1
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Santoro JD, Spinazzi NA, Filipink RA, Hayati-Rezvan P, Kammeyer R, Patel L, Sannar EA, Dwyer L, Banerjee AK, Khoshnood M, Jafarpour S, Boyd NK, Partridge R, Gombolay GY, Christy AL, Real de Asua D, Del Carmen Ortega M, Manning MA, Van Mater H, Worley G, Franklin C, Stanley MA, Brown R, Capone GT, Quinn EA, Rafii MS. Immunotherapy responsiveness and risk of relapse in Down syndrome regression disorder. Transl Psychiatry 2023; 13:276. [PMID: 37553347 PMCID: PMC10409776 DOI: 10.1038/s41398-023-02579-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 08/10/2023] Open
Abstract
Down syndrome regression disorder (DSRD) is a clinical symptom cluster consisting of neuropsychiatric regression without an identifiable cause. This study evaluated the clinical effectiveness of IVIg and evaluated clinical characteristics associated with relapse after therapy discontinuation. A prospective, multi-center, non-randomized, observational study was performed. Patients met criteria for DSRD and were treated with IVIg. All patients underwent a standardized wean-off therapy after 9-12 months of treatment. Baseline, on-therapy, and relapse scores of the Neuropsychiatric Inventory Total Score (NPITS), Clinical Global Impression-Severity (CGI-S), and the Bush-Francis Catatonia Rating Scale (BFCRS) were used to track clinical symptoms. Eighty-two individuals were enrolled in this study. Patients had lower BFCRS (MD: -6.68; 95% CI: -8.23, -5.14), CGI-S (MD: -1.27; 95% CI: -1.73, -0.81), and NPITS scores (MD: -6.50; 95% CI: -7.53, -5.47) while they were on therapy compared to baseline. Approximately 46% of the patients (n = 38) experienced neurologic relapse with wean of IVIg. Patients with neurologic relapse were more likely to have any abnormal neurodiagnostic study (χ2 = 11.82, P = 0.001), abnormal MRI (χ2 = 7.78, P = 0.005), and abnormal LP (χ2 = 5.45, P = 0.02), and a personal history of autoimmunity (OR: 6.11, P < 0.001) compared to patients without relapse. IVIg was highly effective in the treatment of DSRD. Individuals with a history of personal autoimmunity or neurodiagnostic abnormalities were more likely to relapse following weaning of immunotherapy, indicating the potential for, a chronic autoimmune etiology in some cases of DSRD.
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Affiliation(s)
- Jonathan D Santoro
- Division of Neurology, Children's Hospital Los Angeles, Los Angeles, CA, USA.
- Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.
| | - Noemi A Spinazzi
- Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Robyn A Filipink
- Division of Child Neurology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Panteha Hayati-Rezvan
- Division of Research on Children, Youth and Families, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Ryan Kammeyer
- Department of Neurology, Children's Hospital of Colorado, Aurora, CO, USA
| | - Lina Patel
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA
| | - Elise A Sannar
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA
| | - Luke Dwyer
- Department of Psychiatry, University of Utah, Salt Lake City, UT, USA
| | - Abhik K Banerjee
- Division of Neurology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Mellad Khoshnood
- Division of Neurology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Saba Jafarpour
- Division of Neurology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Natalie K Boyd
- Division of Neurology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | | | - Grace Y Gombolay
- Department of Pediatrics, Division of Neurology Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | | | - Diego Real de Asua
- Adult Down Syndrome Outpatient Clinic, Department of Internal Medicine, Fundación de Investigación Biomédica, Hospital Universitario de La Princesa, Madrid, Spain
| | | | - Melanie A Manning
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Heather Van Mater
- Division of Rheumatology, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Gordan Worley
- Division of Pediatric Neurology and Developmental Medicine, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Cathy Franklin
- Queensland Center for Intellectual and Developmental Disability, Mater Research Institute, The University of Queensland, South Brisbane, QLD, Australia
| | - Maria A Stanley
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ruth Brown
- Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA
| | - George T Capone
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Eileen A Quinn
- Department of Pediatrics, University of Toledo College of Medicine and Life Science, Toledo, OH, USA
| | - Michael S Rafii
- Department of Neurology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
- Alzheimer's Therapeutic Research Institute (ATRI), Keck School of Medicine at the University of Southern California, San Diego, CA, USA
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Santoro J, Spinazzi N, Filipink R, Hayati-Rezvan P, Kammeyer R, Patel L, Sannar E, Dwyer L, Banerjee A, Khoshnood M, Jafarpour S, Boyd N, Partridge R, Gombolay G, Christy A, Real de Asua D, Del Carmen Ortega M, Manning M, Van Mater H, Worley G, Franklin C, Stanley M, Brown R, Capone G, Quinn E, Rafii M. Immunotherapy Responsiveness and Risk of Relapse in Down Syndrome Regression Disorder. Res Sq 2023:rs.3.rs-2521595. [PMID: 36824719 PMCID: PMC9949176 DOI: 10.21203/rs.3.rs-2521595/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
Down syndrome regression disorder (DSRD) is a clinical symptom cluster consisting of neuropsychiatric regression without an identifiable cause. This study evaluated the clinical effectiveness of IVIg and evaluated clinical characteristics associated with relapse after therapy discontinuation. A prospective, multi-center, non-randomized, observational study was performed. Patients met criteria for DSRD and were treated with IVIg. All patients underwent a standardized wean off therapy after 9-12 months of treatment. Baseline, on therapy, and relapse scores of the Neuropsychiatric Inventory Total Score (NPITS), Clinical Global Impression-Severity (CGI-S), and the Bush-Francis Catatonia Rating Scale (BFCRS) were used to track clinical symptoms. Eighty-two individuals were enrolled in this study. Patients had lower BFCRS (MD: -6.68; 95% CI: -8.23, -5.14), CGI-S (MD: -1.27; 95% CI: -1.73, -0.81), and NPITS scores (MD: -6.50; 95% CI: -7.53, -5.47) while they were on therapy compared to baseline. Approximately 46% of the patients (n = 38) experienced neurologic relapse with wean of IVIg. Patients with neurologic relapse were more likely to have any abnormal neurodiagnostic study (χ2 = 11.82, p = 0.001), abnormal MRI (χ2 = 7.78, p = 0.005), and abnormal LP (χ2 = 5.45, p = 0.02), and a personal history of autoimmunity (OR: 6.11, p < 0.001) compared to patients without relapse. IVIg was highly effective in the treatment of DSRD. Individuals with a history of personal autoimmunity or neurodiagnostic abnormalities were more likely to relapse following weaning of immunotherapy, indicating the potential for, a chronic autoimmune etiology in some cases of DSRD.
