COVID-19 in an Infant with Congenital Adrenal Hyperplasia: A Case Report.

In the midst of current SARS-CoV-2 pandemic, little is known about the implications of this new virus on patients with underlying chronic comorbidities. Herein, we present a case of a 5-week-old infant with congenital adrenal hyperplasia who acquired SARS-CoV-2 and recovered with minimal medical support.

A Rare Case of Autoimmune Polyglandular Syndrome Type 2 in a Child With Persistent Fatigue.

Adrenal insufficiency is a rare, potentially life-threatening condition whose diagnosis requires a high index of suspicion. Adrenal insufficiency may be primary, secondary, or tertiary with varied etiologies. Primary insufficiency may be part of a cluster of autoimmune diseases, referred to as autoimmune polyglandular syndrome(s) (APS). We describe a case of a 15-year-old male who presents to a local emergency department complaining of fatigue, fever, abdominal pain, nausea, and vomiting for a few days with a preceding viral illness. The patient was hyponatremic and hyperkalemic with skin hyperpigmentation, raising concern for adrenal insufficiency. Laboratory workup confirmed autoimmune primary adrenal insufficiency, with subsequent laboratory studies revealing autoimmune thyroiditis and celiac disease. Concomitant Addison's and Hashimoto's diseases led to a diagnosis of APS type 2. The patient was started on steroid replacement with rapid clinical improvement.

Molecular genetic testing of patients with monogenic diabetes and hyperinsulinism.

Genetic sequencing has become a critical part of the diagnosis of certain forms of pancreatic beta cell dysfunction. Despite great advances in the speed and cost of DNA sequencing, determining the pathogenicity of variants remains a challenge, and requires sharing of sequence and phenotypic data between laboratories. We reviewed all diabetes and hyperinsulinism-associated molecular testing done at the Seattle Children's Molecular Genetics Laboratory from 2009 to 2013. 331 probands were referred to us for molecular genetic sequencing for Neonatal Diabetes (NDM), Maturity-Onset Diabetes of the Young (MODY), or Congenital Hyperinsulinism (CHI) during this period. Reportable variants were identified in 115 (35%) patients with 91 variants in one of 6 genes: HNF1A, GCK, HNF4A, ABCC8, KCNJ11, or INS. In addition to identifying 23 novel variants, we identified unusual mechanisms of inheritance, including mosaic and digenic MODY presentations. Re-analysis of all reported variants using more recently available databases led to a change in variant interpretation from the original report in 30% of cases. These results represent a resource for molecular testing of monogenic forms of diabetes and hyperinsulinism, providing a mutation spectrum for these disorders in a large North American cohort. In addition, they highlight the importance of periodic review of molecular testing results.

[A girl with abdominal pain and progressive vomiting]. / Een meisje met buikpijn en progressief braken.

An 11-year-old girl with a history of trichophagia presented with abdominal pain and progressive vomiting. The MRI scan showed a gastric mass and multiple masses in the small intestine. A large trichobezoar was removed from the stomach by laparotomy.

Calculating nasoseptal flap dimensions: a cadaveric study using cone beam computed tomography.

We hypothesize that three-dimensional imaging using cone beam computed tomography (CBCT) is suitable for calculating nasoseptal flap (NSF) dimensions. To evaluate our hypothesis, we compared CBCT NSF dimensions with anatomical dissections. The NSF reach and vascularity were studied. In an anatomical study (n = 10), CBCT NSF length and surface were calculated and compared with anatomical dissections. The NSF position was evaluated by placing the NSF from the anterior sphenoid sinus wall and from the sella along the skull base towards the frontal sinus. To visualize the NSF vascularity in CBCT, the external carotic arteries were perfused with colored Iomeron. Correlations between CBCT NSFs and anatomical dissections were strongly positive (r > 0.70). The CBCT NSF surface was 19.8 cm(2) [16.6-22.3] and the left and right CBCT NSF lengths were 78.3 mm [73.2-89.5] and 77.7 mm [72.2-88.4] respectively. Covering of the anterior skull base was possible by positioning the NSF anterior to the sphenoid sinus. If the NSF was positioned from the sella along the skull base towards the frontal sinus, the NSF reached partially into the anterior ethmoidal sinuses. CBCT is a valuable technique for calculating NSF dimensions. CBCT to demonstrate septum vascularity in cadavers proved to be less suitable. The NSF reach for covering the anterior skull base depends on positioning. This study encourages preoperative planning of a customized NSF, in an attempt to spare septal mucosa. In the concept of minimal invasive surgery, accompanied by providing customized care, this can benefit the patients' postoperative complaints.

