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Mulligan MJ, Breviu AB, Hall SK, Stenehjem KE, Cioletti AC. Beyond the Exam Room: Teaching Intervisit Care to Internal Medicine Residents. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2024; 20:11479. [PMID: 39741870 PMCID: PMC11685312 DOI: 10.15766/mep_2374-8265.11479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 09/23/2024] [Indexed: 01/03/2025]
Abstract
Introduction Intervisit care, asynchronous care provided between patient visits, represents an essential part of patient care. Despite the importance of intervisit care, residency programs have not traditionally taught residents how to effectively manage intervisit care within the formal curriculum. We aimed to improve resident preparedness in providing intervisit care with an intervisit workshop. Methods We developed a 2-hour, small-group, interactive workshop on intervisit care for categorical internal medicine interns at the University of Utah in Fall of 2023. The workshop consisted of a didactic session introducing a novel framework for intervisit care medical decision-making, case-based application, and practical site-specific applications using the electronic health record. We evaluated the workshop with an electronic survey following the session. Results Thirty-two internal medicine residents (100% participation rate) participated in the workshop and 26/32 (81%) completed the survey. Residents felt intervisit care education was extremely important (median = 5, interquartile range [IQR] = 1). Residents felt more prepared to provide intervisit care after the workshop (median = 2, IQR = 2, vs. median = 4, IQR = 0; p < .001). Residents felt the framework for medical decision-making was helpful (median = 4, IQR = 1). Discussion By employing a framework to guide medical decision-making and guided application, our intervisit care workshop improved residents' perceived preparedness in providing intervisit care for their patients. This workshop addresses a major gap in medical education and can be adapted by other institutions and specialties. Further work is needed to reinforce content and develop metrics of intervisit care.
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Madaras-Kelly K, Hostler C, Townsend M, Potter EM, Spivak ES, Hall SK, Goetz MB, Nevers M, Ying J, Haaland B, Rovelsky SA, Pontefract B, Fleming-Dutra K, Hicks LA, Samore MH. Impact of Implementation of the Core Elements of Outpatient Antibiotic Stewardship Within Veterans Health Administration Emergency Departments and Primary Care Clinics on Antibiotic Prescribing and Patient Outcomes. Clin Infect Dis 2020; 73:e1126-e1134. [PMID: 33289028 DOI: 10.1093/cid/ciaa1831] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Core Elements of Outpatient Antibiotic Stewardship provide a framework to improve antibiotic use. We report the impact of core elements implementation within Veterans Health Administration sites. METHODS In this quasiexperimental controlled study, effects of an intervention targeting antibiotic prescription for uncomplicated acute respiratory tract infections (ARIs) were assessed. Outcomes included per-visit antibiotic prescribing, treatment appropriateness, ARI revisits, hospitalization, and ARI diagnostic changes over a 3-year pre-implementation period and 1-year post-implementation period. Logistic regression adjusted for covariates (odds ratio [OR], 95% confidence interval [CI]) and a difference-in-differences analysis compared outcomes between intervention and control sites. RESULTS From 2014-2019, there were 16 712 and 51 275 patient visits within 10 intervention and 40 control sites, respectively. Antibiotic prescribing rates pre- and post-implementation within intervention sites were 59.7% and 41.5%, compared to 73.5% and 67.2% within control sites, respectively (difference-in-differences, P < .001). Intervention site pre- and post-implementation OR to receive appropriate therapy increased (OR, 1.67; 95% CI, 1.31-2.14), which remained unchanged within control sites (OR,1.04; 95% CI, .91-1.19). ARI-related return visits post-implementation (-1.3% vs -2.0%; difference-in-differences P = .76) were not different, but all-cause hospitalization was lower within intervention sites (-0.5% vs -0.2%; difference-in-differences P = .02). The OR to diagnose non-specific ARI compared with non-ARI diagnoses increased post-implementation forintervention (OR, 1.27; 95% CI, 1.21 -1.34) but not control (OR, 0.97; 95% CI, .94-1.01) sites. CONCLUSIONS Implementation of the core elements was associated with reduced antibiotic prescribing for RIs and a reduction in hospitalizations. Diagnostic coding changes were observed.
