Three siblings with variable degrees of neuromuscular involvement and congenital sideroblastic anemia: A peculiar phenotype and a surprise genotypic explanation

INTRODUCTION

Congenital sideroblastic anemias (CSAs) are a group of inherited bone-marrow disorders manifesting with erythroid hyperplasia and ineffective erythropoiesis.

METHODS

We describe a detailed clinical and genetic characterization of three siblings with CSA.

RESULTS

Two of them had limb-girdle myopathy and global developmental delay. The two elder siblings performed allogenic hematopoietic stem-cell transplantation 5 and 3 years prior with stabilization of the hematological features. Exome sequencing in the non-transplanted sibling revealed a novel homozygous nonsense variant in SLC25A38 gene NM_017875.2:c.559C > T; p.(Arg187*) causing autosomal-recessive sideroblastic anemia type-2, and a second homozygous pathogenic previously reported variant in GMPPB gene NM_013334.3:c.458C > T; p.(Thr153Ile) causing autosomal-recessive muscular dystrophy-dystroglycanopathy type B14. With the established diagnosis, hematopoietic stem cell transplantation is now being scheduled for the youngest sibling, and a trial therapy with acetylcholine esterase inhibitors was started for the two neurologically affected patients with partial clinical improvement.

CONCLUSION

This family emphasizes the importance of whole-exome sequencing for familial cases with complex phenotypes and vague neurological manifestations.

Assessment of Cardiac Functions and Arrhythmia in Children with Beta-Thalassemia Major and Beta-Thalassemia Intermedia

BACKGROUND: Heart disease is a major complication in thalassemic patients. Heart injuries in iron overload cases include arrhythmia, pulmonary hypertension, systolic/diastolic dysfunction, and heart failure. AIM: This study aimed to assess cardiac functions and arrhythmia in children with β-thalassemia major (TM) and β-thalassemia intermedia (TI) and its relation to cardiac iron overload. METHODS: Thirty β-TM patients and 30 β-TI patients were evaluated using echocardiography and 24-h ambulatory electrocardiogram monitoring (Holter). Among these patients, 15 β-TM and 15 β-TI patients were evaluated using cardiac magnetic resonance imaging T2* by single breath-hold multi-echo technique. RESULTS: Arrhythmia was detected significantly more in β-TM patients than β-TI (p = 0.049). Nine (30%) β-TM and five (16.6%) β-TI patients had Sinus tachycardia. Two (6.7%) β-TM patients compared to one (3.33%) β-TI patient had supraventricular tachycardia runs. Three (10%) β-TM and one (3.33%) β-TI patient had extreme sinus tachycardia. Two (3.3%) β-TI patients had sinus bradycardia, while two (3.3%) β-TM patients had incomplete Right bundle branch block. Regarding echo parameters: Isovolumic relaxation time (IVRT), Left ventricle myocardial performance index (MPI LV), Right ventricle myocardial performance index (MPI RV) and end systolic pulmonary artery pressure, were significantly higher in β-TM than TI group (p < 0.05). Fractional shortening, Ejection fraction were significantly lower in β-TM than TI group (p < 0.001). A statistically significant negative correlation was found between cardiac T2* and each of (IVRT, MPI LV, MPI RV) (p ˂ 0.05). CONCLUSION: Arrhythmias are more common in the β-TM group. Systolic, diastolic dysfunction and high pulmonary pressure are more prevalent in TM than in TI. Global myocardial performance is more impaired in TM than in TI patients. Iron overload has a deleterious effect on cardiac function.

MultipleXLab: A high-throughput portable live-imaging root phenotyping platform using deep learning and computer vision

BACKGROUND

Profiling the plant root architecture is vital for selecting resilient crops that can efficiently take up water and nutrients. The high-performance imaging tools available to study root-growth dynamics with the optimal resolution are costly and stationary. In addition, performing nondestructive high-throughput phenotyping to extract the structural and morphological features of roots remains challenging.

