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Finch CE, Raol N, Roser SM, Leu RM. Multisystem approach for management of OSA in Down syndrome: a case report. J Clin Sleep Med 2024; 20:471-473. [PMID: 37937612 PMCID: PMC11019208 DOI: 10.5664/jcsm.10914] [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] [Received: 07/09/2023] [Revised: 11/05/2023] [Accepted: 11/06/2023] [Indexed: 11/09/2023]
Abstract
Obstructive sleep apnea (OSA) is common in children with Down syndrome, with reported prevalence rates as high as 69-76%. Multiple factors predispose children with Down syndrome for OSA, including craniofacial hypoplasia (maxillary and mandibular), airway abnormalities, macroglossia, generalized hypotonia, airway hypotonia, adenotonsillar hypertrophy, and obesity. Despite the fact that the pathophysiology for OSA in children with Down syndrome is multifactorial in nature, treatment methods have focused on soft tissue in the upper airway using adenotonsillectomy and/or continuous positive airway pressure therapy. Here we present a case of a patient with Down syndrome whose severe OSA was approached in a multisystem manner, including upper airway soft tissue, orthognathic, maxillofacial, and bariatric surgery, resulting in resolution of the OSA without reliance on a continuous positive airway pressure device. CITATION Finch CE, Raol N, Roser SM, Leu RM. Multisystem approach for management of OSA in Down syndrome: a case report. J Clin Sleep Med. 2024;20(3):471-473.
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Affiliation(s)
- Christina E. Finch
- Department of Pediatrics, Division of Pulmonology, Asthma, Cystic Fibrosis, and Sleep, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Nikhila Raol
- Division of Pediatric Otolaryngology, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Steven M. Roser
- Division of Oral and Maxillofacial Surgery, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Roberta M. Leu
- Department of Pediatrics, Division of Pulmonology, Asthma, Cystic Fibrosis, and Sleep, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
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Fain ME, Raghunandan S, Pencheva B, Leu RM, Kasi AS. Images: Atypical presentation of congenital central hypoventilation syndrome in an infant with central and obstructive sleep apnea. J Clin Sleep Med 2024; 20:478-481. [PMID: 37861394 PMCID: PMC11019219 DOI: 10.5664/jcsm.10884] [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] [Received: 06/06/2023] [Revised: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 10/21/2023]
Abstract
Congenital central hypoventilation syndrome (CCHS), a rare disease caused by paired-like homeobox 2B variants, affects control of breathing. We report on a 21-month-old boy with CCHS caused by a novel nonpolyalanine repeat mutation, neuroblastoma, severe obstructive and central sleep apnea, and sleep-related hypoxemia without hypoventilation. At 10 months, due to persistent central sleep apnea during serial polysomnography, bilevel positive airway pressure therapy was initiated despite the absence of hypoventilation. Nonpolyalanine repeat mutations are associated with severe phenotypes requiring continuous assisted ventilation, Hirschsprung's disease, and neural crest tumors; however, our patient had a relatively milder respiratory phenotype requiring sleep-only assisted ventilation without tracheostomy. Although alveolar hypoventilation is the hallmark of CCHS, our patient lacked hypoventilation. Bilevel positive airway pressure could be considered in some infants with CCHS requiring sleep-only assisted ventilation for tracheostomy avoidance. Our case demonstrates the expanding phenotypic spectrum in CCHS and the importance of formulating an individualized care plan. CITATION Fain ME, Raghunandan S, Pencheva B, Leu RM, Kasi AS. Images: atypical presentation of congenital central hypoventilation syndrome in an infant with central and obstructive sleep apnea. J Clin Sleep Med. 2024;20(3):478-481.