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Lawson AJ, Bernstone L, Hall SK. Newborn screening blood spot analysis in the UK: influence of spot size, punch location and haematocrit. J Med Screen 2015; 23:7-16. [DOI: 10.1177/0969141315593571] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 05/20/2015] [Indexed: 11/16/2022]
Abstract
Objective In dried blood spot analysis, punch location and variations in applied sample volume and haematocrit can produce different measured concentrations of analytes. We investigated the magnitude of these effects in newborn screening in the UK. Methods Heparinized blood spiked with thyroid stimulating hormone (TSH), phenylalanine, tyrosine, leucine, methionine, octanoyl carnitine (C8), and immunoreactive trypsinogen (IRT) was spotted onto filter paper: (i) at a constant haematocrit of 50% at various volumes, and (ii) at a range of haematocrits using a constant volume. Subpunches (3.2 mm) of the dried blood spots were then analysed. Results Compared with a central punch from a 50 µL blood spot with 50% haematocrit, 10 µL spots can have significantly lower measured concentrations of all analytes, with decreases of 15% or more observed for leucine, methionine, phenylalanine, and tyrosine. Punching at the edge of a spot can increase measured concentrations up to 35%. Higher haematocrit decreased measured TSH and C8 yet increased amino acids and IRT by 15% compared with 50% haematocrit. Lower haematocrits had the opposite effect, but only with higher concentrations of some analytes. Conclusions Differences in blood spot size, haematocrit and punch location substantially affect measured concentrations for analytes used in the UK newborn screening programme, and this could affect false positive and negative rates. To minimize analytical bias, these variables should be controlled or adjusted for where possible.
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Hu X, Zhang B, Liu W, Paciga S, He W, Lanz TA, Kleiman R, Dougherty B, Hall SK, McIntosh AM, Lawrie SM, Power A, John SL, Blackwood D, St Clair D, Brandon NJ. A survey of rare coding variants in candidate genes in schizophrenia by deep sequencing. Mol Psychiatry 2014; 19:857-8. [PMID: 24126932 PMCID: PMC4113932 DOI: 10.1038/mp.2013.131] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Hu X, Pickering EH, Hall SK, Naik S, Liu YC, Soares H, Katz E, Paciga SA, Liu W, Aisen PS, Bales KR, Samad TA, John SL. Genome-wide association study identifies multiple novel loci associated with disease progression in subjects with mild cognitive impairment. Transl Psychiatry 2011; 1:e54. [PMID: 22833209 PMCID: PMC3309471 DOI: 10.1038/tp.2011.50] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Alzheimer's disease (AD) is the leading cause of dementia among the elderly population; however, knowledge about genetic risk factors involved in disease progression is limited. We conducted a genome-wide association study (GWAS) using clinical decline as measured by changes in the Clinical Dementia Rating-sum of boxes as a quantitative trait to test for single-nucleotide polymorphisms (SNPs) that were associated with the rate of progression in 822 Caucasian subjects of amnestic mild cognitive impairment (MCI). There was no significant association with disease progress for any of the recently identified disease susceptibility variants in CLU, CR1, PICALM, BIN1, EPHA1, MS4A6A, MS4A4E or CD33 following multiple testing correction. We did, however, identify multiple novel loci that reached genome-wide significance at the 0.01 level. These top variants (rs7840202 at chr8 in UBR5: P=4.27 × 10(-14); rs11637611 with a cluster of SNPs at chr15q23 close to the Tay-Sachs disease locus: P=1.07 × 10(-15); and rs12752888 at chr1: P=3.08 × 10(-11)) were also associated with a significant decline in cognition as well as the conversion of subjects with MCI to a diagnosis of AD. Taken together, these variants define approximately 16.6% of the MCI sub-population with a faster rate of decline independent of the other known disease risk factors. In addition to providing new insights into protein pathways that may be involved with the progress to AD in MCI subjects, these variants if further validated may enable the identification of a more homogeneous population of subjects at an earlier stage of disease for testing novel hypotheses and/or therapies in the clinical setting.
