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Ward RJ, Fryer AA, Hanna FW, Spencer N, Mahmood M, Wu P, Heald AH, Duff CJ. Inadequate postpartum screening for type 2 diabetes in women with previous gestation diabetes mellitus: A retrospective audit of practice over 17 years. Int J Clin Pract 2021; 75:e14447. [PMID: 34105863 DOI: 10.1111/ijcp.14447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 05/11/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Women with gestational diabetes (GDM) are at greatly increased risk of type 2 diabetes (T2DM). The UK guidance recommends screening for T2DM at around 6-week postpartum and annually thereafter. We evaluated conformity to this guidance in two separate time periods. METHODS The proportion of tests performed within guidance was assessed using longitudinal plasma glucose and glycated haemoglobin data in two cohorts (1999-2007, n = 251; 2015-2016, n = 260) from hospital records on women previously diagnosed with GDM. RESULTS In the 1999-2007 and 2015-2016 cohorts, 59.8% and 35.0% of women had the recommended postpartum testing, respectively (P < .001); just 13.5% and 14.2%, respectively, underwent the first annual test on time. During long-term follow-up of the 1999-2007 cohort (median follow-up: 12.3 years), the proportion of women tested in any given year averaged 34.2% over a 17-year period; there was a progressive decline in the proportion of women receiving a yearly test with time since delivery (P = .002). Over the follow-up period, 85 women from the 1999-2007 cohort developed blood test results in the diabetic range with a median time to presumed DM diagnosis of 5.2 years (range 0.11-15.95 years). Kaplan-Meier analysis showed that 18.8% of women had blood test results in the diabetes range by 5-year postpartum and 37.8% by 10-year postpartum. CONCLUSIONS Despite high profile guidelines and a clear clinical rationale to screen women with a past diagnosis of GDM, many women did not receive adequate screening for T2DM both in the short term and long term. This suggests that alternative approaches are needed to ensure effective follow-up of this high-risk group. To have an impact, interventions need to be tailored to a young, generally healthy group in which traditional approaches to follow-up may not be best suited.
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Affiliation(s)
- Rebecca J Ward
- Department of Clinical Biochemistry, University Hospitals of the North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Anthony A Fryer
- Department of Clinical Biochemistry, University Hospitals of the North Midlands NHS Trust, Stoke-on-Trent, UK
- School of Medicine, Keele University, Stoke-on-Trent, UK
| | - Fahmy W Hanna
- Department of Diabetes and Endocrinology, University Hospitals of the North Midlands NHS Trust, Stoke-on-Trent, UK
- Centre for Health and Development, Staffordshire University, Stoke-on-Trent, UK
| | - Nathaniel Spencer
- Department of Clinical Biochemistry, University Hospitals of the North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Madia Mahmood
- Department of Clinical Biochemistry, University Hospitals of the North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Pensee Wu
- School of Medicine, Keele University, Stoke-on-Trent, UK
- Academic Department of Obstetrics and Gynaecology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Adrian H Heald
- Department of Endocrinology, Salford Royal NHS Foundation Trust, Salford, UK
| | - Christopher J Duff
- Department of Clinical Biochemistry, University Hospitals of the North Midlands NHS Trust, Stoke-on-Trent, UK
- School of Medicine, Keele University, Stoke-on-Trent, UK
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Wu P, Farrell WE, Haworth KE, Emes RD, Kitchen MO, Glossop JR, Hanna FW, Fryer AA. Maternal genome-wide DNA methylation profiling in gestational diabetes shows distinctive disease-associated changes relative to matched healthy pregnancies. Epigenetics 2018; 13:122-128. [PMID: 27019060 DOI: 10.1080/15592294.2016.1166321] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Several recent reports have described associations between gestational diabetes (GDM) and changes to the epigenomic landscape where the DNA samples were derived from either cord or placental sources. We employed genome-wide 450K array analysis to determine changes to the epigenome in a unique cohort of maternal blood DNA from 11 pregnant women prior to GDM development relative to matched controls. Hierarchical clustering segregated the samples into 2 distinct clusters comprising GDM and healthy pregnancies. Screening identified 100 CpGs with a mean β-value difference of ≥0.2 between cases and controls. Using stringent criteria, 5 CpGs (within COPS8, PIK3R5, HAAO, CCDC124, and C5orf34 genes) demonstrated potentials to be clinical biomarkers as revealed by differential methylation in 8 of 11 women who developed GDM relative to matched controls. We identified, for the first time, maternal methylation changes prior to the onset of GDM that may prove useful as biomarkers for early therapeutic intervention.
