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Lyon ME, Fraser JL, Thompkins JD, Clark H, Brodie N, Detwiler K, Torres C, Guerrera MF, Younge T, Aoun S, Trujillo Rivera EA. Advance Care Planning for Children With Rare Diseases: A Pilot RCT. Pediatrics 2024:e2023064557. [PMID: 38699801 DOI: 10.1542/peds.2023-064557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Pediatric rare diseases are often life-limiting conditions and/or require constant caregiving. Investigators assessed the initial efficacy of the FAmily CEntered (FACE) pediatric advance care planning (pACP), FACE-Rare, intervention on families' quality of life. METHODS A pilot-phase, single-blinded, intent-to-treat, randomized controlled clinical trial enrolled families from 1 pediatric quaternary hospital between 2021 and 2023. Intervention families received 3 weekly 60-minute (FACE-Rare pACP) sessions: (1) Carer Support Needs Assessment Tool or Action Plan, (2) Carer Support Needs Assessment Tol Action Plan Review, and (3) Pediatric Next Steps: Respecting Choices pACP. Controls received treatment as usual (TAU). Outcome measures were Beck Anxiety Inventory, Family Appraisal of Caregiving, Functional Assessment of Chronic Illness Therapy (FACIT)-Spirituality, and health care utilization. Generalized mixed effect models with γ response assessed the intervention effect at 3-month follow-up. RESULTS Children (n = 21) were aged 1 to 10 years, 48% male, 24% Black; and 100% technology dependent. Primary family caregivers (n = 21) were aged 30 to 43 years, 19% male, 19% Black; and 27% household income below the Federal poverty level. Dyads underwent 1:1 randomization: 9 to FACE-Rare and 12 to TAU. TAU caregivers reported statistically lower meaning and peace than FACE-Rare caregivers (0.9, P = .03, confidence interval [CI]: 0.75-0.99). Black caregivers reported significantly less caregiver distress (0.7, P = .04, CI: 0.47-0.98) than non-Black caregivers. Poor families reported more anxiety (3.5, P = .002, CI: 1.62-7.94), more caregiver strain (1.2, P = .006, CI: 1.07-1.42); and less family well-being (0.8, P = .02, CI: 0.64-0.95). CONCLUSIONS FACE®-Rare was feasible, acceptable, safe, and demonstrated initial efficacy, providing greater feelings of meaning and peace to caregivers. Poverty impacted well-being. A multisite trial is needed to determine generalizability.
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Affiliation(s)
- Maureen E Lyon
- Children's National Hospital, Washington, District of Columbia
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Jamie L Fraser
- Children's National Hospital, Washington, District of Columbia
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | | | - Heidi Clark
- Children's National Hospital, Washington, District of Columbia
| | - Nicola Brodie
- Children's National Hospital, Washington, District of Columbia
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | | | - Clarivet Torres
- Children's National Hospital, Washington, District of Columbia
| | | | - Tamiko Younge
- Children's National Hospital, Washington, District of Columbia
| | - Samar Aoun
- Peron Institute, Palliative Care, The Western University of Australia, Perth, Washington, Australia
| | - Eduardo A Trujillo Rivera
- Children's National Hospital, Washington, District of Columbia
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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Bulas DI, Fraser JL, Cilli K. Using MRI derived observed to expected total lung volume to predict lethality in fetal skeletal dysplasia. Pediatr Radiol 2024; 54:854-856. [PMID: 38438708 DOI: 10.1007/s00247-024-05893-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 02/16/2024] [Accepted: 02/19/2024] [Indexed: 03/06/2024]
Affiliation(s)
- Dorothy I Bulas
- Department of Diagnostic Imaging and Radiology, Zickler Family Prenatal Pediatrics Institute, Children's National Hospital, 111 Michigan Ave, Washington, DC, 20010, USA.
| | - Jamie L Fraser
- Division of Genetics and Metabolism, Department of Pediatrics, Rare Disease Institute, Zickler Family Prenatal Pediatrics Institute, Children's National Hospital, 7125 Michigan Ave, Washington, DC, 20012, USA
| | - Kate Cilli
- Department of Diagnostic Imaging and Radiology, Zickler Family Prenatal Pediatrics Institute, Children's National Hospital, 111 Michigan Ave, Washington, DC, 20010, USA
- Zickler Family Prenatal Pediatrics Institute, Children's National Hospital, 111 Michigan Ave, Washington, DC, 20010, USA
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Gold JI, Stefanatos AK, Fraser JL, Vanderver A, Cuddapah S. Enasidenib-induced hepatitis in an individual with Type II D2-hydroxyglutaric aciduria. JIMD Rep 2024; 65:156-162. [PMID: 38736636 PMCID: PMC11078709 DOI: 10.1002/jmd2.12421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 05/14/2024] Open
Abstract
Type II D-2-Hydroxyglutaric aciduria (T2D2HGA) is caused by a gain-of-function pathogenic variant in Isocitrate Dehydrogenase 2 (IDH2). Patients with T2D2HGA commonly present with developmental delay, seizures, cardiomyopathy, and arrhythmias. The recently approved IDH2-inhibitor Enasidenib targets the p.Arg140Gln pathogenic IDH2 variant and decreases production of D2HGA. We present a 7-year-old female with T2D2HGA due to the p.Arg140Gln variant. She was diagnosed at 3-years-old after presenting with global developmental delay, leukoencephalopathy, communicating hydrocephalus, seizures, and dilated cardiomyopathy. At age 3 years 11 months, 50 mg Enasidenib daily was initiated. Primary outcomes included seizure frequency, hospital admissions, development, and cardiac structure. Laboratories were monitored biweekly for common Enasidenib side effects. Our patient tolerated Enasidenib well. Urine 2-HGA decreased significantly from 244 mg/g creatinine to undetectable within 2 weeks of treatment. Inpatient admissions decreased from 8 during the 2 years preceding treatment to 1 during treatment. She has been seizure-free since Enasidenib initiation. Echocardiography showed improvement in dilated cardiomyopathy with normal left ventricular systolic function. Developmental assessment demonstrated improvements in gross motor, fine motor, language, and socialization domains. Treatment was complicated by mild elevations in alanine transaminase (118 IU/L, range 0-28) and creatine kinase (334 U/L, range 45-198) that resolved by decreasing Enasidenib dosing frequency to three times weekly. Enasidenib is a viable treatment for Type II D2HGA with benefits including developmental gains, fewer acute medical interventions, and cardiomyopathy improvement. While drug-induced hepatitis is a novel adverse effect of Enasidenib, it can be ameliorated by decreasing dose frequency.
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Affiliation(s)
- Jessica I. Gold
- Division of Medical Genetics, Department of PediatricsNorthwell HealthNew YorkNew YorkUSA
| | - Arianna K. Stefanatos
- Department of Child and Adolescent Psychiatry and Behavioral SciencesChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Jamie L. Fraser
- Prenatal Pediatrics InstituteChildren's National HospitalWashingtonDCUSA
- The George Washington University School of Medicine and Health SciencesWashingtonDCUSA
- Division of Fetal and Translational MedicineChildren's National HospitalWashingtonDCUSA
| | - Adeline Vanderver
- Division of Neurology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
- Department of NeurologyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Sanmati Cuddapah
- Section of Biochemical Genetics, Division of Genetics, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
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Adang LA, Sevagamoorthy A, Sherbini O, Fraser JL, Bonkowsky JL, Gavazzi F, D'Aiello R, Modesti NB, Yu E, Mutua S, Kotes E, Shults J, Vincent A, Emrick LT, Keller S, Van Haren KP, Woidill S, Barcelos I, Pizzino A, Schmidt JL, Eichler F, Fatemi A, Vanderver A. Longitudinal natural history studies based on real-world data in rare diseases: Opportunity and a novel approach. Mol Genet Metab 2024; 142:108453. [PMID: 38522179 DOI: 10.1016/j.ymgme.2024.108453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 03/13/2024] [Accepted: 03/16/2024] [Indexed: 03/26/2024]
Abstract
Growing interest in therapeutic development for rare diseases necessitate a systematic approach to the collection and curation of natural history data that can be applied consistently across this group of heterogenous rare diseases. In this study, we discuss the challenges facing natural history studies for leukodystrophies and detail a novel standardized approach to creating a longitudinal natural history study using existing medical records. Prospective studies are uniquely challenging for rare diseases. Delays in diagnosis and overall rarity limit the timely collection of natural history data. When feasible, prospective studies are often cross-sectional rather than longitudinal and are unlikely to capture pre- or early- symptomatic disease trajectories, limiting their utility in characterizing the full natural history of the disease. Therapeutic development in leukodystrophies is subject to these same obstacles. The Global Leukodystrophy Initiative Clinical Trials Network (GLIA-CTN) comprises of a network of research institutions across the United States, supported by a multi-center biorepository protocol, to map the longitudinal clinical course of disease across leukodystrophies. As part of GLIA-CTN, we developed Standard Operating Procedures (SOPs) that delineated all study processes related to staff training, source documentation, and data sharing. Additionally, the SOP detailed the standardized approach to data extraction including diagnosis, clinical presentation, and medical events, such as age at gastrostomy tube placement. The key variables for extraction were selected through face validity, and common electronic case report forms (eCRF) across leukodystrophies were created to collect analyzable data. To enhance the depth of the data, clinical notes are extracted into "original" and "imputed" encounters, with imputed encounter referring to a historic event (e.g., loss of ambulation 3 months prior). Retrospective Functional Assessments were assigned by child neurologists, using a blinded dual-rater approach and score discrepancies were adjudicated by a third rater. Upon completion of extraction, data source verification is performed. Data missingness was evaluated using statistics. The proposed methodology will enable us to leverage existing medical records to address the persistent gap in natural history data within this unique disease group, allow for assessment of clinical trajectory both pre- and post-formal diagnosis, and promote recruitment of larger cohorts.
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Affiliation(s)
- Laura Ann Adang
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Anjana Sevagamoorthy
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Omar Sherbini
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jamie L Fraser
- Rare Disease Institute, Children's National Medical Center, Washington, DC, USA; Leukodystrophy and Myelin Disorders Program, Children's National Medical Center, Washington, DC, USA
| | - Joshua L Bonkowsky
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA; Center for Personalized Medicine, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Francesco Gavazzi
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Russel D'Aiello
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nicholson B Modesti
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Emily Yu
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sylvia Mutua
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Emma Kotes
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Justine Shults
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Ariel Vincent
- CHOP Research Institute, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lisa T Emrick
- Division of Neurology and Developmental Neuroscience in Department Pediatrics, Baylor College Medicine and Texas Children's Hospital, Houston, TX, USA; Department of Human and Molecular Genetics, Baylor College of Medicine, Houston, TX, USA
| | - Stephanie Keller
- Children's Healthcare of Atlanta Scottish Rite Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Sarah Woidill
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Isabella Barcelos
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Amy Pizzino
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Johanna L Schmidt
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Florian Eichler
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Ali Fatemi
- Moser Center for Leukodystrophies, Kennedy Krieger Institute, Baltimore, MD, USA; Departments of Neurology & Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Adeline Vanderver
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Fortin O, Christoffel K, Shoaib A, Venkatesan C, Cilli K, Schroeder JW, Alves C, Ganetzky RD, Fraser JL. Characteristic Fetal Brain MRI Abnormalities in Pyruvate Dehydrogenase Complex Deficiency. medRxiv 2024:2024.04.08.24303574. [PMID: 38645225 PMCID: PMC11030481 DOI: 10.1101/2024.04.08.24303574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Pyruvate dehydrogenase complex deficiency (PDCD) is a disorder of mitochondrial metabolism that is caused by pathogenic variants in multiple genes, including PDHA1. Typical neonatal brain imaging findings in PDCD have been described, with a focus on malformative features and chronic encephaloclastic changes. However, fetal brain MRI imaging in confirmed PDCD has not been comprehensively described. We sought to demonstrate the prenatal neurological and systemic manifestations of PDCD determined by comprehensive fetal imaging and genomic sequencing. All fetuses with a diagnosis of genetic PDCD who had undergone fetal MRI were included in the study. Medical records, imaging data, and genetic testing results were reviewed and reported descriptively. Ten patients with diagnosis of PDCD were included. Most patients had corpus callosum dysgenesis, abnormal gyration pattern, reduced brain volumes, and periventricular cystic lesions. One patient had associated intraventricular hemorrhages. One patient had a midbrain malformation with aqueductal stenosis and severe hydrocephalus. Fetuses imaged in the second trimester were found to have enlargement of the ganglionic eminences with cystic cavitations, while those imaged in the third trimester had germinolytic cysts. Fetuses with PDCD have similar brain MRI findings to neonates described in the literature, although some of these findings may be subtle early in pregnancy. Additional features, such as cystic cavitations of the ganglionic eminences, are noted in the second trimester in fetuses with PDCD, and these may represent a novel early diagnostic marker for PDCD. Using fetal MRI to identify these radiological hallmarks to inform prenatal diagnosis of PDCD may guide genetic counseling, pregnancy decision-making, and neonatal care planning.
