Current survey of early childhood intervention services in infants and young children with sex chromosome aneuploidies

Sex chromosome aneuploidies (SCAs) are the most commonly occurring aneuploidies in children with a collective prevalence rate of 1 in 500 live births. Prior research has documented SCAs are associated with an increased risk for early expressive language and gross motor delays, learning disorders, ADHD, autism spectrum disorder, anxiety, and executive function problems. Although SCAs have been historically underdiagnosed in young children, recent advances in noninvasive prenatal testing have resulted in an increasing nationwide cohort of infants with confirmed diagnoses. Consequently, early childhood support systems must prepare for an influx of children with known risks for associated developmental delays and potential school problems. This national survey aimed to update our understanding of current early childhood intervention services for young children with SCA in the United States and to describe parent perspectives and priorities. Descriptive statistics, chi-square tests, and logistic regression models controlling for parent education revealed a majority of respondents reported receiving public early childhood intervention services with speech therapy as the most common service. There were significant differences in early childhood intervention services by timing of diagnosis (prenatal vs. postnatal), number of sex chromosomes (trisomy vs. tetra/pentasomy), and geographic location. Parents described interventions as desirable and effective yet also difficult to obtain due to issues with the SCA phenotype, lack of provider knowledge, and challenges navigating the intervention systems. Results support the need for enhanced provider training in SCAs, policy change for early childhood intervention qualification criteria for SCA conditions, and collaboration between medical and early childhood settings.

The behavioral profile of children aged 1-5 years with sex chromosome trisomy (47,XXX, 47,XXY, 47,XYY)

Children with SCT have an increased risk of suboptimal neurodevelopment. Previous studies have shown an elevated risk for neurobehavioral problems in individuals with SCT. However, not much is known about neurobehavioral problems in very young children; knowledge that could help with early identification of children at risk for suboptimal development, and that could help establish targets for early intervention. This study addressed the question of what the behavioral profile of children with SCT aged 1–5 years looks like. In total, 182 children aged 1–5 years participated in this study (N_SCT=87, N_{nonclinical controls} = 95). Recruitment and assessment took place in the Netherlands and the United States. The SCT group was recruited through prospective follow‐up (50%), information seeking parents (31%), and clinical referral (18%). Behavioral profiles were assessed with the child behavior checklist and the ages‐and‐stages social–emotional questionnaire.

Levels of parent‐rated problem behavior were higher in children with SCT. Difficulties with overall social–emotional functioning were already present in 1‐year‐olds, and elevated scores were persistent across the full age range. Affective and pervasive developmental behaviors were seen in late toddlerhood and prominent at preschool age. Anxiety, attention deficit, and oppositional defiant behaviors were seen in preschool‐aged children. Within this cross‐sectional study, the developmental trajectory of affective, pervasive developmental, and oppositional defiant behaviors seemed to be different for SCT children than nonclinical controls.

Collectively, these results demonstrate the importance of behavioral screening for behavioral problems in routine clinical care for children with SCT from a young age. Social–emotional problems may require special attention, as these problems seem most prominent, showing increased risk across the full age range, and with these problems occurring regardless of the timing of diagnosis, and across all three SCT karyotypes.

Evaluating Social Interactions Using the Autism Screening Instrument for Education Planning-3rd Edition (ASIEP-3): Interaction Assessment in Children and Adults with Fragile X Syndrome

An efficient and direct measure of social interactions and autism symptoms is needed for fragile X syndrome (FXS) research and clinical care. The Autism Screening Instrument for Educational Planning-Third Edition (ASIEP-3) Interaction assessment is a brief standardized measure that quantifies social responses under different conditions. The feasibility and validity of the ASIEP-3 was evaluated in 26 males and 13 females with FXS, along with cognitive testing and behavior questionnaires. The videos were scored at 10-second intervals, and the observed behaviors were scored as an interaction, independent play, no response, or aggression. In total, 39/41 participants successfully completed the ASIEP-3 (age M = 14.4 ± 10.2), with a range of cognitive abilities (abbreviated IQ (ABIQ) M = 58.9 ± 17.3, median = 50), behaviors (Aberrant Behavior Checklist (ABC) Total M = 37.00 ± 27.3), and autism diagnoses (N = 22/39). Reliable administration was demonstrated by all team members. The mean coded behaviors included interaction (40.6%), independent play (36.8%), no response (21.1%), and aggressive behavior (<10%). The interaction score was negatively correlated with the Social Communication Questionnaire (SCQ) score (p = 0.037), and the profiles differed by autism spectrum disorder (ASD) diagnosis. The intraclass correlation coefficients (ICCs) ranged from 0.79 to 0.93 for master's level and above. Administration of the ASIEP-3 was feasible for FXS across sex, age, ability, and behavior ratings by a trained research team. Reliable scoring required advanced training in the assessment of social development and FXS experience. The scores correlated to ratings and diagnoses of ASD. The ASIEP-3 shows promise to reliably index social interactions in FXS.