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Murray C, Hall SK, Griffiths P. An evaluation of the Sebia capillarys Neonat Haemoglobin FAST™ system for routine newborn screening for sickle cell disease. Int J Lab Hematol 2011; 33:533-9. [PMID: 21535479 DOI: 10.1111/j.1751-553x.2011.01315.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The West Midlands Newborn Screening Laboratory (NBSL) at Birmingham Children's Hospital (BCH), UK, screens approximately 71 000 babies per annum using the Bio-Rad automated VARIANT™ nbs (Vnbs) high-pressure liquid chromatograph (HPLC). Any abnormal haemoglobins detected, including S, C, D-Punjab, E and O-Arab as directed by the NHS Sickle Cell and Thalassaemia Screening Programme (NHS Sickle Cell and Thalassaemia Screening Programme Website, http://sct.screening.nhs.uk), are then confirmed using Resolve® isoelectric electric focusing (IEF) kits supplied by Perkin-Elmer. The Sebia capillarys Neonat Haemoglobin FAST™ system was evaluated as a possible replacement for the first- or second-line methods used. Both the Sebia and Bio-Rad methods were compared using anonymized blood spots with known haemoglobin patterns. These results were then confirmed when necessary by IEF. The Sebia-recommended sample preparation was also modified to enable testing to be more comparable with our current processes. Percentages of haemoglobins calculated from integration of areas under the peaks were compared between the Bio-Rad Vnbs HPLC and Sebia capillarys Neonat Haemoglobin FAST™ system. Of the 347 blood spots tested by both HPLC and capillary electrophoresis, there were no significant differences. The Sebia capillarys Neonat Haemoglobin FAST™ system can be used to successfully screen newborns for sickle cell disease in blood spots collected for newborn screening with full positive sample identification and traceability.
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Puntis JW, Hall SK, Green A, Smith DE, Ball PA, Booth IW. Biochemical stability during parenteral nutrition in children. Clin Nutr 2009; 12:153-9. [PMID: 16843305 DOI: 10.1016/0261-5614(93)90074-e] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/1992] [Accepted: 01/21/1993] [Indexed: 11/19/2022]
Abstract
The aim of this study was to assess the frequency and importance of biochemical abnormality related to parenteral nutrition (PN) in a group of infants, and to devise an appropriate policy for routine biochemical surveillance. A standard monitoring protocol based on widely published guidelines was applied to 30 consecutive patients (age 3 days-3 years) referred to a children's hospital nutritional care team for PN. No serious biochemical abnormalities were observed to arise simply as a consequence of PN. Electrolyte disturbance most commonly occurred before starting PN. Biochemical abnormality was most likely to be found in patients with abnormal fluid and electrolyte losses. Protocols for biochemical surveillance during PN err on the side of caution and often suggest frequent and comprehensive testing. In stable patients such as the surgical newborn, this is both expensive and unnecessary, and simpler monitoring regimes may be used with safety.