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Affiliation(s)
- Pensee Wu
- a Institute for Science and Technology in Medicine , Keele University, Guy Hilton Research Center , Staffordshire , UK.,b Academic Unit of Obstetrics and Gynecology, University Hospital of North Midlands NHS Trust , Stoke-on-Trent, Staffordshire , UK
| | - William E Farrell
- a Institute for Science and Technology in Medicine , Keele University, Guy Hilton Research Center , Staffordshire , UK
| | - Kim E Haworth
- a Institute for Science and Technology in Medicine , Keele University, Guy Hilton Research Center , Staffordshire , UK
| | - Richard D Emes
- c School of Veterinary Medicine and Science, University of Nottingham , Leicestershire , UK.,d Advanced Data Analysis Center , University of Nottingham , Leicestershire , UK
| | - Mark O Kitchen
- a Institute for Science and Technology in Medicine , Keele University, Guy Hilton Research Center , Staffordshire , UK
| | - John R Glossop
- a Institute for Science and Technology in Medicine , Keele University, Guy Hilton Research Center , Staffordshire , UK.,e Haywood Rheumatology Center, Haywood Hospital , Staffordshire , UK
| | - Fahmy W Hanna
- f Department of Diabetes and Endocrinology , University Hospital of North Midlands NHS Trust , Stoke-on-Trent, Staffordshire , UK
| | - Anthony A Fryer
- a Institute for Science and Technology in Medicine , Keele University, Guy Hilton Research Center , Staffordshire , UK
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Pappachan JM, Hariman C, Edavalath M, Waldron J, Hanna FW. Cushing's syndrome: a practical approach to diagnosis and differential diagnoses. J Clin Pathol 2017; 70:350-359. [PMID: 28069628 DOI: 10.1136/jclinpath-2016-203933] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 11/01/2016] [Accepted: 12/08/2016] [Indexed: 02/05/2023]
Abstract
Diagnosis of Cushing's syndrome (CS) and identification of the aetiology of hypercortisolism can be challenging. The Endocrine Society clinical practice guidelines recommends one of the four tests for initial screening of CS, namely, urinary-free cortisol, late night salivary cortisol, overnight dexamethasone suppression test or a longer low-dose dexamethasone suppression test, for 48 hours. Confirmation and localisation of CS requires additional biochemical and radiological tests. Radiological evaluation involves different imaging modalities including MRI with or without different radio-nuclear imaging techniques. Invasive testing such as bilateral inferior petrosal sinus sampling may be necessary in some patients for accurate localisation of the cause for hypercortisolism. This best practice review discusses a practical approach for the diagnostic evaluation of CS with a brief discussion on differential diagnoses, and cyclical CS, to enhance the skills of clinicians and laboratory personnel.
