This document summarizes a workshop on developing clinical care guidelines for growth hormone treatment in Prader-Willi syndrome. The workshop brought together over 40 experts, including endocrinologists, geneticists, clinicians with an interest in growth hormone research, patient advocates, and methodologists. It utilized a multi-criteria decision analysis framework to develop the guidelines, taking into account scientific evidence, disease impact, safety, and other criteria. The goal was to produce consensus guidelines that integrated evidence, values, and ethics to guide policy and clinical practice around this complex treatment decision.
Basics of palliative care including symptom management: pain, dyspnea, nausea and constipation; family meetings, goals-of-care, end-of-life care, and artificial nutrition.
Palliative care is about providing well-being and the highest quality of life to patients with serious, progressive, chronic life-limiting illness, including during the dying process.
Three hour slide deck for basics of palliative care including what is palliative care, symptom management (pain, dyspnea, nausea, constipation), goals-of-care, family meetings, comfort care, and issues around artificial nutrition.
Carle Palliative Care Journal Club for 7/3/18Mike Aref
Journal club review of "Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial" by D. Hui et. al. in JAMA. 2017 Sep 19;318(11):1047-1056.
Basics of palliative care including symptom management: pain, dyspnea, nausea and constipation; family meetings, goals-of-care, end-of-life care, and artificial nutrition.
Palliative care is about providing well-being and the highest quality of life to patients with serious, progressive, chronic life-limiting illness, including during the dying process.
Three hour slide deck for basics of palliative care including what is palliative care, symptom management (pain, dyspnea, nausea, constipation), goals-of-care, family meetings, comfort care, and issues around artificial nutrition.
Carle Palliative Care Journal Club for 7/3/18Mike Aref
Journal club review of "Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial" by D. Hui et. al. in JAMA. 2017 Sep 19;318(11):1047-1056.
Transition from allopathic to integrated practiceLouis Cady, MD
This lecture was the fifth and concluding lecture for Dr. Cady at the IMMH Conference in Santa Fe, NM. In it, he discusses crossing the divide separating us - with our new knowledge and ideas - from the opportunity and privilege of offering it to our patients.
Dr. Gregory Jantz Lifestyle Intervention Conference 2014 - Whole Person Treat...Dr. Gregory Jantz
Dr. Gregory Jantz delivered this presentation "Whole Person Treatment of Eating Disorders" at the 2014 Lifestyle Intervention Conference in Las Vegas.
If you or a loved one is struggling with an eating disorder or associated issues of depression, anxiety, addiction, abuse or other concerns, contact The Center • A Place of HOPE today at 1.888.771.5166 to speak with a licensed specialist. It is a free, confidential call. We care and we can help.
In this first lecture of 2013 at Cady Wellness Institute, Dr. Cady presented the facts and strategies in front of a live audience for rebroadcast on WNIN - our local public television station. These are the EXACT SLIDES used in the presentation. We would like to thank all of those in the live audience who attended. For questions or comments, please feel free to contact us at front desk@cadywellness.com or call the Institute at ()812) 429 - 0772.
David Wiss MS RDN walks you through research on childhood adversity and the various ways that trauma can become embedded into physiology and impact health, such as eating behavior.
Review of Anorexia Nervosa and Bulimia Nervosa for Mankindijsrd.com
Anorexia Nervosa and Bulimia Nervosa are not called as a disease, but the today mankind is suffering from it. Hence, the present review of studies of literature is an important prerequisite for actual planning and then execution of any research work. The research workers need to acquire up-to-date information on what has been thought and said in a particular area so that they can derive benefit from the work of their predecessors.
Transition from allopathic to integrated practiceLouis Cady, MD
This lecture was the fifth and concluding lecture for Dr. Cady at the IMMH Conference in Santa Fe, NM. In it, he discusses crossing the divide separating us - with our new knowledge and ideas - from the opportunity and privilege of offering it to our patients.
Dr. Gregory Jantz Lifestyle Intervention Conference 2014 - Whole Person Treat...Dr. Gregory Jantz
Dr. Gregory Jantz delivered this presentation "Whole Person Treatment of Eating Disorders" at the 2014 Lifestyle Intervention Conference in Las Vegas.
If you or a loved one is struggling with an eating disorder or associated issues of depression, anxiety, addiction, abuse or other concerns, contact The Center • A Place of HOPE today at 1.888.771.5166 to speak with a licensed specialist. It is a free, confidential call. We care and we can help.
