Risk of meningomyelocele mediated by the common 22q11.2 deletion

Meningomyelocele is one of the most severe forms of neural tube defects (NTDs) and the most frequent structural birth defect of the central nervous system. We assembled the Spina Bifida Sequencing Consortium to identify causes. Exome and genome sequencing of 715 parent-offspring trios identified six patients with chromosomal 22q11.2 deletions, suggesting a 23-fold increased risk compared with the general population. Furthermore, analysis of a separate 22q11.2 deletion cohort suggested a 12- to 15-fold increased NTD risk of meningomyelocele. The loss of Crkl, one of several neural tube-expressed genes within the minimal deletion interval, was sufficient to replicate NTDs in mice, where both penetrance and expressivity were exacerbated by maternal folate deficiency. Thus, the common 22q11.2 deletion confers substantial meningomyelocele risk, which is partially alleviated by folate supplementation.

Sleep Characteristics in Pediatric Anti-N-methyl-d-aspartate (NMDA) Receptor Encephalitis: A Retrospective Cohort Study

Background: Rates of sleep problems in children with anti-N-methyl-d-aspartate (NMDA) receptor encephalitis are unknown. Methods: We used a retrospective observational cohort database of children with a diagnosis of NMDA receptor encephalitis at a single freestanding institution. One-year outcomes were assessed with the pediatric modified Rankin Score (mRS), with 0 to 2 as good and 3 or greater as poor outcome. Results: Ninety-five percent (39/41) of children with NMDA receptor encephalitis had sleep dysfunction at onset; 34% (11/32) reported sleep problems at 1 year. Sleep problems at onset and propofol use were not associated with poor outcomes at 1 year. Poor sleep at 1 year correlated with mRS scores (range 2-5) at 1 year. Discussion: High rates of sleep dysfunction occur in children with NMDA receptor encephalitis. Persistent sleep problems at 1 year may correlate with outcomes as assessed by mRS at 1 year. Further studies comparing the relationship of poor sleep with outcomes in NMDA receptor encephalitis are needed.

Assessment of cognitive status in pediatric anti-NMDA receptor encephalitis during inpatient rehabilitation: A retrospective cohort

OBJECTIVES

Anti-NMDA receptor autoimmune encephalitis (NMDARE) is a common pediatric encephalitis, resulting in neuropsychiatric symptoms. Predicting severity and course is challenging, with objective cognitive assessments lacking in NMDARE, especially in children. The CASE (Clinical Assessment Scale in Autoimmune Encephalitis) measures severity in autoimmune encephalitis. The CALS (Cognitive and Linguistic Scale) assesses cognitive-linguistic recovery in children with acquired brain injury. This study examines severity and cognitive status in pediatric NMDARE by comparing objectives measures: modified Rankin score (mRS), CASE, and CALS.

METHODS

Twenty-one patients were identified via retrospective chart review with a confirmed NMDARE diagnosis (ages of 3-18 years) who required inpatient rehabilitation. The mRS, CASE, and CALS were assessed at admission and discharge.

RESULTS

Scores demonstrated improvement from admission to discharge, with variability in individual recovery trajectories. CALS identified three clusters of patients with differential rates of early recovery. CALS <30 was associated with minimal improvement and poor outcomes. CALS ≥30 had a likelihood ratio score of 12.0 to predict improvement. CASE and CALS were moderately correlated, but neither correlated with mRS.

DISCUSSION

CALS and CASE appear to be complementary measures for assessing severity and cognitive status in pediatric NMDARE, including those with low responsiveness, with implications for treatment and outcomes.

The neutrophil-to-lymphocyte ratio is associated with intubation in pediatric anti-NMDA receptor encephalitis: A retrospective study

Background The neutrophil-to-lymphocyte ratio (NLR) may predict poor outcomes in adult anti-NMDAR encephalitis (NMDARE). The association of NLR with outcomes in pediatric NMDARE was examined. Methods Pediatric NMDARE patients (N = 36) were retrospectively studied. Results High NLR (>6) had a higher proportion of tumors (43% versus 7%) and higher intubation rates (100% versus 38%, p = 0.008). Multivariate analyses showed that high NLR did not correlate with one-year outcomes, inpatient length of stay (LOS), or with tumor, but was associated with intubation and rehabilitation LOS. Conclusion NLR is associated with intubation and rehabilitation LOS. Further investigation is needed for prognostic biomarkers in NMDARE.

