As noted in the article by Davenport et al.,[1] in addition to “BASM,” another term for infants with BA and stereotypical syndromic abdominal and vascular anomalies is “biliary atresia laterality sequence.” Given that only 70% of our patients with laterality defects actually had splenic anomalies, the latter term might be preferable in the future to Ibrutinib in vivo “BASM” to describe this stereotypical group of infants. The Canadian Pediatric Hepatology Research group has recently reported their analysis of 382 infants with BA and the associated anomalies.[22] Forty-four (13%) had

associated anomalies, only 25 (6.5%) of which were associated with SM. The authors concluded that BA infants with anomalies demonstrated a spectrum of laterality defects and suggested that the meaning of the acronym BASM be modified to “biliary atresia structural malformation.” Our conclusions are somewhat similar in that a total of 16% of our infants were in the anomaly Groups 2 and 3. On the other hand, the main difference between our observations and those of the Canadian group was that Group 2 infants frequently exhibited major birth defects click here of the genitourinary and/or gastrointestinal systems, not considered part of defective lateralization, suggesting that this group may represent a different etiopathogenesis than Groups 1 and 3. Group 3

infants were younger at the time of initial evaluation compared to Group 1. The associated anomalies in Group 3, especially the cardiac lesions associated with murmurs or cyanosis, probably brought the patient to medical attention sooner than the infants with isolated cholestasis. An unexpected finding was the high incidence of

autoimmunity in first-degree relatives of all BA groups (average 44%). The occurrence of autoimmune diseases in relatives provides circumstantial evidence that a candidate disease (i.e., BA) may be autoimmune in nature.[23] The incidence of autoimmunity in first-degree relatives is much higher than that found in the general population, where autoimmunity rates vary from 2.5%-9%.[26, 27] Importantly, the incidence of autoimmunity see more in first-degree relatives of BA patients was similar to the rate of 37%-43% identified in autoimmune hepatitis[26] and 25.5% in type-1 diabetes mellitus.[25] This intriguing finding of autoimmunity in first-degree relatives of BA patients warrants further investigation. The fact that there was no difference in autoimmunity rates between the three groups suggests that the autoimmune hypothesis of BA may be relevant to the pathogenesis of all types of BA and is a clue to be pursued in further studies. It is also possibly that the high incidence simply resulted from our rigorous questionnaire containing a long list of autoimmune diseases and not being of pathogenetic significance.