TROPHY registry - status report.

INTRODUCTION: The TROPHY registry has been established to conduct an international multicenter prospective data collection on the surgical management of neonatal intraventricular hemorrhage (IVH)-related hydrocephalus to possibly contribute to future guidelines. The registry allows comparing the techniques established to treat hydrocephalus, such as external ventricular drainage (EVD), ventricular access device (VAD), ventricular subgaleal shunt (VSGS), and neuroendoscopic lavage (NEL). This first status report of the registry presents the results of the standard of care survey of participating centers assessed upon online registration. METHODS: On the standard of treatment forms, each center indicated the institutional protocol of interventions performed for neonatal post-hemorrhagic hydrocephalus (nPHH) for a time period of 2 years (Y1 and Y2) before starting the active participation in the registry. In addition, the amount of patients enrolled so far and allocated to a treatment approach are reported. RESULTS: According to the standard of treatment forms completed by 56 registered centers, fewer EVDs (Y1 55% Y2 46%) were used while more centers have implemented NEL (Y1 39%; Y2 52%) to treat nPHH. VAD (Y1 66%; Y2 66%) and VSGS (Y1 42%; Y2 41%) were used at a consistent rate during the 2 years. The majority of the centers used at least two different techniques to treat nPHH (43%), while 27% used only one technique, 21% used three, and 7% used even four different techniques. Patient data of 110 infants treated surgically between 9/2018 and 2/2021 (13% EVD, 15% VAD, 30% VSGS, and 43% NEL) were contributed by 29 centers. CONCLUSIONS: Our results emphasize the varying strategies used for the treatment of nPHH. The international TROPHY registry has entered into a phase of growing patient recruitment. Further evaluation will be performed and published according to the registry protocol.

Noninvasive Follow-up Imaging of Ruptured Pediatric Brain AVMs Using Arterial Spin-Labeling.

BACKGROUND AND PURPOSE: Brain AVMs represent the main etiology of pediatric intracranial hemorrhage. Noninvasive imaging techniques to monitor the treatment effect of brain AVMs remain an unmet need. In a large cohort of pediatric ruptured brain AVMs, we aimed to investigate the role of arterial spin-labeling for the longitudinal follow-up during treatment and after complete obliteration by analyzing CBF variations across treatment sessions. MATERIALS AND METHODS: Consecutive patients with ruptured brain AVMs referred to a pediatric quaternary care center were prospectively included in a registry that was retrospectively queried for children treated between 2011 and 2019 with unimodal or multimodal treatment (surgery, radiosurgery, embolization). We included children who underwent an arterial spin-labeling sequence before and after treatment and a follow-up DSA. CBF variations were analyzed in univariable analyses. RESULTS: Fifty-nine children with 105 distinct treatment sessions were included. The median CBF variation after treatment was -43 mL/100 mg/min (interquartile range, -102-5.5), significantly lower after complete nidal surgical resection. Following radiosurgery, patients who were healed on the last DSA follow-up demonstrated a greater CBF decrease on intercurrent MR imaging, compared with patients with a persisting shunt at last follow-up (mean, -62 [SD, 61] mL/100 mg/min versus -17 [SD, 40.1] mL/100 mg/min; P = .02). In children with obliterated AVMs, recurrences occurred in 12% and resulted in a constant increase in CBF (mean, +89 [SD, 77] mL/100 mg/min). CONCLUSIONS: Our results contribute data on the role of noninvasive arterial spin-labeling monitoring of the response to treatment or follow-up after obliteration of pediatric AVMs. Future research may help to better delineate how arterial spin-labeling can assist in decisions regarding the optimal timing for DSA.

Pre-activated antiviral innate immunity in the upper airways controls early SARS-CoV-2 infection in children.

Children have reduced severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection rates and a substantially lower risk for developing severe coronavirus disease 2019 compared with adults. However, the molecular mechanisms underlying protection in younger age groups remain unknown. Here we characterize the single-cell transcriptional landscape in the upper airways of SARS-CoV-2-negative (n = 18) and age-matched SARS-CoV-2-positive (n = 24) children and corresponding samples from adults (n = 44), covering an age range of 4 weeks to 77 years. Children displayed higher basal expression of relevant pattern recognition receptors such as MDA5 (IFIH1) and RIG-I (DDX58) in upper airway epithelial cells, macrophages and dendritic cells, resulting in stronger innate antiviral responses upon SARS-CoV-2 infection than in adults. We further detected distinct immune cell subpopulations including KLRC1 (NKG2A)+ cytotoxic T cells and a CD8+ T cell population with a memory phenotype occurring predominantly in children. Our study provides evidence that the airway immune cells of children are primed for virus sensing, resulting in a stronger early innate antiviral response to SARS-CoV-2 infection than in adults.

