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Kaseka ML, Dlamini N. Investigation and management of pediatric moyamoya arteriopathy in the era of genotype-phenotype correlation studies. Eur J Hum Genet 2023; 31:735-737. [PMID: 37188827 PMCID: PMC10326028 DOI: 10.1038/s41431-023-01369-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 04/17/2023] [Indexed: 05/17/2023] Open
Affiliation(s)
- M L Kaseka
- Division of Neurology, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada.
| | - N Dlamini
- Division of Neurology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
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Feugang J, Gad A, Ishak G, Gebremedhn S, Gastal M, Dlamini N, Gastal E, Tesfaye D. 152 Seasonal dynamics of extracellular vesicle-coupled microRNAs in equine follicular fluid. Reprod Fertil Dev 2022. [DOI: 10.1071/rdv35n2ab152] [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: 12/11/2022] Open
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3
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Dlamini N, Santos-Rivera M, Duncan B, Nguyen T, Vance-Kouba C, Pechanova O, Pechan T, Feugang J. 147 Profiling boar semen quality through near-infrared spectroscopy and proteomic tools. Reprod Fertil Dev 2022. [DOI: 10.1071/rdv35n2ab147] [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: 12/12/2022] Open
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Chan A, Begum Y, Robertson A, Walker K, Westmacott R, Shroff M, Dlamini N, Narang I. The Impact of Experimental Sleep Restriction on Neurocognition in Healthy Adolescents. Sleep Med 2022. [DOI: 10.1016/j.sleep.2022.05.564] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Chan A, Begum Y, Robertson A, Walker K, Westmacott R, Shroff M, Dlamini N, Narang I. The Impact of Experimental Sleep Restriction on Endothelial Function in Healthy Adolescents. Sleep Med 2022. [DOI: 10.1016/j.sleep.2022.05.563] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Padayachy L, Ford L, Dlamini N, Mazwi A. Surgical treatment of post-infectious hydrocephalus in infants. Childs Nerv Syst 2021; 37:3397-3406. [PMID: 34148129 DOI: 10.1007/s00381-021-05237-1] [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] [Received: 03/14/2021] [Accepted: 05/27/2021] [Indexed: 11/29/2022]
Abstract
The management of post-infective hydrocephalus in infants remains a challenging task for the pediatric neurosurgeon. The decision-making curve is often complex in that appropriate temporizing measures need to be implemented to properly clear any infection within the CSF before any decision can be made regarding a permanent solution. The etiology differs at varying stages of neonatal development, and the weight of the child, skin fragility, and relevant surgical treatment options are often important limiting factors. Deciding on the optimal treatment option involves assessing the etiology, age, and clinical and radiological features of the individual case and selecting the most appropriate surgical option.
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Affiliation(s)
- L Padayachy
- Pediatric Neurosurgery Unit, Department of Neurosurgery, School of Medicine, Faculty of Health Sciences, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa.
| | - L Ford
- Pediatric Neurosurgery Unit, Department of Neurosurgery, School of Medicine, Faculty of Health Sciences, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa
| | - N Dlamini
- Pediatric Neurosurgery Unit, Department of Neurosurgery, School of Medicine, Faculty of Health Sciences, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa
| | - A Mazwi
- Department of Neurosurgery, School of Medicine, Faculty of Health Sciences, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa
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Mtetwa G, Anabwani-Richter F, Dlamini N, Dlamini Q, Devezin T, Kay A, DiNardo A, Mandalakas A, Lukhele B. Sterilization of gowns: making the most of a scarce commodity during the COVID-19 pandemic. Public Health Action 2021; 11:112-113. [PMID: 34567985 DOI: 10.5588/pha.21.0024] [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] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/08/2021] [Indexed: 11/10/2022] Open
Abstract
Baylor Clinic in Mbabane, Eswatini, convened a crisis meeting to tackle critical shortages of long-sleeved disposable gowns that resulted from COVID-19 pandemic constraints on available personal protective equipment (PPE). A strategy deemed safe, affordable and sustainable was adopted to autoclave and re-use gowns based on a risk-stratified approach. Key objectives were to ensure essential infection control and prevention (ICP) for medical doctors, nurses, and laboratory teams. Administrative, environmental and personal protective measures for ICP were enhanced through regular staff training. This strategy for gown re-use has been invaluable in motivating responsible stewardship and maximization of available gowns during the COVID-19 pandemic.