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MacDonald A, Lilburn M, Davies P, Evans S, Daly A, Hall SK, Hendriksz C, Chakrapani A, Lee P. 'Ready to drink' protein substitute is easier is for people with phenylketonuria. J Inherit Metab Dis 2006; 29:526-31. [PMID: 16736099 DOI: 10.1007/s10545-006-0234-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2005] [Accepted: 03/15/2006] [Indexed: 10/24/2022]
Abstract
UNLABELLED In phenylketonuria (PKU), compliance with taking protein substitute is an issue in teenage and older patients. A 'ready to drink' protein substitute may overcome many of the practical issues associated with its administration. OBJECTIVE To investigate the efficacy of a liquid protein substitute in a 6-week, three-part, randomized, crossover, controlled study. METHODS 27 subjects (15 female; 12 male) with PKU with a median age of 30 years (range 8-49 years) were recruited. One subject withdrew from the study. Their median daily dose of protein equivalent was 60 g (range 45-75 g). In parts 1 and 2, subjects were randomized to either a liquid or a powder protein substitute with the same nutritional composition per unit (each 130 ml liquid pouch or 25 g powder sachet contained 15 g protein equivalent). In part 3, subjects chose liquid, powder or a combination of both. Weekly blood phenylalanine (Phe) concentrations were estimated, and during weeks 2, 4 and 6 subjects completed a daily questionnaire on administration issues. RESULTS All but one of 26 subjects chose the liquid in part 3 as either their sole (69%, n = 18) or partial source (28%, n = 7) of protein substitute. Blood Phe concentrations were significantly better on the liquid (p = 0.03). With the liquid protein substitute, subjects were less self-consciousness (p = 0.003) and found it easier to take away from home (p = 0.001). Overall, the liquid was easier (p < 0.0001), more convenient (p = 0.002) and resulted in less wastage of protein substitute (p = 0.001). CONCLUSION Liquid protein substitute was popular and efficacious, reduced self-consciousness and overall improved compliance of teenagers and adults with PKU.
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Abstract
Protein substitutes are an essential component in the management of phenylketonuria. A series of studies at Birmingham Children's Hospital have investigated their optimal dosage, timing and practical administration as well as the efficacy and tolerance of novel protein substitutes. The key findings are as follows. (1). Lower dosages of protein substitute (1.2 g/kg per day of protein equivalent) adversely affect blood phenylalanine control in children aged 1-10 years. (2). There is wide variability in 24 h blood phenylalanine concentrations. (3). Adjusting protein substitute timing during daytime does not reduce blood phenylalanine variability. (4). Repeated 4 h administration of protein substitute throughout 24 h markedly reduces phenylalanine variability and leads to lower phenylalanine concentrations. (5). The new, concentrated, low-volume protein substitutes and amino acid tablet preparations are efficacious and well tolerated by patients. (6). Administration of protein substitute as a gel or paste has reduced difficulties with administration of protein substitute in children. These findings are important in rationalizing treatment strategies, improving patient compliance and overall in improving blood phenylalanine control.
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MacDonald A, Lilburn M, Cochrane B, Davies P, Daly A, Asplin D, Hall SK, Cousins A, Chakrapani A, Robinson P, Lee P. A new, low-volume protein substitute for teenagers and adults with phenylketonuria. J Inherit Metab Dis 2004; 27:127-35. [PMID: 15159643 DOI: 10.1023/b:boli.0000028784.11080.9b] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Some older patients with phenylketonuria (PKU) fail to consume their protein substitute (with or without vitamin and mineral supplements) in prescribed amounts, which contributes to poor blood phenylalanine control. PKU Express (Vitaflo), is a new low-volume (amino acids 72 g/100 g), low-carbohydrate, phenylalanine-free protein substitute with added vitamins and minerals designed for people with PKU over 8 years of age. In an open intervention study, the aim was to investigate its acceptability and effectiveness in a group of teenagers and adults with PKU. Twenty-three subjects (15 female; 8 male) with PKU, who had a median age of 17 years (range 8-37 years) took the substitute for 8 weeks. A 3-day prospective diet diary, height, weight, plasma amino acids, biochemical and haematological nutritional analytes were measured at weeks 0 and 8. Skin-puncture bloods for plasma phenylalanine were collected every 2 weeks. The median weight of protein substitute (with or without vitamin and mineral supplements) consumed decreased by 33% from 150 g (range 140-180) daily to 100 g (range 100-125) daily ( p <0.001). Median change in energy intake decreased by a median of 10% (95% CI 2.0 to 18.0) when compared to intake on original protein substitute. On PKU Express, the intakes of all nutrients exceeded the dietary reference values but none was excessively high. Blood phenylalanine decreased by a mean of 37 micromol/L (95% CI-27 to 102) during the trial. Body mass index decreased in 40% of subjects. Changes in blood phenylalanine or body mass index were not statistically significant. Most of the nutritional, haematological and biochemical indices stayed within normal reference ranges for the analytes studied. Sixteen (70%) of the subjects had low plasma selenium at the start, but only 13 (57%) at the study end. Plasma vitamin B12 was high in 8 subjects at the start of the study and 9 at the end. Twenty-one subjects (96%) stated that the product was convenient and easy to prepare. However, 7 (32%) described the smell and 9 (46%) the texture as the same as or worse than those of previous protein substitutes. Because of the use of the premeasured sachets, some subjects were able to prepare their own protein substitute for the first time. PKU Express is a safe, efficacious, protein substitute that significantly reduces the daily volume of prescribed protein substitute.
