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Goez H, Nielsen CC, Bryan S, Clark B, Zwaigenbaum L, Yamamoto SS, Osornio-Vargas AR. Autistic Regression and Exposure to Industrial Chemicals: Preliminary Observations. Can J Neurol Sci 2024; 51:289-292. [PMID: 37519226 DOI: 10.1017/cjn.2023.265] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
Exposure to industrial pollutants is a potential risk factor not fully explored in ASD with regression (ASD+R). We studied geographical collocation patterns of industrial air chemical emissions and the location of homes of children with ASD+R at different exposure times, compared with ASD cases without regression (ASD-R). Fifteen of 111 emitted chemicals collocated with ASD+R, and 65 with ASD-R. ASD+R collocated more strongly with different neurotoxicants/immunotoxicants a year before diagnosis, whereas ASD-R were moderately collocated with chemicals across all exposure periods. This preliminary exploratory analysis of differences in exposure patterns raises a question regarding potential pathophysiological differences between the conditions.
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Affiliation(s)
- Helly Goez
- Division of Developmental Medicine and Rehabilitation, Children's Hospital of Eastern Ontario (CHEO), Ottawa, ON, Canada
| | | | - Sean Bryan
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Brenda Clark
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | | | - Shelby S Yamamoto
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Alvaro R Osornio-Vargas
- School of Public Health, University of Alberta, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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2
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Sukhera J, Goez H, Brown A, Haddara W, Razack S. Codesigning Policy-Based Solutions to Discrimination and Harassment in Academic Medicine: An Inclusive Approach. Acad Med 2023; 98:1356-1359. [PMID: 37801596 DOI: 10.1097/acm.0000000000005466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/08/2023]
Abstract
ABSTRACT Academic medicine institutions have historically employed policies as a means to tackle various types of discrimination and harassment within educational and professional settings, thereby affirming their dedication to promoting diversity, equity, and inclusion. However, the implementation and effectiveness of policies are constrained by limitations, including a lack of awareness and barriers to reporting. Due to concerns about accountability and transparency, many groups and individuals experiencing discrimination have lost trust in policy-based solutions to address equity in academic medicine. To address such challenges, the authors offer an evidence-informed policy framework with actionable recommendations. First, policy should be cowritten through meaningful and participatory engagement. Second, organizations should publicly report on metrics of policy effectiveness. Third, to ensure accountability, external organizations or adjudicators should be involved in oversight of policy-based processes. Fourth, leadership commitment is essential for success. Overall, policy can be an effective mechanism to address discrimination and harassment; however, a more inclusive approach is needed.
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3
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Goez H, Nielsen CC, Bryan S, Clark B, Zwaigenbaum L, Yamamoto SS, Osornio-Vargas AR. Autistic Regression and Exposure to Industrial Chemicals: Preliminary Observations - ERRATUM. Can J Neurol Sci 2023:1. [PMID: 37855232 DOI: 10.1017/cjn.2023.293] [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: 10/20/2023]
Affiliation(s)
- Helly Goez
- Division of Developmental Medicine and Rehabilitation, Children's Hospital of Eastern Ontario (CHEO), Ottawa, ON, Canada
| | | | - Sean Bryan
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Brenda Clark
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | | | - Shelby S Yamamoto
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Alvaro R Osornio-Vargas
- School of Public Health, University of Alberta, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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Ali A, Nguyen J, Dennett L, Goez H, Rashid M. A scoping review for designing a disability curriculum and its impact for medical students. Can Med Educ J 2023; 14:75-86. [PMID: 37465749 PMCID: PMC10351622 DOI: 10.36834/cmej.74411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Background There is an increasing need for a standardized undergraduate disability curriculum for medical students to better equip students with the proper training, knowledge, and skills to provide holistic care for individuals with disabilities. Objectives The aim of this scoping review was to better understand and analyze the current body of literature focusing on best practice for including disability curricula and its impact on undergraduate medical students. Results Three major components for designing a disability curriculum for undergraduate medical students were obtained from our analysis. The components were: (1) effective teaching strategies, (2) competencies required for disability curriculum, and (3) impact of disability curriculum on medical students. Conclusions Current literature revealed that exposing medical students to a disability curriculum impacted their overall perceptions about people with disabilities. This allowed them to develop a sense of understanding towards patients with disabilities during their clinical encounters. The effectiveness of a disability curriculum is dependent on the extent to which these interventions are incorporated into undergraduate medical education.
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Affiliation(s)
- Abdinasir Ali
- Faculty of science, University of Alberta, Alberta, Canada
| | - Julie Nguyen
- Department of Paediatrics, University of Alberta, Alberta, Canada
| | - Liz Dennett
- Scott Health Sciences Library, University of Alberta, Alberta, Canada
| | - Helly Goez
- Department of Pediatrics, University of Ottawa
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Al Zahrani H, Siriwardena K, Young D, Lehman A, Horvath GA, Goez H. Genomics in Cerebral Palsy phenotype across the lifespan: Comparison of diagnostic yield between children and adult population. Mol Genet Metab 2022; 137:420-427. [PMID: 34364746 DOI: 10.1016/j.ymgme.2021.07.007] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 07/17/2021] [Accepted: 07/18/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE The presentation and underlying etiology of Cerebral Palsy (CP) in general are heterogenous. Clinical features present differently in pediatric versus adult patient populations. Many metabolic and genetic conditions present with clinical symptoms suggestive of CP. Precision medicine practices are currently a standard of care, and Next-Generation-Sequencing (NGS) tools are used for the purpose of diagnosis and management. We describe the diagnostic yield and impact on management of NGS comparing a cohort of 102 children and 37 adults with CP, referred to two tertiary care centres between 2015 and 2020 (adult cohort) and 2017-2020 (pediatric cohort) respectively. PRINCIPAL RESULTS In the adult cohort, 28 patients had a positive genetic diagnosis, giving a yield of 75.6%. Their age varied between 18 and 59 years, with a median of 28 years. Out of the positive diagnoses, 12 were consistent with an inborn error of metabolism and in 9 patients (32.1%) some form of treatment or management guideline was recommended. In the pediatric cohort 21 patients had a positive genetic diagnosis and 22 results are still pending, giving a yield of 32.8%. Age at diagnosis ranged between 18 months and 12 years. In 15 patients (71.4%) there was some form of management recommendation. All families benefited from genetic counseling. MAJOR CONCLUSIONS Given the combined high yield of positive genetic diagnosis in pediatric and adult cases presenting with symptoms of Cerebral Palsy, and the more readily available Next Generation Sequencing testing in major academic centres, we recommend that either a referral to a pediatric or adult neurometabolic centre to be made, or genetic testing to be initiated where this is available.