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Affiliation(s)
- Mary Ellen Fain
- Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Sharmila Raghunandan
- Division of Pediatric Hematology and Oncology, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Bojana Pencheva
- Division of Pediatric Hematology and Oncology, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Roberta M. Leu
- Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Ajay S. Kasi
- Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
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Schotland H, Wickwire E, Aaronson RM, Dawson SC, Khosla S, Lee-Iannotti JK, Leu RM, Lewin DS, McCrae CS, Neubauer D, Ong JC, Heffron TM, Whittington C, Martin JL. Increasing access to evidence-based insomnia care in the United States: findings from an American Academy of Sleep Medicine stakeholder summit. J Clin Sleep Med 2024; 20:455-459. [PMID: 37942936 PMCID: PMC11019205 DOI: 10.5664/jcsm.10922] [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] [Received: 11/07/2023] [Accepted: 11/07/2023] [Indexed: 11/10/2023]
Abstract
Challenges exist in access to high-quality care for insomnia disorder. After the recent publication of a clinical practice guideline on behavioral and psychological treatments for insomnia in adults, the American Academy of Sleep Medicine (AASM) hosted a 1-day virtual Insomnia Summit in September 2022 to discuss improving care for patients with insomnia disorder. Fifty participants representing a variety of organizations (eg, medical, psychological, and nursing associations; patient advocacy groups; and federal institutions) participated in the event. Videos highlighting patient perspectives on insomnia and an overview of current insomnia disorder treatment guidelines were followed by thematic sessions, each with 3 to 4 brief, topical presentations by content experts. Breakout groups were used to brainstorm and prioritize issues in each thematic area. Top barriers to care for insomnia disorder include limited access, limited awareness of treatment options, low perceived value of insomnia treatment, and an insufficient number of trained clinicians. Top facilitators of high-quality care include education and awareness, novel care models to increase access, expanding the insomnia patient care workforce, incorporating research into practice, and increasing reimbursement for psychotherapies. Priorities for the future include increasing awareness among patients and providers, increasing the number of skilled behavioral sleep medicine providers, increasing advocacy efforts to address insurance issues (eg, billing, reimbursement, and performance measures), and working collaboratively with multidisciplinary organizations to achieve common goals. These priorities highlight that goals set to improve accessible, high-quality care for insomnia disorder will require sustained, coordinated efforts to increase awareness, improve reimbursement, and grow the necessary skilled health care workforce. CITATION Schotland H, Wickwire E, Aaronson RM, et al. Increasing access to evidence-based insomnia care in the United States: findings from an American Academy of Sleep Medicine stakeholder summit. J Clin Sleep Med. 2024;20(3):455-459.
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Affiliation(s)
| | - Emerson Wickwire
- Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Spencer C. Dawson
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana
| | - Seema Khosla
- North Dakota Center for Sleep, Fargo, North Dakota
| | - Joyce K. Lee-Iannotti
- Department of Internal Medicine, Department of Neurology, University of Arizona College of Medicine–Phoenix, Phoenix, Arizona
| | - Roberta M. Leu
- Division of Pulmonology and Sleep, Department of Pediatrics, Emory University, Atlanta, Georgia
- Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | - Christina S. McCrae
- Department of Psychiatry, University of Missouri-Columbia, Columbia, Missouri
| | - David Neubauer
- Sleep Disorders Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jason C. Ong
- Nox Health, Inc, Alpharetta, Georgia
- Center for Circadian and Sleep Medicine, Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | - Jennifer L. Martin
- VA Greater Los Angeles Healthcare System, Geriatric Research, Education and Clinical Center, Los Angeles, California
- David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California
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Shah AS, Leu RM, Shah SP, Martinez F, Kasi AS. Images: Caffeine therapy for central sleep apnea, hypoxemia, and hypoventilation in a term neonate. J Clin Sleep Med 2023; 19:1005-1008. [PMID: 36747487 PMCID: PMC10152353 DOI: 10.5664/jcsm.10504] [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] [Received: 11/14/2022] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 02/08/2023]
Abstract
The evaluation of higher-risk infants with brief resolved unexplained events and term infants with central sleep apnea can be clinically challenging due to the multitude of potential etiologies. We report a 7-day-old term neonate hospitalized for evaluation of brief resolved unexplained events with oxygen desaturations during sleep. Polysomnography showed central sleep apnea, hypoxemia, hypoventilation, periodic breathing, and mild obstructive sleep apnea. Following initial evaluations and while awaiting genetic testing, primary central sleep apnea of infancy was suspected and caffeine was initiated. Three days after initiating caffeine, polysomnography showed resolution of hypoxemia, hypoventilation, obstructive sleep apnea, and periodic breathing and improved central sleep apnea. The central apnea-hypopnea index reduced from 58 to 6.8 events/h. Although caffeine is utilized in apnea of prematurity, there is limited literature regarding caffeine in term infants with apnea. Our case demonstrates that in term infants with primary central sleep apnea of infancy, immature regulation of respiration may persist and a trial of caffeine could be considered. CITATION Shah AS, Leu RM, Shah SP, Martinez F, Kasi AS. Caffeine therapy for central sleep apnea, hypoxemia, and hypoventilation in a term neonate. J Clin Sleep Med. 2023;19(5):1005-1008.