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Affiliation(s)
- G Mtetwa
- Baylor College of Medicine Children's Foundation Eswatini, Mbabane, Eswatini
| | - F Anabwani-Richter
- Baylor College of Medicine Children's Foundation Eswatini, Mbabane, Eswatini
| | - N Dlamini
- Baylor College of Medicine Children's Foundation Eswatini, Mbabane, Eswatini
| | - Q Dlamini
- Baylor College of Medicine Children's Foundation Eswatini, Mbabane, Eswatini
| | - T Devezin
- Global TB Program, Department of Pediatrics Baylor College of Medicine, Children's Hospital, Houston, TX, USA
| | - A Kay
- Baylor College of Medicine Children's Foundation Eswatini, Mbabane, Eswatini.,Global TB Program, Department of Pediatrics Baylor College of Medicine, Children's Hospital, Houston, TX, USA
| | - A DiNardo
- Global TB Program, Department of Pediatrics Baylor College of Medicine, Children's Hospital, Houston, TX, USA
| | - A Mandalakas
- Global TB Program, Department of Pediatrics Baylor College of Medicine, Children's Hospital, Houston, TX, USA
| | - B Lukhele
- Baylor College of Medicine Children's Foundation Eswatini, Mbabane, Eswatini
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Vambe D, Kay AW, Furin J, Howard AA, Dlamini T, Dlamini N, Shabangu A, Hassen F, Masuku S, Maha O, Wawa C, Mafukidze A, Altaye K, Sikhondze W, Gwitima T, Keus K, Simelane T, Kerschberger B. Bedaquiline and delamanid result in low rates of unfavourable outcomes among TB patients in Eswatini. Int J Tuberc Lung Dis 2020; 24:1095-1102. [DOI: 10.5588/ijtld.20.0082] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING: Since 2015, Eswatini has been scaling up bedaquiline (BDQ) and delamanid (DLM) based drug-resistant TB treatment regimens under programmatic conditions.OBJECTIVE: Identification of factors associated with treatment outcomes in patients receiving BDQ and/or
DLM either as a new treatment initiation or drug substitution.DESIGN: This is a retrospective cohort study of patients receiving BDQ and/or DLM in Eswatini between March 2015 and October 2018. We describe factors associated with unfavourable treatment outcomes (death, lost to follow-up,
treatment failure and amplification of resistance) and culture conversion using multivariable flexible parametric survival and competing-risks regression analyses.RESULTS: Of 352 patients receiving BDQ and/or DLM, 7.8% and 21.2% had an unfavourable treatment outcome at 6 and 24
months, respectively. Predictors were age ≥ 60 years (adjusted hazard ratio aHR 4.49, 95%CI 1.61–12.57) vs. age 20–39 years, and a treatment regimen combining both drugs (aHR 4.49, 95%CI 1.61–12.57) vs. BDQ only. The probability of culture conversion was increased for
two health facilities and patients with a poly resistance profile (adjusted sub-hazard ratio 2.01, 95%CI 1.13–3.59) vs. multidrug resistance.CONCLUSION: Single use of BDQ or DLM was associated with low rates of unfavourable outcomes, suggesting that these medications may be
effectively adopted at scale under routine programmatic conditions. Combined use of BDQ and DLM was a risk factor for unfavourable outcomes and should prompt for collection of more data on the combined use of these medications.
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Affiliation(s)
- D. Vambe
- Eswatini National Tuberculosis Control Programme, Manzini, Eswatini
| | - A. W. Kay
- Baylor College of Medicine, Houston, TX, USA, Baylor Children´s Foundation, Mbabane, Eswatini
| | - J. Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA
| | - A. A. Howard
- ICAP at Columbia University, New York, NY, Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - T. Dlamini
- Eswatini National Tuberculosis Control Programme, Manzini, Eswatini
| | - N. Dlamini
- Eswatini National Tuberculosis Control Programme, Manzini, Eswatini
| | | | - F. Hassen
- National TB Referral Hospital, Manzini
| | - S. Masuku
- Eswatini National Tuberculosis Control Programme, Manzini, Eswatini
| | - O. Maha
- Eswatini National Tuberculosis Control Programme, Manzini, Eswatini, Matsapha Comprehensive Care Clinic, Manzini
| | - C. Wawa
- Eswatini National Tuberculosis Control Programme, Manzini, Eswatini, Mankanyane Hospital, Manzini
| | | | - K. Altaye
- ICAP at Columbia University, Mbabane
| | - W. Sikhondze
- Eswatini National Tuberculosis Control Programme, Manzini, Eswatini
| | | | - K. Keus
- Médecins Sans Frontières (MSF) Operational Centre Amsterdam, Manzini
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Ibrahim AY, Amirabadi A, Shroff MM, Dlamini N, Dirks P, Muthusami P. Fractional Flow on TOF-MRA as a Measure of Stroke Risk in Children with Intracranial Arterial Stenosis. AJNR Am J Neuroradiol 2020; 41:535-541. [PMID: 32115418 DOI: 10.3174/ajnr.a6441] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 01/04/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Conventional angiography is the criterion standard for measuring intracranial arterial stenosis. We evaluated signal intensity ratios from TOF-MRA as a measure of intracranial stenosis and infarct risk in pediatric stroke. MATERIALS AND METHODS A retrospective study was undertaken in children with intracranial arterial stenosis, who had TOF-MRA and conventional angiography performed within 6 months. Arterial diameters were measured for percentage stenosis. ROI analysis on TOF-MRA measured signal intensity in pre- and poststenotic segments, with post-/pre-signal intensity ratios calculated. The Pearson correlation was used to compare percentage stenosis on MRA with conventional angiography and signal intensity ratios with percentage stenosis; the point-biserial correlation was used for infarcts compared with percentage stenosis and signal intensity ratios. Sensitivity, specificity, and positive and negative predictive values were calculated for determining severe (≥70%) stenosis from MRA and signal intensity ratios against the criterion standard conventional angiography. P < .05 was considered statistically significant. RESULTS Seventy stenotic segments were found in 48 studies in 41 children (median age, 11.0 years; range, 5 months to 17.0 years; male/female ratio, 22:19): 20/41 (48.8%) bilateral, 11/41 (26.8%) right, and 10/41 (24.4%) left, with the most common site being the proximal middle cerebral artery (22/70, 31%). Moyamoya disease accounted for 27/41 (65.9%). Signal intensity ratios and conventional angiography stenosis showed a moderate negative correlation (R = -0.54, P < .001). Receiver operating characteristic statistics showed an area under the curve of 0.86 for using post-/pre-signal intensity ratios to determine severe (≥70%) carotid stenosis, yielding a threshold of 1.00. Sensitivity, specificity, and positive and negative predictive values for severe stenosis were the following-MRA: 42.8%, 58.8%, 30.0%, and 71.4%; signal intensity ratio >1.00: 97.1%, 77.8%, 71.7%, and 97.4%; combination: 75.5%, 100%, 100%, and 76.8%, respectively. Signal intensity ratios decreased with increasing grade of stenosis (none/mild-moderate/severe/complete, P < .001) and were less when associated with infarcts (0.81 ± 0.52 for arteries associated with downstream infarcts versus 1.31 ± 0.55 for arteries without associated infarcts, P < .001). CONCLUSIONS Signal intensity ratios from TOF-MRA can serve as a noninvasive measure of intracranial arterial stenosis and allow identification of high-risk lesions in pediatric stroke.
