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Living amphibians (Lissamphibia) include frogs and salamanders (Batrachia) and the limbless worm-like caecilians (Gymnophiona). The estimated Palaeozoic era gymnophionan–batrachian molecular divergence suggests a major gap in the record of crown lissamphibians prior to their earliest fossil occurrences in the Triassic period. Recent studies find a monophyletic Batrachia within dissorophoid temnospondyls, but the absence of pre-Jurassic period caecilian fossils has made their relationships to batrachians and affinities to Palaeozoic tetrapods controversial. Here we report the geologically oldest stem caecilian—a crown lissamphibian from the Late Triassic epoch of Arizona, USA—extending the caecilian record by around 35 million years. These fossils illuminate the tempo and mode of early caecilian morphological and functional evolution, demonstrating a delayed acquisition of musculoskeletal features associated with fossoriality in living caecilians, including the dual jaw closure mechanism, reduced orbits and the tentacular organ. The provenance of these fossils suggests a Pangaean equatorial origin for caecilians, implying that living caecilian biogeography reflects conserved aspects of caecilian function and physiology19, in combination with vicariance patterns driven by plate tectonics. These fossils reveal a combination of features that is unique to caecilians alongside features that are shared with batrachian and dissorophoid temnospondyls, providing new and compelling evidence supporting a single origin of living amphibians within dissorophoid temnospondyls. This study was supported by the David R. Wones Geological Scholarship (to B.T.K.), the USA National Park Service (PMIS 209814 to B.T.K., W.G.P. and A.D.M.), the Virginia Tech Department of Geosciences (to B.T.K., M.R.S. and S.J.N.), the National Science Foundation (DEB1655609 to M.R.S.; EAR480383 to S.J.N., M.R.S. and B.T.K.; and DPP1947094 to C. Sidor, supporting B.M.G.), the David B. Jones Foundation (to M.R.S. and S.J.N.) and the Petrified Forest Museum Association (to B.T.K.). Published version

Purpose: To determine whether the appearance of strabismus is noted in a race implicit association test by medical students. Methods: Medical students participated in a survey evaluating for the appearance of strabismus in photographs from a commonly used race implicit association test. Analysis was performed to determine whether strabismus was perceived equally between both groups tested. Results: Photographs of six individuals of African descent were perceived as having strabismus more frequently (62%) than photographs of individuals of European descent (31%; odds ratio: 3.85; 95% CI: 3.34 to 4.44; P < .0001). Participants who identified as Black or African American similarly perceived strabismus more frequently in individuals of African descent (58%) than those of European descent (24%; odds ratio: 4.36; 95% CI: 2.13 to 8.96; P < .0001). Conclusions: Photographs used in a common race implicit association test appear to differ not only in ethnicity but also in extraocular alignment. Because extraocular alignment is a known cause of negative prejudice, results of this particular implicit association test should be interpreted with caution. [ J Pediatr Ophthalmol Strabismus . 20XX;X(X):XX–XX.]

One route to mitigate the increasing costs of total hip arthroplasty (THA) is outpatient THA, discharging patients on the same day as their surgery. The purpose of this study was to compare the cost of outpatient THA to standard overnight stay in hospital.This was a preliminary analysis of the first group of patients to complete follow-up in a larger randomized controlled trial among patients who underwent primary THA through a direct anterior approach between June 2015 and November 2017. The study was conducted at a single centre among patients of 1 fellowship-trained arthroplasty surgeon. We randomly allocated participants to be discharged either as outpatients or on postsurgery day 1 using a modified Zelen consent model. Adverse events were recorded. Participants completed cost questionnaires 2, 6 and 12 weeks after surgery, and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) before and 12 weeks after surgery. We performed cost analyses from health care payer and societal perspectives.A total of 115 participants completed this study, 49 allocated to the outpatient group and 56 to the inpatient group. The adverse event rate was similar for the 2 groups. The WOMAC total score and function subscale score were higher for the outpatient group than the inpatient group at 12 weeks (mean difference 2.1, 95% confidence interval [CI] 0.0 to 4.1, and 6.5, 95% CI 0.4 to 12.5, respectively). From both a health care payer and a societal perspective, inpatient THA was more costly than outpatient THA (mean difference $1006.86, 95% CI -$2158.92 to $145.21, and $1667.40, 95% CI -$3856.64 to $521.84, respectively).Our results suggest that outpatient THA may be a cost-saving procedure compared to inpatient THA from both health care payer and societal perspectives. Further study with larger samples is needed to provide more precision around our estimates.ClinicalTrials.gov, no. NCT03026764.