RESULTS

We developed the MultipleXLab: a modular, mobile, and cost-effective setup to tackle these limitations. The system can continuously monitor thousands of seeds from germination to root development based on a conventional camera attached to a motorized multiaxis-rotational stage and custom-built 3D-printed plate holder with integrated light-emitting diode lighting. We also developed an image segmentation model based on deep learning that allows the users to analyze the data automatically. We tested the MultipleXLab to monitor seed germination and root growth of Arabidopsis developmental, cell cycle, and auxin transport mutants non-invasively at high-throughput and showed that the system provides robust data and allows precise evaluation of germination index and hourly growth rate between mutants.

CONCLUSION

MultipleXLab provides a flexible and user-friendly root phenotyping platform that is an attractive mobile alternative to high-end imaging platforms and stationary growth chambers. It can be used in numerous applications by plant biologists, the seed industry, crop scientists, and breeding companies.

Sepsis profile and outcome of preterm neonates admitted to neonatal intensive care unit of Cairo University Hospital

Background

This study demonstrates the experience of the neonatal intensive care unit (NICU) of a tertiary referral center in Egypt in management of prematures with neonatal sepsis. This retrospective study included preterm neonates admitted to NICU with clinical and/or laboratory diagnosis of sepsis. Blood culture was done followed by antimicrobial susceptibility testing for positive cases. Neonates with sepsis were classified into early onset sepsis (EOS) and late onset sepsis (LOS). Hematological scoring system (HSS) for detection of sepsis was calculated.

Results

The study included 153 cases of neonatal sepsis; 63 (41.2%) EOS and 90 (58.8%) LOS. The majority of the neonates had very low or moderately low birth weight (90.9%). All neonates received first-line antibiotics in the form of ampicillin-sulbactam, and gentamicin. Second-line antibiotics were administered to 133 neonates (86.9%) as vancomycin and imipenem-cilastatin. Mortalities were more common among EOS group (p < 0.017). Positive blood cultures were detected in 61 neonates (39.8%) with a total number of 66 cultures. The most commonly encountered organisms were Klebsiella MDR and CoNS (31.8% each). Klebsiella MDR was the most predominant organism in EOS (28.9%), while CoNS was the most predominant in LOS (39.2%) The detected organisms were divided into 3 families; Enterobacteriaceae, non-fermenters, and Gram-positive family. There 3 families were 100% resistant to ampicillin. The highest sensitivity in Enterobacteriaceae and Non-fermenters was for colistin and polymyxin-B. An HSS of 3–8 had a sensitivity and specificity of 62.3% and 57.6%, respectively for diagnosis of culture-proven sepsis.

Conclusion

Neonatal sepsis was encountered in 21.5% of admitted preterm neonates; LOS was more common (58.8%). Mortality was 51.6%. Klebsiella MDR and CoNS were the most commonly encountered organisms in both EOS and LOS. The isolated families were 100% resistant to ampicillin. The hematological scoring system (HSS) showed limited sensitivity for detection of sepsis.

Profiling of Essential Mineral Content, Heavy Metals, and Bacterial Contaminants in Conventional and Organic Eggs Available in the Hypermarkets of the Eastern Province of Saudi Arabia

BACKGROUND

Eggs are commonly regarded as one of the best sources of various macro and micronutrients, in particular, high biological value (BV) proteins and both saturated and unsaturated fatty acids. Apart from proteins, eggs are excellent sources of various high health value lipid components, carotenoids, minerals, and both water and lipid-soluble vitamins. However, the nutrient-rich nature of this 'superfood' also makes them susceptible to microbial contamination from various sources, such as fecal matter, drinking water for layer chicken, and the surrounding environment. Moreover, drinking water and chicken feed are also sources of heavy metal contamination. The presence of both factors poses serious health concerns for consumers.

OBJECTIVE

The main aim of this research was to proximate heavy metals and bacterial contaminants in nine different brands of brown organic and conventional white eggs available in the hypermarkets of the Eastern Province of Saudi Arabia.