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Affiliation(s)
- A Y Ibrahim
- From the Department of Diagnostic Imaging (A.Y.I., A.A., M.M.S., P.M.)
- Department of Clinical Sciences (A.Y.I.), Faculty of Medicine, Yarmouk University, Irbid, Jordan
| | - A Amirabadi
- From the Department of Diagnostic Imaging (A.Y.I., A.A., M.M.S., P.M.)
| | - M M Shroff
- From the Department of Diagnostic Imaging (A.Y.I., A.A., M.M.S., P.M.)
| | | | - P Dirks
- Division of Neurosurgery (P.D.), Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - P Muthusami
- From the Department of Diagnostic Imaging (A.Y.I., A.A., M.M.S., P.M.)
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Dlamini N, Slim M, Kirkham F, Shroff M, Dirks P, Moharir M, MacGregor D, Robertson A, deVeber G, Logan W. Predicting Ischemic Risk Using Blood Oxygen Level-Dependent MRI in Children with Moyamoya. AJNR Am J Neuroradiol 2019; 41:160-166. [PMID: 31806596 DOI: 10.3174/ajnr.a6324] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 10/02/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Moyamoya is a progressive steno-occlusive arteriopathy. MR imaging assessment of cerebrovascular reactivity can be performed by measuring the blood oxygen level-dependent cerebrovascular reactivity response to vasoactive stimuli. Our objective was to determine whether negative blood oxygen level-dependent cerebrovascular reactivity status is predictive of ischemic events in childhood moyamoya. MATERIALS AND METHODS We conducted a retrospective study of a consecutive cohort of children with moyamoya who underwent assessment of blood oxygen level-dependent cerebrovascular reactivity. The charts of patients with written informed consent were reviewed for the occurrence of arterial ischemic stroke, transient ischemic attack, or silent infarcts. We used logistic regression to calculate the OR and 95% CI for ischemic events based on steal status. Hazard ratios for ischemic events based on age at blood oxygen level-dependent cerebrovascular reactivity imaging, sex, and moyamoya etiology were calculated using Cox hazards models. RESULTS Thirty-seven children (21 female; median age, 10.7 years; interquartile range, 7.5-14.7 years) were followed for a median of 28.8 months (interquartile range, 13.7-84.1 months). Eleven (30%) had ischemic events, 82% of which were TIA without infarcts. Steal was present in 15 of 16 (93.8%) hemispheres in which ischemic events occurred versus 25 of 58 (43.1%) ischemic-free hemispheres (OR = 19.8; 95% CI, 2.5-160; P = .005). Children with idiopathic moyamoya were at significantly greater risk of ischemic events (hazard ratio, 3.71; 95% CI, 1.1-12.8; P = .037). CONCLUSIONS Our study demonstrates that idiopathic moyamoya and the presence of steal are independently associated with ischemic events. The use of blood oxygen level-dependent cerebrovascular reactivity could potentially assist in the selection of patients for revascularization surgery and the direction of therapy in children with moyamoya.
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Affiliation(s)
- N Dlamini
- From the Division of Neurology (N.D., M. Slim, M.M., D.M., A.R., G.d.V., W.L.)
| | - M Slim
- From the Division of Neurology (N.D., M. Slim, M.M., D.M., A.R., G.d.V., W.L.)
| | - F Kirkham
- Developmental Neurosciences Unit and Biomedical Research Centre (F.K.), University College London Great Ormond Street Institute of Child Health, London, UK
| | - M Shroff
- Department of Pediatrics, and Departments of Diagnostic Imaging (M. Shroff)
| | - P Dirks
- Surgery (P.D.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - M Moharir
- From the Division of Neurology (N.D., M. Slim, M.M., D.M., A.R., G.d.V., W.L.)
| | - D MacGregor
- From the Division of Neurology (N.D., M. Slim, M.M., D.M., A.R., G.d.V., W.L.)
| | - A Robertson
- From the Division of Neurology (N.D., M. Slim, M.M., D.M., A.R., G.d.V., W.L.)
| | - G deVeber
- From the Division of Neurology (N.D., M. Slim, M.M., D.M., A.R., G.d.V., W.L.)
| | - W Logan
- From the Division of Neurology (N.D., M. Slim, M.M., D.M., A.R., G.d.V., W.L.)