A retrospective review of the electronic medical records of patients presenting to the University Medical Center in Lubbock, Texas with orbital wall fractures. Clinical data such as associated ocular injuries and different management approaches are analyzed and discussed to help clarify the specific indications for, and timing of, a formal ophthalmologic examination. All patients who presented to the emergency department for an orbital fracture after suffering various types of traumas between 2008 and 2017 were included. The study reviewed 451 patients with orbital wall fractures with a wide variety of presentations as well as demographics. There were 411 cases of adults presenting with an average age of 34 years and 40 pediatric presentations with an average age of 14 years. The average age of the combined study population was 30 years. Only 16.9% of patients required surgical correction for their orbital fractures and assault accounted for nearly 50% of all the orbital fractures reviewed in this study. In this large retrospective review, no notable relationship was found between orbital wall fractured and ocular injury. Alarm symptoms for more visual threatening injuries such as retinal tears, detachments, open globe injury, and extraocular muscle entrapment are all reasonable indications to consult ophthalmology emergently. Most orbital fractures are not vision threatening, do not usually require surgical correction, and typically occur in the setting of assault.

Non-archosaur archosauromorphs are a paraphyletic group of diapsid reptiles that were important members of global Middle and Late Triassic continental ecosystems. Included in this group are the azendohsaurids, a clade of allokotosaurians (kuehneosaurids and Azendohsauridae + Trilophosauridae) that retain the plesiomorphic archosauromorph postcranial body plan but evolved disparate cranial features that converge on later dinosaurian anatomy, including sauropodomorph-like marginal dentition and ceratopsian-like postorbital horns. Here we describe a new malerisaurine azendohsaurid from two monodominant bonebeds in the Blue Mesa Member, Chinle Formation (Late Triassic, ca. 218–220 Ma); the first occurs at Petrified Forest National Park and preserves a minimum of eight individuals of varying sizes, and the second occurs near St. Johns, Arizona. Puercosuchus traverorum n. gen. n. sp. is a carnivorous malerisaurine that is closely related to Malerisaurus robinsonae from the Maleri Formation of India and to Malerisaurus langstoni from the Dockum Group of western Texas. Dentigerous elements from Puercosuchus traverorum n. gen. n. sp. confirm that some Late Triassic tooth morphotypes thought to represent early dinosaurs cannot be differentiated from, and likely pertain to, Puercosuchus-like malerisaurine taxa. These bonebeds from northern Arizona support the hypothesis that non-archosauriform archosauromorphs were locally diverse near the middle Norian and experienced an extinction event prior to the end-Triassic mass extinction coincidental with the Adamanian-Revueltian boundary recognized at Petrified Forest National Park. The relatively late age of this early-diverging taxon (Norian) suggests that the diversity of azendohsaurids is underrepresented in Middle and Late Triassic fossil records around the world.UUID: http://zoobank.org/e6eeefd2-a0ae-47fc-8604-9f45af8c1147.

Olawale A Sogbein,1,2 Jacquelyn D Marsh,1 Lyndsay E Somerville,1 James L Howard,1 Brent A Lanting1 1Division of Orthopaedic Surgery, Department of Surgery, London Health Sciences Centre – University Hospital, London, Ontario, Canada; 2Schulich School of Medicine & Dentistry, Western University, London, Ontario, CanadaCorrespondence: Olawale A Sogbein, Tel +1 519-476-1151, Email olsogbein@nosm.caBackground: We recently performed a clinical trial comparing motor sparing blocks (MSB) to periarticular infiltration (PAI) following total knee arthroplasty (TKA). We found that MSBs provided longer analgesia (8.8 hours) than PAI with retention of quadriceps strength, and with similar function, satisfaction, and length hospital stay. However, its potential increased cost could serve as a barrier to its adoption. Therefore, our aim was to compare the costs of MSBs to PAI following TKA.Methods: We conducted a retrospective review of data from our previous RCT. There were 82 patients included in the RCT (n = 41 MSB group, n = 41 PAI group). We compared the mean total costs associated with each group until hospital discharge including intervention costs, health-care professional service fees, intraoperative medications, length of stay, and postoperative opioid use.Results: Seventy patients were included (n = 35 MSB group, n = 35 PAI group). The mean total costs for the MSB group were significantly higher ($1959.46 ± 755.4) compared to the PAI group ($1616.25 ± 488.33), with a mean difference of $343.21 (95% CI = $73.28 to $664.11, p = 0.03). The total perioperative intervention costs for performing the MSB was also significantly higher; however, postoperative inpatient costs including length of stay and total opioid use did not differ significantly.Conclusion: Motor sparing blocks had significantly higher mean total and perioperative costs compared to PAI with no significant difference in postoperative inpatient costs. However, its quadricep sparing nature and previously demonstrated prolonged postoperative analgesia can be used to facilitate an outpatient TKA pathway thereby offsetting its increased costs.Keywords: costs, total knee arthroplasty, outpatient arthroplasty, adductor canal blocks, periarticular infiltration, motor sparing blocks

