3-M syndrome: a growth disorder associated with IGF2 silencing.

3-M syndrome is an autosomal recessive disorder characterised by pre- and post-natal growth restriction, facial dysmorphism, normal intelligence and radiological features (slender long bones and tall vertebral bodies). It is known to be caused by mutations in the genes encoding cullin 7, obscurin-like 1 and coiled-coil domain containing 8. The mechanisms through which mutations in these genes impair growth are unclear. The aim of this study was to identify novel pathways involved in the growth impairment in 3-M syndrome. RNA was extracted from fibroblast cell lines derived from four 3-M syndrome patients and three control subjects, hybridised to Affymetrix HU 133 plus 2.0 arrays with quantitative real-time PCR used to confirm changes found on microarray. IGF-II protein levels in conditioned cell culture media were measured by ELISA. Of the top 10 downregulated probesets, three represented IGF2 while H19 was identified as the 23rd most upregulated probeset. QRT-PCR confirmed upregulation of H19 (P<0.001) and downregulation of IGF2 (P<0.001). Levels of IGF-II secreted into conditioned cell culture medium were higher for control fibroblasts than those for 3-M fibroblasts (10.2±2.9 vs 0.6±0.9 ng/ml, P<0.01). 3-M syndrome is associated with a gene expression profile of reduced IGF2 expression and increased H19 expression similar to that found in Silver-Russell syndrome. Loss of autocrine IGF-II in the growth plate may be associated with the short stature seen in children with 3-M syndrome.

Pseudohypoparathyroidism type 1b due to paternal uniparental disomy of chromosome 20q.

CONTEXT: Pseudohypoparathyroidism type 1b (PHP1b) is the result of end-organ resistance to PTH and other hormones such as TSH in the absence of any features of Albright's hereditary osteodystrophy. Patients with PHP1b show imprinting abnormalities at the complex GNAS locus. The molecular cause of autosomal dominant familial PHP1b has been well-defined with identification of microdeletions within the GNAS locus or the nearby STX16, but the molecular mechanism of the GNAS imprinting defects in sporadic PHP1b cases remains elusive. OBJECTIVE: We investigated the underlying molecular mechanism of GNAS imprinting defects in two patients with sporadic PHP1b. RESULTS: We identified paternal uniparental disomy of the long arm of chromosome 20 (patUPD20) in two unrelated patients with sporadic PHP1b. This provides an explanation for the patients' GNAS methylation abnormalities and hormone resistance. Our data and a review of the six published cases of patUPD20 suggest that high birth weight and/or early-onset obesity and macrocephaly may also represent features of patUPD20. CONCLUSION: We suggest that patUPD20 should be considered in the evaluation of patients with sporadic PHP1b.

Epigenotype-phenotype correlations in Silver-Russell syndrome.

BACKGROUND: Silver-Russell syndrome (SRS) is characterised by intrauterine growth restriction, poor postnatal growth, relative macrocephaly, triangular face and asymmetry. Maternal uniparental disomy (mUPD) of chromosome 7 and hypomethylation of the imprinting control region (ICR) 1 on chromosome 11p15 are found in 5-10% and up to 60% of patients with SRS, respectively. As many features are non-specific, diagnosis of SRS remains difficult. Studies of patients in whom the molecular diagnosis is confirmed therefore provide valuable clinical information on the condition. METHODS: A detailed, prospective study of 64 patients with mUPD7 (n=20) or ICR1 hypomethylation (n=44) was undertaken. RESULTS AND CONCLUSIONS: The considerable overlap in clinical phenotype makes it difficult to distinguish these two molecular subgroups reliably. ICR1 hypomethylation was more likely to be scored as 'classical' SRS. Asymmetry, fifth finger clinodactyly and congenital anomalies were more commonly seen with ICR1 hypomethylation, whereas learning difficulties and referral for speech therapy were more likely with mUPD7. Myoclonus-dystonia has been reported previously in one mUPD7 patient. The authors report mild movement disorders in three further cases. No correlation was found between clinical severity and level of ICR1 hypomethylation. Use of assisted reproductive technology in association with ICR1 hypomethylation seems increased compared with the general population. ICR1 hypomethylation was also observed in affected siblings, although recurrence risk remains low in the majority of cases. Overall, a wide range of severity was observed, particularly with ICR1 hypomethylation. A low threshold for investigation of patients with features suggestive, but not typical, of SRS is therefore recommended.

Further refinement of the critical minimal genetic region for the imprinting disorder 6q24 transient neonatal diabetes.