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Dlamini N, Mukaya HE, Van Zyl RL, Chen CT, Zeevaart RJ, Mbianda XY. Synthesis, characterization, kinetic drug release and anticancer activity of bisphosphonates multi-walled carbon nanotube conjugates. Mater Sci Eng C Mater Biol Appl 2019; 104:109967. [PMID: 31499981 DOI: 10.1016/j.msec.2019.109967] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 06/06/2019] [Accepted: 07/09/2019] [Indexed: 12/21/2022]
Abstract
The statistical proof that most forms of cancer metastasize to bone tissue has redirected research focus to the development of efficient secondary bone cancer treatment regimens. Bisphosphonates (BPs) have been earmarked as a drug of choice for bone metastasis. However, they have a shortcoming of being released before reaching targeted sites due to their low molecular weight. In haste to attain increased efficacy, there is a tendency for drug overdose to occur, resulting in systemic toxicity. One way to curb this is by employing drug delivery systems for targeted and controlled release of the drugs. Having been explored as versatile and innovative drug carriers, multi-walled carbon nanotubes (MWCNTs) have emerged as potential drug delivery systems. Hence, in the present study, alendronate, neridronate and pamidronate are three classes of bisphosphonates that were conjugated onto multi-walled carbon nanotubes. Conjugation was confirmed by characterization techniques including SEM, TEM, EDX, FTIR, Raman and TGA. Drug release studies were also conducted at pH 1.2, 5.5 and 7.4 to study the mechanism of release for neridronate. Results obtained were fitted into Zero order (42.6%), Higuchi (26%) and Korsmeyer-Peppas (22%). The best models describing the release of neridronate from MWCNTs were Zero order, Higuchi and Korsmeyer-Peppas at pH 1.2, 5.5 and 7.4, respectively. A tetrazolium cell viability assay was performed to assess the anticancer activity of the MWCNTs conjugated BPs.
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Affiliation(s)
- N Dlamini
- Department of Applied Chemistry; Faculty of Science; University of Johannesburg, Doornfontein Campus, P.O. Box 17011, Johannesburg, South Africa
| | - H E Mukaya
- Department of Applied Chemistry; Faculty of Science; University of Johannesburg, Doornfontein Campus, P.O. Box 17011, Johannesburg, South Africa
| | - R L Van Zyl
- Pharmacology Division, Department of Pharmacy and Pharmacology; WITS Institute for Malaria (WRIM), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - C T Chen
- Pharmacology Division, Department of Pharmacy and Pharmacology; WITS Institute for Malaria (WRIM), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - R J Zeevaart
- Radiochemistry, NECSA (South African Nuclear Energy Corporation Ltd.), Pretoria, South Africa
| | - X Y Mbianda
- Department of Applied Chemistry; Faculty of Science; University of Johannesburg, Doornfontein Campus, P.O. Box 17011, Johannesburg, South Africa.
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Dlamini N, Shah-Basak P, Leung J, Kirkham F, Shroff M, Kassner A, Robertson A, Dirks P, Westmacott R, deVeber G, Logan W. Breath-Hold Blood Oxygen Level-Dependent MRI: A Tool for the Assessment of Cerebrovascular Reserve in Children with Moyamoya Disease. AJNR Am J Neuroradiol 2018; 39:1717-1723. [PMID: 30139753 DOI: 10.3174/ajnr.a5739] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [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: 02/15/2018] [Accepted: 06/10/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE There is a critical need for a reliable and clinically feasible imaging technique that can enable prognostication and selection for revascularization surgery in children with Moyamoya disease. Blood oxygen level-dependent MR imaging assessment of cerebrovascular reactivity, using voluntary breath-hold hypercapnic challenge, is one such simple technique. However, its repeatability and reliability in children with Moyamoya disease are unknown. The current study sought to address this limitation. MATERIALS AND METHODS Children with Moyamoya disease underwent dual breath-hold hypercapnic challenge blood oxygen level-dependent MR imaging of cerebrovascular reactivity in the same MR imaging session. Within-day, within-subject repeatability of cerebrovascular reactivity estimates, derived from the blood oxygen level-dependent signal, was computed. Estimates were associated with demographics and intellectual function. Interrater reliability of a qualitative and clinically applicable scoring scheme was assessed. RESULTS Twenty children (11 males; 12.1 ± 3.3 years) with 30 MR imaging sessions (60 MR imaging scans) were included. Repeatability was "good" on the basis of the intraclass correlation coefficient (0.70 ± 0.19). Agreement of qualitative scores was "substantial" (κ = 0.711), and intrarater reliability of scores was "almost perfect" (κ = 0.83 and 1). Younger participants exhibited lower repeatability (P = .027). Repeatability was not associated with cognitive function (P > .05). However, abnormal cerebrovascular reactivity was associated with slower processing speed (P = .015). CONCLUSIONS Breath-hold hypercapnic challenge blood oxygen level-dependent MR imaging is a repeatable technique for the assessment of cerebrovascular reactivity in children with Moyamoya disease and is reliably interpretable for use in clinical practice. Standardization of such protocols will allow further research into its application for the assessment of ischemic risk in childhood cerebrovascular disease.
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Affiliation(s)
- N Dlamini
- From the Division of Neurology (N.D., G.d.V., W.L.)
- Neurosciences and Mental Health Program (N.D.)
- Child Health Evaluative Sciences Program (N.D., A.R., G.d.V.)
- Institute of Medical Science (N.D., G.d.V.)
- Developmental Neurosciences (N.D., F.K.), University College London, Great Ormond Street Institute of Child Health, London, UK
| | - P Shah-Basak
- Diagnostic Imaging (P.S.-B., M.S.)