CDKL5 deficiency disorder (CDD) results in early-onset epilepsy and lifelong cognitive and motor impairments. With no validated measure for communication in CDD, this study evaluated the psychometric properties of the Communication and Symbolic Behavior Scales-Developmental Profile Infant Toddler Checklist (CSBS–DP ITC). Caregivers (n = 150; affected individuals aged 1–29 years) completed the CSBS-DP ITC. Distribution of scores indicated a floor effect. There was poor divergent validity for the three-factor model but goodness of fit and convergent validity data were satisfactory for the one-factor model. Individuals with poorer overall functional abilities scored lower on the CSBS-DP ITC. Test–retest reliability was excellent. The floor effect could explain the very high reliability, suggesting problems as a sensitive outcome measure in clinical trials for CDD.

Purpose: Rett syndrome is a severe neurodevelopmental disorder that affects about 1 in 10,000 females. Clinical trials of disease modifying therapies are on the rise, but there are few psychometrically sound caregiver-reported outcome measures available to assess treatment benefit. We report on a new caregiver-reported outcome measure, the Rett Caregiver Assessment of Symptom Severity (RCASS). Methods: Using data from the Rett Natural History Study (n=649), we examined the factor structure, using both exploratory and confirmatory factor analysis, and the reliability and validity of the RCASS. Results: The four-factor model had the best overall fit, which covered movement, communication, behavior, and Rett-specific symptoms. The RCASS had moderate internal consistency. Strong face validity was found with age and mutation type, and criterion validity was established with other similar measures, including the Revised Motor-Behavior Assessment Scale, Clinical Severity Scale, Clinical Global Impression Scale, and the Child Health Questionnaire. Conclusion: These data provide initial evidence that the RCASS is a viable caregiver-outcome measure for use in clinical trials in Rett syndrome. Future work to assess sensitivity to change and other measures of reliability, such as test-retest and inter-rater agreement, are needed.

Pathogenic variants in CASK, an X-linked gene that plays a role in brain development and synaptic function, are the cause of both microcephaly with pontine and cerebellar hypoplasia (MICPCH), and X-linked intellectual disability (XLID) with or without nystagmus. MICPCH is caused by loss of function variants in CASK, typically affects females, and is associated with moderate-to-severe intellectual disability (ID). Additional findings, present in about one-third of individuals, include feeding difficulties, ophthalmologic issues, hypertonicity, epilepsy, and sensorineural hearing loss. Only a few affected males with MICPCH phenotype have been reported and most have had profound developmental disability and intractable epilepsy. The XLID phenotype is typically caused by missense variants and most often manifests in males; carrier females are mildly affected or unaffected. Nystagmus is often present. In total, over 175 patients have been reported in the literature. We now report an additional 11 patients with pathogenic variants in CASK that expand these phenotypes and reported genotype-phenotype correlations.

The periodontal pathogen Porphyromonas gingivalis is genetically heterogeneous. However, the spontaneous generation of phenotypically different sub-strains has also been reported. McKee et al. (1988) cultured P. gingivalis W50 in a chemostat during investigations into the growth and properties of this bacterium. Cell viability on blood agar plates revealed two types of non-pigmenting variants, W50 beige (BE1), and W50 brown (BR1), in samples grown in a high-hemin medium after day 7, and the population of these variants increased to approximately 25% of the total counts by day 21. W50, BE1 and BR1 had phenotypic alterations in pigmentation, reduced protease activity and haemagglutination and susceptibility to complement killing. Furthermore, the variants exhibited significant attenuation in a mouse model of virulence. Other investigators showed that in BE1, the predominant extracellular Arg-gingipain was RgpB, and no reaction with an A-lipopolysaccharide-specific MAb 1B5 (Collinson et al., 1998; Slaney et al., 2006). In order to determine the genetic basis for these phenotypic properties, we performed hybrid DNA sequence long reads using Oxford Nanopore and the short paired-end DNA sequence reads of Illumina HiSeq platforms to generate closed circular genomes of the parent and variants. Comparative analysis indicated loss of intact kgp in the 20 kb region of the hagA-kgp locus in the two variants BE1 and BR1. Deletions in hagA led to smaller open reading frames in the variants, and BR1 had incurred a major chromosomal DNA inversion. Additional minor changes to the genomes of both variants were also observed. Given the importance of Kgp and HagA to protease activity and haemagglutination, respectively, in this bacterium, genomic changes at this locus may account for most of the phenotypic alterations of the variants. The homologous and repetitive nature of hagA and kgp and the features at the inverted junctions are indicative of specific and stable homologous recombination events, which may underlie the genetic heterogeneity of this species.