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MacDonald A, Ferguson C, Rylance G, Morris AAM, Asplin D, Hall SK, Booth IW. Are tablets a practical source of protein substitute in phenylketonuria? Arch Dis Child 2003; 88:327-9. [PMID: 12651759 PMCID: PMC1719524 DOI: 10.1136/adc.88.4.327] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND A phenylalanine-free amino acid based protein substitute is necessary to provide the major source of protein in phenylketonuria (PKU). Protein substitutes in PKU are usually given as drinks. These are unpalatable and compliance is often poor. Tablets containing a suitable mixture of phenylalanine-free amino acids (Aminogran Food Supplement, UCB) are now available. AIMS To compare the effectiveness and acceptability of these tablets with conventional protein substitute drinks. METHODS Twenty one subjects with PKU, aged 8-25 years, participated in a randomised crossover study. During one phase, subjects received at least 40% of their protein substitute requirements from the amino acid tablets and the rest from their usual protein substitute tablets. During the other phase, they received their usual protein substitute. Each period lasted 12 weeks. Blood phenylalanine concentrations were measured at least once every two weeks and other plasma amino acids were measured at the beginning, at crossover, and at the end of the study. The subjects kept a diary of all protein substitute taken. RESULTS Compliance appeared to be better with the new tablets than with patients' usual protein substitutes. Ninety per cent (18/20) recorded that they took the tablets as prescribed, compared with 65% (13/20) fully compliant with their usual protein substitute. Moreover, plasma phenyalanine was lower on the amino acid tablets, and the median difference in blood concentrations between the two groups was 46 micro mol/l (95% CI 14.8 to 89.0, p = 0.02). Tyrosine increased by a median of 16 micro mol/l daily on the amino acid tablets (95% CI 7.1 to 40.5, p = 0.01). Most subjects (70%) preferred incorporating the new tablets into their usual protein substitute regimen. CONCLUSIONS Amino acid tablets are an effective and relatively popular protein substitute in older children, teenagers, and adults with PKU.
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MacDonald A, Rylance G, Davies P, Asplin D, Hall SK, Booth IW. Administration of protein substitute and quality of control in phenylketonuria: a randomized study. J Inherit Metab Dis 2003; 26:319-26. [PMID: 12971419 DOI: 10.1023/a:1025186217369] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Uneven administration of an L-amino acid protein substitute is an important contributing factor in variability in plasma phenylalanine concentrations over the 24-hour period in patients with phenylketonuria under treatment. The aim of this study was to determine whether manipulating the timing of protein substitution would reduce variability in plasma phenylalanine over 24 h. Sixteen children (aged 1-11 years) with well-controlled phenylketonuria were entered into a randomized crossover study in which four protocols of the same daily dose of protein substitute administration were compared. In protocol A, three equal, divided doses were given with meals over 10 h; in protocol B, three equal doses over 14 h; in protocol C, four equal doses over 14 h; and in protocol D, six equal doses over 24 h (3 subjects only). Four-hourly skin puncture blood specimens were collected for 48 h in each study protocol. In protocols A, B and C, but not in protocol D, there was wide variability in 24 h plasma phenylalanine. The median daily differences (micromol/L) between highest and lowest phenylalanine concentrations were: for protocol A, 140; for protocol B, 100; for protocol C, 120; and for protocol D, 40. In protocol D, 97% of all phenylalanine concentrations were below 120 micromol/L and no concentration fell below 40 micromol/L. Administration of protein substitute overnight as well as during daytime produces stable and lower plasma phenylalanine concentrations and may lead to improved dietary phenylalanine tolerance.
