Prenatal dexamethasone use for the prevention of virilization in pregnancies at risk for classical congenital adrenal hyperplasia because of 21-hydroxylase (CYP21A2) deficiency: A systematic review and meta-analyses
Merce Fernandez-Balsells M.,Knowledge and Encounter Research Unit |
Merce Fernandez-Balsells M.,Hospital Universitari Of Girona |
Muthusamy K.,Mayo Medical School |
Smushkin G.,Mayo Medical School |
And 13 more authors.
Clinical Endocrinology | Year: 2010
Context Prenatal treatment with dexamethasone to prevent virilization in pregnancies at risk for classical congenital adrenal hyperplasia (CAH) remains controversial. Objective To conduct a systematic review and meta-analyses of studies that evaluated the effects of dexamethasone administration during pregnancies at risk for classical CAH because of 21-hydroxylase deficiency (CYP21A2). Data Sources We searched MEDLINE, EMBASE, and Cochrane CENTRAL from inception through August 2009. Review of reference lists and contact with CAH experts further identified candidate studies. Study Selection Reviewers working independently and in duplicate determined trial eligibility. Eligible studies reported the effects on either foetal or maternal outcomes of dexamethasone administered during pregnancy compared to a control group that did not receive any treatment. Data Extraction Reviewers working independently and in duplicate determined the methodological quality of studies and collected data on patient characteristics, interventions, and outcomes. Data Synthesis We identified only four eligible observational studies (325 pregnancies treated with dexamethasone). The methodological quality of the included studies was overall low. Meta-analysis demonstrates a reduction in foetus virilization measured by Prader score in female foetuses treated with dexamethasone initiated early during pregnancy (weighted mean difference, -2·33, 95% CI, -3·38, -1·27). No deleterious effects of dexamethasone on stillbirths, spontaneous abortions, foetal malformations, neuropsychological or developmental outcomes were found although these data are quite sparse. There was increased oedema and striae in the mothers treated with dexamethasone. There were no data on long-term follow-up of physical and metabolic outcomes in children exposed to dexamethasone. Conclusions The observational nature of the available evidence and the overall small sample size of the whole body of the literature significantly weaken inferences about the benefits and harms of dexamethasone in this setting. Dexamethasone seems to be associated with reduction in foetus virilization without significant maternal or foetal adverse effects. However, this review underscores the current uncertainty and further investigation is clearly needed. The decision about initiating treatment should be based on patients' values and preferences and requires fully informed and consenting parents. © 2010 Blackwell Publishing Ltd.
Muthusamy K.,Knowledge and Encounter Research Unit |
Muthusamy K.,Mayo Medical School |
Elamin M.B.,Knowledge and Encounter Research Unit |
Smushkin G.,Knowledge and Encounter Research Unit |
And 18 more authors.
Journal of Clinical Endocrinology and Metabolism | Year: 2010
Context: Treatment for patients with congenital adrenal hyperplasia (CAH) may affect the final height of these patients. Objective: Our objective was to determine the distribution of achieved height in patients with classic CAH diagnosed at infancy or early childhood and treated with glucocorticoids. Data Sources: We searched MEDLINE, EMBASE, Cochrane Library, ISI Web of Science, and Scopus through September 2008; the reference sections of included studies; and expert files. Study Selection: Eligible studies included patients diagnosed with CAH before age 5 and followed to final height. Data Extraction: Reviewers working in duplicate independently extracted data on study characteristics and outcomes and determined each study's risk of bias. Data Synthesis: The SD score (SDS) for final height and corrected height (defined as final height SDS - midparental height SDS) were estimated from each study and pooled using random-effects metaanalysis. The I2 statistic was used to assess inconsistency in results across studies. Results: We found 35 eligible studies, most of which were retrospective single-cohort studies. The final height SDS achieved by CAH patients was -1.38 (-1.56 to -1.20; I2 - 90.2%), and the corrected height SDS was -1.03 (-1.20 to -0.86; I2 = 63.1%). This was not significantly associated with age at diagnosis, gender, type and dose of steroid, and age of onset of puberty. Mineralocorticoid users had a better height outcome in comparison with the nonusers (P = 0.02). Conclusion: Evidence derived from observational studies suggests that the final height of CAH patients treated with glucocorticoids is lower than the populationnormand is lower than expected given parental height. Copyright © 2010 by The Endocrine Society.