METHODS

An Inductively Coupled Plasma-Optical Emission Spectrometer (ICP-OES) was used to determine the concentration of metals with high sensitivity. Standard plate count was followed by enrichment of bacterial contaminants in a double-strength nutrient broth medium for microbiological assessment.

RESULTS

The results indicated that Pb, Cd, Al, and As were present in high concentrations in all egg brands of both types (organic and conventional). The estimated daily intake (EDI) values for Ca, Fe, Mn, and Mg were within the range of WHO-recommended thresholds, and these essential minerals were present in adequate amounts in all egg brands. The two major groups predominating the microbial loads were the family Enterobacteriaceae and Pseudomonas sp.

CONCLUSION

The presence of heavy metals, such as Al, As, Pb, and Cd, in nearly all the brands in amounts that exceeded the established ADI and EDI thresholds was considerably concerning. In particular, the elevated levels of Cd and Pb in group 1 and group 2A probable human carcinogens, respectively, demands that local regulatory authorities investigate the sources of heavy metal contamination and alleviate this considerable risk to human health. Furthermore, this study could be a benchmark for establishing food safety and hygiene standards for local egg production, storage, handling, and transport in Saudi Arabia.

Transcranial Doppler Velocities among Sickle Cell Disease Patients in Steady State

Transcranial Doppler (TCD) screening is an established tool to identify children with sickle cell disease at high risk of stroke. Our objective was to study TCD velocities among sickle cell disease patients while in a steady state. This cross-sectional study included 78 steady state sickle cell disease patients [31 Hb SS (β^S/β^S) (sickle cell anemia), 47 Hb S/β-thalassemia (HBB: c.20A>T/β-thal)], attending the Pediatric Hematology Clinic at Cairo University Children's Hospital, Cairo, Egypt. All patients underwent TCD velocity assessment as per the Stroke Prevention Trial in Sickle Cell Anemia (STOP) protocol. In our cohort, TCD velocities were comparable among Hb S/β-thal vs. SS patients. Hemolysis indicators correlated significantly to TCD velocities in Hb S/β-thal patients; positive correlation was found between total bilirubin level and right middle cerebral artery (MCA) and right distal internal carotid artery (dICA) TCD velocities (r = 0.428, p = 0.00, r = 0.360, p = 0.01), respectively as well as between reticulocyte count and right MCA, right dICA and right anterior cerebral artery (ACA) TCD velocities (r = 0.424, p = 0.01), (r = 0.40, p = 0.00), (r = 0.303, p = 0.04), respectively. On the other hand, statistically significant negative correlations were found between hemoglobin (Hb) level and right ACA, right dICA TCD velocities (r = -0.290, p = 0.05), (r = -0.324, p = 0.03). Although Hb F is considered an ameliorating factor for disease severity; hemolysis stands as an indicator of risk for TCD velocity elevation, and in turn, risk for stroke among sickle cell disease patients.

The relationships between pancreatic T2* values and pancreatic iron loading with cardiac dysfunctions, hepatic and cardiac iron siderosis among Egyptian children and young adults with β-thalassaemia major and sickle cell disease: a cross-sectional study

Background: Cardiac, hepatic and pancreatic T2* measured by magnetic resonance imaging (MRI) has been proven to be an accurate and non-invasive method for measuring iron overload in iron overload conditions. There is accumulating evidence that pancreatic iron can predict cardiac iron in young children because the pancreas loads earlier than the heart. The aim of our study was to assess the relationships between pancreatic T2* values and pancreatic iron loading with cardiac dysfunctions and liver and cardiac iron among patients with β-thalassaemia major (βTM) and sickle cell disease (SCD).

Methods: 40 βTM and 20 transfusion-dependant SCD patients were included along with 60 healthy age and sex-matched controls. Echocardiography and Tissue Doppler Imaging were performed for all subjects as well as the control group.  Hepatic, cardiac and pancreatic iron overload in cases were assessed by MRI T2*.