CDKL5 deficiency disorder (CDD) is a rare, X-linked, developmental and epileptic encephalopathy characterised by severe global developmental impairment and seizures that can begin in the first few months after birth and are often treatment refractory. Ganaxolone, an investigational neuroactive steroid, reduced seizure frequency in an open-label, phase 2 trial that included patients with CDD. We aimed to further assess the efficacy and safety of ganaxolone in patients with CDD-associated refractory epilepsy.In the double-blind phase of this randomised, placebo-controlled, phase 3 trial, done at 39 outpatient clinics in eight countries (Australia, France, Israel, Italy, Poland, Russia, the UK, and the USA), patients were eligible if they were aged 2-21 years with a pathogenic or probably pathogenic CDKL5 variant and at least 16 major motor seizures (defined as bilateral tonic, generalised tonic-clonic, bilateral clonic, atonic, or focal to bilateral tonic-clonic) per 28 days in each 4-week period of an 8-week historical period. After a 6-week prospective baseline period, patients were randomly assigned (1:1) via an interactive web response system to receive either enteral adjunctive ganaxolone or matching enteral adjunctive placebo (maximum dose 63 mg/kg per day for patients weighing ≤28 kg or 1800 mg/day for patients weighing28 kg) for 17 weeks. Patients, caregivers, investigators (including those analysing data), trial staff, and the sponsor (other than the investigational product manager) were masked to treatment allocation. The primary efficacy endpoint was percentage change in median 28-day major motor seizure frequency from the baseline period to the 17-week double-blind phase and was analysed (using a Wilcoxon-rank sum test) in all patients who received at least one dose of trial treatment and for whom baseline data were available. Safety (compared descriptively across groups) was analysed in all patients who received at least one dose of trial treatment. This study is registered with ClinicalTrials.gov, NCT03572933, and the open-label extension phase is ongoing.Between June 25, 2018, and July 2, 2020, 114 patients were screened for eligibility, of whom 101 (median age 6 years [IQR 3 to 10]) were randomly assigned to receive either ganaxolone (n=50) or placebo (n=51). All patients received at least one dose of a study drug, but seizure frequency for one patient in the ganaxolone group was not recorded at baseline and so the primary endpoint was analysed in a population of 100 patients. There was a median percentage change in 28-day major motor seizure frequency of -30·7% (IQR -49·5 to -1·9) in the ganaxolone group and of -6·9% (-24·1 to 39·7) in the placebo group (p=0·0036). The Hodges-Lehmann estimate of median difference in responses to ganaxolone versus placebo was -27·1% (95% CI -47·9 to - 9·6). Treatment-emergent adverse events occurred in 43 (86%) of 50 patients in the ganaxolone group and in 45 (88%) of 51 patients in the placebo group. Somnolence, pyrexia, and upper respiratory tract infections occurred in at least 10% of patients in the ganaxolone group and more frequently than in the placebo group. Serious adverse events occurred in six (12%) patients in the ganaxolone group and in five (10%) patients in the placebo group. Two (4%) patients in the ganaxolone group and four (8%) patients in the placebo group discontinued the trial. There were no deaths in the double-blind phase.Ganaxolone significantly reduced the frequency of CDD-associated seizures compared with placebo and was generally well tolerated. Results from what is, to our knowledge, the first controlled trial in CDD suggest a potential treatment benefit for ganaxolone. Long-term treatment is being assessed in the ongoing open-label extension phase of this trial.Marinus Pharmaceuticals.

Pathogenic variants in the CDKL5 gene result in CDKL5 deficiency disorder (CDD), which is characterized by early-onset epilepsy, severe developmental delay, and often, cortical visual impairment. Validated clinical outcome measures are needed for future clinical trials to be successful. This study aimed to adapt the Rett Syndrome Hand Function Scale for CDKL5 deficiency disorder and evaluate its feasibility, acceptability, content validity, and reliability. Consultation with a cortical visual impairment experienced specialist and the Consumer Reference Group informed modifications to the instructions of the Rett Syndrome Hand Function Scale for children with CDKL5 deficiency disorder (CDD-Hand). Eighty-six families registered with the International CDKL5 Disorder Database provided video clips of their child's hand function and provided feedback about the measure. Video data were coded by 2 researchers to evaluate intra- and interrater reliability. This study provides initial evidence of validation and reliability. The scale appears to be suitable for a range of ages and functional abilities for CDKL5 deficiency disorder.

