A very mild phenotype in six individuals of a three-generation family with the novel HRAS variant c.176C > G p.(Ala59Gly): Emergence of a new HRAS-related RASopathy distinct from Costello syndrome

Costello syndrome is a clinically recognizable, severe neurodevelopmental disorder caused by heterozygous activating variants in HRAS. The vast majority of affected patients share recurring variants affecting HRAS codons 12 and 13 and a relatively uniform phenotype. Here, we report the unique and attenuated phenotype of six individuals of an extended family affected by the HRAS variant c.176C>T p.(Ala59Gly), which, to our knowledge, has never been reported as a germline variant in patients so far. HRAS Alanine 59 has been previously functionally investigated as an oncogenic hotspot and the p.Ala59Gly substitution was shown to impair intrinsic GTP hydrolysis. All six individuals we report share a phenotype of ectodermal anomalies and mild features suggestive of a RASopathy, reminiscent of patients with Noonan syndrome-like disorder with loose anagen hair. All six are of normal intelligence, none have a history of failure to thrive or malignancy, and they have no known cardiac or neurologic pathologies. Our report adds to the previous reports of patients with rare variants affecting amino acids located in the SWITCH II/G3 region of HRAS and suggests a consistent, attenuated phenotype distinct from classical Costello syndrome. We propose the definition of a new distinct HRAS-related RASopathy for patients carrying HRAS variants affecting codons 58, 59, 60

The current benefit of genome sequencing compared to exome sequencing in patients with developmental or epileptic encephalopathies

Background: As the technology of next generation sequencing rapidly develops and costs are constantly reduced, the clinical availability of whole genome sequencing (WGS) increases. Thereby, it remains unclear what exact advantage WGS offers in comparison to whole exome sequencing (WES) for the diagnosis of genetic diseases using current technologies. Methods: Trio-WGS was conducted for 20 patients with developmental or epileptic encephalopathies who remained undiagnosed after WES and chromosomal microarray analysis. Results: A diagnosis was reached for four patients (20%). However, retrospectively all pathogenic variants could have been detected in a WES analysis conducted with today's methods and knowledge. Conclusion: The additional diagnostic yield of WGS versus WES is currently largely explained by new scientific insights and the general technological progress. Nevertheless, it is noteworthy that whole genome sequencing has greater potential for the analysis of small copy number and copy number neutral variants not seen with WES as well as variants in noncoding regions, especially as potentially more knowledge of the function of noncoding regions arises. We, therefore, conclude that even though today the added value of WGS versus WES seems to be limited, it may increase substantially in the future

Trend and development of epidural analgesia and epidural anesthesia in the maternitiy ward of UHC Sestre milosrdnice over the past ten years

Tijekom posljednjih godina epiduralna analgezija za obezboljavanje vaginalnog porođaja primjenjuje se sve češće i jedna je od najčešće rabljenih regionalnih tehnika. Epiduralna anestezija uglavnom se rabi za hitni carski rez u rodilja koje već imaju postavljen epiduralni kateter za epiduralnu analgeziju tijekom vaginalnog porođaja. U rodilištu Kliničkoga bolničkog centra Sestre milosrdnice proveli smo retrospektivnu kohortnu studiju od 2008. do 2018. godine. Proučavali smo desetogodišnji trend incidencije epiduralne analgezije u odnosu prema ukupnom broju porođaja i incidencije epiduralne anestezije za hitni carski rez u odnosu prema ukupnom broju hitnih carskih rezova. U 2008. godini učestalost epiduralne analgezije u odnosu prema ukupnom broju porođaja bila je 21% (662/3125), a u 2018. godini 34% (1059/3083). U 2008. godini broj epiduralnih anestezija u odnosu prema ukupnom broju anestezija za hitni carski rez bio je 9% (51/552), a u 2018. 27% (172/639). Trend porasta vidljiv je kod obaju postupaka i iznosi 13% za epiduralne analgezije i 18% pri epiduralnim anestezijama.Over the years, epidural analgesia for pain relief of vaginal delivery is increasingly being applied and is one of the most frequently used regional techniques. Epidural anesthesia is mainly used in emergency cesarean section in parturients who already have an epidural catheter for epidural analgesia during vaginal delivery. In the delivery ward at the Sestre milosrdnice University Hospital Center we have conducted a retrospective cohort study from 2008 to 2018.We studied the incidence of epidural analgesia in relation to the total number of births and the incidence of epidural anesthesia for emergency cesarean section in relation to the total number of emergency cesarean sections. In 2008, the incidence of epidural analgesia in the relation to the total number of births was 21% (662/3125),and in 2018 it was 34% (1059/3083). In 2008, the number of epidural anesthesia for emergency cesarean section in the relation to the total number of emergency cesarean sections was 9% (51/552), andn in 2018 it was 27% (172/639). An increasing trend is seen in both procedures and is 13% for epidural analgesiaand 18% for epidural anesthesia

