Multicenter appraisal of comorbid TANGO2 deficiency disorder in patients with 22q11.2 deletion syndrome.

TANGO2 deficiency disorder (TDD) is a rare, autosomal recessive condition caused by pathogenic variants in TANGO2, a gene residing within the region commonly deleted in 22q11.2 deletion syndrome (22q11.2DS). Although patients with 22q11.2DS are at substantially higher risk for comorbid TDD, it remains underdiagnosed within 22q11.2DS, likely due to overlapping symptomatology and a lack of knowledge about TDD. Initiation of B-vitamin supplementation may provide therapeutic benefit in TDD, highlighting the need for effective screening methods to improve diagnosis rates in this at-risk group. In this retrospective, multicenter study, we evaluated two cohorts of patients with 22q11.2DS (total N = 435) for possible comorbid TDD using two different symptom-based screening methods (free text-mining and manual chart review versus manual chart review alone). The methodology of the cohort 1 screening method successfully identified a known 22q11.2DS patient with TDD. Combined, these two cohorts identified 21 living patients meeting the consensus recommendation for TANGO2 testing for suspected comorbid TDD. Of the nine patients undergoing TANGO2 sequencing with del/dup analysis, none were ultimately diagnosed with TDD. Of the 12 deaths in the suspected comorbid TDD cohort, some of these patients exhibited symptoms (rhabdomyolysis, cardiac arrhythmia, or metabolic crisis) suspicious of comorbid TDD contributing to their death. Collectively, these findings highlight the need for robust prospective screening tools for diagnosing comorbid TDD in patients with 22q11.2DS.

Novel insights into symbiont population structure: Globe-trotting avian feather mites contradict the specialist-generalist variation hypothesis.

Researchers often examine symbiont host specificity as a species-level pattern, but it can also be key to understanding processes occurring at the population level, which are not as well understood. The specialist-generalist variation hypothesis (SGVH) attempts to explain how host specificity influences population-level processes, stating that single-host symbionts (specialists) exhibit stronger population genetic structure than multi-host symbionts (generalists) because of fewer opportunities for dispersal and more restricted gene flow between populations. However, this hypothesis has not been tested in systems with highly mobile hosts, in which population connectivity may vary temporally and spatially. To address this gap, we tested the SGVH on proctophyllodid feather mites found on migratory warblers (family Parulidae) with contrasting host specificities, Amerodectes protonotaria (a host specialist of Protonotaria citrea) and A. ischyros (a host generalist of 17 parulid species). We used a pooled-sequencing approach and a novel workflow to analyse genetic variants obtained from whole genome data. Both mite species exhibited fairly weak population structure overall, and contrary to predictions of the SGVH, the generalist was more strongly structured than the specialist. These results may suggest that specialists disperse more freely among conspecifics, whereas generalists sort according to geography. Furthermore, our results may reflect an unexpected period for mite transmission - during the nonbreeding season of migratory hosts - as mite population structure more closely reflects the distributions of hosts during the nonbreeding season. Our findings alter our current understanding of feather mite biology and highlight the potential for studies to explore factors driving symbiont diversification at multiple evolutionary scales.

Breaking Barriers to Rapid Whole Genome Sequencing in Pediatrics: Michigan's Project Baby Deer.

The integration of precision medicine in the care of hospitalized children is ever evolving. However, access to new genomic diagnostics such as rapid whole genome sequencing (rWGS) is hindered by barriers in implementation. Michigan's Project Baby Deer (PBD) is a multi-center collaborative effort that sought to break down barriers to access by offering rWGS to critically ill neonatal and pediatric inpatients in Michigan. The clinical champion team used a standardized approach with inclusion and exclusion criteria, shared learning, and quality improvement evaluation of the project's impact on the clinical outcomes and economics of inpatient rWGS. Hospitals, including those without on-site geneticists or genetic counselors, noted positive clinical impacts, accelerating time to definitive treatment for project patients. Between 95-214 hospital days were avoided, net savings of $4155 per patient, and family experience of care was improved. The project spurred policy advancement when Michigan became the first state in the United States to have a Medicaid policy with carve-out payment to hospitals for rWGS testing. This state project demonstrates how front-line clinician champions can directly improve access to new technology for pediatric patients and serves as a roadmap for expanding clinical implementation of evidence-based precision medicine technologies.

