Fabry disease Enzyme Enhancement on migalastat Study: FEES.

BACKGROUND: There is limited information on the α-galactosidase A (α-Gal-A) in vivo response in Fabry patients receiving migalastat. In this single centre study, we evaluated changes from baseline in α-Gal A activity, lyso-Gb3 and other assessments in patients on migalastat. RESULTS: 79 patients were recruited (48 M:31F; median duration receiving migalastat 3.8 years [range = 0.4-14.9 years]). N215S was the commonest genotype in males (67 %) and females (29 %). Leukocyte α-Gal-A showed a positive change from baseline in males (n = 4; median = 20.05); females (n = 8; median = 26). Of these, 3 males and 1 female had N215S (median = 16.7), while 7 females and 1 male had other genotypes (median = 26). No significant changes observed in plasma α-Gal-A. Cross-sectional analysis of post-baseline data confirmed leukocyte α-Gal-A enhancement in males (n = 47; median = 20); females (n = 30; median = 72); N215S (n = 41; median = 29) and other genotypes (n = 36; median = 36.5). Plasma and dried blood spot (DBS) lyso-Gb3 correlated at baseline and post-baseline (r = 0.77 and r = 0.96; p=<0.0001). CONCLUSIONS: In the 12 patients with paired data, there was a median enzyme enhancement of 17.4 (relative change = 2.54) and 33 (relative change = 0.87) in males and in females, respectively. The cross-sectional post-baseline data in 47 patients corroborated leukocyte α-Gal-A enhancement on migalastat. Plasma and DBS lyso-Gb3 correlated well supporting DBS utility for disease monitoring.

Evaluation, in a highly specialised enzyme laboratory, of a digital microfluidics platform for rapid assessment of lysosomal enzyme activity in dried blood spots.

Lysosomal storage disorders (LSDs) are predominantly enzyme deficiencies leading to substrate accumulation, causing progressive damage to multiple organs. To date, a crucial part of diagnosing LSDs is measuring enzymatic activity in leucocytes, plasma, or dried blood spots (DBS). Here, we present results from a proof-of-principle study, evaluating an innovative digital microfluidics (DMF) platform, referred to as SEEKER®, that can measure the activity of the following four lysosomal enzymes from DBS: α-L-iduronidase (IDUA) for mucopolysaccharidosis I (MPS I), acid α-glucosidase (GAA) for Pompe disease, ß-glucosidase (GBA) for Gaucher disease, and α-galactosidase A (GLA) for Fabry disease. Over 900 DBS were analysed from newborns, children, and adults. DMF successfully detected known patients with MPS I, Pompe disease, and Gaucher disease, and known males with Fabry disease. This is the first demonstration of this multiplexed DMF platform for identification of patients with LSDs in a specialised diagnostic enzyme laboratory environment. We conclude that this DMF platform is relatively simple, high-throughput, and could be readily accommodated into a specialised laboratory as a first-tier test for MPS I, Pompe disease, and Gaucher disease for all patients, and Fabry disease for male patients only.

Making Emergency Surgical Decisions Without any Imaging Evidence: A Case Report of Complicated Diverticular Phlegmon.

Acute left-sided diverticulitis is the third most common gastrointestinal disease after acute pancreatitis and cholecystitis requiring hospitalization. From those patients, 15% to 20% were diagnosed with abscess on the computed tomography (CT) scan. Usually, abscess larger than 5 cm are not amenable for medical treatment. A 61-year-old woman presented to emergency department of the general hospital in the remote island with 48-h history of fever, tachypnea, and tachycardia. Physical examination revealed 15 × 7 cm mass occupying the left mid-abdomen and iliac fossa. Patient did not report any unintentional loss of weight or change of bowel habits. She only reported that the last month she felt her lower tummy bloated. Due to absence of radiographer during this period in the hospital there was no possibility for any imaging investigations. Diagnostic laparoscopy revealed a phlegmon in the left abdomen consisting of the sigmoid colon, loops of the small bowel and wrapped by the omentum. Hartmann procedure was performed. Patient recovered uneventfully and was scheduled for reversal procedure. Surgical intervention is the treatment of choice for complicated large diverticular abscess; in the remote island, any delayed diagnosis may lead to life-threatening complications.

