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Worth C, Worthington S, Auckburally S, O'Shea E, Ahmad S, Fullwood C, Salomon-Estebanez M, Banerjee I. First Accuracy and User-Experience Evaluation of New Continuous Glucose Monitoring System for Hypoglycemia Due to Hyperinsulinism. J Diabetes Sci Technol 2024:19322968241245923. [PMID: 38616550 DOI: 10.1177/19322968241245923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
INTRODUCTION Patients with congenital hyperinsulinism (HI) require constant glucose monitoring to detect and treat recurrent and severe hypoglycemia. Historically, this has been achieved with intermittent self-monitoring blood glucose (SMBG), but patients are increasingly using continuous glucose monitoring (CGM). Given the rapidity of CGM device development, and increasing calls for CGM use from HI families, it is vital that new devices are evaluated early. METHODS We provided two months of supplies for the new Dexcom G7 CGM device to 10 patients with HI who had recently finished using the Dexcom G6. Self-monitoring blood glucose was performed concurrently with paired readings providing accuracy calculations. Patients and families completed questionnaires about device use at the end of the two-month study period. RESULTS Compared to the G6, the G7 showed a significant reduction in mean absolute relative difference (25%-18%, P < .001) and in the over-read error (Bland Altman +1.96 SD; 3.54 mmol/L to 2.95 mmol/L). This resulted in an improvement in hypoglycemia detection from 42% to 62% (P < .001). Families reported an overall preference for the G7 but highlighted concerns about high sensor failure rates. DISCUSSION The reduction in mean absolute relative difference and over-read error and the improvement in hypoglycemia detection implies that the G7 is a safer and more useful device in the management of hypoglycemia for patients with HI. Accuracy, while improved from previous devices, remains suboptimal with 40% of hypoglycemia episodes not detected.
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Affiliation(s)
- Chris Worth
- Department Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Sarah Worthington
- Department Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Sameera Auckburally
- Department Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
- Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Elaine O'Shea
- Department Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Sumera Ahmad
- Department Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Catherine Fullwood
- Research and Innovation, Manchester University National Health Service Foundation Trust, Manchester, UK
- Centre for Biostatistics, Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | | | - Indraneel Banerjee
- Department Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Worth C, Gokul PR, Ramsden K, Worthington S, Salomon-Estebanez M, Maniyar A, Banerjee I. Brain magnetic resonance imaging review suggests unrecognised hypoglycaemia in childhood. Front Endocrinol (Lausanne) 2024; 15:1338980. [PMID: 38616820 PMCID: PMC11010682 DOI: 10.3389/fendo.2024.1338980] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 03/21/2024] [Indexed: 04/16/2024] Open
Abstract
Introduction Neonatal and early-life hypoglycaemia, is a frequent finding but is often non-specific and asymptomatic, making detection and diagnosis challenging. Hypoglycaemia-induced cerebral injury can be identified by magnetic resonance imaging (MRI) changes in cerebral white matter, occipital lobes, and posterior parietotemporal regions. It is unknown if children may have hypoglycaemic brain injury secondary to unrecognised hypoglycaemia in early life. We have examined retrospective radiological findings of likely brain injury by neuroimaging to investigate the existence of previous missed hypoglycaemic events. Methods Retrospective MRI data in children in a single tertiary centre, over a ten-year period was reviewed to identify potential cases of unrecognised early-life hypoglycaemia. A detailed search from an electronic radiology repository involved the term "hypoglycaemia'' from text-based reports. The initial report was used for those who required serial scanning. Images specific to relevant reports were further reviewed by a designated paediatric neuroradiologist to confirm likely hypoglycaemia induced brain injury. Medical records of those children were subsequently reviewed to assess if the hypoglycaemia had been diagnosed prior to imaging. Results A total of 107 MR imaging reports were identified for review, and 52 (48.5%) showed typical features strongly suggestive of hypoglycaemic brain injury. Medical note review confirmed no documented clinical information of hypoglycaemia prior to imaging in 22 (42%) patients, raising the likelihood of missed hypoglycaemic events resulting in brain injury. Conclusions We have identified the existence of unrecognised childhood hypoglycaemia through neuroimaging review. This study highlights the need for heightened awareness of early life hypoglycaemia to prevent adverse neurological outcomes later in childhood.