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Affiliation(s)
| | | | | | | | - Ryan Kammeyer
- Kennedy-Krieger Institute and Johns Hopkins University
| | - Lina Patel
- Kennedy-Krieger Institute and Johns Hopkins University
| | - Elise Sannar
- Kennedy-Krieger Institute and Johns Hopkins University
| | - Luke Dwyer
- Kennedy-Krieger Institute and Johns Hopkins University
| | | | | | | | - Natalie Boyd
- Kennedy-Krieger Institute and Johns Hopkins University
| | | | | | | | | | | | | | | | - Gordon Worley
- Kennedy-Krieger Institute and Johns Hopkins University
| | | | - Maria Stanley
- Kennedy-Krieger Institute and Johns Hopkins University
| | - Ruth Brown
- Kennedy-Krieger Institute and Johns Hopkins University
| | - George Capone
- Kennedy-Krieger Institute and Johns Hopkins University
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Zhang L, Sanchez B, Moldenhauer F, de Asua DR, Brudfors M, Foulon C, del Ser T, Ashburner J, Nachev P, Strange BA. Neuroanatomy of dementia in Down Syndrome revealed using a voxel‐based morphometry approach to computed tomography. Alzheimers Dement 2022. [DOI: 10.1002/alz.062219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Linda Zhang
- CIEN Foundation, Queen Sofia Foundation Alzheimer Centre Madrid Spain
| | | | | | | | - Mikael Brudfors
- Wellcome Centre for Human Neuroimaging, UCL London United Kingdom
| | - Chris Foulon
- UCL Queen Square Institute of Neurology London United Kingdom
| | - Teodoro del Ser
- CIEN Foundation, Queen Sofia Foundation Alzheimer Centre Madrid Spain
| | - John Ashburner
- Wellcome Centre for Human Neuroimaging, UCL London United Kingdom
| | | | - Bryan A Strange
- CIEN Foundation, Queen Sofia Foundation Alzheimer Centre Madrid Spain
- Centre for Biomedical Technology, Universidad Politecnica de Madrid Madrid Spain
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Zhang L, Sanchez B, Moldenhauer F, de Asua DR, Brudfors M, Foulon C, del Ser T, Ashburner J, Nachev P, Strange BA. Neuroanatomy of dementia in Down Syndrome revealed using a voxel‐based morphometry approach to computed tomography. Alzheimers Dement 2022. [DOI: 10.1002/alz.065754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Linda Zhang
- CIEN Foundation, Queen Sofia Foundation Alzheimer Centre Madrid Spain
| | | | | | | | - Mikael Brudfors
- Wellcome Centre for Human Neuroimaging, UCL London United Kingdom
| | - Chris Foulon
- UCL Queen Square Institute of Neurology London United Kingdom
| | - Teodoro del Ser
- CIEN Foundation, Queen Sofia Foundation Alzheimer Centre Madrid Spain
| | - John Ashburner
- Wellcome Centre for Human Neuroimaging, UCL London United Kingdom
| | | | - Bryan A Strange
- CIEN Foundation, Queen Sofia Foundation Alzheimer Centre Madrid Spain
- Centre for Biomedical Technology, Universidad Politecnica de Madrid Madrid Spain
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Santoro JD, Patel L, Kammeyer R, Filipink RA, Gombolay GY, Cardinale KM, Real de Asua D, Zaman S, Santoro SL, Marzouk SM, Khoshnood M, Vogel BN, Tanna R, Pagarkar D, Dhanani S, Ortega MDC, Partridge R, Stanley MA, Sanders JS, Christy A, Sannar EM, Brown R, McCormick AA, Van Mater H, Franklin C, Worley G, Quinn EA, Capone GT, Chicoine B, Skotko BG, Rafii MS. Assessment and Diagnosis of Down Syndrome Regression Disorder: International Expert Consensus. Front Neurol 2022; 13:940175. [PMID: 35911905 PMCID: PMC9335003 DOI: 10.3389/fneur.2022.940175] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 06/24/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo develop standardization for nomenclature, diagnostic work up and diagnostic criteria for cases of neurocognitive regression in Down syndrome.BackgroundThere are no consensus criteria for the evaluation or diagnosis of neurocognitive regression in persons with Down syndrome. As such, previously published data on this condition is relegated to smaller case series with heterogenous data sets. Lack of standardized assessment tools has slowed research in this clinical area.MethodsThe authors performed a two-round traditional Delphi method survey of an international group of clinicians with experience in treating Down syndrome to develop a standardized approach to clinical care and research in this area. Thirty-eight potential panelists who had either previously published on neurocognitive regression in Down syndrome or were involved in national or international working groups on this condition were invited to participate. In total, 27 panelists (71%) represented nine medical specialties and six different countries reached agreement on preliminary standards in this disease area. Moderators developed a proposed nomenclature, diagnostic work up and diagnostic criteria based on previously published reports of regression in persons with Down syndrome.ResultsDuring the first round of survey, agreement on nomenclature for the condition was reached with 78% of panelists agreeing to use the term Down Syndrome Regression Disorder (DSRD). Agreement on diagnostic work up and diagnostic criteria was not reach on the first round due to low agreement amongst panelists with regards to the need for neurodiagnostic testing. Following incorporation of panelist feedback, diagnostic criteria were agreed upon (96% agreement on neuroimaging, 100% agreement on bloodwork, 88% agreement on lumbar puncture, 100% agreement on urine studies, and 96% agreement on “other” studies) as were diagnostic criteria (96% agreement).ConclusionsThe authors present international consensus agreement on the nomenclature, diagnostic work up, and diagnostic criteria for DSRD, providing an initial practical framework that can advance both research and clinical practices for this condition.