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Affiliation(s)
- Haifa Al Zahrani
- Adult Metabolic Diseases Clinic, Vancouver General Hospital, Vancouver, Canada
| | - Komudi Siriwardena
- Department of Medical Genetics, University of Alberta/Stollery Children's Hospital, Canada
| | - Dana Young
- Adult Metabolic Diseases Clinic, Vancouver General Hospital, Vancouver, Canada
| | - Anna Lehman
- Adult Metabolic Diseases Clinic, Vancouver General Hospital, Vancouver, Canada
| | - Gabriella A Horvath
- Adult Metabolic Diseases Clinic, Vancouver General Hospital, Vancouver, Canada.
| | - Helly Goez
- Pediatric Neurometabolic Clinic, Glenrose Rehabilitation Hospital, Stollery Children's Hospital, Edmonton, Alberta, Canada
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Rosenblum S, Nardi-Moses T, Goez H, Demeter N. Children Who Experience Unintentional Injuries: Their Functional Profiles. Occup Ther Int 2022; 2022:6731339. [PMID: 36419546 PMCID: PMC9649315 DOI: 10.1155/2022/6731339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/15/2022] [Indexed: 11/14/2023] Open
Abstract
Unintentional injuries are accidents that pose a major health problem among school children. This study compared the functional behavior and executive function characteristics of school-aged children who experienced unintentional injuries with those of controls who had not been injured. We investigated the background characteristics of injured children, injury characteristics, and parents' perceptions of the children's functional behaviors and executive function abilities. The study included 53 children aged 6 years to 18 years. Of them, 32 had experienced unintentional injuries. The 21 children who had not experienced unintentional injuries served as a control group matched for age and living environment. Parents of both groups completed (1) a demographic questionnaire addressing their children's background, daily functional behavior characteristics, and injury characteristics and (2) the Behavior Rating Inventory of Executive Function (BRIEF). Sixty percent of the children in the research (injured) group had been prediagnosed with learning disabilities or attention deficit hyperactivity disorders, compared with no child in the control (uninjured) group. Most injuries were limb fractures (60%) and sustained outside the home (50%). Parents of children who had been injured expressed significantly more concerns about their children's daily behavior than did parents of the control group and reported their children as usually, but not always, independent and responsible. Compared with the children in the uninjured group, the children in the injured group had significantly lower executive function abilities in the BRIEF's eight subscales, total behavioral regulation and metacognitive indices, and global executive function scores (p < .001). Children with certain diagnoses, functional behavior features, and deficient executive function abilities may be at risk for unintentional injuries. Raising occupational therapists' awareness of these aspects may contribute to identifying, treating, and preventing accidental injuries among at-risk children.
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Affiliation(s)
- Sara Rosenblum
- Laboratory of Complex Human Activity and Participation (CHAP), Department of Occupational Therapy, Faculty of Social Welfare & Health Sciences, University of Haifa, Mount Carmel, Haifa 3498838, Israel
| | | | - Helly Goez
- Division of Rehabilitation Medicine and Developmental Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Canada
| | - Naor Demeter
- Department of Occupational Therapy, Faculty of Social Welfare & Health Sciences, University of Haifa, Mount Carmel, Haifa 3498838, Israel
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Sukhera J, Goez H, Brown A, Haddara W, Razack S. Freedom from discrimination or freedom to discriminate? Discursive tensions within discrimination policies in medical education. Adv Health Sci Educ Theory Pract 2022; 27:387-403. [PMID: 35025019 PMCID: PMC8757400 DOI: 10.1007/s10459-022-10090-1] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 01/05/2022] [Indexed: 06/14/2023]
Abstract
The importance of advancing equity, diversity, and inclusion for all members of the academic medical community has gained recent attention. Academic medical organizations have attempted to increase broader representation while seeking structural reforms consistent with the goal of enhancing equity and reducing disproportionality. However, efforts remain constrained while minority groups continue to experience discrimination. In this study, the authors sought to identify and understand the discursive effects of discrimination policies within medical education. The authors assembled an archive of 22 texts consisting of publicly available discrimination and harassment policy documents in 13 Canadian medical schools that were active as of November 2019. Each text was analysed to identify themes, rhetorical strategies, problematization, and power relations. Policies described truth statements that appear to idealize equity, yet there were discourses related to professionalism and neutrality that were in tension with these ideals. There was also tension between organizations' framing of a shared responsibility for addressing discrimination and individual responsibility on complainants. Lastly, there were also competing discourses on promoting freedom from discrimination and the concept of academic freedom. Overall, findings reveal several areas of tension that shape how discrimination is addressed in policy versus practice. Existing discourses regarding self-protection and academic freedom suggest equity cannot be advanced through policy discourse alone and more substantive structural transformation may be necessary. Existing approaches may be inadequate to address discrimination unless academic medical organizations interrogate the source of these discursive tensions and consider asymmetries of power.
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Affiliation(s)
- Javeed Sukhera
- Chair/Chief of Psychiatry, Institute of Living, Hartford Hospital, Terry Building, 200 Retreat Avenue, 06102, Hartford, Connecticut, USA.
| | - Helly Goez
- Chair/Chief of Psychiatry, Institute of Living, Hartford Hospital, Terry Building, 200 Retreat Avenue, 06102, Hartford, Connecticut, USA
- Department of Pediatrics, Faculty of Medicine and Dentistry, College of Health Sciences University of Alberta, Edmonton, Canada
| | - Allison Brown
- Chair/Chief of Psychiatry, Institute of Living, Hartford Hospital, Terry Building, 200 Retreat Avenue, 06102, Hartford, Connecticut, USA
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Wael Haddara
- Chair/Chief of Psychiatry, Institute of Living, Hartford Hospital, Terry Building, 200 Retreat Avenue, 06102, Hartford, Connecticut, USA
- Department of Medicine and Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, Ontario, Canada
| | - Saleem Razack
- Chair/Chief of Psychiatry, Institute of Living, Hartford Hospital, Terry Building, 200 Retreat Avenue, 06102, Hartford, Connecticut, USA
- Department of Paediatrics and Institute for Health Sciences Education, McGill University, Montreal, Canada
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Forgie EME, Lai H, Cao B, Stroulia E, Greenshaw AJ, Goez H. Social Media and the Transformation of the Physician-Patient Relationship: Viewpoint. J Med Internet Res 2021; 23:e25230. [PMID: 34951596 PMCID: PMC8742211 DOI: 10.2196/25230] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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: 10/23/2020] [Revised: 01/25/2021] [Accepted: 10/26/2021] [Indexed: 12/29/2022] Open
Abstract
As many as 80% of internet users seek health information online. The social determinants of health (SDoH) are intimately related to who has access to the internet and health care as a whole. Those who face more barriers to care are more likely to benefit from accessing health information online, assuming the information they are retrieving is accurate. Virtual communities on social media platforms are beginning to serve as venues for seeking health information online because peers have been shown to influence health behavior more than almost anything else. As a positive mediator of health, social media can be used as a direct or indirect mode of communication between physicians and patients, a venue for health promotion and health information, and a community support network. However, false or misleading content, social contagion, confirmation bias, and security and privacy concerns must be mitigated to realize the full potential of social media as a positive mediator of health. This paper presents the shifting dynamics of how such communities are affecting physician-patient relationships. With the intersections between the SDoH, social media, and health evolving, physicians must take into consideration these factors when establishing their relationships with patients. We argue a paradigm shift in the physician-patient relationship is warranted, one where physicians acknowledge the impacts of the SDoH on information-seeking behavior, recognize the positive and negative roles of social media as a mediator of health through the lens of the SDoH, and use social media to catalyze positive changes in the physician-patient relationship. We discuss how the physician-patient relationship must evolve to accommodate for the ever-increasing role of social media in health and to best use social media as a tool to improve health outcomes. Finally, we present a fluid and multicomponent diagram that we believe will assist in framing future research in this area. We conclude that it is ineffective and even counterproductive for physicians to ignore the relationship between social media, the SDoH and health, their impact on one another, and the effect it has on designing the medical encounter and the delivery of care under the definition of precision medicine.
