A randomized trial of ketorolac and metoclopramide for migraine in the emergency department

Richer LP, Ali S, Johnson DW, Rosychuk RJ, Newton AS, Rowe BH. A randomized trial of ketorolac and metoclopramide for migraine in the emergency department. Headache. 2022 Jun;62(6):681-689. doi: 10.1111/head.14307. Epub 2022 Jun 7. PMID: 35670115.

Abstract

Objective: The objective of this study was to assess the efficacy and safety of a common monotherapy (intravenous [iv] metoclopramide) compared to a combination strategy (adding iv ketorolac to metoclopramide) in children presenting for acute treatment of migraine headache in the emergency department (ED).

Methods: Children aged 5-17 years presenting for acute treatment of migraine headache at two pediatric EDs were enrolled in a double-blind randomized controlled trial. Children were randomly assigned to receive iv metoclopramide 0.2 mg/kg) and placebo or iv metoclopramide (0.2 mg/kg) and ketorolac (0.5 mg/kg). The primary outcome was a mean change in pain from baseline to 120 min via a 100 mm Visual Analog Scale (VAS). Follow-up was conducted 24-h after discharge.

Results: Fifty-three children were randomized and included in the analysis (monotherapy group [metoclopramide + placebo], n = 27; and ketorolac group [metoclopramide + ketorolac], n = 26); mean age was 12.9 ± 2.7 years and baseline pain severity on VAS was 67.3 ± 2.7 mm. The mean change in pain intensity at 120 min was -44 mm (SD: 24; 95% confidence interval [CI]: 32-57) for the monotherapy group and -36 mm (SD: 24; 95% CI: 23-49) for the ketorolac group, with a mean difference between groups of 8 mm (95% CI: -9-25; p = 0.360). Seventeen percent of the children (9/53; 95% CI: 7-27%) were pain-free at discharge. There was no difference in headache recurrence or adverse events between groups.

Conclusions: The approach of combining iv metoclopramide with ketorolac failed to improve pain scores in children presenting for acute treatment of migraine headache in the ED compared to metoclopramide monotherapy. Most patients were discharged with residual pain. Further comparative studies are needed to test alternative ED treatments for migraine in children or adolescents.

ZBTB11 mutations

Inspired by a patient

Sumathipala D, Strømme P, Fattahi Z, Lüders T, Sheng Y, Kahrizi K, Einarsen IH, Sloan JL, Najmabadi H, van den Heuvel L, Wevers RA, Guerrero-Castillo S, Mørkrid L, Valayannopoulos V, Backe PH, Venditti CP, van Karnebeek CD, Nilsen H, Frengen E, Misceo D. ZBTB11 dysfunction: spectrum of brain abnormalities, biochemical signature and cellular consequences. Brain. 2022 Jul 29;145(7):2602-2616. doi: 10.1093/brain/awac034. PMID: 35104841; PMCID: PMC9337812.

Abstract

Bi-allelic pathogenic variants in ZBTB11 have been associated with intellectual developmental disorder, autosomal recessive 69 (MRT69; OMIM 618383). We report five patients from three families with novel, bi-allelic variants in ZBTB11. We have expanded the clinical phenotype of MRT69, documenting varied severity of atrophy affecting different brain regions and described combined malonic and methylmalonic aciduria as a biochemical manifestation. As ZBTB11 encodes for a transcriptional regulator, we performeded chromatin immunoprecipitation-sequencing targeting ZBTB11 in fibroblasts from patients and controls. Chromatin immunoprecipitation-sequencing revealed binding of wild-type ZBTB11 to promoters in 238 genes, among which genes encoding proteins involved in mitochondrial functions and RNA processing are over-represented. Mutated ZBTB11 showed reduced binding to 61 of the targeted genes, indicating that the variants act as loss of function. Most of these genes are related to mitochondrial functions. Transcriptome analysis of the patient fibroblasts revealed dysregulation of mitochondrial functions. In addition, we uncovered that reduced binding of the mutated ZBTB11 to ACSF3 leads to decreased ACSF3 transcript level, explaining combined malonic and methylmalonic aciduria. Collectively, these results expand the clinical spectrum of ZBTB11-related neurological disease and give insight into the pathophysiology in which the dysfunctional ZBTB11 affect mitochondrial functions and RNA processing contributing to the neurological and biochemical phenotypes.