- Rotman Research Institute (P.S.-B.), Baycrest, Toronto, Ontario, Canada
| | - J Leung
- Translational Medicine (J.L., A.K.)
| | - F Kirkham
- Developmental Neurosciences (N.D., F.K.), University College London, Great Ormond Street Institute of Child Health, London, UK
| | - M Shroff
- Diagnostic Imaging (P.S.-B., M.S.)
| | - A Kassner
- Translational Medicine (J.L., A.K.)
- Department of Medical Imaging (A.K.), University of Toronto, Toronto, Ontario, Canada
| | - A Robertson
- Child Health Evaluative Sciences Program (N.D., A.R., G.d.V.)
| | - P Dirks
- Department of Neurosurgery (P.D.)
| | - R Westmacott
- Department of Neuropsychology (R.W.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - G deVeber
- From the Division of Neurology (N.D., G.d.V., W.L.)
- Child Health Evaluative Sciences Program (N.D., A.R., G.d.V.)
- Institute of Medical Science (N.D., G.d.V.)
| | - W Logan
- From the Division of Neurology (N.D., G.d.V., W.L.)
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Cunnama L, Abrams EJ, Myer L, Gachuhi A, Dlamini N, Hlophe T, Kikuvi J, Langwenya N, Mthethwa S, Mudonhi D, Nhlabatsi B, Nuwagaba-Biribonwoha H, Okello V, Sahabo R, Zerbe A, Sinanovic E. Cost and cost-effectiveness of transitioning to universal initiation of lifelong antiretroviral therapy for all HIV-positive pregnant and breastfeeding women in Swaziland. Trop Med Int Health 2018; 23:950-959. [PMID: 29956426 DOI: 10.1111/tmi.13121] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To assess the costs and cost-effectiveness of transitioning from antiretroviral therapy (ART) initiation based on CD4 cell count and WHO clinical staging ('Option A') to universal ART ('Option B+') for all HIV-infected pregnant and breastfeeding women in Swaziland. METHODS We measured the total costs of prevention of mother-to-child HIV transmission (PMTCT) service delivery at public sector facilities with empirical cost data collected at three points in time: once under Option A and again twice after transition to the Option B+ approach. The cost per woman treated per month includes recurrent costs (personnel, overheads, medication and diagnostic tests) and capital costs (buildings, furniture, start-up costs and training). Cost-effectiveness was estimated from the health services perspective as the cost per woman retained in care through 6 months postpartum. This analysis is nested within a larger stepped-wedge evaluation, which demonstrated a 26% increase in maternal retention after the transition to Option B+. RESULTS Across the five sites, the total cost for PMTCT during the study period (from August 2013 to October 2015, in 2015 US$) was $868,426 for Option B+ and $680 508 for Option A. The cost per woman treated per month was $183 for a woman on ART under Option B+, and $127 and $118 for a woman on ART and zidovudine (AZT), respectively, under Option A. The weighted average cost per woman treated on Option B+ was $826 compared to $525 under Option A. The main cost drivers were the start-up costs, additional training provided and staff time spent on PMTCT tasks for Option B+. The incremental cost-effectiveness ratio was estimated at $912 for every additional mother retained in care through six months postpartum. CONCLUSIONS The cost and cost-effectiveness outcomes from this study indicate that there is a robust economic case for pursuing the Option B+ approach in Swaziland and similar settings such as South Africa. Furthermore, these costs can be used to aid decision making and budgeting, for similar settings transitioning to test and treat strategy.
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Affiliation(s)
- L Cunnama
- Health Economics Unit, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - E J Abrams
- Mailman School of Public Health, ICAP at Columbia University, New York, NY, USA.,College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - L Myer
- Division of Epidemiology & Biostatistics, University of Cape Town, Cape Town, South Africa
| | - A Gachuhi
- Mailman School of Public Health, ICAP at Columbia University, New York, NY, USA
| | - N Dlamini
- ICAP at Columbia University, Mbabane, Swaziland
| | - T Hlophe
- Monitoring & Evaluation, Deputy Prime Minister's Office, Mbabane, Swaziland
| | - J Kikuvi
- Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, South Africa
| | - N Langwenya
- Division of Epidemiology & Biostatistics, University of Cape Town, Cape Town, South Africa
| | - S Mthethwa
- Swaziland Ministry of Health, Mbabane, Swaziland
| | - D Mudonhi
- ICAP at Columbia University, Mbabane, Swaziland
| | - B Nhlabatsi
- Swaziland Ministry of Health, Mbabane, Swaziland
| | - H Nuwagaba-Biribonwoha
- Mailman School of Public Health, ICAP at Columbia University, New York, NY, USA.,ICAP at Columbia University, Mbabane, Swaziland
| | - V Okello
- Swaziland Ministry of Health, Mbabane, Swaziland
| | - R Sahabo
- Mailman School of Public Health, ICAP at Columbia University, New York, NY, USA.,ICAP at Columbia University, Mbabane, Swaziland
| | - A Zerbe
- Mailman School of Public Health, ICAP at Columbia University, New York, NY, USA
| | - E Sinanovic
- Health Economics Unit, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
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14
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Dlamini N, Zulu Z, Kunene S, Geoffroy E, Ntshalintshali N, Owiti P, Sikhondze W, Makadzange K, Zachariah R. From diagnosis to case investigation for malaria elimination in Swaziland: is reporting and response timely? Public Health Action 2018; 8:S8-S12. [PMID: 29713587 DOI: 10.5588/pha.17.0043] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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: 06/27/2017] [Accepted: 10/12/2017] [Indexed: 01/21/2023] Open
Abstract
Background: Swaziland is one of the southern African countries that aim to eliminate malaria by 2020. In 2010, the country introduced an Immediate Disease Notification System (IDNS) for immediate reporting of notifiable diseases, including malaria. Health facilities are to report malaria cases within 24 h through a toll-free telephone number (977), triggering an alert for case investigation at the patient's household within 48 h. We assessed the completeness of reporting in the IDNS, the subsequent case investigation, and whether it was done within the stipulated timelines. Methods: A cross-sectional study using routine country-wide data. Results: Of 1991 malaria cases notified between July 2011 and June 2015, 76% were reported in the IDNS, of which 68% were investigated-a shortfall of 24% in reporting and 32% in case investigations. Of the 76% of cases reported through the IDNS, 62% were reported within 24 h and 20% were investigated within 48 h. These shortcomings were most pronounced in hospitals and private facilities. Investigated cases (n = 1346) were classified as follows: 60% imported, 35% local and 5% undetermined. Conclusion: The utilisation of the IDNS for case reporting to trigger investigation is crucial for active surveillance. There is a need to address the reporting and investigation gaps identified to ensure that malaria cases receive appropriate interventions.