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Affiliation(s)
- Ella M E Forgie
- Department of Anthropology, University of Alberta, Edmonton, AB, Canada
| | - Hollis Lai
- Department of Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Bo Cao
- Department of Computing Science, University of Alberta, Edmonton, AB, Canada
| | - Eleni Stroulia
- Department of Computing Science, University of Alberta, Edmonton, AB, Canada
| | | | - Helly Goez
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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Keller M, Brennenstuhl H, Kuseyri Hübschmann O, Manti F, Julia Palacios NA, Friedman J, Yıldız Y, Koht JA, Wong SN, Zafeiriou DI, López-Laso E, Pons R, Kulhánek J, Jeltsch K, Serrano-Lomelin J, Garbade SF, Opladen T, Goez H, Burlina A, Cortès-Saladelafont E, Fernández Ramos JA, García-Cazorla A, Hoffmann GF, Kiat Hong ST, Honzík T, Kavecan I, Kurian MA, Leuzzi V, Lücke T, Manzoni F, Mastrangelo M, Mercimek-Andrews S, Mir P, Oppebøen M, Pearson TS, Sivri HS, Steel D, Stevanović G, Fung CW. Assessment of intellectual impairment, health-related quality of life, and behavioral phenotype in patients with neurotransmitter related disorders: Data from the iNTD registry. J Inherit Metab Dis 2021; 44:1489-1502. [PMID: 34245036 DOI: 10.1002/jimd.12416] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 05/21/2021] [Revised: 06/30/2021] [Accepted: 07/07/2021] [Indexed: 12/30/2022]
Abstract
Inherited disorders of neurotransmitter metabolism are a group of rare diseases, which are caused by impaired synthesis, transport, or degradation of neurotransmitters or cofactors and result in various degrees of delayed or impaired psychomotor development. To assess the effect of neurotransmitter deficiencies on intelligence, quality of life, and behavior, the data of 148 patients in the registry of the International Working Group on Neurotransmitter Related Disorders (iNTD) was evaluated using results from standardized age-adjusted tests and questionnaires. Patients with a primary disorder of monoamine metabolism had lower IQ scores (mean IQ 58, range 40-100) within the range of cognitive impairment (<70) compared to patients with a BH4 deficiency (mean IQ 84, range 40-129). Short attention span and distractibility were most frequently mentioned by parents, while patients reported most frequently anxiety and distractibility when asked for behavioral traits. In individuals with succinic semialdehyde dehydrogenase deficiency, self-stimulatory behaviors were commonly reported by parents, whereas in patients with dopamine transporter deficiency, DNAJC12 deficiency, and monoamine oxidase A deficiency, self-injurious or mutilating behaviors have commonly been observed. Phobic fears were increased in patients with 6-pyruvoyltetrahydropterin synthase deficiency, while individuals with sepiapterin reductase deficiency frequently experienced communication and sleep difficulties. Patients with BH4 deficiencies achieved significantly higher quality of life as compared to other groups. This analysis of the iNTD registry data highlights: (a) difference in IQ and subdomains of quality of life between BH4 deficiencies and primary neurotransmitter-related disorders and (b) previously underreported behavioral traits.
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Affiliation(s)
- Mareike Keller
- Division of Child Neurology and Metabolic Medicine, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Heiko Brennenstuhl
- Division of Child Neurology and Metabolic Medicine, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Oya Kuseyri Hübschmann
- Division of Child Neurology and Metabolic Medicine, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Filippo Manti
- Department of Human Neuroscience, Unit of Child Neurology and Psychiatry, Università degli Studi di Roma La Sapienza, Rome, Italy
| | - Natalia Alexandra Julia Palacios
- Inborn errors of metabolism Unit, Department of Neurology, Institut de Recerca Sant Joan de Déu and CIBERER-ISCIII, Barcelona, Spain
| | - Jennifer Friedman
- UCSD Departments of Neuroscience and Pediatrics; Rady Children's Hospital Division of Neurology, Rady Children's Institute for Genomic Medicine, San Diego, California, USA
| | - Yılmaz Yıldız
- Hacettepe University, Faculty of Medicine, Department of Pediatrics, Section of Pediatric Metabolism, Ankara, Turkey
| | | | - Suet-Na Wong
- Department of Pediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Hong Kong, Hong Kong
| | - Dimitrios I Zafeiriou
- First Department of Pediatrics Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eduardo López-Laso
- Pediatric Neurology Unit, Department of Pediatrics, University Hospital Reina Sofía, IMIBIC and CIBERER, Córdoba, Spain
| | - Roser Pons
- First Department of Pediatrics of the University of Athens, Aghia Sofia Hospital, Athens, Greece
| | - Jan Kulhánek
- Department of Pediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Kathrin Jeltsch
- Division of Child Neurology and Metabolic Medicine, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Jesus Serrano-Lomelin
- Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Sven F Garbade
- Division of Child Neurology and Metabolic Medicine, University Children's Hospital Heidelberg, Heidelberg, Germany
- Dietmar-Hopp Metabolic Center, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Opladen
- Division of Child Neurology and Metabolic Medicine, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Helly Goez
- Department of Pediatrics, University of Alberta, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada
| | - Alberto Burlina
- U.O.C. Malattie Metaboliche Ereditarie, Dipartimento della Salute della Donna e del Bambino, Azienda Ospedaliera Universitaria di Padova - Campus Biomedico Pietro d'Abano, Padova, Italy
| | - Elisenda Cortès-Saladelafont
- Inborn errors of metabolism Unit, Department of Neurology, Institut de Recerca Sant Joan de Déu and CIBERER-ISCIII, Barcelona, Spain
- Inborn Errors of Metabolism and Child Neurology Unit, Department of Pediatrics, Hospital Germans Trias i Pujol, Badalona and Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Angeles García-Cazorla
- Inborn errors of metabolism Unit, Department of Neurology, Institut de Recerca Sant Joan de Déu and CIBERER-ISCIII, Barcelona, Spain
| | - Georg F Hoffmann
- Division of Child Neurology and Metabolic Medicine, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Stacey Tay Kiat Hong
- KTP-National University Children's Medical Institute, National University Health System, Singapore, Singapore
| | - Tomáš Honzík
- Department of Pediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Ivana Kavecan
- Faculty of Medicine, University of Novi Sad, Institute for Children and Youth Health Care of Vojvodina, Novi Sad, Serbia
| | - Manju A Kurian
- Developmental Neurosciences, UCL Great Ormond Street-Institute of Child Health and Department of Neurology, Great Ormond Street Hospital, London, UK
| | - Vincenzo Leuzzi
- Department of Human Neuroscience, Unit of Child Neurology and Psychiatry, Università degli Studi di Roma La Sapienza, Rome, Italy
| | - Thomas Lücke
- University Children's Hospital, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Francesca Manzoni
- U.O.C. Malattie Metaboliche Ereditarie, Dipartimento della Salute della Donna e del Bambino, Azienda Ospedaliera Universitaria di Padova - Campus Biomedico Pietro d'Abano, Padova, Italy
| | - Mario Mastrangelo
- Department of Human Neuroscience, Unit of Child Neurology and Psychiatry, Università degli Studi di Roma La Sapienza, Rome, Italy
| | - Saadet Mercimek-Andrews
- Division of Clinical and Metabolic Genetics, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Medical Genetics, University of Alberta, Women and Children's Health Research Institute, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Pablo Mir
- Unidad de Trastornos del Movimiento Servicio de Neurología y Neurofisiología Clínica Unidad de Gestión Clínica de Neurociencias Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Mari Oppebøen
- Children's Department Division of Child Neurology Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Toni S Pearson
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - H Serap Sivri
- Hacettepe University, Faculty of Medicine, Department of Pediatrics, Section of Pediatric Metabolism, Ankara, Turkey
| | - Dora Steel
- Developmental Neurosciences, UCL Great Ormond Street-Institute of Child Health and Department of Neurology, Great Ormond Street Hospital, London, UK
| | - Galina Stevanović
- Clinic of Neurology and Psychiatry for Children and Youth, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Cheuk-Wing Fung
- Department of Pediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Hong Kong, Hong Kong
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Vincent KM, Eaton A, Yassaee VR, Miryounesi M, Hashemi-Gorji F, Rudichuk L, Goez H, Leonard N, Lazier J. Delineating the expanding phenotype of HERC2-related disorders: The impact of biallelic loss of function versus missense variation. Clin Genet 2021; 100:637-640. [PMID: 34370298 DOI: 10.1111/cge.14039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/06/2021] [Accepted: 07/24/2021] [Indexed: 11/28/2022]
Abstract
HECT And RLD Domain-Containing E3 Ubiquitin Protein Ligase 2, or HERC2, codes an ubiquitin ligase that has an important role in key cellular processes including cell cycle regulation, DNA repair, mitochondrial functions, and spindle formation during mitosis. While HERC2 Neurodevelopmental Disorder in Old Order Amish is a well characterized human disorder involving HERC2, bi-allelic HERC2 loss of function has only been described in three families and results in a more severe neurodevelopmental disorder. Herein, we delineate the HERC2 loss of function phenotype by describing three previously unreported patients, and by summarizing the molecular and phenotypic information of all known HERC2 missense variants and biallelic loss of function patients. Collectively, these twelve individuals present with recurring features that define a syndrome with varying combinations of severe neurodevelopmental delay, structural brain anomalies, seizures, hypotonia, feeding difficulties, hearing and vision issues, and renal anomalies. This study describes a distinct neurodevelopmental disorder, emphasizing the importance of further characterization of HERC2-related disorders, as well as highlighting the importance of ongoing work into understanding these critical neurodevelopmental pathways.