Anesthesia and analgesia for FAUCS technique of cesarean section – case report

Carski rez povezan je s povećanim brojem komplikacija i velikom postoperativnom boli koja uzrokuje produljenje oporavka za tri do pet dana u odnosu prema vaginalnom porođaju. Novijom kirurškom metodom FAUCS (engl. French Ambulatory Cesarean Section) smanjuju se poslijeoperacijske komplikacije i bolnost. U Klinici za ženske bolesti i porodništvo Kliničkoga bolničkog centra Sestre milosrdnice u Zagrebu započelo se primjenjivati ovu operacijsku metodu u ožujku 2019. godine, prvi put u Hrvatskoj. Spinalna (subarahnoidalna) anestezija jest anestezija izbora za ovakav zahvat zbog potrebe sudjelovanja rodilje pri ekstrakciji novorođenčeta. Bolnost je zahvata manja, stoga spinalna anestezija iziskuje nižu dozu lokalnog anestetika u odnosu prema uobičajenoj standardnoj dozi za carski rez. Sniženje doze lokalnog anestetika omogućuje brži oporavak motoričke funkcije, a samim time i bržu mobilizaciju rodilje. Uz spinalnu anesteziju kombinira se analgezija blokom ravnine transversusa abdominis (engl. Transversus abdominis plane – TAP block) na kraju zahvata. Blok TAP-a doveo je do potpunog uklanjanja boli tijekom prva 24 poslijeoperacijska sata. Potreba za medikamentnom terapijom boli smanjena je na najmanju moguću, a opioidni analgetici nisu bili potrebni. Ovakva kombinacija poštednijega carskog reza i regionalne analgezije omogućila je brži oporavak rodilje, što je povezano s brojnim dobrobitima i za majku i za dijete. Donosimo prikaz jedne od prvih primjena metode FAUCS uz spinalnu anesteziju i blok TAP-a u Hrvatskoj.Cesarean section is correlated with a higher number of complications and higher postoperative pain which prolongs recovery in comparison with vaginal delivery for three to five days. With a relatively new and advanced surgical technique French Ambulatory Cesarean section (FAUCS) there are fewer postoperative complications and lower pain scores. In our Clinical Department of Gynecology and Obstetrics, Sestre milosrdnice University Hospital Center, Zagreb, we started with this surgical technique at the beginning of 2019 for the first time in Croatia. The choice of anesthesia for this procedure is spinal anesthesia because the cooperation of the patient is essential for successful extraction of the neonate. As this procedure is less painful it is possible to reduce the dosage of spinal local anesthetic in comparison with the usual dose for classical cesarean section. Lower local anesthetic dose enables faster recovery of motor function, and allows faster mobilization of the parturients. We combined spinal anesthesia with Trans-Abdominal Plain (TAP) block at the end of the procedure. TAP block led to the complete elimination of postoperative pain during the first 24 postoperative hours. The necessity for pain medication therapy after day one was reduced to minimal doses, and opiate analgesics were not used. This combination of less painful cesarean section and regional anesthesia enabled faster patient recovery with many benefits for the woman and the newborn. In this case report we present one of our first cases