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Affiliation(s)
- Chris Worth
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, United Kingdom
| | - Pon Ramya Gokul
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, United Kingdom
| | - Katie Ramsden
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, United Kingdom
| | - Sarah Worthington
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, United Kingdom
| | - Maria Salomon-Estebanez
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, United Kingdom
| | - Amit Maniyar
- Department of Radiology, Royal Manchester Children’s Hospital, Manchester, United Kingdom
| | - Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, United Kingdom
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
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3
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Shaikh MG, Lucas-Herald AK, Dastamani A, Salomon Estebanez M, Senniappan S, Abid N, Ahmad S, Alexander S, Avatapalle B, Awan N, Blair H, Boyle R, Chesover A, Cochrane B, Craigie R, Cunjamalay A, Dearman S, De Coppi P, Erlandson-Parry K, Flanagan SE, Gilbert C, Gilligan N, Hall C, Houghton J, Kapoor R, McDevitt H, Mohamed Z, Morgan K, Nicholson J, Nikiforovski A, O'Shea E, Shah P, Wilson K, Worth C, Worthington S, Banerjee I. Standardised practices in the networked management of congenital hyperinsulinism: a UK national collaborative consensus. Front Endocrinol (Lausanne) 2023; 14:1231043. [PMID: 38027197 PMCID: PMC10646160 DOI: 10.3389/fendo.2023.1231043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/04/2023] [Indexed: 12/01/2023] Open
Abstract
Congenital hyperinsulinism (CHI) is a condition characterised by severe and recurrent hypoglycaemia in infants and young children caused by inappropriate insulin over-secretion. CHI is of heterogeneous aetiology with a significant genetic component and is often unresponsive to standard medical therapy options. The treatment of CHI can be multifaceted and complex, requiring multidisciplinary input. It is important to manage hypoglycaemia in CHI promptly as the risk of long-term neurodisability arising from neuroglycopaenia is high. The UK CHI consensus on the practice and management of CHI was developed to optimise and harmonise clinical management of patients in centres specialising in CHI as well as in non-specialist centres engaged in collaborative, networked models of care. Using current best practice and a consensus approach, it provides guidance and practical advice in the domains of diagnosis, clinical assessment and treatment to mitigate hypoglycaemia risk and improve long term outcomes for health and well-being.
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Affiliation(s)
- M. Guftar Shaikh
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Angela K. Lucas-Herald
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Antonia Dastamani
- Department of Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Maria Salomon Estebanez
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Senthil Senniappan
- Department of Paediatric Endocrinology, Alder Hey Children’s Hospital, Liverpool, United Kingdom
| | - Noina Abid
- Department of Paediatric Endocrinology, Royal Belfast Hospital for Sick Children, Belfast, United Kingdom
| | - Sumera Ahmad
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Sophie Alexander
- Department of Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Bindu Avatapalle
- Department of Paediatric Endocrinology and Diabetes, University Hospital of Wales, Cardiff, United Kingdom
| | - Neelam Awan
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Hester Blair
- Department of Dietetics, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Roisin Boyle
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Alexander Chesover
- Department of Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Barbara Cochrane
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Ross Craigie
- Department of Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Annaruby Cunjamalay
- Department of Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Sarah Dearman
- The Children’s Hyperinsulinism Charity, Accrington, United Kingdom
| | - Paolo De Coppi
- SNAPS, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- NIHR BRC UCL Institute of Child Health, London, United Kingdom
| | - Karen Erlandson-Parry
- Department of Paediatric Endocrinology, Alder Hey Children’s Hospital, Liverpool, United Kingdom
| | - Sarah E. Flanagan
- Department of Clinical and Biomedical Science, University of Exeter, Exeter, United Kingdom
| | - Clare Gilbert
- Department of Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Niamh Gilligan
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Caroline Hall
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Jayne Houghton
- Exeter Genomics Laboratory, Royal Devon University Healthcare NHS Foundation Trust, Exeter, United Kingdom
| | - Ritika Kapoor
- Department of Paediatric Endocrinology, Faculty of Medicine and Life Sciences, King’s College London, King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Helen McDevitt
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Zainab Mohamed
- Department of Paediatric Endocrinology, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Kate Morgan
- Department of Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Jacqueline Nicholson
- Paediatric Psychosocial Service, Royal Manchester Children’s Hospital, Manchester, United Kingdom
| | - Ana Nikiforovski
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Elaine O'Shea
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Pratik Shah
- Department of Paediatric Endocrinology, Barts Health NHS Trust, Royal London Children’s Hospital, London, United Kingdom
| | - Kirsty Wilson
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Chris Worth
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Sarah Worthington
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
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Worthington S, Shim A, Garafalo-Peterson J, Ryan K. Does BMI influence foot reaction time and balance scores in elderly women? J Sci Med Sport 2022. [DOI: 10.1016/j.jsams.2022.09.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Cohen OC, Brodermann MH, Blakeney IJ, Mahmood S, Sachchithanantham S, Ravichandran S, Law S, Lachmann HJ, Whelan CJ, Popat R, Rabin N, Yong K, Kyriakou C, Shah R, Cheesman S, Worthington S, Hawkins P, Gillmore JD, Wechalekar AD. Rapid response to single agent daratumumab is associated with improved progression-free survival in relapsed/refractory AL amyloidosis. Amyloid 2020; 27:200-205. [PMID: 32408823 DOI: 10.1080/13506129.2020.1765768] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 12/19/2022]
Abstract
Background: Daratumumab is a monoclonal antibody, which targets CD38; an antigen expressed on malignant plasma cells in AL amyloidosis thus providing a rationale for its use.Method: Patients treated with daratumumab monotherapy (2016-2019) for relapsed/refractory systemic AL amyloidosis were identified from the database at the UK National Amyloidosis Centre.Results: Of 50 evaluable patients, haematological responses at 3 months were: CR - 19 (38%), VGPR - 14 (28%), PR - 9 (18%) and no response - 8 (16%). Median time to response was 1 (1-6) month. Of assessable patients, cardiac, renal and hepatic responses were seen in 43.8%, 25.0% and 0% of patients whilst progression occurred in 25.0%, 12.5% and 37.5% respectively. Patients achieving a CR had longer median OS (not reached vs. 22.7 months [95% CI 17.0-28.4 months]) (p = .036). Furthermore, patients achieving a rapid response (at 1 month) had a longer median PFS (not reached vs. 9 months [95% CI 5.8-12.2 months]) (p = .013).Conclusion: Daratumumab monotherapy is effective in multiply-relapsed systemic AL amyloidosis and should be considered, if available, in patients who have not received prior daratumumab therapy. Responses are achieved rapidly and overall response rate was 84%. CR predicts overall survival whilst speed of response is predictive of a longer PFS.
