A girl with atypical chronic inflammatory demyelinating polyneuropathy

Posters: no. P13Chronic inflammatory demyelinating polyneuropathy (CIDP) is a chronic, acquired immune and inflammatory disorder that targets the peripheral nerves. The cardinal features include a progressive or a relapsing-remitting course, predominant motor symptoms and signs, symmetrical involvement of arms and legs, proximal muscles involvement along with distal muscles, and decrease or absence of deep tendon reflexes. The diagnosis is confirmed by cerebrospinal fluid (CSF) protein elevation without pleocytosis, and nerve conduction evidence of a primary demyelinating polyneuropathy. A 17-year-old girl was admitted with increase in falling and progressive difficulty in raising arms for 6 months. The weakness had a waxing and waning course for the past few months. One month before admission, she noticed diurnal variation of weakness with most severe weakness in the morning that usually got better in the afternoon. She complained of frequent shoulder pain, fluctuating limb weakness and chronic fatigability. Examination showed multiple sites of tenderness, neck and shoulder stiffness and fatigability. Rapid fluctuation of muscle weakness within the same day or within 1 to 2 days were observed. She was initially suspected to have fibromyalgia and she had slightly elevated erythrocyte sedimentation rate and positive for anti-dsDNA. Subsequent nerve conduction study confirmed demyelinating sensorimotor polyneuropathy with sparing of sural nerves. Lumbar puncture showed raised protein level and protein-cytological dissociation. MRI spine demonstrated gadolinium contrast enhanced nerve roots at the cauda equina. Chronic inflammatory demyelinating polyneuropathy was diagnosed. She was started on intravenous immunoglobulin with rapid clinical improvement. Our patient demonstrated a close relationship between fibromyalgia and CIDP. The predominant presentation of fibromyalgia highlighting that neuropathic nature of pain and morning stiffness can be the atypical presentation at some stage of CIDP.published_or_final_versionThe 1st Hong Kong Neurological Congress cum 22nd Annual Scientific Meeting of the Hong Kong Neurological Society, Hong Kong, 6-8 November 2009. In Hong Kong Medical Journal, 2009, v. 15 n. 6, suppl. 7, p. 46, abstract P1

An X-linked dominant mutation in LAMP2 causing Danon disease associated with myotonia expanding the spectrum

Poster PresentationThis journal issues entitled: 18th International Congress of The World Muscle SocietyWe describe a family with strong family history of cardiomyopathy. The mother has dilated cardiomyopathy with symptoms onset around 40 years old requiring treatment for both heart failure and atrial fibrillation. She does not have muscle weakness and her creatine kinase level was normal. The elder son has hypertrophic cardiomyopathy with symptoms onset at 20 years old, a mildly elevated creatine kinase of 1000 U/L but no muscle weakness. The younger brother with limited intelligence was asymptomatic all along. At the age of 15 with an incidental finding of raised serum transaminase levels he was referred for further investigations. Initial consultation confirmed mild proximal weakness, calves hypertrophy, creatine kinase up to 3500 U/L and echocardiogram ...postprin

Anti-NMDA-R encephalitis: an encephalitis lerthargica-like illness

Posters: no. P14A girl of 3 years and 9 months with a 3-day history of fever and upper respiratory tract infection (URTI) was admitted with a generalised tonic-clonic convulsion, and delirium with screaming, non-sense talking, and agitation. For the first week after admission, she was lethargic with fluctuating awareness and mutism during the day but poor sleep at night. Workup for acute encephalopathy including autoimmune, infective, toxicology, metabolic and vasculitic screening showed negative findings. Erythrocyte sedimentation rate was markedly elevated and ...published_or_final_versionThe 1st Hong Kong Neurological Congress cum 22nd Annual Scientific Meeting of the Hong Kong Neurological Society, Hong Kong, 6-8 November 2009. In Hong Kong Medical Journal, 2009, v. 15 n. 6, suppl. 7, p. 47, abstract P1

Nascent chains can form co-translational folding intermediates that promote post-translational folding outcomes in a disease-causing protein

During biosynthesis, proteins can begin folding co-translationally to acquire their biologically-active structures. Folding, however, is an imperfect process and in many cases misfolding results in disease. Less is understood of how misfolding begins during biosynthesis. The human protein, alpha-1-antitrypsin (AAT) folds under kinetic control via a folding intermediate; its pathological variants readily form self-associated polymers at the site of synthesis, leading to alpha-1-antitrypsin deficiency. We observe that AAT nascent polypeptides stall during their biosynthesis, resulting in full-length nascent chains that remain bound to ribosome, forming a persistent ribosome-nascent chain complex (RNC) prior to release. We analyse the structure of these RNCs, which reveals compacted, partially-folded co-translational folding intermediates possessing molten-globule characteristics. We find that the highly-polymerogenic mutant, Z AAT, forms a distinct co-translational folding intermediate relative to wild-type. Its very modest structural differences suggests that the ribosome uniquely tempers the impact of deleterious mutations during nascent chain emergence. Following nascent chain release however, these co-translational folding intermediates guide post-translational folding outcomes thus suggesting that Z’s misfolding is initiated from co-translational structure. Our findings demonstrate that co-translational folding intermediates drive how some proteins fold under kinetic control, and may thus also serve as tractable therapeutic targets for human disease