Scala M, De Grandis E, Nobile G, Iacomino M, Madia F, Capra V, Nobili L, Zara F, Striano P. Biallelic ZBTB11 variants associated with complex neuropsychiatric phenotype featuring Tourette syndrome. Brain. 2023 Jan 5;146(1):e1-e4. doi: 10.1093/brain/awac323. PMID: 36068688; PMCID: PMC9825546.

No abstract. From the article:

In summary, we report a complex neuropsychiatric phenotype associated with ZBTB11 variants not strictly overlapping the previously described classic phenotype. However, milder phenotypes have been reported in subjects boring the homozygous c.154C>T (p.Arg52Trp) variant. These patients showed a mild cognitive impairment, subtle brain malformations, and no evident metabolic abnormalities, thus partially resembling our patient.1 The (p.Arg52Trp) change affects a conserved residue outside ZBTB11 functional domains and lies very close to the Arg34 residue, which is affected in our patient. Although further confirmation is needed, this would lead to suggest that variants located early in the ZBTB11 protein, outside the main functional domains, may be associated with a likely milder and more heterogeneous clinical phenotype.

Behavioural abnormalities reported in ZBTB11 patients include autism, stereotypies and ritualistic behaviour. The neuropsychiatric manifestations in our patient are instead suggestive of Tourette syndrome, a complex condition characterized by tics involving any part of the body (especially the face), usually starting in childhood and often improving in adult life.5 Although Tourette syndrome is a highly heritable disorder, it has complex genetics involving both common mildly deleterious and rare highly damaging variants in several crucial genes for neuronal function. Recently, a potentially relevant pathophysiological role has been suggested for genes encoding proteins involved in mitochondrial transport (NDE1, DISC1, OPA1), fusion (OPA1) and fission (ADCY). Of note, ZBTB11 variants were found to affect ZBTB11 binding to several target genes, including those encoding proteins involved in mitochondrial functions. This is also supported by the mitochondrial dysfunction observed in ZBTB11 patient fibroblasts, mainly resulting from the downregulation of genes implicated in the mitochondrial respiratory complex biogenesis and translation. Overall, these findings suggest a pathophysiological link between Tourette syndrome and the ZBTB11 variants detected in our patient. The lack of similar neuropsychiatric manifestations in other ZBTB11 patients might depend on several factors, including the localization of the variants, and further studies should confirm this association. However, our case raises the possibility that ZBTB11, as an essential transcriptional regulator, plays a role as a risk gene in Tourette syndrome...

Hence, our case raises the possibility that the phenotypical spectrum of MRT69 may be wider than expected based on previous reports, suggesting that patients harbouring biallelic variants in ZBTB11 may show a more heterogeneous neurodevelopmental and neuropsychiatric involvement. In particular, Tourette syndrome in our patient suggests a possible pathophysiological link between this condition and the mitochondrial dysfunction resulting from loss of function ZBTB11 variants. Further studies will play a pivotal role in the refinement of ZBTB11-related neuropsychiatric features and the investigation of the potential role of ZBTB11 as a risk gene for Tourette syndrome.

Fattahi Z, Sheikh TI, Musante L, Rasheed M, Taskiran II, Harripaul R, Hu H, Kazeminasab S, Alam MR, Hosseini M, Larti F, Ghaderi Z, Celik A, Ayub M, Ansar M, Haddadi M, Wienker TF, Ropers HH, Kahrizi K, Vincent JB, Najmabadi H. Biallelic missense variants in ZBTB11 can cause intellectual disability in humans. Hum Mol Genet. 2018 Sep 15;27(18):3177-3188. doi: 10.1093/hmg/ddy220. PMID: 29893856.

Abstract

Exploring genes and pathways underlying intellectual disability (ID) provides insight into brain development and function, clarifying the complex puzzle of how cognition develops. As part of ongoing systematic studies to identify candidate ID genes, linkage analysis and next-generation sequencing revealed Zinc Finger and BTB Domain Containing 11 (ZBTB11) as a novel candidate ID gene. ZBTB11 encodes a little-studied transcription regulator, and the two identified missense variants in this study are predicted to disrupt canonical Zn2+-binding residues of its C2H2 zinc finger domain, leading to possible altered DNA binding. Using HEK293T cells transfected with wild-type and mutant GFP-ZBTB11 constructs, we found the ZBTB11 mutants being excluded from the nucleolus, where the wild-type recombinant protein is predominantly localized. Pathway analysis applied to ChIP-seq data deposited in the ENCODE database supports the localization of ZBTB11 in nucleoli, highlighting associated pathways such as ribosomal RNA synthesis, ribosomal assembly, RNA modification and stress sensing, and provides a direct link between subcellular ZBTB11 location and its function. Furthermore, given the report of prominent brain and spinal cord degeneration in a zebrafish Zbtb11 mutant, we investigated ZBTB11-ortholog knockdown in Drosophila melanogaster brain by targeting RNAi using the UAS/Gal4 system. The observed approximate reduction to a third of the mushroom body size-possibly through neuronal reduction or degeneration-may affect neuronal circuits in the brain that are required for adaptive behavior, specifying the role of this gene in the nervous system. In conclusion, we report two ID families segregating ZBTB11 biallelic mutations disrupting Zn2+-binding motifs and provide functional evidence linking ZBTB11 dysfunction to this phenotype.

