1
|
Amin S, Kingswood JC, Bolton PF, Elmslie F, Gale DP, Harland C, Johnson SR, Parker A, Sampson JR, Smeaton M, Wright I, O'Callaghan FJ. The UK guidelines for management and surveillance of Tuberous Sclerosis Complex. QJM 2019; 112:171-182. [PMID: 30247655 DOI: 10.1093/qjmed/hcy215] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 09/15/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The severity of Tuberous Sclerosis Complex (TSC) can vary among affected individuals. Complications of TSC can be life threatening, with significant impact on patients' quality of life. Management may vary dependent on treating physician, local and national policies, and funding. There are no current UK guidelines. We conducted a Delphi consensus process to reach agreed guidance for the management of patients with TSC in the UK. METHODS We performed a literature search and reviewed the 2012/13 international guideline for TSC management. Based on these, a Delphi questionnaire was formed. We invited 86 clinicians and medical researchers to complete an online survey in two rounds. All the people surveyed were based in the UK. Clinicians were identified through the regional TSC clinics, and researchers were identified through publications. In round one, 55 questions were asked. In round two, 18 questions were asked in order to obtain consensus on the outstanding points that had been contentious in round one. The data was analysed by a core committee and subcommittees, which consisted of UK experts in different aspects of TSC. The Tuberous Sclerosis Association was consulted. RESULTS About 51 TSC experts took part in this survey. Two rounds were required to achieve consensus. The responders were neurologists, nephrologists, psychiatrist, psychologists, oncologists, general paediatricians, dermatologist, urologists, radiologists, clinical geneticists, neurosurgeons, respiratory and neurodisability clinicians. CONCLUSIONS These new UK guidelines for the management and surveillance of TSC patients provide consensus guidance for delivery of best clinical care to individuals with TSC in the UK.
Collapse
Affiliation(s)
- S Amin
- University Hospitals Bristol, Upper Maudlin Street, Education Centre Level 6, Bristol, UK
| | - J C Kingswood
- Brighton and Sussex University Hospitals, Eastern Rd, Brighton, East Sussex, UK
| | - P F Bolton
- King's College London, Institute of Psychiatry, London, UK
| | - F Elmslie
- St George's University Hospitals, Cranmer Terrace, London, UK
| | - D P Gale
- UCL Centre for Nephrology, Royal Free Hospital, University College London, London, UK
| | - C Harland
- Epsom & St Helier Hospital, Wrythe Lane, Carshalton, Surrey, UK
| | - S R Johnson
- Division of Respiratory Medicine, Faculty of Medicine & Health Sciences, Nottingham University, Nottingham, UK
| | - A Parker
- Addenbrooke's Hospital, Hills Road, Cambridge, Cambridgeshire, UK
| | - J R Sampson
- Division of Cancer and Genetics, University of Cardiff, Cardiff, UK
| | - M Smeaton
- Tuberous Sclerosis Association, CAN Mezzanine, 32-36 Loman Street, London, UK
| | - I Wright
- University of Bristol, The Priory Road Complex, Priory Road, Bristol, Clifton, UK
| | - F J O'Callaghan
- UCL GOS Institute of Child Health, 41 Clinical Neurosciences Section, 4th Floor Philip Ullman Wing South, London, UK
| |
Collapse
|
2
|
Mallick AA, Sharples PM, Calvert SE, Jones RWA, Leary M, Lux AL, O'Callaghan FJ, Osborne JP, Patel JS, Prendiville AT, Renowden S, Jardine PE. Cerebral venous sinus thrombosis: a case series including thrombolysis. Arch Dis Child 2009; 94:790-4. [PMID: 19556220 DOI: 10.1136/adc.2008.154708] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Cerebral venous sinus thrombosis (CVST) in children is associated with a high incidence of serious morbidity and mortality. The presenting features are variable. It can be diagnostically challenging and the optimal treatment is uncertain. AIM To describe the features of a series of children with CVST treated in a single paediatric neurology centre and to discuss the role of local thrombolysis. METHODS Electronic databases were searched using diagnostic labels and International Classification of Diseases (ICD) codes to identify children aged 1 month to under 17 years with CVST. Their records were reviewed. RESULTS 21 children were identified over a period of 8.25 years with a median age of 7.1 years. The presenting symptoms included headache (15 children), vomiting (14 children) and visual disturbance (eight children). Signs found included papilloedema (16 children), fever (six children) and sixth nerve palsy (six children). The most common underlying condition was middle ear infection (13 children). All cases received unfractionated heparin and four severe cases received local pharmacological thrombolysis. 48% of cases had an adverse outcome (death, chronic intracranial hypertension, residual hemiparesis or sixth nerve palsy). DISCUSSION CVST has non-specific presenting features and a high risk of significant morbidity. CVST is typically found in association with a predisposing condition. Although heparin is the mainstay of treatment, thrombolysis may reverse deterioration as seen in three cases in this series. However, there is insufficient evidence to recommend the routine use of thrombolysis at present.