The influence of the segmentation process on 3D measurements from cone beam computed tomography-derived surface models.

To compare the accuracy of linear and angular measurements between cephalometric and anatomic landmarks on surface models derived from 3D cone beam computed tomography (CBCT) with two different segmentation protocols was the aim of this study. CBCT scans were made of cadaver heads and 3D surface models were created of the mandible using two different segmentation protocols. A high-resolution laser surface scanner was used to make a 3D model of the macerated mandibles. Twenty linear measurements at 15 anatomic and cephalometric landmarks between the laser surface scan and the 3D models generated from the two segmentation protocols (commercial segmentation (CS) and doctor's segmentation (DS) groups) were measured. The interobserver agreement for all the measurements of the all three techniques was excellent (intraclass correlation coefficient 0.97-1.00). The results are for both groups very accurate, but only for the measurements on the condyle and lingual part of the mandible, the measurements in the CS group is slightly more accurate than the DS group. 3D surface models produced by CBCT are very accurate but slightly inferior to reality when threshold-based methods are used. Differences in the segmentation process resulted in significant clinical differences between the measurements. Care has to be taken when drawing conclusions from measurements and comparisons made from different segmentations, especially at the condylar region and the lingual side of the mandible.

Spumiform capillary basement membrane swelling: a new type of microvascular degeneration in senescent hamster.

Brain microvasculature plays a critical role in the regulation of homeostasis of neural tissues. The present study focuses on characteristic microvascular basement membrane (bm) aberrations in the midbrain periaqueductal gray matter (PAG) and their relation to aging. The PAG can be considered a caudal extension of the limbic system and is a key structure in the regulation of a myriad of autonomic and motor control functions. In an ultrastructural study, morphologic changes in mesencephalic PAG capillaries were assessed in aged and young hamster and compared with those in caudal brainstem areas. Bm aberrations were studied in 1200 capillaries (n = 600 young hamsters; n = 600 aged hamsters). A new, never reported variant of bm degeneration was found that presented itself as foamy-like structures accumulating within the lamina densa of notably PAG capillaries. We classified these foamy structures as 'spumiform basement membrane degenerations' (sbmd) in which we could distinguish 4 stages depending on the size and intramembranous localization, ranging from split bm (stage I), intermediate stages II and III, to extensive stage IV, affecting almost the complete capillary bm outline. In the PAG of senescent animals various stages of sbmd were observed in 92 ± 3% of all capillaries. Stage II was most prominently present (59%), followed by stage III (20%), and stage IV (13%). These bm aberrations were clearly age-dependent because in young animals, only 5% of the PAG capillaries showed characteristics of sbmd. For comparison, in the pontine reticular formation at the PAG-level, 41% of the capillaries showed a form of sbmd, but these defects were significantly less severe (stages I-II, 98%), and caudal brainstem structures displayed no sbmd at all. In addition to sbmd, diffuse endothelial changes, disrupted tight junctions, thickening of the bm, pericyte degeneration, and gliosis were observed in PAG capillaries. It is hypothesized that selective bm permeability of PAG capillaries results in a sequence of bm damage events that start with split bm, gradually changing into more and more extensive sbmd accumulations that eventually almost completely surround the capillary. Progressive sbmd in PAG capillaries might lead to a loss of blood-brain barrier function and consequently to impairment of autonomic and motor control functions exerted by the PAG.

Leonardo da Vinci's "A skull sectioned": skull and dental formula revisited.

