Stepwise genetic approach for the diagnosis of primary ciliary dyskinesia in highly consanguineous populations

BACKGROUND

The American Thoracic Society guidelines for the diagnosis of primary ciliary dyskinesia (PCD) consider the presence of a bi-allelic pathogenic variant confirmatory for the diagnosis of PCD, with genetic testing recommended when other confirmatory diagnostic tests are less accessible. We present our experience with genetic testing as first line with a proposed algorithm for high consanguinity populations.

METHODS

Patients with a suspected diagnosis of PCD underwent genetic testing according to a diagnostic algorithm composed of three steps: (1) patients with a previously known causative familial/Bedouin tribal pathogenic variant completed direct testing for a single variant; (2) if the initial test was negative or there was no known pathogenic variant, a PCD genetic panel was completed; (3) if the panel was negative, whole exome sequencing (WES) was completed.

RESULTS

Since the implementation of the protocol, diagnosis was confirmed by genetic testing in 21 patients. The majority of them were of Bedouin origin (81%) and had a positive history of consanguinity (65%). Nine patients (43%) had a sibling with a confirmed diagnosis. Most patients (15/21, 71%) were diagnosed by direct pathogenic variant testing and the remainder by genetic panel (19%) and WES (10%). Disease-causing variants were found in nine genes, with DNAL1 (24%) and DNAAF3, DNAAF5, ZMYND10 (14% each) as the most prevalent ones.

CONCLUSIONS

In highly consanguineous regions, a stepwise genetic testing approach is recommended. This approach may be particularly useful in areas where the ability to obtain confirmatory diagnostic tests through other modalities is less accessible.

The new face of cystic fibrosis in the era of population genetic carrier screening

BACKGROUND

Population genetic carrier screening (PGCS) for cystic fibrosis (CF) has been offered to couples in Israel since 1999 and was included in a fully subsidized national program in 2008. We evaluated the impact of PGCS on CF incidence, genetic and clinical features.

METHODS

This was a retrospective national study. Demographic and clinical characteristics of children with CF born in Israel between 2008 and 2018 were obtained from the national CF registry and from patients' medical records. Data on CF births, preimplantation genetic testing (PGT), pregnancy termination and de-identified data from the PGCS program were collected.

RESULTS

CF births per 100,000 live births decreased from 8.29 in 2008 to 0.54 in 2018 (IRR = 0.84, p < 0.001). The CF pregnancy termination rate did not change (IRR = 1, p=  0.9) while the CF-related PGT rate increased markedly (IRR = 1.33, p < 0.001). One hundred and two children were born with CF between 2008 and 2018 with a median age at diagnosis of 4.8 months, range 0-111 months. Unlike the generally high uptake nationally, 65/102 had not performed PGCS. Even if all had utilized PGCS, only 51 would have been detected by the existing genetic screening panel. Clinically, 34 % of children were pancreatic sufficient compared to 23 % before 2008 (p = 0.04).

CONCLUSIONS

Since institution of a nationwide PGCS program, the birth of children with CF decreased markedly. Residual function variants and pancreatic sufficiency were more common. A broader genetic screening panel and increased PGCS utilization may further decrease the birth of children with CF.

Is corticophobia spreading among pediatricians?-Insights from a self-efficacy survey on the management of pediatric atopic dermatitis

Background

Atopic dermatitis (AD) is a chronic dermatological condition, often diagnosed and managed by pediatricians. However, pediatricians have difficulties with adhering to guidelines, which recommend the use of topical corticosteroids (TCS) as a first-line treatment and oral corticosteroids (OCS) for resistant cases. Our aim was to assess pediatricians' self-confidence in using steroids in the management of pediatric AD, and investigate which characteristics are related to high self-confidence in prescribing corticosteroids (CS).

Methods

We conducted a cross-sectional questionnaire study among Israeli pediatricians between April 2022 and June 2022. Participants were asked to answer questions dealing with self-assessment of prescribing CS in the management of AD.

Results

A total of 171 residents and pediatricians participated in the survey; 86.6% and 28.1% admitted feeling either average or below-average confidence in the prescription of OCS and TCS, respectively. Physicians who were exposed to higher AD patients (P=0.048) and worked at the clinics (88.2% vs. 60.4%, P<0.001) had high self-confidence in treating AD with TCS. Males (20.3% vs. 8%, P=0.03), and having gone to medical school outside Israel (22.2% vs. 10.4%, P=0.09) were all related to high self-efficacy in prescribing OCS. In total, 11.7% of participants confessed to refraining from prescribing steroids because of fear of side effects.

Conclusions

Most pediatricians have below-average confidence in prescribing OCS for the treatment of AD. Males, working in a community setting, and previous exposure improve the confidence level and can be easily considered in future pediatric training programs.