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Shaikh MG, Anderson JM, Hall SK, Jackson MA. Transient neonatal hypothyroidism due to a maternal vegan diet. J Pediatr Endocrinol Metab 2003; 16:111-3. [PMID: 12585349 DOI: 10.1515/jpem.2003.16.1.111] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Iodine is an important constituent of thyroid hormones and deficiency can lead to a range of problems depending on the degree and at what stage of life the deficiency occurs. We report a 10 day-old infant with a goitre, who presented with raised TSH on dried blood spot screening. It was observed that her mother also had a goitre. The mother was a vegan and, on dietary assessment, her iodine intake was extremely low. Both mother and infant had abnormal thyroid function tests. Mother was given Lugol's iodine and her thyroid function tests normalised. Her baby was initially prescribed thyroxine on the basis of the raised screening TSH. This was subsequently withdrawn at the age of 2 weeks, following a normal plasma TSH. Thyroid function tests remained normal and the goitre disappeared by the age of 2 months. Iodine deficiency is uncommon in the Western World. However the incidence may be rising in otherwise iodine replete areas, particularly in those who adhere to restrictive and unusual diets. In the case of pregnant mothers their unborn child's health is in danger. This report demonstrates the need to ascertain maternal diets early in antenatal care, and supplement if necessary to avoid risk to their own health and that of their offspring.
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MacDonald A, Rylance G, Davies P, Asplin D, Hall SK, Booth IW. Free use of fruits and vegetables in phenylketonuria. J Inherit Metab Dis 2003; 26:327-38. [PMID: 12971420 DOI: 10.1023/a:1025150901439] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This study aimed to evaluate systematically the effect of the free use of fruits and vegetables containing an intermediate amount of phenylalanine (51-100 mg/100 g) on the biochemical control in children with phenylketonuria (PKU). Fifteen subjects with PKU, with a median age of 6 years (range 1-24 years) were studied. In a three-part prospective 15-week study, subjects sequentially ate fruits and vegetables containing phenylalanine 0-50 mg/100 g for weeks 1 to 3; 51-75 mg/100 g for weeks 4 to 8; and 76-100 mg/100 g for weeks 9 to 15. Plasma phenylalanine concentrations were measured twice daily for three consecutive days in weeks 1, 3, 6, 8, 11, 13 and 15. A standard menu was followed on the blood sampling days. Daily dietary records of fruits and vegetables under study were kept throughout the trial. Control of phenylalanine concentrations was not adversely affected by the free use of fruits and vegetables containing 51-100 mg/100 g. Pre-breakfast median plasma concentrations were: weeks 1 to 3, 260 micromol/L (range 90-890); weeks 4 to 8, 255 micromol/L (range 130-920); and weeks 9 to 15, 278 micromol/L (range 30-880). Pre-evening meal median plasma phenylalanine concentrations were: weeks 1 to 3, 240 micromol/L (range 30-820); weeks 4 to 8, 210 micromol/L (40-880); and weeks 9 to 15, 238 micromol/L (range 20-880). These data suggest that free use of fruits and vegetables containing 51-75 mg/100 g poses no problem for children with PKU.
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Walter JH, White FJ, Hall SK, MacDonald A, Rylance G, Boneh A, Francis DE, Shortland GJ, Schmidt M, Vail A. How practical are recommendations for dietary control in phenylketonuria? Lancet 2002; 360:55-7. [PMID: 12114043 DOI: 10.1016/s0140-6736(02)09334-0] [Citation(s) in RCA: 225] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In patients with phenylketonuria, blood phenylalanine concentration during childhood is the major determinant of cognitive outcome. Guidelines provide age-related recommendations for treatment. To ascertain the extent to which these aims are achievable, we audited results from four centres for the years 1994-2000. The median proportion of samples with phenylalanine concentrations above those recommended was less than 30% for those younger than age 10 years but almost 80% for those aged 15 years and older. Similarly, the median frequency of blood sampling, expressed as a proportion of that recommended, was more than 80% for patients younger than 10 years but less than 50% by age 15 years. Our results indicate the difficulty of maintaining control in phenylketonuria, especially in older rather than younger children.