Delineating Repetitive Behavior Profiles across the Lifespan in Fragile X Syndrome

Restricted repetitive behaviors (RRBs) are a core area of impairment in autism spectrum disorder (ASD), but also affect several other neurodevelopmental disorders including fragile X syndrome (FXS). Current literature has begun to describe the RRB profile in FXS up through adolescence; however, little is known about the subtypes of RRBs in adolescents and adults. Further, literature on the RRB profile of females with FXS is limited. The present study examines the RRB profile across subtypes and specific items in both males and females with FXS while assessing for differences based on age, ASD diagnosis and the impact of IQ. Participants included 154 individuals with FXS (ages 2 to 50 years old). Results revealed a peak in RRB severity in FXS between 7–12 years for the majority of RRB subscales with the exception of Sensory-Motor behaviors peaking between 2 and 12 years before declining. Distinct RRB profiles in males and females with FXS emerged in addition to significant overlap among the item and subscale levels of RRBs across gender. Further, an added diagnosis of ASD significantly increased rates of RRBs across all subscale levels, but not necessarily across all items. Lastly, IQ did not solely account for the presence of RRBs in FXS, with Sensory-Motor behaviors being driven by comorbid ASD in males with FXS, and Restricted Interest behaviors being driven by comorbid ASD regardless of gender. These findings build on the current understanding of RRBs in FXS based on gender and comorbid ASD and lay important groundwork for the development of targeted behavioral and pharmacological treatments.

Examination of Correlates to Health-Related Quality of Life in Individuals with Fragile X Syndrome

Health-related quality of life (HRQoL) is a multidimensional concept involving physical, psychological, social, and cognitive aspects of life. Individuals with Fragile X syndrome (FXS) experience a life-long disorder that impacts the HRQoL of the affected individual and their family. Thus, HRQoL may be an important outcome measure following intervention. However, it is yet not known whether HRQoL concerns relate to observed impairments in FXS. In the present study, we examined the nature and degree of association between HRQoL and established measures of functioning in FXS using the Parent Report for Children version of the PedsQL 4.0 Generic Core Scales and Cognitive Functioning Scale. We observed significant relationships between HRQoL a nd measures of adaptive behavior, maladaptive behaviors, and social functioning. The present study has implications for treatment outcomes for clinical trials in FXS.

Quantifying the resolution of spatial and temporal representation in children with 22q11.2 deletion syndrome

OBJECTIVES

Our ability to generate mental representation of magnitude from sensory information affects how we perceive and experience the world. Reduced resolution of the mental representations formed from sensory inputs may generate impairment in the proximal and distal information processes that utilize these representations. Impairment of spatial and temporal information processing likely underpins the non-verbal cognitive impairments observed in 22q11.2 deletion syndrome (22q11DS). The present study builds on prior research by seeking to quantify the resolution of spatial and temporal representation in children with 22q11DS, sex chromosome aneuploidy (SCA), and a typically developing (TD) control group.

PARTICIPANTS AND METHODS

Children (22q11DS = 70, SCA = 49, TD = 46) responded to visual or auditory stimuli with varying difference ratios. The participant's task was to identify which of two sequentially presented stimuli was of larger magnitude in terms of, size, duration, or auditory frequency. Detection threshold was calculated as the minimum difference ratio between the "standard" and the "target" stimuli required to achieve 75% accuracy in detecting that the two stimuli were different.