Impairment of Sox9 expression in limb buds of rats homozygous for hypodactyly mutation.

Rat hypodactyly (hd) is an autosomal recessive mutation manifesting in homozygotes as reduction or loss of digits II and III. We mapped the hd allele to a short segment of chromosome 10, containing 16 genes. None of these genes has been shown to influence limb development yet. In situ hybridization showed no changes in several important patterning genes (Shh, Fgf8, Bmp2, 4, 7). However, we found that expression of cartilage condensation marker Sox9, and Bmp receptor Bmpr1b (acting as an upstream activator of Sox9 expression) is absent from the subepithelial mesenchyme of the digit condensations II and III. The failure of the chondrogenic condensations to extend towards the subepithelial mesenchyme may reduce the size of digit primordia and underlie the subsequent loss of phalanges and reduction of metacarpals/metatarsals in hd rats.

Risk Factors for Early Brain AVM Rupture: Cohort Study of Pediatric and Adult Patients.

BACKGROUND AND PURPOSE: Whether architectural characteristics of ruptured brain AVMs vary across the life span is unknown. We aimed to identify angioarchitectural features associated with brain AVMs ruptured early in life. MATERIALS AND METHODS: Patients with ruptured brain AVMs referred to 2 distinct academic centers between 2000 and 2018 were pooled and retrospectively analyzed. Imaging was retrospectively reviewed for angioarchitectural characteristics, including nidus size, location, Spetzler-Martin grade, venous drainage, and arterial or nidal aneurysm. Angioarchitecture variations across age groups were analyzed using uni- and multivariable models; then cohorts were pooled and analyzed using Kaplan-Meier and Cox models to determine factors associated with earlier rupture. RESULTS: Among 320 included patients, 122 children (mean age, 9.8 ± 3.8 years) and 198 adults (mean age, 43.3 ± 15.7 years) were analyzed. Pediatric brain AVMs were more frequently deeply located (56.3% versus 21.2%, P < .001), with a larger nidus (24.2 versus 18.9 mm, P = .002), were less frequently nidal (15.9% versus 23.5%, P = .03) and arterial aneurysms (2.7% versus 17.9%, P < .001), and had similar drainage patterns or Spetzler-Martin grades. In the fully adjusted Cox model, supratentorial, deep brain AVM locations (adjusted relative risk, 1.19; 95% CI, 1.01-1.41; P = .03 and adjusted relative risk, 1.43; 95% CI, 1.22-1.67; P < .001, respectively) and exclusively deep venous drainage (adjusted relative risk, 1.46, 95% CI, 1.21-1.76; P < .001) were associated with earlier rupture, whereas arterial or nidal aneurysms were associated with rupture later in life. CONCLUSIONS: The angioarchitecture of ruptured brain AVMs significantly varies across the life span. These distinct features may help to guide treatment decisions for patients with unruptured AVMs.

Regulation of long-term depression by increases in [guanosine 3',5'-cyclic monophosphate] in the hippocampal CA1 region of freely behaving rats.

A role for guanosine 3',5'-cyclic monophosphate (cGMP) and the protein kinase G (PKG) pathway in synaptic long-term depression (LTD) in the hippocampal CA1 region has been proposed, based on observations in vitro, where, for example, increases of [cGMP] result in short-term depression (STD) coupled with a reduction in presynaptic glutamate release. To date, no evidence exists to support that LTD in the intact, freely behaving animal involves these mechanisms. We examined the effect of increases of [cGMP] on basal transmission and electrically-induced STD at hippocampal CA1 synapses in vivo. We found that elevating [cGMP] dose-dependently caused a chemically-induced STD which occluded electrically-induced STD. Repeated administration of Zaprinast, an inhibitor of cGMP-degrading phosphodiesterase, resulted in persistent LTD (>24 h). Paired-pulse analysis supported a presynaptic mechanism of action. Application of an inhibitor of soluble guanylate cyclase prevented LTD induced by low-frequency stimulation (LFS), and impaired LFS-STD elicited in the presence of Zaprinast. These data suggest the involvement of cGMP in LTD in the CA1 region of freely behaving adult rats.