Elevated Neutrophil-to-Lymphocyte Ratio Is Associated with Severe Asthma Exacerbation in Children

Asthma is the most common chronic respiratory disease in children. The neutrophil-to-lymphocyte ratio (NLR) is a marker of a chronic inflammatory state; however, data on the association of NLR with acute asthma exacerbations in children is lacking. In this cross-sectional study, between 2016 and 2021, children aged 2-18 years who were referred to the emergency department (ED) due to asthma exacerbation, were included. NLR, calculated from complete blood count upon arrival, was assessed as a continuous variable and was classified into four groups according to quartiles. The association between severity parameters and NLR quartiles was examined. A total of 831 ED visits for asthma exacerbation were included in the study. The median NLR was 1.6, 3.8, 6.7, and 12.9 in quartiles 1-4, respectively (p < 0.001). Demographic parameters, background diseases, and chronic medications were similar between the quartiles. Higher heart rate, body temperature, systolic blood pressure, and respiratory rate were observed in the higher NLR quartiles, as well as lower oxygen saturation. Higher urgency scale and higher rates of intravenous magnesium sulfate were observed in the higher NLR quartiles, with higher admission rates and prolonged hospitalizations. In summary, NLR upon admission is associated with the severity of asthma exacerbation and higher chances of hospitalization among children in the ED.

Pediatric psoriasis negatively influences parental sleep quality

BACKGROUND

One-third of psoriasis cases occur in the pediatric population. Pediatric psoriasis has a negative long-term impact on the quality of life of children and their families. However, data regarding the impact of pediatric psoriasis on parental sleep quality are scarce.

OBJECTIVES

This study examined the effects of pediatric psoriasis on the quality of parents' sleep compared to parents of healthy, non-psoriatic children.

METHODS

A cross-sectional questionnaire study was conducted from September 2020 to November 2021, using the validated Pittsburgh Sleep Quality Index (PSQI). The study population included parents of patients aged 2-18 years diagnosed with psoriasis and parents of healthy children of the same gender and ethnicity. We further compared sleep quality between parents of children with mild and moderate-to-severe psoriasis, and fathers to mothers.

RESULTS

A total of 301 parents were enrolled; 151 parents of 83 children diagnosed with psoriasis and 150 parents of 124 healthy controls. Parents of children with psoriasis had significantly longer sleep latency (p = 0.031), worse subjective sleep quality (p = 0.043), and greater use of sleep medications (p < 0.001). The comparison between parents of moderate-severe with mild psoriatic children as well as mothers with fathers showed no statistical significance.

CONCLUSION

Poor sleep quality was demonstrated among parents of children diagnosed with psoriasis compared to parents of healthy children. This finding is crucial for the direction of treatment efforts regarding parental well-being and functioning.

Effect of Paediatric Atopic Dermatitis on Parental Sleep Quality

Data on the impact of paediatric atopic dermatitis on parental sleep are scarce. The aim of this study was to examine the effects of paediatric atopic dermatitis on the quality of parents' sleep. This cross-sectional study included parents of patients with atopic dermatitis and parents of healthy children who completed validated Pittsburgh Sleep Quality Index questionnaires. The study and control groups were compared, as were results for mild and moderate atopic dermatitis with severe atopic dermatitis, mothers and fathers, and different ethnic groups. A total of 200 parents were enrolled. Sleep latency was significantly longer in the study group compared with the control group. Sleep duration was shorter in the parents of the mild AD group compared with the moderate-severe and control groups. Parents in the control group reported more daytime dysfunction than parents in the AD group. Fathers of children with AD reported more sleep disturbance than mothers.

High flow nasal cannula therapy in the pediatric home setting

BACKGROUND

High-flow nasal cannula (HFNC) therapy may be better tolerated than traditional noninvasive ventilation (NIV) and is rapidly gaining acceptance in pediatric acute care. In Israel, HFNC is approved for domestic use. We aim to describe its indications, efficacy, parental satisfaction, and safety.

METHODS

Retrospective study of children treated with home HFNC therapy in three pediatric centers. Data included demographic parameters, indication of use, weight and days of hospitalization before and after initiation. Safety, tolerability, and parental satisfaction were assessed via standardized telephone questionnaire.

RESULTS

Median (interquartile range [IQR]) age of initiating home HFNC in 75 children was 8.3 (2.2, 29.6) months. Indications were obstructive sleep apnea (33; 44%), airway malacia (19; 25%), chronic lung disease (15; 20%), neuromuscular disease (4; 5%), and postextubation support (4; 5%). Weight standard deviation score rose from -2.3 pre-HFNC to -1.7 at 6.7 months post-HFNC initiation, p < 0.001. Hospital admission days during the 2 months pre- versus post-HFNC initiation were 22 (5.5, 60) and 5 (0, 14.7) respectively, p < 0.008. Median (IQR) parental satisfaction score was 5/5 (4, 5). Fifty of 60 (83%) respondents would recommend home HFNC to other families in a similar situation. There were no serious adverse events.

