High-resolution pediatric reference intervals for 15 biochemical analytes described using fractional polynomials.

OBJECTIVES: Assessment of children's laboratory test results requires consideration of the extensive changes that occur during physiological development and result in pronounced sex- and age-specific dynamics in many biochemical analytes. Pediatric reference intervals have to account for these dynamics, but ethical and practical challenges limit the availability of appropriate pediatric reference intervals that cover children from birth to adulthood. We have therefore initiated the multi-center data-driven PEDREF project (Next-Generation Pediatric Reference Intervals) to create pediatric reference intervals using data from laboratory information systems. METHODS: We analyzed laboratory test results from 638,683 patients (217,883-982,548 samples per analyte, a median of 603,745 test results per analyte, and 10,298,067 test results in total) performed during patient care in 13 German centers. Test results from children with repeat measurements were discarded, and we estimated the distribution of physiological test results using a validated statistical approach (kosmic). RESULTS: We report continuous pediatric reference intervals and percentile charts for alanine transaminase, aspartate transaminase, lactate dehydrogenase, alkaline phosphatase, γ-glutamyl-transferase, total protein, albumin, creatinine, urea, sodium, potassium, calcium, chloride, anorganic phosphate, and magnesium. Reference intervals are provided as tables and fractional polynomial functions (i.e., mathematical equations) that can be integrated into laboratory information systems. Additionally, Z-scores and percentiles enable the normalization of test results by age and sex to facilitate their interpretation across age groups. CONCLUSIONS: The provided reference intervals and percentile charts enable precise assessment of laboratory test results in children from birth to adulthood. Our findings highlight the pronounced dynamics in many biochemical analytes in neonates, which require particular consideration in reference intervals to support clinical decision making most effectively.

Next-generation reference intervals for pediatric hematology.

Background Interpreting hematology analytes in children is challenging due to the extensive changes in hematopoiesis that accompany physiological development and lead to pronounced sex- and age-specific dynamics. Continuous percentile charts from birth to adulthood allow accurate consideration of these dynamics. However, the ethical and practical challenges unique to pediatric reference intervals have restricted the creation of such percentile charts, and limitations in current approaches to laboratory test result displays restrict their use when guiding clinical decisions. Methods We employed an improved data-driven approach to create percentile charts from laboratory data collected during patient care in 10 German centers (9,576,910 samples from 358,292 patients, 412,905-1,278,987 samples per analyte). We demonstrate visualization of hematology test results using percentile charts and z-scores (www.pedref.org/hematology) and assess the potential of percentiles and z-scores to support diagnosis of different hematological diseases. Results We created percentile charts for hemoglobin, hematocrit, red cell indices, red cell count, red cell distribution width, white cell count and platelet count in girls and boys from birth to 18 years of age. Comparison of pediatricians evaluating complex clinical scenarios using percentile charts versus conventional/tabular representations shows that percentile charts can enhance physician assessment in selected example cases. Age-specific percentiles and z-scores, compared with absolute test results, improve the identification of children with blood count abnormalities and the discrimination between different hematological diseases. Conclusions The provided reference intervals enable precise assessment of pediatric hematology test results. Representation of test results using percentiles and z-scores facilitates their interpretation and demonstrates the potential of digital approaches to improve clinical decision-making.

Thalamo-telencephalic pathways in the fire-bellied toad Bombina orientalis.

It was suggested that among extant vertebrates, anuran amphibians display a brain organization closest to the ancestral tetrapod condition, and recent research suggests that anuran brains share important similarities with the brains of amniotes. The thalamus is the major source of sensory input to the telencephalon in both amphibians and amniote vertebrates, and this sensory input is critical for higher brain functions. The present study investigated the thalamo-telencephalic pathways in the fire-bellied toad Bombina orientalis, a basal anuran, by using a combination of retrograde tract tracing and intracellular injections with the tracer biocytin. Intracellular labeling revealed that the majority of neurons in the anterior and central thalamic nuclei project to multiple brain targets involved in behavioral modulation either through axon collaterals or en passant varicosities. Single anterior thalamic neurons target multiple regions in the forebrain and midbrain. Of note, these neurons display abundant projections to the medial amygdala and a variety of pallial areas, predominantly the anterior medial pallium. In Bombina, telencephalic projections of central thalamic neurons are restricted to the dorsal striato-pallidum. The bed nucleus of the pallial commissure/thalamic eminence similarly targets multiple brain regions including the ventral medial pallium, but this is accomplished through a higher variety of distinct neuron types. We propose that the amphibian diencephalon exerts widespread influence in brain regions involved in behavioral modulation and that a single dorsal thalamic neuron is in a position to integrate different sensory channels and distribute the resulting information to multiple brain regions.