Several commonly used procedures for knee osteoarthritis (OA) are not supported by evidence-based guidelines. The objective of this study was to identify the proportion of patients who underwent knee arthroscopy or magnetic resonance imaging (MRI) and the timing of these procedures before total knee arthroplasty (TKA).We conducted a retrospective cohort study using administrative data sets from Ontario, Canada. We identified the proportion of patients who underwent knee arthroscopy in the previous 10 years or an MRI in the 3 years before their primary TKA. We also evaluated the rate of arthroscopies by diagnosis. We report the timing of each outcome in relation to the TKA, rates by geographical area, and differences in rates over time.We included 142 275 patients, of whom 36 379 (25.57%) underwent knee arthroscopy (median time 2.8 [interquartile range (IQR) 1.1-6.0] years); 22% of those were within 1 year of TKA and 52% were within 3 years. The rates of arthroscopies for a diagnosis of osteoarthritis (OA) steadily decreased, while those for meniscal-related diagnoses increased over the study period (A substantial proportion of patients with knee OA received diagnostic and therapeutic interventions before TKA that are contrary to clinical practice guidelines.

Intrauterine hypoxia is a common cause of brain injury in children resulting in a broad spectrum of long-term neurodevelopmental sequela, including life-long disabilities that can occur even in the absence of severe neuroanatomic damage. Postnatal hypoxia-ischemia rodent models are commonly used to understand the effects of ischemia and transient hypoxia on the developing brain. Postnatal models, however, have some limitations. First, they do not test the impact of placental pathologies on outcomes from hypoxia. Second, they primarily recapitulate severe injury because they provoke substantial cell death, which is not seen in children with mild hypoxic injury. Lastly, they do not model preterm hypoxic injury. Prenatal models of hypoxia in mice may allow us to address some of these limitations to expand our understanding of developmental brain injury. The published rodent models of prenatal hypoxia employ multiple days of hypoxic exposure or complicated surgical procedures, making these models challenging to perform consistently in mice. Furthermore, large animal models suggest that transient prenatal hypoxia without ischemia is sufficient to lead to significant functional impairment to the developing brain. However, these large animal studies are resource-intensive and not readily amenable to mechanistic molecular studies. Therefore, here we characterized the effect of late gestation (embryonic day 17.5) transient prenatal hypoxia (5% inspired oxygen) on long-term anatomical and neurodevelopmental outcomes in mice. Late gestation transient prenatal hypoxia increased hypoxia-inducible factor 1 alpha protein levels (a marker of hypoxic exposure) in the fetal brain. Hypoxia exposure predisposed animals to decreased weight at postnatal day 2, which normalized by day 8. However, hypoxia did not affect gestational age at birth, litter size at birth, or pup survival. No differences in fetal brain cell death or long-term gray or white matter changes resulted from hypoxia. Animals exposed to prenatal hypoxia did have several long-term functional consequences, including sex-dichotomous changes. Hypoxia exposure was associated with a decreased seizure threshold and abnormalities in hindlimb strength and repetitive behaviors in males and females. Males exposed to hypoxia had increased anxiety-related deficits, whereas females had deficits in social interaction. Neither sex developed any motor or visual learning deficits. This study demonstrates that late gestation transient prenatal hypoxia in mice is a simple, clinically relevant paradigm for studying putative environmental and genetic modulators of the long-term effects of hypoxia on the developing brain.

To determine the effect of implanting electrodes on electrographic features of nearby and connected brain regions in patients with drug-resistant epilepsy, we analyzed intracranial EEG recordings from 10 patients with drug-resistant epilepsy who underwent implant revision (placement of additional electrodes) during their hospitalization. We performed automated spike detection and measured EEG functional networks. We analyzed the original electrodes that remained in place throughout the full EEG recording, and we measured the change in spike rates and network connectivity in these original electrodes in response to implanting new electrodes. There was no change in overall spike rate pre- to post-implant revision (t(9) = 0.1, p = 0.95). The peri-revision change in the distribution of spike rate and connectivity across electrodes was no greater than chance (Monte Carlo method, spikes: p = 0.40, connectivity: p = 0.42). Electrodes closer to or more functionally connected to the revision site had no greater change in spike rate or connectivity than more distant or less connected electrodes. Changes in electrographic features surrounding electrode implantation are no greater than baseline fluctuations occurring throughout the intracranial recording. These findings argue against an implant effect on spikes or network connectivity in nearby or connected brain regions.

Gene Set Enrichment Analysis shows close resemblance between human and mouse brain tumors.

