International Consensus Statement on the diagnosis, multidisciplinary management and lifelong care of individuals with achondroplasia.

Achondroplasia, the most common skeletal dysplasia, is characterized by a variety of medical, functional and psychosocial challenges across the lifespan. The condition is caused by a common, recurring, gain-of-function mutation in FGFR3, the gene that encodes fibroblast growth factor receptor 3. This mutation leads to impaired endochondral ossification of the human skeleton. The clinical and radiographic hallmarks of achondroplasia make accurate diagnosis possible in most patients. However, marked variability exists in the clinical care pathways and protocols practised by clinicians who manage children and adults with this condition. A group of 55 international experts from 16 countries and 5 continents have developed consensus statements and recommendations that aim to capture the key challenges and optimal management of achondroplasia across each major life stage and sub-specialty area, using a modified Delphi process. The primary purpose of this first International Consensus Statement is to facilitate the improvement and standardization of care for children and adults with achondroplasia worldwide in order to optimize their clinical outcomes and quality of life.

Bi-allelic Variants in TONSL Cause SPONASTRIME Dysplasia and a Spectrum of Skeletal Dysplasia Phenotypes.

SPONASTRIME dysplasia is an autosomal-recessive spondyloepimetaphyseal dysplasia characterized by spine (spondylar) abnormalities, midface hypoplasia with a depressed nasal bridge, metaphyseal striations, and disproportionate short stature. Scoliosis, coxa vara, childhood cataracts, short dental roots, and hypogammaglobulinemia have also been reported in this disorder. Although an autosomal-recessive inheritance pattern has been hypothesized, pathogenic variants in a specific gene have not been discovered in individuals with SPONASTRIME dysplasia. Here, we identified bi-allelic variants in TONSL, which encodes the Tonsoku-like DNA repair protein, in nine subjects (from eight families) with SPONASTRIME dysplasia, and four subjects (from three families) with short stature of varied severity and spondylometaphyseal dysplasia with or without immunologic and hematologic abnormalities, but no definitive metaphyseal striations at diagnosis. The finding of early embryonic lethality in a Tonsl-/- murine model and the discovery of reduced length, spinal abnormalities, reduced numbers of neutrophils, and early lethality in a tonsl-/- zebrafish model both support the hypomorphic nature of the identified TONSL variants. Moreover, functional studies revealed increased amounts of spontaneous replication fork stalling and chromosomal aberrations, as well as fewer camptothecin (CPT)-induced RAD51 foci in subject-derived cell lines. Importantly, these cellular defects were rescued upon re-expression of wild-type (WT) TONSL; this rescue is consistent with the hypothesis that hypomorphic TONSL variants are pathogenic. Overall, our studies in humans, mice, zebrafish, and subject-derived cell lines confirm that pathogenic variants in TONSL impair DNA replication and homologous recombination-dependent repair processes, and they lead to a spectrum of skeletal dysplasia phenotypes with numerous extra-skeletal manifestations.

GGC Repeat Expansion and Exon 1 Methylation of XYLT1 Is a Common Pathogenic Variant in Baratela-Scott Syndrome.

Baratela-Scott syndrome (BSS) is a rare, autosomal-recessive disorder characterized by short stature, facial dysmorphisms, developmental delay, and skeletal dysplasia caused by pathogenic variants in XYLT1. We report clinical and molecular investigation of 10 families (12 individuals) with BSS. Standard sequencing methods identified biallelic pathogenic variants in XYLT1 in only two families. Of the remaining cohort, two probands had no variants and six probands had only a single variant, including four with a heterozygous 3.1 Mb 16p13 deletion encompassing XYLT1 and two with a heterozygous truncating variant. Bisulfite sequencing revealed aberrant hypermethylation in exon 1 of XYLT1, always in trans with the sequence variant or deletion when present; both alleles were methylated in those with no identified variant. Expression of the methylated XYLT1 allele was severely reduced in fibroblasts from two probands. Southern blot studies combined with repeat expansion analysis of genome sequence data showed that the hypermethylation is associated with expansion of a GGC repeat in the XYLT1 promoter region that is not present in the reference genome, confirming that BSS is a trinucleotide repeat expansion disorder. The hypermethylated allele accounts for 50% of disease alleles in our cohort and is not present in 130 control subjects. Our study highlights the importance of investigating non-sequence-based alterations, including epigenetic changes, to identify the missing heritability in genetic disorders.