In this first lecture of 2013 at Cady Wellness Institute, Dr. Cady presented the facts and strategies in front of a live audience for rebroadcast on WNIN - our local public television station. These are the EXACT SLIDES used in the presentation. We would like to thank all of those in the live audience who attended. For questions or comments, please feel free to contact us at front desk@cadywellness.com or call the Institute at ()812) 429 - 0772.
David Wiss MS RDN walks you through research on childhood adversity and the various ways that trauma can become embedded into physiology and impact health, such as eating behavior.
Review of Anorexia Nervosa and Bulimia Nervosa for Mankindijsrd.com
Anorexia Nervosa and Bulimia Nervosa are not called as a disease, but the today mankind is suffering from it. Hence, the present review of studies of literature is an important prerequisite for actual planning and then execution of any research work. The research workers need to acquire up-to-date information on what has been thought and said in a particular area so that they can derive benefit from the work of their predecessors.
1ANNOTATED BIBLIOGRAPHY FOR SEDENTARY LIFESTYLESTHESE ARE.docxhyacinthshackley2629
1
ANNOTATED BIBLIOGRAPHY FOR SEDENTARY LIFESTYLES
THESE ARE THE INSTRUCTORS REMARKS AFTER GRADING AND GIVING ME A ZERO/100. PLEASE CORRECT THIS DOCUMENT FOR ME. THANKS.
I HAVE ALSO ATTACHED A Turnitin Report in pdf format.
Hi, Jude. Your Turnitin report showed that 74% of your draft matches sources that were not cited properly. Please review the plagiarism tutorial in the syllabus, and review the APA materials on how to cite sources. Paraphrase your sources whenever possible; this shows you understand the material and can restate it in your own words. This also enables you to claim ownership of the language while still giving credit for the ideas. When you use source material verbatim, make sure to place it in quotation marks. Avoid copying and pasting large chunks of text. Even if you include proper citations, your essay will lack originality. Please review the attached Turnitin report so you can see which sections need attention. I will review your draft and update your score once you've rewritten it in your own words and cited sources properly. Please note the late policy in the syllabus. Let me know if you have any questions. Thanks.
Annotated Bibliography for Sedentary Lifestyles
Jude Kum
DeVry University
Sedentary lifestyle is predominant in our everyday life be it in workplace, school, social or homes and the fact is we have got accustomed to sitting down and doing many things forgetting the impact this is causing to our health. People fail to realize how valuable exercise is in their life and especially in improving their health and well-being. Sitting down on the computer with all focused attention and forgetting that we need to get up and even eat cause problems to many people.
Guedes, N.G., Lopes, M.V., Leite de Araujo, T. Moreira, R.P. and Martins, L.C. G. (2010). Predictive Factors of the Nursing Diagnosis Sedentary Lifestyle in People with High Blood Pressure. Public Health Nursing. Vol. 28 No. 2, p. 193-200. Wiley Periodicals, Inc.
The research question for the study conducted by Guesdes, et al (2010) is based on the following: 1.what is the result of the defining characteristics and related factors of sedentary lifestyle diagnosis in patients with high blood pressure? 2. What are the predictive value and possible predictors of the nursing diagnosis sedentary lifestyle in patients with high blood pressure? The study looked at the validation of diagnostic groupings of the population being studied including aspects of their clinical situations. The study looked at diagnosis resulting from insufficient physical activity, intolerance of activity, fatigue, impaired physical mobility, self-care deficit.
My assessment: Using this article, I will bring out the important indicators and useful predictors for identification of sedentary lifestyle; demonstrated the benefits of physical fitness, verbalized preferences for activities that are to accomplish real training or exercises. I will point out appr.
Speaker presentation from U.S. News Healthcare of Tomorrow leadership summit, Nov. 17-19, 2019 in Washington, DC. Find out more about this forum at www.usnewshot.com.
Speaker presentation from U.S. News Healthcare of Tomorrow leadership summit, Nov. 17-19, 2019 in Washington, DC. Find out more about this forum at www.usnewshot.com.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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1. Integrating Evidence, Values and Ethics from Policy to
Practice: A Multicriteria Reflection
Cheri L. Deal, Ph.D., M.D.