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Affiliation(s)
- Amit S. Shah
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Roberta M. Leu
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Samar P. Shah
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Frances Martinez
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Ajay S. Kasi
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
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Finch CE, Leu RM, Harford KL, Westbrook AL, Kasi AS. Sleep disturbances in parental caregivers and patients with congenital central hypoventilation syndrome. J Clin Sleep Med 2023; 19:549-554. [PMID: 36541215 PMCID: PMC9978429 DOI: 10.5664/jcsm.10384] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 12/24/2022]
Abstract
STUDY OBJECTIVES Congenital central hypoventilation syndrome (CCHS) is a rare disease characterized by impaired control of breathing caused by paired-like homeobox 2B (PHOX2B) gene variants, necessitating lifelong assisted ventilation (AV). This study aimed to assess sleep quality in patients with CCHS and their parents using sleep questionnaires. METHODS Parents of patients with CCHS completed the Pittsburgh Sleep Quality Index (PSQI) regarding their sleep and the Sleep Disturbance Scale for Children (SDSC) regarding their child's sleep. RESULTS Twenty participants completed the questionnaires. The median (interquartile range) ages of the parents and patients were 41.5 (38.5-51.5) and 11.5 (7.4-16.7) years, respectively. The median (interquartile range) PSQI and SDSC scores were elevated at 6.5 (4-10) and 41.5 (34-51.5), respectively, suggesting that parents and patients with CCHS can experience sleep disturbances and poor sleep quality. There were no significant differences in SDSC (P = 1.0) and PSQI (P = .76) scores for AV with or without tracheostomy. Similarly, there were no significant differences in SDSC (P = .22) and PSQI (P = .34) scores based on PHOX2B genotypes. There was a moderately strong, significant, and positive correlation between the CCHS SDSC scores and parental PSQI scores (r = .48, P = .03), suggesting that sleep disturbances in patients with CCHS were associated with poor parental sleep quality. There was no difference in the median parental sleep duration between those with and without nighttime home nursing (P = .09). CONCLUSIONS Patients with CCHS and their parents are at risk for sleep disturbances regardless of their AV modality and PHOX2B genotype. In addition to AV management, patients with CCHS and their parents should be assessed for sleep disturbances. CITATION Finch CE, Leu RM, Harford K-L, Westbrook AL, Kasi AS. Sleep disturbances in parental caregivers and patients with congenital central hypoventilation syndrome. J Clin Sleep Med. 2023;19(3):549-554.
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Affiliation(s)
- Christina E. Finch
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Roberta M. Leu
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Kelli-Lee Harford
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Adrianna L. Westbrook
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Ajay S. Kasi
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
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Kasi AS, Li H, Harford KL, Lam HV, Mao C, Landry AM, Mitchell SG, Clifton MS, Leu RM. Congenital Central Hypoventilation Syndrome: Optimizing Care with a Multidisciplinary Approach. J Multidiscip Healthc 2022; 15:455-469. [PMID: 35360554 PMCID: PMC8963195 DOI: 10.2147/jmdh.s284782] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 02/15/2022] [Indexed: 11/24/2022] Open
Abstract
Congenital central hypoventilation syndrome (CCHS) is a rare genetic disorder affecting respiratory control and autonomic nervous system function caused by variants in the paired-like homeobox 2B (PHOX2B) gene. Although most patients are diagnosed in the newborn period, an increasing number of patients are presenting later in childhood, adolescence, and adulthood. Despite hypoxemia and hypercapnia, patients do not manifest clinical features of respiratory distress during sleep and wakefulness. CCHS is a lifelong disorder. Patients require assisted ventilation throughout their life delivered by positive pressure ventilation via tracheostomy, noninvasive positive pressure ventilation, and/or diaphragm pacing. At different ages, patients may prefer to change their modality of assisted ventilation. This requires an individualized and coordinated multidisciplinary approach. Additional clinical features of CCHS that may present at different ages and require periodic evaluations or interventions include Hirschsprung’s disease, gastrointestinal dysmotility, neural crest tumors, cardiac arrhythmias, and neurodevelopmental delays. Despite an established PHOX2B genotype and phenotype correlation, patients have variable and heterogeneous clinical manifestations requiring the formulation of an individualized plan of care based on collaboration between the pulmonologist, otolaryngologist, cardiologist, anesthesiologist, gastroenterologist, sleep medicine physician, geneticist, surgeon, oncologist, and respiratory therapist. A comprehensive multidisciplinary approach may optimize care and improve patient outcomes. With advances in CCHS management strategies, there is prolongation of survival necessitating high-quality multidisciplinary care for adults with CCHS.