Wilson BC, Boehme L, Annibali A, Hodgkinson A, Carroll TS, Oakey RJ, Seitan VC. Intellectual disability-associated factor Zbtb11 cooperates with NRF-2/GABP to control mitochondrial function. Nat Commun. 2020 Oct 29;11(1):5469. doi: 10.1038/s41467-020-19205-x. PMID: 33122634; PMCID: PMC7596099.

Abstract

Zbtb11 is a conserved transcription factor mutated in families with hereditary intellectual disability. Its precise molecular and cellular functions are currently unknown, precluding our understanding of the aetiology of this disease. Using a combination of functional genomics, genetic and biochemical approaches, here we show that Zbtb11 plays essential roles in maintaining the homeostasis of mitochondrial function. Mechanistically, we find Zbtb11 facilitates the recruitment of nuclear respiratory factor 2 (NRF-2) to its target promoters, activating a subset of nuclear genes with roles in the biogenesis of respiratory complex I and the mitoribosome. Genetic inactivation of Zbtb11 resulted in a severe complex I assembly defect, impaired mitochondrial respiration, mitochondrial depolarisation, and ultimately proliferation arrest and cell death. Experimental modelling of the pathogenic human mutations showed these have a destabilising effect on the protein, resulting in reduced Zbtb11 dosage, downregulation of its target genes, and impaired complex I biogenesis. Our study establishes Zbtb11 as an essential mitochondrial regulator, improves our understanding of the transcriptional mechanisms of nuclear control over mitochondria, and may help to understand the aetiology of Zbtb11-associated intellectual disability.

MYT1L haploinsufficiency in human neurons and mice causes autism-associated phenotypes that can be reversed by genetic and pharmacologic intervention

Weigel, B., Tegethoff, J.F., Grieder, S.D. et al. MYT1L haploinsufficiency in human neurons and mice causes autism-associated phenotypes that can be reversed by genetic and pharmacologic intervention. Mol Psychiatry (2023). https://doi.org/10.1038/s41380-023-01959-7

Abstract

MYT1L is an autism spectrum disorder (ASD)-associated transcription factor that is expressed in virtually all neurons throughout life. How MYT1L mutations cause neurological phenotypes and whether they can be targeted remains enigmatic. Here, we examine the effects of MYT1L deficiency in human neurons and mice. Mutant mice exhibit neurodevelopmental delays with thinner cortices, behavioural phenotypes, and gene expression changes that resemble those of ASD patients. MYT1L target genes, including WNT and NOTCH, are activated upon MYT1L depletion and their chemical inhibition can rescue delayed neurogenesis in vitro. MYT1L deficiency also causes upregulation of the main cardiac sodium channel, SCN5A, and neuronal hyperactivity, which could be restored by shRNA-mediated knockdown of SCN5A or MYT1L overexpression in postmitotic neurons. Acute application of the sodium channel blocker, lamotrigine, also rescued electrophysiological defects in vitro and behaviour phenotypes in vivo. Hence, MYT1L mutation causes both developmental and postmitotic neurological defects. However, acute intervention can normalise resulting electrophysiological and behavioural phenotypes in adulthood. ____________________________________________________

The behavioral disorders observed in autism are associated with a multitude of genetic alterations. Scientists from the Hector Institute for Translational Brain Research (HITBR) have now found another molecular cause for this condition. The transcription factor MYT1L normally protects the molecular identity of nerve cells. If it is genetically switched off in human nerve cells or in mice, the functional changes and symptoms typical of autism occur. A drug that blocks sodium channels in the cell membrane can reverse the consequences of MYT1L failure and alleviate the functional and behavioral abnormalities in mice. 

Disorders from the autism spectrum (ASD, autism spectrum disorders) are not only manifested by impairments in social interaction, communication, interest formation, and by stereotypical behavior patterns. This is often accompanied by other abnormalities such as epilepsy or hyperactivity. 