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Affiliation(s)
- Oliver C Cohen
- National Amyloidosis Centre, University College London, London, UK
| | | | - Iona J Blakeney
- National Amyloidosis Centre, University College London, London, UK
| | - Shameem Mahmood
- National Amyloidosis Centre, University College London, London, UK.,University College London Hospitals NHS Foundation Trust, London, UK
| | - Sajitha Sachchithanantham
- National Amyloidosis Centre, University College London, London, UK.,University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Steven Law
- National Amyloidosis Centre, University College London, London, UK
| | - Helen J Lachmann
- National Amyloidosis Centre, University College London, London, UK
| | - Carol J Whelan
- National Amyloidosis Centre, University College London, London, UK
| | - Rakesh Popat
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Neil Rabin
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Kwee Yong
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Raakhee Shah
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Simon Cheesman
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Sarah Worthington
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Philip Hawkins
- National Amyloidosis Centre, University College London, London, UK
| | | | - Ashutosh D Wechalekar
- National Amyloidosis Centre, University College London, London, UK.,University College London Hospitals NHS Foundation Trust, London, UK
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6
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Sharpley FA, De-Silva D, Mahmood S, Sachchithanantham S, Ramsay I, Garcia Mingo A, Worthington S, Hughes D, Mehta A, Kyriakou C, Griffiths PD, Wechalekar AD. Cytomegalovirus reactivation after bortezomib treatment for multiple myeloma and light chain amyloidosis. Eur J Haematol 2020; 104:230-235. [PMID: 31815313 DOI: 10.1111/ejh.13366] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/03/2019] [Accepted: 09/05/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Cytomegalovirus (CMV) is an opportunistic herpesvirus, and reactivation of infection is possible in immunocompromised patients. Historically, the risk for haematology patients is restricted to those treated with an allogeneic transplant or T-cell depleting agents. Bortezomib is a highly efficacious proteasome inhibitor widely used to treat multiple myeloma and light chain (AL) amyloidosis patients. The objective of this small prospective study was to quantify the risk of CMV reactivation associated with bortezomib treatment. METHODS Fifty-seven consecutive multiple myeloma or AL amyloidosis patients commencing bortezomib-based therapy were included. Viral copy numbers were established at baseline and then at fortnightly intervals during treatment. Pre-emptive anti-viral treatment was initiated in patients with a viral load >7500 copies/mL. RESULTS Reactivation of CMV was detected in 39% (n = 12/31) of seropositive bortezomib treated patients compared with 0% of CMV seronegative patients. Detectable DNAemia developed during the first two cycles of treatment in 83% (n = 10/12) patients. Anti-viral treatment was initiated in 42% (n = 5/12), but no cases of active CMV disease were seen. CONCLUSION This study suggests that there is a substantial risk of CMV reactivation in CMV-seropositive plasma cell dyscrasia patients treated with bortezomib.