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Affiliation(s)
- N Dlamini
- National Malaria Control Programme, Ministry of Health (MoH), Mbabane, Swaziland
| | - Z Zulu
- National Malaria Control Programme, Ministry of Health (MoH), Mbabane, Swaziland
| | - S Kunene
- National Malaria Control Programme, Ministry of Health (MoH), Mbabane, Swaziland
| | - E Geoffroy
- Global AIDS Interfaith Alliance, San Rafael, California, USA
| | | | - P Owiti
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - W Sikhondze
- National Tuberculosis Control Programme, MoH, Mbabane, Swaziland
| | - K Makadzange
- World Health Organization Country Office for Swaziland, Mbabane, Swaziland
| | - R Zachariah
- Médecins Sans Frontières, Luxembourg, Luxembourg
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15
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Makadzange K, Dlamini N, Zulu Z, Dlamini S, Kunene S, Sikhondze W, Owiti P, Geoffroy E, Zachariah R, Mengestu TK. Low uptake of preventive interventions among malaria cases in Swaziland: towards malaria elimination. Public Health Action 2018; 8:S29-S33. [PMID: 29713591 DOI: 10.5588/pha.17.0016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 02/13/2017] [Accepted: 08/12/2017] [Indexed: 11/10/2022] Open
Abstract
Settings: Swaziland is striving to achieve sustainable malaria elimination. Three preventive interventions are vital for reaching this goal: 1) effective household utilisation of long-lasting insecticide nets (LLINs), 2) indoor residual spraying (IRS), and 3) provision of chemoprophylaxis for those travelling to malaria-endemic areas. Objectives: To assess the uptake of preventive intervention among confirmed malaria cases. Design: A longitudinal study using nation-wide programme data from 2010 to 2015. Data on malaria cases from health facilities were sourced from the Malaria Surveillance Database System. Results: Of a total 2568 confirmed malaria cases in Swaziland, 2034 (79%) had complete data on case investigations and were included in the analysis. Of 341 (17%) individuals who owned LLINs, 169 (8%) used them; 338 (17%) had IRS and 314 (15%) slept in sprayed structures. Of 1403 travellers to areas at high malaria risk, 59 (4%) used any form of malaria prevention, including chemoprophylaxis. Conclusion: The uptake of all three key malaria prevention interventions is low, and could threaten the progress made thus far toward malaria elimination. Efforts to improve this situation, including qualitative research to understand the reasons for low uptake, are urgently needed.
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Affiliation(s)
- K Makadzange
- World Health Organization Country Office for Swaziland, Mbabane, Swaziland
| | - N Dlamini
- National Malaria Control Programme, Ministry of Health, Mbabane, Swaziland
| | - Z Zulu
- National Malaria Control Programme, Ministry of Health, Mbabane, Swaziland
| | - S Dlamini
- University of Swaziland, Mbabane, Swaziland
| | - S Kunene
- National Malaria Control Programme, Ministry of Health, Mbabane, Swaziland
| | - W Sikhondze
- National Malaria Control Programme, Ministry of Health, Mbabane, Swaziland
| | - P Owiti
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - E Geoffroy
- Global AIDS Interfaith Alliance, San Rafael, California, USA
| | - R Zachariah
- Operations Research Unit, Médecins Sans Frontières, Luxembourg City, Luxembourg
| | - T K Mengestu
- World Health Organization Country Office for Swaziland, Mbabane, Swaziland
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16
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Aw B, Ade S, Hinderaker SG, Dlamini N, Takarinda KC, Chiaa K, Feil A, Traoré A, Reid T. Childhood tuberculosis in Mauritania, 2010-2015: diagnosis and outcomes in Nouakchott and the rest of the country. Public Health Action 2017; 7:199-205. [PMID: 29201655 DOI: 10.5588/pha.16.0123] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 05/25/2017] [Indexed: 11/10/2022] Open
Abstract
Setting: The National Tuberculosis Programme, Mauritania. Objective: To compare the diagnosis and treatment outcomes of childhood tuberculosis (TB) cases (aged <15 years) registered between 2010 and 2015 inside and outside Nouakchott, the capital city. Design: This was a retrospective comparative cohort study. Results: A total of 948 children with TB were registered. The registration rate was 10 times higher in Nouakchott. The proportion of children among all TB cases was higher inside than outside Nouakchott (7.5% vs. 4.6%, P < 0.01). Under-fives represented 225 (24%) of all childhood TB cases, of whom 204 (91%) were registered in Nouakchott. Extra-pulmonary TB was more common in Nouakchott, while smear-negative TB was less common. Treatment success was similar inside and outside Nouakchott (national rate 61%). The principal unsuccessful outcomes were loss to follow-up outside Nouakchott (21% vs. 11%, P < 0.01) while transfers out were more common in the city (25% vs. 14%, P = 0.01). Being aged <5 years (OR 1.2, 95%CI 1.1-1.5) was associated with an unsuccessful outcome. Conclusion: This study indicates problems in the diagnosis and treatment of childhood TB in Mauritania, especially outside the city of Nouakchott. We suggest strengthening clinical diagnosis and management, improving communications between TB treatment centres and health services and pressing the TB world to develop more accurate and easy-to-use diagnostic tools for children.
