Brugada Syndrome and Pulmonary Atresia with Intact Interventricular Septum: Fortuitous Finding or New Genetic Connection?

Brugada syndrome is a rare arrhythmogenic syndrome associated mainly with pathogenic variants in the SCN5A gene. Right ventricle outflow tract fibrosis has been reported in some cases of patients diagnosed with Brugada syndrome. Pulmonary atresia with an intact ventricular septum is characterized by the lack of a functional pulmonary valve, due to the underdevelopment of the right ventricle outflow tract. We report, for the first time, a 4-year-old boy with pulmonary atresia with an intact ventricular septum who harbored a pathogenic de novo variant in SCN5A, and the ajmaline test unmasked a type-1 Brugada pattern. We suggest that deleterious variants in the SCN5A gene could be implicated in pulmonary atresia with an intact ventricular septum embryogenesis, leading to overlapping phenotypes.

Assessment of Quality of Life Using the Kidslife Scale in Individuals With Cornelia de Lange Syndrome.

BACKGROUND: Cornelia de Lange syndrome (CdLS) is a rare polymalformative genetic disorder with multisystemic involvement. Despite numerous clinical and molecular studies, the specific evaluation of the quality of life (QoL) and its relationship with syndrome-specific risk factors has not been explored. METHODS: The QoL of 33 individuals diagnosed with CdLS, aged between 4 and 21 years, was assessed using the Kidslife questionnaire. Specifically, the influence of 14 risk factors on overall QoL and 8 of its domains was analyzed. RESULTS: The study revealed below-median QoL (45.3 percentile), with the most affected domains being physical well-being, personal development, and self-determination. When classifying patients based on their QoL and affected domains, variants in the NIPBL gene, clinical scores ≥11, and severe behavioral and communication issues were found to be the main risk factors. CONCLUSIONS: We emphasize the need for a comprehensive approach to CdLS that encompasses clinical, molecular, psychosocial, and emotional aspects. The "Kidslife questionnaire" proved to be a useful tool for evaluating QoL, risk factors, and the effectiveness of implemented strategies. In this study, we underscore the importance of implementing corrective measures to improve the clinical score. Furthermore, we highlight the necessity of applying specific therapies for behavioral problems after ruling out underlying causes such as pain or gastroesophageal reflux and implementing measures that facilitate communication and promote social interaction.

Early assessment of cardiomyopathy in Duchenne patients by means of longitudinal strain echocardiography.

INTRODUCTION: The diagnosis of Duchenne-linked cardiomyopathy may be challenging. Conventional echocardiographic measurements typically show deterioration beyond the second decade. Global longitudinal strain has been proposed as an earlier marker than left ventricular ejection fraction. MATERIAL AND METHODS: A prospective, observational, cross-sectional, case-control study was carried out. Both Duchenne patients and control subjects underwent transthoracic echocardiogram in order to assess left ventricle function. Bayesian linear regression was the main tool for inference. Age effects were parameterised by means of a spline function because of its simplicity to characterise continuous variables and smooth contributions. The posterior distribution of the marginal age effects was used to assess the earliest age of deterioration of each marker. RESULTS: Sixteen Duchenne patients and twenty-two healthy male subjects were enrolled. On overage, cardiac function measures were found for ejection fraction and longitudinal strain among different groups. Age effects on global longitudinal strain are more reliably found at ages of 6 and above, while ejection fraction starts to deteriorate at an older age. Progressive left ventricular dysfunction in Duchenne patients is one of the key issues and starts at an early age with subtle symptoms. CONCLUSION: This cross-sectional study provides supporting evidence that global longitudinal strain is an earlier marker of disease progression than ejection fraction in Duchenne patients.

