James A Blackman

University of Virginia, Charlottesville, Virginia, United States

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Publications (34)73.55 Total impact

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    ABSTRACT: The apoE protein is the most important lipid transporter in the brain and has also been shown to have several regulatory functions in the central nervous system. The production of apoE is regulated by a number of genes and increases under certain conditions such as cerebral injury in adults. Our aim was to study whether variations in genes regulating the expression of the APOE gene were associated with severity of cerebral palsy (CP). Children enrolled in the Cerebral Palsy Register of Norway (CPRN) were invited to participate in this cross-sectional study; 281 of the invited 703 children (40%) returned swabs with buccal cells collected by parents. Six genetic variations thought to affect the production of apoE were genotyped and correlated with clinical data recorded in the CPRN. Compared with children carrying the GG allele, children with genotype GT or TT in a specific genetic variation (rs59007384 located in the nearby TOMM40 gene) had excess risk for worse fine motor function (Odds ratio (OR): 1.82; 95% Confidence interval (CI): 1.10-2.99; p = 0.019) and epilepsy (OR: 2.32; CI: 1.17-4.61; p = 0.016). There was no association between severity of CP and any of the other five genetic variations analyzed. Our findings suggest that genetic variations in one of the sequences regulating the expression of APOE, may be associated with worse clinical outcome in children with cerebral palsy.
    European journal of paediatric neurology: EJPN: official journal of the European Paediatric Neurology Society 04/2014; · 2.01 Impact Factor
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    ABSTRACT: Objective:Brain injury in preterm infants may lead to an inflammatory response and central nervous system dysfunction reflected by abnormal heart rate characteristics (HRC). We hypothesized that a continuously monitored HRC index reflecting reduced HR variability and decelerations correlates with abnormal neuroimaging and outcomes in extremely low birth weight infants (ELBW).Study Design:We analyzed the average HRC index within 28 days after birth (aHRC28) and head ultrasound (HUS) in 384 ELBW infants. In 50 infants with brain magnetic resonance imaging (MRI) and 70 infants with Bayley neurodevelopmental testing at 1 year of age, we analyzed the relationship between aHRC28, MRI abnormalities and low Bayley scores.Result:aHRC28 was higher in infants with severe HUS abnormalities (2.65±1.27 for Grade III-IV intraventricular hemorrhage (IVH) or cystic periventricular leukomalacia (cPVL) versus 1.72±0.95 for normal or Grade I-II IVH, P<0.001). Higher aHRC28 was also associated with white matter damage on MRI and death or Bayley motor or mental developmental index <70. Associations persisted after adjusting for gestational age, birth weight and septicemia. For every one point increase in aHRC28, the odds ratio of death or Bayley score <70 was 2.45 (95% CI 1.46, 4.05, P<0.001).Conclusion:A continuously monitored HRC index provides an objective, noninvasive measure associated with abnormal brain imaging and adverse neurologic outcomes in ELBW infants.Journal of Perinatology advance online publication, 20 February 2014; doi:10.1038/jp.2014.18.
    Journal of perinatology: official journal of the California Perinatal Association 02/2014; · 1.59 Impact Factor
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    ABSTRACT: Background: Extremely preterm infants have an increased risk of brain injury and, consequently, are more likely to exhibit signs of motor, cognitive or behavioral impairment. Various factors, including genetic, may influence how the brain responds to an injury, ranging from no to complete recovery. The apolipoprotein E (APOE) gene codes for a protein in the brain involved in maintenance and repair of neurons. Objective: To determine whether any of the three APOE alleles are related to improved outcome. Methods: A total of 87 preterm infants with birth weights less than 1,000 g and no obvious preexisting brain abnormalities were genotyped for the APOE gene; 71 of these were assessed with the Bayley III Scales at a corrected age of 12-15 months. Brain MRI was obtained on a subgroup of 52 infants at term equivalent. Results: No significant relationship was found between the three APOE alleles and developmental outcomes or brain MRI findings. Conclusion: APOE does not appear to be related in a direct way to the developmental sequelae of white or gray matter injury in extremely preterm infants. © 2014 S. Karger AG, Basel.