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Affiliation(s)
- Joseph M Pappachan
- Department of Endocrinology & Diabetes, New Cross Hospital, The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Christian Hariman
- Department of Endocrinology & Diabetes, New Cross Hospital, The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Mahamood Edavalath
- Department of Endocrinology & Diabetes, Imperial College London Diabetes Centre, Abu Dhabi, UAE
| | - Julian Waldron
- Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Fahmy W Hanna
- Department of Endocrinology & Diabetes, University Hospitals of North Midlands NHS Trust & North Staffordshire University, Stoke-on-Trent, UK
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Hanna FW, Duff CJ, Shelley-Hitchen A, Hodgson E, Fryer AA. Diagnosing gestational diabetes mellitus: implications of recent changes in diagnostic criteria and role of glycated haemoglobin (HbA1c). Clin Med (Lond) 2017; 17:108-113. [PMID: 28365618 PMCID: PMC6297607 DOI: 10.7861/clinmedicine.17-2-108] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Gestational diabetes mellitus (GDM; approximately 5% of pregnancies) represents the most important risk factor for development of later-onset diabetes mellitus. We examined concordance between GDM diagnosis defined using the original 1999 World Health Organization (WHO) criteria and the more recent 2013 WHO criteria and 2015 National Institute for Health and Care Excellence (NICE) criteria. We studied two groups: a case-control group of 257 GDM positive and 266 GDM negative cases, and an incident cohort 699 GDM positive and 6,231 GDM negative cases. In the incident cohort, GDM prevalence was 3.7% (WHO 1999 criteria), 11.4% (NICE 2015 criteria) and 13.7% (WHO 2013 criteria). Our results showed that a significant number of additional cases are detected using the more recent NICE and WHO criteria than the original 1999 WHO criteria, but these additional cases represent an intermediate group with 'moderate' dysglycaemia (abnormal blood glucose levels). Our results also show that use of these newer criteria misses a similar group of intermediate cases that were defined as GDM by the 1999 WHO criteria and that glycated haemoglobin in isolation is unlikely to replace the oral glucose tolerance test in GDM diagnosis.
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Affiliation(s)
- Fahmy W Hanna
- University Hospital of North Midlands, Stoke-on-Trent and Centre for Health and Development, Staffordshire University, Stoke-on-Trent, UK
| | - Christopher J Duff
- University Hospital of North Midlands, Stoke-on-Trent and Institute for Applied Clinical Sciences, Keele University, Stoke-on-Trent, UK
| | | | - Ellen Hodgson
- University Hospital of North Midlands, Stoke-on-Trent, UK
| | - Anthony A Fryer
- University Hospital of North Midlands, Stoke-on-Trent and Institute for Applied Clinical Sciences, Keele University, Stoke-on-Trent, UK
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Ismail KMK, Issa BG, Jones P, Hanna FW, Indusekhar R. Hypoglycaemic agents for pregnant women with polycystic ovarian syndrome. Hippokratia 2016. [DOI: 10.1002/14651858.cd009828.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Khaled MK Ismail
- University of Birmingham; School of Clinical and Experimental Medicine, College of Medical and Dental Sciences; 3rd Floor, Birmingham Women's Foundation Trust Edgbaston Birmingham UK B15 2TG
| | - Basil G Issa
- South Manchester University Hospital Trust; Department of Endocrinology and Diabetes; Wythenshawe Hospital Southmoor Road Manchester UK M23 9LT
| | - Peter Jones
- Keele University; School of Computing & Mathematics; Keele Stafforshire UK ST5 5BG
| | - Fahmy W Hanna
- University Hospital of North Staffordshire; Department of Diabetes and Endocrinology; Stoke-on-Trent UK ST4 6QG
| | - Radha Indusekhar
- University Hospital of North Staffordshire, City General Hospital; Department of Obstetrics and Gynaecology, Women and Children's Division; Stoke-on-Trent Staffordshire UK
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Driskell OJ, Holland D, Waldron JL, Ford C, Scargill JJ, Heald A, Tran M, Hanna FW, Jones PW, Pemberton RJ, Fryer AA. Reduced testing frequency for glycated hemoglobin, HbA1c, is associated with deteriorating diabetes control. Diabetes Care 2014; 37:2731-7. [PMID: 25249670 DOI: 10.2337/dc14-0297] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We previously showed that in patients with diabetes mellitus, glycated hemoglobin (HbA1c) monitoring outside international guidance on testing frequency is widespread. Here we examined the relationship between testing frequency and diabetes control to test the hypothesis that retest interval is linked to change in HbA1c level. RESEARCH DESIGN AND METHODS We examined repeat HbA1c tests (400,497 tests in 79,409 patients, 2008-2011) processed by three U.K. clinical laboratories. We examined the relationship between retest interval and 1) percentage change in HbA1c and 2) proportion of cases showing a significant HbA1c rise. The effect of demographics factors on these findings was also explored. RESULTS Our data showed that the optimal testing frequency required to maximize the downward trajectory in HbA1c was four times per year, particularly in those with an initial HbA1c of ≥7% (≥53 mmol/mol), supporting international guidance. Testing 3-monthly was associated with a 3.8% reduction in HbA1c compared with a 1.5% increase observed with annual testing; testing more frequently provided no additional benefit. Compared with annual monitoring, 3-monthly testing was associated with a halving of the proportion showing a significant rise in HbA1c (7-10 vs. 15-20%). CONCLUSIONS These findings provide, in a large, multicenter data set, objective evidence that testing outside guidance on HbA1c monitoring frequency is associated with a significant detrimental effect on diabetes control. To achieve the optimum downward trajectory in HbA1c, monitoring frequency should be quarterly, particularly in cases with suboptimal HbA1c. While this impact appears small, optimizing monitoring frequency across the diabetes population may have major implications for diabetes control and comorbidity risk.