Collapse
Affiliation(s)
- A A Mallick
- Department of Paediatric Neurology, Bristol Royal Hospital for Children, Bristol, UK
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Gale CR, Robinson SM, Godfrey KM, Law CM, Schlotz W, O'Callaghan FJ. Oily fish intake during pregnancy--association with lower hyperactivity but not with higher full-scale IQ in offspring. J Child Psychol Psychiatry 2008; 49:1061-8. [PMID: 18422546 DOI: 10.1111/j.1469-7610.2008.01908.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Long-chain omega-3 polyunsaturated fatty acids are thought to be important for fetal neurodevelopment. Animal studies suggest that a deficiency of omega-3 fatty acids may lead to behavioural or cognitive deficits. As oily fish is a major dietary source of omega-3 fatty acids, it is possible that low intake of fish during pregnancy may have adverse effects on the developing fetal brain. METHODS We used the Strengths and Difficulties Questionnaire and the Wechsler Abbreviated Scale of Intelligence to assess behavioural problems and intelligence in 217 nine-year-old children. The mothers of these children had participated in a study of nutrition during pregnancy during which fish intake was assessed in early and late gestation. RESULTS Children whose mothers had eaten oily fish in early pregnancy had a reduced risk of hyperactivity compared to those whose mothers did not eat oily fish: OR .34, 95% CI .15 to .78, after adjustment for potential confounding factors. Children whose mothers had eaten fish (whether oily or non-oily) in late pregnancy had a verbal IQ that was 7.55 points higher (95% CI .75 to 14.4) than those whose mothers did not eat fish. There were, however, no significant associations between fish intake in pregnancy and other behavioural problems or full-scale and performance intelligence, after adjustment for potential confounding factors. CONCLUSIONS Although maternal fish intake in pregnancy was associated with hyperactivity scores and verbal IQ in children, in general, how much fish women ate during pregnancy appeared to have little long-term relation with neurodevelopmental outcomes in their child.
Collapse
Affiliation(s)
- Catharine R Gale
- MRC Epidemiology Resource Centre (University of Southampton), Southampton General Hospital, UK.
| | | | | | | | | | | |
Collapse
|
4
|
Joinson C, O'Callaghan FJ, Osborne JP, Martyn C, Harris T, Bolton PF. Learning disability and epilepsy in an epidemiological sample of individuals with tuberous sclerosis complex. Psychol Med 2003; 33:335-344. [PMID: 12622312 DOI: 10.1017/s0033291702007092] [Citation(s) in RCA: 209] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Intellectual impairments are a recognized feature of tuberous sclerosis complex (TSC), but the frequency and degree of intellectual impairments has not been systematically studied in large epidemiological samples using standardized measures. As such, the form of the IQ distribution (uni- or bi-modal) has not been established and the relationship between IQ and other features (e.g. epilepsy history) is poorly delineated. To address these shortcomings, we assessed the intellectual abilities of a large epidemiological sample of individuals with TSC, drawn from the 'Wessex' area of SW England and compared them with the abilities of their unaffected siblings. METHOD Standardized tests were used to estimate the abilities of 108 (56 males, 52 females, median age = 25, range = 4-75) individuals with TSC and 29 unaffected siblings (14 males, 15 females, median age = 18, range = 6-55). Seizure history was obtained from informants and medical records. RESULTS Estimated IQ was bi-modally distributed: 55.5% had an IQ in the normal range; 14% had mild to severe impairments: and 30.5% had profound disability (IQ < 21). Forty-four per cent of the individuals with TSC had an IQ < 70. In the subset of normally intelligent individuals with TSC, IQ was normally distributed with a mean of 93.6. This mean was significantly lower than the mean IQ of unaffected siblings (IQ = 105.6). All individuals with learning disability had a history of seizures that usually commenced before 12 months of age and that often presented as infantile spasms. Multivariate analyses indicated that a history of seizures as well as a history of infantile spasms was predictive of the degree of intellectual impairment. CONCLUSIONS Intellectual abilities were bi-modally distributed in a representative sample of individuals with TSC. The likelihood of impairment was associated with a history of seizures, particularly infantile spasms. The genetic and brain basis of these findings requires further investigation.
