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Sagir A, Murphy M, Teames R, Calenda D. Enhancing post-operative analgesia following spinal cord stimulation implant: a comprehensive evaluation of the effectiveness of erector spinae plane block utilizing liposomal bupivacaine. Pain Manag 2023; 13:717-722. [PMID: 38054404 DOI: 10.2217/pmt-2023-0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Indexed: 12/07/2023] Open
Abstract
Erector spinae plane block (ESPB) is an inter-fascial plane block that provides multi-dermatomal analgesia for treatment of acute pain and chronic neuropathic pain in the trunk. This retrospective case series describes a novel method of treating acute postoperative pain after spinal cord stimulation implant with erector spinae plane block using liposomal bupivacaine. Bilateral erector spinae plane block was administered at L1-L2 intervertebral level in 18 cases prior to performing spinal cord stimulation implant at one interspace above. This study reveals that the block provides effective analgesia as evidenced by low pain scores and less opioid consumption after surgery.
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Affiliation(s)
- Afrin Sagir
- Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Melissa Murphy
- North Texas Orthopedics & Spine Center, Grapevine, TX 76051
| | | | - Doug Calenda
- North Texas Orthopedics & Spine Center, Grapevine, TX 76051
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Grieve S, Brunner F, Cabral DF, Connett R, Hirata H, Iwasaki N, Nakagawa Y, Sagir A, Sousa G, Vatine JJ, Vaughan-Spickers N, Xu J, Buckle L, McCabe C. An international study to explore the feasibility of collecting standardised outcome data for Complex Regional Pain Syndrome: recommendations for an international clinical research registry. Br J Pain 2023; 17:468-478. [PMID: 38107759 PMCID: PMC10722111 DOI: 10.1177/20494637231188333] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Abstract
Introduction Complex Regional Pain Syndrome (CRPS) is a persistent pain condition with low prevalence. Multi-centre collaborative research is needed to attain sufficient sample sizes for meaningful studies. This international observational study: (1) tested the feasibility and acceptability of collecting outcome data using an agreed core measurement set (2) tested and refined an electronic data management system to collect and manage the data. Methods Adults with CRPS, meeting the Budapest diagnostic clinical criteria, were recruited to the study from 7 international research centres. After informed consent, a questionnaire comprising the core set outcome measures was completed: on paper at baseline (T1), and at 3 or 6 months (T2) using a paper or e-version. Participants and clinicians provided feedback on the data collection process. Clinicians completed the CRPS severity score at T1 and optionally, at T2. Ethical approval was obtained at each international centre. Results Ninety-eight adults were recruited (female n=66; mean age 46.6 years, range 19-89), of whom 32% chose to receive the T2 questionnaire in an electronic format. Fifty-five participants completed both T1 and T2. Eighteen participants and nine clinicians provided feedback on their data collection experience. Conclusion This study confirmed the questionnaire core outcome data are feasible and practicable to collect in clinical practice. The electronic data management system provided a robust means of collecting and managing the data across an international population. The findings have informed the final data collection tools and processes which will comprise the first international, clinical research registry and data bank for CRPS.
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Affiliation(s)
- Sharon Grieve
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- University of the West of England, Bristol, UK
| | | | - Danylo F Cabral
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | | | | | | | - Afrin Sagir
- Cleveland Clinic, Cleveland, Ohio, USA
- University of Pennsylvania, Philadelphia, USA
| | | | - Jean-Jacques Vatine
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Reuth Rehabilitation Hospital, Tel Aviv, Israel
| | | | - Jijun Xu
- Cleveland Clinic, Cleveland, Ohio, USA
| | - Lisa Buckle
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- University of the West of England, Bristol, UK
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Segev A, Sagir A, Matezky S, Segev A, Atar S, Shechter M. Admission serum magnesium levels associated with short- and long-term clinical outcomes in COVID-19 patients. Eur Heart J 2022. [PMCID: PMC9619595 DOI: 10.1093/eurheartj/ehac544.2430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction In the face of the global pandemic coronavirus disease 2019 (COVID-19) has created, readily available prognostic markers may be of great use. Purpose To evaluate the association between serum magnesium levels (sMg) on admission and clinical outcomes in hospitalized COVID-19 patients. Methods We retrospectively analyzed all consecutive patients admitted to our medical center with a primary de novo diagnosis of COVID-19.Demographic, clinical and laboratory data were extracted from the electronic medical record. Clinical outcomes were compared between five groups of patients according to the quintiles of sMg on hospital admission. Results From 2,433 consecutive COVID-19 patients during the years 2020–2021, we included 1,522 patients with sMg on admission (1–3 day of hospitalization) (58% male, 69±17 years old). Patients were followed for a mean of 10±7 months. A low sMg level (1st quintile) was associated with higher rates of diabetes and steroid use, whereas a high sMg level (5th quintile) was associated with dyslipidemia, chronic kidney disease, andhigher levels of inflammatory markers (Table 1). Both low and high sMg levels were associated with lower oxygen saturation during hospitalization. All-cause in-hospital and long-term mortality was higher in patients with both low and high sMg levels, compared with mid-range sMg levels (2nd, 3rd and 4thquintiles; 19% and 30% vs. 9.5%, 10.7% and 17.8% and 35% and 45.3% vs. 23%, 26.8% and 27.3% respectively; p<0.001 for all) (Figure 1). Conclusions Both low and high sMg levels were associated with worse short- and long-term clinical outcomes and all-cause mortality in a large cohort of hospitalized COVID-19 patients. Thus, admission sMg levels may play a prognostic role in risk stratificationof COVID-19 patients. Funding Acknowledgement Type of funding sources: None.