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Hardy DT, Hall SK, Preece MA, Green A. Quantitative determination of plasma phenylalanine and tyrosine by electrospray ionization tandem mass spectrometry. Ann Clin Biochem 2002; 39:73-5. [PMID: 11853196 DOI: 10.1258/0004563021901612] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Phenylketonuria patients on protein-restricted diets require monitoring of their blood phenylalanine concentrations. Small sample volumes are essential for neonates and infants, with the need for results to be generated in a timely manner by robust methods. We present a tandem mass spectrometry assay for phenylalanine (and tyrosine) which fulfils these criteria. METHODS Plasma samples were deproteinized using a methanolic solution of phenylalanine-d5 and tyrosine-d4 that served as the internal standards for the assay. Following centrifugation each liquid phase was dried in a well of a microtitre plate and the amino acids converted to butyl esters using butanolic hydrogen chloride. After drying again and reconstituting in 80% acetonitrile in water, the samples were analysed using electrospray ionization tandem mass spectrometry. RESULTS For both phenylalanine and tyrosine the limit of detection was 1 micromol/L and the carry-over less than 1%. The assay was linear to 3000 micromol/L in both amino acids (phenylalanine: r= 0.999; tyrosine: r= 0.992). Inter-sample precision varied with concentration but was 3.4-5.2% for phenylalanine and 4.3-7.6% for tyrosine. Between-batch precision was more variable, being 4.1-12.9% for phenylalanine and 8.4%-10.5% for tyrosine. CONCLUSIONS Good agreement was found between the assay and results from existing ion-exchange chromatography and high performance liquid chromatographic assays in this department. Carry-over and precision were acceptable for monitoring work and the linearity allowed most specimens to be analysed without dilution. Where available, tandem mass spectrometry offers a convenient means of transferring the routine work for both neonatal screening and monitoring to one instrument.
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Hall SK, Robinson P, Green A. Could salivary phenylalanine concentrations replace blood concentrations? Ann Clin Biochem 2001. [DOI: 10.1258/0004563011901244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Mikulich SK, Hall SK, Whitmore EA, Crowley TJ. Concordance between DSM-III-R and DSM-IV diagnoses of substance use disorders in adolescents. Drug Alcohol Depend 2001; 61:237-48. [PMID: 11164688 DOI: 10.1016/s0376-8716(00)00143-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Except for cannabis and alcohol, concordance between DSM-III-R and DSM-IV substance use disorder diagnoses has not been reported in adolescents. We assessed a clinical sample of 102 adolescents using CIDI-SAM. Prevalence of either an abuse or dependence diagnosis was lower with DSM-IV than DSM-III-R except for cannabis and alcohol, and concordance rates were better for dependence than for abuse. For most substances, rates of DSM-IV withdrawal were lower than in DSM-III-R, but rates of DSM-IV physiological dependence remained high. Changes in DSM-IV criteria appear to have impacted diagnoses in these adolescents, particularly for the substances they use most--i.e. alcohol, tobacco, and cannabis.
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Hall SK, Robinson P, Green A. Could salivary phenylalanine concentrations replace blood concentrations? Ann Clin Biochem 2000; 37 ( Pt 2):222-3. [PMID: 10735369 DOI: 10.1258/0004563001899050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Hall SK, Armstrong DL. Conditional and unconditional inhibition of calcium-activated potassium channels by reversible protein phosphorylation. J Biol Chem 2000; 275:3749-54. [PMID: 10660522 DOI: 10.1074/jbc.275.6.3749] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Large conductance, calcium-activated potassium channels (BK(Ca) or maxi-K) are important determinants of membrane excitability in many cell types. We used patch clamp techniques to study the biochemical regulation of native BK(Ca) channel proteins by endogenous Ser/Thr-directed protein kinases and phosphatases in cell-free membrane patches from rat pituitary tumor cells (GH(4)C(1)). When protein kinase activity was blocked by removing ATP, endogenous protein phosphatases slowly increased BK(Ca) channel activity approximately 3-fold. Dephosphorylated channels could be activated fully by physiological increases in cytoplasmic calcium or membrane depolarization. In contrast, endogenous protein kinases inhibited BK(Ca) channel activity at two functionally distinct sites. A closely associated, cAMP-dependent protein kinase rapidly reduced channel activity in a conditional manner that could be overcome completely by increasing cytoplasmic free calcium 3-fold or 20 mV further depolarization. Phosphorylation at a pharmacologically distinct site inhibited channel activity unconditionally by reducing availability to approximately half that of maximum at all physiological calcium and voltages. Conditional versus unconditional inhibition of BK(Ca) channel activity through different protein kinases provides cells with a powerful computational mechanism for regulating membrane excitability.