Scientists are intensively searching for the molecular abnormalities that contribute to this complex developmental disorder. A multitude of genetic factors that influence the molecular programs of the nerve cells have already been linked to the development of autism. 

Moritz Mall from the Hector Institute for Translational Brain Research (HITBR) has long been researching the role of the protein MYT1L in various neuronal diseases. The protein is a so-called transcription factor that decides which genes are active in the cell and which are not. Almost all nerve cells in the body produce MYT1L throughout their entire life span. 

Mall had already shown a few years ago that MYT1L protects the identity of nerve cells by suppressing other developmental pathways that program a cell toward muscle or connective tissue, for example. Mutations in MYT1L have been found in several neurological diseases, such as schizophrenia and epilepsy, but also in brain malformations. In their current work, which is funded by the European Research Council ERC, Mall and his team examined the exact role of the “guardian of neuronal identity” in the development of an ASD. To do this, they genetically switched off MYT1L — both in mice and in human nerve cells that had been derived from reprogrammed stem cells in the laboratory. 

The loss of MYT1L led to electrophysiological hyperactivation in mouse and human neurons and thus impaired nerve function. Mice lacking MYT1L suffered from brain abnormalities, such as a thinner cerebral cortex. The animals also showed several ASS-typical behavioral changes such as social deficits or hyperactivity. 

What was particularly striking about the MYT1L-deficient neurons was that they produced an excess of sodium channels that are normally mainly restricted to the heart muscle cells. These pore-shaped proteins allow sodium ions to pass through the cell membrane and are thus crucial for electrical conductivity and thus also for the functioning of the cells. If a nerve cell produces too many of these channel proteins, electrophysiological hyperactivation can be the result. 

In clinical medicine, drugs that block sodium channels have been used for a long time. These include the agent lamotrigine, which is supposed to prevent epileptic seizures. When MYT1L-deficient nerve cells were treated with lamotrigine, their electrophysiological activity returned to normal. In mice, the drug was even able to curb ASD-associated behaviors such as hyperactivity. 

“Apparently, drug treatment in adulthood can alleviate brain cell dysfunction and thus counteract the behavioral abnormalities typical of autism — even after the absence of MYT1L has already impaired brain development during the developmental phase of the organism,” explains Moritz Mall. However, the results are still limited to studies in mice; clinical studies in patients with disorders from the ASD spectrum have not yet been conducted. The first clinical studies are in the early planning phase. 

https://scitechdaily.com/a-drug-that-cures-autism-neuroscience-study-yields-promising-results/

Autoimmune encephalitis misdiagnosis in adults

Courtesy of a colleague

Flanagan EP, Geschwind MD, Lopez-Chiriboga AS, Blackburn KM, Turaga S, Binks S, Zitser J, Gelfand JM, Day GS, Dunham SR, Rodenbeck SJ, Clardy SL, Solomon AJ, Pittock SJ, McKeon A, Dubey D, Zekeridou A, Toledano M, Turner LE, Vernino S, Irani SR. Autoimmune Encephalitis Misdiagnosis in Adults. JAMA Neurol. 2023 Jan 1;80(1):30-39. doi: 10.1001/jamaneurol.2022.4251. PMID: 36441519; PMCID: PMC9706400.

Abstract

Importance: Autoimmune encephalitis misdiagnosis can lead to harm.

Objective: To determine the diseases misdiagnosed as autoimmune encephalitis and potential reasons for misdiagnosis.

Design, setting, and participants: This retrospective multicenter study took place from January 1, 2014, to December 31, 2020, at autoimmune encephalitis subspecialty outpatient clinics including Mayo Clinic (n = 44), University of Oxford (n = 18), University of Texas Southwestern (n = 18), University of California, San Francisco (n = 17), University of Washington in St Louis (n = 6), and University of Utah (n = 4). Inclusion criteria were adults (age ≥18 years) with a prior autoimmune encephalitis diagnosis at a participating center or other medical facility and a subsequent alternative diagnosis at a participating center. A total of 393 patients were referred with an autoimmune encephalitis diagnosis, and of those, 286 patients with true autoimmune encephalitis were excluded.

Main outcomes and measures: Data were collected on clinical features, investigations, fulfillment of autoimmune encephalitis criteria, alternative diagnoses, potential contributors to misdiagnosis, and immunotherapy adverse reactions.