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Affiliation(s)
- Krista M Vincent
- Department of Medical Genetics, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Alison Eaton
- Department of Medical Genetics, University of Alberta, Edmonton, Canada
| | - Vahid Reza Yassaee
- Genomic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Miryounesi
- Genomic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Lauren Rudichuk
- Department of Medical Genetics, University of Alberta, Edmonton, Canada
| | - Helly Goez
- Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Norma Leonard
- Department of Medical Genetics, University of Alberta, Edmonton, Canada.,Women's and Children's Research Institute, Edmonton, Canada
| | - Joanna Lazier
- Department of Medical Genetics, Children's Hospital of Eastern Ontario, Ottawa, Canada.,Department of Medical Genetics, University of Alberta, Edmonton, Canada.,Women's and Children's Research Institute, Edmonton, Canada
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Asgarpour J, Lam L, Vogel T, Goez H, Fiorillo L. 18462 HLA gene testing and carbamazepine-induced toxic epidermal necrolysis in pediatric patients. J Am Acad Dermatol 2020. [DOI: 10.1016/j.jaad.2020.06.936] [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: 11/25/2022]
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Abstract
Phenomenon: An increasing number of refugees in recent years has led to changes in healthcare delivery. Historically, health care providers did not receive systematic and longitudinal training in refugee health. There is increasing interest among educators in developing educational opportunities for medical students to gain more training on how to care for this population. The aim of this scoping review was to identify and analyze existing literature on educational content and methods of delivery in Undergraduate Medical Education (UME) curricula related to refugees. Approach: The authors conducted a scoping review. Our search was conducted in seven electronic bibliographic databases. The search strategy was restricted to English language and scholarly articles. Three members of the research team tabulated and summarized extracted data. A qualitative thematic analysis was conducted to present findings. Findings: Of the 717 publications found, 24 met our inclusion criteria. The articles included in this review were published between 2003 and 2019. Thirteen (57.6%) were descriptive papers, three (11.5%) qualitative, four (15.3%) quantitative, and one (3.8%) mixed methods. Other publications included one commentary, one letter to the editor, and one review paper. Three main descriptive themes were identified: (1) Content related to refugees' curriculum, (2) Teaching strategies, and (3) Learning outcomes. Insights: Studies included in our review suggest that delivering refugee health curricula to medical students improve self-perception of cross-cultural knowledge, communication, and physical exam skills that are necessary to deliver proper healthcare. Medical schools should focus on developing a longitudinal and standardized approach to teaching refugee health through the use of interactive and diverse learning methods while engaging with the community to ensure a better provision of health care for vulnerable populations.
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Affiliation(s)
- Marghalara Rashid
- Department of Paediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Helly Goez
- Department of Paediatrics, University of Alberta, Edmonton, Alberta, Canada
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Wei L, Goez H, Hillier T, Brett-MacLean P. A Visiting Professorship in Undergraduate Medical Education at the University of Alberta: Reflections on possibilities for medical humanities in China, and elsewhere. MedEdPublish (2016) 2020; 9:190. [PMID: 38073836 PMCID: PMC10699406 DOI: 10.15694/mep.2020.000190.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Abstract
This article was migrated. The article was marked as recommended. Enhancing humanities in medical education is a pressing concern in China. Similar to other countries, medical education in China evolved over the past century to emphasize bioscience and technology in treating illness and disease. Increasing recognition of the limitations of biomedical technology led to emergence of the medical humanities in the West in the latter half of the 20 th century, an interdisciplinary area that has continued to expand and grow. In China and elsewhere, activity in this area developed somewhat later. Ongoing patient-doctor disputes and decline in public trust in the medical profession in China has led many to advocate for enhanced emphasis on humanism and medical humanities. In 2017, the Chinese government introduced new healthcare reforms which included an education and training plan that promotes medical humanities teaching. Global developments have led to a wide variety of models and approaches that may be considered in cultivating medical humanities and humanism in China. With the support of China Medical University in Shenyang, Liaoning Province, PRC, Professor Wei visited the Faculty of Medicine & Dentistry at the University of Alberta through the 2019/20 academic year. This article provides an overview of a wide array of medical humanities teaching and learning opportunities associated with the undergraduate medical education program at the University of Alberta. Professor Wei reflects on possibilities for medical humanities in medical education in China given all she learned and experienced as a visiting professor at the University of Alberta, which may be of interest to others who are also developing new approaches to introducing medical humanities as part of their health professions education program. Additional reflections regarding possibilities for global medical humanities are also offered.
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Goez H, Lai H, Rodger J, Brett-MacLean P, Hillier T. The DISCuSS model: Creating connections between community and curriculum - A new lens for curricular development in support of social accountability. Med Teach 2020; 42:1058-1064. [PMID: 32608298 DOI: 10.1080/0142159x.2020.1779919] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Medicine's social mandate recognizes the importance of introducing changes to systems and practices to meet the healthcare needs of marginalized populations. Social accountability efforts encompass a wide array of actions, including equity, diversity and inclusion initiatives, and adapting knowledge relevant to practice across education, research, and clinical domains. To influence change in education, ongoing structures and processes are needed to ensure adequacy, relevance, and effectiveness of curricular coverage. In support of this, we created an innovative and creative approach to developing curricular modules to prepare medical students to provide care that is responsive to the cultural, economic, and psychosocial realities of diverse patient populations. The DISCuSS model (Diversity, Identify, Search, Create module (with community engagement), Sustainability, Social accountability) provides a community-engaged, iterative approach to curriculum development relevant to social accountability. Over the past 5 years, we have created nine curricular modules focused on health-related inequities and social concerns, including modules on Indigenous and refugee health, sexual and gender minority health, human trafficking, and addiction. AFMC Graduation Questionnaire results have shown a statistically significant increase in our students 'preparedness to provide care to diverse populations.' The DISCuSS model, which continues to evolve, can be adapted and used in other settings.
