Later Onset Congenital Central Hypoventilation Syndrome

Congenital central hypoventilation syndrome (CCHS) is a rare disorder of the autonomic nervous system involving multiple organ systems, with the hallmark symptom of respiratory failure due to aberrant central control of breathing resulting in hypoxemia and hypercapnia. Later onset CCHS (LOCCHS) is defined as the diagnosis of CCHS in children older than 1 month. Molecular genetic testing for PHOX2B variants has led not only to increased diagnosis of neonates with CCHS but also the increased identification of older children, adolescents, and adults with LOCCHS who may have a milder clinical presentation of this multisystem disease.

Age and weight considerations for the use of continuous positive airway pressure therapy in pediatric populations: an American Academy of Sleep Medicine position statement

This position statement provides guidance for age and weight considerations for using continuous positive airway pressure (CPAP) therapy in pediatric populations. The American Academy of Sleep Medicine (AASM) commissioned a task force of experts in pediatric sleep medicine to review the medical literature and develop a position statement based on a thorough review of these studies and their clinical expertise. The AASM Board of Directors approved the final position statement. It is the position of the AASM that CPAP can be safe and effective for the treatment of obstructive sleep apnea (OSA) for pediatric patients, even in children of younger ages and lower weights, when managed by a clinician with expertise in evaluating and treating pediatric OSA. The clinician must make the ultimate judgment regarding any specific care in light of the individual circumstances presented by the patient, accessible treatment options, patient/parental preference, and resources.

965 Complication Rates in Operatively Managed Ankle Fracture/Dislocations - The Effect of Pre-Reduction Imaging and Compliance with BOAST 12 Guidance

Aim

The BOAST-12 guidelines for the management of ankle fractures aims to optimise functional recovery and reduce complications. They advise against having radiographs prior to urgent reduction of clinically deformed ankles as it could cause an unacceptable delay to subsequent management. Our study aimed to assess the effect of time to acceptable reduction on the risk of complications and time to definitive reduction.

Method

This was a retrospective observational study of patients with ankle fracture-dislocations between 2013 to 2017 at the Northern General Hospital’s Emergency Department (ED). Information collected from 2 patient groups (with and without pre-reduction radiographs), included patient demographics, time to accepted reduction, number of manipulations, operations, and subsequent complications.

Results

242 patients were identified. Time from arrival in ED to acceptable reduction was significantly longer in patients with pre-reduction radiographs versus patients without (184.5 vs 82 minutes, p < 0.00), but did not increase the overall risk of complications (p = 0.62). Pre-reduction radiographs were associated with insignificantly higher rates of post-traumatic osteoarthritis (p = 0.17) and slightly longer wait time for definitive intervention (1 vs 2 days, p = 0.72). However, this had no relationship with the number of manipulations (p = 0.53).

Conclusions

The use of pre-reduction radiographs significantly increased time to acceptable reduction of ankle fracture-dislocations. However, this was not associated with increased risk of complications or time to definitive management.

606 Incidence & Influence of Drug Screening in Children with Hypersomnolence During MSLT: Analysis of the Children’s Wisconsin Cohort

Introduction

The Multiple Sleep Latency Test (MSLT) is a validated test for evaluation of hypersomnolence in children and adults. AASM practice parameters recommend performing urine drug screens (UDS) in patients undergoing MSLT to identify substances that alter MSLT results. The study aims are to determine the incidence of positive UDS and their influence on MSLT variables in a cohort of children evaluated for hypersomnolence.

Methods

All children undergoing an MSLT in Children’s Wisconsin sleep laboratory over an 8-year period (11/1/2012 to 9/30/2020) were included in this retrospective chart review study. Clinical and demographic data, including UDS results were manually abstracted. Record validation conducted by random allocation. Data were summarized as median and IQR or n (%). Chi-square test or Fisher’s exact test were used to examine associations between categorical variables.

Results

236 children completed an MSLT. The sample had a median age of 14.1 (IQR 10.5–16.2) years (50.9% female; 63.1% Caucasian). Narcolepsy I (“N1”; n=14; 5.9%), Narcolepsy II (“N2”; n=56; 23.7%), Idiopathic Hypersomnia (“IH”; n=39; 16.5%) were frequently diagnosed. Most children (97.9%) completed a UDS; 60.2% tested positive. Common substances found on UDS were caffeine (62.6%), OTC medications (40.3%), and prescription medications (33.8%), however nicotine (14.3%) and cannabis (5.8%) were also seen. Caffeine was commonly found in those diagnosed with N1 (70%), N2 (69.4%), and IH (54.2%). Fewer children diagnosed with narcolepsy were positive for prescription medications compared to those diagnosed with IH (21.7% versus 41.7%) although results did not reach significance (p=0.08). No child with N1 tested positive for prescription medications. ≥2 substances were found in 43.2% of positive drug screens. OTC medications and caffeine were most commonly co-occurring (23%); OTC analgesics being the most common OTC medication. No association between positivity for >2 substances and sleep diagnosis was found (p=0.5).