Results: A total of 107 patients were misdiagnosed with autoimmune encephalitis, and 77 (72%) did not fulfill diagnostic criteria for autoimmune encephalitis. The median (IQR) age was 48 (35.5-60.5) years and 65 (61%) were female. Correct diagnoses included functional neurologic disorder (27 [25%]), neurodegenerative disease (22 [20.5%]), primary psychiatric disease (19 [18%]), cognitive deficits from comorbidities (11 [10%]), cerebral neoplasm (10 [9.5%]), and other (18 [17%]). Onset was acute/subacute in 56 (52%) or insidious (>3 months) in 51 (48%). Magnetic resonance imaging of the brain was suggestive of encephalitis in 19 of 104 patients (18%) and cerebrospinal fluid (CSF) pleocytosis occurred in 16 of 84 patients (19%). Thyroid peroxidase antibodies were elevated in 24 of 62 patients (39%). Positive neural autoantibodies were more frequent in serum than CSF (48 of 105 [46%] vs 7 of 91 [8%]) and included 1 or more of GAD65 (n = 14), voltage-gated potassium channel complex (LGI1 and CASPR2 negative) (n = 10), N-methyl-d-aspartate receptor by cell-based assay only (n = 10; 6 negative in CSF), and other (n = 18). Adverse reactions from immunotherapies occurred in 17 of 84 patients (20%). Potential contributors to misdiagnosis included overinterpretation of positive serum antibodies (53 [50%]), misinterpretation of functional/psychiatric, or nonspecific cognitive dysfunction as encephalopathy (41 [38%]).

Conclusions and relevance: When evaluating for autoimmune encephalitis, a broad differential diagnosis should be considered and misdiagnosis occurs in many settings including at specialized centers. In this study, red flags suggesting alternative diagnoses included an insidious onset, positive nonspecific serum antibody, and failure to fulfill autoimmune encephalitis diagnostic criteria. Autoimmune encephalitis misdiagnosis leads to morbidity from unnecessary immunotherapies and delayed treatment of the correct diagnosis.

Dalmau J, Graus F. Autoimmune Encephalitis-Misdiagnosis, Misconceptions, and How to Avoid Them. JAMA Neurol. 2023 Jan 1;80(1):12-14. doi: 10.1001/jamaneurol.2022.4154. PMID: 36441535.

No abstract. From the article.

How can we prevent misdiagnoses? (1) Become familiar with the syndromes and favor clinical reasoning over antibody results. (2) Use CSF and serum testing; if forced to pick one, use CSF. (3) Be aware that a positive test result does not always mean presence of antibodies; thus, request antibody confirmation by at least 2 techniques (brain tissue immunohistochemistry and CBA). (4) Doubt any positive serum result that in the context of suspected AE is accompanied by negative CSF antibodies. An exception is the antibodies against myelin oligodendrocyte glycoprotein (MOG) that are more frequently detected in serum and can associate with symptoms of AE.14 Even for anti-LGI1 encephalitis, the concept that antibodies occur more frequently in serum is inaccurate; virtually all patients have LGI1 antibodies in CSF if properly studiedwith brain immunohistochemistry and CBA expressing LGI1 with one of its natural ligands (ADAM23).15 Therefore, diagnostic laboratories should strongly consider including a warning message in their reports, indicating that a positive serum result for antibodies against neuronal surface proteins mandates the confirmation of antibodies in CSF, as the risk for clinical misdiagnosis of AE dramatically increases if the CSF status is negative or unknown. 

Flanagan and colleagues suggest the misdiagnosis of AEs can be lessened by educating physicians; for example, most of the brain MRI images provided should have raised a red flag against AEs. However, a critical analysis of what is occurring in the fields of autoimmune neurology and immunopsychiatry uncovers a more fundamental problem: the education provided has not been adequate. Ifmisdiagnoses are frequent, it is because the clinical-immunological concepts derived from many investigations are not solid, favoring antibody testing over clinical judgment. A careful clinical differential diagnosiswith better selection of cases for antibody studies and appropriate biological samples and techniques would represent a colossal step to prevent the misdiagnosis of AEs

Physical interventions to interrupt or reduce the spread of respiratory viruses

Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al-Ansary LA, Bawazeer GA, van Driel ML, Jones MA, Thorning S, Beller EM, Clark J, Hoffmann TC, Glasziou PP, Conly JM. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst Rev. 2020 Nov 20;11(11):CD006207. doi: 10.1002/14651858.CD006207.pub5. Update in: Cochrane Database Syst Rev. 2023 Jan 30;1:CD006207. PMID: 33215698; PMCID: PMC8094623.