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Affiliation(s)
- Helly Goez
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Hollis Lai
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Joanne Rodger
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | | | - Tracey Hillier
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
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Opladen T, López-Laso E, Cortès-Saladelafont E, Pearson TS, Sivri HS, Yildiz Y, Assmann B, Kurian MA, Leuzzi V, Heales S, Pope S, Porta F, García-Cazorla A, Honzík T, Pons R, Regal L, Goez H, Artuch R, Hoffmann GF, Horvath G, Thöny B, Scholl-Bürgi S, Burlina A, Verbeek MM, Mastrangelo M, Friedman J, Wassenberg T, Jeltsch K, Kulhánek J, Kuseyri Hübschmann O. Correction to: Consensus guideline for the diagnosis and treatment of tetrahydrobiopterin (BH4) deficiencies. Orphanet J Rare Dis 2020; 15:202. [PMID: 32758270 PMCID: PMC7409715 DOI: 10.1186/s13023-020-01464-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
An amendment to this paper has been published and can be accessed via the original article.
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Affiliation(s)
- Thomas Opladen
- Division of Child Neurology and Metabolic Disorders, University Children's Hospital, Heidelberg, Germany.
| | - Eduardo López-Laso
- Pediatric Neurology Unit, Department of Pediatrics, University Hospital Reina Sofía, IMIBIC and CIBERER, Córdoba, Spain
| | - Elisenda Cortès-Saladelafont
- Inborn errors of metabolism Unit, Institut de Recerca Sant Joan de Déu and CIBERER-ISCIII, Barcelona, Spain.,Unit of Pediatric Neurology and Metabolic Disorders, Department of Pediatrics, Hospital Germans Trias i Pujol, and Faculty of Medicine, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Toni S Pearson
- Department of Neurology, Washington University School of Medicine, St. Louis, USA
| | - H Serap Sivri
- Department of Pediatrics, Section of Metabolism, Hacettepe University, Faculty of Medicine, 06100, Ankara, Turkey
| | - Yilmaz Yildiz
- Department of Pediatrics, Section of Metabolism, Hacettepe University, Faculty of Medicine, 06100, Ankara, Turkey
| | - Birgit Assmann
- Division of Child Neurology and Metabolic Disorders, University Children's Hospital, Heidelberg, Germany
| | - Manju A Kurian
- Developmental Neurosciences, UCL Great Ormond Street-Institute of Child Health, London, UK.,Department of Neurology, Great Ormond Street Hospital, London, UK
| | - Vincenzo Leuzzi
- Unit of Child Neurology and Psychiatry, Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Simon Heales
- Neurometabolic Unit, National Hospital, Queen Square, London, UK
| | - Simon Pope
- Neurometabolic Unit, National Hospital, Queen Square, London, UK
| | - Francesco Porta
- Department of Pediatrics, AOU Città della Salute e della Scienza, Torino, Italy
| | - Angeles García-Cazorla
- Inborn errors of metabolism Unit, Institut de Recerca Sant Joan de Déu and CIBERER-ISCIII, Barcelona, Spain
| | - Tomáš Honzík
- Department of Paediatrics and Adolescent Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Roser Pons
- First Department of Pediatrics of the University of Athens, Aghia Sofia Hospital, Athens, Greece
| | - Luc Regal
- Department of Pediatric, Pediatric Neurology and Metabolism Unit, UZ Brussel, Brussels, Belgium
| | - Helly Goez
- Department of Pediatrics, University of Alberta Glenrose Rehabilitation Hospital, Edmonton, Canada
| | - Rafael Artuch
- Clinical biochemistry department, Institut de Recerca Sant Joan de Déu, CIBERER and MetabERN Hospital Sant Joan de Déu, Barcelona, Spain
| | - Georg F Hoffmann
- Division of Child Neurology and Metabolic Disorders, University Children's Hospital, Heidelberg, Germany
| | - Gabriella Horvath
- Department of Pediatrics, Division of Biochemical Genetics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Beat Thöny
- Division of Metabolism, University Children's Hospital Zurich, Zürich, Switzerland
| | - Sabine Scholl-Bürgi
- Clinic for Pediatrics I, Medical University of Innsbruck, Anichstr 35, Innsbruck, Austria
| | - Alberto Burlina
- U.O.C. Malattie Metaboliche Ereditarie, Dipartimento della Salute della Donna e del Bambino, Azienda Ospedaliera Universitaria di Padova - Campus Biomedico Pietro d'Abano, Padova, Italy
| | - Marcel M Verbeek
- Departments of Neurology and Laboratory Medicine, Alzheimer Centre, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Mario Mastrangelo
- Unit of Child Neurology and Psychiatry, Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Jennifer Friedman
- UCSD Departments of Neuroscience and Pediatrics, Rady Children's Hospital Division of Neurology, Rady Children's Institute for Genomic Medicine, San Diego, USA
| | - Tessa Wassenberg
- Department of Pediatric, Pediatric Neurology and Metabolism Unit, UZ Brussel, Brussels, Belgium
| | - Kathrin Jeltsch
- Division of Child Neurology and Metabolic Disorders, University Children's Hospital, Heidelberg, Germany
| | - Jan Kulhánek
- Department of Paediatrics and Adolescent Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.
| | - Oya Kuseyri Hübschmann
- Division of Child Neurology and Metabolic Disorders, University Children's Hospital, Heidelberg, Germany
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16
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Ma K, Ali J, Deutscher J, Silverman JA, Novak C, Dong S, Chmelicek J, Dance E, Goez H. Preparing residents to deal with human trafficking. Clin Teach 2020; 17:674-679. [PMID: 32716146 DOI: 10.1111/tct.13187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Victims of human trafficking (HT) are predisposed to numerous health concerns. Many encounter health care practitioners during captivity, but awareness and knowledge among front-line physicians is low. Limited data exist on attempts to address this within residency training programmes. Formal curriculum time in residency is limited and online modules may be a useful educational option. METHODS Residents in family medicine, emergency medicine and general paediatrics at the University of Alberta were invited to participate. They completed short surveys to assess knowledge both before and after completing an online learning module either individually (n = 15) or in a facilitated session (n = 17). Baseline and post-intervention changes in self-reported and tested knowledge were assessed. RESULTS Thirty-two residents completed the pre-intervention survey: only 6% self-identified as somewhat knowledgeable on HT and 16% knew the red flags used to identify victims. Eighty-one percent wanted this topic incorporated into residency training, but only 6% and 25% had received education previously in residency or medical school, respectively. Thirteen percent were comfortable supporting victims, and 6% reported knowing how to provide support. Twenty residents completed the post-intervention survey, with improvements in both self-reported (p < 0.001) and tested (p = 0.005) knowledge of HT. Residents also reported being more prepared to identify victims (p < 0.001), more comfortable supporting victims (p < 0.001) and more confident in knowing how to support victims (p < 0.001). DISCUSSION Baseline HT knowledge in residents providing first-contact care appears limited. Residency programmes should consider providing more HT education in order to improve competency in care. Although an online module was shown to be effective, protected time might be necessary for the widespread adoption of online education delivery.