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Affiliation(s)
- Faye A Sharpley
- National Amyloidosis Centre, University College London, London, UK
| | - Dunnya De-Silva
- Department of Haematology, University College London Hospitals, London, UK
| | - Shameem Mahmood
- National Amyloidosis Centre, University College London, London, UK.,Department of Haematology, University College London Hospitals, London, UK.,Department of Virology, Royal Free London NHS Foundation Trust, London, UK
| | - Sajitha Sachchithanantham
- National Amyloidosis Centre, University College London, London, UK.,Department of Haematology, University College London Hospitals, London, UK.,Department of Virology, Royal Free London NHS Foundation Trust, London, UK
| | - Isobel Ramsay
- Department of Virology, Royal Free London NHS Foundation Trust, London, UK
| | - Ana Garcia Mingo
- Department of Virology, Royal Free London NHS Foundation Trust, London, UK
| | - Sarah Worthington
- Department of Haematology, University College London Hospitals, London, UK
| | - Derralynn Hughes
- Department of Haematology, Royal Free London NHS Foundation Trust, London, UK
| | - Atul Mehta
- Department of Haematology, Royal Free London NHS Foundation Trust, London, UK
| | | | - Paul D Griffiths
- Department of Virology, Royal Free London NHS Foundation Trust, London, UK
| | - Ashutosh D Wechalekar
- National Amyloidosis Centre, University College London, London, UK.,Department of Haematology, University College London Hospitals, London, UK.,Department of Virology, Royal Free London NHS Foundation Trust, London, UK
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7
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Manwani R, Mahmood S, Sachchithanantham S, Lachmann HJ, Gillmore JD, Yong K, Rabin N, Popat R, Kyriakou C, Worthington S, Sharpley F, Smith M, Shah R, Cheesman S, Hawkins PN, Wechalekar AD. Carfilzomib is an effective upfront treatment in AL amyloidosis patients with peripheral and autonomic neuropathy. Br J Haematol 2019; 187:638-641. [DOI: 10.1111/bjh.16122] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 05/29/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Richa Manwani
- National Amyloidosis Centre University College London (Royal Free Campus) LondonUK
| | - Shameem Mahmood
- National Amyloidosis Centre University College London (Royal Free Campus) LondonUK
- Department of Haematology University College London Hospitals London UK
| | - Sajitha Sachchithanantham
- National Amyloidosis Centre University College London (Royal Free Campus) LondonUK
- Department of Haematology University College London Hospitals London UK
| | - Helen J. Lachmann
- National Amyloidosis Centre University College London (Royal Free Campus) LondonUK
| | - Julian D. Gillmore
- National Amyloidosis Centre University College London (Royal Free Campus) LondonUK
| | - Kwee Yong
- Department of Haematology University College London Hospitals London UK
| | - Neil Rabin
- Department of Haematology University College London Hospitals London UK
| | - Rakesh Popat
- Department of Haematology University College London Hospitals London UK
| | | | - Sarah Worthington
- Department of Haematology University College London Hospitals London UK
| | - Faye Sharpley
- National Amyloidosis Centre University College London (Royal Free Campus) LondonUK
| | - Mark Smith
- Department of Haematology University College London Hospitals London UK
| | - Raakhee Shah
- Department of Haematology University College London Hospitals London UK
| | - Simon Cheesman
- Department of Haematology University College London Hospitals London UK
| | - Philip N. Hawkins
- National Amyloidosis Centre University College London (Royal Free Campus) LondonUK
| | - Ashutosh D. Wechalekar
- National Amyloidosis Centre University College London (Royal Free Campus) LondonUK
- Department of Haematology University College London Hospitals London UK
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8
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Coates LC, Savage L, Waxman R, Moverley AR, Worthington S, Helliwell PS. Comparison of screening questionnaires to identify psoriatic arthritis in a primary-care population: a cross-sectional study. Br J Dermatol 2016; 175:542-8. [PMID: 27031574 DOI: 10.1111/bjd.14604] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Many questionnaires are available for assessment of psoriatic arthritis (PsA), but there is little evidence comparing them. OBJECTIVES To test the proposed CONTEST questionnaire, which was developed to identify patients with psoriasis who have undiagnosed PsA, and compare it with the validated Psoriasis Epidemiology Screening Tool (PEST) questionnaire in a primary-care setting. METHODS A random sample of adult patients with psoriasis and no diagnosis of arthritis was identified from five general practice surgeries in Yorkshire, U.K. Consenting patients completed both questionnaires and were assessed by a dermatologist and rheumatologist. Diagnosis of PsA was made by the assessing rheumatologist. Receiver operator characteristic (ROC) curve analysis examined the sensitivity and specificity of potential cut points. RESULTS In total 932 packs were sent to recruit 191 (20·5%) participants. Of these, 169 (88·5%) were confirmed to have current or previous psoriasis. Using physician diagnosis 17 (10·1%) were found to have previously undiagnosed PsA, while 90 (53·3%) had another musculoskeletal complaint and 62 (36·7%) had no musculoskeletal problems. Using ROC curve analysis, all of the questionnaires showed a significant ability to identify PsA. The area under the curve (AUC) for the CONTEST questionnaires was slightly higher than that of PEST (0·69 and 0·70 vs. 0·65), but there was no significant difference identified. Examining the sensitivities and specificities for the different cut points suggested that a PEST score ≥ 2 would perform better in this dataset, and the optimal scores for CONTEST and CONTEST plus joint manikin were 3 and 4, respectively. CONCLUSIONS The accuracy of the questionnaires to identify PsA appeared similar, with a slightly higher AUC for the CONTEST questionnaires. The optimal cut points in this study appeared lower than in previous studies.
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Affiliation(s)
- L C Coates
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, 2nd Floor, Chapel Allerton Hospital, Harehills Lane, Leeds, LS7 4SA, U.K.,Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, U.K
| | - L Savage
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, 2nd Floor, Chapel Allerton Hospital, Harehills Lane, Leeds, LS7 4SA, U.K.,Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, U.K
| | - R Waxman
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, 2nd Floor, Chapel Allerton Hospital, Harehills Lane, Leeds, LS7 4SA, U.K
| | - A R Moverley
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, 2nd Floor, Chapel Allerton Hospital, Harehills Lane, Leeds, LS7 4SA, U.K.,Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, U.K
| | - S Worthington
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, 2nd Floor, Chapel Allerton Hospital, Harehills Lane, Leeds, LS7 4SA, U.K.,Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, U.K
| | - P S Helliwell
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, 2nd Floor, Chapel Allerton Hospital, Harehills Lane, Leeds, LS7 4SA, U.K.. .,Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, U.K..