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Affiliation(s)
- Olivier Fortin
- Zickler Family Prenatal Pediatrics Institute, Children’s National Hospital, Washington, District of Columbia, USA, 20010
| | - Kelsey Christoffel
- Zickler Family Prenatal Pediatrics Institute, Children’s National Hospital, Washington, District of Columbia, USA, 20010
- Department of Neurology and Rehabilitation Medicine, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA, 20052
| | - Abdullah Shoaib
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA, 75235
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas, USA, 75235
| | - Charu Venkatesan
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA, 45229
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA, 45221
| | - Kate Cilli
- Zickler Family Prenatal Pediatrics Institute, Children’s National Hospital, Washington, District of Columbia, USA, 20010
| | - Jason W. Schroeder
- Department of Radiology, Children’s National Hospital, Washington, District of Columbia, USA, 20010
- Department of Radiology, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA, 20052
| | - Cesar Alves
- Department of Radiology, Boston Children’s Hospital, Boston, Massachusetts, USA, 02115
| | - Rebecca D. Ganetzky
- Division of Human Genetics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA, 19104
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, 19104
| | - Jamie L. Fraser
- Zickler Family Prenatal Pediatrics Institute, Children’s National Hospital, Washington, District of Columbia, USA, 20010
- Rare Disease Institute, Children’s National Hospital, Washington, District of Columbia, USA, 20010
- Center for Genetic Medicine Research, Children’s National Hospital, Washington, District of Columbia, USA, 20010
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6
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Chen Y, Dawes R, Kim HC, Stenton SL, Walker S, Ljungdahl A, Lord J, Ganesh VS, Ma J, Martin-Geary AC, Lemire G, D'Souza EN, Dong S, Ellingford JM, Adams DR, Allan K, Bakshi M, Baldwin EE, Berger SI, Bernstein JA, Brown NJ, Burrage LC, Chapman K, Compton AG, Cunningham CA, D'Souza P, Délot EC, Dias KR, Elias ER, Evans CA, Ewans L, Ezell K, Fraser JL, Gallacher L, Genetti CA, Grant CL, Haack T, Kuechler A, Lalani SR, Leitão E, Fevre AL, Leventer RJ, Liebelt JE, Lockhart PJ, Ma AS, Macnamara EF, Maurer TM, Mendez HR, Montgomery SB, Nassogne MC, Neumann S, O'Leary M, Palmer EE, Phillips J, Pitsava G, Pysar R, Rehm HL, Reuter CM, Revencu N, Riess A, Rius R, Rodan L, Roscioli T, Rosenfeld JA, Sachdev R, Simons C, Sisodiya SM, Snell P, Clair LS, Stark Z, Tan TY, Tan NB, Temple SE, Thorburn DR, Tifft CJ, Uebergang E, VanNoy GE, Vilain E, Viskochil DH, Wedd L, Wheeler MT, White SM, Wojcik M, Wolfe LA, Wolfenson Z, Xiao C, Zocche D, Rubenstein JL, Markenscoff-Papadimitriou E, Fica SM, Baralle D, Depienne C, MacArthur DG, Howson JM, Sanders SJ, O'Donnell-Luria A, Whiffin N. De novo variants in the non-coding spliceosomal snRNA gene RNU4-2 are a frequent cause of syndromic neurodevelopmental disorders. medRxiv 2024:2024.04.07.24305438. [PMID: 38645094 PMCID: PMC11030480 DOI: 10.1101/2024.04.07.24305438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Around 60% of individuals with neurodevelopmental disorders (NDD) remain undiagnosed after comprehensive genetic testing, primarily of protein-coding genes 1 . Increasingly, large genome-sequenced cohorts are improving our ability to discover new diagnoses in the non-coding genome. Here, we identify the non-coding RNA RNU4-2 as a novel syndromic NDD gene. RNU4-2 encodes the U4 small nuclear RNA (snRNA), which is a critical component of the U4/U6.U5 tri-snRNP complex of the major spliceosome 2 . We identify an 18 bp region of RNU4-2 mapping to two structural elements in the U4/U6 snRNA duplex (the T-loop and Stem III) that is severely depleted of variation in the general population, but in which we identify heterozygous variants in 119 individuals with NDD. The vast majority of individuals (77.3%) have the same highly recurrent single base-pair insertion (n.64_65insT). We estimate that variants in this region explain 0.41% of individuals with NDD. We demonstrate that RNU4-2 is highly expressed in the developing human brain, in contrast to its contiguous counterpart RNU4-1 and other U4 homologs, supporting RNU4-2 's role as the primary U4 transcript in the brain. Overall, this work underscores the importance of non-coding genes in rare disorders. It will provide a diagnosis to thousands of individuals with NDD worldwide and pave the way for the development of effective treatments for these individuals.
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Adang LA, Bonkowsky JL, Boelens JJ, Mallack E, Ahrens-Nicklas R, Bernat JA, Bley A, Burton B, Darling A, Eichler F, Eklund E, Emrick L, Escolar M, Fatemi A, Fraser JL, Gaviglio A, Keller S, Patterson MC, Orchard P, Orthmann-Murphy J, Santoro JD, Schöls L, Sevin C, Srivastava IN, Rajan D, Rubin JP, Van Haren K, Wasserstein M, Zerem A, Fumagalli F, Laugwitz L, Vanderver A. Consensus guidelines for the monitoring and management of metachromatic leukodystrophy in the United States. Cytotherapy 2024:S1465-3249(24)00579-6. [PMID: 38613540 DOI: 10.1016/j.jcyt.2024.03.487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/20/2024] [Accepted: 03/24/2024] [Indexed: 04/15/2024]
Abstract
Metachromatic leukodystrophy (MLD) is a fatal, progressive neurodegenerative disorder caused by biallelic pathogenic mutations in the ARSA (Arylsulfatase A) gene. With the advent of presymptomatic diagnosis and the availability of therapies with a narrow window for intervention, it is critical to define a standardized approach to diagnosis, presymptomatic monitoring, and clinical care. To meet the needs of the MLD community, a panel of MLD experts was established to develop disease-specific guidelines based on healthcare resources in the United States. This group developed a consensus opinion for best-practice recommendations, as follows: (i) Diagnosis should include both genetic and biochemical testing; (ii) Early diagnosis and treatment for MLD is associated with improved clinical outcomes; (iii) The panel supported the development of newborn screening to accelerate the time to diagnosis and treatment; (iv) Clinical management of MLD should include specialists familiar with the disease who are able to follow patients longitudinally; (v) In early onset MLD, including late infantile and early juvenile subtypes, ex vivo gene therapy should be considered for presymptomatic patients where available; (vi) In late-onset MLD, including late juvenile and adult subtypes, hematopoietic cell transplant (HCT) should be considered for patients with no or minimal disease involvement. This document summarizes current guidance on the presymptomatic monitoring of children affected by MLD as well as the clinical management of symptomatic patients. Future data-driven evidence and evolution of these recommendations will be important to stratify clinical treatment options and improve clinical care.
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Affiliation(s)
- Laura A Adang
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | | | - Jaap Jan Boelens
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapies, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Eric Mallack
- Kennedy Krieger Institute, Baltimore, Maryland, USA
| | | | - John A Bernat
- University of Iowa Stead Family Children's Hospital, Iowa City, Iowa, USA
| | - Annette Bley
- University Children's Hospital, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Barbara Burton
- Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | | | | | | | - Lisa Emrick
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Maria Escolar
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Forge Biologics, Grove City, Ohio, USA
| | - Ali Fatemi
- Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Jamie L Fraser
- Children's National Hospital, Washington, District of Columbia, USA
| | - Amy Gaviglio
- Division of Laboratory Services, Newborn Screening and Molecular Biology Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA; Association of Public Health Laboratories, Silver Spring, Maryland, USA
| | | | - Marc C Patterson
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA; Department of Clinical Genomics, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul Orchard
- University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Jonathan D Santoro
- University of Southern California, Children's Hospital Los Angeles, Keck School of Medicine, Los Angeles, California, USA
| | - Ludger Schöls
- Department of Neurology and Hertie-Institute for Clinical Brain Research German Center of Neurodegenerative Diseases (DZNE), Tübingen, Germany
| | | | - Isha N Srivastava
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Deepa Rajan
- University of Pittsburgh, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Keith Van Haren
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Melissa Wasserstein
- Department of Pediatrics, Albert Einstein College of Medicine and the Children's Hospital at Montefiore, Bronx, New York, USA
| | - Ayelet Zerem
- Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Lucia Laugwitz
- Department of Pediatric Neurology and Developmental Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Adeline Vanderver
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Whitehead MT, Limperopoulos C, Schlatterer SD, Mulkey SB, Fraser JL, du Plessis AJ. Hippocampal rotation is associated with ventricular atrial size. Pediatr Radiol 2023; 53:1941-1950. [PMID: 37183230 DOI: 10.1007/s00247-023-05687-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 04/13/2023] [Accepted: 04/27/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Fetal ventriculomegaly is a source of apprehension for expectant parents and may present prognostic uncertainty for physicians. Accurate prenatal counseling requires knowledge of its cause and associated findings as the differential diagnosis is broad. We have observed an association between ventriculomegaly and incomplete hippocampal inversion. OBJECTIVE To determine whether ventricular size is related to incomplete hippocampal inversion. MATERIALS AND METHODS We retrospectively evaluated pre- and postnatal brain MRIs in normal subjects (mean GA, 31 weeks; mean postnatal age, 27 days) and patients with isolated ventriculomegaly (mean GA, 31 weeks; mean postnatal age, 68 days) at a single academic medical center. Lateral ventricular diameter, multiple qualitative and quantitative markers of hippocampal inversion, and evidence of intraventricular hemorrhage were documented. RESULTS Incomplete hippocampal inversion and ventricular size were associated in both normal subjects (n=51) and patients with ventriculomegaly (n=32) (P<0.05). Severe ventriculomegaly was significantly associated with adverse clinical outcome in postnatal (P=0.02) but not prenatal (P=0.43) groups. In all additional cases of isolated ventriculomegaly, clinical outcome was normal over the time of assessment (mean 1±1.9 years; range 0.01 to 10 years). CONCLUSION Lateral ventricular atrial diameter and incomplete hippocampal inversion are associated. Less hippocampal inversion correlates with larger atria. For every 1-mm increase in fetal ventricular size, the odds of incomplete hippocampal inversion occurring increases by a factor of 1.6 in normal controls and 1.4 in patients with ventriculomegaly.
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Affiliation(s)
- Matthew T Whitehead
- Department of Neuroradiology, Children's National Hospital, Washington, DC, USA.
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, DC, USA.
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
- Division of Fetal and Transitional Medicine, Children's National Hospital, Washington, DC, USA.
- Division of Neuroradiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
- Department of Radiology Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Catherine Limperopoulos
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, DC, USA
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Division of Fetal and Transitional Medicine, Children's National Hospital, Washington, DC, USA
| | - Sarah D Schlatterer
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, DC, USA
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Division of Fetal and Transitional Medicine, Children's National Hospital, Washington, DC, USA
| | - Sarah B Mulkey
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, DC, USA
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Division of Fetal and Transitional Medicine, Children's National Hospital, Washington, DC, USA
| | - Jamie L Fraser
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, DC, USA
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Division of Fetal and Transitional Medicine, Children's National Hospital, Washington, DC, USA
| | - Adre J du Plessis
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, DC, USA
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Division of Fetal and Transitional Medicine, Children's National Hospital, Washington, DC, USA
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9
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Whitehead MT, Limperopoulos C, Schlatterer SD, Mulkey SB, Fraser JL, du Plessis AJ. Correction to: Hippocampal rotation is associated with ventricular atrial size. Pediatr Radiol 2023; 53:1963. [PMID: 37237068 DOI: 10.1007/s00247-023-05697-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Matthew T Whitehead
- Department of Neuroradiology, Children's National, Hospital, Washington, DC, USA.
