Precision or narrative medicine? Child neurology needs both!

Precision medicine aims to understand the mechanisms of diseases and to find treatments adapted to each individual or group of patients, on the basis of biological characteristics and environment. It uses new tools based on digital technologies. Narrative medicine was theorized, in the 2000s, as a reaction to the increasing technicality and the notion of a lack of human relations in care: It focuses on recognizing the essential place of the patient's experience of illness and life history in the diagnosis and management of diseases as well as in the training of caregivers. These two opposite currents are rarely considered together. In fact, they have in common the basic principle that each patient is unique, and both are often more closely intertwined than we think, especially in the field of child neurology. Five case histories and discussions presented here aim to demonstrate that combining the precision approach with the narrative approach can improve the diagnosis, treatment, classification, and understanding of neurological conditions, as well as enhance the dialog with families and make teaching more meaningful. Not only rare diseases but common problems, such as paroxysmal events, pain, epilepsy, intellectual disability, and autism spectrum disorder, are addressed from both perspectives

Pediatric stroke related to Lyme neuroborreliosis: Data from the Swiss NeuroPaediatric Stroke Registry and literature review.

Cerebrovascular complications of Lyme neuroborreliosis (LNB) are poorly documented in the paediatric population. We performed a retrospective analysis from prospectively registered cases of acute ischemic stroke (AIS) from the Swiss NeuroPaediatric Stroke Registry (SNPSR) from 2000 to 2015. Only cases with serologically confirmed LNB were included. In addition, a literature review on paediatric stroke cases secondary to Lyme neuroborreliosis in the same time frame was performed. 4 children out of 229 children with arterial ischemic childhood stroke and serologically confirmed LNB were identified in the SNPSR giving a global incidence of 1.7%. Median age was 9.9 years. A prior history of tick bites or erythema migrans (EM) was reported in two cases. Clinical presenting signs were suggestive of acute cerebellar/brainstem dysfunction. On imaging, three children demonstrated a stroke in the distribution of the posterior inferior cerebellar artery. The remaining fourth child had a "stroke-like" picture with scattered white matter lesions and a multifocal vasculitis with prominent basilar artery involvement. Lymphocytic pleocytosis as well as intrathecal synthesis of Borrelia burgdorferi antibodies were typical biological features. Acute intravenous third generation cephalosporins proved to be effective with rapid improvement in all patients. No child had recurrent stroke. Data from the literature concerning eight patients gave similar results, with prominent posterior circulation stroke, multifocal vasculitis and abnormal CSF as distinctive features. Lyme Neuroborreliosis accounts for a small proportion of paediatric stroke even in an endemic country. The strong predilection towards posterior cerebral circulation with clinical occurrence of brainstem signs associated with meningeal symptoms and CSF lymphocytosis are suggestive features that should rapidly point to the diagnosis. This can be confirmed by appropriate serological testing in the serum and CSF. Clinicians must be aware of this rare neurological complication of Lyme disease that demands specific antibiotic treatment

Congenital disorder of glycosylation type Id (CDG Id): phenotypic, biochemical and molecular characterization of a new patient

Summary: Congenital disorders of glycosylation (CDG) are a family of multisystem inherited disorders caused by defects in the biosynthesis of N- or O-glycans. Among the many different subtypes of CDG, the defect of a mannosyltransferase encoded by the human ALG3 gene (chromosome 3q27) is known to cause CDG Id. Six patients with CDG Id have been described in the literature so far. We further delineate the clinical, biochemical, neuroradiological and molecular features of CDG Id by reporting an additional patient bearing a novel missense mutation in the ALG3 gene. All patients with CDG Id display a slowly progressive encephalopathy with microcephaly, severe psychomotor retardation and epileptic seizures. They also share some typical dysmorphic features but they do not present the multisystem involvement observed in other CDG syndromes or any biological marker abnormalities. Unusually marked osteopenia is a feature in some patients and may remain undiagnosed until revealed by pathological fractures. Serum transferrin screening for CDG should be extended to all patients with encephalopathy of unknown origin, even in the absence of multisystem involvemen

Engineering HIV-Resistant Human CD4+ T Cells with CXCR4-Specific Zinc-Finger Nucleases