Chief, Endocrine and Diabetes Service, CHU- Ste-Justine
Professor of Pediatrics, Université de Montréal
The View of a Practicing Physician
2. Recent/Ongoing Research Contracts
- Lilly, Merck-EMD Serono, Sandoz, Versartis
Continuing Medical Education Grants
- Lilly, Merck-EMD Serono, Sandoz, Pfizer,
Hoffmann- La Roche
Ad hoc Consulting
- Lilly, Merck-EMD Serono, Pfizer, Sandoz, Novo-Nordisk,
Hoffmann-LaRoche, Versartis, Prolor
Invited Speaker and/or Chairperson for Symposia
sponsored by: Lilly, Merck-EMD Serono, Pfizer,
Sandoz, Novo-Nordisk
CONFLICTS OF INTEREST/BIASES
3. ‘Children represent the future, and ensuring their
healthy growth and development ought to be a prime
concern of all societies’
BIASES and BELIEFS
Access to
medical products
Address contextual
factors to ill health:
social, economic and
environmental
Access to universal healthcare
5. • Reflections on Hippocrates
• Brief medical history of Prader-Willi
Syndrome, and the use of Growth
Hormone (GH)
• Why evidence for GH treatment in this
population is very difficult to obtain,
assess and act upon
• The GRS International Consensus
Guidelines Publication and MCDA
Deal et al, J Clin Endocrinol Metab, 2013
Outline
7. Hippocratic Oath
I will swear to fulfill, to the best
of my ability and judgement:
I will respect the hard-won scientific gains of those physicians in
whose steps I walk, and gladly share such knowledge as is mine with
those who are to follow.
I will apply, for the benefit of the sick, all measures which are
required, avoiding those twin traps of overtreatment and therapeutic
nihilism.
I will remember that there is art to medicine as well as science, and
that warmth, sympathy, and understanding may outweigh the surgeon's
knife or the chemist's drug.
I will not be ashamed to say "I know not," nor will I fail to call in my
colleagues when the skills of another are needed for a patient's
recovery.
8. I will respect the privacy of my patients, for their problems are not
disclosed to me that the world may know. Most especially must I tread
with care in matters of life and death. If it is given me to save a life,
all thanks. But it may also be within my power to take a life; this
awesome responsibility must be faced with great humbleness and
awareness of my own frailty. Above all, I must not play at God.
I will remember that I do not treat a fever chart, a cancerous growth,
but a sick human being, whose illness may affect the person's family
and economic stability. My responsibility includes these related
problems, if I am to care adequately for the sick.
I will prevent disease whenever I can, for prevention is preferable to
cure.
I will remember that I remain a member of society, with special
obligations to all my fellow human beings, those sound of mind and
body as well as the infirm.
9. de Sanctis V: Manual of Growth Charts and Body Standard Measurements, 2nd
ed. Pacini ed, S.p.A., Pisa, 2001. p 83-84.
Data from: Butler MG, Meaney FJ: Standards for selected anthropometric measurements in PWS. Pediatrics 88:853, 1989.
BOYS
GIRLS
Height Weight
10. Prader-Willi SyndromePrader-Willi Syndrome
• Pre- and post-natal hypotonia
• Weak cry, poor suck, failure to thrive
• Characteristic facial features
• Obesity syndrome with hyperphagia
• Hypogonadism with LH/FSH deficiency
• Short adult stature with GH deficiency
• Potential TSH and ACTH deficiency
• Global developmental delay, intellectual
disability (IQ 70-80), behavioural problems
± epilepsy, ± psychiatric phenotypes
11. Patients with PWS Are Not All The Same!
• Growth and GH status
• Dysmorphic features
• Obesity and body composition
• Metabolic profile
• Sleep
• Breathing
• Scoliosis
• Psychomotor development and cognitive aspects
• Behavioral phenotype (food-seeking)
• Mortality
→ Not entirely due to the differentNot entirely due to the different
genetic causes of PWSgenetic causes of PWS
→→ Bckg genetics, environments differBckg genetics, environments differ
Cassidy et al, Am J Med Genet, 1997; Whittington et al, J Dis Res, 2004; Varela et al, Clin
Genet, 2005; Theodoro et al, Obesity, 2006; Torado et al, Am J Med Genet, 2007; Lin et
al, Acta Paediatr, 2007; Odent et al, Pediatrics, 2008; Williams et al, J Clin Sleep Med,
2008; Holsen et al, Int. J Obesity, 2009; Grugni et al, J Endocrinol Invest, 2011; Sinnema