Conclusion

More than half of children undergoing an MSLT had a positive UDS for >1 substance. The impact of these substances on PSG/MSLT parameters (total sleep time, mean sleep onset latency, sleep onset REM periods) is under investigation through additional analysis. Based on the above data our findings support the AASM guidelines of children obtaining a UDS on the day of MSLT.

Support (if any):

844 Pediatric Vagus Nerve Stimulator-Induced Obstructive Sleep Apnea

Introduction

Vagus nerve stimulation (VNS) is an adjunct treatment for seizures refractory to medications. VNS in children with epilepsy can reduce seizures by up to 90%. VNS settings include stimulation on-time, off-time, frequency and output current. Complications of VNS include sleep-disordered breathing due to laryngopharyngeal dysfunction, which can also cause voice alteration, hoarseness, and cough. Both obstructive apneas (more common) and central apneas can be seen in those patients who have VNS-induced sleep-disordered breathing.

Report of case(s)

A 14-year-old male with Lennox-Gastaut syndrome treated with multiple antiepileptic drugs and VNS was admitted to the PICU with worsening seizures. He developed acute respiratory failure due to status epilepticus, requiring intubation. After extubation, he was observed to have repetitive respiratory obstruction at regular intervals, occurring throughout the day and night, and associated with mild oxygen desaturations. Polysomnography showed cyclical obstructive respiratory events lasting 30 seconds followed by approximately 2-minute intervals of regular breathing. Interrogation of his VNS device revealed the following settings: output current of 1.75 mA, 30 seconds on, and 1.8 minutes off. CPAP therapy improved his oxygen saturations, but he continued to clinically exhibit the repetitive obstructive apneas even on positive pressure. However, after his VNS device settings were decreased, repeat polysomnography showed resolution of his obstructive breathing.

Conclusion

This case report demonstrates pediatric VNS-induced obstructive sleep apnea. Activation of the vagus nerve can cause laryngopharyngeal dysfunction, including laryngospasm and vocal cord dysfunction, with subsequent upper airway obstruction, causing obstructive apneas or hypopneas. Treatment options for pediatric VNS-induced OSA include CPAP, decreasing the VNS settings and adenotonsillectomy.

Support (if any):

1224 Treatment of Severe OSA Using Low Flow Oxygen in a Neonate with Robin Sequence

Introduction

Robin Sequence (RS) involves the clinical triad of micrognathia, glossoptosis and cleft palate. There is a spectrum of severity, but most neonates with RS have upper airway obstruction, resulting in severe obstructive sleep apnea, sometimes requiring surgical interventions such as tongue-lip adhesion, mandibular distraction, or tracheostomy. We present an infant with RS and severe obstructive sleep apnea which was managed with supplemental oxygen.

Report of Case

Our patient was born at 39 weeks gestation with RS. He had a normal DNA microarray. He was discharged after a 3 week NICU hospitalization for poor feeding. Over the next 2 months, he had poor weight gain and worsening obstructive breathing and was evaluated by craniofacial surgery at that time. Room air polysomnography (PSG) was recommended and revealed an AHI of 21, REM AHI of 48, supine AHI of 25, prone AHI of 19, mean SPO2 of 98%, minimum SPO2 of 61%, and normal capnography with 0% of the time spent > 50 mmHg. A repeat sleep study on 1/4LPM oxygen in the supine position revealed an AHI of 1.7, mean SPO2 of 99%, minimum SPO2 of 92%, and normal capnography. He was discharged on supplemental oxygen. At 4 months of age, he had good weight gain. At 10 months of age, room air PSG revealed persistent OSA with an AHI of 7.2, REM AHI of 21, mean SPO2 of 97%, minimum SPO2 of 81%, and normal capnography. At age 3 yrs, his PSG on room air showed resolution of his OSA with an AHI of 0.6, mean SPO2 of 97%, minimum SPO2 of 87% and normal capnography.