Procena psihomotornog razvoja dece s Vestovim sindromom

Introduction. West Syndrome (WS) is age-related epileptic encephalopathy characterised by a triad of symptoms: specific seizure type, pathognomonic electroencephalographic (EEG) pattern - hypsarrhythmia and delay and/or regression in psychomotor development (PMD). Aetiologically, it occurs in three forms: symptomatic, cryptogenic and idiopathic. Objective. Estimation of PMD in children with WS according to aetiology. Methods. The observed group consisted of 65 children. Age range was between 6 and 30 months. The patients were divided into three groups according to aetiology. All patients underwent psychological examination with Brunet-Lesine test, as well as PMD evaluation based on achieved developmental milestones for the corresponding age. Results. Statistically significant better values in the Human Developmental Index (HDI) had patients with idiopathic compared to other forms of WS, at testing after 12 months (93.0±8.1 vs. 46.8±6.1 vs. 45.6±3.8), as well as after 24 months (93.9±7.7 vs. 51.9±5.5 vs. 50.9±4.4). The best values of HDI after 24 months had patients with improvement in PMD with the average of 66.2±4.4, which was statistically significant compared to those with unchanged PMD (41.5±5.3) and with further regression in PMD (28.3±4.4). Significant correlation was obtained between PMD after 12 and 24 months (r=0.477), as well as a considerable improvement in HDI from the 12th to 24th month (49.4±4.0 vs. 53.7±3.9). Conclusion. The patients with idiopathic WS accomplished the best PMD. Improvement in PMD after 12 and 24 months of treatment was associated with improved HDI. Improvement in PMD was observed in all patients after 2 years of follow-up.Uvod. Vestov (West) sindrom (VS) je uzrasno zavisna epileptična encefalopatija koju odlikuje trojstvo simptoma: specifičan obrazac napada, tipičan elektroencefalografski (EEG) obrazac - hipsaritmija i zastoj, odnosno regresija u psihomotornom razvoju (PMR). Etiološki, javlja se u tri oblika: simptomatskom, kriptogenom i idiopatskom. Cilj rada. Cilj istraživanja bila je procena PMR dece sa VS u odnosu na etiologiju. Metode rada. Ispitivanu grupu činilo je 65 dece sa VS uzrasta 6-30 meseci. Bolesnici su svrstani u tri grupe prema etiologiji oboljenja. Svi su podvrgnuti psihološkom testiranju Brine-Lesinovim (Brunet- Ljsine) testom i proceni PMR na osnovu ostvarivanja miljokaza razvoja. Rezultati. Statistički značajno bolju vrednost indeksa razvoja (IR) ostvarili su bolesnici s idiopatskim oblikom VS, kako pri testiranju posle 12 meseci (93,0±8,1 prema 46,8±6,1 prema 45,6±3,8), tako i nakon 24 meseca kliničkog praćenja (93,9±7,7 prema 51,9±5,5 prema 50,9±4,4). Najbolje vrednosti IR posle 24 meseca postigli su bolesnici s napretkom u PMR, kod kojih je srednja vrednost ovog parametra bila 66,2±4,4, što je bilo statistički značajno u odnosu na bolesnike s nepromenjenim PMR (41,5±5,3) i regresijom u PMR (28,3±4,4). Dobijena je značajna korelacija između PMR posle godinu dana i dve godine (r=0,477), a uočeno je i značajno poboljšanje vrednosti IR između 12. i 24. meseca (49,2±4,0 prema 53,7±3,9). Zaključak. Deca s idiopatskim oblikom VS ostvaruju najbolji PMR. Napredak u PMR posle 12 meseci i 24 meseca lečenja bio je udružen sa boljim IR. Kod svih bolesnika uočen je napredak u PMR posle dve godine lečenja

The genetic landscape and clinical implication of pediatric Moyamoya angiopathy in an international cohort