Kourtoglou G.I.,St. Lukes General Hospital
Diabetes Research and Clinical Practice | Year: 2011
Medical nutrition therapy and physical exercise are the cornerstones of the diabetes management. Patients with type 1 DM always need exogenous insulin administration, recently available in the form of insulin analogs. In type 2 DM, characterized by increased insulin resistance and progressive decline of the beta-cell function, various antidiabetic medications are used. Most of the subjects with type 2 DM will finally need insulin. The main site of insulin action is the skeletal muscle, while the liver is the main site of glucose storage in the form of glycogen. With the modern diabetes therapies it is possible to rapidly reach and maintain normoglycemia in both types of DM but with the cost of higher incidence of hypoglycemia, especially related to exercise. Regular physical exercise causes a lot of beneficial effects in healthy as well as diabetic subjects of all age groups. In type 1 DM physical exercise is a fundamental element for both physical and mental development. In type 2 DM it has a main role in diabetes control. The increased hepatic glucose production and the increased muscular glucose uptake during exercise are closely interrelated in all exercise intensities. In diabetes mellitus there is a disturbed energy substrate use during exercise leading to either hypo- or hyperglycemia. The influence of low or moderate intensity aerobic exercise on diabetes control has been well studied. The inappropriately high insulinemia combined with the low glucose levels can lead to severe hypoglycemia if proper measures are not taken. Prolonged exercise can also predispose to decreased glucose counter regulation. It is better for the type 1 diabetic subject to postpone the exercise session in very high (>300 mg/dl) or very low (<70 mg/dl) BG levels. Every insulin treated subject is recommended to be checked for any existing diabetic complication before the start of every exercise program. Glucose measurement with glucose meters or sometimes with Continuous Glucose Monitoring System (CGMS) must be made before, during and most importantly after the end of the exercise session. It is recommended either to reduce or suspend the previous insulin dose depending on the insulin regime or to receive extra carbohydrates before, during or after the exercise session or both. Subjects with type 1 DM may participate at almost all the competitive sports if precautions are taken. These measures must be individualized and readjusted, even empirically. In very high intensity exercise (about 80% of VO 2 max) or when high intensity exercise follows a low intensity one, there is a tendency of the BG to increase due to excessive circulating catecholamines necessitating postexercise short acting insulin. In anaerobic or resistance exercise lactic acid is produced. This exercise type is recommended for people in whom aerobic exercise is contraindicated. These two exercise types can be combined. The incidence of hypoglycemia or hyperglycemia in specific forms of resistance exercise as well as the appropriate insulin dose adjustment are not well studied. In conclusion all exercise types are beneficial for both types of diabetes. © 2011 Elsevier Ireland Ltd.
Ellanti P.,Park University |
Cushen B.,St. Lukes General Hospital |
Galbraith A.,St. Lukes General Hospital |
Brent L.,Waterford University Hospital |
And 2 more authors.
Journal of Osteoporosis | Year: 2014
Introduction. Hip fractures are common injuries in the older persons, with significant associated morbidity and mortality. The Irish Hip Fracture Database (IHFD) was implemented to monitor standards of care against international standards.Methods. The IHFD is a clinically led web-based audit. We summarize the data collected on hip fractures from April 2012 to March 2013 from 8 centres. .Results. There were 843 patients with the majority being (70%) female. The 80-89-year age group accounted for the majority of fractures (44%). Most (71%) sustained a fall at home. Intertrochanteric fractures (40%) were most common. Only 28% were admitted to an orthopaedic ward within 4 hours. The majority (97%) underwent surgery with 44% having surgery within 36 hours. Medical optimization (35%) and lack of theatre space (26%) accounted for most of the surgical delay. While 29% were discharged home, 33% were discharged to a nursing home or other long-stay facilities. There was a 4% in-hospital mortality rate. .Conclusions. Several key areas in both the database and aspects of patient care needing improvement have been highlighted. The implementation of similar databases has led to improved hip fracture care in other countries and we believe this can be replicated in Ireland. © 2014 Prasad Ellanti et al.
Blanchfield D.,St. Lukes General Hospital |
McGurk C.,St. Lukes General Hospital
Journal of Diabetes Nursing | Year: 2012
Approximately 13% of the adult population suffers from chronic kidney disease (CKD) and the numbers are expected to continue to climb (Coresh et al, 2007). Hypertension and diabetes are the main causes of progression from CKD to end stage renal disease (Arikan and Tuglular, 2005). An effective disease management strategy requires consolidation of all aspects of the condition, such as effective hypertension, lipid and glycaemic management together with assessment of renal function, to ensure timely and appropriate interventions which can have a significant impact on slowing the progression of CKD. This challenges existing services to adopt innovative ways of delivering care to meet patient and service need within current resources. In the Carlow/Kilkenny diabetes service in Ireland, one such innovation was the development of an advanced nurse practitioner role in diabetes and renal impairment. This article outlines how this new role combines elements from the disciplines of medicine and nursing to meet service needs and achieve clinical targets and low patient default rates (<1%).