RESULTS

Children with 22q11DS required larger magnitude difference between spatial stimuli for accurate identification compared with both the SCA and TD groups (% difference from standard: 22q11DS = 14; SCA = 8; TD: 7; F  = 8.42, p < 0.001). Temporal detection threshold was also higher for the 22q11DS group to both visual (% difference from standard: 22q11DS = 14; SCA = 8; TD = 7; F  = 8.33, p < 0.001) and auditory (% difference from standard: 22q11DS = 23; SCA = 12; TD: 8; F  = 8.99, p < 0.001) stimuli compared with both the SCA and TD groups, while the SCA and TD groups displayed equivalent performance on these measures (p's > 0.05). Pitch detection threshold did not differ among the groups (p's > 0.05).

CONCLUSIONS

The observation of higher detection thresholds to spatial and temporal stimuli indicates further evidence for reduced resolution in both spatial and temporal magnitude representation in 22q11DS, that does not extend to frequency magnitude representation (pitch detection), and which is not explained by generalized cognitive impairment alone. These findings generate further support for the hypothesis that spatiotemporal hypergranularity of mental representations contributes to the non-verbal cognitive impairment seen in 22q11DS.

SUN-263 Evidence for Diminished Ovarian Reserve in Youth with Trisomy X

Background: An additional X chromosome occurs in 1 in 1,000 females resulting in a 47,XXX karyotype also known as Trisomy X. Abnormal ovarian function was suggested from a cohort of 10 females with Trisomy X followed from birth through young adulthood who had later age of menarche and one girl who developed secondary amenorrhea with elevated gonadotropin levels (1). There have since been several case reports of premature menopause in women with Trisomy X, and 3.8% of women with premature ovarian insufficiency (POI) have been reported to have Trisomy X (2). Ovarian reserve can be estimated by serum anti-mullerian hormone (AMH) concentrations, with low AMH concentrations concerning for diminished ovarian reserve and poor fertility prospects. Ovarian function in youth with Trisomy X has not been evaluated. The purpose of this study was to evaluate AMH as a marker of ovarian reserve in girls with Trisomy X. Methods: Parents and youth with Trisomy X seen at a tertiary care referral center were counselled on the risk for POI and AMH was offered as a screen for ovarian reserve. All participants provided informed consent to use their clinical data for research purposes. A total of 11 girls with a non-mosaic 47,XXX karyotype had AMH measured by chemiluminescent assay (Esoterix Laboratory Services) between December 2015 and October 2018. Results: The median age of participants was 13.3 years (IQR 12.4 – 17.9) and 9 of 11 girls had experienced menarche at a median age of 12.5 years (IQR 11.5-12.6); none had primary or secondary amenorrhea. The median AMH concentration was 0.7 ng/ml (IQR 0.2-1.7), significantly lower than the laboratory provided median of 5.23 ng/ml (one sample Wilcoxin Signed Rank Test p=0.001). 72% had an AMH below 1.05 ng/ml, the lower limit of normal for age. Discussion: Despite normal menarchal timing and ongoing menses, the majority of youth with Trisomy X had a low AMH concerning for diminished ovarian reserve and potentially impaired fertility. Although there is great interest in fertility preservation for girls with oncological diagnoses and Turner syndrome, there is limited awareness of ovarian dysfunction in Trisomy X. Research on ovarian function and fertility in Trisomy X is needed across the lifespan, as well as investigation into the mechanisms of the additional X chromosome leading to the diminished ovarian reserve observed in this adolescent sample. (1) Ratcliffe et al, 1990, Birth Defects: Original Article Series, 26(4): 1-44. (2) Goswami et al, 2003, Fertil Steril, 80(4): 1052-4.