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Affiliation(s)
- Ajay S Kasi
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children’s Healthcare of Atlanta, Atlanta, GA, USA
- Correspondence: Ajay S Kasi, Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children’s Healthcare of Atlanta, 1400 Tullie Road NE, Atlanta, GA, 30329, USA, Tel +1 404 785 5437, Fax +1 404 785 9087, Email
| | - Hong Li
- Department of Human Genetics, Emory University, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Kelli-Lee Harford
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Humphrey V Lam
- Division of Pediatric Anesthesiology, Emory University, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Chad Mao
- Department of Pediatrics, Division of Pediatric Cardiology, Emory University, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - April M Landry
- Division of Pediatric Otorhinolaryngology, Emory University, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Sarah G Mitchell
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Emory University, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Matthew S Clifton
- Division of Pediatric Surgery, Emory University, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Roberta M Leu
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children’s Healthcare of Atlanta, Atlanta, GA, USA
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Shah AS, Leu RM, Keens TG, Kasi AS. Annual Respiratory Evaluations in Congenital Central Hypoventilation Syndrome and Changes in Ventilatory Management. Pediatr Allergy Immunol Pulmonol 2021; 34:97-101. [PMID: 34449269 DOI: 10.1089/ped.2021.0072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background: Annual in-hospital respiratory evaluations (AREs) during wakefulness and sleep are recommended to assess ventilatory requirements in patients with congenital central hypoventilation syndrome (CCHS) aged ≥2-3 years based on expert consensus. This study aimed to determine if AREs in patients with CCHS led to changes in ventilatory management. Methods: Retrospective review of patients with CCHS who underwent AREs with or without polysomnography between 2017 and 2019 was conducted. Clinical symptoms, results of AREs, and subsequent changes in ventilatory management were analyzed. Results: We identified 10 patients with CCHS aged 4-20 years. All patients required assisted ventilation (AV) only during sleep delivered by positive pressure ventilation via tracheostomy (n = 7) or diaphragm pacing (n = 3). In total, 7 (70%) patients had abnormal oxygenation and/or ventilation requiring changes in ventilator settings or duration of AV. Six patients required an increase in settings and/or duration of AV, and only 1 patient required a decrease in ventilator settings. Two patients had awake hypercapnia during a routine outpatient visit that improved following increase in ventilator settings and a period of continuous AV. One patient who was previously ventilator-dependent only during sleep was identified to require 16 h per day of AV. All patients (n = 3) who reported symptoms such as headache or oxygen desaturations during sleep required an increase in ventilator settings. Conclusion: We report a high prevalence of changes in AV management following an ARE. Our results demonstrate the importance of regular AREs in patients with CCHS to assess their ventilatory requirements and optimize AV.
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Affiliation(s)
- Amit S Shah
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Roberta M Leu
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Thomas G Keens
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Ajay S Kasi
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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Kasi AS, Anand N, Harford KL, Landry AM, Alfonso KP, Taylor M, Keens TG, Leu RM. Tracheostomy decannulation to noninvasive positive pressure ventilation in congenital central hypoventilation syndrome. Sleep Breath 2021; 26:133-139. [PMID: 33852109 DOI: 10.1007/s11325-021-02368-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/13/2021] [Accepted: 04/01/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Noninvasive positive pressure ventilation (NPPV) may permit tracheostomy decannulation (TD) in patients with congenital central hypoventilation syndrome (CCHS) requiring nocturnal positive pressure ventilation via tracheostomy (PPV-T). There is limited evidence on optimal strategies for transitioning patients from PPV-T to NPPV. This study aimed to describe the clinical course and outcome of children with CCHS who underwent TD and transitioned from PPV-T to NPPV. METHODS Retrospective review was conducted on patients with CCHS using nocturnal PPV-T who underwent TD to NPPV. The results of clinical evaluations, airway endoscopy, polysomnography, and clinical course leading to TD were analyzed. RESULTS We identified 3 patients with CCHS aged 8-17 years who required PPV-T only during sleep. Patients underwent systematic multidisciplinary evaluations with a pediatric psychologist, pulmonologist, sleep physician, and otolaryngologist utilizing a TD algorithm. These included evaluation in the sleep clinic, NPPV mask fitting and desensitization, endoscopic airway evaluation, daytime tracheostomy capping, acclimatization to low-pressure NPPV, polysomnography with capped tracheostomy and NPPV titration, and if successful, TD. All patients underwent successful TD following optimal titration of NPPV during polysomnography. The duration to TD from decision to pursue NPPV was between 2.4 and 10.6 months, and the duration of hospitalization for TD was between 4 and 5 days. There were no NPPV-related complications; however, all patients required surgical closure of tracheocutaneous fistula. CONCLUSION NPPV may be an effective and feasible option for patients with CCHS requiring PPV-T during sleep and permits TD. In patients with CCHS, a systematic multidisciplinary algorithm may optimize successful transition to NPPV and TD.