    Neonatology 02/2014; 105(3):227-229. · 2.57 Impact Factor
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    ABSTRACT: Background The apoE protein is the most important lipid transporter in the brain and has also been shown to have several regulatory functions in the central nervous system. The production of apoE is regulated by a number of genes and increases under certain conditions such as cerebral injury in adults. Aims Our aim was to study whether variations in genes regulating the expression of the APOE gene were associated with severity of cerebral palsy (CP). Methods Children enrolled in the Cerebral Palsy Register of Norway (CPRN) were invited to participate in this cross-sectional study; 281 of the invited 703 children (40%) returned swabs with buccal cells collected by parents. Six genetic variations thought to affect the production of apoE were genotyped and correlated with clinical data recorded in the CPRN. Results Compared with children carrying the GG allele, children with genotype GT or TT in a specific genetic variation (rs59007384 located in the nearby TOMM40 gene) had excess risk for worse fine motor function (Odds ratio (OR): 1.82; 95% Confidence interval (CI): 1.10 – 2.99; p=0.019) and epilepsy (OR: 2.32; CI: 1.17 – 4.61; p=0.016). There was no association between severity of CP and any of the other five genetic variations analyzed. Conclusion Our findings suggest that genetic variations in one of the sequences regulating the expression of APOE, may be associated with worse clinical outcome in children with cerebral palsy
    European Journal of Paediatric Neurology. 01/2014;
  • James A Blackman, Mark R Conaway
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    ABSTRACT: Data from the 2009-2010 US National Survey of Children with Special Health Care Needs were examined to determine the health, developmental and behavioral status of adolescents with cerebral palsy (CP) and to assess how well pediatric health care providers were preparing them for transition to adult health care services. Adolescents with CP had no higher rates of attention deficit hyperactivity disorder, depression, anxiety, oppositional or conduct disorders, or autism spectrum than a comparison group. However, those with CP participated less in sports, clubs, or other organized activities (P < .001). Neither group reported much help in coordinating health services or preparing for transition to adult health care services. Inadequate adult health care services have a direct and unsatisfactory impact on the adult life span. Physicians and other health care providers who include adolescents with CP in their practices should begin discussion and planning for transition to adult health care early in adolescence.
    Clinical Pediatrics 11/2013; · 1.27 Impact Factor
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    ABSTRACT: Background and methods. Our goal was to identify factors that affect neonatal intensive care unit (NICU) follow-up appointment compliance. Compliant and noncompliant infants discharged from the NICU over 1 year and scheduled for follow-up (133) were compared retrospectively; a prospective telephone survey of noncompliant families was also undertaken. Results. Maternal drug use (odds ratio [OR] = 0.049, 95% confidence interval [CI] = 0.005-0.506), multiple gestation pregnancy (OR = 0.163, 95% CI = 0.050-0.533), male sex (OR = 0.308, 95% CI = 0.112-0.850), and greater distance from the hospital (OR = 0.987, 95% CI = 0.976-0.999) were independently associated with lower appointment compliance. A greater number of days on oxygen was associated with greater odds of compliance (OR = 1.057, 95% CI = 0.976-0.999). Shorter NICU stays (P = .047) and less chronic lung disease (P = .026) were significantly associated with noncompliance by bivariate analysis only. Distance from the hospital and travel expense were the most often self-cited reasons for appointment noncompliance. Conclusion. Understanding factors associated with NICU follow-up noncompliance is a starting point for providing targeted intervention.
    Clinical Pediatrics 02/2013; · 1.27 Impact Factor
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    ABSTRACT: AIM: The aim of this study was to examine whether the presence of the apolipoprotein E (ApoE) allele APOEε4 is associated with less severe manifestations of cerebral palsy (CP), consistent with the suggested beneficial effect of this allele on neurodevelopment in children. METHOD: ApoE genotyping was performed on buccal epithelial cells from 255 children (141 males 114 females; mean age 12y, SD 2y 3mo, range 9-17y) recorded in the Cerebral Palsy Register of Norway. The main outcome measure of CP severity was the Gross Motor Function Classification System (GMFCS). Secondary outcome measures were fine motor function, epilepsy, and the need for gastrostomy tube feeding (GTF). RESULTS: There was no association between the APOEε4 genotype and GMFCS levels (odds ratio [OR] 1.15; 95% confidence interval [CI] 0.66-1.99). However, the APOEε4 genotype was more often present among children with epilepsy (OR 2.2; 95% CI 1.1-4.2) and/or receiving GTF (OR 2.7; 95% CI 1.1-6.6). Among children with unilateral CP, the presence of APOEε4 was associated with more severe fine motor impairment (OR 2.6; 95% CI 1.3-6.9). INTERPRETATION: Our main hypothesis that APOEε4 would have a protective effect on neurodevelopment was not supported. Instead, subgroup analyses suggested an adverse effect of the APOEε4 genotype on the developing brain after injury.
