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Stafford F, Krishnan N, Richardson E, Butters A, Hespe S, Burns C, Gray B, Medi C, Nowak N, Isbister JC, Raju H, Richmond D, Ryan MP, Singer ES, Sy RW, Yeates L, Bagnall RD, Semsarian C, Ingles J. The role of genetic testing in diagnosis and care of inherited cardiac conditions in a specialised multidisciplinary clinic. Genome Med 2022; 14:145. [PMID: 36578016 PMCID: PMC9795753 DOI: 10.1186/s13073-022-01149-0] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 12/12/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The diagnostic yield of genetic testing for inherited cardiac diseases is up to 40% and is primarily indicated for screening of at-risk relatives. Here, we evaluate the role of genomics in diagnosis and management among consecutive individuals attending a specialised clinic and identify those with the highest likelihood of having a monogenic disease. METHODS A retrospective audit of 1697 consecutive, unrelated probands referred to a specialised, multidisciplinary clinic between 2002 and 2020 was performed. A concordant clinical and genetic diagnosis was considered solved. Cases were classified as likely monogenic based on a score comprising a positive family history, young age at onset, and severe phenotype, whereas low-scoring cases were considered to have a likely complex aetiology. The impact of a genetic diagnosis was evaluated. RESULTS A total of 888 probands fulfilled the inclusion criteria, and genetic testing identified likely pathogenic or pathogenic (LP/P) variants in 330 individuals (37%) and suspicious variants of uncertain significance (VUS) in 73 (8%). Research-focused efforts identified 46 (5%) variants, missed by conventional genetic testing. Where a variant was identified, this changed or clarified the final diagnosis in a clinically useful way for 51 (13%). The yield of suspicious VUS across ancestry groups ranged from 15 to 20%, compared to only 10% among Europeans. Even when the clinical diagnosis was uncertain, those with the most monogenic disease features had the greatest diagnostic yield from genetic testing. CONCLUSIONS Research-focused efforts can increase the diagnostic yield by up to 5%. Where a variant is identified, this will have clinical utility beyond family screening in 13%. We demonstrate the value of genomics in reaching an overall diagnosis and highlight inequities based on ancestry. Acknowledging our incomplete understanding of disease phenotypes, we propose a framework for prioritising likely monogenic cases to solve their underlying cause of disease.
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Affiliation(s)
- Fergus Stafford
- grid.1013.30000 0004 1936 834XCardio Genomics Program at Centenary Institute, The University of Sydney, Sydney, Australia ,grid.415306.50000 0000 9983 6924Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, 384 Victoria Street, Darlinghurst, NSW 2010 Australia ,grid.1058.c0000 0000 9442 535XCentre for Population Genomics, Murdoch Children’s Research Institute, Melbourne, Australia
| | - Neesha Krishnan
- grid.1013.30000 0004 1936 834XCardio Genomics Program at Centenary Institute, The University of Sydney, Sydney, Australia ,grid.415306.50000 0000 9983 6924Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, 384 Victoria Street, Darlinghurst, NSW 2010 Australia ,grid.1058.c0000 0000 9442 535XCentre for Population Genomics, Murdoch Children’s Research Institute, Melbourne, Australia
| | - Ebony Richardson
- grid.1013.30000 0004 1936 834XCardio Genomics Program at Centenary Institute, The University of Sydney, Sydney, Australia ,grid.415306.50000 0000 9983 6924Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, 384 Victoria Street, Darlinghurst, NSW 2010 Australia ,grid.1058.c0000 0000 9442 535XCentre for Population Genomics, Murdoch Children’s Research Institute, Melbourne, Australia
| | - Alexandra Butters
- grid.1013.30000 0004 1936 834XCardio Genomics Program at Centenary Institute, The University of Sydney, Sydney, Australia ,grid.415306.50000 0000 9983 6924Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, 384 Victoria Street, Darlinghurst, NSW 2010 Australia ,grid.1058.c0000 0000 9442 535XCentre for Population Genomics, Murdoch Children’s Research Institute, Melbourne, Australia ,grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Sophie Hespe
- grid.415306.50000 0000 9983 6924Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, 384 Victoria Street, Darlinghurst, NSW 2010 Australia ,grid.1058.c0000 0000 9442 535XCentre for Population Genomics, Murdoch Children’s Research Institute, Melbourne, Australia ,grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Charlotte Burns
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia ,grid.1013.30000 0004 1936 834XAgnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | - Belinda Gray
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia ,grid.413249.90000 0004 0385 0051Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Caroline Medi
