Plural molecular and cellular mechanisms of pore domain KCNQ2 encephalopathy

KCNQ2 variants in children with neurodevelopmental impairment are difficult to assess due to their heterogeneity and unclear pathogenic mechanisms. We describe a child with neonatal-onset epilepsy, developmental impairment of intermediate severity, and KCNQ2 G256W heterozygosity. Analyzing prior KCNQ2 channel cryoelectron microscopy models revealed G256 as keystone of an arch-shaped non-covalent bond network linking S5, the pore turret, and the ion path. Co-expression with G256W dominantly suppressed conduction by wild-type subunits in heterologous cells. Ezogabine partly reversed this suppression. G256W/+ mice have epilepsy leading to premature deaths. Hippocampal CA1 pyramidal cells from G256W/+ brain slices showed hyperexcitability. G256W/+ pyramidal cell KCNQ2 and KCNQ3 immunolabeling was significantly shifted from axon initial segments to neuronal somata. Despite normal mRNA levels, G256W/+ mouse KCNQ2 protein levels were reduced by about 50%. Our findings indicate that G256W pathogenicity results from multiplicative effects, including reductions in intrinsic conduction, subcellular targeting, and protein stability. These studies reveal pore "turret arch" bonding as a KCNQ structural novelty and introduce a valid animal model of KCNQ2 encephalopathy. Our results, spanning structure to behavior, may be broadly applicable because the majority of KCNQ2 encephalopathy patients share variants near the selectivity filter.

Menstrual Suppression in the Myelosuppressed: A Retrospective Cohort Study

PURPOSE

Adolescent and young adult female patients receiving myelosuppressive cancer treatments are at risk of abnormal uterine bleeding (AUB). The frequency with which patients with cancer receive menstrual suppression and the agents used have not previously been well-characterized. We studied the rate of menstrual suppression, the effect of suppression on bleeding and blood product utilization, and if there were practice pattern differences between adult and pediatric oncologists.

METHODS

We established a retrospective cohort of 90 females with a diagnosis of Hodgkin or non-Hodgkin lymphoma (n = 25), AML (n = 46), or sarcoma (n = 19) and treated with chemotherapy between 2008 and 2019 at our institutions (University of Alabama at Birmingham [UAB] adult oncology: UAB hospital; UAB pediatric oncology: Children's of Alabama). Data were abstracted from the medical record including sociodemographics, primary oncologist specialty (pediatric v adult), cancer details (diagnosis and treatment) and gynecologic course (documented gynecologic history, menstrual suppression agents used, reported AUB outcomes, and treatments).

RESULTS

The majority of patients (77.8%) received menstrual suppression. Compared with nonsuppressed patients, suppressed patients had similar rates of packed red blood cell transfusions but higher number of platelet transfusions. Adult oncologists were more likely to document a gynecologic history, consult gynecology, and list AUB as a problem. Among suppressed patients, there was heterogeneity in the agents used for menstrual suppression, with a predilection toward progesterone-only agents; a low rate of thrombotic events was observed.

CONCLUSION

Menstrual suppression was common in our cohort with variability in agents used. Pediatric and adult oncologists demonstrated different practice patterns.

Internalized HIV-Related Stigma and Neurocognitive Functioning Among Women Living with HIV

The prevalence of HIV-associated neurocognitive impairment persists despite highly effective antiretroviral therapy (ART). In this study we explore the role of internalized stigma, acceptance of negative societal characterizations, and perceptions about people living with HIV (PLWH) on neurocognitive functioning (executive function, learning, memory, attention/working memory, psychomotor speed, fluency, motor skills) in a national cohort of women living with HIV (WLWH) in the United States. We utilized observational data from a multicenter study of WLWH who are mostly African American living in low-resource settings. Neurocognitive function was measured using an eight-test battery. A multiple linear regression model was constructed to investigate the relationship between internalized stigma and overall neurocognitive functioning (mean of all neurocognitive domain standardized T-scores), adjusting for age, education, race, previous neuropsychological battery scores, illicit drug use, viral load, and years on ART. Our analysis revealed that internalized HIV-related stigma is significantly associated with worse performance on individual domain tests and overall neurocognitive performance (B = 0.27, t = 2.50, p = 0.01). This suggests HIV-related internalized stigma may be negatively associated with neurocognitive functioning for WLWH. This finding highlights a specific psychosocial factor associated with poor neurocognitive function that may be targeted to better promote the health of PLWH. Future research on the longitudinal relationship between these variables and the effects of other stigma dimensions on poor neurocognitive function would provide further insights into the pathways explaining the relationship between internalized stigma and neurocognition.