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Affiliation(s)
- A Segev
- Sheba Medical Center , Ramat Gan , Israel
| | - A Sagir
- Nahariya Hospital for the Western Galilee , Nahariya , Israel
| | - S Matezky
- Sheba Medical Center , Ramat Gan , Israel
| | - A Segev
- Sheba Medical Center , Ramat Gan , Israel
| | - S Atar
- Nahariya Hospital for the Western Galilee , Nahariya , Israel
| | - M Shechter
- Sheba Medical Center , Ramat Gan , Israel
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Solomons JNT, Sagir A, Yazdi C. Meralgia Paresthetica. Curr Pain Headache Rep 2022; 26:525-531. [PMID: 35622311 DOI: 10.1007/s11916-022-01053-7] [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] [Accepted: 04/01/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW This review article summaries the epidemiology, etiology, clinical presentations, and latest treatment modalities of meralgia paresthetica, including the latest data about peripheral and spinal cord stimulation therapy. Meralgia paresthetica (MP) causes burning, stinging, or numbness in the anterolateral part of the thigh, usually due to compression of the lateral femoral cutaneous nerve (LFCN). RECENT FINDINGS There are emerging data regarding the benefit of interventional pain procedures, including steroid injection and radiofrequency ablation, and other interventions including spinal cord and peripheral nerve stimulation reserved for refractory cases. The strength of evidence for treatment choices in meralgia paraesthetica is weak. Some observational studies are comparing local injection of corticosteroid versus surgical interventions. However, more extensive studies are needed regarding the long-term benefit of peripheral and spinal cord stimulation therapy.
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Affiliation(s)
| | - Afrin Sagir
- Beth Israel Deaconess Medical Center, Brookline, MA, USA
| | - Cyrus Yazdi
- Beth Israel Deaconess Medical Center, Brookline, MA, USA.
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Mejia-Renteria H, Travieso A, Sagir A, Martinez-Gomez E, Carrascosa-Granada A, Nunez-Gil I, Estrada V, Lerman A, Escaned J. Assessment of vascular endothelial function in COVID-19 patients. Eur Heart J 2021. [PMCID: PMC8767623 DOI: 10.1093/eurheartj/ehab724.2017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) uses angiotensin-converting enzyme 2 (ACE2) receptor as a means to enter the host. High density of ACE2 receptor in vascular endothelial cells may explain why vascular complications related to endothelial dysfunction occur in COVID-19. However, in vivo assessment of vascular endothelial function during COVID-19 has not been reported. Objective To investigate the vascular endothelial function and its temporal changes in COVID-19 patients. Methods In this prospective blinded study, systemic endothelial function was assessed using plethysmography-derived peripheral arterial tonometry (PAT). The reactive hyperemia index (LnRHI), a measure of endothelium-mediated hyperaemia, and the augmentation index, a measure of arterial vascular stiffness, were measured in 102 individuals across three study groups using PAT: group 1 (active infection), constituted by 20 patients hospitalised due to acute COVID-19; group 2 (past infection), constituted by 52 patients who had recovered from COVID-19; and group 3 (controls), constituted by 30 healthcare workers not infected by SARS-CoV-2. Additionally, among group 1, PAT assessment was repeated in 14 patients several weeks after recovery from acute COVID-19. PAT studies were analysed at a blinded fashion with respect to the assigned study group. Results Lower resting PAT amplitude was found in acute COVID-19 patients compared to the other groups (ratio of arterial tone signal between hyperemia to resting condition was 1.5 [interquartile range, 1.1] in group 1, 1.3 [0.3] in group 2 and 1.2 [0.3] in group 3, p=0.041). On the contrary, no significant differences between groups were found with respect to the hyperemic PAT amplitude (867.9 [486.1] in group 1, 944.7 [748.1] in group 2 and 819.3 [639.6] in group 3, p=0.444). Due to the lower resting PAT amplitude, there was a paradoxically significantly increased LnRHI during acute COVID-19 compared to past infection and controls (0.73 [0.32] vs. 0.53 [0.31] vs. 0.44 [0.23], respectively; p=0.013) (Figure A). Furthermore, among group 1 patients, LnRHI normalised markedly from acute COVID-19 to past infection stage (0.73 [0.32] vs. 0.49 [0.28], respectively; p=0.005) (Figure B). Augmentation index was significantly higher during acute COVID-19 compared to past COVID-19 and controls (9.6 [19.1] in group 1, 6.97 [18.6] in group 2 and −0.35 [20.53] in group 3; p=0.045 for COVID groups vs. controls). Conclusions Non-invasive assessment of systemic vascular endothelial function with PAT revealed significant differences between subjects with acute COVID-19, past COVID-19 and controls. Lower baseline PAT amplitude and high augmentation index suggest vasoconstriction at rest during the acute phase of COVID-19. These findings open new research opportunities to investigate the prognostic value of PAT in COVID-19 patients. Funding Acknowledgement Type of funding sources: None.