Electroencephalography characteristics to predict one-year outcomes in pediatric anti-NMDA receptor encephalitis

BACKGROUND

Electrographic characteristics (extreme delta brush, posterior dominant rhythm and slow waves) may predict outcomes in anti-NMDA receptor encephalitis (NMDARE). However, whether changes in EEG sleep architecture predict outcomes are unknown. We examine electrophysiological characteristics including sleep architecture in a pediatric NMDARE population and correlate with outcomes at one year.

METHODS

Retrospective chart and EEG review was performed in pediatric NMDARE patients at a single center. Patients with first EEGs available within 48 h of admission, prior to treatment, and one-year follow-up data were included. EEGs were independently reviewed by two epileptologists, and a third when disagreement occurred. Clinical outcomes included modified Rankin scale (mRS) at one year.

RESULTS

Nine patients (6 females) (range 1.9-16.7 years) were included. Five of nine patients had loss of posterior dominant rhythm (PDR) and three of nine patients had absent sleep architecture. Loss of PDR correlated with a worse mRS score at one year (2.8 versus 0.5, p = 0.038). Loss of PDR and loss of sleep architecture was associated with increased inpatient rehabilitation stay and in higher number of immunotherapy treatments administered. In multivariate analysis, absence of sleep architecture (p = 0.028), absence of PDR (p = 0.041), and epileptiform discharges (p = 0.041) were predictors of mRS at one year.

CONCLUSIONS

Loss of normal PDR, absence of sleep architecture, and epileptiform discharges are associated with worse outcomes at one year which has not been reported before. EEG characteristics may help prognosticate in NMDARE. Larger studies are needed to confirm these findings.

Acute Flaccid Myelitis: A Single Pediatric Center Experience From 2014 to 2019

BACKGROUND

Acute flaccid myelitis has emerged as the leading cause of acute flaccid paralysis in children. Acute flaccid myelitis leads to significant physical disability; hence, objective outcome measures to study disease severity and progression are desirable. In addition, nerve transfer to improve motor function in affected children needs further study.

METHODS

Retrospective study of acute flaccid myelitis subjects managed at Children's Healthcare of Atlanta from August 2014 to December 2019. Clinical, electromyography and nerve conduction study, neuropsychological functional independence (WeeFIM), and nerve transfer data were reviewed.

RESULTS

Fifteen children (11 boys and 4 girls) mean age 5.1±3.2 years (range 14 months to 12 years) were included. All subjects (n = 15) presented with severe asymmetric motor weakness and absent tendon reflexes. Motor nerve conduction study of the affected limbs in 93% (n = 14) showed absent or markedly reduced amplitude. Ten patients received comprehensive inpatient rehabilitation and neuropsychological evaluation. Admission and discharge WeeFIM scores showed deficits most consistent and pronounced in the domains of self-care and mobility. Multiple nerve transfer surgery was performed on 13 limbs (9 upper and 4 lower extremities) in 6 children. Postsurgery (mean duration of 10.4 ± 5.7 months) follow-up demonstrated improvement on active movement scale (AMS) in 4 subjects.

CONCLUSION

Acute flaccid myelitis affects school-age children with asymmetric motor weakness, absent tendon reflexes, and reduced or absent motor amplitude on nerve conduction study. Comprehensive rehabilitation and nerve transfer led to improvement in motor function on neuropsychology WeeFIM and AMS scores.

Cognitive recovery of children and adolescents with moderate to severe TBI during inpatient rehabilitation

OBJECTIVE

Traumatic brain injury (TBI) is the leading cause of morbidity and mortality in children and adolescents. This study examines the early cognitive-linguistic recovery of pediatric patients who sustained TBI and required inpatient rehabilitation and investigates the contribution of various demographic, clinical, and preinjury factors to recovery.

METHODS

A retrospective chart review of children and adolescents, ages 3-20 years, admitted to an inpatient rehabilitation unit. Acute outcomes were assessed at admission and discharge using the WeeFIM and CALS. Premorbid measures of behavioral and emotional functioning were also collected.

RESULTS

One hundred and one children and adolescents (mean age = 12.31, SD = 4.46) diagnosed with TBI requiring inpatient rehabilitation were included. Patients displayed significant improvements on cognitive-linguistic skills and functional independence between admission and discharge, with medium to large effect sizes. Premorbid behavioral-emotional functioning was not found to be associated with early cognitive recovery.