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, DC, USA.
- The George Washington University School of Medicine, and Health Sciences, Washington, DC, USA.
- Division of Fetal and Transitional Medicine, Children's, National Hospital, Washington, DC, USA.
- Division of Neuroradiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
- Department of Radiology Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Catherine Limperopoulos
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, DC, USA
- The George Washington University School of Medicine, and Health Sciences, Washington, DC, USA
- Division of Fetal and Transitional Medicine, Children's, National Hospital, Washington, DC, USA
| | - Sarah D Schlatterer
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, DC, USA
- The George Washington University School of Medicine, and Health Sciences, Washington, DC, USA
- Division of Fetal and Transitional Medicine, Children's, National Hospital, Washington, DC, USA
| | - Sarah B Mulkey
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, DC, USA
- The George Washington University School of Medicine, and Health Sciences, Washington, DC, USA
- Division of Fetal and Transitional Medicine, Children's, National Hospital, Washington, DC, USA
| | - Jamie L Fraser
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, DC, USA
- The George Washington University School of Medicine, and Health Sciences, Washington, DC, USA
- Division of Fetal and Transitional Medicine, Children's, National Hospital, Washington, DC, USA
| | - Adre J du Plessis
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, DC, USA
- The George Washington University School of Medicine, and Health Sciences, Washington, DC, USA
- Division of Fetal and Transitional Medicine, Children's, National Hospital, Washington, DC, USA
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10
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Lyon ME, Thompkins JD, Fratantoni K, Fraser JL, Schellinger SE, Briggs L, Friebert S, Aoun S, Cheng YI, Wang J. Family caregivers of children and adolescents with rare diseases: a novel palliative care intervention. BMJ Support Palliat Care 2022; 12:e705-e714. [PMID: 31345846 PMCID: PMC8040699 DOI: 10.1136/bmjspcare-2019-001766] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 04/24/2019] [Accepted: 05/29/2019] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To develop and pilot test a palliative care intervention for family caregivers of children with rare diseases (FAmily-CEntered pediatric Advance Care Planning-Rare (FACE-Rare)). METHODS FACE-Rare development involved an iterative, family-guided process including review by a Patient and Family Advisory Council, semistructured family interviews and adaptation of two evidence-based person-centred approaches and pilot testing their integration. Eligible families were enrolled in FACE-Rare (the Carer Support Needs Assessment Tool (CSNAT) Approach Paediatric sessions 1 and 2; plus Respecting Choices Next Steps pACP intervention sessions 3 and 4). Satisfaction, quality of communication and caregiver appraisal were assessed. RESULTS Parents were mean age 40 years, and children 7 years. Children's diseases were rare enough that description would identify patients. All children were technology dependent. Telemedicine, used with four of seven families, was an effective engagement strategy and decreased subject burden. Families found FACE-Rare valuable following a strategy that first elicited palliative care needs and a support plan. Eight families were approached for pilot testing. Of the seven mothers who agreed to participate, six began session 1, and of those, 100% completed: all four FACE-Rare sessions, baseline and 2-week postintervention assessments, and a written pACP which described their preferences for medical decision-making to share with their providers. 100% reported FACE-Rare was helpful. The top three CSNAT concerns were: knowing what to expect in the future, having enough time for yourself and financial issues. Benchmarks were achieved and questionnaires were acceptable to parents and thus feasible to use in a larger trial. CONCLUSIONS FACE-Rare provides an innovative, structured approach for clinicians to deliver person-centred care.
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Affiliation(s)
- Maureen E Lyon
- Adolescent and Young Adult Medicine, Children's National Health System, Washington, DC, USA
| | - Jessica D Thompkins
- Center for Translational Research, Children's National Health System, Washington, DC, USA
| | - Karen Fratantoni
- Complex Care Program, Children's National Health System, Washington, DC, USA
| | - Jamie L Fraser
- Division of Genetics and Metabolism, Children's National Health System, Washington, DC, USA
| | | | - Linda Briggs
- A Division of C-TAC Innovations, Respecting Choices, Washington, DC, USA
| | - Sarah Friebert
- Palliative Care, Akron Children's Hospital, Akron, Ohio, USA
| | - Samar Aoun
- Perron Institute for Neurological and Translational Science, Perth, Western Australia, Australia
- School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Yao Iris Cheng
- Biostatistics, Children's National Health System, Washington, DC, USA
| | - Jichuan Wang
- Biostatistics, Children's National Health System, Washington, DC, USA
- Center for Translational Science, Children's National Health System, Washington, DC, USA
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11
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Gavazzi F, Fraser JL, Bloom M, Tochen L, Rhee J, Kwan M, Victoria T, Teachey DT, Ho CY, Vanderver A, Linn RL. Hodgkin lymphoma in an individual with TREX1-mediated Aicardi Goutières syndrome. Pediatr Blood Cancer 2022; 69:e29322. [PMID: 34490982 DOI: 10.1002/pbc.29322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Francesco Gavazzi
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Jamie L Fraser
- Rare Disease Institute, Division of Genetics and Metabolism, Children's National Hospital, Washington, District of Columbia, USA
| | - Miriam Bloom
- Department of Pediatrics, Children's National Hospital, Washington, District of Columbia, USA
| | - Laura Tochen
- Department of Neurology, Children's National Hospital, Washington, District of Columbia, USA
| | - Jullie Rhee
- Department of Neurology, Children's National Hospital, Washington, District of Columbia, USA
| | - Megan Kwan
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Teresa Victoria
- Division of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - David T Teachey
- Divisions of Hematology and Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Divisions of Hematology and Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Cheng-Ying Ho
- Department of Pathology and Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Adeline Vanderver
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rebecca L Linn
- Department of Pathology and Lab Medicine at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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12
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Klopstock T, Videnovic A, Bischoff AT, Bonnet C, Cif L, Comella C, Correa‐Vela M, Escolar ML, Fraser JL, Gonzalez V, Hermanowicz N, Jech R, Jinnah HA, Kmiec T, Lang A, Martí MJ, Mercimek‐Andrews S, Monduy M, Nimmo GA, Perez‐Dueñas B, Pfeiffer HCV, Planellas L, Roze E, Thakur N, Tochen L, Vanegas‐Arroyave N, Zorzi G, Burns C, Greblikas F. Fosmetpantotenate Randomized Controlled Trial in Pantothenate Kinase-Associated Neurodegeneration. Mov Disord 2021; 36:1342-1352. [PMID: 33200489 PMCID: PMC8246547 DOI: 10.1002/mds.28392] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 10/20/2020] [Accepted: 10/26/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Pantothenate kinase-associated neurodegeneration (PKAN) currently has no approved treatments. OBJECTIVES The Fosmetpantotenate Replacement Therapy pivotal trial examined whether treatment with fosmetpantotenate improves PKAN symptoms and stabilizes disease progression. METHODS This randomized, double-blind, placebo-controlled, multicenter study evaluated fosmetpantotenate, 300 mg oral dose three times daily, versus placebo over a 24-week double-blind period. Patients with pathogenic variants of PANK2, aged 6 to 65 years, with a score ≥6 on the PKAN-Activities of Daily Living (PKAN-ADL) scale were enrolled. Patients were randomized to active (fosmetpantotenate) or placebo treatment, stratified by weight and age. The primary efficacy endpoint was change from baseline at week 24 in PKAN-ADL. RESULTS Between July 23, 2017, and December 18, 2018, 84 patients were randomized (fosmetpantotenate: n = 41; placebo: n = 43); all 84 patients were included in the analyses. Six patients in the placebo group discontinued treatment; two had worsening dystonia, two had poor compliance, and two died of PKAN-related complications (aspiration during feeding and disease progression with respiratory failure, respectively). Fosmetpantotenate and placebo group PKAN-ADL mean (standard deviation) scores were 28.2 (11.4) and 27.4 (11.5) at baseline, respectively, and were 26.9 (12.5) and 24.5 (11.8) at week 24, respectively. The difference in least square mean (95% confidence interval) at week 24 between fosmetpantotenate and placebo was -0.09 (-1.69 to 1.51; P = 0.9115). The overall incidence of treatment-emergent serious adverse events was similar in the fosmetpantotenate (8/41; 19.5%) and placebo (6/43; 14.0%) groups. CONCLUSIONS Treatment with fosmetpantotenate was safe but did not improve function assessed by the PKAN-ADL in patients with PKAN. © 2020 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Thomas Klopstock
- Friedrich Baur Institute at the Department of NeurologyUniversity Hospital, LMU MunichMunichGermany
- German Center for Neurodegenerative Diseases (DZNE), MunichMunichGermany
- Munich Cluster for Systems Neurology (SyNergy), MunichMunichGermany
| | - Aleksandar Videnovic
- Department of NeurologyMassachusetts General Hospital/Harvard Medical SchoolBostonMassachusettsUSA
| | - Almut Turid Bischoff
- Friedrich Baur Institute at the Department of NeurologyUniversity Hospital, LMU MunichMunichGermany
| | - Cecilia Bonnet
- Department of NeurologySorbonne University, AP‐HP Salpêtrière HospitalParisFrance
| | - Laura Cif
- Department of NeurosurgeryCHRU de Montpellier, Gui de Chauliac HospitalMontpellierFrance
| | - Cynthia Comella
- Department of Neurosurgery and Neurological SciencesRush University Medical CenterChicagoIllinoisUSA
| | - Marta Correa‐Vela
- Department of Child NeurologyHospital Universitari Vall d'HebronBarcelonaSpain
| | - Maria L. Escolar
- Department of PediatricsUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Jamie L. Fraser
- Rare Disease Institute, Division of Genetics and MetabolismChildren's National Medical CenterWashingtonDistrict of ColumbiaUSA
| | - Victoria Gonzalez
- Department of NeurosurgeryUniversity Hospital of Montpellier, Gui de Chauliac HospitalMontpellierFrance
| | - Neal Hermanowicz
- Department of NeurologyUniversity of California IrvineIrvineCaliforniaUSA
| | - Robert Jech
- Department of Neurology, First Faculty of MedicineCharles University and General Faculty HospitalPragueCzech Republic
| | - Hyder A. Jinnah
- Departments of Neurology and Human GeneticsEmory University School of MedicineAtlantaGeorgiaUSA
| | - Tomasz Kmiec
- Child Neurology DepartmentChildren's Memorial Health InstituteWarsawPoland
| | - Anthony Lang
- Edmond J. Safra Program in Parkinson's Disease and the Department of Medicine (Neurology)Toronto Western Hospital and the University of TorontoTorontoOntarioCanada
| | - Maria J. Martí
- Movement Disorders UnitHospital Clinic of Barcelona, European Reference Network for Rare Neurological Diseases (ERN‐RND), Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED. CB06/05/0018‐ISCIII)BarcelonaSpain
| | - Saadet Mercimek‐Andrews
- Division of Clinical and Metabolic Genetics, Department of PediatricsUniversity of Toronto, The Hospital for Sick ChildrenTorontoOntarioCanada
| | - Migvis Monduy
- NeurologyNicklaus Children's HospitalMiamiFloridaUSA
| | - Graeme A.M. Nimmo
- Division of Clinical and Metabolic Genetics, The Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | - Belen Perez‐Dueñas
- Department of Child NeurologyHospital Universitari Vall d'HebronBarcelonaSpain
| | | | - Lluis Planellas
- Department of NeurologyHospital Clinic of BarcelonaBarcelonaSpain
| | - Emmanuel Roze
- Department of NeurologySorbonne University, AP‐HP Salpêtrière Hospital, Brain and Spine InstituteParisFrance
| | - Nivedita Thakur
- Department of Pediatrics, Division of Child and Adolescent NeurologyUniversity of Texas at Houston Medical SchoolHoustonTexasUSA
| | - Laura Tochen
- Department of NeurologyChildren's National Medical CenterWashingtonDistrict of ColumbiaUSA
| | - Nora Vanegas‐Arroyave
- Department of NeurologyColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Giovanna Zorzi
- Department of Child NeurologyFondazione IRCCS Istituto Neurologico Carlo BestaMilanItaly
| | - Colleen Burns
- Biostatistics, Retrophin, Inc.San DiegoCaliforniaUSA
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13
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Lawrence AK, Whitehead MT, Kruszka P, Sanapo L, Yano S, Tanpaiboon P, Muenke M, Fraser JL, du Plessis AJ. Prenatal diagnosis of diencephalic-mesencephalic junction dysplasia: Fetal magnetic resonance imaging phenotypes, genetic diagnoses, and outcomes. Prenat Diagn 2021; 41:778-790. [PMID: 33522008 DOI: 10.1002/pd.5909] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 11/17/2020] [Accepted: 12/28/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Report a single-center 12-year experience in the fetal diagnosis of diencephalic-mesencephalic junction dysplasia (DMJD) to expand the phenotype with Magnetic resonance imaging (MRI)-based classification, evaluate genetic etiologies, and ascertain outcomes. METHODS Retrospective medical record and imaging review of all fetal MRI exams with DMJD were performed at our institution. RESULTS Thirty-three pregnancies with fetal MRI findings of DMJD at 24 (18-37) weeks gestational age were studied; 70% were referred for fetal hydrocephalus. Three fetal MRI patterns were recognized. Type A (butterfly/hypothalamus-midbrain union) was seen in two cases (6%), Type B (partial thalamus-midbrain union) in 22 fetuses (70%), and Type C (complete/near complete midbrain-thalamic continuity) in nine fetuses (24%). L1CAM mutations were identified in four cases, and biallelic VRK1 variants in another. Among 14 live-born cases, 11 survived infancy, and 10 underwent postnatal brain MRI which confirmed the fetal MRI diagnosis in all but one case. Development was delayed in all surviving infants, most with additional neurological sequelae. CONCLUSIONS DMJD may be identified by prenatal MRI as early as 18 weeks gestation. We propose three distinct phenotypic forms of DMJD, Types A-C. Next-generation sequencing provides an underlying molecular diagnosis in some patients, but further studies on associated genetic diagnoses and clinical outcomes are indicated.