Conclusion

This case illustrates the spectrum of severity of RS and the utility of low flow oxygen to treat OSA in this patient population.

Metastatic Breast Care E-Learning Modules

Background and context: The McGrath Foundation has created an e-Learning course to upskill breast care nurses in current metastatic breast cancer practice. The e-Learning course has supported better specialist knowledge and helped close the gap in metastatic cancer support services across Australia. Aim: The project aimed to deliver specialist training to breast care nurses on current trends in care and treatment of individuals with metastatic breast cancer, via an e-Learning platform to enable a cost effective delivery across Australia to 119 nurses. Strategy/Tactics: Key learning outcomes were developed to ensure specific information could be delivered via an online platform. Industry experts, clinicians and experienced breast care nurses/nurse practitioners were consulted to develop the content and an outline of what would be delivered. An experienced online content development company was also engaged to ensure that the content would be presented in an engaging way. Program/Policy process: The metastatic e-Learning course was available for McGrath Breast Care Nurses in June 2017 and accredited for professional development hours by the Australian College of Nursing to contribute to registration under the Nursing and Midwifery Board of Australia. Certificates of completion are given to all participants who successfully complete the course once they achieve competency in all areas of assessment. Outcomes: The e-Learning course has had reach across all areas of the country and allowed easy dissemination of information on current trends in metastatic breast cancer to nurses. This is seen to have great reach with almost all McGrath Breast Care Nurses also caring for a proportion of patients with metastatic disease. Additional qualitative and quantitative analysis will be available during the presentation after analysis is completed. What was learned: Some key learnings from this project have been the scalability of e-Learning as a technology enabled professional development solution. The need for good design to enable engagement with content was consistent theme during feedback sessions. As well as using competency based testing to enable participants to gain professional development in a technology enabled platform has reduced nurse down time.

Endoscopic esophageal and tracheal cauterization for closure of recurrent tracheoesophageal fistula: A case report and review of the literature

OBJECTIVE

Recurrent tracheoesophageal fistula (TEF) can be a diagnostic and therapeutic challenge. Traditional treatment is thoracotomy, which carries significant morbidity and technical difficulty especially in a previously operated field. Recently, endoscopic techniques have been advocated as a primary approach for treatment of recurrent TEF prior to open repair. This case report describes the endoscopic technique used to address a recurrent TEF. The existing literature of all reported endoscopic cauterization methods is reviewed.

METHODS

An 8 month old with proximal esophageal atresia and distal TEF underwent endoscopic closure of a recurrent TEF. The fistula was approached endotracheally utilizing Bugbee electrocautery (EC) and endoluminally through the esophagus using argon plasma coagulator and placement of porcine submucosa graft into the tract. Current literature review is presented with a synthesis of data on cases utilizing endoscopically applied EC and the combined results of this closure technique.

RESULTS

Our patient has maintained successful closure after a single treatment confirmed on follow up endoscopy 6 months post repair. Including this patient, there have been 30 patients with recurrent TEF treated utilizing endoscopic EC reported in the literature. The overall success rate is 78.8% with a mean of 1.88 procedures per successful closure. Comparing EC alone to EC combined with tissue glues or laser, success rates are 67% and 86% respectively.

CONCLUSION

Endoscopic repair of recurrent TEF has proven to be safe and effective in the literature as an alternative to a second thoracotomy/open surgical repair. EC combined with tissue glues or laser is more effective than EC alone based on available data.

Retinal disease in the C3 glomerulopathies and the risk of impaired vision

BACKGROUND

Dense deposit disease and atypical hemolytic uremic syndrome are often caused by Complement Factor H (CFH) mutations. This study describes the retinal abnormalities in dense deposit disease and, for the first time, atypical haemolytic uremic syndrome. It also reviews our understanding of drusen pathogenesis and their relevance for glomerular disease.

METHODS

Six individuals with dense deposit disease and one with atypical haemolytic uremic syndrome were studied from 2 to 40 years after presentation. Five had renal transplants. All four who had genetic testing had CFH mutations. Individuals underwent ophthalmological review and retinal photography, and in some cases, optical coherence tomography, and further tests of retinal function.

RESULTS

All subjects with dense deposit disease had impaired night vision and retinal drusen or whitish-yellow deposits. Retinal atrophy, pigmentation, and hemorrhage were common. In late disease, peripheral vision was restricted, central vision was distorted, and there were scotoma from sub-retinal choroidal neovascular membranes and atypical serous retinopathy. Drusen were present but less prominent in the young person with atypical uremic syndrome due to a heterozygous CFH mutation.