Treatment of Fragile X Syndrome with Cannabidiol: A Case Series Study and Brief Review of the Literature

Fragile X syndrome (FXS) is an X-linked dominant disorder caused by a mutation in the fragile X mental retardation 1 gene. Cannabidiol (CBD) is an exogenous phytocannabinoid with therapeutic potential for individuals with anxiety, poor sleep, and cognitive deficits, as well as populations with endocannabinoid deficiencies, such as those who suffer from FXS. The objective of this study was to provide a brief narrative review of recent literature on endocannabinoids and FXS and to present a case series describing three patients with FXS who were treated with oral CBD-enriched (CBD+) solutions. We review recent animal and human studies of endocannabinoids in FXS and present the cases of one child and two adults with FXS who were treated with various oral botanical CBD+ solutions delivering doses of 32.0 to 63.9 mg daily. Multiple experimental and clinical models of FXS combine to highlight the therapeutic potential of CBD for management of FXS. All three patients described in the case series exhibited functional benefit following the use of oral CBD+ solutions, including noticeable reductions in social avoidance and anxiety, as well as improvements in sleep, feeding, motor coordination, language skills, anxiety, and sensory processing. Two of the described patients exhibited a reemergence of a number of FXS symptoms following cessation of CBD+ treatment (e.g., anxiety), which then improved again after reintroduction of CBD+ treatment. Findings highlight the importance of exploring the therapeutic potential of CBD within the context of rigorous clinical trials.

Clinical developmental, neuropsychological, and social-emotional features of Turner syndrome

Individuals with Turner syndrome (TS) are at risk for a constellation of neurocognitive and psychosocial differences, although there is significant individual variability in these features. TS is associated with an increased risk for difficulties with visual-spatial reasoning, visual-spatial memory, attention, executive functioning, motor, and math skills. Additionally, increased rates of social difficulties, anxiety, and depression are observed. There can be significant interplay between all of these factors contributing to the behavioral phenotype. Neuropsychological features and previous research are reviewed. Clinical considerations and recommendations for evaluation and treatment of psychological and behavioral difficulties are provided, including consideration of medical features in TS, as well as therapies, educational supports, and medication treatment. Future research is needed to evaluate effectiveness of different treatments for neuropsychological and psychosocial features of TS, including modification and validation of existing evidence-based treatments and new approaches to care.

The Association of Motor Skills and Adaptive Functioning in XXY/Klinefelter and XXYY Syndromes

Aims: Klinefelter (XXY) and XXYY syndromes are genetic disorders in males characterized by additional sex chromosomes compared to the typical male karyotype of 46, XY. Both conditions have been previously associated with motor delays and motor skills deficits. We aimed to describe and compare motor skills in males with XXY and XXYY syndromes, and to analyze associations with age, cognitive abilities, and adaptive functioning. Methods: Sixty-four males with XXY and 46 males with XXYY, ages 4-20 were evaluated using the Beery Test of Visual Motor Integration and the Bruininks-Oseretsky Test of Motor Proficiency - 2nd Edition assessments, Vineland-2 adaptive scales, and cognitive testing. Results: Motor coordination impairments were found in 39% of the males with XXY and 73% of the males with XXYY. Both groups showed strengths in visual perceptual skills. Males with XXYY had lower mean scores compared to males with XXY across all assessments. Fine motor dexterity and coordination deficits were common. There was a positive correlation between VMI scores and adaptive functioning. Conclusion: Occupational and physical therapists should be aware of the motor phenotype in XXY and XXYY both to aid in diagnosis of unidentified cases and to guide intervention.

Metformin as targeted treatment in fragile X syndrome

BACKGROUND

Individuals with fragile X syndrome (FXS) have both behavioral and medical comorbidities and the latter include obesity in approximately 30% and the Prader-Willi Phenotype (PWP) characterized by severe hyperphagia and morbid obesity in less than 10%. Metformin is a drug used in individuals with type 2 diabetes, obesity or impaired glucose tolerance and it has a strong safety profile in children and adults. Recently published studies in the Drosophila model and the knock out mouse model of FXS treated with metformin demonstrate the rescue of multiple phenotypes of FXS.

MATERIALS AND METHODS

We present 7 cases of individuals with FXS who have been treated with metformin clinically. One case with type 2 diabetes, 3 cases with the PWP, 2 adults with obesity and/or behavioral problems and, a young child with FXS. These individuals were clinically treated with metformin and monitored for behavioral changes with the Aberrant Behavior Checklist and metabolic changes with a fasting glucose and HgbA1c.