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Affiliation(s)
- Jonathan D. Santoro
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States
- Department of Neurology, Keck School of Medicine at USC, Los Angeles, CA, United States
- *Correspondence: Jonathan D. Santoro
| | - Lina Patel
- Department of Psychiatry, University of Colorado School of Medicine, Denver, CO, United States
| | - Ryan Kammeyer
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Robyn A. Filipink
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Grace Y. Gombolay
- Department of Pediatrics, Division of Neurology, Emory University and Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Kathleen M. Cardinale
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Diego Real de Asua
- Adult Down Syndrome Outpatient Clinic, Department of Internal Medicine, Fundación de Investigación Biomédica, Hospital Universitario de La Princesa, Madrid, Spain
| | - Shahid Zaman
- Cambridge Intellectual & Developmental Disabilities Research Group, Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - Stephanie L. Santoro
- Down Syndrome Program, Division of Medical Genetics and Metabolism, Department of Pediatrics, Massachusetts General Hospital, Boston, MA, United States
| | - Sammer M. Marzouk
- Down Syndrome Program, Division of Medical Genetics and Metabolism, Department of Pediatrics, Massachusetts General Hospital, Boston, MA, United States
| | - Mellad Khoshnood
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Benjamin N. Vogel
- Department of Neurology, Keck School of Medicine at USC, Los Angeles, CA, United States
| | - Runi Tanna
- Department of Neurology, Keck School of Medicine at USC, Los Angeles, CA, United States
| | - Dania Pagarkar
- Department of Neurology, Keck School of Medicine at USC, Los Angeles, CA, United States
| | - Sofia Dhanani
- Department of Neurology, Keck School of Medicine at USC, Los Angeles, CA, United States
| | | | | | - Maria A. Stanley
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Jessica S. Sanders
- Sie Center for Down Syndrome at the University of Colorado, Aurora, CO, United States
| | | | - Elise M. Sannar
- Department of Psychiatry, University of Colorado School of Medicine, Denver, CO, United States
- Division of Psychiatry and Behavioral Sciences, Children's Hospital Colorado, Aurora, CO, United States
| | - Ruth Brown
- Department of Psychology, Virginia Commonwealth University, Richmond, VA, United States
| | - Andrew A. McCormick
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Heather Van Mater
- Division of Rheumatology, Department of Pediatrics, Duke University, Durham, NC, United States
| | - Cathy Franklin
- Queensland Center for Intellectual and Developmental Disability, Mater Research Institute, The University of Queensland, South Brisbane, QLD, Australia
| | - Gordon Worley
- Division of Pediatric Neurology and Developmental Medicine, Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Eileen A. Quinn
- Department of Pediatrics, University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States
| | - George T. Capone
- Department of Pediatrics, Kennedy Krieger Institute, Baltimore, MD, United States
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Brian Chicoine
- Advocate Medical Group Adult Down Syndrome Center, Park Ridge, IL, United States
| | - Brian G. Skotko
- Down Syndrome Program, Division of Medical Genetics and Metabolism, Department of Pediatrics, Massachusetts General Hospital, Boston, MA, United States
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Michael S. Rafii
- Department of Neurology, Keck School of Medicine at USC, Los Angeles, CA, United States
- Department of Neurology, Alzheimer's Therapeutic Research Institute (ATRI), Keck School of Medicine at the University of Southern California, San Diego, CA, United States
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Real de Asua D, Fins JJ. Should healthcare workers be prioritised during the COVID-19 pandemic? A view from Madrid and New York. J Med Ethics 2022; 48:397-400. [PMID: 33910974 PMCID: PMC8103555 DOI: 10.1136/medethics-2020-107050] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 03/09/2021] [Accepted: 04/01/2021] [Indexed: 05/30/2023]
Abstract
While COVID-19 has generated a massive burden of illness worldwide, healthcare workers (HCWs) have been disproportionately exposed to SARS-CoV-2 coronavirus infection. During the so-called 'first wave', infection rates among this population group have ranged between 10% and 20%, raising as high as one in every four COVID-19 patients in Spain at the peak of the crisis. Now that many countries are already dealing with new waves of COVID-19 cases, a potential competition between HCW and non-HCW patients for scarce resources can still be a likely clinical scenario. In this paper, we address the question of whether HCW who become ill with COVID-19 should be prioritised in diagnostic, treatment or resource allocation protocols. We will evaluate some of the proposed arguments both in favour and against the prioritisation of HCW and also consider which clinical circumstances might warrant prioritising HCW and why could it be ethically appropriate to do so. We conclude that prioritising HCW's access to protective equipment, diagnostic tests or even prophylactic or therapeutic drug regimes and vaccines might be ethically defensible. However, prioritising HCWs to receive intensive care unit (ICU) beds or ventilators is a much more nuanced decision, in which arguments such as instrumental value or reciprocity might not be enough, and economic and systemic values will need to be considered.
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Affiliation(s)
- Diego Real de Asua
- Department of Internal Medicine, Hospital Universitario de la Princesa, Madrid, Spain
- Division of Medical Ethics, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
| | - Joseph J Fins
- Division of Medical Ethics, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
- CASBI, Consortium for the Advanced Study of Brain Injury, Weill Cornell Medicine and Rockefeller University, New York, New York, USA
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7
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Hüls A, Feany PT, Zisman SI, Costa ACS, Dierssen M, Balogh R, Bargagna S, Baumer NT, Brandão AC, Carfi A, Chicoine BA, Ghosh S, Lakhanpaul M, Levin J, Lunsky Y, Manso C, Okun E, Real de Asua D, Rebillat AS, Rohrer TR, Sgandurra G, Valentini D, Sherman SL, Strydom A. COVID-19 Vaccination of Individuals with Down Syndrome-Data from the Trisomy 21 Research Society Survey on Safety, Efficacy, and Factors Associated with the Decision to Be Vaccinated. Vaccines (Basel) 2022; 10:530. [PMID: 35455279 PMCID: PMC9030605 DOI: 10.3390/vaccines10040530] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/20/2022] [Accepted: 03/23/2022] [Indexed: 01/27/2023] Open
Abstract
Individuals with Down syndrome (DS) are among the groups with the highest risk for severe COVID-19. Better understanding of the efficacy and risks of COVID-19 vaccines for individuals with DS may help improve uptake of vaccination. The T21RS COVID-19 Initiative launched an international survey to obtain information on safety and efficacy of COVID-19 vaccines for individuals with DS. De-identified survey data collected between March and December 2021 were analyzed. Of 2172 individuals with DS, 1973 (91%) had received at least one vaccine dose (57% BNT162b2), 107 (5%) were unvaccinated by choice, and 92 (4%) were unvaccinated for other reasons. Most participants had either no side effects (54%) or mild ones such as pain at the injection site (29%), fatigue (12%), and fever (7%). Severe side effects occurred in <0.5% of participants. About 1% of the vaccinated individuals with DS contracted COVID-19 after vaccination, and all recovered. Individuals with DS who were unvaccinated by choice were more likely to be younger, previously recovered from COVID-19, and also unvaccinated against other recommended vaccines. COVID-19 vaccines have been shown to be safe for individuals with DS and effective in terms of resulting in minimal breakthrough infections and milder disease outcomes among fully vaccinated individuals with DS.