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Clark AG, Hall SK, Shipston MJ. ATP inhibition of a mouse brain large-conductance K+ (mslo) channel variant by a mechanism independent of protein phosphorylation. J Physiol 1999; 516 ( Pt 1):45-53. [PMID: 10066921 PMCID: PMC2269205 DOI: 10.1111/j.1469-7793.1999.045aa.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
1. We investigated the effect of ATP in the regulation of two closely related cloned mouse brain large conductance calcium- and voltage-activated potassium (BK) channel alpha-subunit variants, expressed in human embryonic kidney (HEK 293) cells, using the excised inside-out configuration of the patch-clamp technique. 2. The mB2 BK channel alpha-subunit variant expressed alone was potently inhibited by application of ATP to the intracellular surface of the patch with an IC50 of 30 microM. The effect of ATP was largely independent of protein phosphorylation events as the effect of ATP was mimicked by the non-hydrolysable analogue 5'-adenylylimidodiphosphate (AMP-PNP) and the inhibitory effect of ATPgammaS was reversible. 3. In contrast, under identical conditions, direct nucleotide inhibition was not observed in the closely related mouse brain BK channel alpha-subunit variant mbr5. Furthermore, direct nucleotide regulation was not observed when mB2 was functionally coupled to regulatory beta-subunits. 4. These data suggest that the mB2 alpha-subunit splice variant could provide a dynamic link between cellular metabolism and cell excitability.
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Hall SK, Hutchesson AC, Kirk JM. Congenital hypothyroidism, seasonality and consanguinity in the West Midlands, England. Acta Paediatr 1999; 88:212-5. [PMID: 10102157 DOI: 10.1080/08035259950170411] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
Seasonal variation in the incidence of congenital hypothyroidism (CHT) is reported by some centres. Also, the incidence of CHT varies with ethnic origin. We report our experience in the West Midlands, England. The overall incidence of CHT among 1128 632 neonates screened over 16 years in the West Midlands was 1:2924 live births, but was increased (1:2323; p<0.05) between October and December. In the city of Birmingham between 1981 and 1991, the incidence of CHT was 1:781, 1:5540 and 1:2257 in Pakistani, Indian and North-West European children, respectively; no cases were seen in those from other ethnic groups. Consanguinity among those of Pakistani descent could account for the increased incidence within this population. Identification of the cause of seasonal variation may aid development of preventative strategies.
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Hall SK. Safeguards help avoid embezzlement. JOURNAL (INDIANA DENTAL ASSOCIATION) 1998; 74:12-3. [PMID: 9517332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Leeming RJ, Hall SK, Green A. The origin of red blood cell biopterin. Mol Genet Metab 1998; 65:291-7. [PMID: 9889016 DOI: 10.1006/mgme.1998.2766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Data are presented to support the hypothesis that the biopterin content of red blood cells arises during erythropoiesis. Only when the plasma concentration rises above the erythrocyte concentration of biopterin is there likely to be diffusion into the cell.
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Gray RG, Hall SK. Autoclaving Guthrie cards does not prevent their use in PCR reactions! J Med Genet 1998; 35:702. [PMID: 9719388 PMCID: PMC1051410 DOI: 10.1136/jmg.35.8.702-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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