Triangular tibia with fibular aplasia associated with a microdeletion on 2q11.2 encompassing LAF4.

Nievergelt syndrome (NS) is an autosomal dominant mesomelic dysplasia characterized by specific deformities of the radius, ulna, fibula and a rhomboid shape of the tibia. Phenotypically overlapping conditions such as mesomelic dysplasia, Savarirayan-type (MIM 605274), have been described, but their pathogenesis also remains unknown. We report on a girl with fibular agenesis, severely abnormal, triangular tibiae, urogenital tract malformations, failure to thrive, convulsions and recurrent apnoeas leading to respiratory arrest at the age of 4 months. Her skeletal findings correspond to those of the mesomelic dysplasia, Savarirayan-type recently described in two patients. In addition to the skeletal findings, our patient had central nervous system manifestations and developmental anomalies of the urogenital tract. In the patient described in this study, array comparative genomic hybridization (CGH) analysis revealed a de novo interstitial microdeletion of 500 kb on chromosome 2q11.1 containing the LAF4/AFF3 (lymphoid-nuclear-protein-related AF4) gene. In situ hybridization analysis of Laf4 in mouse embryos revealed expression in the developing brain, in the limb buds and in the zeugopod corresponding to the limb phenotype. Haploinsufficiency for LAF4/AFF3 is associated with limb, brain and urogenital malformations and specific changes of the tibia that are part of the NS spectrum.

Ataxia with oculomotor apraxia type 2: novel mutations in six patients with juvenile age of onset and elevated serum alpha-fetoprotein.

Ataxia with oculomotor apraxia type 2 (AOA2), a neurodegenerative disorder with juvenile to adolescent onset is caused by mutations within the SENATAXIN gene ( SETX). We performed molecular analyses in six patients showing clinically an AOA2 phenotype and moderate to significant elevated serum alpha-fetoprotein levels. Sequencing the 24 coding exons and flanking intronic sequences revealed 11 novel DNA variations, including seven unknown missense mutations, a dinucleotide deletion, a four-nucleotide deletion affecting the 5' splice site of exon 22 and two sequence variations, which are considered to be polymorphisms. By molecular testing the clinical diagnosis has been confirmed in all patients.

Detection of novel skeletogenesis target genes by comprehensive analysis of a Runx2(-/-) mouse model.

Runx2 is an essential factor for skeletogenesis and heterozygous loss causes cleidocranial dysplasia in humans and a corresponding phenotype in the mouse. Homozygous Runx2-deficient mice lack hypertrophic cartilage and bone. We compared the expression profiles of E14.5 wildtype and Runx2(-/-) murine embryonal humeri to identify new transcripts potentially involved in cartilage and bone development. Seventy-one differentially expressed genes were identified by two independent oligonucleotide-microarray hybridizations and quantitative RT-PCR experiments. Gene Ontology analysis demonstrated an enrichment of the differentially regulated genes in annotations to terms such as extracellular, skeletal development, and ossification. In situ hybridization on E15.5 limb sections was performed for all 71 differentially regulated genes. For 54 genes conclusive in situ hybridization results were obtained and all of them showed skeletal expression. Co-expression with Runx2 was demonstrated for 44 genes. While 41 of the 71 differentially expressed genes have a known role in bone and cartilage, we identified 21 known genes that have not yet been implicated in skeletal development and 9 entirely new transcripts. Expression in the developing skeleton was demonstrated for 21 of these genes.

A single amphioxus and sea urchin runt-gene suggests that runt-gene duplications occurred in early chordate evolution.

Runt-homologous molecules are characterized by their DNA binding runt-domain which is highly conserved within bilaterians. The three mammalian runt-genes are master regulators in cartilage/bone formation and hematopoiesis. Historically these features evolved in Craniota and might have been promoted by runt-gene duplication events. The purpose of this study was therefore to investigate how many runt-genes exist in the stem species of chordates, by analyzing the number of runt-genes in what is likely to be the closest living relative of Craniota-amphioxus. To acquire further insight into the possible role of runt-genes in early chordate evolution we have determined the number of runt-genes in sea urchins and have analyzed the runt-expression pattern in this species. Our findings demonstrate the presence of a single runt-gene in amphioxus and sea urchin, which makes it highly likely that the stem species of chordates harbored only a single runt-gene. This suggests that runt-gene duplications occurred later in chordate phylogeny, and are possibly also associated with the evolution of features such as hematopoiesis, cartilage and bone development. In sea urchin embryos runt-expression involves cells of endodermal, mesodermal and ectodermal origin. This complex pattern of expression might reflect the multiple roles played by runt-genes in mammals. A strong runt-signal in the gastrointestinal tract of the sea urchin is in line with runt-expression in the intestine of nematodes and in the murine gastrointestinal tract, and seems to be one of the phylogenetically ancient runt-expression domains.