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Affiliation(s)
- Owen J Driskell
- Department of Clinical Biochemistry, University Hospital of North Staffordshire National Health Service Trust, Stoke-on-Trent, Staffordshire, U.K. Institute of Science and Technology in Medicine, University of Keele, Stoke-on-Trent, Staffordshire, U.K
| | - David Holland
- National Pathology Benchmarking Service, Department of Medicines Management, Keele University, Staffordshire, U.K
| | - Jenna L Waldron
- Department of Clinical Biochemistry, Royal Wolverhampton National Health Service Trust, Wolverhampton, U.K
| | - Clare Ford
- Department of Clinical Biochemistry, Royal Wolverhampton National Health Service Trust, Wolverhampton, U.K
| | - Jonathan J Scargill
- Department of Clinical Biochemistry, Salford Royal Hospital National Health Service Foundation Trust, U.K
| | - Adrian Heald
- Department of Clinical Biochemistry, Salford Royal Hospital National Health Service Foundation Trust, U.K. School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, U.K
| | - Martin Tran
- Department of Clinical Biochemistry, University Hospital of North Staffordshire National Health Service Trust, Stoke-on-Trent, Staffordshire, U.K
| | - Fahmy W Hanna
- Department of Clinical Biochemistry, University Hospital of North Staffordshire National Health Service Trust, Stoke-on-Trent, Staffordshire, U.K. Department of Diabetes and Endocrinology, University Hospital of North Staffordshire National Health Service Trust, Stoke-on-Trent, Staffordshire, U.K
| | - Peter W Jones
- Institute of Science and Technology in Medicine, University of Keele, Stoke-on-Trent, Staffordshire, U.K. School of Computing and Mathematics, Keele University, Keele, Staffordshire, U.K
| | - R John Pemberton
- Diabetes UK, North Staffordshire Branch, Newcastle-under-Lyme, Staffordshire, U.K
| | - Anthony A Fryer
- Department of Clinical Biochemistry, University Hospital of North Staffordshire National Health Service Trust, Stoke-on-Trent, Staffordshire, U.K. Institute of Science and Technology in Medicine, University of Keele, Stoke-on-Trent, Staffordshire, U.K.
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Abstract
Pheochromocytomas (PCCs) are rare catecholamine producing neuroendocrine tumors. The majority of these tumors (85 %) arise from the adrenal medulla. Those arising from the extra-adrenal neural ganglia are called paragangliomas (PGLs). Paroxysmal hypertension with sweating, headaches and palpitation are the usual presenting features of PCCs/ PGLs. Gene mutations are reported in 32-79 % of cases, making genetic screening mandatory in all the cases. The malignancy rates are 10-15 % for PCCs and 20-50 % for PGLs. Measurement of plasma or 24-hour urinary fractionated metanephrines is the best biochemical diagnostic test. Computed tomography or magnetic resonance imaging has high sensitivity (90-100 %) and reasonable specificity (70-90 %) for the anatomical localization. The functionality is assessed by different radionuclide imaging modalities such as metaiodobenzylguanidine (MIBG) scintigraphy, positron emission tomography or single photon emission computed tomography. The only modality of curative treatment is tumor excision. Proper peri-operative management improves the surgical outcomes. Annual follow up with clinical and biochemical assessment is recommended in all the cases after treatment. Children, pregnant women and older people have higher morbidity and mortality risk. De-bulking surgery, chemotherapy, radiotherapy, molecular agents like sunitinib and everolimus, radionuclide agents and different ablation procedures may be useful in the palliation of inoperable/metastatic disease. An update on the diagnostic evaluation and management of PCCs and PGLs is presented here.