Características y resultados del Registro español de válvula aórtica bicúspide en pediatría (REVAB) / Characteristics and outcomes of the Spanish registry for pediatric patients with bicuspid aortic valve (REVAB)

Introducción y objetivos: La válvula aórtica bicúspide (VAB) es la cardiopatía congénita más frecuente. El objetivo de este estudio es describir las características de los pacientes en edad pediátrica con VAB en un registro poblacional. Métodos: Los datos de los pacientes se obtuvieron del Registro español de válvula aórtica bicúspide (REVAB) en pediatría (menores de 18 años). Para el análisis de datos, se dividió a los pacientes en 2 grupos según sus características: pacientes con VAB solo y pacientes con VAB y cardiopatía congénita concomitantes. Resultados: Se analizó a un total de 1.681 pacientes de 33 hospitales. La mayoría (1.158, 69,6%) eran varones. La morfología de la válvula fue horizontal en el 63,4% (1.012), y puras (tipo 0 Sievers), el 28,4% (469). El 63,7% (1.060) tenían solo VAB y en el 23,4% (390) concurrían lesiones obstructivas del lado izquierdo. Del total, el 8,6% (145) precisó alguna intervención en la válvula aórtica. Conclusiones: Estos datos representan la primera descripción de base poblacional de la presentación clínica y los resultados en los pacientes del REVAB Pediátrico.(AU)

Introduction and objectives: Bicuspid aortic valve (BAV) disorder is the most common congenital heart disease. The aim of this study was to describe the characteristics of 0- to 18-year olds with BAV in a population-based registry. Methods: Data from all pediatric patients were obtained from the Spanish registry for pediatric patients with bicuspid aortic valve (REVAB) (< 18 years). For data analysis, patients with BAV were divided into 2 groups by their features: isolated BAV and BAV with associated congenital heart disease. Results: We included 1681 patients from 33 hospitals. Males accounted for 69.6% (n = 1158). Valve morphology was horizontal in 63.4% (n = 1012) and pure (Sievers type 0) in 28.4% (n=469). Isolated BAV was present in 63.7% (n=1060), and concomitant left-sided obstructive lesions in 23.4% (n=390). Interventions were required in 8.6% (n=145). Conclusion: These data represent the first large, population-based description of the clinical presentations and outcomes of patients enrolled in the Spanish registry for pediatric patients with bicuspid aortic valve.(AU)

Heart Disease Characterization and Myocardial Strain Analysis in Patients with PACS1 Neurodevelopmental Disorder.

BACKGROUND: PACS1 neurodevelopmental disorder (PACS1-NDD) (MIM# 615009) is a rare autosomal dominant disease characterized by neurodevelopmental delay, dysmorphic facial features, and congenital malformations. Heart disease (HD) is frequently present in individuals with PACS1-NDD, but a compressive review of these anomalies and an evaluation of cardiac function in a cohort of patients are lacking. METHODS: (i) Cardiac evaluation in 11 PACS1-NDD patients was conducted using conventional echocardiography. (ii) Heart function was assessed by tissue Doppler imaging, and two-dimensional speckle tracking was performed in seven patients and matched controls. (iii) This systematic review focused on determining HD prevalence in individuals with PACS1-NDD. RESULTS: In our cohort, 7 of 11 patients presented HD. (Among them, three cases of ascending aortic dilatation (AAD) were detected and one mitral valve prolapse (MVP).) None of the patients showed echocardiographic pathological values, and the left global longitudinal strain was not significantly different between patients and controls (patients -24.26 ± 5.89% vs. controls -20.19 ± 1.75%, p = 0.3176). In the literature review, almost 42% (42/100) of individuals with PACS1-NDD reportedly experienced HD. Septal defects were the most common malformation, followed by patent ductus arteriosus. CONCLUSIONS: Our results show a high prevalence of HD in PACS1-NDD patients; in this way, AAD and MVP are reported for the first time in this syndrome. Furthermore, a detailed cardiac function evaluation in our cohort did not reveal evidence of cardiac dysfunction in individuals with PACS1-NDD. Cardiology evaluation should be included for all individuals with Schuurs-Hoeijmakers syndrome.

Impact of Suspected Preterm Labor during Pregnancy on Cardiometabolic Profile and Neurodevelopment during Childhood: A Prospective Cohort Study Protocol.