What can be learned from historical anatomical drawings and how to incorporate these drawings into anatomical teaching? The drawing "A skull sectioned" (RL 19058v) by Leonardo da Vinci (1452-1519), hides more detailed information than reported earlier. A well-chosen section cut explores sectioned paranasal sinuses and ductus nasolacrimalis. A dissected lateral wall of the maxilla is also present. Furthermore, at the level of the foramen mentale, the drawing displays compact and spongious bony components, together with a cross-section through the foramen mentale and its connection with the canalis mandibulae. Leonardo was the first to describe a correct dental formula (6424) and made efforts to place this formula above the related dental elements. However, taking into account, the morphological features of the individual elements of the maxilla, it can be suggested that Leonardo sketched a "peculiar dental element" on the position of the right maxillary premolar in the dental sketch. The fact that the author did not make any comment on that special element is remarkable. Leonardo could have had sufficient knowledge of the precise morphology of maxillary and mandibular premolars, since the author depicted these elements in the dissected skull. The fact that the author also had access to premolars in situ corroborates our suggestion that "something went wrong" in this part of the drawing. The present study shows that historical anatomical drawings are very useful for interactive learning of detailed anatomy for students in medicine and dentistry.

Volume transmission of beta-endorphin via the cerebrospinal fluid; a review.

There is increasing evidence that non-synaptic communication by volume transmission in the flowing CSF plays an important role in neural mechanisms, especially for extending the duration of behavioral effects. In the present review, we explore the mechanisms involved in the behavioral and physiological effects of ß-endorphin (ß-END), especially those involving the cerebrospinal fluid (CSF), as a message transport system to reach distant brain areas. The major source of ß-END are the pro-opio-melano-cortin (POMC) neurons, located in the arcuate hypothalamic nucleus (ARH), bordering the 3rd ventricle. In addition, numerous varicose ß-END-immunoreactive fibers are situated close to the ventricular surfaces. In the present paper we surveyed the evidence that volume transmission via the CSF can be considered as an option for messages to reach remote brain areas. Some of the points discussed in the present review are: release mechanisms of ß-END, independence of peripheral versus central levels, central ß-END migration over considerable distances, behavioral effects of ß-END depend on location of ventricular administration, and abundance of mu and delta opioid receptors in the periventricular regions of the brain.

Digitally designed surgical guides for placing implants in the nasal floor of dentate patients: a series of three cases.

PURPOSE: Insight into the bone volume and position of natural teeth is essential when placing implants to retain nasal prostheses. This paper describes a series of three cases in which a new method was applied for implant placement in the nasal floor of dentate patients using digital planning techniques. MATERIALS AND METHODS: With the aid of computer software, digital planning of implants in the nasal floor based on cone beam computed tomography was performed. Next, surgical guides for implant placement were digitally designed and fabricated using rapid prototyping. RESULTS: In all three patients, implants could be placed and nasal prostheses could be manufactured as planned. All anterior teeth remained vital. Analysis of planning and post-implant placement cone beam computed tomography scans revealed high accuracy of implant placement. CONCLUSION: The applied method allows for reliable implant placement in close proximity to the preoperatively planned implant position.

Reduced aging defects in estrogen receptive brainstem nuclei in the female hamster.

UNLABELLED: The nucleus pararetroambiguus (NPRA) and the commissural nucleus of the solitary tract (NTScom) show estrogen nuclear receptor-α immunoreactivity (nuclear ER-α-IR). Both cell groups are involved in estrous cycle related adaptations. We examined in normally cycling aged hamsters the occurrence/amount/frequency of age-related degenerative changes in NPRA and NTScom during estrus and diestrus. In 2640 electron microscopy photomicrographs plasticity reflected in the ratio of axon terminal surface/dendrite surface (t/d) was morphometrically analyzed. Medial tegmental field (mtf, nuclear ER-α-IR poor), served as control. In aged animals, irrespective of nuclear ER-α-IR+ or nuclear ER-α-IR- related cell groups, extensive diffuse degenerative structural aberrations were observed. The hormonal state had a strong influence on t/d ratios in NPRA and NTScom, but not in mtf. In NPRA and NTScom, diestrous hamsters had significantly smaller t/d ratios (NPRA, 0.750 ± 0.050; NTScom, 0.900 ± 0.039) than the estrous hamsters (NPRA, 1.083 ± 0.075; NTScom, 1.204 ± 0.076). Aging affected axodendritic ratios only in mtf (p < 0.001). IN CONCLUSION: in the female hamster brain, estrous cycle-induced structural plasticity is preserved in NPRA and NTScom during aging despite the presence of diffuse age-related neurodegenerative changes.