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Affiliation(s)
- Joseph M Pappachan
- Department of Endocrinology, Walsall Manor Hospital, West Midlands, WS2 9PS, UK,
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Abstract
Ketamine abuse is being increasingly reported worldwide. The drug can produce a dissociative state and hallucinations, making ketamine a favorite recreational agent among drug addicts. Chronic ketamine abuse can damage many organs, including the brain, heart, liver, gastrointestinal tract, and genitourinary system. We report a patient with chronic ketamine abuse who presented with severe cachexia, upper gastrointestinal involvement, hepatobiliary dysfunction, and acute kidney injury.
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Affiliation(s)
- Joseph M Pappachan
- Departments of Endocrinology, Diabetes, and Metabolism (Pappachan, Hanna), Anesthesiology (Raj), and Gastroenterology (Thomas), University Hospital of North Staffordshire, Stoke-on-Trent, United Kingdom
| | - Binu Raj
- Departments of Endocrinology, Diabetes, and Metabolism (Pappachan, Hanna), Anesthesiology (Raj), and Gastroenterology (Thomas), University Hospital of North Staffordshire, Stoke-on-Trent, United Kingdom
| | - Sebastian Thomas
- Departments of Endocrinology, Diabetes, and Metabolism (Pappachan, Hanna), Anesthesiology (Raj), and Gastroenterology (Thomas), University Hospital of North Staffordshire, Stoke-on-Trent, United Kingdom
| | - Fahmy W Hanna
- Departments of Endocrinology, Diabetes, and Metabolism (Pappachan, Hanna), Anesthesiology (Raj), and Gastroenterology (Thomas), University Hospital of North Staffordshire, Stoke-on-Trent, United Kingdom
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Driskell OJ, Holland D, Hanna FW, Jones PW, Pemberton RJ, Tran M, Fryer AA. Inappropriate Requesting of Glycated Hemoglobin (Hb A1c) Is Widespread: Assessment of Prevalence, Impact of National Guidance, and Practice-to-Practice Variability. Clin Chem 2012; 58:906-15. [DOI: 10.1373/clinchem.2011.176487] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
Estimates suggest that approximately 25% of requests for pathology tests are unnecessary. Even in diabetes, for which international guidance provides recommended testing frequency, considerable variability in requesting practice exists. Using the diabetes marker, Hb A1c, we examined (a) the prevalence of under- and overrequesting, (b) the impact of international guidance on prevalence, and (c) practice-to-practice variability.
METHODS
We examined Hb A1c requests (519 664 requests from 115 730 patients, January 2001 to March 2011) processed by the Clinical Biochemistry Department, University Hospital of North Staffordshire, and prevalence of requesting outside guidance from intervals between requests was calculated. Requests were classified as “appropriate,” “too soon,” or “too late.” We also assessed the effect of demographic factors and publication of guidance, along with between-practice variability, on prevalence.
RESULTS
Only 49% of requests conformed to guidance; 21% were too soon and 30% were too late. Underrequesting was more common in primary care, in female patients, in younger patients, and in patients with generally poorer control (all P < 0.001); the reverse generally was true for overrequesting. Publication of guidance (e.g., American Diabetes Association, UK National Institute for Health and Clinical Excellence) had no significant impact on under- or overrequesting rates. Prevalence of inappropriate requests varied approximately 6-fold between general practices.
CONCLUSIONS
Although overrequesting was common, underrequesting was more prevalent, potentially affecting longer-term health outcomes. National guidance appears to be an ineffective approach to changing request behavior, supporting the need for a multisystem approach to reducing variability.
