Palm Beach Neurology

Central disorders of hypersomnolence (CDoH), including the primary hypersomnolence disorders of narcolepsy type 1 (NT1), narcolepsy type 2 (NT2), idiopathic hypersomnia (IH), and Kleine-Levin syndrome (KLS), as well as secondary hypersomnolence disorders, represent an underdiagnosed and under-treated population. Continuing advancements in understanding and treating CDoH rely on an understanding of the patient and caregiver experience. To address this need, a community-led, patient-owned online research study was launched by the nonprofit organizations Sleep Consortium and Global Genes, using the RARE-X research platform. An expert working group of stakeholders with expertise in hypersomnolence disorders, including clinicians, therapy developers, and patient advocates, was convened to identify key patient- and caregiver-reported clinical outcome measures essential for evaluating CDoH symptoms and impacts. These clinical outcome measures have been implemented as part of an online direct-to-patient study. The measures chosen by the Sleep Consortium Expert Working Group are presented here with the hope of supporting the standardization of clinical outcome assessments being used in CDoH research, especially for primary hypersomnolence disorders.

Background: Hypermobile Ehlers–Danlos syndrome (hEDS) and hypermobility spectrum disorders (HSDs) are prevalent, complex conditions marked by chronic pain, joint instability, and multisystem involvement. Despite affecting an estimated 1 in 500 individuals, these conditions remain poorly understood and inconsistently diagnosed. This study aimed to define their clinical burden through a large-scale, international survey. Methods: A cross-sectional, anonymous survey was distributed globally from September 2023 to March 2024. Of 9258 responses, 3906 met inclusion criteria (hEDS: n = 3360; HSD: n = 546). The 418-item questionnaire assessed symptoms, comorbidities, healthcare utilization, and quality of life. The 95% confidence intervals (CIs) were calculated for comparison. Results: Participants with hEDS reported a mean of 24 comorbid conditions and an average diagnostic delay of 22.1 years. Common diagnoses included gastrointestinal disorders (84.3% [95% CI: 98.3–99.2%]), dysautonomia (71.4% [95% CI: 69.9–72.9%]), and chronic pain (98.9% [95% CI: 98.3–99.2%]). In contrast, HSD respondents reported a mean of 17 comorbidities, a 17.5-year time to diagnosis, and lower rates of key complications. Triggering events, such as puberty and infections were commonly reported preceding hEDS or HSD symptom onset. Comparison to the All of Us dataset revealed significantly elevated prevalence ratios of neurological, immune, and autonomic diagnoses. Conclusions: This global survey highlights the extensive multisystemic burden and diagnostic delays faced by individuals with hEDS and HSDs. The high prevalence of immune, neurological, gastrointestinal, and autonomic dysfunctions challenges the notion of these conditions as isolated connective tissue disorders. These findings highlight the need for updated diagnostic frameworks and mechanistic studies that explore multifactorial etiologies beyond the connective tissue paradigm.

This article is a tribute to the life of recently deceased, humanistic psychologist, Ilene Serlin, PhD, a spiritual and academic leader whose legacy of healing will reverberate for generations. It highlights some of her major contributions to the fields of humanistic psychology, the treatment of trauma, and dance therapy.

Metabolic dysfunction-associated steatotic liver disease affects about a third of adults worldwide and is projected soon to be the leading cause of liver cirrhosis. It occurs when fat accumulates in hepatocytes and can progress to metabolic dysfunction-associated steatohepatitis, liver cirrhosis, and HCC. Metabolic dysfunction-associated steatotic liver disease pathogenesis is believed to involve a combination of genetic and environmental risk factors. Single nucleotide polymorphisms have been implicated, but non-syndromic monogenic causes are lacking. We identified a novel genetic variant in a familial case of metabolic dysfunction-associated steatohepatitis and performed deep variant functional analysis, including protein modeling, dynamics, and cell-based assays to assess molecular mechanisms of dysfunction and altered cellular signaling. We analyzed exome sequencing data of 3904 individuals with steatotic liver disease (SLD) to identify additional cases and establish the link between specific gene variants and SLD diagnosis. We discovered and functionally validated the NM_000245.4:c.3505A>T; p.(Ile1169Phe) variant in the MET (mesenchymal-epithelial transition) kinase domain as a monogenic cause of SLD. Subsequently, we detected additional ultra-rare, previously uninterpreted, and likely deleterious variants in MET from screening sequencing data. Among individuals with confirmed SLD based on electronic record review, 1.1% (45/3904) had rare predicted deleterious MET variants. Eight of 45 (17.7%) individuals had predicted deleterious variants in the MET kinase domain confirmed to be functionally like the familial case variant. We report the first germline nonmalignant rare MET -driven disease, a monogenic form of SLD.

Background Vitamin D has been found to be crucial in musculoskeletal health. The role of vitamin D levels in orthopedic patients has become a growing area of interest given its negative impact on fracture healing which can contribute to the development of nonunion following surgery. We sought to investigate the incidence of hypovitaminosis D in a cohort of patients who experienced a nonunion following a foot and ankle arthrodesis procedure. Methodology Patients who underwent a major elective foot and ankle arthrodesis procedure and developed a nonunion were given the opportunity to obtain serum vitamin D levels. All vitamin D levels were reported from percutaneous venous blood samples and compared to our institution's range of accepted normal values (25-80 ng/mL). Results A total of 13 patients who developed a nonunion agreed to have a vitamin D level obtained, and 11 of 13 patients had a low vitamin D level (average = 14.6 ng/mL, range = 9-24 ng/mL). Five patients underwent revision arthrodesis after normalization of vitamin D levels, and four out of five patients went on to successful union. Conclusions Hypovitaminosis D may be a modifiable risk factor for nonunion following a major foot and ankle arthrodesis procedure. Orthopedic surgeons should consider vitamin D screening and supplementation in patients undergoing elective arthrodesis procedures.

In this chapter, we’ll be implementing a configurable ForceField script that pairs with a trigger collider to apply force to Rigidbodies and/or the player. Based on a variable set in the Inspector determining the type of force to apply, we’ll either apply it constantly while the trigger is touched or once when the trigger is first entered. In other words, based on the force mode you choose, you could make an object either get pushed as if by a large fan, or get shoved up like a “jump pad” thrusting them all at once.

The final obstacle we'll implement will be a spike trap. It will teach you a new concept and give you more practice with the concepts we learned in previous chapters, like Slerping over time, working with state, and Invoking methods to time transitions in the state.

Before we give the player any means of moving around, we’re going to provide them with a first- and third-person camera system that lets them turn their character and camera with the mouse. Both systems will be handled by one script, and the player will be able to press a hotkey to smoothly switch from one to the other.