INTRODUCTION: Suspected preterm labor (SPL), defined as the presence of regular and painful uterine contractions and cervical shortening, represents a prenatal insult with potential long-term consequences. However, despite recent evidence demonstrating suboptimal neurodevelopment at 2 years in this population, it remains underestimated as a significant risk factor for neurodevelopmental disorders or other chronic diseases. The aim of this study is to assess the impact of suspected preterm labor during pregnancy on cardiometabolic profile and neurodevelopment during childhood (6-8 years). METHODS AND ANALYSIS: Prospective cohort study including children whose mothers suffered suspected preterm labour during pregnancy and paired controls. Neurodevelopmental, cardiovascular, and metabolic assessments will be performed at 6-8 years of age. A trained psychologist will carry out the neurodevelopment assessment including intelligence, visual perception, and behavioral assessment. Body composition and physical fitness assessment will be performed by one trained pediatrician and nurse. Finally, cardiovascular evaluation, including echocardiography and blood pressure, will be performed by two pediatric cardiologists. Data regarding perinatal and postnatal characteristics, diet, lifestyle, and weekly screen time of the child will be obtained from medical history and direct interviews with families. Primary outcome measures will include body mass index and adiposity, percentage of fat mass and total and regional lean mass, bone mineral content and density, cardiorespiratory resistance, isometric muscle strength, dynamic lower body strength, systolic and diastolic blood pressure, left ventricle (LV) systolic and diastolic function, general intelligence index, visuospatial working memory span, oculomotor control test, index of emotional, and behavioral problems.

Characteristics and outcomes of the Spanish registry for pediatric patients with bicuspid aortic valve (REVAB).

INTRODUCTION AND OBJECTIVES: Bicuspid aortic valve (BAV) disorder is the most common congenital heart disease. The aim of this study was to describe the characteristics of 0- to 18-year olds with BAV in a population-based registry. METHODS: Data from all pediatric patients were obtained from the Spanish registry for pediatric patients with bicuspid aortic valve (REVAB) (< 18 years). For data analysis, patients with BAV were divided into 2 groups by their features: isolated BAV and BAV with associated congenital heart disease. RESULTS: We included 1681 patients from 33 hospitals. Males accounted for 69.6% (n = 1158). Valve morphology was horizontal in 63.4% (n = 1012) and pure (Sievers type 0) in 28.4% (n=469). Isolated BAV was present in 63.7% (n=1060), and concomitant left-sided obstructive lesions in 23.4% (n=390). Interventions were required in 8.6% (n=145). CONCLUSION: These data represent the first large, population-based description of the clinical presentations and outcomes of patients enrolled in the Spanish registry for pediatric patients with bicuspid aortic valve.

Right ventricle speckle tracking in bronchopulmonary dysplasia: one-year follow-up.

BACKGROUND: Bronchopulmonary dysplasia (BPD) is still a major concern in preterm infants and adequate screening methods for secondary right ventricle (RV) failure are needed. Early detection could be aided by taking measurements of RV deformation using speckle tracking echocardiography. A prospective longitudinal study was carried out over 28 months at a tertiary care pediatric cardiology center. Preterm infants < 32 weeks gestational age (GA) were eligible for the study. Enrolled patients were separated in two groups: NO-BPD or BPD. At three timepoints over the first year of life, echocardiogram measurements were performed. Right ventricle strain was studied using speckle tracking analysis and compared to conventional function parameters. RESULTS: Fifty patients were enrolled in the study, 22 in the NO-BPD group and 28 in the BPD group. RV strain showed no statistical differences between groups. However, the BPD group showed worse RV function than the NO-BPD group, using speckle tracking analysis and other conventional parameters. During the study follow-up, an improvement trend is shown in RV strain. CONCLUSIONS: RV longitudinal strain and strain rate derived by speckle tracking is feasible in preterm infants. Although there seems to be a good correlation between RV strain and BPD severity, the results of this study were not conclusive. More studies should be carried out to investigate the optimum echocardiographic screening model of RV dysfunction in BPD patients.

Endocrine Evaluation and Homeostatic Model Assessment in Patients with Cornelia de Lange Syndrome.

Objective: The aim of this study was to expand knowledge about endocrine disorders in individuals with Cornelia de Lange syndrome (CdLS), a rare developmental genetic disorder with anomalies in multiple organs and systems. Methods: Hormone levels, clinical scores, anthropometric measurements, and molecular analysis were assessed in 24 individuals with CdLS. Results: Hyperprolactinemia was the most common endocrine disorder. Three patients showed subclinical hypothyroidism. In the gonadotropic axis, mildly delayed puberty was observed, as well as genital anomalies, such as cryptorchidism. Despite short stature, levels of insulin-like growth factor 1 and insulin-like growth factor-binding protein 3 were normal, on average. Three prepubertal individuals without risk factors had higher than normal values for the homeostatic model assessment of insulin resistance (HOMA-IR) and for insulinemia, suggesting insulin resistance. Furthermore, two adults had elevated BMIs associated with HOMA-IR values over the cut-off values. Conclusion: CdLS can lead to dysregulation of the endocrine system, particularly in patients with high HOMA-IR values and insulinemia who are at risk of insulin resistance. Therefore, clinical follow-ups with hormonal assessments are proposed for individuals with CdLS.