The high-risk hip fracture patient and the palliative care consult : A retrospective study to investigate risks of complications and the utility of a palliative care consult in hip fracture patients undergoing surgical fixation.

We evaluated the utility of a palliative care consult (PCC) in high-risk hip fracture patients. The main result was that a PCC reflects certain risk factors for post-surgical complications and is associated with a delay to surgery in the high-risk patient population that it served. PURPOSE: The objective of this study was to identify risks of complications in surgically managed hip fractures and determine the utility of a PCC in this population, particularly regarding time to the operating room (OR). METHODS: Retrospective cohort at a Level I academic trauma center. RESULTS: Four hundred sixty-two patients were treated surgically for hip fracture. Decreased pre-injury ambulatory status (OR 2.18, 95% CI 1.13-4.20, p = .02), time to OR > 48 h (OR 4.76, 95% CI 1.43-15.87, p = .011), and obtaining a pre-operative PCC (OR 3.03, 95% CI 1.34-6.85, p = .008) were independent risk factors for post-surgical complications. Multivariate risk factors for obtaining a PCC included older age (OR 1.1, CI 1.0-1.1, p = .007), pre-injury ambulatory status (OR 2.2, CI 1.3-3.9, p = .005), renal failure (OR 3.1, CI 1.1-9.0, p = 0.032), and higher ASA category (OR 2.6, CI 1.2-5.5, p = .014). A delay of more than 48 h was associated with being male ( OR 4.6, CI 1.4-15.0, p = .013) or having obtained a PCC (OR 5.5, CI 1.4-22.7, p = .017). CONCLUSIONS: Obtaining a PCC can reflect risks of complications and mortality. It is a valuable resource for use in high-risk patients who are inherently at risk for delays to surgery and should be used judiciously.

Qualitative Study of Orthopedic Surgery Milestones 1.0: Burdens and Benefits.

OBJECTIVE: The purpose of this study was to explore the context and mechanisms by which the first set of Milestones impacted the processes of the Clinical Competency Committee, how programs have incorporated the Milestones into their program, and to understand more about the resident perspective in order to improve Orthopedic Surgery Milestones. DESIGN, SETTING, AND PARTICIPANTS: In 2020 all 201 accredited orthopedic surgery residency programs were invited to participate in qualitative telephone interviews to assess their experience with the Milestones and complete a supplemental online survey about their Clinical Competency Committee. Participants were comprised of a self-selected sample and complemented by a purposeful sample to ensure a breadth of perspectives. Interview data were analyzed using template analysis. Survey data were analyzed with descriptive statistics. RESULTS: Interviews were completed with 101 individuals from 47 programs (23% of all programs). The two overarching themes were implementation and impact of Milestones. Subthemes within implementation were substantial variability in approaches to Milestone use in curriculum and assessment, faculty development, and methods to introduce residents to the Milestones assessment framework. The large number of subcompetencies created a significant burden for almost all programs. The structure of the Milestones was also viewed as poorly aligned with the variable design of rotation schedules across programs. Milestones have the potential to offer valuable feedback for trainees and programs overall. CONCLUSIONS/APPLICATION: While some benefits were noted and most programs appreciated the intent, the structure and design of the initial set of orthopedic surgery Milestones created substantial challenges for these programs. The results of this study helped guide a revision of the Orthopedic Surgery Milestones. These results can also be used by program leadership to encourage reflection around past, current, and future utilization of the Milestones framework. Further research will be needed to determine the impact of the revision on programs.

Further description of two patients with biallelic variants in NADSYN1 in association with cardiac and vertebral anomalies.

