No abstract

The age-dependent nature of the characteristic features of tuberous sclerosis complex has historically presented challenges for the diagnosis in infancy. Although the increasing availability of neuroimaging and genetic testing has facilitated the diagnosis in neonates and infants, there are few reports describing how tuberous sclerosis complex presents in this age group. We performed a retrospective review of children diagnosed with tuberous sclerosis complex during the first year of life, compiling their clinical features at presentation and diagnosis, seizure history, and imaging findings. We identified 41 infants diagnosed with tuberous sclerosis complex before age 1 year. Their age at initial presentation ranged from antenatal to 9 months of age. Twenty-three patients (56%) initially presented with a cardiac rhabdomyoma, of which 15 were identified antenatally. Fourteen patients (34%) initially presented with seizures, and 6 (15%) initially presented with hypomelanotic macules. Five infants (12%) had a family history of tuberous sclerosis complex. A definitive diagnosis of tuberous sclerosis complex was accomplished antenatally in 4 patients, whereas the rest were diagnosed at a median age of 2 months. All 41 patients underwent neuroimaging during infancy; 36 (88%) had radiographic evidence of cortical tubers, and 38 (93%) had subependymal nodules. Neuroimaging resulted in a definitive diagnosis of tuberous sclerosis complex in 95% of patients. The diagnosis of tuberous sclerosis complex in infancy is aided by a high index of suspicion and timely access to neuroimaging. Early diagnosis of tuberous sclerosis complex may be essential to the success of future therapies by providing a window of opportunity for their use.

To expand the availability and solubility range of polymer supports for liquid-phase organic synthesis (LPOS) we have applied a sequence of normal and "living" free radical polymerization to generate a library of block copolymers possessing either block or graft architecture with initiators 1-4 and a diverse set of vinyl monomers 5-9. The structure, molecular weight, and polydispersity (PD) of the individual library members have been determined by size exclusion chromatography (SEC), 1 H and 13 C NMR, and as a function of the solubility of each polymer in a range of solvents. One copolymer, polyBS-DS (M n ) 17 000, PD ) 1.54) derived from 4-tert-butylstyrene (6, BS), 3,4-dimethoxystyrene (7, DS), and initiator 1 has a solubility profile [soluble in toluene, tetrahydrofuran (THF), ether, acetone and methylene chloride (DCM), insoluble in methanol and water] that is different from the present polymer of choice for LPOS, poly(ethylene) glycol (PEG), and has been studied in some detail as a new support in LPOS. The R-nitrile groups of polyBS-DS are reduced smoothly with LiAlH 4 in THF to give the amino functionalized copolymer 22 (0.14 mmol g -1 of amino groups based on a quantitative ninhydrin analysis). Kinetic studies have revealed that derivatization of the amino groups of 22 with 4-dimethylaminocinnamaldehyde 23 occurs at a comparable rate to a solution counterpart 26) and exchange of Rh(I), the resulting phosphine containing copolymer Rh(I)-27, catalyzes the enantioselective hydrogenation of 2-N-acetamidoacrylic acid (28) to N-acetylalanine (29) in THF. An 87% enantiomeric excess (ee) of (S)-29 is obtained, comparable to that observed with a homogeneous phosphine ligand. This work highlights the power of a parallel polymer synthesis strategy, from conception to application, for the generation of polymers possessing unique solubility profiles and functionality which can serve as novel supports in LPOS.

Targeted whole-exome sequencing (WES) is a powerful diagnostic tool for a broad spectrum of heterogeneous neurological disorders. Here, we aim to examine the impact on diagnosis, treatment and cost with early use of targeted WES in early-onset epilepsy. WES was performed on 180 patients with early-onset epilepsy (≤5 years) of unknown cause. Patients were classified as Retrospective (epilepsy diagnosis >6 months) or Prospective (epilepsy diagnosis <6 months). WES was performed on an Ion Proton™ and variant reporting was restricted to the sequences of 620 known epilepsy genes. Diagnostic yield and time to diagnosis were calculated. An analysis of cost and impact on treatment was also performed. A molecular diagnoses (pathogenic/likely pathogenic variants) was achieved in 59/180 patients (33%). Clinical management changed following WES findings in 23 of 59 diagnosed patients (39%) or 13% of all patients. A possible diagnosis was identified in 21 additional patients (12%) for whom supporting evidence is pending. Time from epilepsy onset to a genetic diagnosis was faster when WES was performed early in the diagnostic process (mean: 145 days Prospective vs. 2,882 days Retrospective). Costs of prior negative tests averaged $8,344 per patient in the Retrospective group, suggesting savings of $5,110 per patient using WES. These results highlight the diagnostic yield, clinical utility and potential cost-effectiveness of using targeted WES early in the diagnostic workup of patients with unexplained early-onset epilepsy. The costs and clinical benefits are likely to continue to improve. Advances in precision medicine and further studies regarding impact on long-term clinical outcome will be important.