et al, Res Dev Disabil, 2011
12. Growth Hormone History in PWS:
Evidence for GH Defiency
• Low GH response to pharmacologic stimuli
• Parra et al, 1973; Bray et al 1980
• Low levels of IGF-I, IGF-II and IGFBP-3,
despite obesity
• Lee et al, 1987, Costeff et al, 1990, Thacker et al, 1998
• Initial GH treatment data in children
• Lee et al, 1987, n=4
• Clinical research center study of endocrine
function and GH therapy in children
• Lee et al, 1992
13. GH History in PWS, cont.
• European GH studies in childrenEuropean GH studies in children
Eiholzer; Ritzén & Lindgren, 1990s
• US controlled trial of GH in childhood PWSUS controlled trial of GH in childhood PWS
Carrel et al, 1999 – randomized control, 1y Tx
•TheThe FIRSTFIRST randomized,randomized, double-blinddouble-blind, cross-over, cross-over
design,design, placebo-controlled trialplacebo-controlled trial of GH therapyof GH therapy
in PWS children published in 2003 (in PWS children published in 2003 (6 months6 months))
Haqq et al, J Clin Endocrinol Metab, 2003
Effects on Growth, Body Composition, Pulmonary Function, BehaviourEffects on Growth, Body Composition, Pulmonary Function, Behaviour
14. GH History in PWS, cont.
• US FDA ‘Orphan Drug’ labeling of GH for childhoodUS FDA ‘Orphan Drug’ labeling of GH for childhood
PWS (2000)PWS (2000)
• European labeling of GH for childhood PWS (2006)European labeling of GH for childhood PWS (2006)
• Australian labeling of GH for childhood PWS (2008)Australian labeling of GH for childhood PWS (2008)
FACTS: - GH therapy is expensive (5,000-30,000$/year) and
must be given by subcutaneous injection
- PWS support groups world-wide argue for its use
15. • GH trials (control groups now on GH), long termGH trials (control groups now on GH), long term
Infant Carrel et al, 2010 – 6y Tx
Childhood de Lind van Wijngaarden et al, 2009 – 4y Tx
Adult Höybye et al, 2007 – 5y Tx
• GH randomized, placebo-controlled studies in adultsGH randomized, placebo-controlled studies in adults
6 months Höybye et al, 2003
12 months Sode-Carleson et al, 2010
• Registry data: Pfizer (n=Registry data: Pfizer (n=21512151), Genentech (n=), Genentech (n=564564),),
NovoNordisk (n=NovoNordisk (n=137137), Lilly (n=), Lilly (n=112112),),
• Meta-analysis, GH use in PWSMeta-analysis, GH use in PWS
-Craig, Johnston, Cowell, Cochrane Reviews, in review
-Sanchez-Ortiga, Klibanski, Tritos, Clin Endocrinol, 2011
Data on GH in PWS After Regulatory Approval
16. Side Effects Based on Conditions of GH Excess
(Acromegaly), and/or Theoretical Considerations
and/or Reported Adverse Events in Patients Treated
with GH (PWS and others)
Sleep apnea
Sudden death
Scoliosis
Glucose intolerance, Diabetes
Intracranial hypertension
Epilepsy
Slipped capital femoral epiphyses
Risk of infection
Joint pain, Oedema
Gynecomastia
(Neoplasia) – bone tumors, meningioma, other solid tumors
(data from NON-PWS patients)
(Arterial Hypertension, Stroke/intra-cranial bleeding)
17. Sudden Death and GH Safety
GH Tx= No GH-Tx, BUT 75% of GH-treated
patients died with 9 months of GH start
N=1+2
18. Beyond Stature: Clinical Characteristics of
PWS Potentially Benefiting from GH Therapy
• Hypotonia
• Delayed motor development
• Obesity with low energy expenditure
• Increased body fat
• Decreased muscle mass
• Reduced exercise tolerance
• Metabolic syndrome
• Osteoporosis
• Impaired cognitive function
19. My Dilemma with HTA within the Context of Rare
Diseases such as PWS, and GH Treatment
• Imperfect evidence: study biases
• Population with intellectual disabilities
• Genetic heterogeneity
• Safety concerns around GH
• Clinical observations in the real world
• Clinical goals of physicians at odds with the basis
for GH approval: metabolic outcome versus growth
• Cost of drug not seen in the larger perspective of
the cost of overall care of patients and their
families living with PWS
21. 21
International Clinical Care Guidelines
Workshop on
GH and Prader-Willi Syndrome:
Montreal, October 2011
GRS
Funded by:Funded by:
Growth Hormone Research SocietyGrowth Hormone Research Society
Prader-Willi Research FoundationPrader-Willi Research Foundation
EVIDEMEVIDEM
22. Why The Workshop
• No ‘formal’ consensus guidelines for GH and
PWS, other than 2006 Toulouse Workshop