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Affiliation(s)
| | - A Travieso
- Hospital Clinico San Carlos, Cardiology, Madrid, Spain
| | - A Sagir
- Bar-Ilan University, Safed, Israel
| | | | | | - I Nunez-Gil
- Hospital Clinico San Carlos, Cardiology, Madrid, Spain
| | - V Estrada
- Hospital Clinico San Carlos, Cardiology, Madrid, Spain
| | - A Lerman
- Mayo Clinic, Cardiology, Rochester, United States of America
| | - J Escaned
- Hospital Clinico San Carlos, Cardiology, Madrid, Spain
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Bruckschen F, Gerharz CD, Sagir A. Renal cell carcinoma with unusual metachronous metastasis up to 22 years after nephrectomy: two case reports. J Med Case Rep 2021; 15:490. [PMID: 34607612 PMCID: PMC8491385 DOI: 10.1186/s13256-021-03098-5] [Citation(s) in RCA: 3] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 09/07/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction Renal cell carcinoma is the third most common malignant tumor in the urogenital tract. An estimated 25% of renal cell carcinomas are in stage IV when diagnosed. The 5-year-survival with stage IV is about 20%. Late metastases are found after an extended disease-free interval up to 20 years after primary nephrectomy. Case presentation Here, we present two cases with late-onset metastasis of renal cell carcinoma with different clinical presentations. The first patient, an 88-year-old Caucasian man, presented with bleeding of the upper gastrointestinal tract. Biopsies taken from the duodenal bulb showed a tumor compatible with a solitary metastasis from renal cell carcinoma 22 years ago. The second patient, a 79-year-old Caucasian man, consulted our gastroenterological department with results of an outpatient computed tomography scan with multiple suspected tumor areas in the liver, omentum, thyroid, and mediastinum. A computed tomography-guided liver biopsy was performed that showed a clear-cell tumor consistent with a metastasis of the renal cell carcinoma 17 years ago. Conclusion Both cases show that patients with a history of renal cell carcinoma should be followed up for a longer time than patients with other malignant tumors.
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Affiliation(s)
- F Bruckschen
- Department of Gastroenterology, Academic Teaching Hospital Bethesda Duisburg, Heerstr. 219, 47053, Duisburg, Germany
| | - C D Gerharz
- Department of Pathology, Academic teaching Hospital Bethesda Duisburg, Heerstr. 219, 47053, Duisburg, Germany
| | - A Sagir
- Department of Gastroenterology, Academic Teaching Hospital Bethesda Duisburg, Heerstr. 219, 47053, Duisburg, Germany.
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Sagir A, Ahuja S, Soliman LM, Farag E. Co-presentation of Posterior Reversible Encephalopathy Syndrome in a patient with Post Dural Puncture Headache. Pain Med 2021; 23:1029-1031. [PMID: 34260726 DOI: 10.1093/pm/pnab216] [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] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Post Dural Puncture Headache (PDPH) is a well-known complication of neuraxial anesthesia, however the occurrence of seizures and vision loss within few days after dural puncture could be alarming. Posterior Reversible Encephalopathy Syndrome (PRES) is associated with reversible edema and leukoencephalopathy in the posterior parieto-occipital cortex. We report the co-presentation of PRES and PDPH after labor epidural analgesia. CASE PRESENTATION 25-year-old multiparous African-American woman was admitted for evaluation of new onset seizures and headache in the postpartum period. She had a recent history of multiple needle insertion attempts and inadvertent dural puncture during epidural analgesia for delivery. Soon after delivery, she was diagnosed with PDPH and was treated with epidural blood patch, with no relief of symptoms. Six days later, she developed sudden onset transient blindness, seizures and altered sensorium and magnetic resonance imaging (MRI) of the brain revealed white matter changes suggestive of PRES. CONCLUSION PRES is an uncommon complication of cerebrospinal fluid (CSF) leak and intracranial hypotension. We report the occurrence of PRES in a patient with no known risk factors, except a traumatic dural tap. Is it important to expand the differentials for headache after dural puncture to encompass PRES as a possibility, especially in patients with a delayed presentation of seizures and cortical blindness.