Combined Gluteal and Posterior Thigh Compartment Syndrome Without Associated Fracture: A Case Report.

Compartment syndrome usually occurs after trauma, fracture, or compression injuries. To the authors' best knowledge, this is the first reported case in the medical literature of a combined gluteal and posterior thigh compartment syndrome after an accidental fall without an associated fracture. A 65-year-old man attended the emergency department of the general hospital in a remote island complaining of a swollen painful thigh. He reported that 24 h previously he had an accidental slip and fall on his overstretching right leg. Physical examination revealed right posterior thigh edema, tenderness, paraesthesia, and firmness to palpation. Any attempt to flex the knee provoked pain of intensity 10/10. In addition, there was blue discoloration over the lower half of the gluteal region, non-compressible tense swelling, and pain of intensity 10/10 elicited with passive range of motion of the hip. Compartment syndrome was considered and consequently, fasciotomy of the gluteal and posterior thigh compartments was performed under spinal anesthesia. Compartment syndrome is a surgical emergency. In a remote island, it must be considered and treated early because any delayed diagnosis may lead to loss of an extremity, kidney failure, sepsis and even death.

How to best handle vaccine decliners: scientific facts and psychological approach.

There is currently no curative drug therapy for COVID-19. The spread of the virus seems relentless despite the unprecedented epidemiological measures. Prevention remains the only feasible option to stop the pandemic; without population-level vaccination, we are unlikely to regain the quality of social life and the unrestricted economy/commerce we enjoyed before. Anti-vaxxers and conspiracy theorists are seemingly oblivious to the detrimental effect of COVID-19 both at an individual and societal level. These groups have (and probably will) continue to attempt to undermine efforts to eradicate the virus despite the fact that the major reduction in morbidity/and mortality of infectious diseases of the past century was achieved through the development of vaccines and improved hygiene. Conspiracy theories are directly associated with reduced vaccine uptake and unfortunately neither anti-vaxxers nor vaccine hesitants cannot be persuaded (debunked) with logical arguments; hence, prescribers must not only be aware of the truth underlying the dense web of misinformation but must fully understand the psychological aspects as well to be able to efficiently counsel about the potential benefits and harms. Such knowledge is pivotal to help the lay public to make informed decisions about SARS CoV-2 in general and vaccination in particular; as the COVID-19 situation can probably be best controlled with mass inoculation and novel immune therapies. The lessons learnt regarding the importance of efficient communication and the adherence to the proven epidemiological measures hopefully would be leaving us better prepared for the future if challenged by novel communicable diseases of pandemic potential.

Improving the early identification of COVID-19 pneumonia: a narrative review.

Delayed presentation of COVID-19 pneumonia increases the risk of mortality and need for high-intensity healthcare. Conversely, early identification of COVID-19 pneumonia grants an opportunity to intervene early and thus prevent more complicated, protracted and less successful hospital admissions. To improve the earlier detection of COVID-19 pneumonia in the community we provide a narrative review of current evidence examining the clinical parameters associated with early disease progression. Through an evolving literature review, we examined: the symptoms that may suggest COVID-19 progression; the timing of deterioration; the utility of basic observations, clinical examination and chest X-ray; the value of postexertion oxygen saturations; and the use of CRP to monitor disease progression. We go on to discuss the challenges in monitoring the COVID-19 patient in the community and discuss thresholds for further assessment. Confusion, persistent fever and shortness of breath were identified as worrying symptoms suggestive of COVID-19 disease progression necessitating urgent clinical contact. Importantly, a significant proportion of COVID-19 pneumonia patients appear not to suffer dyspnoea despite severe disease. Patients with this asymptomatic hypoxia seem to have a poorer prognosis. Such patients may present with other signs of hypoxia: severe fatigue, exertional fatigue and/or altered mental status. We found duration of symptoms to be largely unhelpful in determining risk, with evidence of deterioration at any point in the disease. Basic clinical parameters (pulse, respiratory rate, blood pressure, temperature and oxygen saturations (SpO2)) are likely of high value in detecting the deteriorating community COVID-19 patient and/or COVID-19 mimickers/complications (eg, sepsis, bacterial pneumonia and pulmonary embolism). Of these, SpO2 carried the greatest utility in detecting COVID-19 progression. CRP is an early biochemical parameter predictive of disease progression and used appropriately is likely to contribute to the early identification of COVID-19 pneumonia. Identifying progressive COVID-19 in the community is feasible using basic clinical questions and measurements. As such, if we are to limit the mortality, morbidity and the need for complicated, protracted admissions, monitoring community COVID-19 cases for signs of deterioration to facilitate early intervention is a viable strategy.