Pediatric Moyamoya Angiopathy (MMA) is a progressive intracranial occlusive arteriopathy that represents a leading cause of transient ischemic attacks and strokes in childhood. Despite this, up to now no large, exclusively pediatric MMA cohort has been subjected to systematic genetic investigation. In this study, we performed molecular karyotyping, exome sequencing and automated structural assessment of missense variants on a series of 88 pediatric MMA patients and correlated genetic, angiographic and clinical (stroke burden) findings. The two largest subgroups in our cohort consisted of RNF213 and neurofibromatosis type 1 (NF1) patients. While deleterious RNF213 variants were associated with a severe MMA clinical course with early symptom onset, frequent posterior cerebral artery involvement and higher stroke rates in multiple territories, NF1 patients had a similar infarct burden compared to non-NF1 individuals and were often diagnosed incidentally during routine MRIs. Additionally, we found that MMA-associated RNF213 variants have lower predicted functional impact compared to those associated with aortic disease. We also raise the question of MMA as a feature of recurrent as well as rare chromosomal imbalances and further support the possible association of MMA with STAT3 deficiency. In conclusion, we provide a comprehensive characterization at the genetic and clinical level of a large exclusively pediatric MMA population. Due to the clinical differences found across genetic subgroups, we propose genetic testing for risk stratification as part of the routine assessment of pediatric MMA patients

Assessing clinical utility of preconception expanded carrier screening regarding residual risk for neurodevelopmental disorders

The magnitude of clinical utility of preconception expanded carrier screening (ECS) concerning its potential to reduce the risk of affected offspring is unknown. Since neurodevelopmental disorders (NDDs) in their offspring is a major concern of parents-to-be, we addressed the question of residual risk by assessing the risk-reduction potential for NDDs in a retrospective study investigating ECS with different criteria for gene selection and definition of pathogenicity. We used exome sequencing data from 700 parents of children with NDDs and blindly screened for carrier-alleles in up to 3046 recessive/X-linked genes. Depending on variant pathogenicity thresholds and gene content, NDD-risk-reduction potential was up to 43.5% in consanguineous, and 5.1% in nonconsanguineous couples. The risk-reduction-potential was compromised by underestimation of pathogenicity of missense variants (false-negative-rate 4.6%), inherited copy-number variants and compound heterozygosity of one inherited and one de novo variant (0.9% each). Adherence to the ACMG recommendations of restricting ECS to high-frequency genes in nonconsanguineous couples would more than halve the detectable inherited NDD-risk. Thus, for optimized clinical utility of ECS, screening in recessive/X-linked genes regardless of their frequency (ACMG Tier-4) and sensible pathogenicity thresholds should be considered for all couples seeking ECS

Pathogenic SCN2A variants cause early-stage dysfunction in patient-derived neurons

Pathogenic heterozygous variants in SCN2A, which encodes the neuronal sodium channel NaV1.2, cause different types of epilepsy or intellectual disability (ID)/autism without seizures. Previous studies using mouse models or heterologous systems suggest that NaV1.2 channel gain-of-function typically causes epilepsy, whereas loss-of-function leads to ID/autism. How altered channel biophysics translate into patient neurons remains unknown. Here, we investigated iPSC-derived early-stage cortical neurons from ID patients harboring diverse pathogenic SCN2A variants [p.(Leu611Valfs*35); p.(Arg937Cys); p.(Trp1716*)], and compared them to neurons from an epileptic encephalopathy patient [p.(Glu1803Gly)] and controls. ID neurons consistently expressed lower NaV1.2 protein levels. In neurons with the frameshift variant, NaV1.2 mRNA and protein levels were reduced by ~ 50%, suggesting nonsense-mediated decay and haploinsufficiency. In other ID neurons, only protein levels were reduced implying NaV1.2 instability. Electrophysiological analysis revealed decreased sodium current density and impaired action potential (AP) firing in ID neurons, consistent with reduced NaV1.2 levels. By contrast, epilepsy neurons displayed no change in NaV1.2 levels or sodium current density, but impaired sodium channel inactivation. Single-cell transcriptomics identified dysregulation of distinct molecular pathways including inhibition of oxidative phosphorylation in neurons with SCN2A haploinsufficiency, and activation of calcium signaling and neurotransmission in epilepsy neurons. Together, our patient iPSC-derived neurons reveal characteristic sodium channel dysfunction consistent with biophysical changes previously observed in heterologous systems. Additionally, our model links the channel dysfunction in ID to reduced NaV1.2 levels and uncovers impaired AP firing in early-stage neurons. The altered molecular pathways may reflect a homeostatic response to NaV1.2 dysfunction and can guide further investigations