Four of a kind: asthma control, FEV1, FeNO, and psychosocial problems in adolescents.

BACKGROUND: Many adolescents have poor asthma control and are at high risk for psychosocial problems. However, structured assessment of asthma control or psychosocial problems is still not implemented in routine asthma care. Pediatricians typically rely on their clinical view and physiological measurements. To date, it is unknown whether clinical and patient reported outcomes are interrelated. Furthermore, there is no consensus on who should be the informant; the adolescent or his caregiver. STUDY AIM(S): This study aimed to assess the relationship between patient and caregiver reported outcomes [Asthma Control Questionnaire and Strengths and Difficulties Questionnaire (SDQ)] and physiological parameters (FEV1 and Fractional exhaled Nitric Oxide) in adolescents (aged 11-16) with asthma. METHODS: A multicenter observational study was performed in four Dutch pediatric outpatient departments. Association between asthma control, physiological parameters, and results of psychosocial questionnaires completed by both adolescent and caregiver was analyzed. RESULTS: Forty-eight adolescents and their caregivers participated in this study. Asthma was uncontrolled in about 30%. Asthma control was not associated with age, gender, FEV1, FeNO, or psychosocial problems. Agreement between adolescents and caregivers about how well asthma was controlled was moderate (κ = 0.577, P < 0.01). DISCUSSION: Asthma control, physiological parameters, and psychosocial problems are different domains of health status. It could be suggested to use validated patient and caregiver reported outcomes in routine adolescent asthma care. CONCLUSION: Patient and caregiver reported outcomes on asthma control and the presence of psychosocial problems add valuable, unique information to physiological parameters in adolescent asthma management.

Segmentation process significantly influences the accuracy of 3D surface models derived from cone beam computed tomography.

AIMS: To assess the accuracy of surface models derived from 3D cone beam computed tomography (CBCT) with two different segmentation protocols. MATERIALS AND METHODS: Seven fresh-frozen cadaver heads were used. There was no conflict of interests in this study. CBCT scans were made of the heads and 3D surface models were created of the mandible using two different segmentation protocols. The one series of 3D models was segmented by a commercial software company, while the other series was done by an experienced 3D clinician. The heads were then macerated following a standard process. A high resolution laser surface scanner was used to make a 3D model of the macerated mandibles, which acted as the reference 3D model or "gold standard". The 3D models generated from the two rendering protocols were compared with the "gold standard" using a point-based rigid registration algorithm to superimpose the three 3D models. The linear difference at 25 anatomic and cephalometric landmarks between the laser surface scan and the 3D models generate from the two rendering protocols was measured repeatedly in two sessions with one week interval. RESULTS: The agreement between the repeated measurement was excellent (ICC=0.923-1.000). The mean deviation from the gold standard by the 3D models generated from the CS group was 0.330mm±0.427, while the mean deviation from the Clinician's rendering was 0.763mm±0.392. The surface models segmented by both CS and DS protocols tend to be larger than those of the reference models. In the DS group, the biggest mean differences with the LSS models were found at the points ConLatR (CI: 0.83-1.23), ConMedR (CI: -3.16 to 2.25), CoLatL (CI: -0.68 to 2.23), Spine (CI: 1.19-2.28), ConAntL (CI: 0.84-1.69), ConSupR (CI: -1.12 to 1.47) and RetMolR (CI: 0.84-1.80). CONCLUSION: The Commercially segmented models resembled the reality more closely than the Doctor's segmented models. If 3D models are needed for surgical drilling guides or surgical planning which requires high precision, the additional cost of the commercial segmentation services seem to be justified to produce a more accurate surface models.