Confocal laser scanning microscopy of calcium dynamics in living cells.

Confocal laser scanning microscopy (CLSM) is widely used to monitor intracellular calcium levels in living cells loaded with calcium-sensitive fluorophores. This review examines the basic advantages and limitations of CLSM in in vivo imaging analyses of calcium dynamics. The benefits of utilizing ratioed images and dextran-conjugated fluorophores are addressed, and practical aspects of handling confocal datasets are outlined. After considering some relatively new microscopical methods that can be used in conjunction with conventional CLSM, possible future applications of confocal techniques in analyses of intracellular calcium dynamics are discussed.

The ontogeny of shell secretion in Terebratalia transversa (Brachiopoda, Articulata). I. Development of the mantle.

The morphology of the mantle in free-swimming and metamorphosing larvae of the articulate brachiopod Terebratalia transversa has been examined by scanning and transmission electron microscopy. The mantle begins to form approximately 2 days after fertilization and subsequently develops into a skirtlike lobe that encircles the middle region of the larval body. A simple epithelium covers both the outer surface of the mantle lobe and the inner side situated next to the pedicle lobe of the larva. During metamorphosis, the mantle lobe is everted over the anterior end of the larva. Thus, the epithelium covering the outer part of the mantle lobe in the larva subsequently becomes the inner epithelium of the juvenile mantle. Similarly, the inner epithelium of the larval mantle lobe represents the future outer epithelium of the juvenile mantle. In free-swimming larvae, the prospective outer mantle epithelium contains two types of cells, called "lobate" and "vesicular" cells. Lobate cells initially deposit a thin layer of amorphous material, and vesicular cells produce ovoid multigranular bodies. Following settlement at about 5 days postfertilization, the vesicular cells secrete an electron-dense sheet that constitutes the basal layer of the developing periostracum. Within several hours to a day thereafter, reversal of the mantle lobe is rapidly effected, apparently by contractions of the pedicle adjustor muscles.

The ontogeny of shell secretion in Terebratalia transversa (Brachiopoda, Articulata). II. Formation of the protegulum and juvenile shell.

The fine structure of the shell and underlying mantle in young juveniles of the articulate brachiopod Terebratalia transversa has been examined by electron microscopy. The first shell produced by the mantle consists of a nonhinged protegulum that lacks concentric growth lines. The protegulum is secreted within a day after larval metamorphosis and typically measures 140-150 micron long. A thin organic periostracum constitutes the outer layer of the protegulum, and finely granular shell material occurs beneath the periostracum. Protegula resist digestion in sodium hypochlorite and are refractory to sectioning, suggesting that the subperiostracal portion of the primordial shell is mineralized. The juvenile shell at 4 days postmetamorphosis possesses incomplete sockets and rudimentary teeth that consist of nonfibrous material. The secondary layer occuring in the inner part of the juvenile shell contains imbricated fibers, whereas the outer portion of the shell comprises a bipartite periostracum and an underlying primary layer of nonfibrous shell. Deposition of the periostracum takes place within a slot that is situated between the so-called lobate and vesicular cells of the outer mantle lobe. Vesicular cells deposit the basal layer of the periostracum, while lobate cells contribute materials to the overlying periostracal superstructure. Cells with numerous tonofibrils and hemidesmosomes differentiate in the outer mantle epithelium at sites of muscle attachments, and unbranched punctae that surround mantle caeca develop throughout the subperiostracal portion of the shell. Three weeks after metamorphosis, the juvenile shell averages about 320 micron in length and is similar in ultrastructure to the shells secreted by adult articulates.

A time-lapse study of interactions between Echinostoma paraensei intramolluscan larval stages and adherent hemocytes from Biomphalaria glabrata and Helix aspersa.