    Developmental Medicine & Child Neurology 02/2013; · 2.68 Impact Factor
  • James A Blackman, Mark R Conaway
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    ABSTRACT: Estimate the prevalence of specific developmental, emotional, and behavioral (DEB) problems across selected chronic health conditions; examine the relationship of chronic health conditions to functional activities and participation; determine the potential confounding effect of sociodemographic factors on the prevalence of DEB problems.METHODS: The 2007 National Survey of Children's Health, conducted by the Centers for Disease Control and Prevention, served as the primary data source for this study. A total of 91.642 interviews (66.6% response rate for identified households with children) were performed. Population-based estimates were obtained for variables of interest by assigning sampling weights to each child for whom an interview was completed.RESULTS: Parents were two to 30 times more likely to report DEB problems, such as Attention Deficit/Hyperactivity Disorder, depression, learning problems, and challenging behaviors, for children with chronic health conditions. These children had a greater number and range of difficulties with social interaction and school functioning as well as a lower rate of participation in community activities. Although highest rates of DEB problems were reported for those conditions involving the nervous or sensory systems, children with asthma, diabetes, and musculoskeletal conditions also had a higher rate of problems than children without the conditions. The higher prevalence of DEB problems remained after statistical adjustment for socio-demographic factors.CONCLUSIONS: Children with a spectrum of chronic health conditions are at high risk for DEB problems that affect learning, behavior, and emotional well-being. As part of a comprehensive approach to the management of chronic health conditions, children should be screened for these problems and referred for appropriate further evaluation and remediation. Attention to these common co-morbidities will not only result in enhanced quality of life but will also promote better adherence to medical recommendations and, thereby, optimal disease control.
    Journal of pediatric rehabilitation medicine 01/2013; 6(2):63-71.
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    ABSTRACT: Objective: To compare neurocognition and quality-of-life (QoL) in a group of children and adolescents with or without growth hormone deficiency (GHD) following moderate-to-severe traumatic brain injury (TBI). Study designs: Thirty-two children and adolescents were recruited from the TBI clinic at a children's hospital. Growth hormone (GH) was measured by both spontaneous overnight testing and following arginine/glucagon stimulation administration. Twenty-nine subjects participated in extensive neuropsychological assessment. Results: GHD as measured on overnight testing was significantly associated with a variety of neurocognitive and QoL measures. Specifically, subjects with GHD had significantly (p < 0.05) lower scores on measures of visual memory and health-related quality-of-life. These scores were not explained by severity of injury or IQ (p > 0.05). GHD noted in response to provocative testing was not associated with any neurocognitive or QoL measures. Conclusions: GHD following TBI is common in children and adolescents. Deficits in neurocognition and QoL impact recovery after TBI. It is important to assess potential neurocognitive and QoL changes that may occur as a result of GHD. It is also important to consider the potential added benefit of overnight GH testing as compared to stimulation testing in predicting changes in neurocognition or QoL.
    Brain Injury 01/2013; 27(2):200-8. · 1.51 Impact Factor
  • James A Blackman, Mark R Conaway
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    ABSTRACT: The purpose of this study was to determine (1) the progress that has been made in reducing the prevalence of asthma and/or reducing its severity over the past decade and (2) the progress that has been made in reducing the developmental and behavioral comorbidities of asthma during this period. Rates of asthma, asthma severity, and developmental and behavioral problems among children with asthma were compared between the 2003 and 2007 National Surveys of Children's Health. Asthma rates remained stable between the 2 surveys, but there was a shift from moderate to mild and, to a lesser extent, severe asthma. Comorbid rates of developmental and behavioral problems were about twice as high among children with asthma compared with those without asthma. All problems increased for both groups between the surveys but at a significantly greater pace for repeated grades among children with asthma. Children with asthma continue to have high rates of comorbid developmental and behavioral problems. Over the past decade, these problems are becoming more, not less frequent. Primary and asthma specialty caregivers should be attuned to these comorbidities and implement methods to screen for, assess, and remediate these problems as early as possible.