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Affiliation(s)
- Anne K Lawrence
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, District of Columbia, USA.,George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Matthew T Whitehead
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA.,Division of Diagnostic Imaging and Radiology, Children's National Hospital, Washington, District of Columbia, USA
| | - Paul Kruszka
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Laura Sanapo
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, District of Columbia, USA.,George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Sho Yano
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Pranoot Tanpaiboon
- Rare Disease Institute, Division of Genetics and Metabolism, Children's National Hospital, Washington, District of Columbia, USA
| | - Maximilian Muenke
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Jamie L Fraser
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, District of Columbia, USA.,Rare Disease Institute, Division of Genetics and Metabolism, Children's National Hospital, Washington, District of Columbia, USA
| | - Adre J du Plessis
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, District of Columbia, USA.,George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
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14
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Summerlin ML, Regier DS, Fraser JL, Chapman KA, Kafashzadeh D, Billington C, Kisling M, Grochowsky A, Ah Mew N, Shur N. Use of dexamethasone in idiopathic, acute pediatric rhabdomyolysis. Am J Med Genet A 2020; 185:500-507. [PMID: 33300687 DOI: 10.1002/ajmg.a.62000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/12/2020] [Accepted: 11/14/2020] [Indexed: 12/18/2022]
Abstract
Current rhabdomyolysis treatment guidelines vary based on the etiology and diagnosis, yet many cases evade conclusive diagnosis. In these cases, treatment options remain largely limited to fluids and supportive therapy. We present two cases of acute rhabdomyolysis diagnosed in the emergency department: a 5-year-old boy with sudden onset bilateral flank pain, and a 13-year-old boy with 2-3 days of worsening pectoral and shoulder pain. Each patient had a prior similar episode requiring hospitalization in the past. The 5-year-old had no inciting trauma or trigger, medication use, or illness. The 13-year-old previously had an upper respiratory infection during the week prior and had been strenuously exercising at the time of onset. Genetic testing results were unknown for both patients during their hospitalizations, and insurance and other barriers led to delay. Later results for the first patient revealed a heterozygous deletion in intron 19 on the LPIN1 gene interpreted as a variant of unknown significance. During their hospitalizations, both children were started on intravenous (i.v.) fluids, and creatine kinase (CK) initially trended downward, but then began to rise or plateau. After reviewing the cases, prior literature, and anecdotal evidence of benefit from corticosteroid therapy in rhabdomyolysis with our consultant metabolic physicians, dexamethasone was initiated. In both patients, dexamethasone use correlated with relief of patient symptoms, significantly decreased CK value, and our ability to discharge these patients home quickly. Our cases, discussion, and literature review all lead to the consideration of the use of dexamethasone in conjunction with standard therapy for acute rhabdomyolysis.
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Affiliation(s)
- Maxwell L Summerlin
- Genetics and Metabolism, Rare Disease Institute, Children's National Hospital, Washington, District of Columbia, USA
| | - Debra S Regier
- Genetics and Metabolism, Rare Disease Institute, Children's National Hospital, Washington, District of Columbia, USA
| | - Jamie L Fraser
- Genetics and Metabolism, Rare Disease Institute, Children's National Hospital, Washington, District of Columbia, USA
| | - Kimberly A Chapman
- Genetics and Metabolism, Rare Disease Institute, Children's National Hospital, Washington, District of Columbia, USA
| | - Dariush Kafashzadeh
- Genetics and Metabolism, Rare Disease Institute, Children's National Hospital, Washington, District of Columbia, USA
| | - Charles Billington
- Genetics and Metabolism, Rare Disease Institute, Children's National Hospital, Washington, District of Columbia, USA
| | - Monisha Kisling
- Genetics and Metabolism, Rare Disease Institute, Children's National Hospital, Washington, District of Columbia, USA
| | - Angela Grochowsky
- Genetics and Metabolism, Rare Disease Institute, Children's National Hospital, Washington, District of Columbia, USA
| | - Nicholas Ah Mew
- Genetics and Metabolism, Rare Disease Institute, Children's National Hospital, Washington, District of Columbia, USA
| | - Natasha Shur
- Genetics and Metabolism, Rare Disease Institute, Children's National Hospital, Washington, District of Columbia, USA
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15
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Klöckner C, Sticht H, Zacher P, Popp B, Babcock HE, Bakker DP, Barwick K, Bonfert MV, Bönnemann CG, Brilstra EH, Chung WK, Clarke AJ, Devine P, Donkervoort S, Fraser JL, Friedman J, Gates A, Ghoumid J, Hobson E, Horvath G, Keller-Ramey J, Keren B, Kurian MA, Lee V, Leppig KA, Lundgren J, McDonald MT, McLaughlin HM, McTague A, Mefford HC, Mignot C, Mikati MA, Nava C, Raymond FL, Sampson JR, Sanchis-Juan A, Shashi V, Shieh JTC, Shinawi M, Slavotinek A, Stödberg T, Stong N, Sullivan JA, Taylor AC, Toler TL, van den Boogaard MJ, van der Crabben SN, van Gassen KLI, van Jaarsveld RH, Van Ziffle J, Wadley AF, Wagner M, Wigby K, Wortmann SB, Zarate YA, Møller RS, Lemke JR, Platzer K. De novo variants in SNAP25 cause an early-onset developmental and epileptic encephalopathy. Genet Med 2020; 23:653-660. [PMID: 33299146 DOI: 10.1038/s41436-020-01020-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 10/12/2020] [Accepted: 10/13/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE This study aims to provide a comprehensive description of the phenotypic and genotypic spectrum of SNAP25 developmental and epileptic encephalopathy (SNAP25-DEE) by reviewing newly identified and previously reported individuals. METHODS Individuals harboring heterozygous missense or loss-of-function variants in SNAP25 were assembled through collaboration with international colleagues, matchmaking platforms, and literature review. For each individual, detailed phenotyping, classification, and structural modeling of the identified variant were performed. RESULTS The cohort comprises 23 individuals with pathogenic or likely pathogenic de novo variants in SNAP25. Intellectual disability and early-onset epilepsy were identified as the core symptoms of SNAP25-DEE, with recurrent findings of movement disorders, cerebral visual impairment, and brain atrophy. Structural modeling for all variants predicted possible functional defects concerning SNAP25 or impaired interaction with other components of the SNARE complex. CONCLUSION We provide a comprehensive description of SNAP25-DEE with intellectual disability and early-onset epilepsy mostly occurring before the age of two years. These core symptoms and additional recurrent phenotypes show an overlap to genes encoding other components or associated proteins of the SNARE complex such as STX1B, STXBP1, or VAMP2. Thus, these findings advance the concept of a group of neurodevelopmental disorders that may be termed "SNAREopathies."
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Affiliation(s)
- Chiara Klöckner
- Institute of Human Genetics, University of Leipzig Medical Center, Leipzig, Germany
| | - Heinrich Sticht
- Institute of Biochemistry, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Pia Zacher
- The Saxon Epilepsy Center Kleinwachau, Radeberg, Germany
| | - Bernt Popp
- Institute of Human Genetics, University of Leipzig Medical Center, Leipzig, Germany
| | - Holly E Babcock
- Rare Disease Institute, Children's National Hospital, Washington, DC, USA
| | - Dewi P Bakker
- Department of Child Neurology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Katy Barwick
- Institute of Child Health, University Collge London, London, UK
| | - Michaela V Bonfert
- Department of Pediatric Neurology and Developmental Medicine and LMU Center for Children with Medical Complexity, Dr. von Hauner Children's Hospital, LMU - University Hospital, Ludwig-Maximilians-Universität, Munich, Germany
| | - Carsten G Bönnemann
- Neuromuscular and Neurogenetic Disorders of Childhood Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Eva H Brilstra
- Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Wendy K Chung
- Departments of Pediatrics and Medicine, Columbia University Medical Center, New York, NY, USA
| | - Angus J Clarke
- Division of Cancer & Genetics, School of Medicine, Cardiff University, Wales, UK
| | - Patrick Devine
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - Sandra Donkervoort
- Neuromuscular and Neurogenetic Disorders of Childhood Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Jamie L Fraser
- Rare Disease Institute, Division of Genetics and Metabolism, Children's National Hospital, Washington, DC, USA
| | - Jennifer Friedman
- Departments of Neurosciences and Pediatrics, University of California San Diego and Division of Neurology, Rady Children's Hospital, San Diego, CA, USA.,Rady Children's Institute for Genomic Medicine, San Diego, CA, USA
| | - Alyssa Gates
- Department of Genetic Services, Kaiser Permanente Washington, Seattle, WA, USA
| | - Jamal Ghoumid
- Service de Génétique Clinique, Hôpital Jeanne de Flandre, CHU Lille, Lille, France
| | - Emma Hobson
- Yorkshire Clinical Genetics Service, Chapel Allerton Hospital, Leeds, UK
| | - Gabriella Horvath
- Department of Pediatrics, Division of Biochemical Diseases, University of British Columbia, Vancouver, Canada
| | | | - Boris Keren
- APHP, Département de Génétique, Groupe Hospitalier Pitié Salpêtrière, Paris, France
| | - Manju A Kurian
- Institute of Child Health, University Collge London, London, UK
| | - Virgina Lee
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Kathleen A Leppig
- Department of Genetic Services, Kaiser Permanente Washington, Seattle, WA, USA
| | - Johan Lundgren
- Institute of Clinical Sciences, Skane University Hospital, Lund, Sweden
| | - Marie T McDonald
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | | | - Amy McTague
- Institute of Child Health, University Collge London, London, UK
| | - Heather C Mefford
- Division of Genetic Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Cyril Mignot
- Département de Génétique, Centre de Référence Déficiences Intellectuelles de Causes Rares, Groupe Hospitalier Pitié Salpêtrière et Hôpital Trousseau, APHP, Sorbonne Université, Paris, France
| | - Mohamad A Mikati
- Division of Pediatric Neurology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Caroline Nava
- Sorbonne University, Paris Brain Institute, Inserm U1127, CNRS UMR 7225, AP-HP, Pitié Salpêtrière Hospital, Department of Genetics, Paris, France
| | - F Lucy Raymond
- NIHR BioResource, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, UK.,Department of Medical Genetics, Cambridge Institute for Medical Research, University of Cambridge, Cambridge, UK
| | - Julian R Sampson
- Division of Cancer & Genetics, School of Medicine, Cardiff University, Wales, UK
| | - Alba Sanchis-Juan
- NIHR BioResource, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, UK.,Department of Haematology, University of Cambridge, NHS Blood and Transplant Centre, Cambridge, UK
| | - Vandana Shashi
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Joseph T C Shieh
- Division of Medical Genetics, University of California, San Francisco, San Francisco, CA, USA.,Institute for Human Genetics, University of California, San Francisco, San Francisco, CA, USA
| | - Marwan Shinawi
- Department of Pediatrics, Division of Genetics and Genomic Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Anne Slavotinek
- Division of Medical Genetics, University of California, San Francisco, San Francisco, CA, USA
| | - Tommy Stödberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Nicholas Stong
- Institute for Genomic Medicine, Columbia University, New York, NY, USA
| | - Jennifer A Sullivan
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Ashley C Taylor
- Section of Genetics, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Tomi L Toler
- Department of Pediatrics, Division of Genetics and Genomic Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Saskia N van der Crabben
- Department of Clinical Genetics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Koen L I van Gassen
- Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Jessica Van Ziffle
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | | | - Matias Wagner
- Institute of Neurogenomics, Helmholtz Zentrum Munich, Neuherberg, Germany
| | - Kristen Wigby
- Department of Pediatrics, Division of Genetics, University of California, San Diego and Rady Children's Hospital-San Diego, San Diego, CA, USA
| | - Saskia B Wortmann
- Amalia Children's Hospital, Radboud University Nijmegen, Nijmegen, The Netherlands.,University Childrens Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Yuri A Zarate
- Section of Genetics and Metabolism, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Rikke S Møller
- Institute for Regional Health Services, University of Southern Denmark, Odense, Denmark.,Department of Epilepsy Genetics and Personalized Medicine, Danish Epilepsy Centre Filadelfia, Dianalund, Denmark
| | - Johannes R Lemke
- Institute of Human Genetics, University of Leipzig Medical Center, Leipzig, Germany
| | - Konrad Platzer
- Institute of Human Genetics, University of Leipzig Medical Center, Leipzig, Germany.