Results:  The mean age of our patients was 13.7 years with mean frequency of transfusion/year 12. Mean cardiac T2* was 32.9 ms and mean myocardial iron concentration was 0.7 mg/g; One patient had cardiac iron overload of moderate severity. Mean pancreatic T2* was 22.3 ms with 20 patients having mild pancreatic iron overload.

Pancreatic T2* correlated positively peak late diastolic velocity at septal mitral annulus (r=0.269, p=0.038), peak early diastolic velocity at tricuspid annulus (r=0.430, p=0.001) and mitral annular plane systolic excursion (r=0.326, p=0.01); and negatively with end systolic pulmonary artery pressure (r=-0.343, p=0.007) and main pulmonary artery diameter (MPA) (r=-0.259, p=0.046). We couldn’t test the predictability of pancreatic T2* in relation to cardiac T2* as only one patient had cardiac T2*<20 ms.

Conclusion: There was a relationship between pancreatic iron siderosis with cardiac dysfunction in multi-transfused patients with βTM and SCD. No direct relation between pancreatic iron and cardiac siderosis was detected.

AB1181 SHOULD A COMBINED RHEUMATOLOGY-PULMONOLOGY INTERSTITIAL LUNG DISEASE SERVICE BE CONFINED TO TERTIARY CENTRES - A SERVICE EVALUATION

Background:

Interstitial lung disease is a well described extra-articular manifestation in a range of rheumatic diseases. It carries significant morbidity and mortality. Management of rheumatic diseases associated ILD (r-ILD) requires expertise as the needs of such patients are complex and treatment options limited. Historically, such complex ILD has been managed in tertiary referral centres.

Objectives:

We set up a combined service incorporating both rheumatology and respiratory domains in a district general hospital (DGH) to help patients avoid long journeys and improve their experience whilst focusing on an integrated care pathway. We evaluated the outcomes of the first set of patients managed in this proof-of-concept service model.

Methods:

Referrals were accepted from any hospital specialist involved in the management r-ILD. They were triaged by lead ILD pulmonologist to monthly ILD MDT comprising a rheumatologist, respiratory physician, a radiologist and ILD specialist nurse. Appropriate patients were booked into combined clinic, run by the respective rheumatology and chest specialists with ILD interest, attracting a multi-speciality tariff. All the data was recorded electronically with full access to demographics, disease parameters, investigations and drug management.

Results:

89 patients were included in this proof-of-concept. Mean age was 66.1 yrs (19-90 yrs) and 44% (n=39) were male. 35 (40%) had RA, 34 (39%) had CTD, eight (10%) had sarcoidosis, five had IPAF and seven others. Most predominant HRCT pattern was NSIP (n=53,60%) followed by UIP (n=23, 21%), sarcoid (n=10, 12%) and miscellaneous (LIP and mixed). Mean FVC was 2.64 L/min (1.93-4.13) with DLCOc of 52.7% (28.9-90.1%) predicted. Only two patients had all antibodies negative whilst 87 had at least one antibody positive with ANA being the most common (n=28).

Most (83%) patients were treated with immunomodulators including nine with rituximab. 39 (44.3%) patients had significant improvement in clinical, imaging and pulmonary parameters with DLCOc improving to 56.57% and FVC to 2.70 L/min. There were similar improvements in six minute walk test. 17 patients died and 20 patients required long term oxygen therapy.

Conclusion:

This proof-of-concept real world study confirms the utility of a combined specialist service in a district general hospital. Nearly half of this complex and resource intensive patient cohort had good clinical outcomes and derived benefit from the expertise in one room. Feedback from both patients and referrers was unanimously positive. No patient required tertiary centre referral and all could be managed adequately in the clinical setting.

Our report confirms that r-ILD can be managed in a DGH setting with a stream-lined service offering clear benefits to patients. We would argue that r-ILD service, congruent to satellite pulmonary hypertension clinics in secondary care with hub-and-spoke model liaison with tertiary centre, can be established on similar principles and could help over-stretched tertiary care with repatriation of services whilst helping develop local expertise in the management of chronic ILD.