In vitro interactions between intramolluscan stages (sporocyst, daughter rediae, and metacercariae) of the trematode parasite Echinostoma paraensei and adherent hemocytes from the gastropods Biomphalaria glabrata (intermediate host) and Helix aspersa (non-host) were visualized by time-lapse videomicroscopy. Hemocytes of either species not exposed to E. paraensei displayed extensive mobility and activity of cellular extensions. Image analysis disclosed no significant change in the total surface area occupied by hemocytes in a selected field of view over 2 hr. Echinostoma paraensei exerted life stage-specific effects on the behavior of B. glabrata hemocytes; the cells moved away from sporocysts and daughter rediae but not encysted metacercariae. In the presence of sporocysts, hemocytes rounded up, whereas hemocytes adjacent to rediae assumed a stringy, beady appearance. Hemocytes close to the parasite were affected more rapidly than more distant cells. In 2 hr, a hemocyte-free "halo" formed around the parasite larvae, significantly reducing the hemocyte-occupied surface area (to 43% by sporocysts and to 70% by rediae). The changes induced by sporocysts and rediae are similar to those noted in both in vivo and in vitro studies of the B. glabrata-E. paraensei model system and are interpreted as manifestations of parasite-mediated interference with host hemocyte function. Helix aspersa (non-host) hemocytes were not affected, suggesting that E. paraensei-mediated effects on hemocytes exhibit a degree of specificity.

Early one-stage reconstruction of congenital vertical talus.

A simple, one-stage surgical reconstruction was performed on 20 feet with congenital vertical talus in 13 consecutive children. A newly devised outcome scoring system with seven clinical and eight radiographic parameters was utilized to determine correction of all feet at average follow-up of 41 months. There were no excellent, 17 good, 3 fair, and no poor results, with few associated perioperative complications. Clinically, mild postoperative stiffness of ankle and subtalar motion was occasionally noted. Radiographically, many feet had mild residual forefoot abduction with midfoot sagging at the talonavicular joint. Despite these mild postoperative abnormalities, good correction with plantigrade, painless feet was generally obtained when this procedure was performed in children younger than 27 months of age.

Juvenile Tillaux fracture simulating syndesmosis separation: a case report.

The juvenile Tillaux fracture is an avulsion fracture (Salter-Harris type-3) of the anterolateral comer of the distal tibial epiphysis. We present a case in which the severely displaced Tillaux fragment became incarcerated between the distal tibia and fibula, simulating a syndesmotic separation radiographically. To our knowledge, such a fracture pattern as not been previously described. Preoperative computerized tomography provided accurate imaging of the unusual fracture pattern. Open extrication of the fracture fragment was followed by spontaneous reduction of the syndesmosis. The Tillaux fracture healed following open reduction with pin fixation, and the patient had an excellent functional and radiographic result at 2-year follow-up.

Freeze-dried cortical allograft in posterior spinal arthrodesis: use with segmental instrumentation for idiopathic adolescent scoliosis.

Many surgeons use cancellous or corticocancellous allogeneic bone grafts to augment spinal arthrodeses. The efficacy of onlay freeze-dried cortical allografts for posterior spinal fusions has been questioned in the past. In this report, freeze-dried, crushed cortical bone allograft was used as the sole fusion material in 32 consecutive posterior spinal fusions for idiopathic adolescent scoliosis. Absence of clinical or radiographic pseudarthrosis in all patients at an average follow up of 34 months suggests that freeze-dried, crushed cortical bone allograft is a suitable material for augmentation of the fusion mass during posterior spinal fusion with segmental instrumentation.

Extremity handgun injuries in children and adolescents.

The majority of gunshot wounds in the urban pediatric population are inflicted by handguns. This study reviewed the trauma center management of 66 handgun injuries to the upper and lower extremities among 51 children who were aged < or =16 years. As expected, gunshot wounds were more frequent in adolescent males and were usually intentional. About half of the children had police records prior to the gunshot wounds. Fifty-two percent of the extremity handgun injuries resulted in fractures, most commonly to the tibia or forearm. Seventy-nine orthopedic procedures were recorded with an average hospital stay of 4.3 days. Permanent morbidity was undoubtedly underestimated due to poor long-term follow-up.

Solitary osseous myeloma with polyneuropathy. Case report and review of the literature.

Solitary osseous myeloma is an uncommon malignancy of bone which is distinguished from multiple myeloma by being localized and without associated monoclonal gammopathy or Bence-Jones proteinuria. This disease may present with a progressive symmetrical sensorimotor neuropathy. A recent case of localized myeloma with polyneuropathy is presented along with a review of the literature pertinent to orthopedic surgeons.