Subclinical myocardial dysfunction is revealed by speckle tracking echocardiography in patients with Cornelia de Lange syndrome.

This study assesses a possible cardiac dysfunction in individuals with Cornelia de Lange syndrome (CdLS) without diagnosed congenital heart disease (CHD) and its association with other factors. Twenty patients and 20 controls were included in the study divided into three age-dependent groups (A: < 10 yrs, B: 10-20 yrs, C: > 20 yrs), and were evaluated using conventional echocardiography, tissue doppler imaging (TDI), two-dimensional speckle tracking and genetic and biochemical analyses. The left ventricular global longitudinal strain (GLS) was altered (< 15.9%) in 55% of patients, being pathological in the older group (A: 19.7 ± 6.6; B: -17.2 ± 4.7; C: -13.6 ± 2.9). The speckle tracking technique revealed a downward trend in the values of strain, strain rate and velocity, especially in the oldest group. Likewise, the ejection fraction (LVEF) and shortening fraction (LVFS) values, although preserved, also showed a decreased with age (p < 0.05). The analytical markers of cardiovascular risk and cardiac function showed no alterations. The molecular analyses revealed 16 individuals carrying pathogenic variants in NIPBL, two with variants in SMC1A, one with a variant in RAD21 and one with a HDAC8 variant. This is the first systematic approach that demonstrates that individuals with CdLS may present early cardiomyopathy, which can be detected by speckle tracking technique even before the appearance of clinical symptoms and the alteration of other echocardiographic or analytical parameters. For all these reasons, cardiological followup is suggested even in the absence of CHD, especially from adolescence onwards.

Atrial flutter without structural heart disease in pediatrics: a retrospective review of cases in the Hospital Infantil Miguel Servet, Zaragoza, Spain.

BACKGROUND: Atrial flutter is a rare condition in pediatrics that usually occurs as a late complication after surgery for congenital heart diseases, although it can also appear in structurally normal hearts. CLINICAL CASES: We conducted a retrospective study of cases of atrial flutter with no structural heart disease diagnosed in a pediatric population (between 0 and 15 years of age) during 2015-2021 in a tertiary hospital. A total of seven cases were diagnosed, with a clear predominance of males (6/7). Of the seven patients, five debuted in the perinatal period: two were diagnosed at 20 and 36 hours of life, and three, prenatally. Among these perinatal cases, more than half (3/5) were preterm. The treatment was electrical cardioversion. The evolution was satisfactory in these cases, and there were no tachycardias in their subsequent development. In contrast, when the debut occurred at a later age (5-7 years), it was associated with channelopathy (Brugada syndrome and catecholaminergic polymorphic ventricular tachycardia), and electrical ablation of the ectopic focus was required due to poor response to pharmacological treatment. CONCLUSIONS: This study confirms the low incidence of this pathology in pediatrics and the benignity and good prognosis of neonatal flutter in most cases. The prognosis worsens when atrial flutter is diagnosed in older children, and the probability of concomitant associated heart disease increases.

INTRODUCCIÓN: El flutter o aleteo auricular es una patología poco frecuente en pediatría que suele presentarse como complicación tardía tras la cirugía de cardiopatías congénitas, aunque también puede aparecer en corazones estructuralmente normales. CASOS CLÍNICOS: Se llevó a cabo un estudio retrospectivo de los casos de flutter auricular sin cardiopatía estructural diagnosticados en una población pediátrica (entre 0 y 15 años de edad) durante el periodo 2015-2021 en un hospital terciario. En total fueron diagnosticados siete casos, con un claro predominio de varones (6/7). De los siete, cinco debutaron en periodo perinatal: dos fueron diagnosticados a las 20 y 36 horas de vida y tres de ellos, prenatalmente. Entre estos casos perinatales, más de la mitad (3/5) fueron pretérmino. El tratamiento fue la cardioversión eléctrica. La evolución fue satisfactoria en estos casos, y no se presentaron taquicardias en su evolución posterior. Por el contrario, cuando el debut se produjo en edades posteriores (5-7 años), se asoció con canalopatía (síndrome de Brugada y taquicardia ventricular polimorfa catecolaminérgica) que requirió de una ablación eléctrica del foco ectópico por escasa respuesta al tratamiento farmacológico. CONCLUSIONES: En este trabajo se confirma la baja incidencia de esta patología en pediatría, además de la benignidad y el buen pronóstico de flutter neonatal en la mayoría de casos. Cuando el diagnóstico se realiza en niños mayores, el pronóstico empeora, y aumenta la probabilidad de presentar de forma concomitante cardiopatías asociadas.