AIMS/HYPOTHESIS: Transient neonatal diabetes (TND) is associated with overexpression of genes within a critical region on 6q24. This study aims to refine the boundaries of this region to reduce the number of potential candidate genes for 6q24 TND. METHODS: Fifteen patients with transient neonatal diabetes and submicroscopic chromosome 6 duplications were investigated. The duplications were confirmed by microsatellite analysis and subsequently mapped using tiled chromosome 6 array Comparative Genomic Hybridisation (aCGH) and MLPA. Duplication boundaries were compared to identify the minimal shared region of duplication. These data were then used with available clinical data to identify associations between size of 6q24 duplication and severity of TND phenotype. RESULTS: Alignment of the minimal region of duplication to the human genome reduced the minimal TND critical region, formerly estimated at 440 kb, to 160-173 kb, revealing PLAGL1 (pleiomorphic adenoma gene-like 1) and HYMAI (imprinted in hydatidiform mole) to be the only genes wholly included therein. Additionally, the complete paternal duplication of a region containing the theoretical protein FAM164B was associated with the severe growth restriction observed in 6q24 duplication patients. CONCLUSIONS/INTERPRETATION: This study has significantly reduced the critical region associated with 6q24 TND. It has eliminated several previous TND candidate genes, leaving the overlapping imprinted genes PLAGL1 and HYMAI as the only remaining complete candidate genes for 6q24 TND. Moreover, these data provide the first evidence that an additional region, encompassing the theoretical protein FAM164B, may have a critical role in the growth restriction phenotype observed in many 6q24 TND patients.

Clinical pathway for pediatric parenteral nutrition.

The nutrition support team at Lucile Salter Packard Children's Hospital at Stanford developed a clinical pathway for infants and children receiving parenteral nutrition (PN). Use of clinical pathways for health care delivery is one way in which clinicians and institutions are responding to pressure from managed care organizations to reduce costs and maintain or improve quality. This pathway was developed to standardize the process for ordering, implementing, and monitoring PN. Specific goals for the pathway are as follows: to decrease the number of patients receiving PN inappropriately, to decrease the duration of PN for those patients who require it, to determine complication rates, and to monitor outcomes of therapy. Such comprehensive monitoring will help identify areas for improvement. By developing and implementing action plans to address these issues, we expect to improve continuously the processes and outcomes associated with PN therapy.

Medication error prevention by clinical pharmacists in two children's hospitals.

The purpose of this study was to record prospectively the frequency of and potential harm caused by errant medication orders at two large pediatric hospitals. The objective of the study was to assess the impact of pharmacist intervention in preventing potential harm. The study was conducted during a 6-month period. A total of 281 and 198 errors were detected at the institutions. The overall error rates for the two hospitals were 1.35 and 1.77 per 100-patient days, and 4.9 and 4.5 per 1,000 medication orders, respectively. Pediatric patients aged 2 years and less and pediatric intensive care unit patients received the greatest proportion of errant orders. Neonatal patients received the lowest rate of errant orders. The most common type of error was incorrect dosage, and the most prevalent type of error was overdosage. Antibiotics was the class of drugs for which errant orders were most common. Orders for theophylline, analgesics, and fluid and electrolytes, including hyperalimentation, were also frequently in error. In general, the error rate was greatest among physicians with the least training, but no physician group was error free. Involving pharmacists in reviewing drug orders significantly reduced the potential harm resulting from errant medication orders.

Calcium and phosphorus in neonatal parenteral nutrition solutions.

Due to calcium and phosphorus solubility problems in parenteral nutrition solutions, it is difficult to provide the premature infant with enough of these two minerals for adequate bone mineralization. In order to determine the maximum amounts of both Ca and P soluble in neonatal parenteral nutrition solutions, we employed the following procedure: (1) using concentrations of dextrose 10 to 25% and amino acid 0.5 to 4.0% with standard electrolyte and vitamin concentrations, Ca and P additions were sequentially made to determine the critical concentrations at which precipitates formed; (2) the pH of each test solution was determined; (3) all test solutions were incubated for 30 hr at room temperature; (4) following incubation, all tests were visually observed for calcium-phosphate crystals; (5) the solutions not obviously precipitated were filtered using black Millipore filters to determine the presence of any microprecipitates. Multiple graphs of Ca and P solubility in various dextrose/amino acid solutions were prepared from data generated by the study. The Ca and P interaction is primarily pH sensitive. Factors affecting the solution pH include both dextrose and amino acid concentrations. Our study showed that increases in amino acid concentrations enabled us to increase both Ca and P in the solutions.