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Affiliation(s)
- Afrin Sagir
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Sanchit Ahuja
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH.,Department of Anesthesiology, Pain Management & Perioperative Medicine, Henry Ford Health Systems, Detroit, MI
| | - Loran M Soliman
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Ehab Farag
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH.,Department of Outcomes Research, Cleveland Clinic, Cleveland, OH
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Ince I, Chiu A, Sagir A, Chahar P, Lin J, Douglas A, Adi A, Fang J, Mao G, Turan A. Association of Pain With Atrial Fibrillation and Delirium After Cardiac Surgery: A DECADE Sub-Study. J Cardiothorac Vasc Anesth 2021; 35:3021-3026. [PMID: 34148803 DOI: 10.1053/j.jvca.2021.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The authors aimed to evaluate the effects of postoperative pain on the incidence of atrial fibrillation and delirium in patients having surgery with cardiopulmonary bypass (CPB). DESIGN Post hoc analysis of the (An investigator-initiated, multicentre, double-blind trial (ClinicalTrials NCT02004613) (DECADE)), a randomized, placebo-controlled trial. SETTING Tertiary, academic hospital. PARTICIPANTS Six hundred five adults from the DECADE enrolled at Cleveland Clinic Main Campus, who had had surgery with CPB. INTERVENTIONS Dexmedetomidine versus placebo started before surgical incision and postoperatively was maintained until 24 hours. MEASUREMENTS Primary outcomes were atrial fibrillation, diagnosed by clinicians in the intensive care unit (ICU), presence of delirium assessed with the Confusion Assessment Method for the ICU, data on pain scores, and opioid consumption, occurring between ICU admission and the earlier of postoperative day five or hospital discharge. RESULTS Postoperative pain levels were similar among patients with or without atrial fibrillation. Two hundred six (34%) patients had atrial fibrillation and ninety-two (15%) had delirium before hospital discharge within the first five postoperative days. The risk of atrial fibrillation was not significantly different between groups (hazard ratio: 1.09; 97.5% confidence interval [CI]: 0.99, 1.20, p = 0.039); there were no associations between postoperative pain and the risk of postoperative delirium (hazard ratio: 0.96; 97.5% CI: 0.84-1.11; p = 0.57). Postoperative opioid consumption was neither significantly associated with postoperative atrial fibrillation nor delirium. CONCLUSIONS Atrial fibrillation and delirium was not associated with pain after cardiac surgery. Opioid use was not associated with atrial fibrillation and delirium. Because both atrial fibrillation and delirium have a multifactorial nature, further studies should be focused on other plausible mechanisms.
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Affiliation(s)
- Ilker Ince
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH; Anesthesiology Clinical Research Office, Ataturk University, Erzurum, Turkey
| | - Andrew Chiu
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH
| | - Afrin Sagir
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Praveen Chahar
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH; Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Jia Lin
- Department of Cardiovascular Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Aaron Douglas
- Department of Cardiovascular Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Ahmad Adi
- Department of Cardiovascular Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Jonathan Fang
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH
| | - Guangmei Mao
- Department Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH; Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH.