Abstract

Background: Viral epidemics or pandemics of acute respiratory infections (ARIs) pose a global threat. Examples are influenza (H1N1) caused by the H1N1pdm09 virus in 2009, severe acute respiratory syndrome (SARS) in 2003, and coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 in 2019. Antiviral drugs and vaccines may be insufficient to prevent their spread. This is an update of a Cochrane Review published in 2007, 2009, 2010, and 2011. The evidence summarised in this review does not include results from studies from the current COVID-19 pandemic.

Objectives: To assess the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses.

Search methods: We searched CENTRAL, PubMed, Embase, CINAHL on 1 April 2020. We searched ClinicalTrials.gov, and the WHO ICTRP on 16 March 2020. We conducted a backwards and forwards citation analysis on the newly included studies.

Selection criteria: We included randomised controlled trials (RCTs) and cluster-RCTs of trials investigating physical interventions (screening at entry ports, isolation, quarantine, physical distancing, personal protection, hand hygiene, face masks, and gargling) to prevent respiratory virus transmission. In previous versions of this review we also included observational studies. However, for this update, there were sufficient RCTs to address our study aims. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of the evidence. Three pairs of review authors independently extracted data using a standard template applied in previous versions of this review, but which was revised to reflect our focus on RCTs and cluster-RCTs for this update. We did not contact trialists for missing data due to the urgency in completing the review. We extracted data on adverse events (harms) associated with the interventions.

Main results: We included 44 new RCTs and cluster-RCTs in this update, bringing the total number of randomised trials to 67. There were no included studies conducted during the COVID-19 pandemic. Six ongoing studies were identified, of which three evaluating masks are being conducted concurrent with the COVID pandemic, and one is completed. Many studies were conducted during non-epidemic influenza periods, but several studies were conducted during the global H1N1 influenza pandemic in 2009, and others in epidemic influenza seasons up to 2016. Thus, studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID-19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high-income countries; crowded inner city settings in low-income countries; and an immigrant neighbourhood in a high-income country. Compliance with interventions was low in many studies. The risk of bias for the RCTs and cluster-RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included nine trials (of which eight were cluster-RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and seven in the community). There is low certainty evidence from nine trials (3507 participants) that wearing a mask may make little or no difference to the outcome of influenza-like illness (ILI) compared to not wearing a mask (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.82 to 1.18. There is moderate certainty evidence that wearing a mask probably makes little or no difference to the outcome of laboratory-confirmed influenza compared to not wearing a mask (RR 0.91, 95% CI 0.66 to 1.26; 6 trials; 3005 participants). Harms were rarely measured and poorly reported. Two studies during COVID-19 plan to recruit a total of 72,000 people. One evaluates medical/surgical masks (N = 6000) (published Annals of Internal Medicine, 18 Nov 2020), and one evaluates cloth masks (N = 66,000). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). There is uncertainty over the effects of N95/P2 respirators when compared with medical/surgical masks on the outcomes of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; very low-certainty evidence; 3 trials; 7779 participants) and ILI (RR 0.82, 95% CI 0.66 to 1.03; low-certainty evidence; 5 trials; 8407 participants). The evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirator compared to a medical/surgical mask probably makes little or no difference for the objective and more precise outcome of laboratory-confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; moderate-certainty evidence; 5 trials; 8407 participants). Restricting the pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies. One ongoing study recruiting 576 people compares N95/P2 respirators with medical surgical masks for healthcare workers during COVID-19. Hand hygiene compared to control Settings included schools, childcare centres, homes, and offices. In a comparison of hand hygiene interventions with control (no intervention), there was a 16% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.84, 95% CI 0.82 to 0.86; 7 trials; 44,129 participants; moderate-certainty evidence), suggesting a probable benefit. When considering the more strictly defined outcomes of ILI and laboratory-confirmed influenza, the estimates of effect for ILI (RR 0.98, 95% CI 0.85 to 1.13; 10 trials; 32,641 participants; low-certainty evidence) and laboratory-confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials; 8332 participants; low-certainty evidence) suggest the intervention made little or no difference. We pooled all 16 trials (61,372 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. The pooled data showed that hand hygiene may offer a benefit with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.84 to 0.95; low-certainty evidence), but with high heterogeneity. Few trials measured and reported harms. There are two ongoing studies of handwashing interventions in 395 children outside of COVID-19. We identified one RCT on quarantine/physical distancing. Company employees in Japan were asked to stay at home if household members had ILI symptoms. Overall fewer people in the intervention group contracted influenza compared with workers in the control group (2.75% versus 3.18%; hazard ratio 0.80, 95% CI 0.66 to 0.97). However, those who stayed at home with their infected family members were 2.17 times more likely to be infected. We found no RCTs on eye protection, gowns and gloves, or screening at entry ports.