    Journal of developmental and behavioral pediatrics: JDBP 12/2011; 33(1):24-31. · 2.27 Impact Factor
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    ABSTRACT: This study estimated and compared rates of emotional, developmental and behavioural (EDB) problems among children with chronic health conditions. Rates of EDB problems were estimated using data from the 2005-2007 National Survey of Children with Special Health Care Needs. The National Survey of Children's Health (NSCH) 2003 was used to provide national estimates as referent values. The overall rate of EDB problems for children with chronic health conditions was 15%, about three times the rate for children in the general US population. The rate of attention deficit disorder/attention-deficit/hyperactivity disorder was 18%, over twice that for children in the general population. Children with migraine or other types of recurrent headaches had the highest rate of EDB problems (47%), about nine times the rate for the NSCH sample; those with arthritis or other joint problems had nearly 30%, about five times the rate for the NSCH. Chronic health conditions are associated with high rates of EDB problems. Children with recurrent headaches and arthritis have particularly high rates, possibly related to pain associated with these conditions. Chronic health condition management programmes should address both medical treatment as well as EDB co-morbid problems through a multidimensional approach to care.
    Journal of Paediatrics and Child Health 03/2011; 47(10):742-7. · 1.25 Impact Factor
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    Carolyn Long, Matthew J Gurka, James Blackman
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    ABSTRACT: Objective. The purpose of the study was to compare the cognitive skills of young children diagnosed with autism spectrum disorder (ASD) to same-aged peers referred for possible developmental delays or behavioral concerns using the Bayley Scales of Infant Development-Third Edition. Method. A retrospective chart review was conducted of 147 children ages 16 to 38 months who were referred to a diagnostic clinic for developmental evaluation. Children with ASD were compared to those without ASD with respect to cognition and language outcomes, both overall and by age. Results. While language skills in children with ASD were more significantly delayed than language skills in children without ASD, there was less discrepancy in the cognitive skills of children with and without ASD. Conclusion. Formal cognitive assessment of children with ASD can provide guidance for developmental expectations and educational programming. Cognitive skills of children with ASD may be underappreciated.
    Autism research and treatment. 01/2011; 2011:759289.
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    ABSTRACT: Children who sustain traumatic brain injury (TBI) are at risk for developing hypopituitarism, of which growth hormone deficiency (GHD) is the most common manifestation. To determine the prevalence of GHD and associated features following TBI among children and adolescents. A total of 32 children and adolescents were recruited from a pediatric TBI clinic. Participants were diagnosed with GHD based on insufficient growth hormone release during both spontaneous overnight testing and following arginine/glucagon administration. GHD was diagnosed in 5/32 participants (16%). Those with GHD exhibited more rapid weight gain following injury than those without GHD and had lower levels of free thyroxine and follicle-stimulating hormone. Males with GHD had lower testosterone levels. GHD following TBI is common in children and adolescents, underscoring the importance of assessing for GHD, including evaluating height and weight velocities after TBI. Children and adolescents with GHD may further exhibit absence or intermediate function for other pituitary hormones.
    Clinical Pediatrics 11/2010; 49(11):1044-9. · 1.27 Impact Factor
  • James A Blackman
    Developmental Medicine & Child Neurology 07/2010; 52(7):600. · 2.68 Impact Factor
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    ABSTRACT: To compare healthy late-preterm infants with their full-term counterparts from age 4 through 15 years for numerous standard cognitive, achievement, socioemotional, and behavioral outcomes. Prospective cohort study. National Institute of Child Health and Development Study of Early Child Care and Youth Development, 1991-2007. A total of 1298 children (53 born at 34-36 weeks' gestational age), and their families, observed from birth through age 15 years. None of the infants had major health problems before or immediately following birth, and all the infants were discharged from the hospital within 7 days. Preterm status: children born late preterm (34-36 weeks) vs those born full term (37-41 weeks). Eleven standard outcomes measuring cognition, achievement, social skills, and behavioral/emotional problems using the Woodcock-Johnson Psycho-Educational Battery-Revised and the Child Behavior Checklist, administered repeatedly through age 15 years. No consistent significant differences were found between late-preterm and full-term children for these standard measures from ages 4 to 15 years. Through age 15 years, the mean difference of most of these outcomes hovered around 0, indicating, along with small confidence intervals around these differences, that it is unlikely that healthy late-preterm infants are at any meaningful disadvantage regarding these measures. Late-preterm infants born otherwise healthy seem to have no real burdens regarding cognition, achievement, behavior, and socioemotional development throughout childhood.