Haploinsufficiency of the Chromatin Remodeler BPTF Causes Syndromic Developmental and Speech Delay, Postnatal Microcephaly, and Dysmorphic Features.

Bromodomain PHD finger transcription factor (BPTF) is the largest subunit of nucleosome remodeling factor (NURF), a member of the ISWI chromatin-remodeling complex. However, the clinical consequences of disruption of this complex remain largely uncharacterized. BPTF is required for anterior-posterior axis formation of the mouse embryo and was shown to promote posterior neuroectodermal fate by enhancing Smad2-activated wnt8 expression in zebrafish. Here, we report eight loss-of-function and two missense variants (eight de novo and two of unknown origin) in BPTF on 17q24.2. The BPTF variants were found in unrelated individuals aged between 2.1 and 13 years, who manifest variable degrees of developmental delay/intellectual disability (10/10), speech delay (10/10), postnatal microcephaly (7/9), and dysmorphic features (9/10). Using CRISPR-Cas9 genome editing of bptf in zebrafish to induce a loss of gene function, we observed a significant reduction in head size of F0 mutants compared to control larvae. Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) and phospho-histone H3 (PH3) staining to assess apoptosis and cell proliferation, respectively, showed a significant increase in cell death in F0 mutants compared to controls. Additionally, we observed a substantial increase of the ceratohyal angle of the craniofacial skeleton in bptf F0 mutants, indicating abnormal craniofacial patterning. Taken together, our data demonstrate the pathogenic role of BPTF haploinsufficiency in syndromic neurodevelopmental anomalies and extend the clinical spectrum of human disorders caused by ablation of chromatin remodeling complexes.

Stüve-Wiedemann Syndrome: Update on Clinical and Genetic Aspects.

Stüve-Wiedemann syndrome is a rare autosomal recessive disorder characterized by bowed long bones, joint restrictions, dysautonomia, and respiratory and feeding difficulties, leading to death in the neonatal period and infancy in several occasions. Since the first cases in 1971, much has been learned about this condition, including its molecular basis - mutations in the leukemia inhibitory factor receptor gene (LIFR) -, natural history and management possibilities. This review aims to highlight the clinical aspects, radiological features, molecular findings, and management strategies in Stüve-Wiedemann syndrome.

Mutations in PCYT1A cause spondylometaphyseal dysplasia with cone-rod dystrophy.

Spondylometaphyseal dysplasia with cone-rod dystrophy is a rare autosomal-recessive disorder characterized by severe short stature, progressive lower-limb bowing, flattened vertebral bodies, metaphyseal involvement, and visual impairment caused by cone-rod dystrophy. Whole-exome sequencing of four individuals affected by this disorder from two Brazilian families identified two previously unreported homozygous mutations in PCYT1A. This gene encodes the alpha isoform of the phosphate cytidylyltransferase 1 choline enzyme, which is responsible for converting phosphocholine into cytidine diphosphate-choline, a key intermediate step in the phosphatidylcholine biosynthesis pathway. A different enzymatic defect in this pathway has been previously associated with a muscular dystrophy with mitochondrial structural abnormalities that does not have cartilage and/or bone or retinal involvement. Thus, the deregulation of the phosphatidylcholine pathway may play a role in multiple genetic diseases in humans, and further studies are necessary to uncover its precise pathogenic mechanisms and the entirety of its phenotypic spectrum.

Cervicothoracic myelopathy in children with Morquio syndrome A: a report of 4 cases.