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Sagir A, Bolash R. COMBINED BIPOLAR AND V-SHAPED LESIONS FOR LUMBAR FACET RADIOFREQUENCY ABLATION: A TECHNICAL REPORT. Pain Med 2021; 23:862-866. [PMID: 33830202 DOI: 10.1093/pm/pnab136] [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] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 03/23/2021] [Accepted: 04/07/2021] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Radiofrequency ablation (RFA) is a demonstrated safe and effective treatment for chronic low back pain. RFA delivers high density electrical current near lumbar medial branch nerve. The success of RFA is contingent upon creating a lesion that overlaps the sensory nerve supplying the affected facet joint(s). Both bipolar-RFA and V-shaped active tip cannulas increase lesion size in experimental models. We describe successful application of concomitant bipolar and V-shaped lesions in a single patient with chronic low back pain caused by lumbar spondylosis. CASE PRESENTATION An 81-year-old male with atrial fibrillation on chronic warfarin anticoagulation was previously treated with conventional monopolar lumbar facet RFA resulting in a 75% decrement in pain intensity exceeding eight months. Nine months after the procedure, his pain returned with similar pretreatment character and was unresponsive to additional physical therapy and acetaminophen. We elected to use a V-shaped cannula to maximize lesion diameter and lengthen intervals between anticoagulant abstinence to minimize the risk. Intraoperatively, a grounding-pad malfunction compelled us to convert to bipolar-RFA by placing a second adjacent V-shaped cannula, eliminating grounding-pad requirement. Bilateral bipolar medial branch RFA of L3-L4, L4-L5, L5-S1 nerves was performed between these two cannulas without further incident. The patient had sustained analgesia that lasted over twelve months resultant from treatment. CONCLUSION We herein describe a technique of combined bipolar-RFA utilizing proximally adjacent V-shaped cannulas. Both bipolar and V-shaped cannulas create larger lesions in experiments. While both techniques purport theoretical advantages, the clinical superiority of a combined technique warrants continued clinical investigation.
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Affiliation(s)
- Afrin Sagir
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Robert Bolash
- Department of Pain Management, Cleveland Clinic, Cleveland, OH
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Chmiela MA, Hendrickson M, Hale J, Liang C, Telefus P, Sagir A, Stanton-Hicks M. Direct Peripheral Nerve Stimulation for the Treatment of Complex Regional Pain Syndrome: A 30-Year Review. Neuromodulation 2020; 24:971-982. [PMID: 33098229 DOI: 10.1111/ner.13295] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/24/2020] [Accepted: 09/28/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Complex regional pain syndrome (CRPS), formerly known as reflex sympathetic dystrophy (RSD), is a difficult to treat condition characterized by debilitating pain and limitations in functional ability. Neuromodulation, in the form of spinal cord stimulation (SCS) and peripheral nerve stimulation (PNS), have been traditionally used as a treatment for CRPS with variable success. OBJECTIVE This chart review describes the use of implantable PNS systems in the treatment of CRPS of the upper and lower extremities spanning nearly three decades. MATERIALS AND METHODS A retrospective chart review was performed on 240 patients with PNS implanted between 1990 and 2017 at our institution. Of these, 165 patients were identified who had PNS systems implanted for a diagnosis of CRPS. Patient profile, including baseline characteristics, comorbidities, past/current interventions/medications and targeted nerves, was descriptively summarized through standard summary statistics. Patients' pain scores and opioid consumptions at baseline (preimplant), 1 month, 6 months, and 12 months were collected and compared. Device revisions and explants were summarized, and patient functional outcomes were described. RESULTS Pain scores at baseline and at 12-month follow-up were decreased from a mean of 7.4 ± 1.6 to 5.5 ± 2.4 and estimated to be 1.87 (95% CI: [1.29, 2.46], paired t-test p-value <0.001) lower at 12 months. At baseline, 62% of patients were on chronic opioid therapy, compared with 41% at 12 months. Of 126 patients who reported changes in functional status, 64 (51%) reported improvement, 27 (21%) reported worsening, and 35 (28%) did not report any meaningful change. Excluding end-of-life battery replacements, surgical revision occurred in 56 (34%) of patients. Thirteen patients (8%) underwent implantation of a second PNS because of symptomatic expansion outside of the original painful region. Device explant was performed in 32 (19%) of patients. Median length of follow-up was 74 [14, 147] months. Of the 36 patients who continue to follow-up at our institution, 29 (81%) continue to use their PNS. CONCLUSIONS We can conclude that PNS is a useful modality to improve function and reduce long-term pain in selected patients suffering from CRPS type I and type II.
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Affiliation(s)
- Mark A Chmiela
- Department of Pain Management, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mark Hendrickson
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jason Hale
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Chen Liang
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Phillip Telefus
- Department of Pain Management, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Afrin Sagir
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Agarwal D, Chahar P, Chmiela M, Sagir A, Kim A, Malik F, Farag E. Multimodal Analgesia for Perioperative Management of Patients presenting for Spinal Surgery. Curr Pharm Des 2019; 25:2123-2132. [PMID: 31298146 DOI: 10.2174/1381612825666190708174639] [Citation(s) in RCA: 4] [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: 04/25/2019] [Accepted: 06/26/2019] [Indexed: 11/22/2022]
Abstract
Multimodal, non-opioid based analgesia has become the cornerstone of ERAS protocols for effective analgesia after spinal surgery. Opioid side effects, dependence and legislation restricting long term opioid use has led to a resurgence in interest in opioid sparing techniques. The increasing array of multimodal opioid sparing analgesics available for spinal surgery targeting novel receptors, transmitters, and altering epigenetics can help provide an optimal perioperative experience with less opioid side effects and long-term dependence. Epigenetic mechanisms of pain may enhance or suppress gene expression, without altering the genome itself. Such mechanisms are complex, dynamic and responsive to environment. Alterations that occur can affect the pathophysiology of pain management at a DNA level, modifying perceived pain relief. In this review, we provide a brief overview of epigenetics of pain, systemic local anesthetics and neuraxial techniques that continue to remain useful for spinal surgery, neuropathic agents, as well as other common and less common target receptors for a truly multimodal approach to perioperative pain management.
