Viral delivery of tissue nonspecific alkaline phosphatase diminishes craniosynostosis in one of two FGFR2C342Y/+ mouse models of Crouzon syndrome

Craniosynostosis is the premature fusion of cranial bones. The goal of this study was to determine if delivery of recombinant tissue nonspecific alkaline phosphatase (TNAP) could prevent or diminish the severity of craniosynostosis in a C57BL/6 FGFR2^C342Y/+ model of neonatal onset craniosynostosis or a BALB/c FGFR2^C342Y/+ model of postnatal onset craniosynostosis. Mice were injected with a lentivirus encoding a mineral targeted form of TNAP immediately after birth. Cranial bone fusion as well as cranial bone volume, mineral content and density were assessed by micro CT. Craniofacial shape was measured with calipers. Alkaline phosphatase, alanine amino transferase (ALT) and aspartate amino transferase (AST) activity levels were measured in serum. Neonatal delivery of TNAP diminished craniosynostosis severity from 94% suture obliteration in vehicle treated mice to 67% suture obliteration in treated mice, p<0.02) and the incidence of malocclusion from 82.4% to 34.7% (p<0.03), with no effect on cranial bone in C57BL/6 FGFR2^C342Y/+ mice. In contrast, treatment with TNAP increased cranial bone volume (p< 0.01), density (p< 0.01) and mineral content (p< 0.01) as compared to vehicle treated controls, but had no effect on craniosynostosis or malocclusion in BALB/c FGFR2^C342Y/+ mice. These results indicate that postnatal recombinant TNAP enzyme therapy diminishes craniosynostosis severity in the C57BL/6 FGFR2^C342Y/+ neonatal onset mouse model of Crouzon syndrome, and that effects of exogenous TNAP are genetic background dependent.

Titania nanotube-based protein delivery system to inhibit cranial bone regeneration in Crouzon model of craniosynostosis

BACKGROUND

Craniosynostosis is a developmental disorder characterized by the premature fusion of skull sutures, necessitating repetitive, high-risk neurosurgical interventions throughout infancy. This study used protein-releasing Titania nanotubular implant (TNT/Ti) loaded with glypican 3 (GPC3) in the cranial critical-sized defects (CSDs) in Crouzon murine model (Fgfr2c342y/+ knock-in mutation) to address a key challenge of delaying post-operative bone regeneration in craniosynostosis.

MATERIALS AND METHODS

A 3 mm wide circular CSD was created in two murine models of Crouzon syndrome: (i) surgical control (CSDs without TNT/Ti or any protein, n=6) and (ii) experimental groups with TNT/Ti loaded with GPC3, further subdivided into the presence or absence of chitosan coating (on nanotubes) (n=12 in each group). The bone volume percentage in CSDs was assessed 90 days post-implantation using micro-computed tomography (micro-CT) and histological analysis.

RESULTS

Nano-implants retrieved after 90 days post-operatively depicted well-adhered, hexagonally arranged, and densely packed nanotubes with average diameter of 120±10 nm. The nanotubular architecture was generally well-preserved. Compared with the control bone volume percentage data (without GPC3), GPC3-loaded TNT/Ti without chitosan coating displayed a significantly lower volume percent in cranial CSDs (P<0.001). Histological assessment showed relatively less bone regeneration (healing) in GPC3-loaded CSDs than control CSDs.

CONCLUSION

The finding of inhibition of cranial bone regeneration by GPC3-loaded TNT/Ti in vivo is an important advance in the novel field of minimally-invasive craniosynostosis therapy and holds the prospect of altering the whole paradigm of treatment for affected children. Future animal studies on a larger sample are indicated to refine the dosage and duration of drug delivery across different ages and both sexes with the view to undertake human clinical trials.

Severe Dehydration and Acute Renal Failure Associated with External Ventricular Drainage of Cerebrospinal Fluid in Children

We report three paediatric cases of severe dehydration and hyponatraemia with circulatory compromise associated with the use of external ventricular drainage of cerebrospinal fluid. Two of the children had cardiac arrests. All were successfully resuscitated. While there were additional factors that contributed to other fluid losses, and fluid balance data are incomplete, these cases highlight a need for increased vigilance when managing children with external ventricular drains.