BACKGROUND: Craniovertebral junction anomalies and C1-C2 instability resulting in myelopathy have been well described in the literature on mucopolysaccharidosis IV (MPS-IV). Spinal involvement in MPS-IV patients, with neurological impairment, other than atlanto-axial instability and thoracolumbar kyphosis, has been scarcely mentioned in the literature. METHODS: Retrospective clinical and radiologic review of the medical records and imaging studies of 4 individuals with Morquio A syndrome, who had undergone decompression and fusion of the cervicothoracic spine for myelopathy secondary to cervicothoracic stenosis between 1990 and 2009. Data regarding the presence of kyphosis at the cervicothoracic and upper thoracic spine, and neurological symptoms and signs were obtained. RESULTS: There were 3 girls and 1 boy with an average age of 5 years and 11 months at presentation with neurological symptoms. Half of the patients had previously undergone occipitocervical fusion for atlanto-axial instability, whereas the other half were noted to have spinal cord compression at both the upper cervical and cervicothoracic regions, and underwent decompression and fusion at both levels concomitantly. All patients showed postoperative neurological improvement. All patients presented with the classical Morquio syndrome vertebral morphology. Cervicothoracic kyphosis was found in all of our patients in a varying severity (10 to 35 degrees). Levels of stenosis were similar in 3 patients, C7-T2; and occurred at a lower spinal level, T1-T4, in the remaining patient. Posterior disk bulging and thecal sac indentation were found in all 4 patients. CONCLUSIONS: Neurological problems secondary to progressive kyphosis and stenosis at the cervicothoracic and upper thoracic spine are seen in children with Morquio syndrome. Early detection with a careful neurological assessment, whole spine MR imaging, and appropriate surgical treatment can prevent permanent neurological sequelae.

A newly recognized syndrome with characteristic facial features, skeletal dysplasia, and developmental delay.

We describe a series of seven male patients from six different families with skeletal dysplasia, characteristic facial features, and developmental delay. Skeletal findings include patellar dislocation, short tubular bones, mild metaphyseal changes, brachymetacarpalia with stub thumbs, short femoral necks, shallow acetabular roofs, and platyspondyly. Facial features include: a flattened midface with broad nasal bridge, cleft palate or bifid uvula and synophrys. All of the patients demonstrated pre-school onset of a cognitive developmental delay with a shortened attention span. Some of the cognitive delay was masked by a warm and engaging personality. We posit that these individuals have a newly recognized syndrome characterized by the described features. There is some phenotypic overlap between these patients and Desbuquois dysplasia; however molecular testing demonstrated that this is a distinct disorder. Given the family information available for each patient, we are suspicious that the constellation of findings reported herein could be an X-linked recessive syndrome.

Karyotype/phenotype correlation in partial trisomies of the long arm of chromosome 16: case report and review of literature.

Trisomy 16q is a clinically recognizable entity presenting with a wide spectrum of abnormalities. Only five infants with a diagnosis of partial trisomy 16q13 → qter have been previously reported, and all died during the first year of life. We report the clinical and molecular cytogenetic findings in a patient with trisomy 16q13 → qter due to the presence of a supernumerary marker chromosome (SMC). The child presented with microcephaly, ambiguous genitalia, cardiac malformations and dysmorphic features. Cytogenetic investigation using GTG-banding, spectral karyotyping (SKY) and fluorescence in situ hybridization analyses revealed an SMC of maternal origin with karyotype der(15)t(15;16)(q13;q13). Specific genotype-phenotype correlations among different segments of the 16q region cannot yet be defined. We suggest that the involvement of the entire region spanning from 16q11 to 16q22 is necessary for the characteristic phenotype of the trisomy 16q.

A componential view of configural cues in generalization and discrimination in Pavlovian conditioning.

This paper describes three theoretical approaches to the representation of configural cues in generalization and discrimination in Pavlovian conditioning: that of the Rescorla-Wagner model, the Pearce model, and the authors' 'replaced elements' model. We summarize the results of a generalization experiment using the rabbit Pavlovian conditioned eyeblink response where animals were trained with cues A, AB, or ABC, and tested with A, AB, and ABC. The pattern of generalization decrement in testing supported the replaced elements model.

Modulation of the acquisition of the rabbit eyeblink conditioned response by conditioned contextual stimuli.