Safety and efficacy of an engineered hepatotropic AAV gene therapy for ornithine transcarbamylase deficiency in cynomolgus monkeys.

X-linked inherited ornithine transcarbamylase deficiency (OTCD) is the most common disorder affecting the liver-based urea cycle, a pathway enabling detoxification of nitrogen waste and endogenous arginine biosynthesis. Patients develop acute hyperammonemia leading to neurological sequelae or death despite the best-accepted therapy based on ammonia scavengers and protein-restricted diet. Liver transplantation is curative but associated with procedure-related complications and lifelong immunosuppression. Adeno-associated viral (AAV) vectors have demonstrated safety and clinical benefits in a rapidly growing number of clinical trials for inherited metabolic liver diseases. Engineered AAV capsids have shown promising enhanced liver tropism. Here, we conducted a good-laboratory practice-compliant investigational new drug-enabling study to assess the safety of intravenous liver-tropic AAVLK03 gene transfer of a human codon-optimized OTC gene. Juvenile cynomolgus monkeys received vehicle and a low and high dose of vector (2 × 1012 and 2 × 1013 vector genome (vg)/kg, respectively) and were monitored for 26 weeks for in-life safety with sequential liver biopsies at 1 and 13 weeks post-vector administration. Upon completion of monitoring, animals were euthanized to study vector biodistribution, immune responses, and histopathology. The product was well tolerated with no adverse clinical events, predominant hepatic biodistribution, and sustained supra-physiological OTC overexpression. This study supports the clinical deployment of intravenous AAVLK03 for severe OTCD.

Previously undiagnosed scoliosis presenting as pleuritic chest pain in the emergency department - a case series and a validating retrospective audit.

BACKGROUND: Chest pain is one of the commonest presenting complaints in urgent/emergency care, with a lifelong prevalence of up to 25% in the adult population. Pleuritic chest pain is a subset of high investigation burden because of a diverse range of possible causes varying from simple musculoskeletal conditions to pulmonary embolism. CASE SERIES: Among otherwise fit and healthy adult patients presenting in our emergency department with sudden onset of unilateral pleuritic chest pain, within 1 month we identified a cohort of five patients with pin-point tenderness in one specific costo-sternal joint often with referred pain to the back. All cases had apparent and, previously undiagnosed mild/moderate scoliosis. METHODS: To confirm and validate the observed association between scoliosis and pleuritic chest pain, a retrospective audit was designed and performed using the hospital's electronic medical record system to reassess all consecutive adult chest pain patients. RESULTS: The Odds Ratio for having chest pain with scoliosis was 30.8 [95%CI 1.71-553.37], twenty times higher than suggested by prevalence data. DISCUSSION: In scoliosis the pathologic lateral curvature of the spine adversely affects the functional anatomy of both the spine and ribcage. In our hypothesis the chest wall asymmetry enables minor slip/subluxation of a rib either in the costo-sternal and/or costovertebral junction exerting direct pressure on the intercostal nerve causing pleuritic pain. CONCLUSION: Thorough physical examination of the anterior and posterior chest wall is key to identify underlying scoliosis in otherwise fit patients presenting with sudden onset of pleuritic pain. Incorporating assessment for scoliosis in the low-risk chest pain protocols/tools may help reducing the length of stay in the emergency department and, facilitate speedy but safe discharge with increased patient satisfaction.

Traumatic brain injury probability of survival assessment in adults using iterative random comparison classification.