Congenital nicotinamide adenine dinucleotide (NAD) deficiency disorders are associated with pathogenic variants in the genes NADSYN1, HAAO, and KYNU. These disorders overlap with the anomalies present in vertebral, anal, cardiac, tracheoesophageal, radial and renal, and limb anomalies (VATER/VACTERL) association and often result in premature death. Children who survive typically have developmental delays or intellectual disability. Here, we describe two patients with compound heterozygous variants in NADSYN1 who presented with cardiac and vertebral defects overlapping with the VATER/VACTERL association, although the patients did not satisfy criteria for the diagnosis of VATER/VACTERL due to their lack of limb anomalies and significant renal anomalies. One patient survived into childhood with developmental delays and may represent an expansion of the survival data for NADSYN1-associated NAD deficiency disorders. Interestingly, one patient had hypoplastic left heart syndrome (HLHS) and one had an aortic coarctation and transverse hypoplasia of the aortic arch, suggesting that NADSYN1 sequencing should be performed in children presenting with congenital anomalies related to VATER/VACTERL association and with HLHS and aortic arch abnormalities.

Multisite Retrospective Review of Outcomes in Renal Replacement Therapy for Neonates with Inborn Errors of Metabolism.

OBJECTIVE: To assess the outcomes of neonates in a contemporary multi-institutional cohort who receive renal replacement therapy (RRT) for hyperammonemia. STUDY DESIGN: We performed a retrospective analysis of 51 neonatal patients with confirmed inborn errors of metabolism that were treated at 9 different children's hospitals in the US between 2000 and 2015. RESULTS: Twenty-nine patients received hemodialysis (57%), 21 patients received continuous renal replacement therapy (41%), and 1 patient received peritoneal dialysis (2%). The median age at admission of both survivors (n = 33 [65%]) and nonsurvivors (n = 18) was 3 days. Peak ammonia and ammonia at admission were not significantly different between survivors and nonsurvivors. Hemodialysis, having more than 1 indication for RRT in addition to hyperammonemia, and complications during RRT were all risk factors for mortality. After accounting for multiple patient factors by multivariable analyses, hemodialysis was associated with a higher risk of death compared with continuous renal replacement therapy. When clinical factors including evidence of renal dysfunction, number of complications, concurrent extracorporeal membrane oxygenation, vasopressor requirement, and degree of hyperammonemia were held constant in a single Cox regression model, the hazard ratio for death with hemodialysis was 4.07 (95% CI 0.908-18.2, P value = .067). To help providers caring for neonates with hyperammonemia understand their patient's likelihood of survival, we created a predictive model with input variables known at the start of RRT. CONCLUSIONS: Our large, multicenter retrospective review supports the use of continuous renal replacement therapy for neonatal hyperammonemia.

Programmed Cell Death in Cystinosis.

Cystinosis is a lethal autosomal recessive disease that has been known clinically for over 100 years. There are now specific treatments including dialysis, renal transplantation and the orphan drug, cysteamine, which greatly improve the duration and quality of patient life, however, the cellular mechanisms responsible for the phenotype are unknown. One cause, programmed cell death, is clearly involved. Study of extant literature via Pubmed on "programmed cell death" and "apoptosis" forms the basis of this review. Most of such studies involved apoptosis. Numerous model systems and affected tissues in cystinosis have shown an increased rate of apoptosis that can be partially reversed with cysteamine. Proposed mechanisms have included changes in protein signaling pathways, autophagy, gene expression programs, and oxidative stress.

Symptom Prevalence and Genotype-Phenotype Correlations in Patients With TANGO2-Related Metabolic Encephalopathy and Arrhythmias (TRMEA).

BACKGROUND: TANGO2-related metabolic encephalopathy and arrhythmias (TRMEA) is a rare, phenotypically heterogeneous, neurological disease affecting children. METHODS: We conducted a chart review of five children with molecularly confirmed TRMEA diagnosed at our institution and compiled pathogenic variant frequency and symptom prevalence from cases previously reported in the literature. RESULTS: Including those patients in our case series, 76 patients with TRMEA have been described. Developmental delay (93%) and/or regression (71%), spasticity (78%), and seizures (57%) are common in TRMEA and frequently precede life-threatening symptoms such as metabolic decompensation with lactic acidosis (83%), cardiomyopathy (38%), and cardiac arrhythmias (68%). Deletion of exons 3 to 9 is the most common pathogenic variant (39% of alleles). The majority of reported intragenic variants (17 of 27) result in disruption of the reading frame, and no clear genotype-phenotype correlations could be identified for those variants wherein the reading frame is maintained, highlighting instead the variable expressivity of the disease. CONCLUSIONS: Patients with TRMEA frequently experience life-threatening complications that are preceded by common neurological symptoms underscoring the need for pediatric neurologists to be familiar with this condition. Additional work pertaining to disease pathophysiology and potential therapeutics is needed.