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Affiliation(s)
- Ajay S Kasi
- Division of Pediatric Pulmonology and Sleep Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, 1400 Tullie Road NE, Atlanta, GA, 30329, USA.
| | - Neesha Anand
- Division of Pediatric Pulmonology and Sleep Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, 1400 Tullie Road NE, Atlanta, GA, 30329, USA
| | - Kelli-Lee Harford
- Division of Pediatric Pulmonology and Sleep Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, 1400 Tullie Road NE, Atlanta, GA, 30329, USA
| | - April M Landry
- Division of Pediatric Otorhinolaryngology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kristan P Alfonso
- Division of Pediatric Otorhinolaryngology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Melissa Taylor
- Pediatric Sleep Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Thomas G Keens
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Roberta M Leu
- Division of Pediatric Pulmonology and Sleep Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, 1400 Tullie Road NE, Atlanta, GA, 30329, USA
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Anand N, Leu RM, Simon D, Kasi AS. Recurrent apnoea and respiratory failure in an infant: congenital central hypoventilation syndrome with a novel PHOX2B gene variant. BMJ Case Rep 2021; 14:e239633. [PMID: 33741569 PMCID: PMC7986671 DOI: 10.1136/bcr-2020-239633] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 20-day-old term infant presented with recurrent apnoea, lethargy and respiratory failure. Examination revealed episodes of apnoea and desaturation to 85% without any signs of respiratory distress requiring initiation of non-invasive positive pressure ventilation (NPPV). Capillary blood gas was indicative of respiratory acidosis and serum bicarbonate was elevated at 35 mmol/L. Chest radiograph, echocardiogram and evaluations for infectious aetiologies resulted normal. Due to inability to wean off NPPV with ensuing apnoea and desaturation, polysomnogram was performed and showed central and obstructive sleep apnoea, hypoxaemia and hypoventilation. Central apnoeas and hypoventilation were worse in non-rapid eye movement sleep. Paired-like homeobox 2B genetic studies showed a novel non-polyalanine repeat mutation (c.429+1G>A) establishing the diagnosis of congenital central hypoventilation syndrome (CCHS). Our case highlights the utility of polysomnography in the evaluation of term infants with apnoea. Although rare, clinicians should consider a diagnosis of CCHS in the evaluation of infants with apnoea and hypoventilation.
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Affiliation(s)
- Neesha Anand
- Pediatric Pulmonology and Sleep Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Roberta M Leu
- Pediatric Pulmonology and Sleep Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Dawn Simon
- Pediatric Pulmonology and Sleep Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ajay S Kasi
- Pediatric Pulmonology and Sleep Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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Abstract
NONE Diaphragm pacing (DP), a modality of ventilatory support in children with congenital central hypoventilation syndrome, generates respiration using the patient's own diaphragm as the respiratory pump. We report a 14-year-old boy with congenital central hypoventilation syndrome who uses DP with an uncapped tracheostomy during sleep. Polysomnography to titrate DP settings identified artifacts occurring in regular intervals coinciding with the onset of inspiration during all sleep stages in several channels including legs, snore, and electrocardiogram. Clinicians interpreting polysomnograms performed during DP should become familiar with the multichannel artifacts due to DP impulses. We also identified that our patient was hyperventilated on home DP settings that led to adjustment of DP settings during the polysomnogram to achieve optimal oxygenation and ventilation. Our case also highlights the utility of polysomnography to ensure optimal gas exchange during sleep in children with congenital central hypoventilation syndrome using DP.