RESULTS

We found consistent improvements in irritability, social responsiveness, hyperactivity, and social avoidance, in addition to comments from the family regarding improvements in language and conversational skills. No significant side-effects were noted and most patients with obesity lost weight.

CONCLUSION

We recommend a controlled trial of metformin in those with FXS. Metformin appears to be an effective treatment of obesity including those with the PWP in FXS. Our study suggests that metformin may also be a targeted treatment for improving behavior and language in children and adults with FXS.

Androgen Treatment Effects on Motor Function, Cognition, and Behavior in Boys with Klinefelter Syndrome

OBJECTIVES

To examine the effects of early low-dose androgen on motor, cognitive, and behavioral function in prepubertal boys with Klinefelter syndrome (47,XXY).

STUDY DESIGN

Double-blind trial of 84 boys, ages 4-12 years, randomized to oxandrolone (Ox; 0.06?mg/kg daily; n?=?43) or placebo (Pl; n?=?41) for 24 months. Standardized assessments were performed at baseline and every 12 months for 24 months evaluating motor, cognitive, and behavioral function.

RESULTS

The 24-month outcomes were better in the Ox vs. Pl group on 1 of 5 primary endpoints (motor function/strength): Bruininks Visual-Motor scale (P?=?.005), without significant differences between the 2 groups for the other 4 components. Secondary analyses suggested improvement in the Ox vs. Pl group in the anxiety/depression (P?=?.03) and social problems (P?=?.01) scales on the Child Behavior Checklist, anxiety (P?=?.04) on the Piers Harris Self Concept Scale, and interpersonal problems (P?=?.02) on the Children's Depression Inventory, without significant differences in hyperactive or aggressive behaviors.

CONCLUSIONS

This double-blind, randomized trial demonstrates that 24 months of childhood low-dose androgen treatment in boys with Klinefelter syndrome benefited 1 of 5 primary endpoints (visual-motor function). Secondary analyses demonstrated positive effects of androgen on aspects of psychosocial function (anxiety, depression, social problems), without significant effects on cognitive function, or hyperactive or aggressive behaviors.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00348946.

The challenge of non-union in subtrochanteric fractures with breakage of intramedullary nail: evaluation of outcomes in surgery revision with angled blade plate and allograft bone strut

PURPOSE

Subtrochanteric fractures have a bimodal age distribution. They usually require open reduction and internal fixation. Closed reduction and intramedullary nail fixation rate are increased for this type of fracture. As a result, the hardware breakage and non-union rate is high among such patients. Our purpose is to evaluate the outcomes of the role of blade plate and bone strut allograft in the management of subtrochanteric non-union by femoral nailing.

MATERIALS AND METHODS

We reported a group of 22 patients with subtrochanteric non-union, associated with breakage of the intramedullary nail with medial femoral allograft bone and lateral blade plate and wire (PS) s; and a group of 13 patients with subtrochanteric non-union, associated with breakage of the intramedullary nail treated with lateral blade plate and screws (CG). The chosen criteria to evaluate the two group during the clinical and radiological follow-up were the quality of life, measured by The Short Form (12) Health Survey (SF-12), the hip function and quality of life related to it, measured by the Harris Hip Score (HHS), bone healing, measured by Radiographic Union Score (RUS) by XR and CT at 1 year after the surgery, and postoperative complications. The evaluation endpoint was set at 12 months.

RESULTS

The Bone healing measured by RUS occurred and also the full recovery before the first trauma measured by SF-12 and HHS are better in PS group. We only had three unimportant complications in PS while four breakage hardware in CG.

CONCLUSION

We conclude that in complicated non-unions, the use of blade plate and bone strut allograft has a definite positive role in the management of such cases.

Arteriovenous Malformation in a Youth with Atypical Autism Symptoms

Cerebral arteriovenous malformations (AVMs) present a challenge to diagnose in children with developmental disability, because of the overlap in behavioral symptoms and neurologic manifestations. They have been very rarely reported in conjunction with autism spectrum disorder. This case involves a 13 year old male with a history of autism spectrum disorder and significant behavioral issues diagnosed with a thalamic AVM following lateralizing neurologic symptoms. Despite radiosurgical treatment, hemorrhage followed consequently causing extensive neurologic injury and death. This case emphasizes the need for close follow up and coordination within a medical home for children with developmental disabilities. A multidisciplinary team approach is ideal to allow detection of subtle neurologic changes over time that may be masked as behavioral difficulties.