Palliation in pediatric otorhinolaryngology

Palliation in pediatric otorhinolaryngology is a rarely discussed but important aspect of care. This review encapsulates current thinking on pediatric palliative care (PC) and demonstrates, through one case, the impact of integrating PC into clinical care. We encourage early consideration of pediatric palliative care approaches for children with complex otorhinolaryngologic disorders.

Non surgical treatment of Crouzon syndrome

Crouzon syndrome is an autosomal dominant disorder with variable expressivity, characterized by skull and facial malformations. Such alterations vary from case to case. Management requires multidisciplinary approach. Two cases of two sisters affected by Crouzon syndrome are described. Treatment was performed by orthopedic and orthodontic devices without surgery. Good esthetics and functional results were obtained. Five-year follow-up records are presented.

[Freeman-Sheldon syndrome - phenotype and course of disease on the base of two cases confirmed by molecular study]

Freeman-Sheldon syndrome is characterized by typical dysmorphic features of the face (microstomia with putting lips and H-shaped dimpling of the chin, giving the appearance of a whistling face) and symmetrical hands and feet defects (camptodactyly, joint contractures). The intelligence quotient is usually within the normal range. Mutations in the MYH3 gene at 17p13 have been shown to cause the syndrome, inherited as an autosomal dominant trait. Two patients with clinical diagnosis of Freeman- Sheldon syndrome, confirmed by molecular study were described in this article. Additionally, clinical aspects, differential diagnosis and genetic basis of the disease were described as well as medical problems concerning patients with Freeman-Sheldon syndrome were discussed such as anesthetic aspects, malignant hyperthermia and pulmonary complications after surgery. The authors highlight the significance of dysmorphic features in patients with developmental delay and congenital defects as well as indicate the role of multidisciplinary approach in the diagnostic and therapeutic process.

First international meeting on “Stem Cell Applications in the Craniofacial Region”

During the 1st International Meeting on "Stem Cell Applications in the Craniofacial Region" promoted in Naples (Italy), invited researchers presented theirwork and the most innovative methods regarding stem cells (SCs) and their application to the craniofacial region of the human body. In addition, some researchers showed their case-reports on craniofacial reconstruction using either osteo-distraction or reconstruction surgical methods. The aim of this biannual meeting is to stimulate discussion, improve knowledge and promote scientific collaboration among basic and clinical scientists in the main topics of SC use in therapy. A summary of this meeting is given.

[Short-term effects of the Michigan splint on muscular and joint pain]

BACKGROUND

In 1966 Ramfjord and Ash proposed the Michigan's splint that, at present, is one of the splints widely accepted for the treatment of craniomandibular disorders (CMD).

METHODS

For this study, thirty-one subjects were examined according to the protocol of the European Academy of CMD; each patient indicated the intensity of pain using a Visual Analogue Scale (VAS). After therapy with Michigan's splint, the visit was repeated and the patient indicated again the VAS.

RESULTS

The results showed that the splint has short-term benefit effects on the muscular and articular pain, even if the effects are lesser on the articular pain.

CONCLUSIONS

The Michigan's splint is a valid device for therapy of CMD, moreover it is very cheap, very easy to use and without contraindications.

Treatment of obstructive sleep apnoea using nasal CPAP in children with craniofacial dysostoses

We studied a group of children (aged 2.2-15 years) with craniofacial dysostosis and obstructive sleep apnoea to assess the use of nasal continuous positive airway pressure (n-CPAP) as a palliative form of treatment. A variable period of time was allowed for acclimatisation to n-CPAP (1 day to 2 months), depending on the patient. Patients were then admitted for their first CPAP trial. Baseline breathing difficulty and the effectiveness of n-CPAP were assessed by respiratory sleep studies. Successful results were obtained with n-CPAP in five of the eight patients, with marked clinical and polygraphic improvements of the respiratory pattern immediately after n-CPAP was established. Of the remaining three cases, one child needed a prolonged period of acclimatisation to the n-CPAP system, one was withdrawn from the study, and one failed to respond to n-CPAP and was found to have complete blockage of the upper airways as a result of enlarged adenoids. Our results confirm that n-CPAP can be tolerated even by young patients and can be effective, and that it may be a useful alternative palliative treatment for obstructive sleep apnoea in children with craniofacial syndromes.