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Affiliation(s)
- B Aw
- Programme National de Lutte contre la, Tuberculose et la Lèpre, Nouakchott, Mauritanie
| | - S Ade
- Université de Parakou, Parakou, Bénin.,Programme National contre la Tuberculose, Cotonou, Bénin.,International Union Against Tuberculosis and Lung Disease, Paris, France
| | | | - N Dlamini
- National Malaria Control Programme, Ministry of Health, Mbabane, Swaziland
| | - K C Takarinda
- International Union Against Tuberculosis and Lung Disease, Paris, France.,AIDS & TB Department, Ministry of Health and Child Care, Harare, Zimbabwe
| | - K Chiaa
- Programme National de Lutte contre la, Tuberculose et la Lèpre, Nouakchott, Mauritanie
| | - A Feil
- Centre Hospitalier National de Nouakchott, Mauritanie.,Faculté de Médecine, Université de Nouakchott, Nouakchott, Mauritanie
| | - A Traoré
- Programme National de Lutte contre la, Tuberculose et la Lèpre, Nouakchott, Mauritanie
| | - T Reid
- Operational Research Unit (LuxOR), Medical Department, Operational Centre Brussels, Médecins Sans Frontières Luxembourg
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17
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Pascoe SJS, Moolla A, Tabane R, Mbele-Khama S, Dlamini N, Darkoh E. O12.5 Traditional Explanatory Models of Disease and Messaging Around HIV and STI Risk and Prevention: Findings from an Exploratory Study with Traditional Health Practitioners in South Africa. Br J Vener Dis 2013. [DOI: 10.1136/sextrans-2013-051184.0153] [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: 11/04/2022]
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18
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Dlamini N, Voermans NC, Lillis S, Stewart K, Kamsteeg EJ, Drost G, Quinlivan R, Snoeck M, Norwood F, Radunovic A, Straub V, Roberts M, Vrancken AFJE, van der Pol WL, de Coo RIFM, Manzur AY, Yau S, Abbs S, King A, Lammens M, Hopkins PM, Mohammed S, Treves S, Muntoni F, Wraige E, Davis MR, van Engelen B, Jungbluth H. Mutations in RYR1 are a common cause of exertional myalgia and rhabdomyolysis. Neuromuscul Disord 2013; 23:540-8. [PMID: 23628358 DOI: 10.1016/j.nmd.2013.03.008] [Citation(s) in RCA: 142] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Revised: 03/08/2013] [Accepted: 03/12/2013] [Indexed: 12/23/2022]
Abstract
Mutations in the skeletal muscle ryanodine receptor (RYR1) gene are a common cause of neuromuscular disease, ranging from various congenital myopathies to the malignant hyperthermia (MH) susceptibility trait without associated weakness. We sequenced RYR1 in 39 unrelated families with rhabdomyolysis and/or exertional myalgia, frequent presentations in the neuromuscular clinic that often remain unexplained despite extensive investigations. We identified 9 heterozygous RYR1 mutations/variants in 14 families, 5 of them (p.Lys1393Arg; p.Gly2434Arg; p.Thr4288_Ala4290dup; p.Ala4295Val; and p.Arg4737Gln) previously associated with MH. Index cases presented from 3 to 45 years with rhabdomyolysis, with or without exertional myalgia (n=12), or isolated exertional myalgia (n=2). Rhabdomyolysis was commonly triggered by exercise and heat and, less frequently, viral infections, alcohol and drugs. Most cases were normally strong and had no personal MH history. Inconsistent additional features included heat intolerance, and cold-induced muscle stiffness. Muscle biopsies showed mainly subtle changes. Familial RYR1 mutations were confirmed in relatives with similar or no symptoms. These findings suggest that RYR1 mutations may account for a substantial proportion of patients presenting with unexplained rhabdomyolysis and/or exertional myalgia. Associated clinico-pathological features may be subtle and require a high degree of suspicion. Additional family studies are paramount in order to identify potentially MH susceptible relatives.