Trauma brain injury (TBI) is the most common cause of death and disability in young adults. A method to determine the probability of survival (Ps) in trauma called iterative random comparison classification (IRCC) was developed and its performance was evaluated in TBI. IRCC operates by iteratively comparing the test case with randomly chosen subgroups of cases from a database of known outcomes (survivors and not survivors) and determines the overall percentage match. The performance of IRCC to determine Ps in TBI was compared with two existing methods. One was Ps14 that uses regression and the other was predictive statistical diagnosis (PSD) that is based on Bayesian statistic. The TBI database contained 4124 adult cases (mean age 67.9 years, standard deviation 21.6) of which 3553 (86.2%) were survivors and 571 (13.8%) were not survivors. IRCC determined Ps for the survivors and not survivors with an accuracy of 79.0 and 71.4%, respectively, while the corresponding values for Ps14 were 97.4% (survivors) and 40.2% (not survivors) and for PSD were 90.8% (survivors) and 50% (not survivors). IRCC could be valuable for determining Ps in TBI and with a suitable database in other traumas.

Loss-of-Function Variants in HOPS Complex Genes VPS16 and VPS41 Cause Early Onset Dystonia Associated with Lysosomal Abnormalities.

OBJECTIVES: The majority of people with suspected genetic dystonia remain undiagnosed after maximal investigation, implying that a number of causative genes have not yet been recognized. We aimed to investigate this paucity of diagnoses. METHODS: We undertook weighted burden analysis of whole-exome sequencing (WES) data from 138 individuals with unresolved generalized dystonia of suspected genetic etiology, followed by additional case-finding from international databases, first for the gene implicated by the burden analysis (VPS16), and then for other functionally related genes. Electron microscopy was performed on patient-derived cells. RESULTS: Analysis revealed a significant burden for VPS16 (Fisher's exact test p value, 6.9 × 109 ). VPS16 encodes a subunit of the homotypic fusion and vacuole protein sorting (HOPS) complex, which plays a key role in autophagosome-lysosome fusion. A total of 18 individuals harboring heterozygous loss-of-function VPS16 variants, and one with a microdeletion, were identified. These individuals experienced early onset progressive dystonia with predominant cervical, bulbar, orofacial, and upper limb involvement. Some patients had a more complex phenotype with additional neuropsychiatric and/or developmental comorbidities. We also identified biallelic loss-of-function variants in VPS41, another HOPS-complex encoding gene, in an individual with infantile-onset generalized dystonia. Electron microscopy of patient-derived lymphocytes and fibroblasts from both patients with VPS16 and VPS41 showed vacuolar abnormalities suggestive of impaired lysosomal function. INTERPRETATION: Our study strongly supports a role for HOPS complex dysfunction in the pathogenesis of dystonia, although variants in different subunits display different phenotypic and inheritance characteristics. ANN NEUROL 2020;88:867-877.

Lentiviral Hematopoietic Stem Cell Gene Therapy Rescues Clinical Phenotypes in a Murine Model of Pompe Disease.

Pompe disease is a lysosomal storage disorder caused by malfunctions of the acid alpha-glucosidase (GAA) enzyme with a consequent toxic accumulation of glycogen in cells. Muscle wasting and hypertrophic cardiomyopathy are the most common clinical signs that can lead to cardiac and respiratory failure within the first year of age in the more severe infantile forms. Currently available treatments have significant limitations and are not curative, highlighting a need for the development of alternative therapies. In this study, we investigated the use of a clinically relevant lentiviral vector to deliver systemically GAA through genetic modification of hematopoietic stem and progenitor cells (HSPCs). The overexpression of GAA in human HSPCs did not exert any toxic effect on this cell population, which conserved its stem cell capacity in xenograft experiments. In a murine model of Pompe disease treated at young age, we observed phenotypic correction of heart and muscle function with a significant reduction of glycogen accumulation in tissues after 6 months of treatment. These findings suggest that lentiviral-mediated HSPC gene therapy can be a safe alternative therapy for Pompe disease.

A genetic and clinical study of individuals with nonsyndromic retinopathy consequent upon sequence variants in HGSNAT, the gene associated with Sanfilippo C mucopolysaccharidosis.