Disclosure of Interests:

Karim Salama: None declared, Natasha Ramsundar: None declared, Vijay Joshi: None declared, Muhammad Khurram Nisar Grant/research support from: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Celgene, Novartis and UCB

, Consultant of: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Celgene, Novartis and UCB

, Speakers bureau: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Celgene, Novartis and UCB

Bariatric Bypass Surgery to Resolve Complicated Childhood Morbid Obesity: Case Report Study

Children obesity has become one of the most important public health problems in many countries worldwide. Although the awareness of childhood obesity as a modifiable health risk is high, but many societies do not prioritize this issue as a health care problem, which may lead to comorbidities and even premature death. Despite the rising interest in bariatric surgery for children, only laparoscopic sleeve gastrectomy (LSG) is being considered in resolving childhood obesity who failed other dietary or drug therapies; however many of LSG procedures failed to reduce the weight in children or resulted in complications postsurgery.Here, we present a novel bariatric procedure to clue out a female child 13 years old presented with Legg-Calvé-Perthes disease-associated morbid obesity. The surgical bariatric technique applied both fundal resection and surgical bypass in pediatric obesity using the Elbanna novel bariatric technique.Bariatric surgical bypass may be considered in complicated-childhood cases who failed all other options.

The Value of U/S to Determine Priority for Upper Gastrointestinal Endoscopy in Emergency Room

In countries endemic for liver and GIT diseases, frequent emergency department (ED) patients contribute to a disproportionate number of visits consuming substantial amount of medical resources. One of the most frequent ED visits is patients who present with hypovolemic shock, abdominal pain, or confusion with or without signs of upper gastrointestinal bleeding (UGIB). The use of conventional two-dimensional ultrasound (2D-U/S) may provide immediate and useful information on the presence of esophageal varices, gastrointestinal tumors, and other GIT abnormalities.The current study investigated the feasibility of using (2D-U/S) to predict the source of UGIB in ED and to determine patients' priority for UGE.Between February 2003 and March 2013, we retrospectively reviewed the profiles of 38,551 Egyptian patients, aged 2 to 75 years old, who presented with a history of GI/liver diseases and no alcohol consumption. We assessed the value of 2D-U/S technology in predicting the source of UGIB.Of 38,551 patients presenting to ED, 900 patients (2.3%), 534 male (59.3%) and 366 female (40.7%) developed UGIB. Analyzing results obtained from U/S examinations by data mining for emergent UGE were patients with liver cirrhosis (LC), splenomegaly, and ascites (42.6% incidence of UGIB), followed by LC and splenomegaly (14.6%), LC only (9.4%), and was only 0.5% who had no morbidity finding by 2D-U/S.Ultrasonographic instrumentation increases the feasibility of predictive emergency medicine. The area has recently not only gained a fresh impulse, but also a new set of complex problems that needs to be addressed in the emergency medicine setting according to each priority.

The effect of oral contraceptive different patterns of use on circulating IGF-1 and bone mineral density in healthy premenopausal women

Both insulin-like growth factor-1(IGF-1) and oral contraceptive (OC) use have been linked to premenopausal breast and colorectal cancers, osteoporosis and cardiovascular disease. Understanding the effects of different patterns of use of OC on IGF-1 levels and bone mineral density (BMD) may offer insight into its influence on osteoporosis. We conducted a cross-sectional study, which included 135 women, who were then divided into three groups: Group A who were OC current users, 41 women; Group B who never use OC, 51 women; and Group C who were past users of OC, 41 women. Each patient completed a questionnaire on demographic parameters, marital state history and contraception history including duration of use and type of contraceptive pills or used method. Lower-end radius, proximal femur and lumbar spine BMD were measured by dual-energy X-ray absorptiometry. IGF-1 was assessed with chemiluminescent immunometric assay. The three groups were similar in total body T value of BMD (with slight better results in past users than the other two groups but it was statistically insignificant difference), and past users showed significantly higher BMD values compared to current users at spine, femur and forearm. Nonusers also had better BMD values compared to current users (spine and forearm BMD). Among past users, the mean level of circulating IGF-1 was higher than the other two groups and that difference was statistically significant. Past OC use and/or nonuse has a more favorable impact on BMD compared to current use and that this relationship is in part mediated by IGF-1. Hence, it appears that OC use is beneficial to BMD if used in the past and then discontinued or if never used at all compared to current use.