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16
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Shur N, Atabaki SM, Kisling MS, Tabarani A, Williams C, Fraser JL, S Regier D, Summar M. Rapid deployment of a telemedicine care model for genetics and metabolism during COVID-19. Am J Med Genet A 2020; 185:68-72. [PMID: 33051968 PMCID: PMC7675281 DOI: 10.1002/ajmg.a.61911] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/15/2020] [Accepted: 09/24/2020] [Indexed: 11/21/2022]
Abstract
The national importance of telemedicine for safe and effective patient care has been highlighted by the current COVID‐19 pandemic. Prior to the 2020 pandemic the Division of Genetics and Metabolism piloted a telemedicine program focused on initial and follow‐up visits in the patients' home. The goals were to increase access to care, decrease missed work, improve scheduling, and avoid the transport and exposure of medically fragile patients. Visits were conducted by physician medical geneticists, genetic counselors, and biochemical dietitians, together and separately. This allowed the program to develop detailed standard operating procedures. At the onset of the COVID‐19 pandemic, this pilot‐program was deployed by the full team of 22 providers in one business day. Two physicians remained on‐site for patients requiring in‐person evaluations. This model optimized patient safety and workforce preservation while providing full access to patients during a pandemic. We provide initial data on visit numbers, types of diagnoses, and no‐show rates. Experience in this implementation before and during the pandemic has confirmed the effectiveness and value of telemedicine for a highly complex medical population. This program is a model that can and will be continued well‐beyond the current crisis.
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Affiliation(s)
- Natasha Shur
- Children's National Hospital, Washington, District of Columbia, USA
| | | | | | - Abir Tabarani
- Children's National Hospital, Washington, District of Columbia, USA
| | | | - Jamie L Fraser
- Children's National Hospital, Washington, District of Columbia, USA
| | - Debra S Regier
- Children's National Hospital, Washington, District of Columbia, USA
| | - Marshall Summar
- Children's National Hospital, Washington, District of Columbia, USA
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17
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Guillen Sacoto MJ, Tchasovnikarova IA, Torti E, Forster C, Andrew EH, Anselm I, Baranano KW, Briere LC, Cohen JS, Craigen WJ, Cytrynbaum C, Ekhilevitch N, Elrick MJ, Fatemi A, Fraser JL, Gallagher RC, Guerin A, Haynes D, High FA, Inglese CN, Kiss C, Koenig MK, Krier J, Lindstrom K, Marble M, Meddaugh H, Moran ES, Morel CF, Mu W, Muller EA, Nance J, Natowicz MR, Numis AL, Ostrem B, Pappas J, Stafstrom CE, Streff H, Sweetser DA, Szybowska M, Walker MA, Wang W, Weiss K, Weksberg R, Wheeler PG, Yoon G, Kingston RE, Juusola J, Juusola J. De Novo Variants in the ATPase Module of MORC2 Cause a Neurodevelopmental Disorder with Growth Retardation and Variable Craniofacial Dysmorphism. Am J Hum Genet 2020; 107:352-363. [PMID: 32693025 DOI: 10.1016/j.ajhg.2020.06.013] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 06/17/2020] [Indexed: 12/13/2022] Open
Abstract
MORC2 encodes an ATPase that plays a role in chromatin remodeling, DNA repair, and transcriptional regulation. Heterozygous variants in MORC2 have been reported in individuals with autosomal-dominant Charcot-Marie-Tooth disease type 2Z and spinal muscular atrophy, and the onset of symptoms ranges from infancy to the second decade of life. Here, we present a cohort of 20 individuals referred for exome sequencing who harbor pathogenic variants in the ATPase module of MORC2. Individuals presented with a similar phenotype consisting of developmental delay, intellectual disability, growth retardation, microcephaly, and variable craniofacial dysmorphism. Weakness, hyporeflexia, and electrophysiologic abnormalities suggestive of neuropathy were frequently observed but were not the predominant feature. Five of 18 individuals for whom brain imaging was available had lesions reminiscent of those observed in Leigh syndrome, and five of six individuals who had dilated eye exams had retinal pigmentary abnormalities. Functional assays revealed that these MORC2 variants result in hyperactivation of epigenetic silencing by the HUSH complex, supporting their pathogenicity. The described set of morphological, growth, developmental, and neurological findings and medical concerns expands the spectrum of genetic disorders resulting from pathogenic variants in MORC2.
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18
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Vanderver A, Bernard G, Helman G, Sherbini O, Boeck R, Cohn J, Collins A, Demarest S, Dobbins K, Emrick L, Fraser JL, Masser-Frye D, Hayward J, Karmarkar S, Keller S, Mirrop S, Mitchell W, Pathak S, Sherr E, van Haren K, Waters E, Wilson JL, Zhorne L, Schiffmann R, van der Knaap MS, Pizzino A, Dubbs H, Shults J, Simons C, Taft RJ. Randomized Clinical Trial of First-Line Genome Sequencing in Pediatric White Matter Disorders. Ann Neurol 2020; 88:264-273. [PMID: 32342562 DOI: 10.1002/ana.25757] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 04/19/2020] [Accepted: 04/20/2020] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Genome sequencing (GS) is promising for unsolved leukodystrophies, but its efficacy has not been prospectively studied. METHODS A prospective time-delayed crossover design trial of GS to assess the efficacy of GS as a first-line diagnostic tool for genetic white matter disorders took place between December 1, 2015 and September 27, 2017. Patients were randomized to receive GS immediately with concurrent standard of care (SoC) testing, or to receive SoC testing for 4 months followed by GS. RESULTS Thirty-four individuals were assessed at interim review. The genetic origin of 2 patient's leukoencephalopathy was resolved before randomization. Nine patients were stratified to the immediate intervention group and 23 patients to the delayed-GS arm. The efficacy of GS was significant relative to SoC in the immediate (5/9 [56%] vs 0/9 [0%]; Wild-Seber, p < 0.005) and delayed (control) arms (14/23 [61%] vs 5/23 [22%]; Wild-Seber, p < 0.005). The time to diagnosis was significantly shorter in the immediate-GS group (log-rank test, p = 0.04). The overall diagnostic efficacy of combined GS and SoC approaches was 26 of 34 (76.5%, 95% confidence interval = 58.8-89.3%) in <4 months, greater than historical norms of <50% over 5 years. Owing to loss of clinical equipoise, the trial design was altered to a single-arm observational study. INTERPRETATION In this study, first-line GS provided earlier and greater diagnostic efficacy in white matter disorders. We provide an evidence-based diagnostic testing algorithm to enable appropriate clinical GS utilization in this population. ANN NEUROL 2020;88:264-273.
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Affiliation(s)
- Adeline Vanderver
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Geneviève Bernard
- Departments of Neurology and Neurosurgery, Pediatrics, and Human Genetics, McGill University, Montreal, Quebec, Canada.,Department of Specialized Medicine, Division of Medical Genetics, Montreal Children's Hospital and McGill University Health Centre, Montreal, Quebec, Canada.,Child Health and Human Development Program, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Guy Helman
- Institute for Molecular Bioscience, University of Queensland, Brisbane, Queensland, Australia.,Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Omar Sherbini
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ryan Boeck
- Child Neurology Consultants of Austin, Austin, Texas, USA.,University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Jeffrey Cohn
- Family Medicine, Broadlands Family Practice at Ashburn, Ashburn, Virginia, USA
| | - Abigail Collins
- Department of Neurology, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Scott Demarest
- Department of Neurology, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Katherine Dobbins
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Lisa Emrick
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
| | - Jamie L Fraser
- Division of Genetics and Metabolism, Rare Disease Institute, Children's National Hospital, Washington, District of Columbia, USA.,George Washington University, Washington, District of Columbia, USA
| | | | - Jean Hayward
- Department of Pediatrics, Kaiser Oakland, Oakland, California, USA
| | - Swati Karmarkar
- Department of Neurology, Le Bonheur Children's Hospital, Memphis, Tennessee, USA.,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Stephanie Keller
- Division of Neurology, Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | | | - Wendy Mitchell
- Division of Neurology, Children's Hospital of Los Angeles, Los Angeles, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Sheel Pathak
- Clinical Neurology, Washington University Clinical Associates, St Louis, Missouri, USA.,Department of Neurology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Elliott Sherr
- Department of Neurology, University of California, San Francisco School of Medicine, San Francisco, California, USA
| | - Keith van Haren
- Department of Neurology, Stanford University Medical Center, Stanford, California, USA
| | - Erica Waters
- Pediatric Associates of Stockton, Stockton, California, USA
| | - Jenny L Wilson
- Division of Pediatric Neurology, Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | - Leah Zhorne
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa Health Care, Iowa City, Iowa, USA
| | - Raphael Schiffmann
- Institute of Metabolic Disease, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Marjo S van der Knaap
- Department of Child Neurology, VU University Medical Center, Amsterdam, the Netherlands.,Department of Functional Genomics, Amsterdam Neuroscience, VU University, Amsterdam, the Netherlands
| | - Amy Pizzino
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Holly Dubbs
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Justine Shults
- Department of Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cas Simons
- Institute for Molecular Bioscience, University of Queensland, Brisbane, Queensland, Australia.,Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia
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19
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Lowe DW, Fraser JL, Rollins LG, Bentzley J, Nie X, Martin R, Singh I, Jenkins D. Vitamin D improves functional outcomes in neonatal hypoxic ischemic male rats treated with N-acetylcysteine and hypothermia. Neuropharmacology 2017; 123:186-200. [PMID: 28599922 DOI: 10.1016/j.neuropharm.2017.06.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 04/21/2017] [Accepted: 06/05/2017] [Indexed: 12/29/2022]
Abstract
Hypothermia treatment neuroprotects approximately 50% of neonates who present with moderate to severe hypoxic ischemic encephalopathy (HIE). N-acetylcysteine (NAC), a potent antioxidant, is neuroprotective in combination with hypothermia in neonatal hypoxia-ischemia (HI) female rats, but less protective in males. Vitamin D is a neurosteroid, which may provide immunomodulation and improve outcomes for both sexes. We investigated the efficacy of this combination of drugs with hypothermia after severe HI, as well as potential mechanisms of vitamin D effects in the transition to chronic inflammation. DOL 7 rats were randomized to sham, or HI and hypothermia treated with either saline (HYPO), NAC (50 mg/kg/d, HNAC), or HNAC plus 1,25-dihydroxy-vitamin D3 (0.1 μg/kg/d, HNAC + VitD) daily for 2 weeks. A second set of animals were randomized and treated for 11 days to investigate vitamin D metabolism and inflammatory mediators. Rats treated with HNAC + VitD performed significantly better on tests of strength and use of affected limb, adaptive sensorimotor skills, motor sequence learning, and working memory than either HYPO or HNAC, particularly benefiting male rats. Significantly fewer rats in the HNAC + VitD group had severe hemispheric volume loss. HI injury decreased serum vitamin D at 11 days and induced the enzyme that deactivates vitamin D in the hippocampus, particularly in males. Persistent vitamin D dysregulation was seen in both hippocampi in males, which was not reversed by hypothermia. Vitamin D in combination with hypothermia and NAC supports functional recovery in both sexes of neonatal rats significantly better than hypothermia alone or hypothermia and NAC in this severe HI model.