Pathogenic variants in the gene HGSNAT (heparan-α-glucosaminide N-acetyltransferase) have been reported to underlie two distinct recessive conditions, depending on the specific genotype, mucopolysaccharidosis type IIIC (MPSIIIC)-a severe childhood-onset lysosomal storage disorder, and adult-onset nonsyndromic retinitis pigmentosa (RP). Here we describe the largest cohort to-date of HGSNAT-associated nonsyndromic RP patients, and describe their retinal phenotype, leukocyte enzymatic activity, and likely pathogenic genotypes. We identified biallelic HGSNAT variants in 17 individuals (15 families) as the likely cause of their RP. None showed any other symptoms of MPSIIIC. All had a mild but significant reduction of HGSNAT enzyme activity in leukocytes. The retinal condition was generally of late-onset, showing progressive degeneration of a concentric area of paramacular retina, with preservation but reduced electroretinogram responses. Symptoms, electrophysiology, and imaging suggest the rod photoreceptor to be the cell initially compromised. HGSNAT enzymatic testing was useful in resolving diagnostic dilemmas in compatible patients. We identified seven novel sequence variants [p.(Arg239Cys); p.(Ser296Leu); p.(Phe428Cys); p.(Gly248Ala); p.(Gly418Arg), c.1543-2A>C; c.1708delA], three of which were considered to be retina-disease-specific alleles. The most prevalent retina-disease-specific allele p.(Ala615Thr) was observed heterozygously or homozygously in 8 and 5 individuals respectively (7 and 4 families). Two siblings in one family, while identical for the HGSNAT locus, but discordant for retinal disease, suggest the influence of trans-acting genetic or environmental modifying factors.

Infrared thermal imaging as a screening tool for paediatric wrist fractures.

Wrist injuries are common in paediatric trauma; however, only half of children evaluated with an x-ray for possible fractures will have one. Thermal imaging offers a possible non-ionising method of screening for fractures and thus reducing negative x-ray rates. One hundred five children attending the Emergency Department for wrist injuries were recruited. Two 30-s thermal videos were recorded from injured and uninjured wrists-in flat and 45° elevated positions. A region of interest (ROI) was defined on each wrist. Cases in which the ROI was covered or had ice applied were excluded, leaving 40 patients for analysis. Comparisons of ROI included (i) injured and uninjured wrists-flat and elevated positions; (ii) as in (i) with a reference region on the proximal forearm subtracted; (iii) injured wrist ROI-flat and elevated positions. Fractures and sprains increased the mean skin surface temperature by 1.519% (p = 0.008) and 0.971% (p = 0.055) respectively compared with the uninjured wrist. The mean temperature difference between flat and elevated positions for fractures was 0.268% and - 0.1291% for sprains. This difference was statistically significant for fracture (p = 0.004) but not sprain (p = 0.500). The temperature differences recorded by thermal imaging between fractured and sprained wrists may assist in differentiation of these injuries. Graphical abstract Operational stages involved from thermal video recording to generation of results.

Inhibition of Mitochondrial Complex I Impairs Release of α-Galactosidase by Jurkat Cells.

Fabry disease (FD) is caused by mutations in the GLA gene that encodes lysosomal α-galactosidase-A (α-gal-A). A number of pathogenic mechanisms have been proposed and these include loss of mitochondrial respiratory chain activity. For FD, gene therapy is beginning to be applied as a treatment. In view of the loss of mitochondrial function reported in FD, we have considered here the impact of loss of mitochondrial respiratory chain activity on the ability of a GLA lentiviral vector to increase cellular α-gal-A activity and participate in cross correction. Jurkat cells were used in this study and were exposed to increasing viral copies. Intracellular and extracellular enzyme activities were then determined; this in the presence or absence of the mitochondrial complex I inhibitor, rotenone. The ability of cells to take up released enzyme was also evaluated. Increasing transgene copies was associated with increasing intracellular α-gal-A activity but this was associated with an increase in Km. Release of enzyme and cellular uptake was also demonstrated. However, in the presence of rotenone, enzyme release was inhibited by 37%. Excessive enzyme generation may result in a protein with inferior kinetic properties and a background of compromised mitochondrial function may impair the cross correction process.

Vitamin D intake, calcium intake and physical activity among children with wrist and ankle injuries and the association with fracture risk.