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Abstract
The objective of this meta-analysis was to evaluate the prevalence of third molar (M3) impaction worldwide in individuals ≥17 y, from either sex, who had undergone oral radiography and presented with no orofacial syndromes or defects. We performed a literature search using PubMed, ISI Web of Science, and Google Scholar and retrieved English and non-English articles from any period for review. We included studies reporting M3 impaction prevalence based on radiographic examination. Risk of bias was assessed regarding individuals with craniofacial syndromes, prior extraction of permanent teeth, multiple effect size estimates, and studies conflating lack of eruption with impaction. Our search yielded 49 studies involving 83,484 individuals. Worldwide M3 impaction prevalence was found to be 24.40% (95% confidence interval [95% CI]: 18.97% to 30.80%). The odds of M3 impaction in the mandible were 57.58% (95% CI: 43.3% to 68.3%, P < 0.0001) higher than in the maxilla, but we did not detect any difference in the odds of impaction between men and women (18.62%, 95% CI: –4.9% to 48.0%, P = 0.12). Mesioangular impaction was most common (41.17%, 95% CI: 33.8% to 49.0%), followed by vertical (25.55%, 95% CI: 20.0% to 32.0%), distoangular (12.17%, 95% CI: 9.1% to 16.0%), and horizontal (11.06%, 95% CI: 8.3% to 14.6%). Impaction of 1 (42.71%, 95% CI: 30.0% to 56.5%) or 2 (29.64%, 95% CI: 19.5% to 42.3%) M3s was much more common than 3 (12.04%, 95% CI: 7.2% to 19.3%) or 4 (8.74%, 95% CI: 5.2% to 14.5%). There were small differences among impaction prevalence depending on geographic region ( F test, P = 0.049). Selection bias was evident because individuals had to undergo radiographic examination to be included in the analysis. The subgroup analysis by sex was underpowered. Worldwide M3 impaction prevalence is lower than previously reported. The percentage of individuals with impacted M3s is much smaller than the percentage that undergoes clinical treatment for M3 problems.
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Affiliation(s)
- K. Carter
- Department of Human Evolutionary Biology, Harvard University, Cambridge, MA, USA
| | - S. Worthington
- Institute for Quantitative Social Science, Harvard University, Cambridge, MA, USA
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Abstract
We aimed to consolidate all available data on worldwide third molar agenesis frequencies, with a particular emphasis on exploring the factors leading authors to find contradictory results for the demographic and morphologic predictors of this anomaly. A total of 12,376 studies were originally identified, then narrowed down to 1,312 for title/abstract screening. On the basis of our inclusion and exclusion criteria, we selected 92 studies, containing 100 effect sizes and 63,314 subjects, for systematic review and metaregression. The worldwide rate of agenesis was found to be 22.63% (95% confidence interval = 20.64% to 24.76%), although the estimates ranged from 5.32% to 56.0%. Our subgroup analyses revealed that women are 14% more likely than men to have agenesis of ≥1 third molars and that maxillary agenesis was 36% more likely than mandibular agenesis in both sexes. Furthermore, we found that having agenesis of 1 or 2 molars was most common, while agenesis of 3 or 4 molars was least common. Finally, we found large differences among agenesis frequency depending on geographic region. This information is expected to be of use not only to clinicians and patients but also to policy makers, given the implications for third molar extraction protocols.
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Affiliation(s)
- K Carter
- Department of Human Evolutionary Biology, Harvard University, Cambridge, MA, USA
| | - S Worthington
- Institute for Quantitative Social Science, Harvard University, Cambridge, MA, USA
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11
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Jacobs JA, Clayton PF, Dove C, Funchess T, Jones E, Perveen G, Skidmore B, Sutton V, Worthington S, Baker EA, Deshpande AD, Brownson RC. A survey tool for measuring evidence-based decision making capacity in public health agencies. BMC Health Serv Res 2012; 12:57. [PMID: 22405439 PMCID: PMC3364859 DOI: 10.1186/1472-6963-12-57] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Accepted: 03/09/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While increasing attention is placed on using evidence-based decision making (EBDM) to improve public health, there is little research assessing the current EBDM capacity of the public health workforce. Public health agencies serve a wide range of populations with varying levels of resources. Our survey tool allows an individual agency to collect data that reflects its unique workforce. METHODS Health department leaders and academic researchers collaboratively developed and conducted cross-sectional surveys in Kansas and Mississippi (USA) to assess EBDM capacity. Surveys were delivered to state- and local-level practitioners and community partners working in chronic disease control and prevention. The core component of the surveys was adopted from a previously tested instrument and measured gaps (importance versus availability) in competencies for EBDM in chronic disease. Other survey questions addressed expectations and incentives for using EBDM, self-efficacy in three EBDM skills, and estimates of EBDM within the agency. RESULTS In both states, participants identified communication with policymakers, use of economic evaluation, and translation of research to practice as top competency gaps. Self-efficacy in developing evidence-based chronic disease control programs was lower than in finding or using data. Public health practitioners estimated that approximately two-thirds of programs in their agency were evidence-based. Mississippi participants indicated that health department leaders' expectations for the use of EBDM was approximately twice that of co-workers' expectations and that the use of EBDM could be increased with training and leadership prioritization. CONCLUSIONS The assessment of EBDM capacity in Kansas and Mississippi built upon previous nationwide findings to identify top gaps in core competencies for EBDM in chronic disease and to estimate a percentage of programs in U.S. health departments that are evidence-based. The survey can serve as a valuable tool for other health departments and non-governmental organizations to assess EBDM capacity within their own workforce and to assist in the identification of approaches that will enhance the uptake of EBDM processes in public health programming and policymaking. Localized survey findings can provide direction for focusing workforce training programs and can indicate the types of incentives and policies that could affect the culture of EBDM in the workplace.