Interspecific competition between resident and wintering birds: experimental evidence and consequences of coexistence.

The contribution of interspecific competition to structuring population and community dynamics remains controversial and poorly tested. Interspecific competition has long been thought to influence the structure of migrant-resident bird communities in winter, yet experimental evidence remains elusive. The arrival of billions of songbirds into Neotropical habitats, where they co-exist with residents, provides a unique opportunity to assess interspecific competition and its consequences. Working in 15 ha of Jamaican black mangrove forest, we used removal experiments to test whether dominant resident Yellow Warblers compete interspecifically with subordinate wintering American Redstarts; we also used observational evidence (interspecific territorial overlap) to understand whether this coexistence influences physical condition, spring departure dates or annual return rates. Consistent with interspecific competition, after experimental removal of the resident, yearling male Redstarts (but not females or adult males) immediately moved into vacated Yellow Warbler territories, increasing their overlap with the space by 7.3%. Yearling Redstarts also appeared to adjust their territorial space use by actively avoiding Yellow Warblers; for example, Redstarts departing the wintering grounds as yearlings and returning the following winter shifted such that their territories overlapped 32% less with those of Yellow Warblers. Adult Redstarts showed no such territorial flexibility. Adult male Redstarts also showed evidence supporting the consequences of coexistence: territorial overlap with Yellow Warblers was negatively correlated with body condition and annual return rates. Adult male Redstarts with <25% territorial overlap with Yellow Warblers were more than three times as likely to return between seasons than those with 100% overlap. We propose that the territorial inflexibility of adult male Redstarts produces these consequences, which may be due to their years-long investment in that particular territory. More generally, the temporary nature of migrant-resident interspecific competition is likely what allows coexistence during winter, the most resource-poor time of year. Interspecific competition and the consequences of coexistence are likely age- and sex-specific and the product of intraspecific dominance hierarchy in Redstarts. Our observations suggest that interspecific coexistence has measurable consequences, and our experiments support the long-held, but previously untested belief that resident birds compete interspecifically with wintering migrants.

Current Practices for U.S. Newborn Screening of Pompe Disease and MPSI.

Two lysosomal storage disorders (LSDs), Pompe disease and Mucopolysaccharidosis type I (MPSI) were added to the Recommended Uniform Screening Panel (RUSP) for newborn screening (NBS) in 2015 and 2016, respectively. These conditions are being screened with variable practice in terms of primary and reflex analytes (either biochemical or molecular testing) as well as collection of short- and long-term follow-up elements. The goal of this study is to evaluate practices of state health departments in regards to screening methods and follow-up data collected. We conducted online surveys and phone questionnaires to determine each U.S. state's practices for screening and follow-up of positive newborn screens. We report the first snapshot of practices for NBS for the LSDs included on the RUSP. All 50 U.S. states responded to our survey. The majority of U.S. states are not currently screening for Pompe disease and MPSI as of March 2020, but this number will increase to 38 states in the coming 1-3 years based on survey results. Our survey identifies data elements used by state health departments for short-and long-term follow-up that could serve as the basis of common elements for larger, public health-based analyses of the benefits and efficacy of screening for Pompe disease and MPSI.

Bergmann's rule is followed at multiple stages of postembryonic development in a long-distance migratory songbird.

