Trends in telehealth versus on-site clinical genetics appointments in Manitoba: a comparative study

Telehealth involves the use of information and communications technology to deliver health services to patients over distance. Canada is well suited to benefit from telehealth since many individuals live in remote, rural and isolated locations. Manitoba is the easternmost prairie province and MBTelehealth is an active Canadian program that currently has 105 sites in 73 communities. Although studies of patient satisfaction comparing telehealth to on-site clinical visits have been conducted, a comparative study of the types of genetics patients seen via these two modalities has not been performed previously. In this study we: (1) examined the uptake of telehealth in Genetics in Manitoba; (2) contrasted telehealth usage in Genetics with other clinical programs; and (3) performed a comparative study of the types of Genetics referrals seen in 2008 on-site versus via telehealth. Results indicate the uptake of telehealth is increasing and has made genetics outreach clinics unnecessary. The Program of Genetics and Metabolism is consistently one of the top ten utilizers of telehealth within the province. With respect to discipline, chi square analysis revealed the trends were not significantly different for on-site and telehealth encounters, with prenatal referrals being the most common and Hereditary Breast and Ovarian Cancer referrals being the least common. Referrals within each discipline varied depending on the need for fetal assessment and physical examination. Telehealth was utilized regularly for test results sessions across all disciplines.

Persistent neonatal hypoglycemia: Diagnosis and management

Maintenance of plasma glucose depends on a normal endocrine system, functional enzyme levels for glycogenolysis, gluconeogenesis and other processes, and there must be an adequate supply of endogenous fat, glycogen and substrates of gluconeogenesis. Neonatal hypoglycemia should be defined as serum glucose less than 2.2 mmol/L in the first 72 h of life and less than 2.5 mmol/L thereafter. The purpose of this paper is to review the more uncommon causes of hypoglycemia in the full term, apparently healthy neonate. Most of these conditions are inborn errors of metabolism. A protocol for investigation of these conditions and some of the more common diseases, such as hyperinsulinism, is provided, with a rationale explaining why these tests may be helpful.

Early-onset neurodegenerative disease of the cerebellum and motor axons

We describe a novel hereditary neurodegenerative disease of infancy affecting an Aboriginal family from northern Manitoba, Canada. The parents are nonconsanguineous, without a family history of neurodegenerative diseases. Four of 10 siblings (three males and one female) presented with neurologic abnormalities including arthrogryposis, seizures, and severe developmental delay shortly after birth. In two children, cerebellar atrophy and mild cerebral atrophy were documented on neuroimaging. Two children, a boy who died at age 40 months and a girl who died at age 22 months, underwent muscle biopsies at 3 weeks and 4 months of age, respectively. The biopsies revealed fiber-size variability in the boy, and grouped atrophy with fiber-type grouping in the girl. Two boys who died at ages 7.5 and 37 months underwent autopsies that indicated severe atrophy of the cerebellar hemispheres (especially the inferior lobules and vermis), hypomyelination of white-matter fascicles in the striatum, severe atrophy of corticospinal tracts in the brainstem and spinal cord, and atrophy of the anterior spinal roots. In the spinal cord, motor neuron cell bodies and the posterior columns were spared. This clinical entity likely represents a novel neurodegenerative disease of the cerebellum and long motor axons.

Concordance of three methods for palpebral fissure length measurement in the assessment of fetal alcohol spectrum disorder

BACKGROUND

The assessment of individuals at risk of fetal alcohol spectrum disorders (FASD) includes the assessment of the craniofacial features that can result from prenatal alcohol exposure. The characteristic facial features of fetal alcohol syndrome (FAS) consist of short palpebral fissures, smooth or flattened philtrum, and thin vermilion border of the upper lip. There are various methods for measuring palpebral fissure lengths (PFLs) and it can be challenging for clinicians to obtain reproducibly accurate measurements. The development of the FAS Facial Photographic Analysis Software by the University of Washington FAS Diagnostic and Prevention Network (DPN) is one such means of improving the accuracy and reproducibility in these measurements.

