg g–1 of feces. Successful binding of 2 polyclonal antibodies to the 15-kDa subunit of the TTR protein was verified via western blot and indicated that fecal proteins can retain antibody-binding capacity. The parallelism exhibited strong correlation with the standard curve (R2 = 0.989). Data suggest that fecal TTR is higher during late summer or early fall in pregnant bears (588.40 ± 116.52) when compared to the pseudopregnant state (111.23 ± 15.98) and the nonpregnant state (250.83 ± 34.34). This is the first EIA developed to measure fecal TTR in any species. Although preliminary, these data suggest that the fecal TTR EIA may be useful in diagnosing pregnancy in polar bears.

Chromosomal microarray in unexplained severe early onset epilepsy - A single centre cohort

BACKGROUND

Severe early onset epilepsy may lead to impaired cognitive and motor development, and consists of a group of specific and overlapping electro-clinical phenotypes which may be the result of an inborn error of metabolism, congenital or acquired structural brain lesion, known chromosomal or mono-genetic disorder. A significant proportion of cases however remain unexplained, representing a major diagnostic and management challenge.

METHODS

In this study we describe a cohort of children with severe early onset epilepsy and examine the clinical utility of chromosomal microarray (array-comparative genomic hybridisation, CGH) in this group of epilepsies.

RESULTS

In 51 children with unexplained severe early onset epilepsy, all of whom had chromosomal array tested, copy number variants were detected in 17.6% and pathogenic variants in 5.9% of infants.

CONCLUSIONS

Chromosomal microarray is a useful investigation in early onset refractory epilepsy and epileptic encephalopathy. Detailed review of the precise array abnormality and phenotypes associated are important for determining significance.

Neurodevelopmental outcome at seven years in term, acidotic newborns

The objective was to follow up a cohort of acidotic full-term infants with or without hypoxic ischemic encephalopathy (HIE) and determine if at 7 years they displayed any neurodevelopmental delays. Children (n=44) were divided according to those with mild (n=25) or severe (n=19) acidosis and were then further subdivided into those with or without HIE. Participants were assessed using the Wechsler Intelligence Scale for Children (WISC-IVUK) and Achenbach Child Behaviour Checklist (CBCL). No differences in WISC-IVUK scores in children without HIE irrespective of the cord pH values were found. Children with HIE grade I scored significantly higher in perceptual reasoning than those with grade III (p<0.01). CBCL scores revealed no differences between groups. Findings suggest evidence of impairment at school-age that correlates with the degree of encephalopathy. Acidosis without the presence of clinical encephalopathy was associated with normal outcome.

Does early treatment improve outcomes in N-methyl-D-aspartate receptor encephalitis?

N-methyl-d-aspartate (NMDA) receptor encephalitis is a treatable cause of autoimmune encephalitis in both children and adults. It is still unclear if the natural history of the condition in children is altered by early treatment with immunosuppressive therapy. We looked at the outcomes of five children (two males, three females; mean age 6y 9mo, range 4-8y) who were treated empirically for autoimmune encephalitis within a brief period of presentation. Features that led clinicians to suspect autoimmune encephalitis included prominent neuropsychiatric features, movement disorder, seizures, and dysautonomic features. Immunosuppressive therapy was carried out in all cases. In this series of children, in whom the median time from symptom onset to treatment was 5 days and median length of time for follow-up was 24 months, four out of the five (80%) recovered to their baseline. Early initiation of immunosuppressive therapy may result in improved clinical outcomes.

Benign hereditary chorea related to NKX2.1: expansion of the genotypic and phenotypic spectrum

AIM

Benign hereditary chorea is a dominantly inherited, childhood-onset hyperkinetic movement disorder characterized by non-progressive chorea and variable degrees of thyroid and respiratory involvement. Loss-of-function mutations in NKX2.1, a gene vital to the normal development and function of the brain, lungs, and thyroid, have been identified in a number of individuals.

METHOD

Clinical data from individuals with benign hereditary chorea identified through paediatric neurology services were collected in a standardized format. The NKX2.1 gene was analysed by Sanger sequencing, multiplex ligation-dependent probe amplification, and microarray analysis.

RESULTS

Six of our cohort were female and four male, median age at assessment was 8 years 6 months (range 1 y 6 mo-18 y). We identified 10 probands with NKX2.1 mutations; nine of these mutations are novel (including two whole-gene deletions) and one has been previously reported. Of the 10 individuals, eight presented with muscle hypotonia and four had evidence of hypothyroidism or respiratory involvement. Only three out of the 10 individuals had the full triad of 'brain-lung-thyroid syndrome' symptoms. Additional clinical characteristics occurring in individual participants included growth hormone deficiency, pes cavus, kyphosis, duplex kidney, and obsessive-compulsive disorder.

INTERPRETATION

Our data suggest that the neurological phenotype is prominent in this condition and that many patients with benign hereditary chorea do not have the classic triad of brain-lung-thyroid syndrome. The extended phenotype may include obsessive-compulsive disorder and skeletal abnormalities.

Investigation of an association between onset of narcolepsy and vaccination with pandemic influenza vaccine, Ireland April 2009-December 2010

In 2011, the Irish Medicines Board received reports of onset of narcolepsy following vaccination against influenza A(H1N1)pdm09 with Pandemrix. A national steering committee was convened to examine the association between narcolepsy and pandemic vaccination. We conducted a retrospective population-based cohort study. Narcolepsy cases with onset from 1 April 2009 to 31 December 2010 were identified through active case finding. Narcolepsy history was gathered from medical records. Pandemic vaccination status was obtained from vaccination databases. Two independent experts classified cases using the Brighton case definition. Date of onset was defined as date of first healthcare contact for narcolepsy symptoms. Incidence of narcolepsy in vaccinated and non-vaccinated individuals was compared. Of 32 narcolepsy cases identified, 28 occurred in children/adolescents and for 24 first healthcare contact was between April 2009 and December 2010. Narcolepsy incidence was 5.7 (95% confidence interval (CI): 3.4–8.9) per 100,000 children/adolescents vaccinated with Pandemrix and 0.4 (95% CI: 0.1–1.0) per 100,000 unvaccinated children/adolescents (relative risk: 13.9; absolute attributable risk: 5.3 cases per 100,000 vaccinated children/adolescents). This study confirms the crude association between Pandemrix vaccination and narcolepsy as observed in Finland and Sweden. The vaccine is no longer in use in Ireland. Further studies are needed to explore the immunogenetic mechanism of narcolepsy.