- grid.413249.90000 0004 0385 0051Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Natalie Nowak
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia ,grid.1013.30000 0004 1936 834XAgnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | - Julia C. Isbister
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia ,grid.1013.30000 0004 1936 834XAgnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia ,grid.413249.90000 0004 0385 0051Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Hariharan Raju
- grid.413249.90000 0004 0385 0051Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia ,grid.1004.50000 0001 2158 5405Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - David Richmond
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia ,grid.413249.90000 0004 0385 0051Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Mark P. Ryan
- grid.413249.90000 0004 0385 0051Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Emma S. Singer
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia ,grid.1013.30000 0004 1936 834XAgnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | - Raymond W. Sy
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia ,grid.1013.30000 0004 1936 834XAgnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | - Laura Yeates
- grid.1013.30000 0004 1936 834XCardio Genomics Program at Centenary Institute, The University of Sydney, Sydney, Australia ,grid.415306.50000 0000 9983 6924Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, 384 Victoria Street, Darlinghurst, NSW 2010 Australia ,grid.1058.c0000 0000 9442 535XCentre for Population Genomics, Murdoch Children’s Research Institute, Melbourne, Australia ,grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia ,grid.1013.30000 0004 1936 834XAgnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia ,grid.413249.90000 0004 0385 0051Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Richard D. Bagnall
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia ,grid.1013.30000 0004 1936 834XAgnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | - Christopher Semsarian
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Sydney, Australia ,grid.1013.30000 0004 1936 834XAgnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia ,grid.413249.90000 0004 0385 0051Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Jodie Ingles
- grid.1013.30000 0004 1936 834XCardio Genomics Program at Centenary Institute, The University of Sydney, Sydney, Australia ,grid.415306.50000 0000 9983 6924Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, 384 Victoria Street, Darlinghurst, NSW 2010 Australia ,grid.1058.c0000 0000 9442 535XCentre for Population Genomics, Murdoch Children’s Research Institute, Melbourne, Australia ,grid.1013.30000 0004 1936 834XAgnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia ,grid.413249.90000 0004 0385 0051Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
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Butters A, Do J, Stafford F, Krishnan N, Brown J, Hespe S, Richardson E, Bagnall R, Bhaskaran A, Burns C, Driscoll T, Fatkin D, Gray B, Iglesias C, Isbister J, Jabbour A, Johnson R, Kumar S, Leslie F, MacArthur D, Nowak N, Pouliopoulos J, Puranik R, Semsarian C, Sweeting J, Sy R, Ugander M, Yeates L, Ingles J. NSW HEARTS: The NSW Inherited Cardiomyopathy Cohort Study protocol. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Richardson E, Krishnan N, Stafford F, Yeates L, Nowak N, McGaughran J, Wildschutt J, Smith J, Turner C, Kevin L, Davis A, Macciocca I, Connell V, Ma A, Semsarian C, Bagnall R, Siggs O, Skinner J, MacArthur D, Ingles J. The Elusive Hearts Study: Seeking Genetic Diagnoses in Gene-elusive Cases of Rare Monogenic Cardiovascular Diseases. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Stafford F, Dore GJ, Clackett S, Martinello M, Matthews GV, Grebely J, Balcomb AC, Hajarizadeh B. Prescribing of direct-acting antiviral therapy by general practitioners for people with hepatitis C in an unrestricted treatment program. Med J Aust 2021; 215:332-333. [PMID: 34346057 DOI: 10.5694/mja2.51204] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 11/13/2020] [Indexed: 11/17/2022]
Affiliation(s)
| | | | - Shawn Clackett
- The Kirby Institute, UNSW Sydney, Sydney, NSW.,Centre for Population Health, NSW Health, Sydney, NSW