Regional differences in age-related lipofuscin accumulation in the female hamster brainstem.

Lipofuscin accumulation is a characteristic feature of senescent postmitotic neuronal cells but estrogen may have protecting effects by inhibiting its formation. In the present ultrastructural study, lipofuscin accumulation was studied in 2 estrogen-α-receptive brainstem areas: nucleus pararetroambiguus (NPRA) and the commissural part of the solitary tract nucleus/A2 catecholaminergic group (NTScom/A2) and compared with the estrogen-insensitive medial tegmental field (mtf), in young (23 weeks) and aged (95 weeks) female hamsters. In the aged animals, extensive intracytoplasmic lipofuscin accumulation was observed. A total number of 6450 neurons were classified in 4 categories. Levels were significantly elevated in each of the brain areas studied. Lipofuscin accumulation was strongest in the mtf, less in NPRA, and remarkably less in the area of NTScom/A2. In conclusion, the observed differences in lipofuscin accumulation suggest: (1) considerable regional differences in the degree of neuronal vulnerability; and (2) a possible neuroprotective role for estrogen, because the degree of accumulation is inversely related to the density of the estrogen receptors, varying from nonreceptive (mtf) to NPRA and NTScom/A2 (most receptive).

Over my dead body: body donation and the rise in donor registrations in The Netherlands.

In The Netherlands, the number of body donor registrations has been increasing for several years. Body donors are people who register at an anatomical institute to donate their entire body, after death, for scientific education and research. Although only 0.1% of the Dutch population is registered as a body donor, this is sufficient to realize the anatomical demand of about 650 bodies annually. Due to the recent rise of registrations many anatomical institutes have (temporarily) stopped registering new donors to prevent a surplus of bodies. Based on a large body donor survey (n=759) and in-depth anthropological interviews with 20 body donors, we try to give an explanation for the rising registration numbers. We argue that the choice for body donation in contemporary, individualized Dutch society is an autonomous way to give meaning and sense to life and death outside the framework of institutionalized religion.

Anatomist on the dissecting table? Dutch anatomical professionals' views on body donation.

Anatomical professionals know better than anyone else that donated bodies are a valuable asset to anatomical science and medical education. They highly value voluntary donations, since a dearth of bodies negatively affects their profession. With this in mind, we conducted a survey (n = 54) at the 171st scientific meeting of the Dutch Anatomical Society in 2009 to see to what extent anatomical professionals are willing to donate their own body. The results reveal that none of the survey participants are registered as a whole body donor and that only a quarter of them would consider the possibility of body donation. We argue that the two main constraints preventing Dutch anatomical professionals from donating their own body are their professional and their social environments. In contrast to the absence of registered body donors, half of the anatomical professionals are registered as an organ donor. This figure far exceeds the proportion of registered organ donors among the general Dutch population.

Personality and motivation for body donation.

BACKGROUND: This study examines the relationship between motivation for body donation to science and personality characteristics using a body donor survey (N=759) conducted by the University Medical Centre Groningen (UMCG) in The Netherlands. The survey expands on anthropological studies that suggest an association between donor motivation and personality. METHODS: A structural equation model was used to investigate the relationship between personality and motivation for body donation. FINDINGS: The results show that, compared to society at large, body donors have a similar spectrum of personality characteristics. However, we found statistically significant positive relationships between donor motivation and Big Five personality traits. Together the personality traits explain between 5% and 15% of the variance in motivation for body donation. CONCLUSIONS: We argue that donor campaigns should not focus solely on altruistic motives, but should include the aspect of possible personal achievement by the donor. This is a fruitful starting point for approaching potential donors and anticipating their needs.

Evaluation of anthropometric accuracy and reliability using different three-dimensional scanning systems.