The treatment of distal third humeral diaphyseal fractures: Is there still a place for the external fixation?

INTRODUCTION

The treatment for humeral diaphyseal fractures is still controversial. The purpose of this study was to evaluate the clinical and radiographic outcomes of treating humeral distal third diaphyseal fractures by using external fixation technique.

MATERIALS AND METHODS

We retrospectively review 65 cases of diaphyseal humeral fractures (31 type A, 23 type B and 11 type C of the AO/OTA classification) treated with external fixation (Orthofix FAD small) between 2008 and 2013. The mean follow-up was 48 months (24-72 months). There were 12 open fractures; however, no cases of concomitant vascular injury were described. The transolecranic traction was always applied to promote partial reduction through ligamentotaxis. In case of interposition of soft tissues impeding reduction, a small incision was performed allowing mobilization of bone ends.

RESULTS

All fractures resulted healed at a mean of 11 weeks (range 9-13 weeks); the average time of removal of the external fixator was 88 days (range 65-95 days). At the last follow-up, the mean elbow flexion was 132.6° (Min 126°-Max 137°) and the mean elbow extension was 6.4° (Max 0°-Min 13°). The Cassebaum's index rated as excellent in 47.8 % (31 patients), good in 37 % (24 patients), fair in 9.2 % (6 patients) and poor in 6 % (4 patients). The mean DASH score at the final follow-up was 14.7 (range 0-33); 15 patients had a range score between 10 and 20, 43 had less than 10, and seven had more than 20. We observed three cases of superficial infections and two cases of acute radial nerve palsy recovered within 3 months.

CONCLUSION

According to the excellent clinical results and full rate of consolidation, we state external fixation as a valid option in the treatment of distal third humeral diaphyseal fractures.

Expanding the phenotype of Triple X syndrome: A comparison of prenatal versus postnatal diagnosis

Triple X syndrome (47, XXX) occurs in approximately 1:1,000 female births and has a variable phenotype of physical and psychological features. Prenatal diagnosis rates of 47, XXX are increasing due to non-invasive prenatal genetic testing. Previous studies suggest that prenatal diagnosed females have better neurodevelopmental outcomes. This cross-sectional study describes diagnosis, physical features, medical problems, and neurodevelopmental features in a large cohort of females with 47, XXX. Evaluation included review of medical and developmental history, physical exam, cognitive, and adaptive testing. Medical and developmental features were compared between the prenatal and postnatal diagnosis groups using rate calculations and Fisher's exact test. Cognitive and adaptive tests scores were compared using t-tests. Seventy-four females age 6 months-24 years (mean 8.3 years) participated. Forty-four (59.5%) females were in the prenatal diagnosis group. Mean age of postnatal diagnosis was 5.9 years; developmental delay was the most common indication for postnatal genetic testing. Common physical features included hypertelorism, epicanthal folds, clinodactyly, and hypotonia. Medical problems included dental disorders (44.4%), seizure disorders (16.2%), genitourinary malformations (12.2%). The prenatal diagnosis group had higher verbal (P < 0.001), general ability index (P = 0.004), and adaptive functioning scores (P < 0.001). Rates of ADHD (52.2% vs. 45.5%, P = 0.77) and learning disabilities (39.1% vs. 36.3%, P = 1.00) were similar between the two groups. These findings expand on the phenotypic features in females with Triple X syndrome and support that prenatally ascertained females have better cognitive and functional outcomes. However, prenatally diagnosed females are still at risk for neurodevelopmental disorders. Genetic counseling and treatment recommendations are summarized. © 2016 Wiley Periodicals, Inc.