Interactions between nascent proteins and the ribosome surface inhibit co-translational folding

Most proteins begin to fold during biosynthesis on the ribosome. It has been suggested that interactions between the emerging polypeptide and the ribosome surface might allow the ribosome itself to modulate co-translational folding. Here we combine protein engineering and NMR spectroscopy to characterize a series of interactions between the ribosome surface and unfolded nascent chains of the immunoglobulin-like FLN5 filamin domain. The strongest interactions are found for a C-terminal segment that is essential for folding, and we demonstrate quantitative agreement between the strength of this interaction and the energetics of the co-translational folding process itself. Mutations in this region that reduce the extent of binding result in a shift in the co-translational folding equilibrium towards the native state. Our results therefore demonstrate that a competition between folding and binding provides a simple, dynamic mechanism for the modulation of co-translational folding by the ribosome

Common sequence motifs of nascent chains engage the ribosome surface and trigger factor

In the cell, the conformations of nascent polypeptide chains during translation are modulated by both the ribosome and its associated molecular chaperone, trigger factor. The specific interactions that underlie these modulations, however, are still not known in detail. Here, we combine protein engineering, in-cell and in vitro NMR spectroscopy, and molecular dynamics simulations to explore how proteins interact with the ribosome during their biosynthesis before folding occurs. Our observations of α-synuclein nascent chains in living Escherichia coli cells reveal that ribosome surface interactions dictate the dynamics of emerging disordered polypeptides in the crowded cytosol. We show that specific basic and aromatic motifs drive such interactions and directly compete with trigger factor binding while biasing the direction of the nascent chain during its exit out of the tunnel. These results reveal a structural basis for the functional role of the ribosome as a scaffold with holdase characteristics and explain how handover of the nascent chain to specific auxiliary proteins occurs among a host of other factors in the cytosol

Opioid therapy for chronic non-cancer pain: guidelines for Hong Kong

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Mental health & maltreatment risk of children with special educational needs during COVID-19

BACKGROUND: Children with special educational needs (SEN) are more vulnerable during the COVID-19 pandemic with risk of poor mental wellbeing and child maltreatment. OBJECTIVE: To examine the impact of COVID-19 on the mental health of children with SEN and their maltreatment risk. PARTICIPANTS AND SETTING: 417 children with SEN studying at special schools and 25,427 children with typical development (TD) studying at mainstream schools completed an online survey in April 2020 in Hong Kong during school closures due to COVID-19. METHOD: Emotional/behavioural difficulties, quality of life and parental stress of children with SEN were compared with typically developed children using mixed effect model. Linear regression analyses were performed to explore factors associated with child emotional/behavioural difficulties and parental stress during the pandemic. Chi-square test was performed to detect the differences in maltreatment risk before and during COVID-19. RESULTS: Children with SEN had significantly poorer overall quality of life (68.05 vs 80.65, p < 0.01). 23.5% of children had at least one episode of severe physical assault and 1.9% experienced very severe physical assault during COVID-19. Rates of physical assault increased significantly (59.8% vs. 71.2% p < 0.001) while children with mental disorders had increased risk of severe physical assault comparing to those without mental disorders (RR = 1.58, ꭓ2 = 5.19 p = 0.023). CONCLUSION: Children with SEN had poorer mental health than typically developed children during the COVID-19 pandemic. Maltreatment risk for children with SEN is higher in comparison to pre-COVID-19 era. Surveillance of child maltreatment, continuity of medical and rehabilitation care to support children with SEN are essential during a disease pandemic

Diagnostic value of whole-exome sequencing in Chinese pediatric-onset neuromuscular patients

BACKGROUND: Neuromuscular disorders (NMDs) comprise a group of heterogeneous genetic diseases with a broad spectrum of overlapping the clinical presentations that makes diagnosis challenging. Notably, the recent introduction of whole-exome sequencing (WES) is introducing rapid changes on the genetic diagnosis of NMDs. We aimed to investigate the diagnostic value of WES for pediatric-onset NMDs. METHODS: We applied integrated diagnostic approach and performed WES in 50 Chinese subjects (30 males, 20 females) with undiagnosed pediatric-onset NMDs despite previous specific tests. The patients were categorized in four subgroups according to phenotyping and investigation findings. Variants on NMDs gene list and open exome analysis for those with initial negative findings were identified. RESULTS: WES identified causative variants in ACTA1 (n = 2), POMT1, COL6A1 (n = 2), MTMR2, LMNA, SELENON, DNM2, TGFB1, MPZ, IGHMBP2, and LAMA2 in 13 patients. Two subjects have variants of uncertain significance (VUSs) in TTN and SCN11A, unlikely to be pathogenic due to incompatible phenotypes. The mean interval time from symptom onset to genetic diagnosis was 10.4 years (range from 1 month to 33 years). The overall diagnostic yield of WES in our cohort was 26%. Open exome analysis was necessary to identify the pathogenic variant in TGFB1 that caused skeletal dysplasia with neuromuscular presentation. CONCLUSION: Our study shows a clear role of WES in the pathway of integrated diagnostic approach to shorten the diagnostic odyssey in patients with rare NMDs