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Affiliation(s)
- Keon Ma
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Jahaan Ali
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Julianna Deutscher
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Jason A Silverman
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Chris Novak
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Sandy Dong
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - John Chmelicek
- Department of Family Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Erica Dance
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Helly Goez
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
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Opladen T, López-Laso E, Cortès-Saladelafont E, Pearson TS, Sivri HS, Yildiz Y, Assmann B, Kurian MA, Leuzzi V, Heales S, Pope S, Porta F, García-Cazorla A, Honzík T, Pons R, Regal L, Goez H, Artuch R, Hoffmann GF, Horvath G, Thöny B, Scholl-Bürgi S, Burlina A, Verbeek MM, Mastrangelo M, Friedman J, Wassenberg T, Jeltsch K, Kulhánek J, Kuseyri Hübschmann O. Consensus guideline for the diagnosis and treatment of tetrahydrobiopterin (BH 4) deficiencies. Orphanet J Rare Dis 2020; 15:126. [PMID: 32456656 PMCID: PMC7251883 DOI: 10.1186/s13023-020-01379-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 04/07/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Tetrahydrobiopterin (BH4) deficiencies comprise a group of six rare neurometabolic disorders characterized by insufficient synthesis of the monoamine neurotransmitters dopamine and serotonin due to a disturbance of BH4 biosynthesis or recycling. Hyperphenylalaninemia (HPA) is the first diagnostic hallmark for most BH4 deficiencies, apart from autosomal dominant guanosine triphosphate cyclohydrolase I deficiency and sepiapterin reductase deficiency. Early supplementation of neurotransmitter precursors and where appropriate, treatment of HPA results in significant improvement of motor and cognitive function. Management approaches differ across the world and therefore these guidelines have been developed aiming to harmonize and optimize patient care. Representatives of the International Working Group on Neurotransmitter related Disorders (iNTD) developed the guidelines according to the SIGN (Scottish Intercollegiate Guidelines Network) methodology by evaluating all available evidence for the diagnosis and treatment of BH4 deficiencies. CONCLUSION Although the total body of evidence in the literature was mainly rated as low or very low, these consensus guidelines will help to harmonize clinical practice and to standardize and improve care for BH4 deficient patients.
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Affiliation(s)
- Thomas Opladen
- Division of Child Neurology and Metabolic Disorders, University Children's Hospital, Heidelberg, Germany.
| | - Eduardo López-Laso
- Pediatric Neurology Unit, Department of Pediatrics, University Hospital Reina Sofía, IMIBIC and CIBERER, Córdoba, Spain
| | - Elisenda Cortès-Saladelafont
- Inborn errors of metabolism Unit, Institut de Recerca Sant Joan de Déu and CIBERER-ISCIII, Barcelona, Spain
- Unit of Pediatric Neurology and Metabolic Disorders, Department of Pediatrics, Hospital Germans Trias i Pujol, and Faculty of Medicine, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Toni S Pearson
- Department of Neurology, Washington University School of Medicine, St. Louis, USA
| | - H Serap Sivri
- Department of Pediatrics, Section of Metabolism, Hacettepe University, Faculty of Medicine, 06100, Ankara, Turkey
| | - Yilmaz Yildiz
- Department of Pediatrics, Section of Metabolism, Hacettepe University, Faculty of Medicine, 06100, Ankara, Turkey
| | - Birgit Assmann
- Division of Child Neurology and Metabolic Disorders, University Children's Hospital, Heidelberg, Germany
| | - Manju A Kurian
- Developmental Neurosciences, UCL Great Ormond Street-Institute of Child Health, London, UK
- Department of Neurology, Great Ormond Street Hospital, London, UK
| | - Vincenzo Leuzzi
- Unit of Child Neurology and Psychiatry, Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Simon Heales
- Neurometabolic Unit, National Hospital, Queen Square, London, UK
| | - Simon Pope
- Neurometabolic Unit, National Hospital, Queen Square, London, UK
| | - Francesco Porta
- Department of Pediatrics, AOU Città della Salute e della Scienza, Torino, Italy
| | - Angeles García-Cazorla
- Inborn errors of metabolism Unit, Institut de Recerca Sant Joan de Déu and CIBERER-ISCIII, Barcelona, Spain
| | - Tomáš Honzík
- Department of Paediatrics and Adolescent Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Roser Pons
- First Department of Pediatrics of the University of Athens, Aghia Sofia Hospital, Athens, Greece
| | - Luc Regal
- Department of Pediatric, Pediatric Neurology and Metabolism Unit, UZ Brussel, Brussels, Belgium
| | - Helly Goez
- Department of Pediatrics, University of Alberta Glenrose Rehabilitation Hospital, Edmonton, Canada
| | - Rafael Artuch
- Clinical biochemistry department, Institut de Recerca Sant Joan de Déu, CIBERER and MetabERN Hospital Sant Joan de Déu, Barcelona, Spain
| | - Georg F Hoffmann
- Division of Child Neurology and Metabolic Disorders, University Children's Hospital, Heidelberg, Germany
| | - Gabriella Horvath
- Department of Pediatrics, Division of Biochemical Genetics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Beat Thöny
- Division of Metabolism, University Children's Hospital Zurich, Zürich, Switzerland
| | - Sabine Scholl-Bürgi
- Clinic for Pediatrics I, Medical University of Innsbruck, Anichstr 35, Innsbruck, Austria
| | - Alberto Burlina
- U.O.C. Malattie Metaboliche Ereditarie, Dipartimento della Salute della Donna e del Bambino, Azienda Ospedaliera Universitaria di Padova - Campus Biomedico Pietro d'Abano, Padova, Italy
| | - Marcel M Verbeek
- Departments of Neurology and Laboratory Medicine, Alzheimer Centre, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Mario Mastrangelo
- Unit of Child Neurology and Psychiatry, Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Jennifer Friedman
- UCSD Departments of Neuroscience and Pediatrics, Rady Children's Hospital Division of Neurology; Rady Children's Institute for Genomic Medicine, San Diego, USA
| | - Tessa Wassenberg
- Department of Pediatric, Pediatric Neurology and Metabolism Unit, UZ Brussel, Brussels, Belgium
| | - Kathrin Jeltsch
- Division of Child Neurology and Metabolic Disorders, University Children's Hospital, Heidelberg, Germany
| | - Jan Kulhánek
- Department of Paediatrics and Adolescent Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.
| | - Oya Kuseyri Hübschmann
- Division of Child Neurology and Metabolic Disorders, University Children's Hospital, Heidelberg, Germany
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18
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van Karnebeek CDM, Beumer D, Pawliuk C, Goez H, Mostafavi S, Andrews G, Steele R, Siden H. A novel classification system for research reporting in rare and progressive genetic conditions. Dev Med Child Neurol 2019; 61:1208-1213. [PMID: 30868573 DOI: 10.1111/dmcn.14180] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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] [Accepted: 12/18/2018] [Indexed: 01/01/2023]
Abstract
AIM To create a classification system for severe, rare, and progressive genetic conditions for use in research reporting. METHOD A modified Delphi consensus technique was used to create and reach agreement on a new system of condition categories. Interrater reliability was tested via two rounds of an online survey whereby physicians classified a subset of conditions using our novel system. Overall percentage agreement and agreement above chance were calculated using Fleiss' kappa (κ). RESULTS Eleven physicians completed the first Delphi, with an overall agreement of 76.4%, the κ value was 0.57 (95% confidence interval 0.51-0.63), indicating moderate agreement (0.41-0.60) above chance. Based on the first survey several categories were described in more detail. The second survey confirmed a classification system with 12 categories, with an overall percentage agreement among the participants of 82.6%. The overall mean κ value was 0.71 (95% confidence interval 0.65-0.77), indicating substantial agreement (0.61-0.80). INTERPRETATION Our new system was useful in categorizing a broad range of rare childhood diseases and may be applicable to other rare disease studies; further validation in larger cohorts is required. WHAT THIS PAPER ADDS This novel 12-category classification system can be used in research reporting in rare and progressive genetic conditions.