Organization of the pallium in the fire-bellied toad Bombina orientalis. I: Morphology and axonal projection pattern of neurons revealed by intracellular biocytin labeling.

The cytoarchitecture and axonal projection pattern of pallial areas was studied in the fire-bellied toad Bombina orientalis by intracellular injection of biocytin into a total of 326 neurons forming 204 clusters. Five pallial regions were identified, differing in morphology and projection pattern of neurons. The rostral pallium receiving the bulk of dorsal thalamic afferents has reciprocal connections with all other pallial areas and projects to the septum, nucleus accumbens, and anterior dorsal striatum. The medial pallium projects bilaterally to the medial pallium, septum, nucleus accumbens, mediocentral amygdala, and hypothalamus and ipsilaterally to the rostral, dorsal, and lateral pallium. The ventral part of the medial pallium is distinguished by efferents to the eminentia thalami and the absence of contralateral projections. The dorsal pallium has only ipsilateral projections running to the rostral, medial, and lateral pallium; septum; nucleus accumbens; and eminentia thalami. The lateral pallium has ipsilateral projections to the olfactory bulbs and to the rostral, medial, dorsal, and ventral pallium. The ventral pallium including the striatopallial transition area (SPTA) has ipsilateral projections to the olfactory bulbs, rostral and lateral pallium, dorsal striatopallidum, vomeronasal amygdala, and hypothalamus. The medial pallium can be tentatively homologized with the mammalian hippocampal formation, the dorsal pallium with allocortical areas, the lateral pallium rostrally with the piriform and caudally with the entorhinal cortex, the ventral pallium with the accessory olfactory amygdala. The rostral pallium, with its projections to the dorsal and ventral striatopallidum, resembles the mammalian frontal cortex.

Evolution of the amygdala: new insights from studies in amphibians.

The histology of amphibian brains gives an impression of relative simplicity when compared with that of reptiles or mammals. The amphibian telencephalon is small and contains comparatively few and large neurons, which in most parts constitute a dense periventricular cellular layer. However, the view emerging from the last decade is that the brains of all tetrapods, including amphibians, share a general bauplan resulting from common ancestry and the need to perform similar vital functions. To what extent this common organization also applies to higher brain functions is unknown due to a limited knowledge of the neurobiology of early vertebrates. The amygdala is widely recognized as a brain center critical for basic forms of emotional learning (e.g., fear conditioning) and its structure in amphibians could suggest how this capacity evolved. A functional systems approach is used here to synthesize the results of our anatomical investigations of the amphibian amygdala. It is proposed that the connectivity of the amphibian telencephalon portends a capacity for multi-modal association in a limbic system largely similar to that of amniote vertebrates. One remarkable exception is the presence of new sensory-associative regions of the amygdala in amniotes: the posterior dorsal ventricular ridge plus lateral nuclei in reptiles and the basolateral complex in mammals. These presumably homologous regions apparently are capable of modulating the phylogenetically older central amygdala and allow more complex forms of emotional learning.

The septal complex of the fire-bellied toad Bombina orientalis: chemoarchitecture.