Floral Colonization Dynamics and Specificity of Aureobasidium pullulans Strains Used to Suppress Fire Blight of Pome Fruit

Aureobasidium pullulans is used as a biocontrol agent for fire blight protection in organic apple and pear production. We assessed colonization of pome flowers by A. pullulans in orchards located near Corvallis, OR and Wenatchee, WA. Blossom Protect, a mix of A. pullulans strains CF10 and CF40, and its citrate-based companion, Buffer Protect, were sprayed at 70% bloom. Later in bloom, the population size of putative A. pullulans on flowers was estimated by dilution plating; plate scrapings of putative A. pullulans were then sampled and subjected to a PCR analysis. Sequenced PCR amplicons of the internal transcribed spacer region and the elongase gene confirmed the presence of A. pullulans, whereas a multiplex PCR with primers specific to CF10 and CF40 was used to determine the presence of the introduced strains. At Corvallis, a wet spring environment, A. pullulans, was recovered from most (>90%) Bartlett pear and Golden Delicious apple flowers sampled from experimental trees, regardless of whether the trees were treated with Blossom Protect. Nevertheless, population size estimates of A. pullulans on the flowers were correlated with the number of times Blossom Protect was sprayed on the trees. At Wenatchee, an arid spring environment, A. pullulans was detected on most flowers from trees treated with Blossom Protect, but only on a minority of flowers from nontreated controls. In both locations, the combined incidence of strains CF10 and CF40 on flowers averaged 89% on Blossom Protect-treated trees, but only 27% on adjacent, nontreated trees. During subsequent trials, the efficacy of Blossom Protect for fire blight control was compared with alternative yeast isolates, with each applied with Buffer Protect; local isolates of A. pullulans and Cryptococcus neoformans and a postharvest biocontrol strain of Cystofilobasidium infirmominiatum were used All yeast strains suppressed fire blight to a degree; however, in each of four trials, the level of suppression was highest with Blossom Protect, and it was significantly superior (P ≤ 0.05) to other yeast isolates in two of the trials. Because A. pullulans strains CF10 and CF40 were detected primarily on flowers on trees treated with Blossom Protect, and because they were detected much less frequently on nearby nontreated tress, we recommend treating every tree row with Blossom Protect at least once for organic fire blight suppression.

A prospective, randomized study comparing percutaneous with surgical tracheostomy in critically ill patients

OBJECTIVE

To determine the relative cost-effectiveness of percutaneous dilational tracheostomy (PDT) and surgical tracheostomy (ST) in critically ill patients.

DESIGN

Prospective randomized study.

SETTING

Medical, surgical, and coronary intensive care units at Barnes-Jewish Hospital, a tertiary care medical center.

PATIENTS

Eighty critically ill mechanically ventilated patients requiring elective tracheostomy.

INTERVENTIONS

Randomization to either PDT performed in the intensive care unit or ST performed in the operating room.