Bergmann's rule is a well-established, ecogeographical principle that states that body size varies positively with latitude, reflecting the thermoregulatory benefits of larger bodies as temperatures decline. However, this principle does not seem to easily apply to migratory species that are able to avoid the extreme temperatures during winter at higher latitudes. Further, little is known about the ontogeny of this relationship across life stages or how it is influenced by ongoing global climate change. To address these knowledge gaps, we assessed the contemporary relationship between latitude and body size in a long-distance migratory species, the prothonotary warbler (Protonotaria citrea) across life stages (egg to adult) on their breeding grounds. We also measured historic eggs (1865-1961) to assess if the relationship between latitude and size during this life stage has changed over time. In accordance with Bergmann's rule, we found a positive relationship between latitude and body mass during all post-embryonic life stages, from early nestling stage through adulthood. We observed this same predicted pattern with historic eggs, but contemporary eggs exhibited the reverse (negative) relationship. We suggest that these results indicate a genetic component to this pattern and speculate that selection for larger body size in altricial nestlings as latitude increases may possibly drive the pattern in migratory species as even rare extreme cold weather events may cause mortality during early life stages. Furthermore, the opposite relationships observed in eggs, dependent on time period, may be related to the rapidly warming environments of higher latitudes that is associated with climate change. Although it is unclear what mechanism(s) would allow for this recent reversal in eggs (but still allow for its maintenance in later life stages). This evidence of a reversal suggests that anthropogenic climate change may be in the process of altering one of the longest-standing principles in ecology.

A cautionary tale of pyridoxine toxicity in cystathionine beta-synthase deficiency detected by two-tier newborn screening highlights the need for clear pyridoxine dosing guidelines.

Classic homocystinuria is due to deficiency of cystathionine beta-synthase (CBS), a pyridoxine-dependent enzyme that, depending on the molecular variants, may be co-factor responsive. Elevated methionine is often used as the primary analyte to detect CBS deficiency (CBSD) on newborn screening (NBS), but is limited by increased detection of other biochemical disorders with less clear clinical significance such as methionine aminotransferase (MAT) I/III heterozygotes. Our state has implemented a two-tier NBS algorithm for CBSD that successfully reduced the number of MATI/III heterozygotes, yet effectively detected a mild, co-factor responsive form of CBSD. After initial diagnosis, newborns with CBSD often undergo a pyridoxine challenge with high-dose pyridoxine to determine responsiveness. Here we describe our NBS-identified patient with a mild form of pyridoxine responsive CBSD who developed respiratory failure and rhabdomyolysis consistent with pyridoxine toxicity during a pyridoxine challenge. This case highlights the need for weight-based dosing and duration recommendations for pyridoxine challenge in neonates.

Striving for population-level conservation: integrating physiology across the biological hierarchy.

The field of conservation physiology strives to achieve conservation goals by revealing physiological mechanisms that drive population declines in the face of human-induced rapid environmental change (HIREC) and has informed many successful conservation actions. However, many studies still struggle to explicitly link individual physiological measures to impacts across the biological hierarchy (to population and ecosystem levels) and instead rely on a 'black box' of assumptions to scale up results for conservation implications. Here, we highlight some examples of studies that were successful in scaling beyond the individual level, including two case studies of well-researched species, and using other studies we highlight challenges and future opportunities to increase the impact of research by scaling up the biological hierarchy. We first examine studies that use individual physiological measures to scale up to population-level impacts and discuss several emerging fields that have made significant steps toward addressing the gap between individual-based and demographic studies, such as macrophysiology and landscape physiology. Next, we examine how future studies can scale from population or species-level to community- and ecosystem-level impacts and discuss avenues of research that can lead to conservation implications at the ecosystem level, such as abiotic gradients and interspecific interactions. In the process, we review methods that researchers can use to make links across the biological hierarchy, including crossing disciplinary boundaries, collaboration and data sharing, spatial modelling and incorporating multiple markers (e.g. physiological, behavioural or demographic) into their research. We recommend future studies incorporating tools that consider the diversity of 'landscapes' experienced by animals at higher levels of the biological hierarchy, will make more effective contributions to conservation and management decisions.

A retrospective review of outcomes in the treatment of hyperammonemia with renal replacement therapy due to inborn errors of metabolism.