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Affiliation(s)
- Julie A Jacobs
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Paula F Clayton
- Bureau of Health Promotion, Kansas Department of Health and Environment, Topeka, KS, USA
| | - Cassandra Dove
- Office of Preventive Health, Mississippi State Department of Health, Jackson, MS, USA
| | - Tanya Funchess
- Office of Tobacco Control, Mississippi State Department of Health, Jackson, MS, USA
| | - Ellen Jones
- School of Health Related Professions, University of Mississippi Medical Center, and National Association of Chronic Disease Directors, Jackson, MS, USA
| | - Ghazala Perveen
- Bureau of Health Promotion, Kansas Department of Health and Environment, Topeka, KS, USA
| | - Brandon Skidmore
- Bureau of Health Promotion, Kansas Department of Health and Environment, Topeka, KS, USA
| | - Victor Sutton
- Office of Preventive Health, Mississippi State Department of Health, Jackson, MS, USA
| | - Sarah Worthington
- Active Living KC, Kansas City Health Department, Kansas City, MO, USA
| | - Elizabeth A Baker
- Prevention Research Center in St. Louis, Saint Louis University School of Public Health, St. Louis, MO, USA
| | - Anjali D Deshpande
- Division of Health Behavior Research, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Ross C Brownson
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, St. Louis, MO, USA
- Division of Public Health Sciences, Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
- George Warren Brown School of Social Work, Division of Public Health Sciences, School of Medicine, Washington University in St. Louis, Kingshighway Building 660 S. Euclid Campus, Box 8109, St. Louis, MO 63110, USA
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12
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Whitaker IS, Worthington S, Jivan S, Phipps A. The use of Biobrane by burn units in the United Kingdom: a national study. Burns 2007; 33:1015-20. [PMID: 17764848 DOI: 10.1016/j.burns.2006.11.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [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: 09/08/2006] [Accepted: 11/28/2006] [Indexed: 10/22/2022]
Abstract
Biobrane is a biosynthetic wound dressing, first used by Woodruff in 1979, which has many of the ideal properties of a dressing as outlined by Pruitt and Levine [Pruitt Jr BA, Levine NS. Characteristics and uses of biologic dressings and skin substitutes. Arch Surg 1984;119(3):312-22]. It is becoming increasingly popular in the management of superficial and moderate depth partial thickness burns and a range of other conditions. When used appropriately, it has been shown to reduce pain levels, healing time, inpatient stay and nursing requirements when compared to traditional dressings. We present the results of a national study concerning the use of Biobrane in the United Kingdom, highlight variations in practice, discuss the pertinent issues, make suitable recommendations and highlight the versatility of Biobrane as a wound dressing.
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Affiliation(s)
- I S Whitaker
- The Yorkshire Regional Burns Unit, Pinderfield's Hospital, Wakefield, United Kingdom.
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13
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Hogema BM, Akaboshi S, Taylor M, Salomons GS, Jakobs C, Schutgens RB, Wilcken B, Worthington S, Maropoulos G, Grompe M, Gibson KM. Prenatal diagnosis of succinic semialdehyde dehydrogenase deficiency: increased accuracy employing DNA, enzyme, and metabolite analyses. Mol Genet Metab 2001; 72:218-22. [PMID: 11243727 DOI: 10.1006/mgme.2000.3145] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Inherited succinic semialdehyde dehydrogenase (SSADH; EC1.2.1.24; McKusick 271980) deficiency is a defect of GABA degradation which leads to accumulation of 4-hydroxybutyric acid (gamma-hydroxybutyric acid; GHB) in physiologic fluids of patients. Prenatal diagnosis (PND) was performed in three at-risk pregnancies employing combinations of: (1) reverse-transcription-polymerase chain reaction (RT-PCR) and genomic DNA amplification followed by sequencing using isolated leukocytes or cultured human lymphoblasts; (2) GHB quantitation in amniotic fluid; or (3) SSADH enzyme assay in chorionic villus (CV) and/or amniocytes. In two pregnancies, all analyses were concordant for prediction of disease status in the fetus. In the third case, enzyme activity in CV (deficient) and metabolite analysis in amniotic fluid (normal) were discordant. For clarification, mutation analysis was undertaken in CV, confirming heterozygosity for the mutation previously identified in the proband. We hypothesize that delayed transit time for shipment of CV between Greece and the United States (8 days) led to enhanced degradation of heterozygous SSADH enzyme activity. Our data demonstrate the importance of combined metabolite, enzyme, and DNA analysis for increased accuracy in the PND of SSADH deficiency.