MEASUREMENTS AND MAIN RESULTS

Treatment groups were well matched with respect to age (PDT, 65.44 +/- 2.82 [mean +/- se] years; ST, 61.4 +/- 2.89 years, p = Ns), gender (PDT, 45% males; ST, 47.5% males, p = NS), severity of illness (Acute Physiology and Chronic Health Evaluation II score: PDT, 16.87 +/- 0.84; ST, 17.88 +/- 0.92, p = NS), and principle diagnosis. PDT was performed more quickly (PDT, 20.1 +/- 2.0 mins; ST, 41.7 +/- 3.9 mins, p < .0001) and was associated with lower patient charges than ST (total patient charges: PDT, 1,569 dollars +/- 157 dollars vs. ST, 3,172 dollars +/- 114 dollars; equipment/supply charges: PDT, 688 dollars +/- 103 dollars vs. ST, 1,526 dollars +/- 87 dollars; professional charges: PDT, 880 dollars +/- 54 dollars vs. ST, 1,647 dollars +/- 50 dollars; p < .0001 for all). There were no differences in days intubated before tracheostomy (PDT, 12.7 +/- 1.1 days; ST, 15.6 +/- 1.9, p = .20), intensive care unit length of stay (PDT, 24.5 +/- 2.5 days; ST, 28.5 +/- 3.1 days, p = .33), or hospital length of stay (PDT 49.7 +/- 4.2 days; ST, 43.7 +/- 3.5 days, p = .28) when we compared these two techniques.

CONCLUSIONS

PDT is a cost-effective alternative to ST. The reduction in patient charges associated with PDT in this study resulted from the procedure being performed in the intensive care unit, thus eliminating the need for operating room facilities and personnel. PDT may become the procedure of choice for electively establishing tracheostomy in the appropriately selected patient who requires long-term mechanical ventilation.

Percutaneous dilatational tracheostomy in a community hospital setting

BACKGROUND

Over the past 15 years, many large university hospitals have reported their experience with percutaneous dilatational tracheostomy (PDT). The purposes of this study are to evaluate the safety of PDT in a non-university hospital setting and to compare our results with those published in the literature.

METHODS

The study was done by retrospective chart review.

RESULTS

Over a 6-year period, 300 PDTs were done in two community hospitals in Tyler, Texas. There was one death and 12 complications. Comparison of our results and those reported in five recently published articles in the literature showed no significant difference in mortality rate, pneumothorax, bleeding, paratracheal placement, dislodgement, or cellulitis. There was a trend toward a significantly lower incidence of paratracheal placement using bronchoscopic guidance.

CONCLUSION

Bedside PDT with bronchoscopic guidance can be safely done in a community hospital setting.

Popliteal artery injury associated with knee dislocations

Since the Vietnam War experience we have known that there is a high association between knee dislocations and popliteal artery injuries. In an effort to improve the quality of care we asked whether every patient with a knee dislocation needs an arteriogram. This is a retrospective chart review of all injured patients who presented to Louisiana State University Health Science Center with knee dislocations between January 1, 1993 and March 31, 1998. Twenty-one patients met the study criteria. There were no deaths in this series. Twelve patients presented with normal palpable pulses. Nine of these 12 patients underwent an arteriogram. There was only one abnormal arteriogram (intimal defect) in this group. None of the patients who presented with normal pulses were operated on. There were no in-hospital complications from this nonoperative management. In the group of patients with either diminished pulses or no pulses arteriograms were performed on all patients. Fifty-five per cent of these arteriograms were abnormal, and one-third of these patients (two) were taken to the operating room for repair. In the group of patients who present with knee dislocations and normal peripheral vascular examination arteriograms are not helpful.