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Affiliation(s)
- Anke Hüls
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA;
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
| | - Patrick T. Feany
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA;
| | | | - Alberto C. S. Costa
- Department of Psychiatry, Case Western Reserve University, Cleveland, OH 44106, USA;
- Department of Macromolecular Science and Engineering, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Mara Dierssen
- Centre for Genomic Regulation (CRG), The Barcelona Institute of Science and Technology, Universitat Pompeu Fabra, 08016 Barcelona, Spain;
- Universitat Pompeu Fabra (UPF), 08016 Barcelona, Spain
- Centrode Investigación Biomédica en Red de Enfermedades Raras (CIBERER), 08016 Barcelona, Spain
| | - Robert Balogh
- Faculty of Health Sciences, Ontario Tech University, Oshawa, ON L1G 0C5, Canada;
| | - Stefania Bargagna
- Department of Developmental Neuroscience, IRCCS Fondazione Stella Maris, 56128 Calambrone, Italy; (S.B.); (G.S.)
| | - Nicole T. Baumer
- Department of Neurology, Division of Developmental Medicine, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
| | | | - Angelo Carfi
- Policlinico Universitario Agostino Gemelli IRCCS, 00100 Rome, Italy;
| | | | - Sujay Ghosh
- Cytogenetics and Genomics Research Unit, Department of Zoology, University of Calcutta, Kolkata 700073, India;
| | - Monica Lakhanpaul
- Department of Population Policy and Practice, UCL Great Ormond Street Institute of Child Health, University College, London WC1N 1EH, UK;
- Community Paediatrics, Whittington Health NHS, London N19 5NF, UK
| | - Johannes Levin
- Department of Neurology, Ludwig-Maximilians-Universität München, 80539 Munich, Germany;
- German Center for Neurodegenerative Diseases, Site Munich, 53127 Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), 81377 Munich, Germany
| | - Yona Lunsky
- Azrieli Adult Neurodevelopmental Centre, CAMH, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada;
| | | | - Eitan Okun
- The Paul Feder Laboratory on Alzheimer’s Disease Research, Bar Ilan University, Ramat Gan 5290002, Israel;
- The Gonda Brain Research Center, Bar Ilan University, Ramat Gan 5290002, Israel
- The Mina and Everard Goodman Faculty of Life Sciences, Bar Ilan University, Ramat Gan 5290002, Israel
| | - Diego Real de Asua
- Department of Internal Medicine and Instituto de Investigación Biomédica-La Princesa, Hospital Universitario de La Princesa, 28001 Madrid, Spain;
| | | | - Tilman R. Rohrer
- Division of Pediatric Endocrinology, Department of Pediatrics and Neonatology, Saarland University Medical Center, 66424 Homburg, Germany;
| | - Giuseppina Sgandurra
- Department of Developmental Neuroscience, IRCCS Fondazione Stella Maris, 56128 Calambrone, Italy; (S.B.); (G.S.)
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Diletta Valentini
- Pediatric Unit, Pediatric Emergency Department, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Stephanie L. Sherman
- Department of Human Genetics, School of Medicine, Emory University, Atlanta, GA 30322, USA;
| | - Andre Strydom
- South London and Maudsley NHS Foundation Trust, London SE5 8AZ, UK; (S.I.Z.); (A.S.)
- Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London SE5 8AB, UK
- The London Down Syndrome (LonDownS) Consortium, London SE5 8AB, UK
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8
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Real de Asua D, Mayer MA, Ortega MDC, Borrel JM, Bermejo TDJ, González-Lamuño D, Manso C, Moldenhauer F, Carmona-Iragui M, Hüls A, Sherman SL, Strydom A, de la Torre R, Dierssen M. Comparison of COVID-19 and Non-COVID-19 Pneumonia in Down Syndrome. J Clin Med 2021; 10:3748. [PMID: 34442043 PMCID: PMC8397064 DOI: 10.3390/jcm10163748] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 08/02/2021] [Accepted: 08/14/2021] [Indexed: 12/16/2022] Open
Abstract
Whether the increased risk for coronavirus disease 2019 (COVID-19) hospitalization and death observed in Down syndrome (DS) are disease specific or also occur in individuals with DS and non-COVID-19 pneumonias is unknown. This retrospective cohort study compared COVID-19 cases in persons with DS hospitalized in Spain reported to the Trisomy 21 Research Society COVID-19 survey (n = 86) with admissions for non-COVID-19 pneumonias from a retrospective clinical database of the Spanish Ministry of Health (n = 2832 patients). In-hospital mortality rates were significantly higher for COVID-19 patients (26.7% vs. 9.4%), especially among individuals over 40 and patients with obesity, dementia, and/or epilepsy. The mean length of stay of deceased patients with COVID-19 was significantly shorter than in those with non-COVID-19 pneumonias. The rate of admission to an ICU in patients with DS and COVID-19 (4.3%) was significantly lower than that reported for the general population with COVID-19. Our findings confirm that acute SARS-CoV-2 infection leads to higher mortality than non-COVID-19 pneumonias in individuals with DS, especially among adults over 40 and those with specific comorbidities. However, differences in access to respiratory support might also account for some of the heightened mortality of individuals with DS with COVID-19.
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Affiliation(s)
- Diego Real de Asua
- Adult Down Syndrome Outpatient Unit, Department of Internal Medicine, Hospital Universitario de La Princesa, 28006 Madrid, Spain; (D.R.d.A.); (F.M.)
- Instituto de Investigación Sanitaria La Princesa, Hospital Universitario de La Princesa, 28006 Madrid, Spain
| | - Miguel A. Mayer
- Research Programme on Biomedical Informatics, Hospital del Mar Medical Research Institute, 08003 Barcelona, Spain;
- Department of Experimental and Health Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain;
| | - María del Carmen Ortega
- Department of Psychiatry, Research Institute i+12, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain;
| | | | | | - Domingo González-Lamuño
- Department of Pediatrics, University Hospital Marqués de Valdecilla-Universidad de Cantabria, 39008 Santander, Spain;
| | | | - Fernando Moldenhauer
- Adult Down Syndrome Outpatient Unit, Department of Internal Medicine, Hospital Universitario de La Princesa, 28006 Madrid, Spain; (D.R.d.A.); (F.M.)