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Affiliation(s)
- Danielle W Lowe
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States.
| | - Jamie L Fraser
- Division of Genetics and Metabolism, Children's National Medical Center, Washington, DC, United States.
| | - Laura Grace Rollins
- Department of Psychology, University of Massachusetts, Boston, MA, United States.
| | - Jessica Bentzley
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States.
| | - Xingju Nie
- Department of Radiology, Medical University of South Carolina, Charleston, SC, United States.
| | - Renee Martin
- Department of Public Health, Medical University of South Carolina, Charleston, SC, United States.
| | - Inderjit Singh
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States.
| | - Dorothea Jenkins
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States.
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20
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Nie X, Lowe DW, Rollins LG, Bentzley J, Fraser JL, Martin R, Singh I, Jenkins D. Sex-specific effects of N-acetylcysteine in neonatal rats treated with hypothermia after severe hypoxia-ischemia. Neurosci Res 2016; 108:24-33. [PMID: 26851769 DOI: 10.1016/j.neures.2016.01.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 12/16/2015] [Accepted: 01/24/2016] [Indexed: 12/29/2022]
Abstract
Approximately half of moderate to severely hypoxic-ischemic (HI) newborns do not respond to hypothermia, the only proven neuroprotective treatment. N-acetylcysteine (NAC), an antioxidant and glutathione precursor, shows promise for neuroprotection in combination with hypothermia, mitigating post-HI neuroinflammation due to oxidative stress. As mechanisms of HI injury and cell death differ in males and females, sex differences must be considered in translational research of neuroprotection. We assessed the potential toxicity and efficacy of NAC in combination with hypothermia, in male and female neonatal rats after severe HI injury. NAC 50mg/kg/d administered 1h after initiation of hypothermia significantly decreased iNOS expression and caspase 3 activation in the injured hemisphere versus hypothermia alone. However, only females treated with hypothermia +NAC 50mg/kg showed improvement in short-term infarct volumes compared with saline treated animals. Hypothermia alone had no effect in this severe model. When NAC was continued for 6 weeks, significant improvement in long-term neuromotor outcomes over hypothermia treatment alone was observed, controlling for sex. Antioxidants may provide insufficient neuroprotection after HI for neonatal males in the short term, while long-term therapy may benefit both sexes.
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Affiliation(s)
- Xingju Nie
- Center for Biomedical Imaging, Medical University of South Carolina, 165 Ashley Ave, Charleston, SC 29425, United States.
| | - Danielle W Lowe
- Department of Pediatrics, Medical University of South Carolina, 165 Ashley Ave, Charleston, SC 29425, United States.
| | - Laura Grace Rollins
- Department of Psychology, University of Massachusetts, 100 Morrissey Blvd, Boston, MA 02125, United States.
| | - Jessica Bentzley
- Department of Pediatrics, Medical University of South Carolina, 165 Ashley Ave, Charleston, SC 29425, United States.
| | - Jamie L Fraser
- Medical Genetics Training Program, National Human Genome Research Institute, National Institutes of Health, 9000 Rockville Pike, Bethesda, MD 20892-2152, United States.
| | - Renee Martin
- Department of Biostatistics and Epidemiology, Medical University of South Carolina, 165 Ashley Ave, Charleston, SC 29425, United States.
| | - Inderjit Singh
- Department of Pediatrics, Medical University of South Carolina, 165 Ashley Ave, Charleston, SC 29425, United States.
| | - Dorothea Jenkins
- Department of Pediatrics, Medical University of South Carolina, 165 Ashley Ave, Charleston, SC 29425, United States.
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21
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Keppler-Noreuil KM, Sapp JC, Lindhurst MJ, Parker VER, Blumhorst C, Darling T, Tosi LL, Huson SM, Whitehouse RW, Jakkula E, Grant I, Balasubramanian M, Chandler KE, Fraser JL, Gucev Z, Crow YJ, Brennan LM, Clark R, Sellars EA, Pena LDM, Krishnamurty V, Shuen A, Braverman N, Cunningham ML, Sutton VR, Tasic V, Graham JM, Geer J, Henderson A, Semple RK, Biesecker LG. Clinical delineation and natural history of the PIK3CA-related overgrowth spectrum. Am J Med Genet A 2014; 164A:1713-33. [PMID: 24782230 PMCID: PMC4320693 DOI: 10.1002/ajmg.a.36552] [Citation(s) in RCA: 198] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 03/01/2014] [Indexed: 02/02/2023]
Abstract
Somatic mutations in the phosphatidylinositol/AKT/mTOR pathway cause segmental overgrowth disorders. Diagnostic descriptors associated with PIK3CA mutations include fibroadipose overgrowth (FAO), Hemihyperplasia multiple Lipomatosis (HHML), Congenital Lipomatous Overgrowth, Vascular malformations, Epidermal nevi, Scoliosis/skeletal and spinal (CLOVES) syndrome, macrodactyly, and the megalencephaly syndrome, Megalencephaly-Capillary malformation (MCAP) syndrome. We set out to refine the understanding of the clinical spectrum and natural history of these phenotypes, and now describe 35 patients with segmental overgrowth and somatic PIK3CA mutations. The phenotypic data show that these previously described disease entities have considerable overlap, and represent a spectrum. While this spectrum overlaps with Proteus syndrome (sporadic, mosaic, and progressive) it can be distinguished by the absence of cerebriform connective tissue nevi and a distinct natural history. Vascular malformations were found in 15/35 (43%) and epidermal nevi in 4/35 (11%) patients, lower than in Proteus syndrome. Unlike Proteus syndrome, 31/35 (89%) patients with PIK3CA mutations had congenital overgrowth, and in 35/35 patients this was asymmetric and disproportionate. Overgrowth was mild with little postnatal progression in most, while in others it was severe and progressive requiring multiple surgeries. Novel findings include: adipose dysregulation present in all patients, unilateral overgrowth that is predominantly left-sided, overgrowth that affects the lower extremities more than the upper extremities and progresses in a distal to proximal pattern, and in the most severely affected patients is associated with marked paucity of adipose tissue in unaffected areas. While the current data are consistent with some genotype-phenotype correlation, this cannot yet be confirmed.
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Affiliation(s)
- Kim M Keppler-Noreuil
- National Human Genome Research Institute, National Institutes of HealthBethesda, Maryland,*Correspondence to:, Kim M. Keppler-Noreuil, M.D., National Human Genome Research Institute/NIH, 49 Convent Drive 4A83, Bethesda, MD 20892., E-mail:
| | - Julie C Sapp
- National Human Genome Research Institute, National Institutes of HealthBethesda, Maryland
| | - Marjorie J Lindhurst
- National Human Genome Research Institute, National Institutes of HealthBethesda, Maryland
| | - Victoria ER Parker
- The University of Cambridge Metabolic Research Laboratories, Institute of Metabolic ScienceCambridge, UK
| | - Cathy Blumhorst
- National Human Genome Research Institute, National Institutes of HealthBethesda, Maryland
| | - Thomas Darling
- Department of Dermatology, Uniformed Services University of the Health SciencesBethesda, Maryland
| | - Laura L Tosi
- Division of Orthopaedic Surgery and Sports Medicine, Children's National Medical CenterWashington, District of Columbia
| | - Susan M Huson
- Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC)Manchester, UK
| | - Richard W Whitehouse
- Department of Radiology, Central Manchester University Hospitals NHS Foundation Trust Manchester Royal Infirmary Oxford Road ManchesterManchester, UK
| | - Eveliina Jakkula
- Department of Clinical Genetics, Helsinki University Central HospitalHelsinki, Finland
| | - Ian Grant
- Department of Plastic Surgery, Cambridge University Hospitals NHS TrustCambridge, UK
| | - Meena Balasubramanian
- Sheffield Clinical Genetics Service, Sheffield Children's NHS Foundation TrustSheffield, UK
| | - Kate E Chandler
- Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC)Manchester, UK
| | - Jamie L Fraser
- National Human Genome Research Institute, National Institutes of HealthBethesda, Maryland
| | - Zoran Gucev
- Department of Endocrinology and Genetics, Medical Faculty SkopjeSkopje, Macedonia
| | - Yanick J Crow
- Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC)Manchester, UK
| | - Leslie Manace Brennan
- Medical Genetics, Kaiser Permanente Oakland, University of CaliforniaSan Francisco, California
| | - Robin Clark
- Division of Medical Genetics, Department of Pediatrics, Loma Linda University Medical CenterLoma Linda, California
| | - Elizabeth A Sellars
- Section of Genetics and Metabolism, Arkansas Children's HospitalLittle Rock, Arkansas
| | - Loren DM Pena
- Division of Genetics, Department of Pediatrics, Duke University Medical CenterDurham, North Carolina
| | | | - Andrew Shuen
- Department of Medical Genetics, McGill University Health CentreMontreal, Quebec, Canada
| | - Nancy Braverman
- Department of Human Genetics and Pediatrics, McGill University, Montreal Children's Hospital Research InstituteMontreal, Canada
| | - Michael L Cunningham
- Division of Craniofacial Medicine, University of Washington School of MedicineSeattle, Washington
| | - V Reid Sutton
- Department of Molecular and Human Genetics, Baylor College of MedicineHouston, Texas
| | - Velibor Tasic
- University Children's Hospital, Medical SchoolSkopje, Macedonia
| | - John M Graham
- Clinical Genetics and Dysmorphology, Department of Pediatrics, Harbor-UCLA Medical CenterLos Angeles, California
| | - Joseph Geer
- Greenwood Genetics CenterGreenwood, South Carolina
| | - Alex Henderson
- Northern Genetics Service, Newcastle Upon Tyne HospitalsNewcastle Upon Tyne, UK
| | - Robert K Semple
- The University of Cambridge Metabolic Research Laboratories, Institute of Metabolic ScienceCambridge, UK
| | - Leslie G Biesecker
- National Human Genome Research Institute, National Institutes of HealthBethesda, Maryland
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22
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Fraser JL, Vanderver A, Yang S, Chang T, Cramp L, Vezina G, Lichter-Konecki U, Cusmano-Ozog KP, Smpokou P, Chapman KA, Zand DJ. Thiamine pyrophosphokinase deficiency causes a Leigh Disease like phenotype in a sibling pair: identification through whole exome sequencing and management strategies. Mol Genet Metab Rep 2014; 1:66-70. [PMID: 27896076 PMCID: PMC5121315 DOI: 10.1016/j.ymgmr.2013.12.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Accepted: 12/26/2013] [Indexed: 11/29/2022] Open
Abstract
We present a sibling pair with Leigh-like disease, progressive hypotonia, regression, and chronic encephalopathy. Whole exome sequencing in the younger sibling demonstrated a homozygous thiamine pyrophosphokinase (TPK) mutation. Initiation of high dose thiamine, niacin, biotin, α-lipoic acid and ketogenic diet in this child demonstrated improvement in neurologic function and re-attainment of previously lost milestones. The diagnosis of TPK deficiency was difficult due to inconsistent biochemical and diagnostic parameters, rapidity of clinical demise and would not have been made in a timely manner without the use of whole exome sequencing. Molecular diagnosis allowed for attempt at dietary modification with cofactor supplementation which resulted in an improved clinical course.