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Affiliation(s)
- Owen J Driskell
- Department of Clinical Biochemistry, Keele University School of Medicine, University Hospital of North Staffordshire, Stoke-on-Trent, UK
| | - David Holland
- National Pathology Benchmarking Service, Department of Medicines Management, and
| | - Fahmy W Hanna
- Department of Diabetes and Endocrinology, Norton Unit, University Hospital of North Staffordshire, Stoke-on-Trent, UK
| | - Peter W Jones
- School of Computing and Mathematics, Keele University, Staffordshire, UK
| | - R John Pemberton
- Diabetes UK North Staffordshire Branch, Newcastle-under-Lyme, Staffordshire, UK
| | - Martin Tran
- Department of Clinical Biochemistry, Keele University School of Medicine, University Hospital of North Staffordshire, Stoke-on-Trent, UK
| | - Anthony A Fryer
- Department of Clinical Biochemistry, Keele University School of Medicine, University Hospital of North Staffordshire, Stoke-on-Trent, UK
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Siddique H, Baskar V, Chakrabarty A, Clayton RN, Hanna FW. Spontaneous pregnancy after trans-sphenoidal surgery in a patient with lymphocytic hypophysitis. Clin Endocrinol (Oxf) 2007; 66:454-5. [PMID: 17302883 DOI: 10.1111/j.1365-2265.2006.02734.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Varughese GI, Tahrani AA, Smith JL, Clayton RN, Hanna FW. Carbimazole therapy in the setting of end-stage renal disease and haemodialysis. Nephrol Dial Transplant 2006; 21:2318-9. [PMID: 16702200 DOI: 10.1093/ndt/gfl231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- George I Varughese
- Department of Endocrinology, University Hospital of North Staffordshire, Stoke-on-Trent ST4 6QG, UK.
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Issa BG, Hanna FW. Clinical approach to thyrotoxicosis. Practitioner 2004; 248:358-61. [PMID: 15160477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
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Abstract
Necrotizing fasciitis (NF) is a rare and often fatal soft-tissue infection involving the superficial fascial layers of the extremities, abdomen or perineum. Progression to septic shock can occur very rapidly with its associated high morbidity and mortality. NF is usually caused by beta haemolytic streptococci; less often a poly-microbial isolate is the cause. It typically occurs in patients with some degree of immune dysfunction. We present a case of severe pneumococcal necrotizing fasciitis in an obese patient with Type 2 diabetes. There was no history of trauma or evidence of diabetes-related complications. The initial presentation was with features of septic arthritis of the left knee, which subsequently progressed to NF. Differentiation from cellulitis is often difficult in the early stages. Invasive pneumococcal infections are extremely rare, with only a few reported in the literature. Moreover, our case highlights the need to consider other differential diagnoses (and to look out for complications) in patients with diabetes, especially if there is little clinical response to the initial treatment.
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Affiliation(s)
- P K Prakash
- Department of Diabetes and Endocrinology, Prince Charles Hospital, Merthyr Tydfil, UK.
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Hanna FW. Bimonthly update. Hyperlipidaemia and cardiovascular disease. Curr Opin Lipidol 2001; 12:85-7. [PMID: 11176208 DOI: 10.1097/00041433-200102000-00015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Affiliation(s)
- F W Hanna
- Department of Medicine, Prince Charles Hospital, Merthyr Tydfill, Cardiff CF47 9DT.