Sponsored by one pharmaceutical company
→ JCEM 2008 Guidelines from this Expert Meeting
• GH therapy only a small section of the document
• No attempt to grade the level of evidence
• Based on mostly observational (level II B,C or D) and on
2 randomized, controlled trials, moderate evidence only,
due to confounders (level IB)
23. Format
• 3-day meeting Oct 3-7, 2011
• 43 PWS experts, including:
- Pediatric and Adult Endocrinologists
- Geneticists (clinical and basic)
- Clinicians and Scientists with interest growth hormone
research (GRS Council Members)
- PWS Patient Advocate USA/Canada
- Bioethicist
- Orthopedic Surgeon
- Psychiatrist
- Methodologists (epidemiology, health technology
evaluation
- Health Economist (Economics of Obesity)
25. Multi-Criteria Healthcare Decision-Making
Scientific Considerations
Disease impact
• Disease severity, Size of affected population
Context of intervention
• Clinical guidelines, Comparative intervention
Intervention outcomes
•Improvement of efficacy/effectiveness
•Improvement of safety and tolerability
•Improvement of patient reported outcomes
Type of benefit
•Public health interest (prevention, risk reduction)
•Type of medical service (symptom relief, cure)
Economics
•Budget impact (cost of intervention only)
•Impact on other spending (hospitalization, disability)
•Cost-effectiveness of intervention
Quality/uncertainty of evidence
•Adherence to requirements of decisionmaking body
•Completeness and consistency of reporting evidence
•Relevance and validity of evidence
Ethical framework
• Goals of healthcare - utility
• Opportunity costs – efficiency
• Population priority & access –
issues of fairness
Other system related criteria
• System capacity and
appropriate use of intervention
• Stakeholder pressures
• Political/historical context
Contextual Considerations
26. Working Groups Answered (in
writing, with references) Specific
Questions Using MCDA Framework
Example:
CLINICAL ASPECTS
Intervention overview
Indication:
1. Do patients with PWS need GH testing: In infancy? In childhood? In adulthood?
2. What baseline evaluations need to be performed before GH treatment?
Intervention duration:
3. For how long should GH therapy be pursued?
Administration/Description:
4. What clinical lab tests or imaging studies need to be done to monitor treatment?
5. What doses should be used for GH therapy: In infants? In children and adolescents? In adults?
6. Is there an optimal level of circulating IGF-I to obtain with GH treatment?
7. Should GH dose be titrated to IGF-I, and if so, at what frequency?
8. What is the frequency of follow-up visits necessary to adequately monitor GH therapy?
Comparator(s):
9. What other therapies/interventions have been tried in PWS
27. Sample Questions, cont.
Example:
Decision criteria
Disease impact
Disease severity 1. What is the frequency of the various genetic subtypes among various populations?
2. How has evolution of our genetic testing methodology changed genetic subtype frequency?
3. Are all patients with PWS equally GH deficient?
4. Are there genotype-phenotype correlations relevant to specific to clinical outcome measures targeted with GH
therapy? Other correlations?
5. What are the important co-morbidities that need to be considered when considering GH therapy?
6. What is the life expectancy of PWS subjects?
7. What are the major causes of death in PWS subjects?
Size of population 8. What is the birth incidence/prevalence of PWS?
Therapeutic context of
intervention
Clinical guidelines 9. Why are physicians divided in their belief about the benefits of GH therapy?
Comparative
interventions limitations
(unmet needs)
10. For each of the other therapies/interventions tried in PWS, what were: The specific outcomes? The efficacy per
outcome? The safety/tolerability of the therapy/intervention?
11. What specific therapies/interventions have been tried concomitant to GH therapy?
12. What are the nutritional recommendations for: Infants with PWS? Children with PWS? Adolescents with PWS?
Adults with PWS?
Intervention outcomes
Improvement of efficacy/
effectiveness
13. What are the most important clinical outcome priorities when initiating GH therapy in subjects with PWS: In infancy?
In childhood? In adolescence? In Adulthood?