OBJECTIVES

To assess concordance across three methods of PFL measurement: 1) a clear plastic handheld ruler, 2) blunt precision slide calipers, and 3) digital photometric photography (FAS Facial Photographic Analysis Software).

METHODS

The PFLs of 50 children (referred to the Clinic for Alcohol and Drug Exposed Children, CADEC) at Children's Hospital in Winnipeg and 50 adults from the University of Manitoba Medical Class of 2008 were measured once by a single clinician, using each of the three methods. The frequency and magnitude of discordance was tabulated. No method served as a gold-standard.

RESULTS

The PFLs ranged from 20 to 32 mm. The ruler and photometric measures were concordant in 42% of the subjects. When measures were discordant, half the ruler measures were larger and half were smaller. The caliper measure was concordant with the photometric and ruler measures on 18% and 24% of the subjects, respectively. When measures were discordant, the caliper measures were almost always larger than the photometric and ruler method (0.5 to 2.5 mm larger, 83% and 95% of the time, respectively). The presence of epicanthal folds did not appear to be a factor that contributed to discordance.

CONCLUSION

This study demonstrates the challenge in measuring the PFL, even when a single trained clinician is involved. Factors that can contribute to error include the subject's willingness to cooperate, ability to tolerate placement of the tool close enough to the eye to obtain an accurate measure, and precision of the tool. When controlling for the clinician performing the measurements and the quality of the photographs, the ruler and photometric measures were most concordant. The caliper measures tended to measure larger than the ruler and photometric measures.

Manitoba Oculotrichoanal (MOTA) syndrome: report of eight new cases

The Manitoba Oculotrichoanal (MOTA) syndrome was initially described by Marles et al. [1992; Am J Med Genet 42: 793-799] in Aboriginal patients of the Island Lake region of Northern Manitoba. Characteristic findings in affected patients included unilateral upper eyelid coloboma or cryptophthalmus with ipsilateral aberrant anterior hairline pattern and anal anomalies. We describe here seven new patients of the same extended kindred of Cree/Ojibway ethnicity of the Island Lake region and an eighth patient of Caucasian Dutch parents with clinical findings consistent with the diagnosis of MOTA syndrome. Two of the patients have bilateral, instead of unilateral, abnormal anterior hairline patterns. Omphalocele, a feature previously not identified, is present in three of them. The most consistent features appear to be hypertelorism and a broad or notched tip of the nose. Due to the obvious clinical overlap with Fraser syndrome, FRAS1 gene was screened in two of the affected and no mutation was found [Slavotinek et al., submitted].

Bowen-Conradi syndrome: a clinical and genetic study

The purpose of the study was to delineate the anomalies and the natural life history of persons with the Bowen-Conradi syndrome [Bowen and Conradi 1976: Birth Defects: Orig Artic Ser XII(6):101-108]. We ascertained 39 cases and personally examined almost all. For those who were not seen, their clinical record were scrutinized. Pedigree analysis of all 39 was done and kinship coefficients computed. The birth prevalence was estimated to be 1/355 live births.

Humeroradial synostosis, ulnar aplasia and oligodactyly, with contralateral amelia, in a child with prenatal cocaine exposure

Humeral "bifurcation" due to humeroradial synostosis, and amelia are both very rare limb anomalies. We report on a Canadian. Aboriginal boy with both these limb deficiencies. The family history was unremarkable, but he was exposed prenatally to cocaine at the time of limb development. Humeroradial synostosis with ulnar aplasia has been reported by several authors. The majority of cases are unilateral. When both upper limbs arms are involved, cases with oligodactyly often have asymmetrical limb deficiencies and have all been sporadic to date. Some appear to represent cases of the femur-fibula-ulna or FFU complex. Affected individuals with normal hands usually have symmetrical defects and show an autosomal recessive pattern of inheritance. Limb deficiencies have been reported in several infants exposed prenatally to cocaine and have been inducible in animal models. Most are terminal transverse defects or deficiencies of middle digits. When more than one limb is involved, the defects are usually asymmetric. Our case appears to be one of the most severely affected children reported to date.