Clinicians' experiences with the fragile X clinical and research consortium

The objectives of the study were to assess the attitudes and experiences of clinicians involved in a consortium of clinics serving people with fragile X-associated disorders to gauge satisfaction with the consortium and its efforts to improve quality of life for patients and the community. An internet survey was sent to 26 fragile X (FX) clinic directors participating in the Fragile X Clinical and Research Consortium (FXCRC). Respondents were asked to complete 19 questions on consortium performance and outcomes relevant for their own clinic. The response rate was 84% (22/26), with two surveys providing incomplete data. Assistance with clinic establishment, opportunities for research collaborations, and access to colleagues and information were highly valued. Approximately 76% of clinicians reported improvements in patient care and 60% reported an increase in patient services. There was a 57% increase in participation in a FX-related clinical trial among clinics since joining the FXCRC (24% vs. 81%). Overall, respondents reported primarily positive experiences from participation in the FXCRC. Common suggestions for improvement included additional financial support and increased utilization of collected patient data for research purposes. Additionally, a Clinic Services Checklist was administered annually to examine changes in services offered over time. There were several important changes regarding the provision of services by clinics, often with multiple clinics changing with respect to a service. In conclusion, the FXCRC has led to the establishment and sustainment of fragile X clinics in the U.S., fostered cooperation among fragile X clinicians, and provided clinics with a platform to share recommendations and best practices to maximize quality of life for their patients and the overall fragile X community. The results from the survey and checklist also provide suggestions to strengthen the FXCRC and enhance future collaborations among FXCRC members. © 2016 Wiley Periodicals, Inc.

The eXtraordinarY Kids Clinic: an interdisciplinary model of care for children and adolescents with sex chromosome aneuploidy

Purpose

Individuals with sex chromosome aneuploidies (SCAs) are born with an atypical number of X and/or Y chromosomes, and present with a range of medical, developmental, educational, behavioral, and psychological concerns. Rates of SCA diagnoses in infants and children are increasing, and there is a need for specialized interdisciplinary care to address associated risks. The eXtraordinarY Kids Clinic was established to provide comprehensive and experienced care for children and adolescents with SCA, with an interdisciplinary team composed of developmental–behavioral pediatrics, endocrinology, genetic counseling, child psychology, pediatric neuropsychology, speech–language pathology, occupational therapy, nursing, and social work. The clinic model includes an interdisciplinary approach to care, where assessment results by each discipline are integrated to develop unified diagnostic impressions and treatment plans individualized for each patient. Additional objectives of the eXtraordinarY Kids Clinic program include prenatal genetic counseling, research, education, family support, and advocacy.

Methods

Satisfaction surveys were distributed to 496 patients, and responses were received from 168 unique patients.

Results

Satisfaction with the overall clinic visit was ranked as “very satisfied” in 85%, and as “satisfied” in another 9.8%. Results further demonstrate specific benefits from the clinic experience, the importance of a knowledgeable clinic coordinator, and support the need for similar clinics across the country. Three case examples of the interdisciplinary approach to assessment and treatment are included.

Behavioral phenotypes in males with XYY and possible role of increased NLGN4Y expression in autism features

The male sex chromosome disorder, 47,XYY syndrome (XYY), is associated with increased risk for social-emotional difficulties, attention-deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). We hypothesize that increased Y chromosome gene copy number in XYY leads to overexpression of Y-linked genes related to brain development and function, thereby increasing risk for these phenotypes. We measured expression in blood of two Y genes NLGN4Y and RPS4Y in 26 boys with XYY and 11 male controls and evaluated whether NLGN4Y expression correlates with anxiety, ADHD, depression and autistic behaviors (from questionnaires) in boys with XYY. The XYY cohort had increased risk of ASD behaviors on the social responsiveness scale (SRS) and increased attention deficits on the Conners' DSM-IV inattention and hyperactive scales. In contrast, there was no increase in reported symptoms of anxiety or depression by the XYY group. Peripheral expression of two Y genes in boys with XYY vs. typically developing controls was increased twofold in the XYY group. Results from the SRS total and autistic mannerisms scales, but not from the attention, anxiety or depression measures, correlated with peripheral expression of NLGN4Y in boys with XYY. Males with XYY have social phenotypes that include increased risk for autism-related behaviors and ADHD. Expression of NLGN4Y, a gene that may be involved in synaptic function, is increased in boys with XYY, and the level of expression correlates with overall social responsiveness and autism symptoms. Thus, further investigation of NLGN4Y as a plausible ASD risk gene in XYY is warranted.