- Instituto de Investigación Sanitaria La Princesa, Hospital Universitario de La Princesa, 28006 Madrid, Spain
| | - María Carmona-Iragui
- Sant Pau Memory Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona, 08025 Barcelona, Spain;
- Barcelona Down Medical Center, Fundació Catalana de Síndrome de Down, 08029 Barcelona, Spain
| | - Anke Hüls
- Department of Epidemiology and Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA;
| | - Stephanie L. Sherman
- Department of Human Genetics, School of Medicine, Emory University, Atlanta, GA 30322, USA;
| | - Andre Strydom
- Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London SE5 8AF, UK;
- The London Down Syndrome (LonDownS) Consortium, London, United Kingdom and South London and the Maudsley NHS Foundation Trust, London SE5 8AF, UK
| | - Rafael de la Torre
- Department of Experimental and Health Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain;
- Neurosciences Research Programme, Hospital del Mar Medical Research Institute, 08003 Barcelona, Spain
- Biomedical Research Networking Center for Physiopathology of Obesity and Nutrition (CIBEROBN), 08003 Barcelona, Spain
| | - Mara Dierssen
- Department of Experimental and Health Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain;
- Center for Genomic Regulation, The Barcelona Institute for Science and Technology, 08003 Barcelona, Spain
- Biomedical Research Networking Center for Rare Diseases (CIBERER), 08003 Barcelona, Spain
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Hüls A, Costa AC, Dierssen M, Baksh RA, Bargagna S, Baumer NT, Brandão AC, Carfi A, Carmona-Iragui M, Chicoine BA, Ghosh S, Lakhanpaul M, Manso C, Mayer MA, Ortega MDC, de Asua DR, Rebillat AS, Russell LA, Sgandurra G, Valentini D, Sherman SL, Strydom A. Medical vulnerability of individuals with Down syndrome to severe COVID-19-data from the Trisomy 21 Research Society and the UK ISARIC4C survey. EClinicalMedicine 2021; 33:100769. [PMID: 33644721 PMCID: PMC7897934 DOI: 10.1016/j.eclinm.2021.100769] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/05/2021] [Accepted: 02/05/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Health conditions, immune dysfunction, and premature aging associated with trisomy 21 (Down syndrome, DS) may impact the clinical course of COVID-19. METHODS The T21RS COVID-19 Initiative launched an international survey for clinicians or caregivers on patients with COVID-19 and DS. Data collected between April and October 2020 (N=1046) were analysed and compared with the UK ISARIC4C survey of hospitalized COVID-19 patients with and without DS. FINDINGS The mean age of COVID-19 patients with DS in the T21RS survey was 29 years (SD = 18). Similar to the general population, the most frequent signs and symptoms of COVID-19 were fever, cough, and shortness of breath. Joint/muscle pain and vomiting or nausea were less frequent (p < 0.01), whereas altered consciousness/confusion were more frequent (p < 0.01). Risk factors for hospitalization and mortality were similar to the general population with the addition of congenital heart defects as a risk factor for hospitalization. Mortality rates showed a rapid increase from age 40 and were higher in patients with DS (T21RS DS versus non-DS patients: risk ratio (RR) = 3.5 (95%-CI=2.6;4.4), ISARIC4C DS versus non-DS patients: RR = 2.9 (95%-CI=2.1;3.8)) even after adjusting for known risk factors for COVID-19 mortality. INTERPRETATION Leading signs/symptoms of COVID-19 and risk factors for severe disease course are similar to the general population. However, individuals with DS present significantly higher rates of medical complications and mortality, especially from age 40. FUNDING Down Syndrome Affiliates in Action, DSMIG-USA, GiGi's Playhouse, Jerome Lejeune Foundation, LuMind IDSC Foundation, The Matthew Foundation, NDSS, National Task Group on Intellectual Disabilities and Dementia Practices.
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Affiliation(s)
- Anke Hüls
- Department of Epidemiology and Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Alberto C.S. Costa
- Departments of Pediatrics and of Psychiatry, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Mara Dierssen
- Centre for Genomic Regulation (CRG), The Barcelona Institute of Science and Technology, Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Spain
| | - R. Asaad Baksh
- Institute of Psychiatry, Psychology, and Neuroscience, Department of Forensic and Neurodevelopmental Sciences, King's College London, London, United Kingdom
- The London Down Syndrome (LonDownS) Consortium, London, United Kingdom
| | | | - Nicole T. Baumer
- Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Angelo Carfi
- Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Maria Carmona-Iragui
- Sant Pau Memory Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
- Barcelona Down Medical Center, Fundació Catalana de Síndrome de Down, Barcelona, Spain
| | | | - Sujay Ghosh
- Cytogenetics and Genomics Reserach Unit. Department of Zoology, University of Calcutta.Kolkata. West Bengal, India
| | - Monica Lakhanpaul
- UCL- Great Ormond Street Institute of Child Health, London, United Kingdom
- Whttington NHS Trust, London, United Kingdom; Down Syndrome Medical Interest Group, London, United Kingdom
| | | | - Miguel-Angel Mayer
- Research Programme on Biomedical Informatics (GRIB), Hospital del Mar Medical Research Institute and DCEXS Universitat Pompeu Fabra, Barcelona, Spain
| | - Maria del Carmen Ortega
- Department of Psychiatry, Research Institute i+12. Hospital Universitario 12 de Octubre. Madrid, Spain
| | - Diego Real de Asua
- Department of Internal Medicine and Instituto de Investigación Biomédica-La Princesa, Hospital Universitario de La Princesa, Madrid, Spain
| | | | - Lauren Ashley Russell
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Giuseppina Sgandurra
- Department of Developmental Neuroscience, IRCCS Fondazione Stella Maris, Pisa, Italy
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Diletta Valentini
- Pediatric Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Stephanie L. Sherman
- Department of Human Genetics, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Andre Strydom
- Institute of Psychiatry, Psychology, and Neuroscience, Department of Forensic and Neurodevelopmental Sciences, King's College London, London, United Kingdom
- The London Down Syndrome (LonDownS) Consortium, London, United Kingdom
- South London and the Maudsley NHS Foundation Trust
| | - T21RS COVID-19 Initiative
- Department of Epidemiology and Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Departments of Pediatrics and of Psychiatry, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Centre for Genomic Regulation (CRG), The Barcelona Institute of Science and Technology, Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Spain
- Institute of Psychiatry, Psychology, and Neuroscience, Department of Forensic and Neurodevelopmental Sciences, King's College London, London, United Kingdom
- The London Down Syndrome (LonDownS) Consortium, London, United Kingdom
- Fondazione Stella Maris IRCCS, Pisa, Italy
- Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
- Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
- Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Sant Pau Memory Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
- Barcelona Down Medical Center, Fundació Catalana de Síndrome de Down, Barcelona, Spain
- Advocate Medical Group Adult Down Syndrome Center, Park Ridge, IL, USA
- Cytogenetics and Genomics Reserach Unit. Department of Zoology, University of Calcutta.Kolkata. West Bengal, India
- UCL- Great Ormond Street Institute of Child Health, London, United Kingdom
- Whttington NHS Trust, London, United Kingdom; Down Syndrome Medical Interest Group, London, United Kingdom