Prenatal diagnosis of ring chromosome 6

An amniocentesis was performed on a gravida 1, para 0 23-year-old female because of high maternal serum alpha-fetoprotein and nuchal thickening/cystic mass apparent on the fetal ultrasound. Detailed ultrasound examination revealed multiple anomalies including brain abnormalities. The fetus was found to have a mosaic female karyotype: 45,XX, - 6/46,XX,r(6) (p25q27) (62 per cent:38 per cent). This is the first report of a prenatally diagnosed case of ring chromosome 6.

Evidence for Ritscher-Schinzel syndrome in Canadian Native Indians

We report on 8 (3 male, 5 female) native Canadian children with distinctive facial appearance and variable combinations of ocular colobomas, hypertelorism, macrocephaly, hand anomalies, congenital heart defects, structural CNS posterior fossa malformations, and mental retardation. These 8 children belong to 7 families; 3 of the families are related. The parents and other sibs are clinically unaffected. We think these manifestations provide evidence for Ritscher-Schinzel syndrome in native Canadian children, and we have confirmed that ocular colobomas are a common occurrence in this disorder.

Identification of an uncommon haptoglobin type using DNA and protein analysis

The inherited variations in haptoglobin phenotypes are attributed to the homozygous and heterozygous combinations of three common autosomal alleles: HP*1F, HP*1S and HP*2. HP*1F and HP*1S encode polypeptides that differ by two amino acids at positions 51 and 53. The formation of HP*2 is postulated to have resulted from a breakage and subsequent reunion event at non-homologous positions of two HP*1 alleles. The most common form of HP*2 is HP*2FS in which the 5' end of HP*2 resembles HP*1F and the 3' end resembles HP*1S. Homologous crossing over between HP*2 and either an HP*1F or HP*1S allele in HP*2/HP*1 heterozygotes can change the usual type of HP*2 to three other forms: HP*2SS, HP*2FF or HP*2SF. We describe a nuclear family in which the uncommon genotype HP*2SS is one parent caused initial confusion in assigning genotypes to the rest of the nuclear family. The data demonstrate the need for a cautious approach when deducing haptoglobin genotypes from molecular analysis alone.

New familial syndrome of unilateral upper eyelid coloboma, aberrant anterior hairline pattern, and anal anomalies in Manitoba Indians

We report on 6 (3 male, 3 female) Manitoba Indian children with hypertelorism and variable combinations of unilateral eye malformations, aberrant anterolateral scalp hairline, and nasal and anal anomalies. These children belong to 4 related families. The parents and 7 other sibs are clinically unaffected. The family histories are otherwise unremarkable. The presence of 2 major malformations in sibs and related individuals (with unaffected parents) suggests that this is a newly described pleiotropic autosomal recessive syndrome. The differential diagnosis includes cryptophthalmos syndrome and several other related malformation syndromes. Although multifactorial determination cannot be excluded, the inbred, isolated population and distribution make autosomal recessive inheritance more likely.

Ulnar agenesis and endocardial fibroelastosis

We report on an infant with bilateral ulnar agenesis, radial hypoplasia, oligodactyly, hydrops fetalis, and endocardial fibroelastosis (EFE). The presence of the 2 major malformations and parental consanguinity suggests the possibility of a new autosomal recessive MCA syndrome.

Another case of microcephaly, facial clefting, and preaxial polydactyly

We describe a nine month old boy with failure to thrive, developmental delay, bilateral cleft lip and palate, and left preaxial polydactyly. The features are similar to those in a child described by Howard and Young and may be the second case of a previously unknown syndrome.