Deep phenotyping of the neuroimaging and skeletal features in KBG syndrome: a study of 53 patients and review of the literature

Background: KBG syndrome is caused by haploinsufficiency of ANKRD11and is characterised by macrodontia of upper central incisors, distinctive facial features, short stature, skeletal anomalies, developmental delay, brain malformations and seizures. The central nervous system (CNS) and skeletal features remain poorly defined. Methods: CNS and/or skeletal imaging were collected from molecularly confirmed individuals with KBG syndrome through an international network. We evaluated the original imaging and compared our results with data in the literature. Results: We identified 53 individuals, 44 with CNS and 40 with skeletal imaging. Common CNS findings included incomplete hippocampal inversion and posterior fossa malformations; these were significantly more common than previously reported (63.4% and 65.9% vs 1.1% and 24.7%, respectively). Additional features included patulous internal auditory canal, never described before in KBG syndrome, and the recurrence of ventriculomegaly, encephalic cysts, empty sella and low-lying conus medullaris. We found no correlation between these structural anomalies and epilepsy or intellectual disability. Prevalent skeletal findings comprised abnormalities of the spine including scoliosis, coccygeal anomalies and cervical ribs. Hand X-rays revealed frequent abnormalities of carpal bone morphology and maturation, including a greater delay in ossification compared with metacarpal/phalanx bones. Conclusion: This cohort enabled us to describe the prevalence of very heterogeneous neuroradiological and skeletal anomalies in KBG syndrome. Knowledge of the spectrum of such anomalies will aid diagnostic accuracy, improve patient care and provide a reference for future research on the effects ofANKRD11variants in skeletal and brain development

Impact of safety-related dose reductions or discontinuations on sustained virologic response in HCV-infected patients: Results from the GUARD-C Cohort

BACKGROUND: Despite the introduction of direct-acting antiviral agents for chronic hepatitis C virus (HCV) infection, peginterferon alfa/ribavirin remains relevant in many resource-constrained settings. The non-randomized GUARD-C cohort investigated baseline predictors of safety-related dose reductions or discontinuations (sr-RD) and their impact on sustained virologic response (SVR) in patients receiving peginterferon alfa/ribavirin in routine practice. METHODS: A total of 3181 HCV-mono-infected treatment-naive patients were assigned to 24 or 48 weeks of peginterferon alfa/ribavirin by their physician. Patients were categorized by time-to-first sr-RD (Week 4/12). Detailed analyses of the impact of sr-RD on SVR24 (HCV RNA <50 IU/mL) were conducted in 951 Caucasian, noncirrhotic genotype (G)1 patients assigned to peginterferon alfa-2a/ribavirin for 48 weeks. The probability of SVR24 was identified by a baseline scoring system (range: 0-9 points) on which scores of 5 to 9 and <5 represent high and low probability of SVR24, respectively. RESULTS: SVR24 rates were 46.1% (754/1634), 77.1% (279/362), 68.0% (514/756), and 51.3% (203/396), respectively, in G1, 2, 3, and 4 patients. Overall, 16.9% and 21.8% patients experienced 651 sr-RD for peginterferon alfa and ribavirin, respectively. Among Caucasian noncirrhotic G1 patients: female sex, lower body mass index, pre-existing cardiovascular/pulmonary disease, and low hematological indices were prognostic factors of sr-RD; SVR24 was lower in patients with 651 vs. no sr-RD by Week 4 (37.9% vs. 54.4%; P = 0.0046) and Week 12 (41.7% vs. 55.3%; P = 0.0016); sr-RD by Week 4/12 significantly reduced SVR24 in patients with scores <5 but not 655. CONCLUSIONS: In conclusion, sr-RD to peginterferon alfa-2a/ribavirin significantly impacts on SVR24 rates in treatment-naive G1 noncirrhotic Caucasian patients. Baseline characteristics can help select patients with a high probability of SVR24 and a low probability of sr-RD with peginterferon alfa-2a/ribavirin