In order to investigate whether chemoarchitecture would support the subdivision of the anuran septum based on cytoarchitectonic and hodological studies, we performed enzyme-histochemical detection of NADPH-diaphorase and immunohistological demonstration of choline-acetyl transferase (ChAT), aspartate, calretinin, gamma-aminobutyric acid (GABA), 5-hydroxy-tryptamine, tyrosine hydroxylase, neuropeptide Y (NPY), somatostatin, Leu- and Leu + Met-enkephalin, and substance P in the fire-bellied toad Bombina orientalis. Labeling of cell bodies matched well the previously defined subnuclei: The dorsolateral septal nucleus contains enkephalin-immunoreactive (-ir) and weakly stained GABA-ir neurons; calretinin-ir and weakly labeled GABA-ir neurons are found in the ventrolateral septal nucleus. The medial septal nucleus is characterized by the presence of numerous ChAT-ir and some tyrosine hydroxylase-ir neurons, while the dorsal septal nucleus is outlined by its NPY-ir neurons. Many ChAT-ir and some aspartate-ir and somatostatin-ir neurons are found in the diagonal band of Broca, and the central septal nucleus contains some GABA-ir and ChAT-ir neurons. In contrast, labeled fibers form a pattern which does not match the boundaries of septal subnuclei. Comparing the anuran septal complex with that of other vertebrates reveals that the complexity of the lateral septum has increased during the evolution from anamniote to amniote vertebrates. In spite of this fact, many similarities in chemoarchitecture between anurans and other vertebrates are evident. Some basal septal functions such as involvement in learning and memory formation or inhibition of sexual behavior appear to have persisted during vertebrate evolution.

Connectivity and cytoarchitecture of telencephalic centers in the fire-bellied toad Bombina orientalis.

In the fire-bellied toad Bombina orientalis, the connectivity and cytoarchitecture of telencephalic structures were studied by intracellular, anterograde and retrograde biocytin labelling in order to elucidate the neuronal basis of fear conditioning and context learning in amphibians. Our findings suggest the existence of a central amygdala-bed nucleus of the stria terminalis complex in the caudal mid-ventral telencephalon, a vomeronasal amygdala in the caudolateral ventral telencephalon, an olfactory amygdala in the caudal pole of the telencephalon lateral of the vomeronasal amygdala, and a ventromedially situated "medial" amygdala, which is assumed to be functionally equivalent to the basolateral amygdala of mammals. A ventromedial cellular column forms a nucleus accumbens rostrally and continues caudally into a shell-like ventral pallidum. A lateral column constitutes a dorsal striatum proper rostrally, a dorsal pallidum caudally, and a mixed striato-pallidum at intermediate levels. We conclude that the caudal mediolateral complex consisting of an extended central, vomeronasal and olfactory amygdala of anurans represents the ancestral equivalent of the amygdaloid complex of tetrapods. During the evolution of the mammalian telencephalon, this complex apparently was shifted medially and involuted.

Morphology and axonal projection pattern of neurons in the telencephalon of the fire-bellied toad Bombina orientalis: an anterograde, retrograde, and intracellular biocytin labeling study.

The connectivity and cytoarchitecture of telencephalic centers except dorsal and medial pallium were studied in the fire-bellied toad Bombina orientalis by anterograde and retrograde biocytin labeling and intracellular biocytin injection (total of 148 intracellularly labeled neurons or neuron clusters). Our findings suggest the following telencephalic divisions: (1) a central amygdala-bed nucleus of the stria terminalis in the caudal midventral telencephalon, connected to visceral-autonomic centers; (2) a vomeronasal amygdala in the caudolateral ventral telencephalon receiving input from the accessory olfactory bulb and projecting mainly to the preoptic region/hypothalamus; (3) an olfactory amygdala in the caudal pole of the telencephalon lateral to the vomeronasal amygdala receiving input from the main olfactory bulb and projecting to the hypothalamus; (4) a medial amygdala receiving input from the anterior dorsal thalamus and projecting to the medial pallium, septum, and hypothalamus; (5) a ventromedial column formed by a nucleus accumbens and a ventral pallidum projecting to the central amygdala, hypothalamus, and posterior tubercle; (6) a lateral column constituting the dorsal striatum proper rostrally and the dorsal pallidum caudally, and a ventrolateral column constituting the ventral striatum. We conclude that the caudal mediolateral complex consisting of the extended central, vomeronasal, and olfactory amygdala of anurans represents the ancestral condition of the amygdaloid complex. During the evolution of the mammalian telencephalon this complex was shifted medially and involuted. The mammalian basolateral amygdala apparently is an evolutionary new structure, but the medial portion of the amygdalar complex of anurans reveals similarities in input and output with this structure and may serve similar functions.