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Affiliation(s)
- B M Hogema
- Department of Molecular and Medical Genetics, Oregon Health Sciences University, Portland, Oregon 97210, USA
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14
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Abstract
Non-mosaic trisomy 9 was found in a chorionic villus (CV) sample taken from a 43-year-old woman referred for prenatal chromosome analysis due to advanced maternal age. Follow-up amniocentesis revealed level 2 mosaicism for trisomy 9. Trisomy 9 was not detected at fetal blood sampling. Molecular analysis of fetal (amniocyte) DNA showed maternal uniparental heterodisomy (UPD) for chromosome 9. Two crossovers resulted in a region of isodisomy in the distal long arm. Trisomy rescue of a meiosis 1 segregation error seems to have been responsible for the uniparental disomy of chromosome 9. The pregnancy continued and neonatal blood testing showed a mosaic trisomy 9 karyotype, i.e. 4/50 cells analysed. Clinical postnatal follow-up for a period of 1 year has documented only minor facial dysmorphism and skeletal abnormalities. Development appears unremarkable. This case is the second report of maternal uniparental disomy for chromosome 9 detected prenatally and is the first case followed up post-term. This report highlights the difficulty of making informed prognostic assessments in such cases despite extensive laboratory investigation.
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Affiliation(s)
- H R Slater
- VCGS Cytogenetics Laboratory, Murdoch Children's Research Institute, Parkville, Victoria 3052, Australia.
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15
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Abstract
We report a familial case of velocardiofacial syndrome (VCFS) with polymicrogyria to provide further support for the association of disorders of cortical development with del(22q11) syndromes.
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Affiliation(s)
- S Worthington
- Department of Medical Genetics, Sydney Children's Hospital, Australia
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16
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Abstract
OBJECTIVE To ascertain the frequency of 22q11 deletions in a representative population of conotruncal heart defects (CTD) and determine which children are at risk of having a deletion. METHODOLOGY A clinical and laboratory evaluation of 90 children with CTD, including isolated and syndromic cases. RESULTS Fifteen children (17%) were shown to have 22q11 deletions by fluorescence in situ hybridization (FISH) studies with the Oncor probe N25. Varying degrees of developmental delay/learning disabilities and facial dysmorphism were common in these children. None of the isolated cases without dysmorphism had a deletion. CONCLUSION 22q11 deletions are a significant cause of a specific form of congenital heart disease, CTD. It is important to have a high index of suspicion of the 22q11 deletion disorders in children with CTD and other extracardiac manifestations so that the diagnosis can be made early and appropriate interventions implemented.
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Affiliation(s)
- S Worthington
- Genetic Services of Western Australia, Princess Margaret Hospital, Subiaco, Western Australia, Australia
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17
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Abstract
To report the first case of carbohydrate deficient glycoprotein syndrome Type I (CDG I) that has been identified in Australia and confirmed enzymatically to raise the awareness of paediatricians with regard to CDG I and its manifestations, implications and diagnostic investigations. Clinical and autopsy findings of an infant with CDG I are presented. The diagnosis of CDG I was suggested by the clinical findings and biochemical abnormalities and was confirmed by showing an abnormal transferrin isoform pattern. Subsequent studies showed a reduced level of phosphomannomutase in skin fibroblasts. Carbohydrate-deficient glycoprotein syndrome I is one of the many causes of cerebellar hypoplasia. It is an important disorder to identify because of the prognostic and genetic implications and may be underdiagnosed in Australia.
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Affiliation(s)
- S Worthington
- Department of Clinical Genetics, New Children's Hospital, Parramatta, New South Wales, Australia
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18
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Affiliation(s)
- S Worthington
- Department of Clinical Genetics, Sydney Children's Hospital, NSW, Australia
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19
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Abstract
The clinical, radiographic, and morphological findings in 25 cases of atelosteogenesis and boomerang dysplasia have been reviewed. The review confirms the nosologic grouping of atelosteogenesis type I with boomerang dysplasia and the clinical and radiographic overlap of features between atel- osteogenesis I and atelosteogene- sis II (synonymous with De la Chapelle dysplasia) and a group of patients with atelosteogenesis type III. A common pathogenesis is suggested for atelosteogenesis type I and boomerang dysplasia. A marked excess of male fetuses with boomerang dysplasia was observed. Atelosteogenesis type II shows distinctive chondro-osseous histopathology with a major disturbance in cartilage matrix macromolecules. An overlap of phenotypic, radiographic, morphological, and cartilage histochemical features with those observed in diastrophic dysplasia and achondrogenesis type IB suggests that atelosteogenesis type II has common pathogenetic features with disorders of sulfation of connective tissue matrix macro- molecules.