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Affiliation(s)
- Deepak Agarwal
- Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Praveen Chahar
- Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Mark Chmiela
- Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Afrin Sagir
- Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Arnold Kim
- Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Faysal Malik
- Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Ehab Farag
- Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, United States
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Erotokritou A, Gerharz CD, Sagir A. Agenesis of dorsal pancreas associated with pancreatic neuroendocrine tumor: a case report and review of the literature. J Med Case Rep 2018; 12:185. [PMID: 29958547 PMCID: PMC6026343 DOI: 10.1186/s13256-018-1733-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 05/31/2018] [Indexed: 11/10/2022] Open
Abstract
Background Agenesis of the dorsal pancreas is very rare. Less than 70 cases have been reported to date. Some of these cases had an association with a tumor. The literature of agenesis of the dorsal pancreas and agenesis of the dorsal pancreas-associated pancreatic neoplasia is limited. Here we report the second case of a pancreatic neuroendocrine tumor in a setting of agenesis of the dorsal pancreas. Case presentation A 71-year-old man, originally from North Africa, with a history of insulin-dependent diabetes mellitus, presented with a 2-month history of nonspecific abdominal symptoms. Contrast-enhanced computed tomography demonstrated an almost 3 cm round, quite well-defined and homogeneous tumor formation in the area between the neck and absent body and tail of his pancreas. The mass was confirmed by endoscopic ultrasound. Our patient underwent computed tomography-guided biopsy of the mass which provided proof of a neuroendocrine tumor. He underwent pancreas resection because of the presence of a neuroendocrine tumor. Seven months later his glycated hemoglobin increased from 6.9 to 8.7%. Conclusions Diagnosis of agenesis of the dorsal pancreas is based on imaging techniques like computed tomography, magnetic resonance cholangiopancreatography, or endoscopic ultrasound. Endoscopic ultrasound-guided fine-needle aspiration can be helpful for the histological diagnosis of the tumor. The hypothesis of the association between pancreatic neoplasia and agenesis of the dorsal pancreas leads us to the suggestion that every patient with diagnosed agenesis of the dorsal pancreas should be observed with a focus on the early detection of potential malignancy.
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Affiliation(s)
- A Erotokritou
- Department of Gastroenterology, Academic Teaching Hospital Bethesda Duisburg, Heerstr, 219 47053, Duisburg, Germany
| | - C D Gerharz
- Department of Pathology, Academic Teaching Hospital Bethesda Duisburg, Heerstr. 219, 47053, Duisburg, Germany
| | - A Sagir
- Department of Gastroenterology, Academic Teaching Hospital Bethesda Duisburg, Heerstr, 219 47053, Duisburg, Germany.
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Sagir A, Ney D, Oh J, Pandey S, Kircheis G, Mayatepek E, Häussinger D. Evaluation of Acoustic Radiation Force Impulse Imaging (ARFI) for the Determination of Liver Stiffness Using Transient Elastography as a Reference in Children. Ultrasound Int Open 2016; 1:E2-7. [PMID: 27689145 DOI: 10.1055/s-0035-1554659] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [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: 02/08/2023] Open
Abstract
PURPOSE Transient elastography (Fibroscan(©); (FS)) and acoustic radiation force impulse imaging (ARFI) represent noninvasive, user-friendly and quick methods providing an objective and reproducible measure of liver stiffness. The aim of the study was to evaluate cut-off values and performance of ARFI measurements in children using transient elastography as a reference. METHODS/PATIENTS A total of 198 children were enrolled in this study. All patients underwent liver stiffness measurements with FS (FS-LS) as well as ARFI (with shear wave velocity quantification; ARFI-SWV) and the performance of ARFI in comparison to FS was studied. RESULTS Significantly higher rates of successful measurements were found for ARFI compared to FS (198/198 (100%) vs. 160/198 (80.8%); p<0.001). ARFI-SWV correlated significantly with FS-LS (r=0.751, p=0.001). ARFI-SWV increased significantly with the stage of fibrosis (1.19+0.15 m/s for patients with FS-LS<7.6 kPa); 1.34+0.22 m/s for patients with 7.6<FS-LS<13.0 kPa); and 1.83+0.58 m/s for patients with FS-LS>13.0 kPa). ARFI-SWV cut-off values were identified for no significant fibrosis (1.31 m/s; sensitivity 61.8% and specificity 79.5%) and for liver cirrhosis (1.63 m/s; sensitivity 70.0% and specificity 97.4%). The median values of liver stiffness measured by FS were age-dependent in 90 children without liver diseases with 4.8, 5.6, and 5.7 kPa in children 0-5, 6-11, and 12-18 years, respectively.