    JAMA Pediatrics 06/2010; 164(6):525-32. · 4.28 Impact Factor
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    ABSTRACT: The goal was to measure differences in the causes, mechanisms, acute clinical presentations, injuries, and outcomes of children <36 months of age with varying "greatest depths" of acute cranial injury. Children <36 months of age who were hospitalized with acute head trauma were recruited at multiple sites. Clinical and imaging data were collected, and caregivers underwent scripted interviews. Neurodevelopmental evaluations were completed 6 months after injury. Head trauma causes were categorized independently, and subject groups with varying greatest depths of injury were compared. Fifty-four subjects were enrolled at 9 sites. Twenty-seven subjects underwent follow-up neurodevelopmental assessments 6 months after injury. Greatest depth of visible injury was categorized as scalp, skull, or epidural for 20 subjects, subarachnoid or subdural for 13, cortical for 10, and subcortical for 11. Compared with subjects with more-superficial injuries, subjects with subcortical injuries more frequently had been abused (odds ratio [OR]: 35.6; P < .001), more frequently demonstrated inertial injuries (P < .001), more frequently manifested acute respiratory (OR: 43.9; P < .001) and/or circulatory (OR: 60.0; P < .001) compromise, acute encephalopathy (OR: 28.5; P = .003), prolonged impairments of consciousness (OR: 8.4; P = .002), interhemispheric subdural hemorrhage (OR: 10.1; P = .019), and bilateral brain hypoxia, ischemia, or swelling (OR: 241.6; P < .001), and had lower Mental Developmental Index (P = .006) and Gross Motor Quotient (P < .001) scores 6 months after injury. For children <3 years of age, head injury depth is a useful indicator of injury causes and mechanisms.
    PEDIATRICS 03/2010; 125(4):712-20. · 4.47 Impact Factor
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    Matthew J Gurka, James A Blackman, Peter W Heymann
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    ABSTRACT: To examine whether early child care exposure influences the risk for development of asthma. Longitudinal data from 939 children and their families from the National Institute of Child Health and Development Study of Early Child Care and Youth Development were analyzed. Exposure to other children in the primary child care setting as an infant (before 15 months) and as a toddler (16-36 months) were assessed as risk factors for persistent or late-onset asthma by age 15 via logistic regression. The number of children in the child-care environment when the child was a toddler was significantly associated with odds of asthma, even after adjusting for respiratory illnesses and other risk factors (P < .05). The fewer the children exposed to as toddlers, the higher the probability of persistent or late-onset asthma by age 15. This study supports the theory of a protective effect of exposure to other children at an early age, especially as a toddler, on the risk of asthma. This effect appears to be independent of the number of reported respiratory tract illnesses, suggesting that other protective mechanisms related to the number of children in the child care environment may be involved.
    The Journal of pediatrics 09/2009; 155(6):781-787.e1. · 4.02 Impact Factor
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    ABSTRACT: This study examines the relationship between scores on the Western Neuro Sensory Stimulation Profile (WNSSP) and therapeutic participation as it relates to rehabilitation readiness (RR) in adolescents with low response following severe traumatic brain injury (TBI). This is a serial observational design using multiple measures of clinical status and participation. Ten children, mean age 16.7 years, who remained in a low response state (30 days or more) were assessed with the WNSSP and videotaped during physical and occupational therapy sessions. Associations were evaluated between WNSSP scores and participation scores related to arousal, awareness and communication. The WNSSP was only associated with the communication score (p < 0.0001). The arousal and awareness scores had no significant impact on the WNSSP score. These results suggest that scores on the WNSSP may be related to the return of communication skills in adolescents in low response states as one part of assessing their therapeutic participation and ultimate rehabilitation readiness. This ability may assist in making decisions regarding care planning.