CONCLUSION

In our population, domestic HFNC appeared safe and well tolerated for a variety of indications. Its introduction was associated with improved weight gain, fewer hospitalization days and high parental satisfaction. Further work is required to characterize groups of children most likely to benefit from HFNC, as opposed to traditional modes of NIV.

Non-nuberculous mycobacteria infection treated with intermittently inhaled high-dose nitric oxide

Mycobacterium abscessus is an emerging multidrug-resistant non-tuberculous mycobacterium (NTM) with high prevalence in patients with cystic fibrosis. However, studies on antimicrobial susceptibilities and effective treatments against M. abscessus are still limited. Nitric oxide (NO) is important in innate immune response to various infections, including mycobacterial infections. In this case study, we describe a compassionate treatment of inhaled NO (iNO) at 150–250 ppm for 4 weeks. The dosing strategy proposed for this treatment was selected to minimise the potential of adverse events, while maximising the antibacterial effectiveness of NO, and was found to be safe, well tolerated and resulted in positive clinical findings including improvement in patient well-being, CT scan values, quality of life and bacterial load. Taken together, these observations may indicate that iNO could play a crucial role and potentially serve as a reliable option in the treatment of patients with chronic refractory NTM lung infection.

Comparison of septic and nonseptic pulmonary embolism in children

BACKGROUND

Septic pulmonary embolism (SPE) in children is a rare disease. Data are scarce regarding the clinical and laboratory manifestation of SPE compared with nonseptic pulmonary embolism (ns-PE). Furthermore, specific guidelines for the management of SPE in children are lacking.

AIM

We compared the clinical course and outcome of children with SPE and ns-PE.

METHODS

A retrospective, cohort study of hospitalized children, 2005-2020, with documented pulmonary embolism imaging.

RESULTS

Sixteen children (eight SPE, eight ns-PE) were identified. Episodes of SPE occurred secondary to endocarditis, musculoskeletal and soft tissue infections, with Staphylococcus aureus (n = 4) and streptococcus spp. (n = 2) as the most common pathogens. Radiographically, SPE presented as a microvascular disease with parenchymatic nodules/cavitations, whereas ns-PE presented as larger vessel disease with filling defects. Risk factors (including thrombophilia) were noted in 0% and 87.5% of SPE and ns-PE patients, respectively (p < .01). Pulmonary embolism diagnosis was delayed in SPE compared with ns-PE (median: 8.5 days vs. 1 day). The SPE group had higher rates of fever (100% vs. 12.5%, p < .01), C-reactive protein (CRP levels; 18.49 vs. 4.37 mg/dl, p = .02), and fibrinogen levels (880 vs. 467 mg/dl, p < .001). Antithrombotic treatment for >4 months was administrated to 14.3% and 87.5% of SPE and ns-PE patients, respectively (p < .01). One ns-PE patient had a second thromboembolic event compared to none in the SPE group.

CONCLUSIONS

SPE in children is a unique subgroup of PE with different clinical and laboratory findings that requires a different diagnostic approach and probably shorter duration of antithrombotic treatment.

Baseline Cystic fibrosis disease severity has an adverse impact on pregnancy and infant outcomes, but does not impact disease progression

BACKGROUND

With increasing longevity and quality of life in adults with Cystic fibrosis (CF), growing maternity rates are reported. Women with severe CF are becoming pregnant, with unpredictable maternal and fetal outcomes.

AIM

To determine how baseline disease severity, pancreatic insufficiency (PI) and Pseudomonas aeruginosa (PA) infection affect fertility, the pregnancy course, delivery, neonatal outcome, and subsequent disease progression.

METHODS

A multicenter-retrospective cohort study. Data on patients that had been pregnant between 1986-2018 was collected from ten CF centers worldwide. Disease severity [mild or moderate-severe (mod-sev)] was defined according to forced expiratory volume % predicted in 1 second (FEV₁) and body mass index (BMI). Three time periods were compared, 12 months prior to conception, the pregnancy itself and the 12 months thereafter.

RESULTS

Data was available on 171 pregnancies in 128 patients aged 18-45 years; 55.1% with mod-sev disease, 43.1% with PI and 40.3% with PA. Women with mod-sev disease had more CF-related complications during and after pregnancy and delivered more preterm newborns. However, FEV₁ and BMI decline were no different between the mild and mod-sev groups. A more rapid decline in FEV₁ was observed during pregnancy in PI and PA infected patients, though stabilizing thereafter. PI was associated with increased risk for small for gestational age infants.

CONCLUSION

Baseline disease severity, PA infection and PI have an adverse impact on infant outcomes, but do not impact significantly on disease progression during and after pregnancy. Consequently, pregnancies in severe CF patients can have a good prognosis.