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Affiliation(s)
- A Sagir
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Uniklinik Düsseldorf, Düsseldorf, Germany
| | - D Ney
- Kinderklinik, Kath. Kinderkrankenhaus Wilhelmstift, Hamburg, Germany; Klinik für Allgemeine Pädiatrie, Neonatologie und KInderkardiologie, Uniklinik Düseldorf, Düsseldorf, Germany
| | - J Oh
- Klinik für Allgemeine Pädiatrie, Universität Hamburg/Eppendorf, Hamburg, Germany; Klinik für Allgemeine Pädiatrie, Neonatologie und KInderkardiologie, Uniklinik Düseldorf, Düsseldorf, Germany
| | - S Pandey
- Klinik für Allgemeine Pädiatrie, Neonatologie und KInderkardiologie, Uniklinik Düseldorf, Düsseldorf, Germany
| | - G Kircheis
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Uniklinik Düsseldorf, Düsseldorf, Germany
| | - E Mayatepek
- Klinik für Allgemeine Pädiatrie, Neonatologie und KInderkardiologie, Uniklinik Düseldorf, Düsseldorf, Germany
| | - D Häussinger
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Uniklinik Düsseldorf, Düsseldorf, Germany
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Friedrich-Rust M, Lupsor M, de Knegt R, Dries V, Buggisch P, Gebel M, Maier B, Herrmann E, Sagir A, Zachoval R, Shi Y, Schneider MD, Badea R, Rifai K, Poynard T, Zeuzem S, Sarrazin C. Point Shear Wave Elastography by Acoustic Radiation Force Impulse Quantification in Comparison to Transient Elastography for the Noninvasive Assessment of Liver Fibrosis in Chronic Hepatitis C: A Prospective International Multicenter Study. Ultraschall Med 2015; 36:239-247. [PMID: 25970201 DOI: 10.1055/s-0034-1398987] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
PURPOSE The aim of the present prospective European multicenter study was to demonstrate the non-inferiority of point shear wave elastography (pSWE) compared to transient elastography (TE) for the assessment of liver fibrosis in patients with chronic hepatitis C. MATERIALS AND METHODS 241 patients with chronic hepatitis C were prospectively enrolled at 7 European study sites and received pSWE, TE and blood tests. Liver biopsy was performed with histological staging by a central pathologist. In addition, for inclusion of cirrhotic patients, a maximum of 10 % of patients with overt liver cirrhosis confirmed by imaging methods were allowed by protocol (n = 24). RESULTS Owing to slower than expected recruitment due to a reduction of liver biopsies, the study was closed after 4 years before the target enrollment of 433 patients with 235 patients in the 'intention to diagnose' analysis and 182 patients in the 'per protocol' analysis. Therefore, the non-inferiority margin was enhanced to 0.075 but non-inferiority of pSWE could not be proven. However, Paired comparison of the diagnostic accuracy of pSWE and TE revealed no significant difference between the two methods in the 'intention to diagnose' and 'per protocol' analysis (0.81 vs. 0.85 for F ≥ 2, p = 0.15; 0.88 vs. 0.92 for F ≥ 3, p = 0.11; 0.89 vs. 0.94 for F = 4, p = 0.19). Measurement failure was significantly higher for TE than for pSWE (p = 0.030). CONCLUSION Non-inferiority of pSWE compared to TE could not be shown. However, the diagnostic accuracy of pSWE and TE was comparable for the noninvasive staging of liver fibrosis in patients with chronic hepatitis C.