Malignant rhabdoid tumors arise in several anatomic locations and are associated with poor outcomes. In the brain, these tumors are known as atypical teratoid/rhabdoid tumors (AT/RT). While genetically engineered models for malignant rhabdoid tumors exist, none of them recapitulate AT/RT, for which preclinical models remain lacking. In the majority of AT/RT, LOH occurs at the genetic locus SNF5 (Ini1/BAF47/Smarcb1), which functions as a subunit of the SWI/SNF chromatin-remodeling complex and a tumor suppressor in familial and sporadic malignant rhabdoid tumors. Therefore, we generated mice in which Snf5 was ablated specifically in nestin-positive and/or glial fibrillary acid protein (GFAP)-positive progenitor cells of the developing central nervous system (CNS). Snf5 ablation in nestin-positive cells resulted in early lethality that could not be rescued by loss of p53. However, Snf5 ablation in GFAP-positive cells caused a neurodegenerative phenotype exacerbated by p53 loss. Notably, these double mutants exhibited AT/RT development, associated with an earlier failure in granule neuron migration in the cerebellum, reduced neuronal projections in the hippocampus, degeneration of the corpus callosum, and ataxia and seizures. Gene expression analysis confirmed that the tumors that arose in Snf5/p53 mutant mice were distinct from other neural tumors and most closely resembled human AT/RT. Our findings uncover a novel role for Snf5 in oligodendrocyte generation and survival, and they offer evidence of the first genetically engineered mouse model for AT/RT in the CNS. Cancer Res; 75(21); 4629–39. ©2015 AACR.

Description of additional methods and procedures used in the study.

Primer sequences of qRT-PCR.

Legends for Supplemental Figures S1-S5 and Supplemental Table S1.

Objective: Recent advances in the understanding of neurodevelopmental disorders such as Rett syndrome (RTT) has enabled development of novel therapeutic approaches that are currently undergoing clinical evaluation or are proposed to move into clinical development. Clinical trial success depends on outcome measures that assess clinical features that are most impactful for affected individuals. To determine the top concerns in RTT and RTT-related disorders we asked caregivers to list the top clinical concerns in order to gain information to guide the development and selection of outcome measures for future clinical trials. Methods: Caregivers of participants enrolled in the US Natural History Study of RTT and related disorders were asked to identify the top 3 concerning problems impacting the affected participant. We generated a weighted list of top caregiver concerns for each of the diagnostic categories and compared results between the disorders. Further, for Classic RTT, caregiver concerns were analyzed by age, clinical severity, and common RTT-causing mutations in MECP2. Results: The top caregiver concerns for Classic RTT were effective communication, seizures, walking/balance issues, lack of hand use, and constipation. The rank order of the frequency of the top caregiver concerns for Classic RTT varied by age, clinical severity, and specific mutations, consistent with known variation in the frequency of clinical features across these domains. The frequency of caregiver concern for seizures, hand use, and spoken language increased in relation to clinician assessed severity in these clinical domains, showing consistency between clinician assessments and caregiver concerns. Comparison across disorders found commonalities in the top caregiver concerns between Classic RTT, Atypical RTT, MECP2 Duplication Syndrome, CDKL5 Deficiency Disorder, and FOXG1 Syndrome; however, distinct differences in caregiver concerns between these disorders are consistent with the relative prevalence and impact of specific clinical features. Conclusion: The top caregiver concerns for individuals with RTT and the RTT-related disorders reflect the impact of the primary clinical symptoms of these disorders. This work is critical in the development of meaningful therapies, as optimal therapy should address these concerns. Further, outcome measures to be utilized in clinical trials should assess these clinical issues identified as most concerning by caregivers.

Background Developing biomarkers is a priority for drug development for all conditions, but vital in the rare neurodevelopmental disorders where sensitive outcome measures are lacking. We have previously demonstrated the feasibility and tracking of evoked potentials to disease severity in Rett syndrome and CDKL5 deficiency disorder. The aim of the current study is to characterize evoked potentials in two related developmental encephalopathies, MECP2 duplication syndrome and FOXG1 syndrome, and compare across all four groups to better understand the potential of these measures to serve as biomarkers of clinical severity for the developmental encephalopathies. Methods Visual and auditory evoked potentials were acquired from participants with MECP2 duplication syndrome and FOXG1 syndrome across five sites of the Rett Syndrome and Rett-Related Disorders Natural History Study. A group of age-matched individuals (mean = 7.8 years; range = 1–17) with Rett syndrome, CDKL5 deficiency disorder, and typically-developing participants served as a comparison group. The analysis focused on group-level differences as well as associations between the evoked potentials and measures of clinical severity from the Natural History Study. Results As reported previously, group-level comparisons revealed attenuated visual evoked potentials (VEPs) in participants with Rett syndrome (n = 43) and CDKL5 deficiency disorder (n = 16) compared to typically-developing participants. VEP amplitude was also attenuated in participants with MECP2 duplication syndrome (n = 15) compared to the typically-developing group. VEP amplitude correlated with clinical severity for Rett syndrome and FOXG1 syndrome (n = 5). Auditory evoked potential (AEP) amplitude did not differ between groups, but AEP latency was prolonged in individuals with MECP2 duplication syndrome (n = 14) and FOXG1 syndrome (n = 6) compared to individuals with Rett syndrome (n = 51) and CDKL5 deficiency disorder (n = 14). AEP amplitude correlated with severity in Rett syndrome and CDKL5 deficiency disorder. AEP latency correlated with severity in CDKL5 deficiency disorder, MECP2 duplication syndrome, and FOXG1 syndrome. Conclusions There are consistent abnormalities in the evoked potentials in four developmental encephalopathies some of which correlate with clinical severity. While there are consistent changes amongst these four disorders, there are also condition specific findings that need to be further refined and validated. Overall, these results provide a foundation for further refinement of these measures for use in future clinical trials for these conditions.