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Affiliation(s)
- Lehna Pino-Diaz
- Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Roberta M Leu
- Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Ajay S Kasi
- Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
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Chada A, Leu RM, Perez IA, Esther CR, Kasi AS. Positional impairment of gas exchange during diaphragm pacing alleviated by increasing amplitude settings in congenital central hypoventilation syndrome. J Clin Sleep Med 2020; 16:459-462. [PMID: 31992416 DOI: 10.5664/jcsm.8232] [Citation(s) in RCA: 4] [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] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
None Diaphragm pacing (DP) by phrenic nerve stimulation is a modality of chronic ventilatory support in individuals with congenital central hypoventilation syndrome (CCHS). We report a 9-year-old girl with CCHS who uses DP without tracheostomy during sleep. Her parents report hypoxemia and hypercapnia related to positional changes of the body during sleep requiring frequent adjustment of pacer settings. Overnight polysomnography was performed to titrate DP settings that showed adequate gas exchange in the supine position, but intermittent hypoxemia and hypercapnia were noted in the left decubitus position without obstructive sleep apnea occurring. Subsequently, the DP amplitude settings were increased during polysomnography, thereby identifying and treating positional hypoxemia and hypercapnia in various body positions. Our case emphasizes the importance of polysomnography in children with CCHS using DP to monitor for sleep-disordered breathing and titration of DP settings to achieve optimal oxygenation and ventilation with different body positions during sleep.
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Affiliation(s)
- Aditya Chada
- Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Atlanta, Georgia
| | - Roberta M Leu
- Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Atlanta, Georgia
| | - Iris A Perez
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Charles R Esther
- Division of Pediatric Pulmonology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ajay S Kasi
- Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Atlanta, Georgia
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12
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Abstract
The prevalence of severe pediatric obesity is rising and poses many adverse health risks. Children with obesity are at increased risk of several cardiovascular and metabolic diseases. They are also more likely to have obstructive sleep apnea (OSA), which increases the risk of cardiovascular and metabolic problems. In this review, we examine the relationship between OSA and obesity, improvements in OSA after non-surgical and surgical weight loss, and explore potential directions for future research.
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Affiliation(s)
- Michelle L Kanney
- Division of Pulmonology, Allergy, Cystic Fibrosis and Sleep Medicine, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Kelli-Lee Harford
- Division of Pulmonology, Allergy, Cystic Fibrosis and Sleep Medicine, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Nikhila Raol
- Department of Otolaryngology-Head and Neck Surgery, Division of Pediatric Otolaryngology, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Roberta M Leu
- Division of Pulmonology, Allergy, Cystic Fibrosis and Sleep Medicine, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia.
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Riar SK, Greenbaum LA, Bliwise DL, Leu RM. Restless Legs Syndrome in Chronic Kidney Disease: Is Iron or Inflammatory Status To Blame? J Clin Sleep Med 2019; 15:1629-1634. [PMID: 31739853 PMCID: PMC6853406 DOI: 10.5664/jcsm.8028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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] [Received: 05/16/2019] [Revised: 07/20/2019] [Accepted: 07/22/2019] [Indexed: 01/28/2023]
Abstract
STUDY OBJECTIVES Restless legs syndrome (RLS) is increased in pediatric chronic kidney disease (CKD). In adults without CKD, central nervous system iron deficiency is involved in RLS pathogenesis and a low serum ferritin levels is consequently an indication for initiation of iron therapy. However, children with CKD are at risk for iron deficiency and inflammation, which raises serum ferritin. We examined the role of iron deficiency and inflammation in RLS in pediatric CKD. METHODS This cross-sectional study examined RLS prevalence in three groups of pediatric patients with CKD: nontransplant, nondialysis CKD (estimated GFR < 60 mL/min/1.73 m²) (n = 27); renal transplant recipients (n = 65); and dialysis (n = 32). RLS was diagnosed using a validated questionnaire. Serum ferritin < 100 ng/mL or transferrin saturation < 20% defined iron deficiency. Serum high sensitivity C-reactive protein ≥ 1 mg/L defined inflammation. RESULTS Among 124 patients, RLS prevalence was 15.3%; this did not differ across groups. There was no significant difference in RLS prevalence between those with and without iron deficiency, defined by either reduced ferritin or transferrin. Median ferritin levels in patients with RLS tended to be higher than in those without RLS (51.2 versus 40.1 ng/mL; P = .08). Inflammation (elevated CRP) also did not differ significantly by RLS status (57.9% [with RLS] versus 41.2% [without RLS], P = .18). CONCLUSIONS Neither ferritin nor inflammation differentiated pediatric patients with CKD with and without RLS. This study suggests that the factors mediating the pathogenesis and, potentially, treatment, of RLS in pediatric CKD may be different from non-CKD populations.