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Abstract
A 42-year-old house wife presented with worsening headaches over 6 months in the absence of visual symptoms or symptoms suggestive of focal neurology. She was a life-long smoker. Systems review was unremarkable apart from secondary amenorrhoea and galactorrhoea of 6 months duration. Her serum prolactin was found to be 620 mU/l (60-400), FT4 12.6 nmol/l (9.8-23.1), TSH 1.38 mU/l (0.35-5.5), oestradiol < 73 pmol/l, LH and FSH of 4.4 and 12.6 mIU/l, respectively. She was on bromocriptine. A presumptive diagnosis of pneumonia, based on pyrexia and CXR findings, was made and she was started on IV antibiotics. Two days later she developed meningism and deterioration of conscious level. (Lumbar puncture results: no organisms, 312 neutrophils and 164 lymphocytes). CT scan revealed a 2.5-cm pituitary adenoma, with suprasellar extension. A repeat hormonal profile revealed FSH 1.4, LH < 0.3 mU/l, oestradiol < 73 pmol/l, prolactin 488 mU/l (60-400), and low random cortisol at 29 nmol/l. T1-weighted MRI revealed a large pituitary mass with evidence of haemorrhage. The patient subsequently underwent a transsphenoidal exploration with resection of the pituitary lesion. Whilst awaiting the histopathology results, CT of chest revealed a 1. 5-cm diameter rounded well defined density in the right lower lobe associated with hilar, pre- and right para-tracheal lymphadenopathy. The histopathology of the pituitary lesion, obtained piecemeal, revealed fragments of fibrous tissue infiltrated by sheets of acidophilic prolactin-positive cells, in keeping with a prolactinoma. In addition, other fragments with blood clot included highly atypical epithelial cells with mitotic figures. These were negative for prolactin but showed HMFG-and CEA-positivity, excluding them from a pituitary lineage. Transbronchial biopsy revealed moderately differentiated adenocarcinoma, with evidence of lymphatic spread. The overall conclusion was of bronchogenic adenocarcinoma, metastasizing to a prolactinoma and complicated by apoplexy.
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Affiliation(s)
- F W Hanna
- Department of Medicine, University Hospital of Wales, Cardiff, UK
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Hanna FW. Hyperlipidaemia and cardiovascular disease. Curr Opin Lipidol 1998; 9:69-71. [PMID: 9502339 DOI: 10.1097/00041433-199802000-00013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
INTRODUCTION Hyperthyroidism is associated with a reduction in bone mineral density (BMD). Suppressive doses of thyroxine (T4), inducing subclinical hyperthyroidism, have been reported by some investigators to reduce BMD. Little work has been done on replacement doses of T4. AIM The aim was to investigate the effect of replacement doses of T4 on BMD. STUDY DESIGN Cross-sectional study of hypothyroid patients on long-term T4 replacement doses, comparing those who had primary hypothyroidism with those who were previously hyperthyroid. PATIENTS Fifty women on replacement doses of T4 for more than 5 years were recruited. Twenty-five were treated for primary (group 1) and 25 for radioiodine-induced hypothyroidism (group 2). They were well matched for age, menstrual status, smoking history, body mass index (BMI), dose and duration of T4 replacement as well as thyroid status. MEASUREMENTS BMD was assessed by dual energy X-ray absorptiometry. Free T4 (FT4), FT3 as well as ultrasensitive TSH assays were used to assess thyroid status. RESULTS The two groups showed no difference in BMD (g/cm2) of the lumbar spine (1.008 vs. 0.957, P = 0.25), femoral neck (0.745 vs. 0.735, P = 0.79) and total hip (0.878 vs. 0.837, P = 0.24). When the two groups were pooled, there was no significant difference between the patients and a reference population with femoral neck and total hip BMD expressed as a standard deviation (Z) score. However, the lumbar spine mean Z score was significantly greater than zero. For each site, there was a negative correlation of BMD with age in at least one group but, in general, BMI, FT4, FT3 and duration of T4 replacement did not correlate with BMD. T4 dose, however, had a consistent positive correlation with BMD in the spine, femoral neck and the hip (P = 0.01, 0.04 and 0.02, respectively) in group 2 but not group 1. CONCLUSION In this study, there is no evidence for a difference in bone mineral density in patients receiving replacement doses of thyroxine irrespective of the aetiology of their hypothyroidism. The reduced bone mineral density associated with hyperthyroidism appears to be restored, maintained and in some cases possibly improved while on long-term thyroxine replacement post-radioiodine.