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Butters A, Semsarian CR, Bagnall RD, Yeates L, Stafford F, Burns C, Semsarian C, Ingles J. Clinical Profile and Health Disparities in a Multiethnic Cohort of Patients With Hypertrophic Cardiomyopathy. Circ Heart Fail 2021; 14:e007537. [PMID: 33724884 DOI: 10.1161/circheartfailure.120.007537] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Clinical studies of hypertrophic cardiomyopathy are over-represented by individuals of European ethnicity, with less known about other ethnic groups. We investigated differences between patients in a multiethnic Australian hypertrophic cardiomyopathy population. METHODS We performed a retrospective cohort study of 836 unrelated hypertrophic cardiomyopathy probands attending a specialized clinic between 2002 and 2020. Major ethnic groups were European (n=611), East Asian (n=75), South Asian (n=58), and Middle Eastern and North African (n=68). The minor ethnicity groups were Oceanian (n=9), People of the Americas (n=7), and African (n=8). One-way ANOVA with Dunnett post hoc test and Bonferroni adjustment were performed. RESULTS Mean age of the major ethnic groups was 54.9±16.9 years, and 527 (65%) were male. Using the European group as the control, East Asian patients had a lower body mass index (29 versus 25 kg/m2, P<0.0001). South Asians had a lower prevalence of atrial fibrillation (10% versus 31%, P=0.024). East Asians were more likely to have apical hypertrophy (23% versus 6%, P<0.0001) and Middle Eastern and North African patients more likely to present with left ventricular outflow tract obstruction (46% versus 34%, P=0.0003). East Asians were less likely to undergo genetic testing (55% versus 85%, P<0.0001) or have an implantable cardioverter-defibrillator implanted (19% versus 36%, P=0.037). East Asians were more likely to have a causative variant in a gene other than MYBPC3 or MYH7, whereas Middle Eastern and North African and South Asians had the highest rates of variants of uncertain significance (27% and 21%, P<0.0001). CONCLUSIONS There are few clinical differences based on ethnicity, but importantly, we identify health disparities relating to access to genetic testing and implantable cardioverter-defibrillator use. Unless addressed, these gaps will likely widen as we move towards precision-medicine-based care of individuals with hypertrophic cardiomyopathy.
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Affiliation(s)
- Alexandra Butters
- Cardio Genomics Program at Centenary Institute (A.B., L.Y., F.S., J.I.), The University of Sydney, Australia.,Faculty of Medicine and Health (A.B., R.D.B., L.Y., C.B., C.S., J.I.), The University of Sydney, Australia
| | - Caitlin R Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute (C.R.S., R.D.B., L.Y., C.B., C.S.), The University of Sydney, Australia
| | - Richard D Bagnall
- Faculty of Medicine and Health (A.B., R.D.B., L.Y., C.B., C.S., J.I.), The University of Sydney, Australia.,Agnes Ginges Centre for Molecular Cardiology at Centenary Institute (C.R.S., R.D.B., L.Y., C.B., C.S.), The University of Sydney, Australia
| | - Laura Yeates
- Cardio Genomics Program at Centenary Institute (A.B., L.Y., F.S., J.I.), The University of Sydney, Australia.,Faculty of Medicine and Health (A.B., R.D.B., L.Y., C.B., C.S., J.I.), The University of Sydney, Australia.,Agnes Ginges Centre for Molecular Cardiology at Centenary Institute (C.R.S., R.D.B., L.Y., C.B., C.S.), The University of Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (L.Y., C.B., C.S., J.I.)
| | - Fergus Stafford
- Cardio Genomics Program at Centenary Institute (A.B., L.Y., F.S., J.I.), The University of Sydney, Australia
| | - Charlotte Burns
- Faculty of Medicine and Health (A.B., R.D.B., L.Y., C.B., C.S., J.I.), The University of Sydney, Australia.,Agnes Ginges Centre for Molecular Cardiology at Centenary Institute (C.R.S., R.D.B., L.Y., C.B., C.S.), The University of Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (L.Y., C.B., C.S., J.I.)
| | - Christopher Semsarian
- Faculty of Medicine and Health (A.B., R.D.B., L.Y., C.B., C.S., J.I.), The University of Sydney, Australia.,Agnes Ginges Centre for Molecular Cardiology at Centenary Institute (C.R.S., R.D.B., L.Y., C.B., C.S.), The University of Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (L.Y., C.B., C.S., J.I.)
| | - Jodie Ingles
- Cardio Genomics Program at Centenary Institute (A.B., L.Y., F.S., J.I.), The University of Sydney, Australia.,Faculty of Medicine and Health (A.B., R.D.B., L.Y., C.B., C.S., J.I.), The University of Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (L.Y., C.B., C.S., J.I.)
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6
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Abstract
PURPOSE OF REVIEW Our knowledge of the genetic basis and molecular pathogenesis of hypertrophic cardiomyopathy (HCM) continues to evolve. We describe the genetic basis of HCM, recent advances in genetic testing and the role of genetics in guiding risk stratification and management, both now and in the future. RECENT FINDINGS While initially thought to be an exclusively Mendelian disease, we now know there are important HCM sub-groups. A proportion will have sarcomere variants as the cause of their disease, while others will have genetic variants in genes that can give rise to conditions that can mimic HCM. The role of genetics is primarily for cascade genetic testing, though there is emerging evidence of a role for prognosis and patient management. Genetic testing is a useful addition to management. Genotype may play a greater role in risk stratification, management, treatment and prognosis in future, offering improved outcomes for patients and their families with HCM.