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Affiliation(s)
- Sandeep K Riar
- Pediatrics, Nephrology Division, University of Kansas Medical Center, Kansas City, Kansas
| | - Larry A Greenbaum
- Pediatrics, Nephrology Division, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Donald L Bliwise
- Neurology, Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Roberta M Leu
- Division of Pulmonology, Allergy, Cystic Fibrosis and Sleep Medicine, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
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14
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Farrell AN, Landry AM, Yee ME, Leu RM, Goudy SL. Sensorineural hearing loss in children with sickle cell disease. Int J Pediatr Otorhinolaryngol 2019; 118:110-114. [PMID: 30599285 PMCID: PMC6443092 DOI: 10.1016/j.ijporl.2018.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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] [Received: 09/12/2018] [Revised: 11/28/2018] [Accepted: 12/03/2018] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Sensorineural hearing loss (SNHL) has been reported to occur at increased frequency in the pediatric sickle cell disease (SCD) population, likely secondary to ototoxic medication regimens and repeat sickling events that lead to end organ damage. Risk and protective factors of SNHL in this population are not fully characterized. The objective of this study was to describe audiology results in children with SCD and the prevalence and sequelae of SNHL. METHODS A comprehensive clinical database of 2600 pediatric SCD patients treated at 1 institution from 2010-16 was retrospectively reviewed to identify all patients who were referred for audiologic testing. Audiologic test results, patient characteristics, and SCD treatments were reviewed. RESULTS 181 SCD children (97 male, 153 HbSS) underwent audiologic testing, with 276 total audiology encounters, ranging 1-9 per patient. Mean age at first audiogram was 8.9 ± 5.2 years. 29.8% had prior cerebrovascular infarct and an additional 25.4% had prior abnormal transcranial Doppler screens documented at time of first audiogram. Overall, 13.3% had documented hearing loss, with 6.6% SNHL. Mean pure tone average (PTA) among patients with SNHL ranged from mild to profound hearing loss (Right: 43.3 ± 28.9, Left: 40.8 ± 29.7), sloping to more severe hearing loss at higher frequencies. CONCLUSIONS Hearing loss was identified in a significant subset of children with SCD and the hearing loss ranged from normal to profound. Though the overall prevalence of SNHL in SCD patients was low, baseline audiology screening should be considered.
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Affiliation(s)
- Annie N. Farrell
- Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA, 30307, USA,Corresponding author. (A.N. Farrell)
| | - April M. Landry
- Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA, 30307, USA,Children’s Healthcare of Atlanta, Department of Otolaryngology, Division of Pediatric Otolaryngology, 2015 Uppergate Drive, Atlanta, GA, 30322, USA
| | - Marianne E. Yee
- Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA, 30307, USA,Children’s Healthcare of Atlanta, Department of Pediatrics, Division of Hematology/Oncology, 2015 Uppergate Drive, Atlanta, GA, 30322, USA,Children’s Healthcare of Atlanta, Aflac Cancer and Blood Disorders Center, 1405 Clifton Road, Atlanta, GA, 30329, USA
| | - Roberta M. Leu
- Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA, 30307, USA,Children’s Healthcare of Atlanta, Department of Pediatrics, Division of Pulmonary, Allergy/Immunology, Cystic Fibrosis, and Sleep., 1605 Chantilly Drive NE, Atlanta, GA 30324, USA
| | - Steven L. Goudy
- Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA, 30307, USA,Children’s Healthcare of Atlanta, Department of Otolaryngology, Division of Pediatric Otolaryngology, 2015 Uppergate Drive, Atlanta, GA, 30322, USA
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15