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Affiliation(s)
- F W Hanna
- Department of Medicine, University of Wales College of Medicine, Cardiff, UK
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Affiliation(s)
- F W Hanna
- Department of Endocrinology, Diabetes, and Metabolism, University Hospital of Wales, Cardiff, UK
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Hanna FW, Ardill JE, Johnston CF, Cunningham RT, Curry WJ, Russell CF, Buchanan KD. Regulatory peptides and other neuroendocrine markers in medullary carcinoma of the thyroid. J Endocrinol 1997; 152:275-81. [PMID: 9071985 DOI: 10.1677/joe.0.1520275] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [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: 02/04/2023]
Abstract
Medullary thyroid carcinoma (MTC) is an APUDoma (APUD refers to amine precursor uptake and decarboxylation) arising from the parafollicular cells. Diarrhoea has been reported in some 30% of patients, variously attributed to excess production of calcitonin (CT), serotonin (5-HT), vasoactive intestinal peptide (VIP) or other factors. The regulatory factors in MTC were examined employing immunocytochemistry and RIA to tumours and their extracts. The patients were followed up for more than 15 years. CT and calcitonin gene-related peptide were universally expressed in all the tumours. The neuroendocrine markers chromogranin A (and its fragments pancreastatin and WE-14), neurone-specific enolase, protein gene product 9.5 and carcino-embryonic antigen were found in the majority of MTCs and might be useful as immunocytochemical markers. 5-HT, substance P, neurokinin A, glucagon and VIP could not be detected, excluding them as candidates in the diarrhoea of MTC.
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Affiliation(s)
- F W Hanna
- Wellcome Research Laboratories, Department of Medicine, Queen's University of Belfast, UK
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Affiliation(s)
- F W Hanna
- Wellcome Research Laboratories, Department of Medicine, Queen's University of Belfast, UK
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Hanna FW, Peters JR, Rees JA. Evidence for the risk of calcium channel blockers in hypertension was selective. BMJ 1996; 313:1259-60. [PMID: 8939129 PMCID: PMC2352561 DOI: 10.1136/bmj.313.7067.1259c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Affiliation(s)
- F W Hanna
- Department of Medicine, University Hospital of Wales, Health Park Cardiff, UK
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Hanna FW, Smith DM, Johnston CF, Akinsanya KO, Jackson ML, Morgan DG, Bhogal R, Buchanan KD, Bloom SR. Expression of a novel receptor for the calcitonin peptide family and a salmon calcitonin-like peptide in the alpha-thyrotropin thyrotroph cell line. Endocrinology 1995; 136:2377-82. [PMID: 7750458 DOI: 10.1210/endo.136.6.7750458] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
We have previously shown an increased incidence of alpha-subunit-producing thyrotroph tumors after salmon calcitonin (sCT) injection into rats. However, it is not clear whether the effects of CT are direct or indirect. Our hypothesis was that for sCT to act directly, it must have a binding site on thyrotrophs. The alpha TSH cell line was used as a model for thyrotrophs. Receptor binding studies using alpha TSH membranes revealed a high affinity binding site for sCT [IC50 = 0.97 +/- 0.18 nM (n = 4); Kd = 5.45 +/- 0.43 nM (n = 3); binding capacity = 6.6 pmol/mg protein (n = 3)]. Rat CT did not compete with binding at this site. Receptor screening for other CT peptide family members revealed high specific binding for CT gene-related peptide (CGRP; IC50 = 0.25 +/- 0.08 nM; n = 3) and islet amyloid polypeptide (IC50 = 4.36 +/- 1.1 nM; n = 3). This together with the absence of rat CT binding excluded a conventional CT-binding site, and we propose a site similar to the CGRP subtype III receptor described in the rat nucleus accumbens. Guanosine 5'O-(3-thiotriphosphate) (GTP gamma S) (20 microM), reduced [125I]CGRP binding to 38% of maximal, indicating that this site is G-protein coupled. Immunocytochemically, all of the cells displayed intense sCT-like immunoreactivity, which was totally abolished by preabsorption of the antibody with sCT. The presence of this receptor supports the hypothesis that sCT mediates tumorigenesis via a direct pituitary action and, together with the coexistence of a sCT-like peptide in these cells, provides evidence for a possible autocrine role of this peptide in the control of thyrotroph function.
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Affiliation(s)
- F W Hanna
- Department of Medicine, Wellcome Research Laboratories, Queen's University of Belfast, United Kingdom
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