- CM: DOWN ESPAÑA, Madrid, Spain
- Research Programme on Biomedical Informatics (GRIB), Hospital del Mar Medical Research Institute and DCEXS Universitat Pompeu Fabra, Barcelona, Spain
- Department of Psychiatry, Research Institute i+12. Hospital Universitario 12 de Octubre. Madrid, Spain
- Department of Internal Medicine and Instituto de Investigación Biomédica-La Princesa, Hospital Universitario de La Princesa, Madrid, Spain
- Institut Jérôme Lejeune, Paris, France
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Developmental Neuroscience, IRCCS Fondazione Stella Maris, Pisa, Italy
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Pediatric Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
- Department of Human Genetics, School of Medicine, Emory University, Atlanta, Georgia, USA
- Institute of Psychiatry, Psychology, and Neuroscience, Department of Forensic and Neurodevelopmental Sciences, King's College London, London, United Kingdom
- The London Down Syndrome (LonDownS) Consortium, London, United Kingdom
- South London and the Maudsley NHS Foundation Trust
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Hüls A, Costa ACS, Dierssen M, Baksh RA, Bargagna S, Baumer NT, Brandão AC, Carfi A, Carmona-Iragui M, Chicoine BA, Ghosh S, Lakhanpaul M, Manso C, Mayer MA, Del Carmen Ortega M, de Asua DR, Rebillat AS, Russell LA, Sgandurra G, Valentini D, Sherman SL, Strydom A. An international survey on the impact of COVID-19 in individuals with Down syndrome. medRxiv 2020:2020.11.03.20225359. [PMID: 33173907 PMCID: PMC7654903 DOI: 10.1101/2020.11.03.20225359] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Health conditions and immune dysfunction associated with trisomy 21 (Down syndrome, DS) may impact the clinical course of COVID-19 once infected by SARS-CoV-2. METHODS The T21RS COVID-19 Initiative launched an international survey for clinicians or caregivers/family members on patients with COVID-19 and DS (N=1046). De-identified survey data collected between April and October 2020 were analysed and compared with the UK ISARIC4C survey of hospitalized COVID-19 patients with and without DS. COVID-19 patients with DS from the ISARIC4C survey (ISARIC4C DS cases=100) were matched to a random set of patients without DS (ISARIC4C controls=400) and hospitalized DS cases in the T21RS survey (T21RS DS cases=100) based on age, gender, and ethnicity. FINDING The mean age in the T21RS survey was 29 years (SD=18), 73% lived with their family. Similar to the general population, the most frequent signs and symptoms of COVID-19 were fever, cough, and shortness of breath. Pain and nausea were reported less frequently (p<0.01), whereas altered consciousness/confusion were reported more frequently (p<0.01). Risk factors for hospitalization and mortality were similar to the general population (age, male gender, diabetes, obesity, dementia) with the addition of congenital heart defects as a risk factor for hospitalization. Mortality rates showed a rapid increase from age 40 and were higher than for controls (T21RS DS versus controls: risk ratio (RR)=3.5 (95%-CI=2.6;4.4), ISARIC4C DS versus controls: RR=2.9 (95%-CI=2.1;3.8)) even after adjusting for known risk factors for COVID-19 mortality. INTERPRETATION Leading signs/symptoms of COVID-19 and risk factors for severe disease course are similar to the general population. However, individuals with DS present significantly higher rates of mortality, especially from age 40. FUNDING Down Syndrome Affiliates in Action, Down Syndrome Medical Interest Group-USA, GiGi's Playhouse, Jerome Lejeune Foundation, LuMind IDSC Foundation, Matthews Foundation, National Down Syndrome Society, National Task Group on Intellectual Disabilities and Dementia Practices.
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Herreros B, Gella P, Real de Asua D. Triage during the COVID-19 epidemic in Spain: better and worse ethical arguments. J Med Ethics 2020; 46:455-458. [PMID: 32424063 PMCID: PMC7242823 DOI: 10.1136/medethics-2020-106352] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/05/2020] [Accepted: 05/11/2020] [Indexed: 05/06/2023]
Abstract
The COVID-19 pandemic has generated an imbalance between the clinical needs of the population and the effective availability of advanced life support (ALS) resources. Triage protocols have thus become necessary. Triage decisions in situations of scarce resources were not extraordinary in the pre-COVID-19 era; these protocols abounded in the context of organ transplantation. However, this prior experience was not considered during the COVID-19 outbreak in Spain. Lacking national guidance or public coordination, each hospital has been forced to put forth independent and autonomous triage protocols, most of which were, nonetheless, based on common ethical principles and clinical criteria. However, controversial, non-clinical criteria have also been defended by Spanish scientific societies and public institutions, including setting an age cut-off value for unilaterally withholding ALS, using 'social utility' criteria, prioritising healthcare professionals or using 'first come, first served' policies. This paper describes the most common triage criteria used in the Spanish context during the COVID-19 epidemic. We will highlight our missed opportunities by comparing these criteria to those used in organ transplantation protocols. The problems posed by subjective, non-clinical criteria will also be discussed. We hope that this critical review might be of use to countries at earlier stages of the epidemic while we learn from our mistakes.
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Affiliation(s)
- Benjamin Herreros
- Internal Medicine, Hospital Universitario Fundacion Alcorcon Servicio de Medicina Interna, Alcorcón, Comunidad de Madrid, Spain
- Instituto de Ética Clínica Francisco Vallés, Universidad Europea de Madrid Campus de Villaviciosa de Odón, Villaviciosa de Odón, Madrid, Spain
| | - Pablo Gella
- Instituto de Ética Clínica Francisco Vallés, Universidad Europea de Madrid Campus de Villaviciosa de Odón, Villaviciosa de Odón, Madrid, Spain
| | - Diego Real de Asua
- Department of Internal Medicine, Hospital Universitario de la Princesa, Madrid, Spain
- Division of Medical Ethics, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
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McCarthy MW, de Asua DR, Gabbay E, Christos PJ, Fins JJ. Frequency of Ethical Issues on a Hospitalist Teaching Service at an Urban, Tertiary Care Center. J Hosp Med 2019; 14:290-293. [PMID: 30897052 PMCID: PMC7343177 DOI: 10.12788/jhm.3179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 01/29/2019] [Indexed: 11/20/2022]
Abstract
Little is known about the daily ethical conflicts encountered by hospitalists that do not prompt a formal clinical ethics consultation. We describe the frequencies of ethical issues identified during daily rounds on hospitalist teaching services at a metropolitan, tertiary-care, teaching hospital. Data were collected from September 2017 through May 2018 by two attending hospitalists from the ethics committee who were embedded on rounds. A total of 270 patients were evaluated and 113 ethical issues were identified in 77 of those patients. These issues most frequently involved discussions about goals of care, treatment refusals, decision-making capacity, discharge planning, cardiopulmonary resuscitation status, and pain management. Only five formal consults were brought to the Hospital Ethics Committee for these 270 patients. Our data are the first prospective description of ethical issues arising on academic hospitalist teaching services and are an important step in the development of a targeted ethics curriculum for hospitalists.