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Affiliation(s)
- Fergus Stafford
- Cardio Genomics Program at Centenary Institute, The University of Sydney, Locked Bag 6, Newtown, NSW, 2042, Australia
| | - Kate Thomson
- Oxford Medical Genetics Laboratories, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, Division of Cardiovascular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Alexandra Butters
- Cardio Genomics Program at Centenary Institute, The University of Sydney, Locked Bag 6, Newtown, NSW, 2042, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jodie Ingles
- Cardio Genomics Program at Centenary Institute, The University of Sydney, Locked Bag 6, Newtown, NSW, 2042, Australia.
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia.
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Butters A, Semsarian C, Bagnall R, Yeates L, Stafford F, Burns C, Semsarian C, Ingles J. 015 Clinical Profile and Management of Hypertrophic Cardiomyopathy in a Multi-Ethnic Australian Cohort. Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Stafford F, Butters A, Burns C, Medi C, Semsarian C, Ingles J. Familial Factors Predispose to Increased Risk of Ventricular Arrhythmias in Patients with Hypertrophic Cardiomyopathy. Heart Lung Circ 2019. [DOI: 10.1016/j.hlc.2019.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fitzgerald G, Lundon D, Gallagher P, O'Rourke K, Sheehy C, Sullivan C, Silke C, Stafford F, Haroon M, Mullan R, FitzGerald O, O Shea F. FRI0417 Prevalence of Osteoporosis in An Ankylosing Spondylitis Cohort. Ann Rheum Dis 2016. [DOI: 10.1136/annrheumdis-2016-eular.6012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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O'Shea F, Gallagher P, Sullivan C, Sheehy C, Silke C, O'Rourke K, Stafford F, Haroon M, Mullan R, FitzGerald O. FRI0211 High Body Mass Index in Ankylosing Spondylitis is Associated with Greater Disease Activity and More Functional Impairmairment:. Ann Rheum Dis 2015. [DOI: 10.1136/annrheumdis-2015-eular.5580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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11
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Kumar R, Drinnan M, Robinson M, Meikle D, Stafford F, Welch A, Zammit-Maempel I, Paleri V. Thyroid gland invasion in total laryngectomy and total laryngopharyngectomy: a systematic review and meta-analysis of the English literature. Clin Otolaryngol 2013; 38:372-8. [DOI: 10.1111/coa.12165] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2013] [Indexed: 11/28/2022]
Affiliation(s)
- R. Kumar
- Department of Otolaryngology-Head and Neck Surgery; Newcastle upon Tyne Hospitals NHS Foundation Trust; Newcastle upon Tyne UK
| | - M. Drinnan
- Department of Medical Physics; Newcastle upon Tyne Hospitals NHS Foundation Trust; Newcastle upon Tyne UK
| | - M. Robinson
- Department of Oral Pathology; School of Dental Sciences; Newcastle University; Newcastle upon Tyne UK
| | - D. Meikle
- Department of Otolaryngology-Head and Neck Surgery; Newcastle upon Tyne Hospitals NHS Foundation Trust; Newcastle upon Tyne UK
| | - F. Stafford
- Department of Otolaryngology-Head and Neck Surgery; Mid Essex Hospital Services NHS Trust; Newcastle upon Tyne UK
| | - A. Welch
- Department of Otolaryngology-Head and Neck Surgery; Newcastle upon Tyne Hospitals NHS Foundation Trust; Newcastle upon Tyne UK
| | - I. Zammit-Maempel
- Department of Radiology; Newcastle upon Tyne Hospitals NHS Foundation Trust; Newcastle upon Tyne UK
| | - V. Paleri
- Department of Otolaryngology-Head and Neck Surgery; Newcastle upon Tyne Hospitals NHS Foundation Trust; Newcastle upon Tyne UK
- Northern Institute for Cancer Research; Newcastle University; Newcastle upon Tyne UK
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Thompson AC, Zammit-Maempel I, Stafford F, Narayanan M, Kanagasundaram NS. Necrotising otitis externa: an unusual cause of cranial nerve palsy in a diabetic haemodialysis patient. J R Coll Physicians Edinb 2010; 40:26-8. [PMID: 21125035 DOI: 10.4997/jrcpe.2010.106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We present an unusual case of necrotising otitis externa (NOE) causing a lower motor neurone facial nerve palsy in a patient with diabetes mellitus and receiving maintenance haemodialysis for end-stage renal disease (ESRD). Pseudomonas aeruginosa is the most common pathogen isolated in NOE, although our case involved the non-typical pathogens Aspergillus flavus and Proteus mirabilis. We discuss the need for diagnostic rigour and the importance of considering atypical infective pathology in patients with ESRD or diabetes mellitus. We review NOE with reference to causative agents, imaging strategies, prognostic indicators and treatment.