Collapse
Affiliation(s)
- C Joinson
- Developmental Psychiatry Section, University of Cambridge
| | | | | | | | | | | |
Collapse
|
5
|
|
6
|
|
7
|
Abstract
BACKGROUND/AIMS Tuberous sclerosis complex (TSC) has retinal and non-retinal ophthalmic manifestations. This study was designed to determine the prevalence of the ophthalmic manifestations and of refractive errors in a population of patients with TSC. METHODS 179 patients identified were in a prevalence study of TSC in the south of England and 107 of these agreed to full ophthalmic examination which was successful in 100. Ophthalmic examination included examination of the eyelids, cover test, examination of the irides, dilation funduscopy using both direct and indirect ophthalmoscopy, and refraction using retinoscopy. Myopia was defined as a spherical equivalent <-0.5D and hyperopia as a spherical equivalent >+0.5D. RESULTS Retinal hamartomas were seen in 44 of the 100 patients. The commonest morphological type of hamartoma seen was the flat, translucent lesion in 31 of the 44 patients (70%). The multinodular "mulberry" lesion was seen in 24 of the 44 patients (55%) and the transitional type lesion was seen in four of the 44 patients (9%). Punched out areas of retinal depigmentation were seen in 39 of the 100 patients but only six of 100 controls. 27% of eyes were myopic, 22% were hyperopic, and 27% had astigmatism >0.75D. Of the non-retinal findings, 39 patients had angiofibromas of the eyelids, five had non-paralytic strabismus, and three had colobomas. CONCLUSION Apart from the higher prevalence of flat retinal hamartomas, the findings of this study compare closely with previous large clinic based series of TSC patients. Refractive findings were similar to previous studies of a similarly aged non-TSC population. This is the first series to document the statistically significant association of punched out chorioretinal depigmentation with TSC and the authors believe that it should be looked for as an aid to diagnosis.
Collapse
Affiliation(s)
- S A Rowley
- Department of Ophthalmology, Royal United Hospital, Bath, UK.
| | | | | |
Collapse
|
8
|
Lux AL, Edwards SW, Osborne JP, Hancock E, Johnson AL, Kennedy CR, O'Callaghan FJ, Newton RW, Verity CM. Revised guideline for prescribing vigabatrin in children. Guideline's claim about infantile spasms is not based on appropriate evidence. BMJ 2001; 322:236-7. [PMID: 11159628 PMCID: PMC1119485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
|
9
|
|
10
|
Abstract
As a result of extreme clinical variability in tuberous sclerosis, with one well-documented example of non-penetrance, phenotypically normal siblings or children of patients with tuberous sclerosis are thought to be at increased risk of having children with the disease. We report that the case of apparent non-penetrance that was previously described is the result of two independent tuberous-sclerosis mutations in the same family.
Collapse
|
11
|
|
12
|
Abstract
The aim of this study was to analyze time trends in epilepsy mortality in England and Wales and the United States between 1950 and 1994. The authors calculated age- and sex-specific epilepsy mortality rates for the nine quinquennia from 1950-1954 to 1990-1994. Mortality rates were modeled as a function of age, period of death, and cohort of birth by using Poisson regression techniques. From 1950 to 1994, there were more than 110,000 deaths from epilepsy in the two countries. The secular trends in mortality were similar for both sexes and in both countries. Among people younger than age 20 years, epilepsy mortality declined steeply after 1950. For young and middle-aged adults, the rate of decline was lower. In the geriatric population, mortality declined between 1950 and 1974 but then increased. The Poisson model showed pronounced birth cohort effects. In the United States, epilepsy mortality fell with each successive birth cohort after 1905. In England and Wales, there was a similar decline in birth cohort mortality after 1905 for women but not until after 1950 for men. The pronounced birth cohort effect supports explanations that focus on antenatal and developmental factors as the cause for the decline in epilepsy mortality in all but the oldest age groups between 1950 and 1994.