BACKGROUND: Several studies have revealed a substantial increase in the incidence of fractures in children in the past few decades. AIM: To assess the strength of the association between suggested risk factors and fracture prevalence in children. METHOD: A cross sectional observational study. Children aged 6-15 years and their guardians presenting to the Emergency Department of a single tertiary paediatric hospital were recruited. Self-reported data on vitamin D intake, calcium intake and physical activity were collected. All participants had a radiograph of their injured limb reported by a consultant radiologist, on the basis of which they were classified into fracture or no fracture groups. Statistical analysis included descriptive statistics and binary logistic regression. RESULTS: Of the 130 patients recruited, 53 (41%) had sustained a fracture. The overwhelming majority of children (98%) did not consume the recommended daily dietary amount of vitamin D (400 IU/day). Low calcium intake and low levels of physical activity were also ascertained. However, there were no significant differences between fracture and no fracture groups for vitamin D intake, calcium intake or physical activity. Both site of injury (wrist) and sex (male) were associated with increased fracture risk ( p = 0.001 and p = 0.05, respectively). Logistic regression showed a statistically significant relationship between calcium intake and fracture risk (every additional unit of calcium consumption (mg/day) decreased the likelihood of fracture by 0.002, 95% confidence interval, 0.001-0.003). CONCLUSIONS: Low dietary intake of calcium and vitamin D and low levels of physical activity were evident. Fracture risk was significantly associated with reduced calcium intake but showed no association with vitamin D intake or physical activity.

Exploratory Study to Evaluate Respiratory Rate Using a Thermal Imaging Camera.

BACKGROUND: Respiratory rate is a vital physiological measurement used in the immediate assessment of unwell children and adults. Convenient electronic devices exist for the measurement of pulse, blood pressure, oxygen saturation, and temperature. Although devices which measure respiratory rate exist, none have entered everyday clinical practice for acute assessment of children and adults. An accurate and practical device which has no physical contact with the patient is important to ensure readings are not affected by distress caused by the assessment method. OBJECTIVE: The aim of this study was to evaluate the use of a thermal imaging method to monitor the respiratory rate in children and adults. METHODS: Facial thermal images of adult volunteers and children undergoing elective polysomnography were included. Respiration was recorded for at least 2 min with the camera positioned 1 m from the subject's face. Values obtained using the thermal imaging camera were compared with those obtained from contact methods such as the nasal thermistor, respiratory inductance plethysmography, nasal airflow, and end tidal CO2. RESULTS: A total of 61 subjects, including 41 adults (age range 27-46 years) and 20 children (age range 0.5-18 years) were enrolled. The correlation between the respiratory rate measured using thermal imaging and the contact method was r = 0.94. Sequential refinements to the thermal imaging algorithms resulted in the ability to perform real-time measurements and an improvement of the correlation to r = 0.995. CONCLUSION: This exploratory study shows that thermal imaging-derived respiratory rates in children and adults correlate closely with the best performing standard method. With further refinements, this method could be implemented in both acute and chronic care in children and adults.

Implementing the National Institute for Health and Clinical Excellence Head Injury 2014 Guidelines in a major children's hospital emergency department.

OBJECTIVES AND BACKGROUND: Head injury is a common paediatric emergency department presentation. The National Institute for Health and Clinical Excellence updated its guidance in January 2014 regarding imaging required for adults and children following a head injury (CG176). This study looked at the rates of computed tomography (CT) head scans performed and adherence rates to CG176. PATIENTS AND METHODS: A single-centre audit was carried out, examining imaging practice in children with head injuries. CG176 was implemented formally in August 2014 to the new trainee doctors. The primary outcome was adherence to CG176. As the data were binary, 95% confidence intervals were used for comparison. RESULTS: In all, 1797 patients were identified as having a head injury. Implementation at the Sheffield's Children NHS Foundation Trust resulted in a statistically significant increase in guideline adherence from 79.2% [95% confidence interval (CI): 76.4-81.9%] to 85.1% (95% CI: 82.9-87.4%). The greatest impact in adherence was found in CT head scans, from 95.8% (95% CI: 94.5-97.2%) to 97.7% (95% CI: 96.7-98.6%). CONCLUSION: The implementation at the Sheffield's Children NHS Foundation Trust was successful in satisfying the aim of CG176 by increasing adherence and decreasing CT head scans. This success could be explained by the formal implementation to the new cohort of doctors and better physician agreement with the guidelines. The increase in adherence is contrary to the previous studies.