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Affiliation(s)
- A C Thompson
- Department of Renal Medicine, Freeman Hospital, High Heaton, Newcastle upon Tyne NE77DN, UK.
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Affiliation(s)
- P Carding
- Northern Head and Neck Cancer Centre, Freeman Hospital, NE7 7DN, Newcastle upon Tyne, UK.
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Abstract
BACKGROUND Failure of response of giant cell arteritis (GCA) to corticosteroid therapy has invariably been attributed to the delay in diagnosing the disease or the use of inadequate corticosteroid dosage. Following our observation of progressive deterioration following the introduction of prednisolone use in a patient, we examined the possibility that worsening of the condition might be due to corticosteroid therapy rather than coincidence. OBJECTIVE To determine whether corticosteroid therapy may exacerbate GCA. DESLGN: Case report and an analysis of similar cases reported in the medical literature. PATIENT A 64-year-old man had a 3-month history of headache, night sweats, malaise and general weakness, and anorexia and weight loss and a more recent history of jaw claudication, dysphagia, and hoarseness. Clinical findings included prominent temporal arteries with absent pulsation, abnormal saccades to the right, and eyelid retraction. Laboratory findings included an elevated erythrocyte sedimentation rate and platelet count. Results of a biopsy of the temporal artery confirmed GCA. Magnetic resonance imaging scans showed ischemic cerebellar lesions and a mature infarct in the left anterior occipital, posteroparietal region. Following corticosteroid therapy commencement, the patient's condition deteriorated steadily for 5 days with clinical signs suggestive of an evolving vertebrobasilar stroke. Following treatment with high-dose intravenous dexamethasone sodium phosphate and heparin sodium, his symptoms improved. DATA SOURCES The review included analysis of autopsy-based reports in which clinical details are provided and clinical reports in which major visual or cerebral complications are described. Significant complications occurred in many cases shortly following the introduction of corticosteroid therapy. In many of these cases, the symptoms indicated that GCA had been present for a significant period prior to corticosteroid therapy. CONCLUSIONS Progressively evolving occlusive strokes may occur following corticosteroid therapy in patients with GCA. In cerebrovascular complications, vascular occlusion occurs at sites of active vasculitis, usually within the vertebrobasilar system. It is not certain that the worsening of the condition following corticosteroid therapy is always coincidental, and an alternative possibility, namely a functional relationship between the initiation of corticosteroid therapy and clinical deterioration, should be borne in mind.
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Affiliation(s)
- H Staunton
- Department of Neurosciences, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin.
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Abstract
Tissue adhesives have been available and in use for more than 40 years. They have, however, never been popular for ossiculoplasty because of the reported excessive inflammatory reaction and ototoxicity. The authors present a case of ossicular disruption successfully repaired with tissue adhesive and review the literature.
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Affiliation(s)
- R M Adamson
- Department of Otolaryngology, Sunderland Royal Hospital, UK
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16
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Bourke S, Nunes D, Stafford F, Hurley G, Graham I. Percussion of the chest re-visited: a comparison of the diagnostic value of ausculatory and conventional chest percussion. Ir J Med Sci 1989; 158:82-4. [PMID: 2753659 DOI: 10.1007/bf02942111] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Percussion of the chest is thought to be insensitive in detecting small or deeply situated chest lesions. A newer technique, ausculatory percussion, has been reported as having a far higher sensitivity. In a controlled blind study the diagnostic value of conventional chest percussion compared with ausculatory percussion was defined using the chest x-ray as a gold standard. The prevalence of disease in 100 lung fields was 26%. The majority of lesions were not detected by either technique resulting in very low sensitivities of 15.4% for conventional percussion and 19.2% for ausculatory percussion. A positive result with ausculatory percussion was twice as likely to be false as true (positive predictive value 31.2%). The technique did not add to the diagnostic value of conventional percussion. Both techniques have major limitations. Patients with suspected lung disease still require chest x-ray examination if percussion is normal.
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