The effects of age and gender on laryngeal aerodynamics

A computerized airflow/air pressure analysis system, the Aerophone II Model 6800 (Kay Elemetrics Corp.), was used to assess the effects of age and gender on laryngeal aerodynamics. A sample of 56 male and 53 female normal speaking subjects was divided into six age groups (20-30; 31-40; 41-50; 51-60; 61-70 and 71-80 years). The laryngeal aerodynamic parameters measured included phonatory (mean) flow rate, estimated subglottal pressure, laryngeal airway resistance, phonatory sound pressure level, phonatory power, and phonatory efficiency. Most comfortable phonation, vocal efficiency, and running speech tasks were used to collect the aerodynamic data. Comfortable pitch and loudness levels were used for each of these tasks. Age and gender effects were found for a number of the phonatory (mean) flow rate and phonatory sound pressure level values. Results failed, however, to indicate age or gender effects for the estimated subglottal pressure, laryngeal airway resistance, phonatory power and phonatory efficiency parameters. High intersubject variability was found for the phonatory flow rate, laryngeal airway resistance, phonatory power and phonatory efficiency values. Estimated subglottal pressure values, however, appeared to vary the least among subjects. The results are discussed with respect to factors that might influence laryngeal aerodynamics, such as underlying laryngeal anatomical and physiological age-related changes and gender-related differences. The clinical implications of the findings for the assessment and treatment of individuals with voice disorders using the Aerophone II are also discussed.

Lip and tongue function in multiple sclerosis: A physiological analysis

A physiological analysis of the articulatory function of 16 adults with multiple sclerosis (MS) was performed using lip and tongue transduction systems. Sixteen nonneurologically impaired adults, matched for age, gender, and education, served as controls. The MS speakers demonstrated patterns of tongue function that were significantly different from those of the control speakers. Specifically, the MS speakers were found to have significantly reduced tongue strength, endurance, and rate of repetitive movements. In addition, preclinical signs of lingual dysfunction were evident in nondysarthric MS speakers on endurance and rate tasks when compared to control subjects. These physiological findings could account for the perceptual findings of impaired articulation and reduced intelligibility. No lip dysfunction was found on either the physiological or perceptual assessments.

Motor speech impairment in a case of childhood basilar artery stroke: treatment directions derived from physiological and perceptual assessment

The perceptual and physiological characteristics of the speech of a nine year old child who suffered a basilar artery stroke at the age of five years were investigated using a battery of perceptual and physiological instrumental measures. Perceptual tests administered included the Frenchay Dysarthria Assessment, a perceptual analysis of a speech sample based on a reading of the Grandfather Passage and a phonetic intelligibility test. Instrumental procedures included: spirometric and kinematic analysis of speech breathing; electroglottographic evaluation of laryngeal function, nasometric assessment of velopharyngeal function and evaluation of lip and tongue function using pressure transducers. Physiological assessment indicated the most severe deficits to be in the respiratory and velopharyngeal sub-systems with significant deficits in the articulatory sub-system, all of which resulted in severely reduced intelligibility. These results were compared and contrasted with the subject's performance on the perceptual assessment battery. In a number of instances the physiological assessments were able to identify deficits in the functioning of components of the speech production apparatus either not evidenced by the perceptual assessments or where the findings of the various perceptual assessments were contradictory. The resulting comprehensive profile of the child's dysarthria demonstrated the value of using an assessment battery comprised of both physiological and perceptual methods. In particular, the need to include instrumental analysis of the functioning of the various subcomponents of the speech production apparatus in the assessment battery when defining the treatment priorities for children with acquired dysarthria is highlighted. Treatment priorities determined on the basis of both the perceptual and physiological assessments for the present CVA case are discussed.

Variability in upper motor neurone-type dysarthria: an examination of five cases with dysarthria following cerebrovascular accident

The degree of diversity in the nature and extent of the physiological deficits which occur in subjects with dysarthria with similar neurological damage is demonstrated through the individual assessment profiles of five subjects with dysarthria following upper motor neurone (UMN) damage. The perceptual profiles of each subject were compiled using perceptual ratings of deviant speech parameters, intelligibility ratings from the Assessment of Intelligibility of Dysarthric Speech (ASSIDS), and perceptual judgements of subsystem function determined from the Frenchay Dysarthria Assessment (FDA). For each individual, the perceptual profile of their speech impairments was compared and contrasted with the objective results of spirometric and kinematic assessments of respiratory function aerodynamic and electroglottographic evaluations of laryngeal function, pressure and strain gauge evaluations of articulatory function, and nasal accelerometric assessments of nasality. The outcomes of the individual perceptual and physiological profiles are discussed with respect to the presence of differential subsystem impairments both within each subject and between subjects with similar underlying pathophysiological deficits. The importance of interpreting the instrumental findings with respect to the interdependency of each of the motor speech subsystems, the limitations of perceptual assessments, and the advantages of utilising both perceptual and physiological analyses in the process of identifying treatment goals is discussed.