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Affiliation(s)
- Matthew W McCarthy
- Division of Hospital Medicine, Department of Medicine, New York–Presbyterian–Weill Cornell Medical Center, New York, New York
- Corresponding Author: Matthew W McCarthy, MD, FACP; E-mail: ; Telephone: 212-746-4071
| | - Diego Real de Asua
- Division of Medical Ethics, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Ezra Gabbay
- Division of Hospital Medicine, Department of Medicine, New York–Presbyterian–Weill Cornell Medical Center, New York, New York
| | - Paul J Christos
- Department of Healthcare Policy & Research, NewYork–Presbyterian Hospital–Weill Cornell Medicine, New York, New York
| | - Joseph J Fins
- Division of Medical Ethics, Department of Medicine, Weill Cornell Medicine, New York, New York
- Department of Healthcare Policy & Research, NewYork–Presbyterian Hospital–Weill Cornell Medicine, New York, New York
- CASBI, Consortium for the Advanced Study of Brain Injury, Weill Cornell and Rockefeller University, New York, New York
- Solomon Center for Health Law & Policy, Yale Law School, New Haven, Connecticut
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McCarthy MW, de Asua DR, Gabbay E, Fins JJ. Off the Charts: Medical documentation and selective redaction in the age of transparency. Perspect Biol Med 2018; 61:118-129. [PMID: 29805152 DOI: 10.1353/pbm.2018.0031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
A growing demand for transparency in medicine has the potential to strain the doctor-patient relationship. While information can empower patients, unrestricted patient access to the electronic medical record may have unintended consequences. Medical documentation is often written in language that is inaccessible to people without medical training, and without guidance, patients have no way to interpret the constellation of acronyms, diagnoses, treatments, impressions, and arguments that appear throughout their own chart. Additionally, full transparency may not allow physicians the intellectual or clinical freedom they need to authentically express questions, problematic impressions, and concerns about the patient's clinical and psychosocial issues. This article examines the ethical challenges of transparency in the digital era and suggests that selective redaction may serve as a means to maintain transparency, affirm physician's discretion, and uphold the core values of the doctor-patient relationship amidst disruptive technological change.
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McCarthy MW, Real de Asua D, Fins JJ. The Rise of Hospitalists: An Opportunity for Clinical Ethics. The Journal of Clinical Ethics 2017. [DOI: 10.1086/jce2017284325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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McCarthy MW, Real de Asua D, Fins JJ. The Rise of Hospitalists: An Opportunity for Clinical Ethics. J Clin Ethics 2017; 28:325-332. [PMID: 29257769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Translating ethical theories into clinical practice presents a perennial challenge to educators. While many suggestions have been put forth to bridge the theory-practice gap, none have sufficiently remedied the problem. We believe the ascendance of hospital medicine, as a dominant new force in medical education and patient care, presents a unique opportunity that could redefine the way clinical ethics is taught. The field of hospital medicine in the United States is comprised of more than 50,000 hospitalists-specialists in inpatient medicine-representing the fastest growing subspecialty in the history of medicine, and its members have emerged as a dominant new force around which medical education and patient care pivot. This evolution in medical education presents a unique opportunity for the clinical ethics community. Through their proximity to patients and trainees, hospitalists have the potential to teach medical ethics in real time on the wards, but most hospitalists have not received formal training in clinical ethics. We believe it is time to strengthen the ties between hospital medicine and medical ethics, and in this article we outline how clinical ethicists might collaborate with hospitalists to identify routine issues that do not rise to the level of an "ethics consult," but nonetheless require an intellectual grounding in normative reasoning. We use a clinical vignette to explore how this approach might enhance and broaden the scope of medical education that occurs in the inpatient setting: A patient with an intra-abdominal abscess is admitted to the academic hospitalist teaching service for drainage of the fluid, hemodynamic support, and antimicrobial therapy. During the initial encounter with the hospitalist and his team of medical students and residents, the patient reports night sweats and asks if this symptom could be due to the abscess. How should the hospitalist approach this question?
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Affiliation(s)
| | - Diego Real de Asua
- Weill Cornell Medical College, 435 East 70th Street, Suite 43, New York, New York 10021 USA.
| | - Joseph J Fins
- Weill Cornell Medical College, 435 East 70th Street, Suite 4-j, New York, New York 10021 USA.
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Herreros B, Moreno-Milán B, Pacho-Jiménez E, Real de Asua D, Roa-Castellanos RA, Valentia E. [Terminology in clinical bioethics]. Rev Med Inst Mex Seguro Soc 2015; 53:750-761. [PMID: 26506495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
In this article some of the most relevant terms in clinical bioethics are defined. The terms were chosen based on three criteria: impact on the most important problems in clinical bioethics, difficulty in understanding, and need to clarify their meaning. For a better understanding, the terms were grouped into 5 areas: general concepts (conflict of values, deliberation, conflict of interest, conscientious objection); justice (justice, distributive justice, models of justice, triage); clinical matters (information, competency, capability, informed consent, mature minor, coercion, secrecy, privacy, confidentiality, professional secrecy); end of life (prior instructions, limitation of therapeutic efforts, professional obstinacy, futility, palliative care, palliative sedation, principle of double effect, euthanasia, assisted suicide, persistent vegetative state, minimally conscious state, locked-in syndrome, brain death), and beginning of life (assisted reproduction, genetic counseling, preimplantation genetic diagnosis).
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Affiliation(s)
- Benjamín Herreros
- Instituto de Ética Clínica Francisco Vallés, Universidad Europea, Madrid, España.
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Real de Asua D, Quero M, Moldenhauer F, Suarez C. Clinical profile and main comorbidities of Spanish adults with Down syndrome. Eur J Intern Med 2015; 26:385-91. [PMID: 26025226 DOI: 10.1016/j.ejim.2015.05.003] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 03/29/2015] [Accepted: 05/03/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND The life expectancy of adults with Down syndrome (DS) has significantly increased in the last decades. We aim to describe the main demographic and clinical characteristics of a cohort of adults with DS, and analyse their differences according to age and gender groups. METHODS Cross-sectional study of 144 adults with DS from the outpatient clinic of a tertiary care hospital in Madrid, Spain, recruited between February 2012 and March 2013. Demographic data (age, gender, living situation, caregivers, and working situation), clinical conditions, prior medications, and laboratory data were measured and compared between groups. RESULTS Adults with DS were 35±12 years old (range 17-65), and 51% were males. Most subjects lived with their families (112, 78%), and parents were the main caregivers in 73% of cases. However, older adults with DS lived more frequently in residential facilities. Each subject presented an average of 5±2 clinical problems. Eye (117 adults, 81%), skin (86, 60%), thyroid (81, 56%), gastrointestinal (73, 51%), and psychopathological disorders (58, 40%) were amongst the most frequent clinical conditions of adults with DS. Cataracts (14, 61%), keratoconus (4, 17%), dementia (11, 48%), and seizures (6, 26%) were more frequent amongst individuals with DS over 50 years (p<0.001 for the comparisons). No relevant differences were found between genders. The medications most frequently prescribed were levothyroxine (70 subjects, 48.6%), vitamin D (50, 34.7%), antidepressants (32, 22%), and antipsychotics (31, 21.5%). CONCLUSIONS Adults with DS present a wide spectrum of potentially treatable medical conditions, making specially-trained multidisciplinary teams a dire need for this population.