CONCLUSION

Results suggest that significant functional improvements can be expected for pediatric patients with TBI during inpatient rehabilitation. Consistent with previous literature, injury severity was significantly related to acute outcomes. In conjunction with the WeeFIM, the CALS appears to be a meaningful complement for assessing and monitoring cognitive-linguistic skills during inpatient rehabilitation.Implications for RehabiliationOur study provides support for the utility of the CALS to assess cognitive recovery during inpatient rehabilitation following moderate to severe TBI.Injury severity and not pre-injury functioning or demographic variables was related to worse scores on the CALS at discharge.Using a measure sensitive to change over admission, such as the CALS, can inform treatment planning.

A-39 Predictors of Language Functioning Deficits in Pediatric Patients with Anti-NMDAR Encephalitis

Objective

This study aimed to examine predictors of language functioning in a sample of pediatric patients diagnosed with anti-N-methyl-D-aspartate receptor encephalitis (ANMDARE).

Method

Patient data was collected through retrospective chart review within a children’s hospital. Pediatric patients (N=16) treated for ANMDARE (12% male; 25% Caucasian, 50% African American, 25% Latino, mean age = 12.3) who completed a neuropsychological evaluation were identified (time since diagnosis M = 177.4;SD = 310.2). Language assessments included Wechsler Abbreviated Scale of Intelligence-II (WASI-II) Vocabulary; Wide Range Achievement Test- 4 (WRAT-4) Word Reading; Delis-Kaplan Executive Function System (D-KEFS) Verbal Fluency.

Results

Two independent-samples t-tests compared language functioning in patients with normal and abnormal MRI findings. Significant differences were found in vocabulary scores between patients with normal (M = 45.57, SD = 5.50) and abnormal MRIs (M = 36.67, SD = 5.35;t(11) = 2.94,p = 0.013). The magnitude of the differences in means (μd = 8.91,95%CI:2.25-15.56) was medium (η2 = 0.44). A significant difference in semantic fluency scores were also found (Normal MRI; M = 10.67, SD = 2.25 vs abnormal MRI; M = 6.13;SD = 1.23; t(12) = 3.89,p = 0.002). The magnitude of the differences in means (μd = 4.54, 95%CI:2.00- 7.09) was medium (η2 = 0.56). Additional analyses revealed a relationship between seizure presentation and vocabulary scores (t(11) = 2.50;p = 0.029).

Conclusions

Pediatric patients with abnormal MRIs demonstrate greater deficits in vocabulary and semantic fluency compared to those with normal MRIs. Moreover, patients who presented with seizures were more likely to have deficits in vocabulary. Previous research shows variability in prolonged deficits in language functioning in both children and adults. To the best of our knowledge, this is the first study to compare symptom presentation with language outcomes, thus potentially contributing to the clinical utility of MRI scans.

Promoting the Adjustment of Parentally Bereaved Children

The death of a parent is one of the most stressful life events to encounter during childhood. Given its detrimental impact on psychological development, a better understanding of outcomes associated with childhood bereavement and factors that affect these outcomes is necessary. The adjustment of bereaved children is linked to such factors as age of the child, sex of child and parent, circumstances of parent death, and the adjustment of the surviving caregiver. In this article I highlight considerations that may increase children's positive adjustment to parental death and also discuss specific treatment recommendations.

Concepts and Controversies in Grief and Loss

Although grief is a universal experience, the ways in which it occurs are not universally agreed upon. In fact, there is considerable controversy about the "normal" duration of grief, its expected outcome, and its course. Although most grieving adults will achieve a sense of normalcy at some point, others seem not to do so. Continuing impairment by grief raises a question: Is the experience qualitatively different from normal grief or is it different only in degree? This article discusses grief conceptualizations, including that of complicated grief, and approaches to grief counseling.