14. What is the best way to measure GH effectiveness on:
a. Growth
b. Body composition
c. Motor development (infants and children)
d. Neurological status
e. Physical activity
f. Muscle strength
g. Metabolic benefits
h. Resting energy expenditure
i. Cardiovascular status
j. Bone health
k. QoL (specifically in intellectually-disabled individuals)
15. What is the impact of other hormonal deficiencies on GH treatment?
16. Does response to GH vary by:
a. age at start of treatment
b. dose
c. body composition at start
d. degree of dietary control
e. level of physical activity
Improvement of safety &
tolerability
17. What are the major serious adverse events of GH treatment of PWS subjects?
18. What is the evidence that GH treatment in PWS increases the risk of:
a. Sleep apnea
b. Sudden death
c. Scoliosis
28. Questions, cont.
Example:
RESSOURCE ALLOCATION & ETHICS ASPECTS
Overview
Economic burden of illness:
1. What are the major sources of healthcare costs related to the care of patients with PWS?
2. What are the major costs of treating morbid obesity?
3. What are the major costs of treating diabetes?
DECISION CRITERIA
Economics of
intervention
Budget impact on health
plan (cost of
intervention)
4. What is the cost of GH treatment in patients with PWS?
5. What is the budget impact at the country level?
Cost-effectiveness of
intervention
6. What is the cost-effectiveness of GH treatment in patients with PWS?
Impact on other
spending (e.g.,
hospitalization,
disability)
7. What are the economic consequences (beyond drug cost) of GH treatment in patients with PWS?
Ethical criteria*
Utility - Goals of
healthcare *
8. Is the use of GH in patients with PWS aligned with the mission and scope of healthcare systems?
Efficiency -Opportunity
costs & affordability
9. How do we prioritize resources for PWS care, and how does GH fit into this?
Fairness* - Population
priority & access
10. Is access to GH therapy available to all PWS patients, and if not, why?
11. Are there issues of fairness in withholding GH treatment, or in targeting specific sub-populations of PWS subjects for
GH therapy?
Overall context
System capacity &
appropriate use of
intervention
12. How do we organize the comprehensive care of the PWS patient, to optimize GH treatment and particularly to
decrease/prevent potential side effects?
13. What are the evidence-base steps that are needed to harmonize care of patients with PWS?
Stakeholder
pressures/barriers
14. Are there any pressures/barriers for the use of GH in patients with PWS?
Political/ historical
context
15. Are there any specific political/historical context impacting the use of GH in patients with PWS?
29. • Systematic literature review of PubMed, EMBASE, Cochrane
Reviews, Controlled Trials Registries and government and HTA agency
websites; these were completed by hand searching of bibliographies.
• Pediatric AND adult publications included: randomized
controlled trials, comparative observational studies and uncontrolled
trials, longer term studies (>3.5 years in kids; ≥ 6 months in adults)
• Summaries produced for relevant studies and posted on the
web http://www.evidem.org/
• Level of evidence was evaluated using the scoring procedure
based on the Oxford Centre for Evidence-based Medicine
Level of Evidence scale (1 to 5); Level of recommendation
graded from Best (A) to Worst (D)
• 5 companies provided safety data (registry/SAE):
Pfizer, Genentech, Lilly, Novo Nordisk, Serono
31. Summaries Produced for Relevant Studies
(Clinical Trials with Control Group)
METHODOLOGY
ARTICLE PDF
32. Sources of Bias: A Reality
• No placebo; investigators and families not blinded
• Randomization procedure not discussed
• Sample sizes small: no stratification by genotype
• Confounding variables
• inconsistent documentation of food intake
• inconsistent documentation of activity level
• minimal data on psychosocial setting:
parental education, income, employment
• Inconsistent use of intention to treat analyses
• Incomplete reporting of patient numbers
• Limited statistical details (p-values only)
• Rare reporting of individual patient responses
33. Recommendations
After genetic confirmation of the diagnosis ofAfter genetic confirmation of the diagnosis of
PWS,PWS, GH treatmentGH treatment should be consideredshould be considered and, ifand, if
initiated, continued for as long as demonstratedinitiated, continued for as long as demonstrated
benefits outweigh the risks.benefits outweigh the risks.