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Affiliation(s)
- Jamie L Fraser
- Pediatrics Residency Program, Children's National Medical Center, Washington, DC, USA; Medical Genetics Training Program, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Adeline Vanderver
- Division of Neurology, Children's National Medical Center, Washington, DC, USA
| | - Sandra Yang
- Division of Genetics and Metabolism, Children's National Medical Center, Washington, DC, USA
| | - Taeun Chang
- Division of Neurology, Children's National Medical Center, Washington, DC, USA
| | - Laura Cramp
- Division of Neurology, Children's National Medical Center, Washington, DC, USA
| | - Gilbert Vezina
- Department of Radiology, Children's National Medical Center, Washington, DC, USA
| | - Uta Lichter-Konecki
- Division of Genetics and Metabolism, Children's National Medical Center, Washington, DC, USA
| | - Kristina P Cusmano-Ozog
- Division of Genetics and Metabolism, Children's National Medical Center, Washington, DC, USA
| | - Patroula Smpokou
- Division of Genetics and Metabolism, Children's National Medical Center, Washington, DC, USA
| | - Kimberly A Chapman
- Division of Genetics and Metabolism, Children's National Medical Center, Washington, DC, USA
| | - Dina J Zand
- Division of Genetics and Metabolism, Children's National Medical Center, Washington, DC, USA
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23
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Wei L, Fraser JL, Lu ZY, Hu X, Yu SP. Transplantation of hypoxia preconditioned bone marrow mesenchymal stem cells enhances angiogenesis and neurogenesis after cerebral ischemia in rats. Neurobiol Dis 2012; 46:635-45. [PMID: 22426403 DOI: 10.1016/j.nbd.2012.03.002] [Citation(s) in RCA: 261] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Revised: 02/16/2012] [Accepted: 03/01/2012] [Indexed: 12/16/2022] Open
Abstract
Hypoxic preconditioning of stem cells and neural progenitor cells has been tested for promoting cell survival after transplantation. The present investigation examined the hypothesis that hypoxic preconditioning of bone marrow mesenchymal stem cells (BMSCs) could not only enhance their survival but also reinforce regenerative properties of these cells. BMSCs from eGFP engineered rats or pre-labeled with BrdU were pre-treated with normoxia (20% O(2), N-BMSCs) or sub-lethal hypoxia (0.5% O(2). H-BMSCs). The hypoxia exposure up-regulated HIF-1α and trophic/growth factors in BMSCs, including brain-derived neurotrophic factor (BDNF), glial cell-derived neurotrophic factor (GDNF), vascular endothelial growth factor (VEGF) and its receptor FIK-1, erythropoietin (EPO) and its receptor EPOR, stromal derived factor-1 (SDF-1) and its CXC chemokine receptor 4 (CXCR4). Meanwhile, many pro-inflammatory cytokines/chemokines were down-regulated in H-BMSCs. N-BMSCs or H-BMSCs were intravenously injected into adult rats 24h after 90-min middle cerebral artery occlusion. Comparing to N-BMSCs, transplantation of H-BMSCs showed greater effect of suppressing microglia activity in the brain. Significantly more NeuN-positive and Glut1-positive cells were seen in the ischemic core and peri-infarct regions of the animals received H-BMSC transplantation than that received N-BMSCs. Some NeuN-positive and Glut-1-positive cells showed eGFP or BrdU immunoflourescent reactivity, suggesting differentiation from exogenous BMSCs into neuronal and vascular endothelial cells. In Rotarod test performed 15days after stroke, animals received H-BMSCs showed better locomotion recovery compared with stroke control and N-BMSC groups. We suggest that hypoxic preconditioning of transplanted cells is an effective means of promoting their regenerative capability and therapeutic potential for the treatment of ischemic stroke.
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Affiliation(s)
- Ling Wei
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
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Hu X, Yu SP, Fraser JL, Lu Z, Ogle ME, Wang JA, Wei L. Transplantation of hypoxia-preconditioned mesenchymal stem cells improves infarcted heart function via enhanced survival of implanted cells and angiogenesis. J Thorac Cardiovasc Surg 2008; 135:799-808. [PMID: 18374759 DOI: 10.1016/j.jtcvs.2007.07.071] [Citation(s) in RCA: 443] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2007] [Revised: 07/03/2007] [Accepted: 07/09/2007] [Indexed: 02/09/2023]
Abstract
OBJECTIVES This study explored the novel strategy of hypoxic preconditioning of bone marrow mesenchymal stem cells before transplantation into the infarcted heart to promote their survival and therapeutic potential of mesenchymal stem cell transplantation after myocardial ischemia. METHODS Mesenchymal stem cells from green fluorescent protein transgenic mice were cultured under normoxic or hypoxic (0.5% oxygen for 24 hours) conditions. Expression of growth factors and anti-apoptotic genes were examined by immunoblot. Normoxic or hypoxic stem cells were intramyocardially injected into the peri-infarct region of rats 30 minutes after permanent myocardial infarction. Death of mesenchymal stem cells was assessed in vitro and in vivo after transplantation. Angiogenesis, infarct size, and heart function were measured 6 weeks after transplantation. RESULTS Hypoxic preconditioning increased expression of pro-survival and pro-angiogenic factors including hypoxia-inducible factor 1, angiopoietin-1, vascular endothelial growth factor and its receptor, Flk-1, erythropoietin, Bcl-2, and Bcl-xL. Cell death of hypoxic stem cells and caspase-3 activation in these cells were significantly lower compared with that in normoxic stem cells both in vitro and in vivo. Transplantation of hypoxic versus normoxic mesenchymal stem cells after myocardial infarction resulted in an increase in angiogenesis, as well as enhanced morphologic and functional benefits of stem cell therapy. CONCLUSIONS Hypoxic preconditioning enhances the capacity of mesenchymal stem cells to repair infarcted myocardium, attributable to reduced cell death and apoptosis of implanted cells, increased angiogenesis/vascularization, and paracrine effects.
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Affiliation(s)
- Xinyang Hu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University, College of Medicine, Hangzhou, China
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Cui L, Jiang J, Wei L, Zhou X, Fraser JL, Snider BJ, Yu SP. Transplantation of embryonic stem cells improves nerve repair and functional recovery after severe sciatic nerve axotomy in rats. Stem Cells 2008; 26:1356-65. [PMID: 18308951 DOI: 10.1634/stemcells.2007-0333] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Extensive research has focused on transplantation of pluripotent stem cells for the treatment of central nervous system disorders, the therapeutic potential of stem cell therapy for injured peripheral nerves is largely unknown. We used a rat sciatic nerve transection model to test the ability of implanted embryonic stem (ES) cell-derived neural progenitor cells (ES-NPCs) in promoting repair of a severely injured peripheral nerve. Mouse ES cells were neurally induced in vitro; enhanced expression and/or secretion of growth factors were detected in differentiating ES cells. One hour after removal of a 1-cm segment of the left sciatic nerve, ES-NPCs were implanted into the gap between the nerve stumps with the surrounding epineurium as a natural conduit. The transplantation resulted in substantial axonal regrowth and nerve repair, which were not seen in culture medium controls. One to 3 months after axotomy, co-immunostaining with the mouse neural cell membrane specific antibody M2/M6 and the Schwann cell marker S100 suggested that transplanted ES-NPCs had survived and differentiated into myelinating cells. Regenerated axons were myelinated and showed a uniform connection between proximal and distal stumps. Nerve stumps had near normal diameter with longitudinally oriented, densely packed Schwann cell-like phenotype. Fluoro-Gold retrogradely labeled neurons were found in the spinal cord (T12-13) and DRG (L4-L6), suggesting reconnection of axons across the transection. Electrophysiological recordings showed functional activity recovered across the injury gap. These data suggest that transplanted neurally induced ES cells differentiate into myelin-forming cells and provide a potential therapy for severely injured peripheral nerves.
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Affiliation(s)
- Lin Cui
- Department of Pathology, Medical University of South Carolina, Charleston, South Carolina 29425, USA
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Zhang Y, Fraser JL, Wang HH. Morphologic predictors of papillary carcinoma on fine-needle aspiration of thyroid with ThinPrep preparations. Diagn Cytopathol 2001; 24:378-83. [PMID: 11391817 DOI: 10.1002/dc.1084] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Although the cytologic features of papillary carcinoma of the thyroid are well-known, none is entirely specific. We conducted this study to determine the minimal criteria necessary to achieve 100% specificity for the diagnosis of papillary carcinoma on fine-needle aspiration (FNA). Forty patients with histologically confirmed papillary carcinoma and 17 patients with other thyroid lesions who underwent preoperative FNA at Beth Israel Deaconess Medical Center during a 4-yr period were included in the study. All cytology slides were prepared with the ThinPrep processing technique. Various architectural and nuclear features were evaluated, with a score assigned to each feature, and correlated with the histologic diagnosis of papillary carcinoma. Intranuclear inclusions, papillary and/or sheet arrangements, nuclear grooves, powdery chromatin, nuclear molding, high cellularity, and small nucleoli were significantly associated with papillary carcinoma (P < 0.05). The requirement of any intranuclear inclusions and many nuclear grooves, or a minimum of sum of scores (of the above eight features) of 10, yields 100% specificity and approximately 70% sensitivity. Cases with fewer features can be reported as suspicious or indeterminate for papillary carcinoma. A quantitative/probabilistic approach in the reporting of thyroid FNA provides a practical guide for management of patients with thyroid nodules.
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Affiliation(s)
- Y Zhang
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Affiliation(s)
- L Pantanowitz
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA
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Abstract
BACKGROUND The presence of tumor cells in peritoneal washing cytology specimens taken during surgery affects the staging of many gynecologic malignancies. Peritoneal washings are often collected routinely, even in cases of presumed benign disease. This study was designed to address whether evaluation of these specimens is justified. METHODS We reviewed diagnostic reports from all peritoneal washings and the corresponding surgical pathology specimens from patients undergoing gynecologic surgery during a 1-year period in one institution and a 20-month period in the other. Cases were divided into benign and malignant categories based on the surgical pathology diagnosis. RESULTS Three hundred forty-six patients had peritoneal washings collected during the study period. The proportion of cases with malignancy was 30% in one institution and 49% in the other. Of these, 119 had an endometrial or ovarian malignancy, including 16 ovarian tumors of low malignant potential. Malignant cells were detected in 19 cases. In 10 of these 19, grossly apparent peritoneal tumor implants were present at the time of surgery. The remaining 227 were found to have benign disease, and the peritoneal washing cytology diagnosis was negative in all cases. Potential savings of $13,000 to $17,000 based on current insurance reimbursement could have been realized for these 227 patients without compromising patient care. CONCLUSIONS These data suggest that peritoneal washing cytology specimens collected at the time of gynecologic surgery for presumed benign disease can be held and processed later if an unsuspected malignancy is discovered. This practice can result in cost savings without compromising patient care. Cancer (Cancer Cytopathol)
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Affiliation(s)
- S Sharifi
- Department of Pathology, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts 02215, USA
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Abstract
UV damage endonuclease (Uve1p) from Schizosaccharomyces pombe was initially described as a DNA repair enzyme specific for the repair of UV light-induced photoproducts and proposed as the initial step in an alternative excision repair pathway. Here we present biochemical and genetic evidence demonstrating that Uve1p is also a mismatch repair endonuclease which recognizes and cleaves DNA 5' to the mispaired base in a strand-specific manner. The biochemical properties of the Uve1p-mediated mismatch endonuclease activity are similar to those of the Uve1p-mediated UV photoproduct endonuclease. Mutants lacking Uve1p display a spontaneous mutator phenotype, further confirming the notion that Uve1p plays a role in mismatch repair. These results suggest that Uve1p has a surprisingly broad substrate specificity and may function as a general type of DNA repair protein with the capacity to initiate mismatch repair in certain organisms.
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Affiliation(s)
- B Kaur
- Department of Biochemistry, Graduate Program in Biochemistry and Cell and Developmental Biology, Emory University, School of Medicine, Atlanta, Georgia 30322, USA
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Fraser JL, Raza S, Chorny K, Connolly JL, Schnitt SJ. Columnar alteration with prominent apical snouts and secretions: a spectrum of changes frequently present in breast biopsies performed for microcalcifications. Am J Surg Pathol 1998; 22:1521-7. [PMID: 9850178 DOI: 10.1097/00000478-199812000-00009] [Citation(s) in RCA: 177] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We have noted in breast biopsies performed for microcalcifications a spectrum of lesions in the terminal duct lobular unit (TDLU) characterized by columnar epithelial cells with prominent apical cytoplasmic snouts, intraluminal secretions, and varying degrees of nuclear atypia and architectural complexity. The appearance of some of these lesions is worrisome, but diagnostic difficulties arise because the histologic features do not fulfill established criteria for the diagnosis of atypical ductal hyperplasia or ductal carcinoma in situ (DCIS). We have termed such lesions columnar alteration with prominent apical snouts and secretions (CAPSS). The purpose of this study was to define the pathologic spectrum and mammographic features of these lesions. We reviewed histologic sections and mammograms from 100 consecutive breast biopsies performed for microcalcifications. The prevalence and histologic features of CAPSS and the association with other histologic findings were recorded. CAPSS was identified in 42% of cases. At the lower end of the spectrum were lesions similar to columnar alteration of lobules but in which apical cytoplasmic secretion and nuclear stratification were more pronounced and cells with a hobnail configuration were common. More advanced lesions showed columnar epithelial cell tufts, bridges, and micropapillations with prominent apical cytoplasmic snouts and with greater degrees of nuclear stratification and atypia. At the upper end of the spectrum were lesions that could arguably be considered DCIS. Calcifications were present within CAPSS in 74% of cases, were frequently psammomatous, and were typically nonbranching and often round on mammography. Columnar alteration of lobules was more common in biopsies with than without CAPSS (74 versus 36%, p < 0.001). Ductal carcinoma in situ was seen with similar frequency in biopsies with and without CAPSS (38 versus 41%). However, DCIS in cases with CAPSS was more often of the low-grade micropapillary-cribriform type than in cases without CAPSS (56 versus 17%, p < 0.01), and CAPSS and DCIS commonly coexisted in the same or adjacent TDLUs. In conclusion, 1) CAPSS encompasses a spectrum of lesions bounded at the lower end by columnar alteration of lobules and at the upper end by low-grade DCIS. Lesions recently described by Page as "hypersecretory hyperplasia with atypia" fall within this spectrum. 2) Some CAPSS lesions present architectural or cytologic features that create diagnostic difficulties and raise the possibility of atypical ductal hyperplasia or DCIS; however, the level of cancer risk associated with CAPSS lesions that do not fulfill established criteria for atypical ductal hyperplasia or DCIS is unknown and requires evaluation in follow-up studies.