Collapse
Affiliation(s)
- F J O'Callaghan
- Medical Research Council Environmental Epidemiology Unit, University of Southampton, Southampton General Hospital, United Kingdom
| | | | | |
Collapse
|
13
|
|
14
|
Harrison JE, O'Callaghan FJ, Hancock E, Osborne JP, Bolton PF. Cognitive deficits in normally intelligent patients with tuberous sclerosis. Am J Med Genet 1999; 88:642-6. [PMID: 10581483] [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: 02/14/2023]
Abstract
Webb, Thomson, and Osborne [1991: Arch Dis Child 66:1375-1377] reported on the pattern of cerebral lesions found in an epidemiological sample of patients with tuberous sclerosis (TS) and clinically judged to be of normal intellect. Varying numbers of tubers and subependymal nodules were found, but clinically there appeared to be few associated neuropsychological impairments. Our objectives in this study were to conduct a detailed neuropsychological assessment to determine whether these patients were indeed free of cognitive deficits. We report the results of a detailed neuropsychological assessment in this sample and a matched comparison group. Although of average intelligence, most TS individuals had a significant cognitive deficit of one sort or another, and in a number of cases the pattern of cognitive impairments matched that seen in other neurological disorders. Additionally, the overall rate of cognitive deficits was significantly greater than in the controls. We conclude that normally intelligent individuals with TS are prone to specific cognitive difficulties. Further research will be required to clarify the nature of the links between the brain abnormalities and type of neuropsychological dysfunction. Am. J. Med. Genet. (Neuropsychiatr. Genet.) 88:642-646, 1999.
Collapse
Affiliation(s)
- J E Harrison
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom.
| | | | | | | | | |
Collapse
|
15
|
|
16
|
Abstract
The results of a therapeutic trial of the use of melatonin in patients with tuberous sclerosis complex who also have severe sleep problems are reported. We used a randomized double-blind placebo-controlled crossover design. Seven patients with confirmed diagnoses of tuberous sclerosis and significant sleep disorder were recruited. We employed three outcome measures: total sleep time, time to sleep onset, and number of awakenings. Patients treated with melatonin had a small but clinically significant improvement in total sleep time (mean improvement 0.55 hours, P<0.05). They also tended to have an improvement in sleep-onset time but this did not reach statistical significance. Melatonin, in this trial, had no discernible effect on sleep fragmentation. We conclude that melatonin does have a beneficial effect in prolonging the total sleep time of patients with tuberous sclerosis and sleep disorder and that further trials are necessary to investigate the issues of optimal dosage, tolerance, and possible interactions with other medications.
Collapse
Affiliation(s)
- F J O'Callaghan
- Department of Paediatrics, Children's Centre, Royal United Hospital, Bath, UK
| | | | | | | | | |
Collapse
|
17
|
|
18
|
Abstract
This report highlights the association between tuberous sclerosis and Wolff-Parkinson-White syndrome. Ten patients with concurrent diagnoses of Wolff-Parkinson-White syndrome and tuberous sclerosis were identified. Wolff-Parkinson-White syndrome presented early in life, nine cases being diagnosed in the first year. Eight of the 10 cases were male. In eight cases, the syndrome was associated with supraventricular tachycardias, and in nine with cardiac rhabdomyomata. One child died from cardiac failure secondary to obstruction of the left ventricular outflow tract by a rhabdomyoma. Five of nine survivors showed resolution of Wolff-Parkinson-White syndrome on follow up. The accessory pathway was localised in nine patients from surface electrocardiograms: six children had left sided pathways and three had right sided pathways.
Collapse
Affiliation(s)
- F J O'Callaghan
- Bath Unit for Research into Paediatrics, Children's Centre, Royal United Hospital, Combe Park
| | | | | | | | | | | | | | | |
Collapse
|