Authors' conclusions: The high risk of bias in the trials, variation in outcome measurement, and relatively low compliance with the interventions during the studies hamper drawing firm conclusions and generalising the findings to the current COVID-19 pandemic. There is uncertainty about the effects of face masks. The low-moderate certainty of the evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect. The pooled results of randomised trials did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks during seasonal influenza. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness. Harms associated with physical interventions were under-investigated. There is a need for large, well-designed RCTs addressing the effectiveness of many of these interventions in multiple settings and populations, especially in those most at risk of ARIs.

Epileptic spasms related to neuronal differentiation factor 2 (NEUROD2) mutation

Sakpichaisakul K, Boonkrongsak R, Lertbutsayanukul P, Iemwimangsa N, Klumsathian S, Panthan B, Trachoo O. Epileptic spasms related to neuronal differentiation factor 2 (NEUROD2) mutation respond to combined vigabatrin and high dose prednisolone therapy. BMC Neurol. 2022 Dec 9;22(1):461. doi: 10.1186/s12883-022-02992-9. PMID: 36494631; PMCID: PMC9733267. 

Abstract

Background: Epileptic spasms are a devastating form of early infantile epileptic encephalopathy (EIEE) with various etiologies. Early diagnosis and a shorter lead time to treatment are crucial to stop the seizures and optimize the neurodevelopmental outcome. Genetic testing has become an integral part of epilepsy care that directly guides management and family planning and discovers new targeted treatments. Neuronal differentiation Factor 2 (NEUROD2) variants have recently been a cause of neurodevelopmental disorders (NDDs) and EIEEs with distinctive features. However, there is limited information about the clinical and electroencephalographic response of epileptic spasm treatment in NEUROD2-related NDD syndrome.

Case presentation: We report a female patient of Southeast Asian ethnicity with global developmental delay and epileptic spasms commencing in the first few months of life. A novel de novo heterozygous pathogenic NEUROD2 variant, p. E130Q, was subsequently identified by whole-exome sequencing. Electroencephalogram before treatment showed multifocal independent spikes predominantly in both posterior head regions and demonstrated marked improvement following combined vigabatrin and high-dose prednisolone treatment. However, multiple courses of relapse occurred after weaning off the antiseizure medication.

Conclusions: We propose that epileptic spasms related to de novo NEUROD2 pathogenic variant respond well to combined vigabatrin and high-dose prednisolone therapy. These findings may imply the benefit of using combination therapy to treat epileptic spasms in NEUROD2-related NDD syndrome.

Sega AG, Mis EK, Lindstrom K, Mercimek-Andrews S, Ji W, Cho MT, Juusola J, Konstantino M, Jeffries L, Khokha MK, Lakhani SA. De novo pathogenic variants in neuronal differentiation factor 2 (NEUROD2) cause a form of early infantile epileptic encephalopathy. J Med Genet. 2019 Feb;56(2):113-122. doi: 10.1136/jmedgenet-2018-105322. Epub 2018 Oct 15. PMID: 30323019.

Abstract

Background: Early infantile epileptic encephalopathies are severe disorders consisting of early-onset refractory seizures accompanied often by significant developmental delay. The increasing availability of next-generation sequencing has facilitated the recognition of single gene mutations as an underlying aetiology of some forms of early infantile epileptic encephalopathies.

Objectives: This study was designed to identify candidate genes as a potential cause of early infantile epileptic encephalopathy, and then to provide genetic and functional evidence supporting patient variants as causative.

Methods: We used whole exome sequencing to identify candidate genes. To model the disease and assess the functional effects of patient variants on candidate protein function, we used in vivo CRISPR/Cas9-mediated genome editing and protein overexpression in frog tadpoles.

Results: We identified novel de novo variants in neuronal differentiation factor 2 (NEUROD2) in two unrelated children with early infantile epileptic encephalopathy. Depleting neurod2 with CRISPR/Cas9-mediated genome editing induced spontaneous seizures in tadpoles, mimicking the patients' condition. Overexpression of wild-type NEUROD2 induced ectopic neurons in tadpoles; however, patient variants were markedly less effective, suggesting that both variants are dysfunctional and likely pathogenic.

Conclusion: This study provides clinical and functional support for NEUROD2 variants as a cause of early infantile epileptic encephalopathy, the first evidence of human disease caused by NEUROD2 variants.