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Affiliation(s)
- J L Fraser
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts 02215, USA
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Abstract
BACKGROUND The standards of the American Association of Blood Banks describe a minimum hemoglobin level of 12.5 g per dL for apheresis donors. Until 1995, the authors' institution accepted occasional platelet donors with a lower minimum hemoglobin (11.5 g/dL), if accompanied by medical director approval. STUDY DESIGN All donation records from a 6-month period before 1995 were retrospectively reviewed to determine whether this lower hemoglobin cutoff adversely affected either the safety of the platelet donation process or donors' subsequent hemoglobin levels. RESULTS Of 450 donations, 56 (12%, Group 1) were from donors with hemoglobin concentrations between 11.5 and 12.4 g per dL (2 donations from 1 man; 54 donations from 45 women). The remaining 394 donations (88%, Group 2) came from donors with hemoglobin concentrations > or = 12.5 g per dL (216 donations from 118 men; 178 donations from 119 women). The frequency of donor reactions was acceptable (Group 1, 11%; Group 2, 6%); 2 percent of donations by Group 1 donors and 1 percent by Group 2 donors were terminated because of these reactions. Of 46 donors in Group 1, 30 returned to donate platelets again at a later time; at least once, 23 (77%) had a hemoglobin > or = 12.5 g per dL. Ten donors in Group 1 returned for additional donations within 56 days; no meaningful decrease in hemoglobin levels occurred. A hemoglobin cutoff of 12.5 g per dL during the study period would have excluded 1 percent of platelet donations by men and 23 percent by women. CONCLUSION The data demonstrate that the lower hemoglobin cutoff of 11.5 g per dL is a safe and relevant threshold for accepting female plateletpheresis donors and would allow more participation by women in blood donor programs.
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Affiliation(s)
- J L Fraser
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts 02215, USA
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Fraser JL, Lilly C, Israel E, Hulme P, Hanff PA. Diagnostic yield of bronchoalveolar lavage and bronchoscopic lung biopsy for detection of Pneumocystis carinii. Mayo Clin Proc 1996; 71:1025-9. [PMID: 8917286 DOI: 10.4065/71.11.1025] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the need to perform a bronchoscopic lung biopsy (BLB) in addition to bronchoalveolar lavage (BAL) to obtain a definitive diagnosis of Pneumocystis carinii pneumonia. DESIGN We retrospectively reviewed the results of concurrently collected paired BAL and BLB specimens to determine the diagnostic yield of both methods for the detection of P. carinii organisms. MATERIAL AND METHODS During a 3-year period, the BAL fluid specimens stained with a commercially available direct immunofluorescence monoclonal antibody (DFA) reagent and the BLB specimens stained with Grocott methenamine-silver nitrate (GMS) were assessed for the presence of P. carinii. BAL fluid was routinely collected from multiple sites and combined into a single specimen for testing. RESULTS During the 3-year period of study, 119 patients were identified who had paired BAL fluid and BLB specimens tested for the presence of P. carinii. Of the 119 patients, 16 had either BAL fluid that could not be interpreted or BLB tissue that was inadequate. Of the other 103 patients, 21 had P. carinii pneumonia. The sensitivity of the DFA method on BAL fluid and of the GMS method on BLB was 95% and 43%, respectively. CONCLUSION For detection of P. carinii, the diagnostic yield is significantly higher for DFA-stained BAL specimens than for GMS-stained BLB specimens.
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Affiliation(s)
- J L Fraser
- Department of Pathology, Beth Israel Hospital, Boston, Massachusetts, USA
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Fraser JL, Millenson M, Malynn ER, Uhl L, Kruskall MS. Possible association between the Norplant contraceptive system and thrombotic thrombocytopenic purpura. Obstet Gynecol 1996; 87:860-3. [PMID: 8677116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is a rare, potentially fatal disease of uncertain etiology. Early diagnosis and treatment are essential to patient survival. The ]purpose of this report is to describe three patients with levonorgestrel implants (Norplant system) who developed TTP. CASES A 24-year-old woman with levonorgestrel implants in place for 7 months was admitted to our hospital for treatment of TTP. Clinical symptoms included easy bruising, menorrhagia, headaches, and fever; laboratory evaluation revealed thrombocytopenia (18 x 10(9)/L) and microangiopathic hemolytic anemia. She was treated with plasmapheresis, and the implants were removed. Through the Freedom of Information Act, we reviewed all adverse events associated with Norplant use reported to the Food and Drug Administration (FDA) as of the end of 1992. Two additional cases were identified. CONCLUSIONS Although a causal relationship between progestogen-only contraceptives and TTP is not established by the data presented, these three cases may represent an increased incidence of TTP in women using levonorgestrel implants. Patients who receive Norplant should be advised to seek medical attention if symptoms appear. Physicians and other health care providers should be aware of the possible association between use of the Norplant system and TTP and are urged to report similar cases to the FDA.
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Affiliation(s)
- J L Fraser
- Department of Pathology, Charles A. Dana Research Institute, Boston, Massachusetts, USA
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Fraser JL, Antonioli DA, Chopra S, Wang HH. Prevalence and nonspecificity of microvesicular fatty change in the liver. Mod Pathol 1995; 8:65-70. [PMID: 7731944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Hepatic microvesicular fat (MVF) has been associated with clinical syndromes of liver failure (such as acute fatty liver of pregnancy and Reye's syndrome). We performed this pilot study to investigate the specificity and potential risk factors of MVF. Sections of the liver from 17 adult autopsies were snap-frozen, and Oil Red O (ORO)-stained sections were obtained. The presence of MVF in the ORO stains was analyzed in a semiquantitative manner: 3+ = > 90% liver parenchyma with MVF; 2+ = 25-90%; 1+ = 1-24%. H&E-stained liver sections were reviewed independently to determine the presence and extent of inflammation, fibrosis, and necrosis. Autopsy reports were reviewed for the gross findings; medical records were reviewed for demographic data, medical history, and, in particular, medication usage. The study consisted of 10 males and 7 females (15 white, 2 black), with a median age of 76 years (range: 50-88). MVF was identified in 16 patients (94%); it was infrequent (1+, 2+) in the majority, but 4 patients (24%) had 3+ MVF. MVF was not associated with the age or sex of the patients, liver weight, postmortem interval to examination, or other histologic features in the liver. None of the patients, including those with 3+ MVF, had a history of liver disease. All 4 patients with extensive MVF were using salicylates, as opposed to 2 of 5 with 2+ MVF and 1 of 8 with 0 to 1+ MVF (P = 0.015). In this autopsy study, the prevalence of MVF was high, with 24% of patients having extensive MVF.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- J L Fraser
- Department of Pathology, Beth Israel Hospital, Boston, Massachusetts, USA
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Hartmann S, Besra GS, Fraser JL, König WA, Minnikin DE, Ridell M. Stereochemistry of 2,4-dimethyleicos-2-enoate from the pyruvylated glycolipid of Mycobacterium smegmatis. Biochim Biophys Acta 1994; 1201:339-44. [PMID: 7803462 DOI: 10.1016/0304-4165(94)90060-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The absolute stereochemistry of 2,4-dimethyleicos-2-enoic acid, isolated from the pyruvylated glycolipid of Mycobacterium smegmatis, has been determined. The two enantiomers of methyl 2,4-dimethyleicos-2-enoate were synthesised for the first time but could not be separated by gas chromatography on cyclodextrin phases. (E)-2-Methyloctadec-2-enoate, an intermediate in the synthesis, is a characteristic component of acyl trehalose glycolipids from Mycobacterium fortuitum. Ozonolysis of the fatty acid ester mixture, obtained from the pyruvylated glycolipid produced 2-methyloctadecanoate. It was identified as the (S)-enantiomer by comparison with (2R) and (2S)-2-methyloctadecanoic acid, intermediates in the synthesis of (4R)- and (4S)-2,4,-dimethyleicos-2-enoic acid, using enantioselective gas chromatography of the methyl esters with heptakis(2,6-di-O-methyl-3-O-pentyl)-beta-cyclodextrin as a chiral stationary phase. The natural acid was therefore determined to be 2E-(4S)-2,4-dimethyleicos-2-enoic acid.
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Affiliation(s)
- S Hartmann
- Department of Chemistry, University of Newcastle upon Tyne, UK
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Abstract
We studied F-wave minimum latency, persistence, and chronodispersion in the median and ulnar nerves of 70 controls and 75 patients with various polyneuropathies. Prolonged minimum latency was the most frequent F-wave abnormality in all groups of patients with polyneuropathy. The finding of decreased persistence or absence of F-responses was comparable in sensitivity to prolonged minimum latency in Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating polyneuropathy (CIDP), whereas chronodispersion had a comparable sensitivity only in CIDP. Decreased persistence of obtained F-responses, and the absence of F-responses in nerves with low compound muscle action potential amplitudes, were nonspecific findings. F-wave studies often provide useful additional information in the evaluation of patients suspected of having a polyneuropathy. In patients with axonal polyneuropathies, we found that F-wave studies are significantly more sensitive than standard motor conduction studies in identifying physiological abnormalities of motor axons. Furthermore, in a patient with an acquired polyneuropathy, the finding of markedly prolonged minimum latency, or the absence of F-responses in nerves with normal CMAP amplitude, is highly specific for the presence of demyelination.
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Affiliation(s)
- J L Fraser
- Department of Neurology, School of Medicine, University of California, San Francisco 94143-0114
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Proctor DD, Fraser JL, Mangano MM, Calkins DR, Rosenberg SJ. Small cell carcinoma of the esophagus in a patient with longstanding primary achalasia. Am J Gastroenterol 1992; 87:664-7. [PMID: 1317672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Achalasia is believed to be a predisposing factor for the development of esophageal cancer. Small cell carcinoma of the esophagus is a rare neoplasm, with fewer than 150 cases having been reported in the world literature, and it has been described only once previously in a patient with longstanding achalasia. We describe a case of an 85-yr-old woman with long-term primary achalasia who developed primary small cell carcinoma of the esophagus. We hypothesize that this patient's recurrent, worsening dysphagia is related to a paraneoplastic phenomenon. We discuss this association and review the literature.
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Affiliation(s)
- D D Proctor
- Department of Medicine, Harvard Medical School, Beth Israel Hospital, Boston, Massachusetts
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Fraser JL. Persistent lumbar aglycorrhachia of unknown cause. Neurology 1991; 41:1323-4. [PMID: 1866031 DOI: 10.1212/wnl.41.8.1323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- J L Fraser
- Department of Neurology, University of California, San Francisco
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Fraser JL, Eckert LA. Volvulus complicating pregnancy. Can Med Assoc J 1983; 128:1045-1048. [PMID: 6839249 PMCID: PMC1874855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
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Fraser JL, Lum KR. Notes. Availability of elements of environmental importance in incinerated sludge ash. Environ Sci Technol 1983; 17:52-54. [PMID: 22304553 DOI: 10.1021/es00107a013] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Fraser JL, Peterson KS. Letter: Ureteral ectopia. Can Med Assoc J 1974; 110:1234. [PMID: 4834425 PMCID: PMC1947544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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