Family perceptions of medication administration at school: errors, risk factors, and consequences

Medications are administered every day in schools across the country. Researchers and clinicians have studied school nurses' and educators' experiences with medication administration, but not the experiences of children or their parents. This study examined medication administration from the child and parent perspectives to (a) determine problems children experience with medicines at school, (b) clarify risk factors for medication errors, and (c) examine the perceived impact of medication errors on school performance and social relationships. Participants included children ages 8 to 18 years (n=157) being treated at a large Midwestern Children's Hospital in diabetes, asthma, and Attention Deficit Hyperactivity Disorder (ADHD) clinics. Findings suggest that forgetting a dose and running out of medication were the most common problems. Missing a dose was more frequent in students with ADHD than in students with diabetes or asthma. Medication nonadherence at school, which includes medication administration errors such as missing a dose, may potentially lead to a variety of educational, social/emotional, and physical consequences. These results indicate that the impact of missing medication on children with ADHD appeared to have a greater effect on schoolwork and friendships, while the physical consequences appeared to vary widely based on health condition. Interestingly, children with more self-responsibility for medications were less likely to report medication errors. School nurses will want to include students when planning for medication management at school.

Optimizing nitrogen management in food and energy production and environmental protection: summary statement from the Second International Nitrogen Conference

Human efforts to produce food and energy are changing the nitrogen (N) cycle of the Earth. Many of these changes are highly beneficial for humans, while others are detrimental to people and the environment. These changes transcend scientific disciplines, geographical boundaries, and political structures. They challenge the creative minds of natural and social scientists, economists, engineers, business leaders, and decision makers. The Second International Nitrogen Conference was designed to facilitate communications among all stakeholders in the "nitrogen community" of the world. The Conference participants" goal in the years and decades ahead is to encourage every country to make optimal choices about N management in food production and consumption, energy production and use, and environmental protection. Scientific findings and recommendations for decision makers that emerged from the Conference are presented.

Forecasting agriculturally driven global environmental change

During the next 50 years, which is likely to be the final period of rapid agricultural expansion, demand for food by a wealthier and 50% larger global population will be a major driver of global environmental change. Should past dependences of the global environmental impacts of agriculture on human population and consumption continue, 10(9) hectares of natural ecosystems would be converted to agriculture by 2050. This would be accompanied by 2.4- to 2.7-fold increases in nitrogen- and phosphorus-driven eutrophication of terrestrial, freshwater, and near-shore marine ecosystems, and comparable increases in pesticide use. This eutrophication and habitat destruction would cause unprecedented ecosystem simplification, loss of ecosystem services, and species extinctions. Significant scientific advances and regulatory, technological, and policy changes are needed to control the environmental impacts of agricultural expansion.

Use of combined microautoradiography and fluorescence in situ hybridization to determine carbon metabolism in mixed natural communities of uncultured bacteria from the genus Achromatium

Combined microautoradiography and fluorescence in situ hybridization (FISH) was used to investigate carbon metabolism in uncultured bacteria from the genus Achromatium. All of the Achromatium species identified in a freshwater sediment from Rydal Water, Cumbria, United Kingdom, which were distinguishable only by FISH, assimilated both [(14)C]bicarbonate and [(14)C]acetate. This extends previous findings that Achromatium spp. present at another location could only utilize organic carbon sources. Achromatium spp., therefore, probably exhibit a range of physiologies, i.e., facultative chemolithoautotrophy, mixotrophy, and chemoorganoheterotrophy, similar to other large sulfur bacteria (e.g., Beggiatoa spp.).

Natural communities of Achromatium oxaliferum comprise genetically, morphologically, and ecologically distinct subpopulations

The diversity and ecology of natural communities of the uncultivated bacterium Achromatium oxaliferum were studied by use of culture-independent approaches. 16S rRNA gene sequences were PCR amplified from DNA extracted from highly purified preparations of cells that were morphologically identified as A. oxaliferum present in freshwater sediments from three locations in northern England (Rydal Water, Jenny Dam, Hell Kettles). Cloning and sequence analysis of the PCR-amplified 16S rRNA genes revealed that multiple related but divergent sequences were routinely obtained from the A. oxaliferum communities present in all the sediments examined. Whole-cell in situ hybridization with combinations of fluorescence-labelled oligonucleotide probes revealed that the divergent sequences recovered from purified A. oxaliferum cells corresponded to genetically distinct Achromatium subpopulations. Analysis of the cell size distribution of the genetically distinct subpopulations demonstrated that each was also morphologically distinct. Furthermore, there was a high degree of endemism in the Achromatium sequences recovered from different sediments; identical sequences were never recovered from different sampling locations. In addition to ecological differences that were apparent between Achromatium communities from different freshwater sediments, the distribution of different subpopulations of Achromatium in relation to sediment redox profiles indicated that the genetically and morphologically distinct organisms that coexisted in a single sediment were also ecologically distinct and were adapted to different redox conditions. This result suggests that Achromatium populations have undergone adaptive radiation and that the divergent Achromatium species occupy different niches in the sediments which they inhabit.