CONCLUSIONS

Drusen are common in forms of C3 glomerulopathy caused by compound heterozygous or heterozygous CFH mutations. They are useful diagnostically but also impair vision. Drusen have an identical composition to glomerular deposits. They are also identical to the drusen of age-related macular degeneration, and may respond to the same treatments. Individuals with a C3 glomerulopathy should be assessed ophthalmologically at diagnosis, and monitored regularly for vision-threatening complications.

BAG3 myofibrillar myopathy presenting with cardiomyopathy

Myofibrillar myopathies (MFMs) are a heterogeneous group of neuromuscular disorders distinguished by the pathological hallmark of myofibrillar dissolution. Most patients present in adulthood, but mutations in several genes including BCL2-associated athanogene 3 (BAG3) cause predominantly childhood-onset disease. BAG3-related MFM is particularly severe, featuring weakness, cardiomyopathy, neuropathy, and early lethality. While prior cases reported either neuromuscular weakness or concurrent weakness and cardiomyopathy at onset, we describe the first case in which cardiomyopathy and cardiac transplantation (age eight) preceded neuromuscular weakness by several years (age 12). The phenotype comprised distal weakness and severe sensorimotor neuropathy. Nerve biopsy was primarily axonal with secondary demyelinating/remyelinating changes without "giant axons." Muscle biopsy showed extensive neuropathic changes that made myopathic changes difficult to interpret. Similar to previous cases, a p.Pro209Leu mutation in exon 3 of BAG3 was found. This case underlines the importance of evaluating for MFMs in patients with combined neuromuscular weakness and cardiomyopathy.

Modification of Copper Surfaces: Effect on Adhesion at the Copper Polyimide Interface

Copper surfaces were derivatized resulting in the formation of Mx[Cu(II)(CN)Fe(II/III)(CN)5] at the interface. Polyimides were spin coated onto the modified metal surfaces and the degree of adhesion measured by the tape pull test. Effects of mechanical interlocking were evident in the case of modified copper samples, due to derivatization by ferricyanide. The chemical bonding and elemental analyses of the interfaces were studied by XPS and SEM.

Identification and characterization of a novel ABCA3 mutation

Mutations in the gene coding for ATP-binding cassette protein A3 (ABCA3) are recognized as a genetic cause of lung disease of varying severity. Characterization of a number of mutant ABCA3 proteins has demonstrated that the mutations generally affect intracellular localization or the ability of the protein to hydrolyze ATP. A novel heterozygous mutation that results in the substitution of cysteine for arginine at amino acid 295 in ABCA3 was identified in a premature infant with chronic respiratory insufficiency and abnormal lamellar bodies. Sequencing of DNA performed in study participants demonstrated that this was a mutation and not a common variant. Plasmid vectors containing ABCA3 with the identified novel mutation tagged with green fluorescent protein on the carboxy terminus were generated. The effect of the mutation on protein function was characterized by examining the glycosylation state of the mutant protein in transiently transfected HEK293 cells and by examining ATP hydrolysis activity of the mutant protein with a vanadate-induced nucleotide trapping assay in stably transfected HEK293 cells. The ABCA3 protein containing the R295C mutation undergoes normal glycosylation and intracellular localization but has dramatically reduced ATP hydrolysis activity (12% of wild type). The identification of one copy of this novel mutation in a premature infant with chronic respiratory insufficiency suggests that ABCA3 haploinsufficiency together with lung prematurity may result in more severe, or more prolonged, respiratory failure.

Bacterial ancestry of actin and tubulin

The structural and functional resemblance between the bacterial cell-division protein FtsZ and eukaryotic tubulin was the first indication that the eukaryotic cytoskeleton may have a prokaryotic origin. The bacterial ancestry is made even more obvious by the findings that the bacterial cell-shape-determining proteins Mreb and Mbl form large spirals inside non-spherical cells, and that MreB polymerises in vitro into protofilaments very similar to actin. Recent advances in research on two proteins involved in prokaryotic cytokinesis and cell shape determination that have similar properties to the key components of the eukaryotic cytoskeleton are discussed.