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Affiliation(s)
- Diego Real de Asua
- Adult Down Syndrome Outpatient Clinic, Department of Internal Medicine, Fundación de Investigación Biomédica, Hospital Universitario de La Princesa, C/Diego de León 62, 28006 Madrid, Spain.
| | - Miriam Quero
- Adult Down Syndrome Outpatient Clinic, Department of Internal Medicine, Fundación de Investigación Biomédica, Hospital Universitario de La Princesa, C/Diego de León 62, 28006 Madrid, Spain.
| | - Fernando Moldenhauer
- Adult Down Syndrome Outpatient Clinic, Department of Internal Medicine, Fundación de Investigación Biomédica, Hospital Universitario de La Princesa, C/Diego de León 62, 28006 Madrid, Spain.
| | - Carmen Suarez
- Adult Down Syndrome Outpatient Clinic, Department of Internal Medicine, Fundación de Investigación Biomédica, Hospital Universitario de La Princesa, C/Diego de León 62, 28006 Madrid, Spain.
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Real de Asua D, Parra P, Costa R, Moldenhauer F, Suarez C. A cross-sectional study of the phenotypes of obesity and insulin resistance in adults with down syndrome. Diabetes Metab J 2014; 38:464-71. [PMID: 25541610 PMCID: PMC4273033 DOI: 10.4093/dmj.2014.38.6.464] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 03/17/2014] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Despite the confluence of multiple cardiovascular risk factors, subclinical atherosclerotic damage and cardiovascular events remain extremely rare in adults with Down syndrome (DS). We aim to determine the prevalence of obesity and metabolic disorders in an adult cohort with DS and to compare our findings with adults without DS. METHODS Cross-sectional study of 51 consecutively selected adults with DS living in the community and 51 healthy controls in an outpatient clinic of a tertiary care hospital in Madrid, Spain. Epidemiological data (age and gender), anthropometric data (body mass index and waist-to-height ratio), coexisting clinical conditions, and laboratory data (fasting glucose, insulin, glycated hemoglobin, creatinine, thyroid hormones, vitamins, and lipid profile) were measured and compared between the groups. RESULTS Adults with DS were significantly younger and more often men with a higher prevalence of overweight and obesity than controls. Their waist-to-height ratio was higher, and they more frequently had abdominal obesity. The results of an analysis adjusted for age and gender revealed no differences in fasting insulin levels, homeostatic model assessment indexes, or lipid profile between adults with DS and controls. CONCLUSION Adults with DS presented a high prevalence of overweight and obesity. However, we found no differences in lipid profile, prevalence of insulin resistance, or metabolic syndrome between adults with DS and controls.
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Affiliation(s)
- Diego Real de Asua
- Adult Down Syndrome Outpatient Clinic, Department of Internal Medicine, Fundación de Investigación Biomédica, Hospital Universitario de La Princesa, Madrid, Spain
| | - Pedro Parra
- Adult Down Syndrome Outpatient Clinic, Department of Internal Medicine, Fundación de Investigación Biomédica, Hospital Universitario de La Princesa, Madrid, Spain
| | - Ramón Costa
- Adult Down Syndrome Outpatient Clinic, Department of Internal Medicine, Fundación de Investigación Biomédica, Hospital Universitario de La Princesa, Madrid, Spain
| | - Fernando Moldenhauer
- Adult Down Syndrome Outpatient Clinic, Department of Internal Medicine, Fundación de Investigación Biomédica, Hospital Universitario de La Princesa, Madrid, Spain
| | - Carmen Suarez
- Adult Down Syndrome Outpatient Clinic, Department of Internal Medicine, Fundación de Investigación Biomédica, Hospital Universitario de La Princesa, Madrid, Spain
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Real de Asua D, Parra P, Costa R, Moldenhauer F, Suarez C. Evaluation of the impact of abdominal obesity on glucose and lipid metabolism disorders in adults with Down syndrome. Res Dev Disabil 2014; 35:2942-2949. [PMID: 25108610 DOI: 10.1016/j.ridd.2014.07.038] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 07/15/2014] [Accepted: 07/15/2014] [Indexed: 06/03/2023]
Abstract
We aimed to describe anthropometric differences in weight-related disorders between adults with Down syndrome (DS) and healthy controls, as well as their disparate impact on glucose and lipid metabolism disorders. We underwent a cross-sectional study of 49 consecutively selected, community-residing adults with DS and 49 healthy controls in an outpatient clinic of a tertiary care hospital in Madrid, Spain. Siblings of adults with DS were studied as controls in 42 cases. Epidemiological data (age and gender), anthropometric data (body mass index, waist circumference, and waist-to-height ratio [WHR]), coexisting clinical conditions, and laboratory data (fasting glucose, insulin, glycated hemoglobin, creatinine, thyroid hormones, and lipid profile) were measured and compared between the groups. Adults with DS were significantly younger and more often male, with a higher prevalence of overweight and obesity than controls. Adults with DS also had a higher WHR, and more frequently presented abdominal obesity. Moreover, insulin resistance measured using the homeostatic model assessment was more prevalent among adults with DS and abdominal obesity. However, lipid profiles were similar between groups. The kappa correlation index for the diagnosis of abdominal obesity between waist circumference and WHR was 0.24 (95%CI: 0.13-0.34). We concluded that the prevalence of overweight, obesity, and abdominal obesity was higher in adults with DS than in controls. Adults with DS and abdominal obesity showed higher indexes of insulin resistance than their non-obese peers. WHR was a useful tool for the evaluation of abdominal obesity in this population.
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Affiliation(s)
- Diego Real de Asua
- Adult Down Syndrome Outpatient Clinic, Department of Internal Medicine, Fundación de Investigación Biomédica, Hospital Universitario de La Princesa, C/Diego de León 62, 28006 Madrid, Spain.
| | - Pedro Parra
- Adult Down Syndrome Outpatient Clinic, Department of Internal Medicine, Fundación de Investigación Biomédica, Hospital Universitario de La Princesa, C/Diego de León 62, 28006 Madrid, Spain.
| | - Ramón Costa
- Adult Down Syndrome Outpatient Clinic, Department of Internal Medicine, Fundación de Investigación Biomédica, Hospital Universitario de La Princesa, C/Diego de León 62, 28006 Madrid, Spain.
| | - Fernando Moldenhauer
- Adult Down Syndrome Outpatient Clinic, Department of Internal Medicine, Fundación de Investigación Biomédica, Hospital Universitario de La Princesa, C/Diego de León 62, 28006 Madrid, Spain.
| | - Carmen Suarez
- Adult Down Syndrome Outpatient Clinic, Department of Internal Medicine, Fundación de Investigación Biomédica, Hospital Universitario de La Princesa, C/Diego de León 62, 28006 Madrid, Spain.
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