BACKGROUND: Outcomes for severe hyperammonemia treated with renal replacement therapy (RRT) reported in the literature vary widely. This has created differing recommendations regarding when RRT is beneficial for hyperammonemic patients. METHODS: To evaluate our institution's experience with RRT in pediatric patients with inborn errors of metabolism (IEMs) and potential prognostic indicators of a better or worse outcome, we performed a retrospective chart review of patients who received RRT for hyperammonemia. Our cohort included 19 patients with confirmed IEMs who received RRT between 2000 and 2017. Descriptive statistics are presented as medians with interquartile ranges with appropriate statistical testing assuming unequal variance. RESULTS: There were 16 males (84%) and 3 females (16%) identified for inclusion in this study. There were 9 survivors (47%) and 10 non-survivors (53%). The average age of survivors was 67 months (age range from 3 days to 15.6 years). The average age of non-survivors was 1.8 months (age range from 2 days to 18.7 months). Peak ammonia, ammonia on admission, and at RRT initiation were higher in non-survivors compared with survivors. Higher ammonia levels and no change in ammonia between admission and RRT initiation were associated with an increased risk of mortality. CONCLUSIONS: Hyperammonemia affects two distinct patient populations; neonates with markedly elevated ammonia levels on presentation and older children who often have established IEM diagnoses and require RRT after failing nitrogen-scavenging therapy. Our experience demonstrates no significant change in mortality associated with neonatal hyperammonemia, which remains high despite improvements in RRT and intensive care.

Habitat-dependent occupancy and movement in a migrant songbird highlights the importance of mangroves and forested lagoons in Panama and Colombia.

Climate change is predicted to impact tropical mangrove forests due to decreased rainfall, sea-level rise, and increased seasonality of flooding. Such changes are likely to influence habitat quality for migratory songbirds occupying mangrove wetlands during the tropical dry season. Overwintering habitat quality is known to be associated with fitness in migratory songbirds, yet studies have focused primarily on territorial species. Little is known about the ecology of nonterritorial species that may display more complex movement patterns within and among habitats of differing quality. In this study, we assess within-season survival and movement at two spatio-temporal scales of a nonterritorial overwintering bird, the prothonotary warbler (Protonotaria citrea), that depends on mangroves and tropical lowland forests. Specifically, we (a) estimated within-patch survival and persistence over a six-week period using radio-tagged birds in central Panama and (b) modeled abundance and occupancy dynamics at survey points throughout eastern Panama and northern Colombia as the dry season progressed. We found that site persistence was highest in mangroves; however, the probability of survival did not differ among habitats. The probability of warbler occupancy increased with canopy cover, and wet habitats were least likely to experience local extinction as the dry season progressed. We also found that warbler abundance is highest in forests with the tallest canopies. This study is one of the first to demonstrate habitat-dependent occupancy and movement in a nonterritorial overwintering migrant songbird, and our findings highlight the need to conserve intact, mature mangrove, and lowland forests.

Differing Experiences with Breastfeeding in Residency Between Mothers and Coresidents.

Background: Returning to work and lack of support for expressing breast milk (pumping) at work is often cited as a reason that mothers discontinue breastfeeding, particularly among female physicians. It is unclear how these perceived difficulties affect resident mothers and how resident teams perceive coresidents who choose to pump at work. The goal of this study was to identify differences in perception of resident mothers and their coresidents about breastfeeding residents pumping. Materials and Methods: An online survey in 2017 was sent to 413 residents in Pediatrics, Internal Medicine, Family Medicine, and Anesthesia at the University of Michigan Health System. Results: A total of 82 residents completed the survey (20% response rate). Resident mothers (15% of respondents self-identified as a mother) were asked specific questions regarding their experiences with breastfeeding. Almost all mothers (92%) encountered difficulty in breastfeeding after returning to work. The majority of mothers reported that their mood was affected by these difficulties (85%). The most common challenge that breastfeeding residents encountered was not enough time to pump. The majority of all residents surveyed (74%) have worked with a breastfeeding resident. Forty percent of breastfeeding residents felt that their pumping adversely affected the team, whereas only 10% of coresidents felt the same. Conclusions: Breastfeeding residents encountered significant difficulties that affected their well-being when breastfeeding while returning to work. They also felt that their pumping can be detrimental to their job. However, their coresidents felt that pumping had no major setbacks to team efficiency or patient care and did not create additional work.