Substrate uptake by uncultured bacteria from the genus Achromatium determined by microautoradiography

Microautoradiography was used to investigate substrate uptake by natural communities of uncultured bacteria from the genus Achromatium. Studies of the uptake of (14)C-labelled substrates demonstrated that Achromatium cells from freshwater sediments were able to assimilate (14)C from bicarbonate, acetate, and protein hydrolysate; however, (14)C-labelled glucose was not assimilated. The pattern of substrate uptake by Achromatium spp. was therefore similar to those of a number of other freshwater and marine sulfur-oxidizing bacteria. Different patterns of radiolabelled bicarbonate uptake were noted for Achromatium communities from different geographical locations and indicated that one community (Rydal Water) possessed autotrophic potential, while the other (Hell Kettles) did not. Furthermore, the patterns of organic substrate uptake within a single population suggested that physiological diversity existed in natural communities of Achromatium. These observations are consistent with and may relate to the phylogenetic diversity observed in Achromatium communities. Incubation of Achromatium-bearing sediment cores from Rydal Water with (35)S-labelled sulfate in the presence and absence of sodium molybdate demonstrated that this bacterial population was capable of oxidizing sulfide to intracellular elemental sulfur. This finding supported the role of Achromatium in the oxidative component of a tightly coupled sulfur cycle in Rydal Water sediment. The oxidation of sulfide to sulfur and ultimately to sulfate by Achromatium cells from Rydal Water sediment is consistent with an ability to conserve energy from sulfide oxidation.

Phylogenetic relationships of filamentous sulfur bacteria (Thiothrix spp. and Eikelboom type 021N bacteria) isolated from wastewater-treatment plants and description of Thiothrix eikelboomii sp. nov., Thiothrix unzii sp. nov., Thiothrix fructosivorans sp. nov. and Thiothrix defluvii sp. nov

The relationship of mixotrophic and autotrophic Thiothrix species to morphologically similar chemoorganotrophic bacteria (e.g. Leucothrix species, Eikelboom type 021N bacteria) has been a matter of debate for some years. These bacteria have alternatively been grouped together on the basis of shared morphological features or separated on the basis of their nutrition. Many of these bacteria are difficult to maintain in axenic culture and, until recently, few isolates were available to allow comprehensive phenotypic and genotypic characterization. Several isolates of Thiothrix spp. and Eikelboom type 021N strains were characterized by comparative 16S rRNA sequence analysis. This revealed that the Thiothrix spp. and Eikelboom type 021N isolates formed a monophyletic group. Furthermore, isolates of Eikelboom type 021N bacteria isolated independently from different continents were phylogenetically closely related. The 16S rRNA sequence-based phylogeny was congruent with the morphological similarities between Thiothrix and Eikelboom type 021N. However, one isolate examined in this study (Ben47) shared many morphological features with the Thiothrix spp. and Eikelboom type 021N isolates, but was not closely related to them phylogenetically. Consequently, morphology alone cannot be used to assign bacteria to the Thiothrix/type 021N group. Comparative 16S rRNA sequence analysis supports monophyly of the Thiothrix/type 021N group, and phenotypic differences between the Thiothrix spp. and Eikelboom type 021N bacteria are currently poorly defined. For example, both groups include heterotrophic organisms that deposit intracellular elemental sulfur. It is therefore proposed that the Eikelboom type 021N bacteria should be accommodated within the genus Thiothrix as a new species, Thiothrix eikelboomii sp. nov., and three further new Thiothrix species are described: Thiothrix unzii sp. nov., Thiothrix fructosivorans sp. nov. and Thiothrix defluvii sp. nov.

Treatment of diabetes with guar gum. Reduction of urinary glucose loss in diabetics

When nine diabetic patients supplemented either their normal home diets (four patients) or metabolic ward diets (five patients) with 25 g guar gum daily for 5 or 7 days their mean urinary glucose excretion fell by 46% (P less than 0-05) and 54% (P less than 0-01), respectively. Gel-forming,, unabsorbable carbohydrate may therefore be a useful adjunct to anti-diabetic therapy, irrespective of the type of treatment or insulin dosage used.