Nager acrofacial dysostosis: management of a difficult airway

Nager acrofacial dysostosis, first described by Nager and deReynier in 1948, is a rare syndrome characterized by mandibulofacial dysostosis with associated radial defects. The facial features include downward slanting palpebral fissures, absent eyelashes in the medial third of the lower lids, mandibular and malar hypoplasia, dysplastic ears with conductive deafness, and variable degrees of palatal clefting. Upper limb malformation is a constant feature of Nager syndrome and ranges from thumb hypoplasia to absence of the radial ray. The maxillo-mandibular hypoplasia and associated retroplaced tongue set the stage for early and significant upper airway obstruction. The craniofacial anomalies and associated trismus make emergent airway intubation challenging. We present a case of Nager syndrome with life threatening airway obstruction unresponsive to conservative management. This case and a review of the literature emphasize the importance of early tracheotomy for these patients.

Legg-Calvé-Perthes' disease in the Russell-Silver syndrome. A report of two cases and a review of the literature

Perthes' disease was seen in two boys, aged 6 1/2, with the Russell-Silver Syndrome. Both presented with groin or thigh pain in their shortened side together with a progressive limp. They were treated conservatively, and when reviewed 6 1/2 years after diagnosis the lesions of the hip had improved clinically and radiographically. The leg length discrepancy did not increase.

[Treatment of syndromes with abnormalities of the face]

A standard method of treating syndromes with anomalies in the face does not exist. Not only are the differences between the symptoms of different syndromes very important. Also within one syndrome variations can be marked. A team of specialists supports the cranio-facial surgeon in his central role when treating these patients. Type of treatment, sequence, timing, et cetera, follow certain rules, which may be in part the same as for the treatment of 'ordinary' maxillo-mandibular disharmonies, but sometimes differ significantly from it. The most important aspects of treatment of three rather frequently seen cranio-facial syndromes are given. Incidence, symptoms, therapeutical possibilities and timing, and results are discussed as well as the necessity of this kind of surgery.

Craniofacial growth from infancy through adulthood. Background and clinical implications

The purpose of this article was to enable the pediatrician to identify and understand the implications of common facial growth problems in children and adolescents. Problems with facial growth can result in aesthetic and functional complaints. Using a simple method of clinical evaluation, the pediatrician can identify facial growth problems in the anteroposterior, vertical, and transverse dimensions. These problems can then be referred for evaluation and treatment by a variety of means. By adopting a contemporary view that facial growth is the result of genetic and environmental factors (some of which are functional), growth modification becomes a real possibility. Unfortunately, some problems must be camouflaged or treated by combined surgical and orthodontic means. Continued growth in early adulthood can enhance or detract from treatment results obtained in childhood or adolescence. These dynamic properties of the face make management of facial growth challenging but generally rewarding and successful because of substantial aesthetic and functional improvements.

[Tooth and jaw development in the Silver-Russel syndrome]

The symptoms of Silver-Russel syndrome are described using two cases. Special attention was paid to the development of the teeth and the jaws. The typical microretrognathism is accompanied by a frontal crowding especially in the lower jaw. It is possible to adjust it to a regular occlusion using functional orthopedic appliances. Noticeable is the high degree of caries in the first dentition. Paramorphiae are not ascertainable. Etiologically, the submucosal cleft palate, which was diagnosed for the first time, would suggest an intrauterine disturbance in the eighth to the tenth week of pregnancy.

Multidisciplinary management of Crouzon syndrome

The comprehensive management of Crouzon syndrome in a 14-year-old girl has been presented. Because of the complexity of the facial and associated problems, a multidisciplinary approach is necessary to provide maximum functional and esthetic results; however, with such a cooperative interdisciplinary effort, the improvement and benefits derived for these patients are rewarding to all concerned.

[Orthodontic treatment in cases of mandibulo-facial dysostosis]

The author describes the clinical picture of mandibulofacial dysostosis and gives reasons for the necessity for early orthodontic treatment. Two examples are presented. The analysis of the case histories of a total of 10 patients with this syndrome showed that the responsiveness to functional orthodontic appliances is greatest in children with bilateral mandibulofacial dysostosis. The need for co-operation with other disciplines involved is pointed to.