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Affiliation(s)
- N Dlamini
- Department of Paediatric Neurology, Neuromuscular Service, Evelina's Children Hospital, Guy's & St. Thomas' Hospital NHS Foundation Trust, London, UK
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19
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Grigoratos DN, Mazarakis NK, Lumsden DE, Kariyawasam S, Bhangoo R, Gordon A, Lin JP, Dlamini N. Good outcome following emergency decompressive craniectomy in a case of malignant middle cerebral artery infarction in a 14-month-old infant. Br J Neurosurg 2013; 27:694-5. [DOI: 10.3109/02688697.2013.776668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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20
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Kindossi J, Anihouvi V, Vieira-dalodé G, Akissoé N, Jacobs A, Dlamini N, Pallet D, Hounhouigan D. Production, consumption, and quality attributes of Lanhouin, a fish-based condiment from West Africa. ACTA ACUST UNITED AC 2012. [DOI: 10.3362/2046-1887.2012.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- J.M. Kindossi
- Department of Nutrition and Food Science, University of Abomey-Calavi, Cotonou, Benin
| | - V.B. Anihouvi
- Department of Nutrition and Food Science, University of Abomey-Calavi, Cotonou, Benin
| | - G. Vieira-dalodé
- Department of Nutrition and Food Science, University of Abomey-Calavi, Cotonou, Benin
| | - N.H. Akissoé
- Department of Nutrition and Food Science, University of Abomey-Calavi, Cotonou, Benin
| | - A. Jacobs
- Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa
| | - N. Dlamini
- Council for Scientific and Industrial Research (CSIR), Pretoria, South Africa
| | - D. Pallet
- International Agronomic Research Centre for Development (CIRAD), Montpellier, France
| | - D.J. Hounhouigan
- Department of Nutrition and Food Science, University of Abomey-Calavi, Cotonou, Benin
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21
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Dlamini N, Voermans N, Lillis S, Abbs S, Kamsteeg E, Al-Sarraj S, Lammens M, Muntoni F, Quinlivan R, Wraige E, van Engelen B, Jungbluth H. O.15 Mutations in the skeletal muscle ryanodine receptor (RYR1) gene presenting with exertional myalgia and rhabdomyolysis. Neuromuscul Disord 2011. [DOI: 10.1016/j.nmd.2011.06.1109] [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: 10/17/2022]
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22
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Pooe JM, Sokudela B, Roos JL, Motiana LM, Dlamini N, Snyman M. Testing the effectiveness of existing psycho-educational material (The Alliance Programme) for patients suffering from schizophrenia in the South African context. ACTA ACUST UNITED AC 2010; 13:302-8. [DOI: 10.4314/ajpsy.v13i4.61881] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [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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23
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Mercuri E, Messina S, Battini R, Berardinelli A, Boffi P, Bono R, Bruno C, Carboni N, Cini C, Colitto F, D'Amico A, Minetti C, Mirabella M, Mongini T, Morandi L, Dlamini N, Orcesi S, Pelliccioni M, Pane M, Pini A, Swan AV, Villanova M, Vita G, Main M, Muntoni F, Bertini E. Reliability of the Hammersmith functional motor scale for spinal muscular atrophy in a multicentric study. Neuromuscul Disord 2006; 16:93-8. [PMID: 16427782 DOI: 10.1016/j.nmd.2005.11.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2005] [Revised: 11/22/2005] [Accepted: 11/25/2005] [Indexed: 02/01/2023]
Abstract
The aim of this study was to validate the Hammersmith functional motor scale for children with spinal muscular atrophy in a large cohort of 90 non-ambulant children with spinal muscular atrophy type 2 or 3. All had a baseline assessment (T0) and were reassessed either at 3 months (T1) (n = 66) or at 6 months (T2) (n = 24). Inter-observer reliability, tested on 13 children among 3 examiners, was > 95%. Of the 66 children examined after 3 months 4 had adverse effects in between assessments and were excluded from the analysis. Forty-two (68%) of the remaining 62 reassessed had no variation in scores between T0 and T1 and 13 (21%) were within +/- 1 point. 9 (37.5%) of the 24 children reassessed after 6 months had no variation in scores between T0 and T2 and another 9 (37.5%) had variations within +/- 1 point. Our study confirms previous observations of the reliability of the scale and helps to establish a baseline for assessing changes of functional ability over 3 and 6 month intervals. This information can be valuable in view of therapeutic trials.
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Affiliation(s)
- E Mercuri
- Department of Paediatric Neurology, Catholic University, Largo Gemelli, 00168 Rome, Italy.
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Abstract
This article is a summary of a document prepared by a task team appointed by the Superintendent-General, Head: Department of Health, KwaZulu-Natal. The terms of reference of the task team were to scrutinise all available documents on mental health in the province and to come up with a new doc- ument entitled ‘Strategic and Implementation Plan for Delivery of Mental Health Services in KwaZulu-Natal’, with operational plans and time frames, and to make specific recommendations with regard to community mental health services and forensic psychiatry.The documents used to prepare the new document were: A Framework for the Delivery of Mental Health Services by Institutions in KwaZulu-Natal;Mental Health Services Planning Report; Strategic Policy Document for Mental Health Services in KwaZulu-Natal; Community Mental Health Services at Indlovu Region, KwaZulu-Natal; KwaZulu-Natal Health Care Act 2000; Mental Health Act 2002; World Health Report on Mental Health 2001; and Mental Health and Substance Abuse Report.The article is divided into nine sections, namely organisational structure; education, training and research; mental health ser- vice provision; highly specialised services; community mental health services; forensic mental health services; mental health and the private sector; pharmaceutical services; and summary of recommendations.
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