Gonoccocal endocarditis

In the postantibiotic era, systemic complications from a gonococcal infection are rare. Females tend to have a higher frequency of gonococcal sepsis than males. In contrast, males have a higher rate of gonococcal endocarditis. This article describes a case of a previously healthy young male who presented with aortic insufficiency and blood cultures positive for Neisseria gonorrhoeae. Despite adequate antibiotic coverage, the patient's aortic insufficiency worsened, requiring aortic value replacement before discharge from the hospital. The patient's recovery was uneventful.

Causes of gastrointestinal hemorrhage in neonates and children

The causes of gastrointestinal hemorrhage in children were detailed in 1964 by Spencer. We investigated the causes of gastrointestinal hemorrhage in 165 children seen at our institution over a 13-year period. The most common causes of gastrointestinal hemorrhage in the hospitalized patients were necrotizing enterocolitis (44%), anal fissures (23%), and guaiac-positive stools of unknown cause (16%). The mortality rate was 5.4%. Necrotizing enterocolitis was the most common cause of death. Only 16 patients required surgery. Gastrointestinal hemorrhage is an infrequent cause of mortality and morbidity in hospitalized pediatric patients.

Management of BB shot wounds to the heart

OBJECTIVE

The aim of this study was to review our experience with BB shot injuries to the heart.

DESIGN

This is a retrospective chart review.

MATERIALS AND METHODS

Three patients were found to have BB injuries to the heart. All patients were stable upon presentation. Echocardiography localized the BB pellets to the muscular septum.

MEASUREMENTS AND MAIN RESULTS

All patients were treated with nonoperative therapy. There was not mortality. One patient developed an interventricular conduction delay that resolved before discharge.

CONCLUSIONS

Nonoperative management of stable patients who present with BB wounds to the heart is safe and effective if the BB is intramuscular. An echocardiogram should be used to localize the pellets and evaluate the pericardium.

Intrarater and interrater reliability of three isometric dynamometers in assessing shoulder strength

The purpose of this study was to evaluate the reliability of three separate isometric strength testing devices. Seventeen (10 female, 7 male) adult volunteers with no known shoulder dysfunction participated. Each subject's internal rotation, external rotation and abduction strength was measured with the Nicholas Manual Muscle Tester (MMT), Biodex Isokinetic Dynamometer, and Isobex 2.0. Two investigators administered the test to each subject with each device. Data were analyzed with intraclass correlation coefficients (ICCs). Ranges of the intrarater intraclass correlation coefficient (3,1) values for each muscle group with each device for both testers were as follows: Nicholas MMT = .84 to .97, Biodex = .97 to .99, and Isobex 2.0 = .95 to .98. Ranges of interrater intraclass correlation coefficient values for each device and muscle group were as follows: Nicholas MMT = .79 to .94, Biodex = .93 to .96, and Isobex 2.0 = .90 to .97. Time to complete testing was shortest for Nicholas MMT, followed by Isobex 2.0, then Biodex. Measurements taken on the same day by the same therapist appear to be highly reliable for all three devices. Measurements taken over a 3-day period by two therapists appear to be highly reliable for all devices and muscle groups with the exception of Nicholas MMT abduction (.79), which was moderately reliable.