Atrial flutter without structural heart disease in pediatrics: a retrospective review of cases in the Hospital Infantil Miguel Servet, Zaragoza, Spain / Flutter auricular sin cardiopatía estructural en pediatría: una revisión retrospectiva de casos en el Hospital Infantil Miguel Servet, Zaragoza, España

Abstract Background: Atrial flutter is a rare condition in pediatrics that usually occurs as a late complication after surgery for congenital heart diseases, although it can also appear in structurally normal hearts. Clinical cases: We conducted a retrospective study of cases of atrial flutter with no structural heart disease diagnosed in a pediatric population (between 0 and 15 years of age) during 2015-2021 in a tertiary hospital. A total of seven cases were diagnosed, with a clear predominance of males (6/7). Of the seven patients, five debuted in the perinatal period: two were diagnosed at 20 and 36 hours of life, and three, prenatally. Among these perinatal cases, more than half (3/5) were preterm. The treatment was electrical cardioversion. The evolution was satisfactory in these cases, and there were no tachycardias in their subsequent development. In contrast, when the debut occurred at a later age (5-7 years), it was associated with channelopathy (Brugada syndrome and catecholaminergic polymorphic ventricular tachycardia), and electrical ablation of the ectopic focus was required due to poor response to pharmacological treatment. Conclusions: This study confirms the low incidence of this pathology in pediatrics and the benignity and good prognosis of neonatal flutter in most cases. The prognosis worsens when atrial flutter is diagnosed in older children, and the probability of concomitant associated heart disease increases.

Resumen Introducción: El flutter o aleteo auricular es una patología poco frecuente en pediatría que suele presentarse como complicación tardía tras la cirugía de cardiopatías congénitas, aunque también puede aparecer en corazones estructuralmente normales. Casos clínicos: Se llevó a cabo un estudio retrospectivo de los casos de flutter auricular sin cardiopatía estructural diagnosticados en una población pediátrica (entre 0 y 15 años de edad) durante el periodo 2015-2021 en un hospital terciario. En total fueron diagnosticados siete casos, con un claro predominio de varones (6/7). De los siete, cinco debutaron en periodo perinatal: dos fueron diagnosticados a las 20 y 36 horas de vida y tres de ellos, prenatalmente. Entre estos casos perinatales, más de la mitad (3/5) fueron pretérmino. El tratamiento fue la cardioversión eléctrica. La evolución fue satisfactoria en estos casos, y no se presentaron taquicardias en su evolución posterior. Por el contrario, cuando el debut se produjo en edades posteriores (5-7 años), se asoció con canalopatía (síndrome de Brugada y taquicardia ventricular polimorfa catecolaminérgica) que requirió de una ablación eléctrica del foco ectópico por escasa respuesta al tratamiento farmacológico. Conclusiones: En este trabajo se confirma la baja incidencia de esta patología en pediatría, además de la benignidad y el buen pronóstico de flutter neonatal en la mayoría de casos. Cuando el diagnóstico se realiza en niños mayores, el pronóstico empeora, y aumenta la probabilidad de presentar de forma concomitante cardiopatías asociadas.

Molecular Basis of the Schuurs-Hoeijmakers Syndrome: What We Know about the Gene and the PACS-1 Protein and Novel Therapeutic Approaches.