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Affiliation(s)
- D Sillence
- Department of Clinical Genetics, The New Children's Hospital, P. O. Box 3515, Parramatta, NSW 2124, Australia
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20
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Abstract
We report three cases of velocardiofacial syndrome (VCFS) with anal anomalies who have deletions of the 22q11 region and a further case where the proband has VCFS clinically and her father has an anal anomaly. It is important to consider VCFS in the differential diagnosis of children with anal anomalies and to look for other features of the syndrome, such as asymmetrical crying facies, submucous cleft of the palate, developmental delay, cardiac anomalies, and hypoparathyroidism.
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Affiliation(s)
- S Worthington
- Department of Clinical Genetics, Sydney Children's Hospital, Randwick, NSW, Australia
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Abstract
We present the outcome of a pregnancy in a woman with mild argininosuccinic lyase deficiency to add to the collective experience of the maternal and fetal effects of urea cycle defects. In females affected with argininosuccinic lyase deficiency, careful clinical and biochemical monitoring of pregnancy will minimize the risk of metabolic decompensation in the perinatal period. Furthermore, it would appear that argininosuccinate is not teratogenic to the development of the human fetus.
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Affiliation(s)
- S Worthington
- Western Sydney Genetics Program, Westmead, Australia
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Worthington S. Shaping women's health care. NP News 1995; 3:10, 14. [PMID: 7767828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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23
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Abstract
Over the last several years, there has been a steady increase in the number of women experiencing abnormal Papanicolaou test results. Whether the nurse-midwife is performing a colposcopic examination or making a referral, she or he needs to have a clear understanding of cervical pathophysiology, diagnostic modalities, and therapeutic management. This article provides the nurse-midwife with a basic review of the cytologic and histologic findings of the cervix, a description of the colposcopy procedure, observations, terminology, and follow-up treatment, and considerations for adding colposcopy to a nurse-midwifery practice.
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Affiliation(s)
- S Worthington
- PPFA Nurse Practioner Program, Philadelphia, PA 19102
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24
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Stanley FJ, Sim M, Wilson G, Worthington S. The decline in congenital rubella syndrome in Western Australia: an impact of the school girl vaccination program? Am J Public Health 1986; 76:35-7. [PMID: 3940451 PMCID: PMC1646423 DOI: 10.2105/ajph.76.1.35] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Rubella vaccination became available in 1970 in Australia. In Western Australia (WA), a school girl vaccination program was well established by 1971. Mothers under 26 years of age in 1983 would have been eligible for this program and they constitute 40 per cent of WA births. Data on Congenital Rubella Syndrome (CRS) cases were obtained for years of birth 1968-83 inclusive to ascertain if there had been an impact of the program on the CRS rate. Epidemics of rubella occurred in 1970-71, 1974, and 1979-80. The CRS rate has fallen steadily; it did not rise during the 1979-80 epidemic and was less than one in each year after 1977. All CRS cases born since 1974 were to mothers too old to have been eligible for the program. The data suggest that the vaccination program is effective, but this cannot be proven until data become available on pregnancy terminations.
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Worthington S, Lehmann H. The first observation of Hb D Punjab beta zero thalassaemia in an English family with 22 cases of unsuspected beta zero thalassaemia minor among its members. J Med Genet 1985; 22:377-81. [PMID: 4078867 PMCID: PMC1049482 DOI: 10.1136/jmg.22.5.377] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
A 36 year old local Englishman from Nuneaton was referred to hospital with suspected glandular fever. Relevant tests were negative and the symptoms subsided in due course. The finding of a hypochromic microcytic blood picture without iron deficiency led to the discovery that he was heterozygous for Hb D and beta thalassaemia. Hb D trait was established in the father of the proband and beta thalassaemia in his mother and a brother. The father's ancestors were miners who came to Nuneaton from Monmouthshire in the 19th century. The mother's ancestors have belonged to the indigenous population of Nuneaton and neighbouring Leicestershire since the 18th century. Twenty local members of her wider family also had thalassaemia. All thalassaemias had a low MCH and raised level of Hb A2. The Hb F level, however, was normal in five, demonstrating the independent segregation of genetic factors influencing the Hb F level in beta thalassaemia trait.
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26
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Worthington S. Genetic screening. JOGN Nurs 1984; 13:32s-37s. [PMID: 6562263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
The family planning nurse practitioner may be the client's only link to genetic screening, education, and counseling. The principles of genetics, the types of genetic defects and their causes are presented. Clients at risk and the nurse practitioner's role in providing education, support, counseling, and referrals are discussed.
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27
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Pentelow FTK, Worthington S, Worthington EB. African Lakes. J Anim Ecol 1934. [DOI: 10.2307/1289] [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: 11/10/2022]
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