Heel displaced intra-articular fractures treated with mini-calcaneal external fixator

INTRODUCTION

Treatment of displaced heel fractures is controversial; however, ORIF is widely described in the literature to be the gold-standard. Percutaneous reduction and monolateral external fixation is gaining increasing attention because it provides a good and stable reduction, and minimises soft tissue complications due to open surgery, such as deep infections and delays in wound healing. The aim of this study was to show that the new Orthofix Calcaneal Minifixator (six pins) provides a greater stability than the four-pin version to enable a better and more stable reduction, an earlier weight-bearing (30 days) and improved functional outcomes.

METHODS

A series of 69 consecutive closed heel intraarticular displaced fractures treated with the new Orthofix Calcaneal Minifixator were evaluated. Patients were assessed clinically with the Maryland Foot Score and radiologically with standard radiographs.

RESULTS

The clinical results at follow-up were excellent in 37 cases (53.6%), good in 27 (39.2%), fair in two (2.9%) and poor in three (4.3%). The mean preoperative Böhler's angle was 5.2˚ (range 0-18˚) and the mean postoperative value was 28.5˚ (range 16-38˚).

CONCLUSION

The excellent functional outcomes were despite some radiological images of imperfect posterior facet anatomical reduction and seemed to correlate with the use of a good and stable minimally-invasive surgical technique. This technique enabled early weight-bearing, minimised complications, respected the delicate biology of this anatomical site and restored the good heel volume and Böhler angle.

Micromotion in the fracture healing of closed distal metaphyseal tibial fractures: A multicentre prospective study

The dynamic locking screw (DLS) in association with minimally invasive plate osteosynthesis (MIPO) in a bridging construct for simple metadiaphyseal long bone fractures enables modulation of the rigidity of the system and facilitates the development of early and triplanar bone callus. Twenty patients affected by distal tibial fracture were treated with MIPO bridging technique and DLS at the proximal side of the fracture. Time of consolidation, quality of the reduction, complications and American Orthopaedic Foot and Ankle Society (AOFAS) score were monitored and the results compared with those from a control group treated with only standard screws on both fracture sides. Student t-test for independent samples was used for the comparison of means between the two groups. Chi-square test was used for the comparison of proportions. A multiple logistic regression model was constructed to assess the possible confounding effects. Performance was considered significant for p<0.05. The mean healing time was 17.6 ± 2.8 weeks in the group treated with standard screws and 13.5 ± 1.8 weeks in the group treated with DLS (t=5.5, p<0.0001). The DLS was associated with early healing and triplanar bone callus.

"How should I tell my child?" Disclosing the diagnosis of sex chromosome aneuploidies

To date, the disclosure of a sex chromosome aneuploidy (SCA) diagnosis to an affected individual has not been explored. This study aimed to assess the timing and content revealed to an affected child by his or her parent(s), resources accessed in preparation, parental feelings of preparedness, common parental concerns, and recommendations for disclosure approaches. Two online surveys were created: 1) for parents of a child with a diagnosis and 2) for individuals with a diagnosis. One-hundred thirty-nine parent surveys (XXY n = 68, XXX n = 21, XYY n = 9, other SCAs n = 41) and 67 individual surveys (XXY n = 58, XXX n = 9) were analyzed. Parents most frequently discussed the topics of learning disabilities (47 %) and genetics (45 %) with their child during the initial disclosure. A significantly greater proportion of parent respondents reported feeling prepared vs. unprepared for disclosure, regardless of their child's diagnosis (z-test of proportions, all p's < 0.001). Both prepared and unprepared parents most frequently accessed resources such as websites, support groups, and discussion with the child's physician prior to disclosure, with unprepared parents accessing fewer resources (M = 2.0 ± 1.41) than prepared parents [M = 2. ± 1.56; t(101) =-2.02, p < 0.05]. Common parental concerns included making the conversation age-appropriate, discussing infertility, and possible impact on the child's self-esteem. Both parent and individual respondents endorsed being honest with the child, disclosing the diagnosis early and before puberty, and discussing the diagnosis gradually over time. These results provide recommendations for parents, and suggest benefits from additional resources and supports to alleviate concerns when approaching diagnosis disclosure.