Disorders of nasality in subjects with upper motor neuron type dysarthria following cerebrovascular accident

The nasality of 19 subjects with upper motor neuron (UMN) damage following cerebrovascular accident (CVA), and 19 control subjects matched for age and sex, was investigated using both perceptual judgements of nasality and a modified version of the nasal accelerometric procedure described by Horii (1980). Nasality indices were calculated for each subject during the production of a series of nasal and non-nasal sounds, words, and sentences. Statistical comparison of the two groups revealed that the CVA subjects had significantly higher nasality indices on the production of nonnasal speech tasks than the controls. No significant difference was noted between the two groups on nasal tasks. Individual case by case examination of the accelerometer data confirmed the presence of hypernasality in 7 of the 19 CVA subjects. In contrast to the instrumental findings, the results of the perceptual judgements of nasality identified the presence of hypernasality, hyponasality, and normal nasal resonance within the CVA group.

Elephantiasis nostras verrucosa

Elephantiasis is an uncommon disease in the United States. We present a case of nonfilarial elephantiasis nostras verrucosa in a 14-year-old girl. Most commonly, the upper and lower extremities are affected; the disease, in this patient, was confined to the buttock. The patient has done well after excision and primary closure. The patient is currently undergoing pressure therapy 1 year after surgery. She has no evidence of recurrence. We present this case and review the literature.

A critical review of the Couinaud technique of hepatic resection

The Couinaud technique of left hepatic lobectomy involves the isolation and division of portal vein, hepatic artery, and biliary tributaries as a unit within the liver parenchyma. It saves time and minimizes blood loss by virtue of the common investment of the portal structures in a thick connective tissue sheath. Right hepatic lobectomy can be performed in a similar manner based on the same assumption that the biliary and vascular tributaries maintain a constant anatomic relationship with one another. We describe a patient who underwent right hepatic lobectomy by the Couinaud technique who (in retrospect) had congenital absence of a left hepatic duct. Because small bile ducts from the left lobe drained into the right hepatic duct deep to the sight of resection, obstructive jaundice resulted postoperatively, necessitating orthotopic liver transplantation. Presently, the patient is doing well 1 year after transplantation. When the Couinaud technique is used in the setting of a biliary anatomic variant, the results can be disastrous. This case illustrates that the Couinaud technique is unsafe unless biliary anatomic variants are excluded prior to hepatic lobectomy.

Lip function in subjects with upper motor neuron type dysarthria following cerebrovascular accidents

The lip function of 16 speakers with upper motor neuron damage following cerebrovascular accident (CVA), was investigated using instrumental measures. Sixteen, non-neurologically impaired adults matched for age and sex served as controls. The results of the instrumental investigations revealed that the CVA speakers had patterns of lip function that were significantly different from the control speakers. Specifically, on maximum force tasks, the CVA speakers were found to produce significantly lower maximum lip force values. Maximum rate of attempts at lip movement was also slower in the CVA speakers. In addition, the instrumental investigation revealed that the CVA speakers demonstrated a significant decline in pressure over the course of the task involving 10 attempts at maximum lip force. In contrast, the control speakers maintained a consistent level of force throughout the 10 repetitions/attempts. Overall, the findings suggest that the CVA speakers have deficits in maximum lip force, endurance of lip strength and rate of lip movements. Correlations conducted between instrumental measures of maximum lip strength and the perceptual ratings of overall intelligibility, precision of consonants, precision of vowels and length of phonemes revealed no significant relationship.

Yersinia enterocolitica sepsis in a 3-week-old child

Yersinia enterocolitica has been described with increasing frequency in the United States. Commonly, Y enterocolitica is a self-limiting gastrointestinal disorder, but occasionally it can lead to fulminant infection. This case report describes a 3-week-old male who succumbed to Y enterocolitica sepsis and reviews the literature.

Computer-assisted instruction in curricula of physical therapist assistants

This article compares the effectiveness of computer-assisted instruction (CAI) with written, programmed instruction between two groups of physical therapist assistant students. No significant difference in the amount of material learned or retained after completion of testing using either CAI or a written, programmed text was found in this group of 16 subjects. Learning style or attitude about computers did not correlate strongly with performance after the CAI. Findings suggest that more research is needed to support decisions related to fiscal allotments for computer use in college curricula.