Dual-energy X-ray absorptiometry with serum ferritin predicts liver iron concentration and changes in concentration better than ferritin alone

Accurate assessment of liver iron concentration (LIC) is critical for optimal monitoring of iron toxicity in multitransfused patients. Serum ferritin is the most widely used although its association to LIC is only modest. We studied if a liver-specific measure using dual-energy X-ray absorptiometry (DXA) systems could improve LIC estimates over ferritin alone in Thalassemia (Thal) patients. Thirty-seven patients with Thal (19.2 ± 9.0 yr, 20 male) were studied and 10 had multiple visits. Height, weight, ferritin, whole-body DXA, and hepatic superconducting quantum interference device (SQUID) were measured within 5 wk. DXA hepatic density was measured using right rib, whole liver, and multiple subliver regions. The best agreement to SQUID LIC was found using a combination of ferritin, weight, DXA subliver region 3 bone mineral content (BMC), and right rib BMC. DXA with ferritin improved the ferritin alone correlation from R(2)=0.35 to R(2)=0.62. Serial LIC changes using DXA were associated with serial SQUID changes (r=0.73, p=0.02). Changes in ferritin alone were not significant (p=0.06). We conclude that the addition of whole-body DXA measures and body weight substantially increased the accuracy of LIC and change in LIC estimates over the use of ferritin alone and could be useful when magnetic resonance imaging or SQUID is not available.

Modeling and simulation of luminescence detection platforms

Motivated by the design of an integrated CMOS-based detection platform, a simulation model for CCD and CMOS imager-based luminescence detection systems is developed. The model comprises four parts. The first portion models the process of photon flux generation from luminescence probes using ATP-based and luciferase label-based assay kinetics. An optics simulator is then used to compute the incident photon flux on the imaging plane for a given photon flux and system geometry. Subsequently, the output image is computed using a detailed imaging sensor model that accounts for photodetector spectral response, dark current, conversion gain, and various noise sources. Finally, signal processing algorithms are applied to the image to enhance detection reliability and hence increase the overall system throughput. To validate the model, simulation results are compared to experimental results obtained from a CCD-based system that was built to emulate the integrated CMOS-based platform.

Hepatitis C virus infection in Egyptian children: single centre experience

The outcome of hepatitis C virus (HCV) infection acquired in childhood is uncertain because of the diversity of the epidemiological and clinical features of infection and disease. The aim of this study was to determine the outcome of HCV infection in 105 Egyptian children who tested positive for HCV antibody (anti-HCV). The data of 105 anti-HCV-positive children presenting to the Pediatric Hepatology Unit, Cairo University Children's Hospital, between 1995 and 2002, were retrospectively analysed for risk factors. Seventy-four children with available polymerase chain reaction results were further analysed clinically, serologically and histologically. The age range was 1.3-22 years, with a mean of 11.2 +/- 4.9 years. History of blood transfusion was found in 81 children (77%). HCV RNA was detected in 58.1% of 74 children. Persistently elevated alanine aminotransferase (ALT) levels were present in 40 patients (54.1%). Hepatitis B virus markers (HBsAg and/or anti-HBc) were detected in 18 patients (24.3%). Twenty-six of the 43 HCV RNA-positive children underwent a diagnostic liver biopsy that showed chronic hepatitis in 19 patients (73.1%), cirrhosis in one case only (3.8%), and normal biopsy findings in seven children (26.9%). Blood transfusion remains a major risk of HCV transmission among Egyptian children. HCV infection is not always benign in the childhood period. ALT levels remain elevated in half of the children and histological abnormalities are detected in three quarters of HCV RNA-positive cases.