Three experiments were conducted to ask if conditioned emotional responses (CERs) controlled by contextual cues modulate the acquisition of eyelid conditioned responses (CRs) to discrete conditioned stimuli (CSs). Experiment 1 showed that 30-s auditory stimuli that were paired with aversive shocks to one paraorbital region or the other controlled discriminated CERs, as measured by potentiation of a startle response. In Experiments 2 and 3, similarly trained 30-s stimuli served as contexts in which 1.050-ms CSs were paired with a paraorbital unconditioned stimulus (US). Reinforced contexts both impaired (Experiments 2A and 2B) and facilitated (Experiment 3B) acquisition of the eyeblink CR, depending on the locus of the USs involved. The data are consistent with the interpretation that CERs controlled by contextual cues facilitate CR acquisition, but do so in the face of blocking effects of CR tendencies also conditioned to the contextual cues.

Discriminated lateralized eyeblink conditioning in the rabbit: an experimental context for separating specific and general associative influences.

Four experiments are reported that demonstrate discriminated lateralized eyeblink conditioning in rabbits and show how the phenomenon may be used to differentiate between the reflexive and emotive consequences of Pavlovian conditioning. Experiments 1, 2, and 3 characterized how 2 conditioned stimuli (CSs), contemporaneously trained with left vs. right paraorbital unconditioned stimuli (USs), can produce different conditioned reflexes (CRs), each involving predominant closure of the eye ipsilateral to its US. Experiment 4 showed how the associative tendencies controlled by additional stimuli could be evaluated by presentations in compound with such discriminanda: A 30-s stimulus, presumed to acquire a conditioned emotional response but no eyeblink CR, equally potentiated the eyelid CRs elicited by both CSs; a 1,050-ms CS that evoked an eyeblink CR in isolation also increased the responding to both CSs but biased it toward its own lateralized CR.

Modulation of a discrete Pavlovian conditioned reflex by a putative emotive Pavlovian conditioned stimulus.

Three experiments showed the modulation of a rabbit eyeblink conditioned response (CR) to a Pavlovian conditioned stimulus (CS) by 30-s stimuli (A & B) that had been differentially paired with paraorbital shock. The CS (Y) was a 1,050-ms cue that had been paired with paraorbital shock outside A or B. In testing, the amplitude of CRs was greater when Y was presented within A than within B. Differential modulation occurred whether shock in A had been preceded by another 1,050-ms cue, X(AX+,BX-;Experiment 1) or not (A+B-;Experiment 2). Experiment 3 compared the technique of Experiment 1 (AX+) with that of Experiment 2 (A+) and found the latter to be advantageous for facilitation of CRs to Y by A. These data are consistent with the predictions of a model of Pavlovian conditioning (AESOP, Wagner & Brandon, 1989) that distinguishes between emotive and sensory conditioning as did Konorski (1967).

Modulation of unconditioned defense reflexes by a putative emotive Pavlovian conditioned stimulus.

Four experiments showed differential modulation of defensive unconditioned responses (URs) in rabbits by contextual stimuli that Brandon and Wagner (1991) have shown similarly to modulate conditioned eyeblink responses. Two 30-s auditory cues, A and B, were differentially paired with shock. Tests were presentations of a response-eliciting probe stimulus within A, B, or a comparable blank interval, Experiments 1 and 2 demonstrated that A and B differentially facilitated eyeblink URs, and Experiments 3 and 4 showed that A and B similarly differentially facilitated startle responses elicited by airpuffs to the ear. These data are consistent with a characterization of Pavlovian conditioning that distinguishes between emotive and sensory conditioning and assumes that conditioned emotional responses similarly modulate specific conditioned and unconditioned defensive reflexes (Konorski, 1967; Wagner & Brandon, 1989).

Modulation of a conditioned eyeblink response by a putative emotive stimulus conditioned with hindleg shock.

Two experiments with rabbits showed that the differential modulation of a conditioned eyeblink response (CR) by 30-s auditory stimuli previously paired with shock was independent of the locus of shock application. In Experiment 1, the modulation occurred when the CR was trained with paraorbital shock and the 30-s stimuli were trained with either hindleg or paraorbital shock. Experiment 2 replicated the observed adequacy of hindleg shock for modulation training, under 2 different conditions of eyeblink conditioning. The data, along with the findings that the same 30-s stimuli similarly facilitate the unconditioned eyeblink and the airpuff-elicited startle response (Brandon, Bombace, Falls & Wagner, 1991), were viewed as supporting the notion that the CR-modulation is dependent upon a conditioned fear response elicited by the 30-s cues (Wagner & Brandon, 1989).