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Affiliation(s)
- Clara D M van Karnebeek
- Centre for Molecular Medicine and Therapeutics, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada.,Departments of Pediatrics and Clinical Genetics, Amsterdam University Medical Centres, Amsterdam, the Netherlands.,Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Daniël Beumer
- Department of Anesthesiology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Colleen Pawliuk
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Helly Goez
- Division of Pediatric Neurology, Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Sara Mostafavi
- Centre for Molecular Medicine and Therapeutics, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Gail Andrews
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Rose Steele
- School of Nursing, Faculty of Health, York University, Toronto, ON, Canada
| | - Harold Siden
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
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Matthews AM, Blydt-Hansen I, Al-Jabri B, Andersen J, Tarailo-Graovac M, Price M, Selby K, Demos M, Connolly M, Drögemoller B, Shyr C, Mwenifumbo J, Elliott AM, Lee J, Ghani A, Stöckler S, Salvarinova R, Vallance H, Sinclair G, Ross CJ, Wasserman WW, McKinnon ML, Horvath GA, Goez H, van Karnebeek CD. Atypical cerebral palsy: genomics analysis enables precision medicine. Genet Med 2018; 21:1621-1628. [DOI: 10.1038/s41436-018-0376-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 11/08/2018] [Indexed: 11/09/2022] Open
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20
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Amirav I, Goez H. Brain dysplasia and ciliary dysfunction. J Pediatr 2017; 185:253. [PMID: 28279434 DOI: 10.1016/j.jpeds.2017.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 02/07/2017] [Indexed: 10/20/2022]
Affiliation(s)
| | - Helly Goez
- Department of Pediatrics University of Alberta Edmonton, Canada
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21
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Leonard N, Landeghem F, Goez H, Mailo J. Periventricular Cysts, Developmental Impairment in a 9q21.13q21.32 Microdeletion, and a Review of the Literature. J Pediatr Neurol 2016. [DOI: 10.1055/s-0036-1584302] [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: 10/21/2022]
Affiliation(s)
- Norma Leonard
- Department of Medical Genetics, University of Alberta, Edmonton, Alberta, Canada
| | - Frank Landeghem
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta
| | - Helly Goez
- Department of Pediatrics, Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alberta, Canada
| | - Janette Mailo
- Department of Pediatrics, Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alberta, Canada
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22
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Scott O, Goez H, Aljabri B, Prowse M, Mehta V, Ricci F, Amirav I. 47: Decreased Nasal Nitric Oxide in Children with Isolated Midline Neuroanatomical Defects: A Possible Indicator of Ciliary Dysfunction? Paediatr Child Health 2015. [DOI: 10.1093/pch/20.5.e50] [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: 11/13/2022] Open
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23
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Steele R, Siden H, Cadell S, Davies B, Andrews G, Feichtinger L, Singh M, Spicer S, Goez H, Davies D, Rapoport A, Vadeboncoeur C, Liben S, Gregoire MC, Schwantes S, Friedrichsdorf SJ. Charting the territory: symptoms and functional assessment in children with progressive, non-curable conditions. Arch Dis Child 2014; 99:754-62. [PMID: 24833792 DOI: 10.1136/archdischild-2013-305246] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [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: 11/03/2022]
Abstract
BACKGROUND Children with progressive, non-curable genetic, metabolic, or neurological conditions require specialised care to enhance their quality of life. Prevention and relief of physical symptoms for these children needs to begin at diagnosis, yet, little is known about their patterns of symptoms and functional abilities. AIM To describe these children's symptoms, as well as how the children's condition affects them physically. DESIGN Cross-sectional, baseline results from an observational, longitudinal study, Charting the Territory, that followed 275 children and their families. SETTING/PARTICIPANTS Seven tertiary care children's hospitals in Canada, 2 in the USA. Families were eligible based on the child's condition. A total of 275 children from 258 families participated. RESULTS The 3 most common symptoms in these children were pain, sleep problems, and feeding difficulties; on average, they had 3.2 symptoms of concern. There was a pattern of under-reporting of children's symptoms for clinicians compared with parents. Regardless of use of associated medications, pain, feeding and constipation symptoms were often frequent and distressing. Children with a G/J tube had a higher total number of symptoms, and respiratory problems, pain, feeding difficulties and constipation were more likely to occur. They also tended to have frequent and distressing symptoms, and to need extensive mobility modifications which, in turn, were associated with higher numbers of symptoms. CONCLUSIONS These children experience multiple symptoms that have been previously documented individually, but not collectively. Effective interventions are needed to reduce their symptom burden. Future longitudinal analyses will examine which disease-modifying interventions improve, or do not improve, symptom burden.
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Affiliation(s)
- Rose Steele
- School of Nursing, Faculty of Health, York University, Toronto, Ontario, Canada
| | - Harold Siden
- Department of Paediatrics, University of British Columbia; Canuck Place Children's Hospice, Vancouver, British Columbia, Canada Developmental Neuroscience and Child Health, Child & Family Research Institute, Vancouver, British Columbia, Canada
| | - Susan Cadell
- School of Social Work, Renison University College-University of Waterloo, Waterloo, Ontario, Canada
| | - Betty Davies
- School of Nursing, University of Victoria, Victoria, British Columbia, Canada
| | - Gail Andrews
- Developmental Neuroscience and Child Health, Child & Family Research Institute, Vancouver, British Columbia, Canada
| | - Leanne Feichtinger
- Developmental Neuroscience and Child Health, Child & Family Research Institute, Vancouver, British Columbia, Canada
| | - Mina Singh
- School of Nursing, Faculty of Health, York University, Toronto, Ontario, Canada
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24
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Clark B, Breau L, Goez H. 131: Health and Quality of Life Outcomes for a Cohort of Children with Severe Traumatic Brain Injury. Paediatr Child Health 2014. [DOI: 10.1093/pch/19.6.e35-129] [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: 11/14/2022] Open
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25
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Abstract
Schizencephaly is an uncommon congenital malformation of neuronal migration characterized by a gray matter-lined cleft extending from the pial surface to the ependymal surface of the lateral ventricles. Its etiology is heterogeneous and consists of hereditary factors or destructive processes that occur during the second trimester of pregnancy. We report 2 cases with schizencephaly and thrombophilia caused by mutations of the methyltetrahydrofolate reductase and the factor V Leiden genes. Their clinical presentations included motor deficits and mild cognitive deficits.
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Affiliation(s)
- Helly Goez
- Child Neurodevelopment Center, Rakati, Hashmonaim 1 Street, Tiberias, Israel.
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26
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Zelnik N, Isler N, Goez H, Shiffer M, David M, Shahar E. Vigabatrin, lamotrigine, topiramate and serum carnitine levels. Pediatr Neurol 2008; 39:18-21. [PMID: 18555168 DOI: 10.1016/j.pediatrneurol.2008.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [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] [Received: 10/30/2007] [Accepted: 03/10/2008] [Indexed: 11/25/2022]
Abstract
Clinical studies indicate a decrease in free and total carnitine in children treated with old-generation antiepileptic drugs (especially valproate). Here, we studied the effect of new-generation antiepileptic drugs on serum carnitine levels. Serum carnitine levels were measured in 91 children: 24 treated with vigabatrin, 28 treated with lamotrigine, and 21 treated with topiramate. These drugs were given as monotherapy (54 children) or polytherapy (19 children). Eighteen additional children treated with valproate served as control subjects. Reduced mean serum carnitine level was evident only in children treated with valproate, with mean free and total carnitine level of 26.9 +/- 8.6 micromol/L and 29.1 +/- 10.4 micromol/L, respectively. In contrast, the mean serum carnitine levels of children treated with vigabatrin, lamotrigine, or topiramate were similar and normal. In these children, the free carnitine levels were 38.5 +/- 7.8 micromol/L, 37.2 +/- 7.7 microg/mL, and 40.4 +/- 8.7 micromol/L, respectively, and total carnitine levels were 43.5 +/- 8.8 micromol/L, 44.4 +/- 9.2 micromol/L, and 45.5 +/- 9.8 micromol/L (+/-S.D.), respectively. Only 4 children (treated with valproate) exhibited considerably lower serum carnitine levels. None of these children had significant clinical adverse effects attributable to carnitine deficiency. In conclusion, these new-generation antiepileptic drugs probably do not cause carnitine deficiency. In contrast, valproate may induce carnitine deficiency, but most cases are asymptomatic.