Interictal spikes help localize seizure generators as part of surgical planning for drug-resistant epilepsy. However, there are often multiple spike populations whose frequencies change over time, influenced by brain state. Understanding state changes in spike rates will improve our ability to use spikes for surgical planning. Our goal was to determine the effect of sleep and seizures on interictal spikes, and to use sleep and seizure-related changes in spikes to localize the seizure onset zone.We performed a retrospective analysis of intracranial EEG data from patients with focal epilepsy. We automatically detected interictal spikes and we classified different time periods as awake or asleep based on the ratio of alpha to delta power, with a secondary analysis using the recently published SleepSEEG algorithm. We analyzed spike rates surrounding sleep and seizures. We developed a model to localize the seizure onset zone using state-dependent spike rates.We analyzed data from 101 patients (54 women, age range 16-69). The normalized alpha-delta power ratio accurately classified wake from sleep periods (area under the curve = 0.90). Spikes were more frequent in sleep than wakefulness and in the postictal compared to the preictal state. Patients with temporal lobe epilepsy had a greater wake-to-sleep and pre-to-postictal spike rate increase compared to extra-temporal epilepsy. A machine-learning classifier incorporating state-dependent spike rates accurately identified the seizure onset zone (area under the curve = 0.83). Spike rates tended to be higher and better localize the seizure onset zone in NREM sleep than in wake or REM sleep.The change in spike rates surrounding sleep and seizures differs between temporal and extratemporal lobe epilepsy. Spikes are more frequent and better localize the seizure onset zone in sleep, particularly in NREM sleep. Quantitative analysis of spikes may provide useful ancillary data to localize the seizure onset zone and improve surgical planning.

A functional network of blood vessels is essential for organ growth and homeostasis. Yet, how the vasculature matures and maintains adult homeostasis remains elusive in live mice. By longitudinally tracking the same neonatal endothelial cells (ECs) over days to weeks, we found that capillary plexus expansion is driven by network-wide vessel regression and transient angiogenesis. A fixed number of neonatal ECs rearrange their positions to evenly distribute throughout the developing plexus and become positionally stable in adulthood. Upon injury, while neonatal ECs are predisposed to die, adult ECs survive through a plasmalemmal self-repair response. Furthermore, adult neighboring ECs reactivate migration to assist vessel repair. Lastly, neonatal vessel regression and adult vascular maintenance are orchestrated by temporally restricted VEGFR2 dependent signaling. Our work sheds light on fundamental cellular mechanisms that underlie both vascular maturation and adult homeostasisin vivo.

Once known solely from dental material and thought to represent an early ornithischian dinosaur, the early-diverging pseudosuchian Revueltosaurus callenderi is described from a minimum of 12 skeletons from a monodominant bonebed in the upper part of the Chinle Formation of Arizona. This material includes nearly the entire skeleton and possesses a combination of plesiomorphic and derived character states that help clarify ingroup relationships within Pseudosuchia. A phylogenetic analysis recovers R. callenderi in a clade with Aetosauria and Acaenasuchus geoffreyi that is named Aetosauriformes. Key autapomorphies of R. callenderi include a skull that is longer than the femur, a complete carapace of dermal armor including paramedian and lateral rows, as well as ventral osteoderms, and a tail end sheathed in bone. Histology of the femur and associated osteoderms demonstrate that R. callenderi was slow growing and that the individuals from the bonebed were not young juveniles but had not ceased growing. A review of other material assigned to Revueltosaurus concludes that the genus cannot be adequately diagnosed based on the type materials of the three assigned species and that only R. callenderi can be confidently referred to Revueltosaurus. Published version

PURPOSE: A host of recent initiatives relating to adolescent health have been accompanied by varying indicator recommendations, with little stakeholder coordination. We assessed currently included adolescent health-related indicators for their measurement focus, identified overlap across initiatives, and determined measurement gaps. METHODS: We conducted a scoping review to map the existing indicator landscape as depicted by major measurement initiatives. We classified indicators as per 33 previously identified core adolescent health measurement areas across five domains and by age groups. We also identified indicators common across measurement initiatives even if differing in details. RESULTS: We identified 413 indicators across 16 measurement initiatives, with most measuring health outcomes and conditions (162 [39%]) and health behaviors and risks (136 [33%]); followed by policies, programs, and laws (49 [12%]); health determinants (44 [11%]); and system performance and interventions (22 [5%]). Age specification was available for 221 (54%) indicators, with 51 (23%) focusing on the full adolescent age range (10-19 years), 1 (