Recommendation A;Recommendation A;
evidence 1evidence 1
JCEM, 2013
34. 164A:671-675, 2014
• 14 patients (10 DEL, 4 UPD)
• GH Start 11.9 y (7.1-14.1)
• GH Stop 15.6 y (14.0-17.9)
• Duration Tx 4.0 y (1.8-8.8)
BMI-SDS
VisceralFatSubcutaneousFat
-24 m +24 m
35. More Data on Developmental
and Cognitive Impact
Siemensma et al, J Clin Endocrinol Metab, 97:2307, 2012
Reus et al, Res in Develop Disabilities, 34:3092, 2013
N=48
N=22
36. 164A:2226-2231, 2014
• First to study QoL in primary caregivers of patients with PWS
• Questionnaires, 5 domains:
Physical, Psychological, Social, Environmental, QoL Impression
• Group effects studied:
-Deletion (32) vs UPD (13)
-Children 6-12 y (22) vs Adolescents 13-19 y (23)
• Results show deterioration of QoL at adolescence
with caregivers of UPD patients particularly
affected
37. Conclusions
• Evaluations of therapeutic interventions
for rare diseases remind me of Montreal
streets: full of potholes
• MCDA can help us to avoid and/or fill
them, using a systematic, structured
approach
• MCDA is useful as a framework for asking
the right questions in CPG guidelines and
for understanding an individual’s priorities
38. Concerning Budget Considerations
for Unmet Needs in Rare Diseases…
If it’s your car falling in the pothole, will
you really be able to say that you
understand why it hasn’t been filled?
39. Special Thanks To
MY PATIENTS
The Workshop Organising Committee : Jens Christiansen
(Denmark), Maithe Tauber (France), Charlotte Höybye (Sweden), David
Allen (USA)
The GRS : John Kopchick, President (USA), Beverly Biller (USA),
Gudmundur Johannsson (Sweden), Hassy Cohen (USA), Sally Radovick
(USA), Mike Waters (Australia), Kazuo Chihara (Japan)
Workshop Attendees:
•Merlin Butler (USA)
•Suzanne Cassidy (USA)
•Graziano Grugni (Italy)
•Ricard Nergardh (Sweden)
•Ilkka Sipilä (Finland)
•Jean-Eric Tarride (Canada)
•Anita Hokken-Koelega (NL)
•Hariette Mogul (USA)
•Françoise Muscatelli (France)
Maria Craig (Australia)
Rob Nicholls (USA)
Alex Kemper (USA)
Geoff Ambler (Australia)
Sara Rosenthal (USA)
Tiziana Greggi (ITALY)
Jennifer Miller (USA)
Drs. Quigley, Kappelgaard, Wollmann, Lippe, Haahr
•Michèle Tony (Canada)
•Saul Malozowski (USA)
•Glen Berall (Canada)
•Véronique Beauloye (France)
•Tony Goldstone (UK)
•Annick Vogels (Belgium)
•Renaldo Battista (Canada)
•Keegan Johnson (PWS USA/Canada)
•Mireille Goetghebeur (EVIDEM, Canada)
Editor's Notes
Also know as Eugenia Martinez Vallejo Unclothed. Eugenia was six years old at the time of this painting, reportedly weighed 170 pounds. Her parents brought her to the court of King Carlos II because they knew he was fond of hermaphrodites, conjoined twins, and "natural oddities" generally. Eugenia became one of Carlos' favorite freaks.
Only 8 had Abdominal CT, retrospective, no diet or activity history,
Remember – RCT for 2 years showed some difference. 29 tx 21 controls., This is four-year study and therefore the patients now were all treated. 2 dropouts - . Block Design subtest tests performance – they used 4 different subtests including[Vocabulary, Similarities (verbal IQ subtests), Block design, and Picture arrangement (performance IQ subtests)] of the Wechsler Intelligence Scale for Children-Revised, Dutch version (WISC-R), was used in children over 7 yr of age (13). A short form of four subtests [Vocabulary, Similarities (verbal IQ subtests), Block de-sign, and Picture completion (performance IQ subtests)] of the Wechsler Preschool and Primary Scale of Intelligence-Revised,
Dutch version (WPPSI-R) was used for children younger than 7 yr of age (14, 15). We used short forms because of the short attention span in children with PWS.
Reus study 2 years, intense physiotherapy, randomised half GH half no GH, ages 12.9 months + 1 sd 7 mo
Did not look at socioeconomic status as a factor; not clear what the causality is but likely to be worsening behavioral problems and autistic behavior, no comment about GH use