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Affiliation(s)
- Nathanel Zelnik
- Department of Pediatrics, Carmel Medical Center, Haifa, Israel.
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27
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Abstract
Developmental coordination disorder affects 5% to 8% of the general population, and about 50% to 60% of these children have a comorbid attention-deficit disorder with hyperactivity and learning disorders. Left-handedness is relatively common among children with dyslexia, learning disabilities, and autism; however, its frequency in children with developmental coordination disorder is less clear. The present study investigated the distribution of hand dominance in 98 children (age range, 5.5-17 years) with developmental coordination disorder compared with their parents or siblings. Thirty children (30.6%) were left-handed and 13 (13.3%) were ambidextrous. The prevalence of left-handedness among their parents and siblings was similar to that of the general population. The results suggest that children with developmental coordination disorder, like children with learning disorders and deficit disorder with hyperactivity, present with higher frequency of left-hand dominance compared with the general population.
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Affiliation(s)
- Helly Goez
- Child Neurodevelopment Center, Rakati, Tiberias, Isreal.
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28
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Abstract
The clinical features of 37 patients from 32 Israeli families with congenital myopathies evaluated between 1983 and 2004 are described: 13 children were diagnosed with congenital fiber type disproportion, 10 had myotubular myopathy, 7 had nemaline myopathy, 5 had central core disease, 1 had actin myopathy, and 1 had multi-minicore disease. There were 7 families (22%) that had parental consanguinity, and 4 families (12%) had more than 1 patient with congenital myopathy. Of the patients, 31 (84%) presented with clinical symptoms before 4 months of age, and 6 children (16%) presented after 1 year of age. Thirteen children (35%) had a severe phenotype with chronic ventilatory dependence or mortality before the age of 11 years. Facial weakness was associated with a severe phenotype. There was a high rate of a severe clinical phenotype in patients with myotubular myopathy (60%) and in patients with nemaline myopathy (57%), whereas in patients with congenital fiber type disproportion and in patients with central core disease, the proportion of a severe phenotype was lower (23% and 0%, respectively).
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29
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Abstract
Attention-deficit hyperactivity disorder (ADHD) affects 3% to 7% of school-age children. Approximately 30% of the children with ADHD also have comorbid anxiety or oppositional defiant disorder. Methylphenidate is the drug of choice for the medical treatment of such cases. When compared with children with ADHD alone, children with comorbid anxiety or oppositional defiant disorder may show worsening of the global attention score in response to methylphenidate and not only a "reduced response," as reported in previous studies. This study included 1122 children diagnosed as ADHD, of which 174 were diagnosed with comorbid anxiety and 141 with comorbid oppositional defiant disorder. All patients performed the Test of Variables of Attention before and after methylphenidate administration. A normal distribution (Gaussian distribution) of reaction to methylphenidate, as measured by the global ADHD score in children diagnosed as pure ADHD, was found. These findings were in contrast to children with ADHD and comorbid anxiety or oppositional defiant disorder who showed a bimodal distribution and hence represent a distinct population. In both groups with comorbid disorders, there was a larger subgroup in which significant worsening of global ADHD score occurred after methylphenidate administration (P < .05). Children with ADHD and comorbid anxiety or oppositional defiant disorder might represent clinically distinct populations in which inattention is secondary to those disorders; therefore, methylphenidate may be an inappropriate treatment for such children.
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Affiliation(s)
- Helly Goez
- Child Neurodevelopment Center, Rakati, Tiberias.
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30
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Goez H, Sira LB, Jossiphov J, Borochowitz Z, Durling H, Laing NG, Nevo Y. Predominantly upper limb weakness, enlarged cisterna magna, and borderline intelligence in a child with de novo mutation of the skeletal muscle alpha-actin gene. J Child Neurol 2005; 20:236-9. [PMID: 15832616] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
We present a 10-year-old boy from nonconsanguineous parents of Libyan (Sephardi) Jewish origin. Mild dysmorphism, hypotonia, and clubfoot deformities were noted at birth. On follow-up, he had borderline intelligence and nonprogressive muscle weakness, predominantly in the upper extremities. Physical examination revealed mild facial weakness, a bell-shaped chest cavity, kyphosis, winging of the scapula, and hypotonia of the shoulder girdle. Muscle biopsy demonstrated prominent variation in fiber size and central nuclei and numerous subsarcolemmal particles on modified Gomori trichrome stains. Electron microscopy depicted areas of disrupted sarcomeres with abnormal aggregates. Brain magnetic resonance imaging showed mild widening of the lateral ventricles and an enlarged cisterna magna. Molecular DNA analysis by polymerase chain reaction (PCR) and direct sequencing revealed a de novo heterozygous missense mutation in the skeletal muscle alpha-actin gene (ACTA1) changing codon 348 from TCG serine to TTG leucine.
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Affiliation(s)
- Helly Goez
- Child Development Center, Rakati, Tiberias, Israel.
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Kosinovsky B, Hermon S, Yoran-Hegesh R, Golomb A, Senecky Y, Goez H, Kramer U. The yield of laboratory investigations in children with infantile autism. J Neural Transm (Vienna) 2004; 112:587-96. [PMID: 15503196 DOI: 10.1007/s00702-004-0198-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2004] [Accepted: 07/03/2004] [Indexed: 10/26/2022]
Abstract
PURPOSE To evaluate the yield of laboratory investigations in infantile autism. METHODS We retrieved and evaluated the results of investigative procedures recorded in the medical files of autistic infants in four child developmental centers and two pediatric psychiatric outpatient clinics. RESULTS One-hundred and thirty-two infants were included in the study of whom 47 (36%) underwent autistic regression at an average age of 20 months. The investigative procedures included electroencephalogram (n = 132), neuroimaging (n = 70), genetic studies to detect Fragile-X (n = 59) and a metabolic workup (n = 53). Except for the molecular diagnosis that revealed Fragile-X syndrome in two children (3%), all other tests were negative. The two infants with the Fragile-X syndrome belonged to the non-regressive group. CONCLUSIONS The only investigative study that contributed to the diagnosis of autistic infants was the molecular diagnosis detecting Fragile-X. In spite of the high frequency of epilepsy and epileptiform abnormalities in the electroencephalograms of autistic children in general, the contribution of epilepsy, both clinical and subclinical, to the etiology of autism is apparently minimal.
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Affiliation(s)
- B Kosinovsky
- Child Developmental Center, Tel Aviv Sourasky Medical Center, Petah-Tiqva, Israel
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Fattal-Valevski A, Leitner Y, Geva R, Bassan H, Goez H, Jaffa AJ, Harel S. The effect of intrauterine growth restriction on the development and health of children. Nutr Health 2002; 15:169-75. [PMID: 12003081 DOI: 10.1177/026010600101500404] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The neurodevelopmental and cognitive outcome of long-term Intrauterine Growth Restriction (IUGR) has been followed up from pregnancy to school age at the Tel Aviv Child Development Centre.
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Affiliation(s)
- A Fattal-Valevski
- The Institute for Child Development, Division of Pediatrics, Tel Aviv University, Israel
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33
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Goez H, Meiron D, Horowitz J, Schutgens RH, Wanders RJ, Berant M, Mandel H. Infantile Refsum disease: neonatal cholestatic jaundice presentation of a peroxisomal disorder. J Pediatr Gastroenterol Nutr 1995; 20:98-101. [PMID: 7533834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- H Goez
- Department of Pediatrics, Emek Central Hospital, Afula, Israel
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