Third degree anal sphincter tears: risk factors and outcome

The aim of this retrospective study was to determine the incidence, risk factors and anal symptoms related to third degree tears after vaginal delivery. There were 9,631 vaginal deliveries during the 5-year period studied, with 116 (1.2%) having a third degree tear. Statistically significant risk factors for a third degree tear were primiparity, forceps delivery, episiotomy, fetal birth-weight greater than 4,000 g and increased duration of the second stage of labour. Eighty four of the 116 women were able to be interviewed, and 21 (25%) had anal symptoms related to the tear. Only 3 women had sought help for their symptoms. Twelve women experienced anal incontinence and 2 more required delayed repair of the anal sphincter for incontinence. Third degree tears are a major cause of perinatal and postnatal morbidity. Attention needs to be directed to the prevention of such tears by awareness of the women at risk and to better follow-up and counselling of the women sustaining a tear.

Hepatitis B and C markers among alcoholics in Israel: high incidence of HCV infection

Patients with alcoholic liver disease have an increased prevalence of viral hepatitis. However, the role of demographic characteristics has not been adequately delineated. Therefore, we examined and compared the seroprevalences of hepatitis B and C in Israeli alcoholic patients to that of blood donors control group by their country of birth and origin. Hepatitis B surface antigen, hepatitis B core antibody and hepatitis C virus antibody testing (second generation ELISA) and a confirmatory recombinant immunoblot assay was performed on 496 alcoholic attending an alcoholic abstinence program and compared to 193,806 randomly non-alcoholic blood donors on the basis of their country of birth. Three hundred twenty-eight alcoholic patients (66%) were immigrants and Israeli born Jews and 168 (34%) were Israeli Arabs. Of the 496 alcoholic patients, 24 (4.8%) were HBsAg positive, 38 (7.6%) were anti HCV positive, and 2 (North African Jews) were positive for both markers. HBsAg was detected in 13 (3.9%) immigrant and Israeli Jews and 11 (6.5%) Israeli Arabs, significantly higher than in the adjusted non alcoholic blood donors (p < 0.01). Anti-HCV was detected in 33 (10%) immigrants and Israeli Jews and 5 (2.9%) Israeli Arabs, significantly higher than in the control group (p < 0.005). In the subgroup alcoholic Jews there was no significant difference in hepatitis B seropositivity among alcoholic that were native Israeli, Eastern Europe and former USSR, and Western Europe and American immigrants comparing to the control group. In contrast, anti-HCV recombinant immunoblot assay seropositivity in alcoholic Jews from all subgroups was significantly greater than in non alcoholic blood donors (p < 0.001). Odds analysis of all ethnic groups revealed that alcoholism requiring detoxification have a significant risk factor for hepatitis C more than hepatitis B (p < 0.001). The increased seroprevalence of hepatitis C among Israeli alcoholic patients, regardless their country of birth and origin, suggest that alcoholism is likely to have a predisposing factor for HCV infection.

Atrial sounds and endocardial electrograms recorded during coarse atrial fibrillation

Hearing atrial sounds is unusual during atrial flutter and rare during atrial fibrillation. We report a patient with hypertrophic cardiomyopathy and coarse atrial fibrillation in whom atrial sounds were recorded phonocardiographically during endocardial atrial electrography. The atrial sounds were recorded phonocardiographically at the same periodicity as the atrial electrograms, and both had beat-to-beat variability in morphology, amplitude, and cycle length. These observations suggest that atrial sounds originate from the atrium and that organized electrical and mechanical activity occur in some types of atrial fibrillation.

Arrangement of subunits in flagellar microtubules

Electron micrographs of outer doublet tubules from flagella have been analysed by methods which make use of the computed diffraction patterns of electron-microscope images. Analysis of singlet A-tubules in the tips of flagella has led to a determination of the helical surface lattice of the A-subfibre, confirming that there are 13 longitudinal protofilaments in the tubule wall and that dimers in neighbouring protofilaments form a staggered arrangement, equivalent to the lattice with an axial periodicity of 8.0 nm predicted in earlier work. A low-resolution 3-dimensional image of the A-tubule has been reconstructed, which supports the evidence for an 8.0-nm-long heterodimer oriented along the protofilaments. The heterodimer is identified as a pair of 4.0-nm morphological units, which appear to be globular at this resolution.

Filtered images have been obtained from doublet tubules which show that the B-subfibre is also made up of 8.0-nm dimers, but it differs from the A-tubule in that dimers in adjacent filaments are not in a staggered arrangement but are lined up obliquely at a shallow angle. Using the additional information about the hands of the lattices in the 2 subfibres which is presented in the accompanying paper, a model for the whole doublet has been proposed.