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Farrell AN, Goudy SL, Yee ME, Leu RM, Landry AM. Adenotonsillectomy in children with sickle cell disease and obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 2018; 111:158-161. [PMID: 29958601 PMCID: PMC6408690 DOI: 10.1016/j.ijporl.2018.05.034] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 05/26/2018] [Accepted: 05/28/2018] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Obstructive sleep apnea (OSA) is prevalent and may be more severe in children with Sickle Cell Disease (SCD) compared to the general pediatric population. OBJECTIVES The objective of this study was to describe the therapeutic effects and complications of tonsillectomy and adenoidectomy (T&A) for treatment of OSA in children with SCD. METHODS A comprehensive database of pediatric SCD patients was reviewed to identify all patients who underwent T&A between 2010 and 2016. An IRB-approved, retrospective review of laboratory values, perioperative course, pre- and post-T&A hospital utilization, and polysomnography was conducted. RESULTS There were 132 SCD children (108 HbSS) who underwent T&A. Mean age was 7.6 ± 4.6 years. The mean baseline hemoglobin of these patients was 9.3 ± 1.4 g/dL; 72.7% of patients had pre-operative transfusion, such that the mean Hb at time of T&A was 11.4 ± 1.0 g/dL. The average admission length surrounding T&A was 3.5 ± 1.2 days. Complications were documented in 11.4% of operative cases. Polysomnography was available in 104 pre-T&A and 45 post-T&A. The Apnea-Hypopnea Index decreased on post-T&A polysomnogram (7.6 ± 8.7 vs. 1.3 ± 1.9, p = 0.0001). The O2 nadir improved on post-T&A polysomnogram (81.2 ± 10.8 vs. 89.3 ± 7, p = 0.0003). Emergency room visits (mean events per year) decreased post-operatively (2.6 ± 2.8 vs. 1.8 ± 2.2, p = 0.0002). CONCLUSIONS T&A can be a safe and effective option to treat OSA in pediatric patients with SCD and was significantly associated with reduced AHI and fewer ER visits post-operatively.
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Affiliation(s)
- Annie N. Farrell
- Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA, 30307, USA,Corresponding author. (A.N. Farrell)
| | - Steven L. Goudy
- Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA, 30307, USA,Department of Otolaryngology, Children’s Hospital of Atlanta, Division of Pediatric Otolaryngology, 2015 Uppergate Drive, Atlanta, GA, 30322, USA
| | - Marianne E. Yee
- Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA, 30307, USA,Department of Pediatrics, Children’s Hospital of Atlanta, Division of Hematology/Oncology, 2015 Uppergate Drive, Atlanta, GA, 30322, USA,Children’s Hospital of Atlanta, Aflac Cancer and Blood Disorders Center, 1405 Clifton Road, Atlanta, GA, 30329, USA
| | - Roberta M. Leu
- Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA, 30307, USA,Department of Pediatrics, Children’s Hospital of Atlanta, Division of Pulmonary, Allergy/Immunology, Cystic Fibrosis, and Sleep, 1605 Chantilly Drive NE, Atlanta, GA, 30324, USA
| | - April M. Landry
- Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA, 30307, USA,Department of Otolaryngology, Children’s Hospital of Atlanta, Division of Pediatric Otolaryngology, 2015 Uppergate Drive, Atlanta, GA, 30322, USA
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17
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Leu RM, Beyderman L, Botzolakis EJ, Surdyka K, Wang L, Malow BA. Relation of melatonin to sleep architecture in children with autism. J Autism Dev Disord 2011; 41:427-33. [PMID: 20683768 DOI: 10.1007/s10803-010-1072-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Children with autism often suffer from sleep disturbances, and compared to age-matched controls, have decreased melatonin levels, as indicated by urine levels of the primary melatonin metabolite, 6-sulfatoxymelatonin (6-SM). We therefore investigated the relationship between 6-SM levels and sleep architecture in children with autism spectrum disorders (ASD). Twenty-three children, aged 4-10 years, completed two nights of polysomnography and one overnight urine collection for measurement of urinary 6-SM excretion rate. Parents completed the Children's Sleep Habits Questionnaire. We found that higher urinary 6-SM excretion rates were associated with increased N3 sleep, decreased N2 sleep, and decreased daytime sleepiness. The results warrant further examination to examine the effects of supplemental melatonin on sleep architecture and daytime sleepiness.
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Affiliation(s)
- Roberta M Leu
- Sleep Disorders Division, Department of Neurology, Vanderbilt University School of Medicine, Medical Center North, Nashville, TN 37232-2551, USA
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Mongan NP, Jääskeläinen J, Bhattacharyya S, Leu RM, Hughes IA. Steroid receptor coactivator-3 glutamine repeat polymorphism and the androgen insensitivity syndrome. Eur J Endocrinol 2003; 148:277-9. [PMID: 12590649 DOI: 10.1530/eje.0.1480277] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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