The Schuurs−Hoeijmakers syndrome (SHMS) or PACS1 Neurodevelopment Disorder (PACS1-NDD) is a rare autosomal dominant disease caused by mutations in the PACS1 gene. To date, only 87 patients have been reported and, surprisingly, most of them carry the same variant (c.607C>T; p.R203W). The most relevant clinical features of the syndrome include neurodevelopment delay, seizures or a recognizable facial phenotype. Moreover, some of these characteristics overlap with other syndromes, such as the PACS2 or Wdr37 syndromes. The encoded protein phosphofurin acid cluster sorting 1 (PACS-1) is able to bind to different client proteins and direct them to their subcellular final locations. Therefore, although its main function is protein trafficking, it could perform other roles related to its client proteins. In patients with PACS1-NDD, a gain-of-function or a dominant negative mechanism for the mutated protein has been suggested. This, together with the fact that most of the patients carry the same genetic variant, makes it a good candidate for novel therapeutic approaches directed to decreasing the toxic effect of the mutated protein. Some of these strategies include the use of antisense oligonucleotides (ASOs) or targeting of its client proteins.

Alteraciones electrocardiográficas tras electrocución / Electrocardiographic alterations after electrocution

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Seguimiento del derrame pericárdico fetal aislado: ¿debemos preocuparnos? / Isolated fetal pericardial effusion follow-up: Should we worry?

Introducción y objetivos: El derrame pericárdico fetal aparece en diferentes enfermedades como hidropesía fetal, alteraciones estructurales o del ritmo cardiaco, aunque puede observarse de manera aislada. Se ha observado un incremento de su incidencia con relación a la presencia de enfermedades graves. Métodos: Análisis de la totalidad de casos de derrame pericárdico fetal aislado (DPFA) detectados en Aragón y valorados en consulta cardiológica de diagnóstico prenatal de un hospital terciario recogidos durante 10años, así como la evolución de los pacientes hasta la actualidad. Resultados: Se obtuvo una muestra de 38 fetos en 37 gestantes diagnosticados de DPFA con resolución espontánea en el 86,8%. Se registraron 2abortos (interrupciones voluntarias tras diagnóstico prenatal de deleción 22q13 y de primoinfección por citomegalovirus) y una muerte fetal espontánea. Se objetivaron alteraciones patológicas en 10/38 recién nacidos: 2pacientes con metabolopatía, 2pacientes con cromosomopatía, un paciente con hipoplasia pulmonar e hidronefrosis unilateral, un paciente con miocardiopatía hipertrófica y 4pacientes estudiados por alteraciones del desarrollo psicomotor o alteraciones congénitas oftalmológicas o auditivas. La tasa de morbilidad fue del 34,2% y de fallecimiento del 15,7%. La detección de otras alteraciones ecográficas y la alteración en el cribado del primer trimestre se asociaron de forma significativa con la presencia de patología. Conclusiones: El DPFA se ha asociado clásicamente a buen pronóstico, aunque en ocasiones se relaciona con entidades clínicas con elevada morbimortalidad: más de un tercio de los pacientes en nuestra muestra. Se recomienda un seguimiento estrecho pre y posnatal de estos casos para poder realizar una intervención precoz. (AU)

Introduction and objectives: Fetal pericardial effusion appears in different pathologies such as hydrops fetalis, heart structural or rhythm alterations, however, it can be observed in isolation but an increase in its incidence has been observed in relation to the presence of severe pathologies. Methods: Analysis of all cases of IFPE detected in Aragon and assessed in a cardiological consultation for prenatal diagnosis of a tertiary hospital collected over 10years, as well as the evolution of the patients to the present. Results: A sample of 38 fetuses was obtained from 37 pregnant women diagnosed with DPFA with spontaneous resolution in 86.8%. Two abortions (voluntary interruptions after prenatal diagnosis of 22q13 deletion and primary infection by cytomegalovirus) and one spontaneous fetal death were recorded. Pathological alterations were observed in 10/38 newborns: 2patients with metabolic disease, 2patients with chromosomopathies, one patient with pulmonary hypoplasia and unilateral hydronephrosis, one patient with hypertrophic cardiomyopathy, and 4patients studied for alterations in psychomotor development and/or congenital ophthalmological or hearing disorders. The overall morbidity rate was 34.2% and death rate 15.7%. The detection of other ultrasound alterations and the alteration in the first trimester screening were significantly associated with the presence of pathology. Conclusions: IFPE has been classically associated with a good prognosis, although it is sometimes related to clinical entities with high morbidity and mortality: more than a third of the patients in our sample are affected. An exhaustive pre- and posnatal follow-up of these cases is recommended in order to perform an early intervention. (AU)