Ornithine transcarbamylase deficiency diagnosed post-mortem

RaeLynn Forsyth, Ryan H. Peretz, Angela Dempsey, Jacquelyn Britton, Lisa Kratz, Ada Hamosh, Hilary Vernon, Mark L. Batshaw, David Valle. The remarkable journey of one female individual with ornithine transcarbamylase deficiency diagnosed post-mortem. JIMD reports. First published: 29 January 2023 https://doi.org/10.1002/jmd2.12361.  

Urea cycle disorders (UCDs) comprise a group of inborn errors of metabolism with impaired ammonia clearance and an incidence of ~1:35 000 individuals. First described in the 1970s, the diagnosis and management of these disorders has evolved dramatically. We report on a 59‐year‐old woman with a UCD who contributed to advances in the understanding and treatment of this group of disorders. This individual was diagnosed with carbamoyl phosphate synthetase 1 deficiency based on a biochemical assay under a research context predating genetic sequencing, treated longitudinally as having this metabolic disorder, and was among the first participants to trial UCD pharmaceutical therapies. She ultimately succumbed to a SARS‐CoV‐2 infection while maintaining unexpectedly normal ammonium levels. Postmortem genetic testing revealed ornithine transcarbamylase deficiency. This individual's contributions to the field of UCDs is discussed herein. 

From the article:

 

We report the natural history of a 59-year-old woman with a UCD. Her care and management paralleled the development of modern methods of UCD diagnosis and treatment, and she has been included in two previous publications describing these developments over the last 45 years. Together with her family, she was a participant in the clinical research that led to these developments. In an initial report, she was misdiagnosed with CPS1 deficiency based on biochemical and enzyme studies. Subsequent molecular testing obtained post-mortem revealed that her UCD was heterozygosity for OTC deficiency. Just as this patient contributed to the understanding of UCDs throughout her life, the events surrounding her death continue to promote our learning about these rare disorders.  

 

In retrospect, the diagnosis of OTC deficiency is more explanatory than CPS1 deficiency. First, OTC deficiency is more common than CPS1 deficiency, with prevalence of 1:56 500 compared to 1:1 300 000 individuals, respectively.3 Second, the maternal family history of migraines is suggestive of a possible X-linked disorder, and females who are heterozygous for pathogenic variants of OTC have a spectrum of symptoms related to impaired waste nitrogen excretion, including migraine headaches. Because of the variable pattern of X-chromosome inactivation, enzyme testing is not reliable for diagnosis of OTC heterozygosity in females. This is likely the explanation for failing to make an accurate diagnosis with an assay of OTC activity in her liver biopsy. Moreover, these assays were just being developed when performed on this patient and preanalytical handling of the liver biopsy sample was likely not as accurate as required for correct CPS1 enzyme analysis. The lack of orotic acid, a characteristic marker in OTC deficiency in blood and urine samples at times of hyperammonemia, is unusual, but orotic acid can be normal even in hemizygous male individuals with OTC deficiency. 

If this patient had been born today, prompt diagnosis of her OTC deficiency could have been made after her first presentation and effective therapies started before there was irreversible neurological damage. Given that OTC and CPS1 deficiencies are both proximal UCDs, medical management in this patient would not have been different had the correct diagnosis been known sooner. Accurate reproductive and familial risk counseling and testing, however, considering the X-linked inheritance pattern, would have been offered. 

Although she escaped the lethal complications of her genetic disorder, she ultimately succumbed to SARS-CoV-2 infection despite good metabolic control throughout this illness. This patient's relatively delayed presentation and good metabolic control with infrequent hyperammonemic episodes may have also been a clue to a partial defect and suggest that her pattern of X inactivation may have been favorable. Unfortunately, we have no data addressing this possibility. Elevated plasma ammonium levels are commonly seen in patients with UCDs during times of infection, and we would expect the SARS-CoV-2 virus to induce a profound catabolic state. The patient presented with hypothermia, bradycardia, and hypotension, and we hypothesize that this physiological state, in combination with the expeditious initiation of intravenous fluids with 10% dextrose to maintain a high glucose infusion rate and the introduction of enteral feeds upon patient rewarming, may have halted catabolism and prevented hyperammonemia. Hypothermia preventing hyperammonemia in the context of metabolic crises has previously been shown to be safe and feasible in neonates with UCDs, but no studies have been done in adults. This patient raises the notion of utilizing therapeutic hypothermia to help prevent catabolism and hyperammonemia among individuals affected by UCDs, which should be weighed against hemodynamic risks.