The aim of this study was to evaluate the accuracy and reliability of standard anthropometric linear measurements made with three different three-dimensional scanning systems namely laser surface scanning (Minolta Vivid 900), cone beam computed tomography (CBCT), 3D stereo-photogrammetry (Di3D system) and to compare them to physical linear measurements. The study sample consisted of seven cadaver heads. The reliability and accuracy were assessed by means of a series of 21 standardized, linear facial measurements derived from 15 landmarks taken both directly on the face with a set of digital callipers and indirectly from a three-dimensional (3D) soft tissue surface models derived from CBCT, laser surface scans and 3D photographs. Statistical analysis for the reliability was done by means of intraclass correlation coefficients (ICCs). Accuracy was determined by means of the absolute error (AE) and absolute percentage error (APE) by comparison of the 3D measurements to the physical anthropometrical measurements. All the 3D scanning systems were proved to be very reliable (ICC>0.923-0.999) when compared to the physical measurements (ICC; 0.964-0.999). Only one CBCT measurement (t-g) and one Di3D measurement (t-sn left) had a mean AE of more than 1.5mm. There are clear potential benefits of using 3D measurements appose to direct measurements in the assessment of facial deformities. Measurements recorded by the three 3D systems appeared to be both sufficiently accurate and reliable enough for research and clinical use.

Accuracy and repeatability of anthropometric facial measurements using cone beam computed tomography.

OBJECTIVE: The purpose of this study was to determine the accuracy and repeatability of linear anthropometric measurements on the soft tissue surface model generated from cone beam computed tomography scans. MATERIALS AND METHODS: The study sample consisted of seven cadaver heads. The accuracy and repeatability were assessed by means of a series of 21 standardized, linear facial measurements derived from 11 landmarks taken both directly on the face with a set of digital calipers and indirectly from a three-dimensional soft tissue surface model generated from a cone beam computed tomography scan of the heads using SimPlant® Ortho Pro software. The landmarks and measurements were chosen to cover various regions of the face with an emphasis on the oral-nasal region. The cone beam computed tomography measurements were compared with the physical measurements. Statistical analysis for the repeatability was done by means of the intraclass coefficient. Accuracy was determined by means of the absolute error and absolute percentage error. RESULTS: The cone beam computed tomography measurements were very accurate when compared with the physical measurements (0.962 to 0.999). Except for one measurement, between point tragion (t) and nasion (n) (mean, 1.52 mm), all the measurements had a mean absolute error of less than 1.5 mm. CONCLUSIONS: The three-dimensional surface models derived from cone beam computed tomography images are sufficiently precise and accurate for the anthropometric measurements.

An asthma-related quality of life instrument is unable to identify asthmatic children with major psychosocial problems.

Evidence shows that psychosocial problems among children and adolescents with asthma interfere with adherence to treatment and therefore need attention in asthma care. It is unknown whether the already frequently implemented asthma-related quality of life (QoL) instruments reflect psychosocial problems in children with asthma. The aim of this study was to assess the relationship between asthma-related QoL and psychosocial problems and to determine whether an asthma-related QoL instrument is able to identify those children and adolescents with asthma with major psychosocial problems. In a multicenter study psychosocial problems (Strengths and Difficulties Questionnaire) and asthma-related QoL (Pediatric Asthma (Caregivers) Quality of Life Questionnaire) were obtained in children and adolescents with asthma aged 6-16 years and their caregivers. A total of 339 children and adolescents (response rate 95%) from four pediatric outpatient clinics in the Netherlands with doctor-diagnosed asthma participated. Of the caregivers, 43% reported major or minor psychosocial problems of their child or adolescent which is two times more than in the reference group, whereas the percentage of adolescents reporting psychosocial problems was comparable to a reference population. Adolescents and caregivers reported few impairments in asthma-related QoL (median score between 6.2 and 7.0). However, an optimal asthma-related QoL did not rule out major psychosocial problems: 10% of the adolescents with an optimal asthma-related QoL score reported major psychosocial problems. And in one out of seven children with an optimal caregiver's asthma-related QoL score, major psychosocial problems were reported. The prevalence of psychosocial problems in children and adolescents with asthma is considerable. Assessment of asthma-related QoL alone is insufficient to identify those children with major psychosocial problems. We recommend the implementation of psychosocial screening, besides assessment of asthma-related QoL, in routine pediatric asthma care, to improve asthma management.