    Brain Injury 06/2009; 23(6):528-34. · 1.51 Impact Factor
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    ABSTRACT: Cerebral palsy is attributed to non-progressive disturbances in the developing fetal or infant brain. The APOE ε4 allele has been associated with poor outcome after brain injury in adults but may be protective among very young children. We conducted this study to explore the hypothesis that the APOE ε4 is associated with lowered severity of cerebral palsy. 158 individuals with CP and their parents were genotyped for APOE. Mean age was 9.1 years; 54% were males. 61% were preterm at birth; 34% less than 30 weeks gestation. 30% of the CP subjects had at least one ε4 allele. There was a trend towards significance for subjects with at least one ε4 allele assigned to the low severity group (p = 0.11). The greater number of ε4 alleles, the more likely an individual was in the low severity CP group (p = 0.12). Individuals with brain injury in the perinatal period were almost 5 times more likely to be in the low severity group (p < 0.01). Family analysis via the TDT supported a protective effect of APOE ε4. Further study is needed to confirm that, in contrast to adults, the APOE ε4 allele appears to confer protection and/or facilitate recovery after brain injury in the fetus or newborn, particularly when that injury occurs around term.
    Journal of pediatric rehabilitation medicine 01/2009; 2(1):67-74.
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    ABSTRACT: The relationship between a fragile site on the X chromosome and autism has been well documented. The authors report a three-year-old child with partial duplication of the short arm of chromosome Y, who had an autistic disorder. He was microcephalic, but otherwise had a normal phenotype. There was a history of preterm birth and maternal diabetes. This is the sixth case of sex chromosome Y aneuploidy associated with autism, but the first with an isodicentric Y. In well-substantiated cases of autism, clinicians should now consider abnormalities of the Y as well as the X chromosome.RÉSUMÉTroubles autistiques associés à un chromosome Y isodicentriqueLa relation entre un site fragile sur le chromosome X et l'autisme est bien établie. Les auteurs rapportent le cas d'un garcon de trois ans présentant une duplication partielle du bras court du chromosome Y et un trouble autistique. Il était microcéphalique niais de phénotype par ailleurs normall. On relevait une anamnèse de naissance prématurée et de diabéte maternel. C'est le sixième cas d'aneuploïdie du chromosome Y associe a l'autisme, mais le premier cas avec un Y isodicentrique. Dans les cas d'autisme bien établi, les clinciens devront rechercher maintenant des anomalies du chromosome Y aussi bien que celles du chromosome X.ZUSAIMMENFASSUNGAutistische Störung in Verbindung mit einem isodizentrischen Y ChromosomDie Beziehung zwischen einer fragilen Stelle auf dem X Chromosom und Autismus ist gut dokumentiert. Die Autoren berichten über ein dreijähriges Kind mit einer partiellen Dublikation des kurzen Armes beim Y Chromosom, das ein autistisches Krankheitsbild hatte. Es war mikrozephal, hatte aber sonst einen normalen Phänotyp. Die Anamnese enthielt Angaben über Frühgeburt und mütterlichen Diabetes. Dies ist der sechste Fall mit einer Aneuplodie des Y Chromosoms in Verbindung mit Autismus, aber der erste mit einerri isodizentrischen Y. Bei gesicherten Fallen von Autismus sollten die Kliniker jetzt Anomalien des Y Chromosoms sowie des X Chromosoms in Erwägung ziehen.RESUMENAlteración autística asociada a un cromosoma y isodiscentricoLa relación entre un punto frágil en el cromosoma X y el autismo está bien documentada. Los autores aportan un nitlo de tres años de edad con una duplicación parcial del brazo corto del cromosoma Y y que tenia una alteracion autistica. Era microcefalico pero por lo demas tenia un fenotipo normal. Había una historia de nacimiento pretermino y una diabetes materna. Este es el sexto caso de aneuploi dia del cromosoma Y asociada con autismo, pero el primer caso con un cromosoma Y isodicéntrico. En casos bien claros de autismo los clinicos deben considerar la posibilidad de anomalías del cromosoma Y, asi como del cromosoma X;
    Developmental Medicine & Child Neurology 01/2008; 33(2):162-166. · 2.68 Impact Factor

Publication Stats

446 Citations
73.55 Total Impact Points

Institutions

  • 2003–2014
    • University of Virginia
      • • Division of Pediatrics
      • • Department of Pediatrics
      Charlottesville, Virginia, United States
  • 2013
    • St. Olavs Hospital
      Nidaros, Sør-Trøndelag, Norway
  • 2010
    • Dartmouth–Hitchcock Medical Center
      Lebanon, New Hampshire, United States