Modulation of behavioral and insulin responses by contextual stimuli paired with food.

A context-like conditioned stimulus (CS) previously paired with a food unconditioned stimulus (US) enhanced both food-related activity and insulin secretion in rats. Experiment 1 documented the effectiveness of an appetitive conditioning procedure in which a 10 sec visual CS ("x") was followed by food when embedded within one 35 sec auditory CS ("A"), but not another ("B"). Approach to a food magazine during x was enhanced (facilitated) when x was within A, as compared to within B or alone. Experiment 2 documented the adequacy of blood sampling and insulin assay procedures that could be accommodated to the conditioning procedure. Plasma insulin was observably different after unconditioned deliveries of glucose solutions of different intensities. In Experiment 3, training as in Experiment 1 was followed by testing for food magazine approach and changes in insulin levels following x alone or in the presence of A or B. It was demonstrated that the A cue enhanced both responses. The results support the view [e.g., (18,19)] that insulin secretion is in part under the control of environmental cues, and findings (22) that show that conditioned context-like cues can modulate consummatory responding to punctate CSs.

Development of context-specific tolerance to morphine: support for a dual-process interpretation.

Four experiments were concerned with the development in rats of context-specific tolerance to the sedating and analgesic effects of morphine. Experiment 1 was conducted to assess the temporal course of activity changes and analgesia consequent to acute morphine administration. Experiments 2, 3, and 4 were conducted to assess the development of context-specific morphine tolerance in the two measures under different conditions of pairing of morphine with a distinctive environment. In support of a dual-process model (postulating both a general tendency for conditioned diminution of unconditioned responding and a more restricted influence of the development of specific conditioned compensatory responses), tolerance was observed in both measures, but evidence of conditioned compensatory response was found only in the activity measure. The differential evidence of conditioned compensatory response in the two measures was interpreted as consistent with the fact that the activity measure showed a biphasic unconditioned response in Experiment 1 whereas the analgesic measure did not.

Evaluation of blocking and conditioned inhibition to a CS signaling a decrease in US intensity.

Two experiments employing a conditioned emotional response procedure with rats evaluated the associative tendencies acquired by a target CS when a compound of that stimulus and another CS was reinforced by a low-intensity US whereas the latter CS alone was reinforced by a higher intensity US. Experiment 1 involved a blocking sequence in which the element and compound trials occurred in successive phases, followed by eventual testing of the responding to the target CS alone. Less evidence of excitatory conditioning was observed than in a comparison group which had the element and compound paired with the same low-intensity US. Experiment 2 included contemporaneous differential reinforcement of the element and compound CSs and periodic summation tests in which the target CS was compounded with another independently trained CS. Clear evidence was obtained of the development of inhibitory tendencies by the target CS. The results are consistent with the predictions of the Rescorla-Wagner model and are discussed in relation to the several determining assumptions of the model.

One-trial overshadowing: evidence of distributive processing.

Evidence of "overshadowing" following a single training trial was obtained in each of five experiments measuring stimulus-evoked suppression of licking in rats. In three conditioned emotional response experiments, less conditioned suppression was observed to either a light or a tone when the stimuli had been paired with shock in compound that when either had been paired with shock in isolation. This difference occurred when the stimuli were diffuse and produced differential orienting behaviors on the training trial (Experiment 1). But, it was as demonstrable when the stimuli were designed to be localizable from the same source and produce apparently compatible orienting behaviors (Experiments 2A and 3A). The difference was also as substantial when the stimulus compound was composed of successive, nonoverlapping stimulus elements as when composed of simultaneous elements (Experiment 3A). In two companion habituation studies (Experiments 2B and 3B) using the same stimulus arrangements but no pairing with shock, there was consistently less habituation of the unconditioned suppression to the visual and tonal stimuli when exposed in compound rather than in isolation. One-trial "overshadowing" is at odds with those theories that approach overshadowing only as a multiple-trial phenomenon. The apparent generality of the effect provides impetus for a theoretical account that supposes some manner of distributive processing.