HIV-1 entry requires the cell surface expression of CD4 and either the CCR5 or CXCR4 coreceptors on host cells. Individuals homozygous for the ccr5Δ32 polymorphism do not express CCR5 and are protected from infection by CCR5-tropic (R5) virus strains. As an approach to inactivating CCR5, we introduced CCR5-specific zinc-finger nucleases into human CD4+ T cells prior to adoptive transfer, but the need to protect cells from virus strains that use CXCR4 (X4) in place of or in addition to CCR5 (R5X4) remains. Here we describe engineering a pair of zinc finger nucleases that, when introduced into human T cells, efficiently disrupt cxcr4 by cleavage and error-prone non-homologous DNA end-joining. The resulting cells proliferated normally and were resistant to infection by X4-tropic HIV-1 strains. CXCR4 could also be inactivated in ccr5Δ32 CD4+ T cells, and we show that such cells were resistant to all strains of HIV-1 tested. Loss of CXCR4 also provided protection from X4 HIV-1 in a humanized mouse model, though this protection was lost over time due to the emergence of R5-tropic viral mutants. These data suggest that CXCR4-specific ZFNs may prove useful in establishing resistance to CXCR4-tropic HIV for autologous transplant in HIV-infected individuals

Constraining the sources of ultra-high-energy cosmic rays across and above the ankle with the spectrum and composition data measured at the Pierre Auger Observatory

In this work we present the interpretation of the energy spectrum and mass composition data as measured by the Pierre Auger Collaboration above 6 × 1017 eV. We use an astrophysical model with two extragalactic source populations to model the hardening of the cosmic-ray flux at around 5 × 1018 eV (the so-called "ankle"feature) as a transition between these two components. We find our data to be well reproduced if sources above the ankle emit a mixed composition with a hard spectrum and a low rigidity cutoff. The component below the ankle is required to have a very soft spectrum and a mix of protons and intermediate-mass nuclei. The origin of this intermediate-mass component is not well constrained and it could originate from either Galactic or extragalactic sources. To the aim of evaluating our capability to constrain astrophysical models, we discuss the impact on the fit results of the main experimental systematic uncertainties and of the assumptions about quantities affecting the air shower development as well as the propagation and redshift distribution of injected ultra-high-energy cosmic rays (UHECRs)

Search for Ultra-high-energy Photons from Gravitational Wave Sources with the Pierre Auger Observatory

A search for time-directional coincidences of ultra-high-energy (UHE) photons above 10 EeV with gravitational wave (GW) events from the LIGO/Virgo runs O1 to O3 is conducted with the Pierre Auger Observatory. Due to the distinctive properties of photon interactions and to the background expected from hadronic showers, a subset of the most interesting GW events is selected based on their localization quality and distance. Time periods of 1000 s around and 1 day after the GW events are analyzed. No coincidences are observed. Upper limits on the UHE photon fluence from a GW event are derived that are typically at ∼7 MeV cm−2 (time period 1000 s) and ∼35 MeV cm−2 (time period 1 day). Due to the proximity of the binary neutron star merger GW170817, the energy of the source transferred into UHE photons above 40 EeV is constrained to be less than 20% of its total GW energy. These are the first limits on UHE photons from GW sources

A Catalog of the Highest-energy Cosmic Rays Recorded during Phase I of Operation of the Pierre Auger Observatory

A catalog containing details of the highest-energy cosmic rays recorded through the detection of extensive air showers at the Pierre Auger Observatory is presented with the aim of opening the data to detailed examination. Descriptions of the 100 showers created by the highest-energy particles recorded between 2004 January 1 and 2020 December 31 are given for cosmic rays that have energies in the range 78–166 EeV. Details are also given on a further nine very energetic events that have been used in the calibration procedure adopted to determine the energy of each primary. A sky plot of the arrival directions of the most energetic particles is shown. No interpretations of the data are offered

Search for photons above 1019eV with the surface detector of the Pierre Auger Observatory

We use the surface detector of the Pierre Auger Observatory to search for air showers initiated by photons with an energy above 1019 eV. Photons in the zenith angle range from 30° to 60° can be identified in the overwhelming background of showers initiated by charged cosmic rays through the broader time structure of the signals induced in the water-Cherenkov detectors of the array and the steeper lateral distribution of shower particles reaching ground. Applying the search method to data collected between January 2004 and June 2020, upper limits at 95% CL are set to an E-2 diffuse flux of ultra-high energy photons above 1019 eV, 2 × 1019 eV and 4 × 1019 eV amounting to 2.11 × 10-3, 3.12 × 10-4 and 1.72 × 10-4 km-2 sr-1 yr-1, respectively. While the sensitivity of the present search around 2 × 1019 eV approaches expectations of cosmogenic photon fluxes in the case of a pure-proton composition, it is one order of magnitude above those from more realistic mixed-composition models. The inferred limits have also implications for the search of super-heavy dark matter that are discussed and illustrated