Cortical interneurons (GABAergic cells) arise during embryogenesis primarily from the medial and caudal ganglionic eminences (MGE and CGE, respectively) with a small population generated from the preoptic area (POA). Progenitors from the lateral ganglionic eminence (LGE) are thought to only generate GABAergic medium spiny neurons that populate the striatum and project to the globus pallidus. Here, we report evidence that neuronal precursors that express the LGE-specific transcription factor Islet1 (Isl1) can give rise to a small population of cortical interneurons. Lineage tracing and homozygous deletion of Nkx2.1 in Isl1 fate-mapped mice showed that neighboring MGE/POA-specific Nkx2.1 cells and LGE-specific Isl1 cells make both common and distinct lineal contributions towards cortical interneuron fate. Although the majority of cells had overlapping transcriptional domains between Nkx2.1 and Isl1, a population of Isl1-only derived cells also contributed to the adult cerebral cortex. The data indicate that Isl1-derived cells may originate from both the LGE and the adjacent LGE/MGE boundary regions to generate diverse neuronal progeny. Thus, a small population of neocortical interneurons appear to originate from Isl-1-positive precursors.

T-type calcium channels (Cav3.1 to Cav3.3) regulate low-threshold calcium spikes, burst firing and rhythmic oscillations of neurons and are involved in sensory processing, sleep, and hormone and neurotransmitter release. Here, we examined four heterozygous missense variants in CACNA1I, encoding the Cav3.3 channel, in patients with variable neurodevelopmental phenotypes. The p.(Ile860Met) variant, affecting a residue in the putative channel gate at the cytoplasmic end of the IIS6 segment, was identified in three family members with variable cognitive impairment. The de novo p.(Ile860Asn) variant, changing the same amino acid residue, was detected in a patient with severe developmental delay and seizures. In two additional individuals with global developmental delay, hypotonia, and epilepsy, the variants p.(Ile1306Thr) and p.(Met1425Ile), substituting residues at the cytoplasmic ends of IIIS5 and IIIS6, respectively, were found. Because structure modelling indicated that the amino acid substitutions differentially affect the mobility of the channel gate, we analysed possible effects on Cav3.3 channel function using patch-clamp analysis in HEK293T cells. The mutations resulted in slowed kinetics of current activation, inactivation, and deactivation, and in hyperpolarizing shifts of the voltage-dependence of activation and inactivation, with Cav3.3-I860N showing the strongest and Cav3.3-I860M the weakest effect. Structure modelling suggests that by introducing stabilizing hydrogen bonds the mutations slow the kinetics of the channel gate and cause the gain-of-function effect in Cav3.3 channels. The gating defects left-shifted and increased the window currents, resulting in increased calcium influx during repetitive action potentials and even at resting membrane potentials. Thus, calcium toxicity in neurons expressing the Cav3.3 variants is one likely cause of the neurodevelopmental phenotype. Computer modelling of thalamic reticular nuclei neurons indicated that the altered gating properties of the Cav3.3 disease variants lower the threshold and increase the duration and frequency of action potential firing. Expressing the Cav3.3-I860N/M mutants in mouse chromaffin cells shifted the mode of firing from low-threshold spikes and rebound burst firing with wild-type Cav3.3 to slow oscillations with Cav3.3-I860N and an intermediate firing mode with Cav3.3-I860M, respectively. Such neuronal hyper-excitability could explain seizures in the patient with the p.(Ile860Asn) mutation. Thus, our study implicates CACNA1I gain-of-function mutations in neurodevelopmental disorders, with a phenotypic spectrum ranging from borderline intellectual functioning to a severe neurodevelopmental disorder with epilepsy., T-type calcium channels regulate neuronal firing, are implicated in brain disease and are targets for anti-epileptic drugs. El Ghaleb et al. identify heterozygous missense variants of CACNA1I associated with variable neurodevelopmental disorders and epilepsy, and show how gain-of-function mutations cause hyper-excitability.

Precision treatments for epilepsy targeting the underlying genetic diagnoses are becoming a reality. Historically, the goal of epilepsy treatments was to reduce seizure frequency. In the era of precision medicine, however, outcomes such as prevention of epilepsy progression or even improvements in cognitive functions are both aspirational targets for any intervention. Developing methods, both in clinical trial design and in novel endpoints, will be necessary for measuring, not only seizures, but also the other neurodevelopmental outcomes that are predicted to be targeted by precision treatments. Biomarkers that quantitatively measure disease progression or network level changes are needed to allow for unbiased measurements of the effects of any gene-level treatments. Here, we discuss some of the promising electrophysiological biomarkers that may be of use in clinical trials of precision therapies, as well as the difficulties in implementing them. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s13311-021-01132-4.