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Affiliation(s)
- M Friedrich-Rust
- Department of Internal Medicine 1, J. W. Goethe-University Hospital, Frankfurt, Germany
| | - M Lupsor
- Department of Ultrasound, University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - R de Knegt
- Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, Netherlands
| | - V Dries
- Institute of Pathology, Institute of Pathology, Mannheim, Germany
| | - P Buggisch
- Hepatology, Institute for Interdisciplinary Medicine, Hamburg, Germany
| | - M Gebel
- Department of Internal Medicine, Medical School Hannover, Germany
| | - B Maier
- Department of Internal Medicine 1, J. W. Goethe-University Hospital, Frankfurt, Germany
| | - E Herrmann
- Institute of Biostatistics and Mathematical Modelling, Faculty of Medicine, J. W. Goethe-University, Frankfurt, Germany
| | - A Sagir
- Department of Gastroenterology and Infectious Disease, University Hospital Düsseldorf, Germany
| | - R Zachoval
- Department of Medicine II, Campus Grosshadern, University Hospital Munich, Germany
| | - Y Shi
- Institute of Biostatistics and Mathematical Modelling, Faculty of Medicine, J. W. Goethe-University, Frankfurt, Germany
| | - M D Schneider
- Department of Internal Medicine 1, J. W. Goethe-University Hospital, Frankfurt, Germany
| | - R Badea
- Imaging, University Iuliu Hatieganu, Cluj, Romania
| | - K Rifai
- Gastroenterology and Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - T Poynard
- Hôpital Pitié-Salpêtrière, Université Pierre et Marie Curie, Paris, France
| | - S Zeuzem
- Department of Internal Medicine 1, J. W. Goethe-University Hospital, Frankfurt, Germany
| | - C Sarrazin
- Department of Internal Medicine 1, J. W. Goethe-University Hospital, Frankfurt, Germany
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Sagir A, Goyal R. An assessment of the awareness of local anesthetic systemic toxicity among multi-specialty postgraduate residents. J Anesth 2014; 29:299-302. [PMID: 25138822 DOI: 10.1007/s00540-014-1904-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [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: 05/04/2014] [Accepted: 08/01/2014] [Indexed: 11/26/2022]
Abstract
Local anesthetics (LAs) are extensively used in clinical practice by both anesthesiologists and non-anesthesiologists and are often associated with systemic toxicity. We hypothesize that this awareness is inadequate among medical specialists and entails a risk of misdiagnosis and underreporting of such events. We therefore conducted a cross-sectional questionnaire-based study to assess the level of understanding of LA use and effective management of systemic toxicity among 200 postgraduate residents of various specialties (with the exception of anesthesiology) in a tertiary care hospital in India from October to December 2013. Among those residents who had used LAs (193/200), 27 and 25 % of responders correctly identified the toxic doses of lidocaine and of lidocaine + adrenaline, respectively. Of the responders, 70 % always performed a negative aspiration of blood before injecting the drug, 27 % sometimes aspirated and the remaining 3 % never aspirated. The majority of the responders (93 %) were unaware of the toxic dose of bupivacaine. Only 70 % of responders believed that LAs could be toxic [95 % confidence interval (CI) 65.5-74.5 %], and 81 % of these correctly identified the signs and symptoms of cardiotoxicity. Only 2 % of responders knew that lipid emulsion is a part of its treatment (95 % CI 0.6-3.4 %). Based on these results, there is a definite need to increase the awareness of detection and treatment of local anesthetic toxicity among all medical practitioners who regularly use LAs.
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Affiliation(s)
- Afrin Sagir
- Department of Anesthesia and Critical Care, Armed Forces Medical College-Pune and Command Hospital (SC), Pune, India
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Mukhopadhyay C, Vishwanath S, Eshwara VK, Shankaranarayana SA, Sagir A. Microbial quality of well water from rural and urban households in Karnataka, India: A cross-sectional study. J Infect Public Health 2012; 5:257-62. [DOI: 10.1016/j.jiph.2012.03.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2011] [Revised: 02/25/2012] [Accepted: 03/08/2012] [Indexed: 10/28/2022] Open
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Kubitz R, Bode J, Erhardt A, Graf D, Kircheis G, Müller-Stöver I, Reinehr R, Reuter S, Richter J, Sagir A, Schmitt M, Donner M. Cholestatic liver diseases from child to adult: the diversity of MDR3 disease. Z Gastroenterol 2011; 49:728-36. [PMID: 21638239 DOI: 10.1055/s-0031-1273427] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The phospholipidfloppase MDR3 (gene symbol: ABCB4) is expressed in the canalicular membrane of hepatocytes and mediates the biliary excretion of phosphatidylcholine, which is required for the formation of mixed micelles in bile. Several mutations of ABCB4 have been identified, which cause cholestatic liver diseases of varying severity including progressive familial intrahepatic cholestasis type 3 (PFIC-3), intrahepatic cholestasis of pregnancy (ICP) and the low phospholipid associated cholelithiasis syndrome (LPAC). Here, we report on four new (S1076N; L 23Hfs16X; c.286 + 1G > A; Q 1181E) and one known (S27G) MDR3 mutations in eight patients of three families. The patients presented with a wide spectrum of liver diseases. The clinical presentation and decisive laboratory findings or the association to a trend-setting family history led to the identification of the genetic background in these patients. Even the same mutation may be associated with varying disease progression.
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Affiliation(s)
- R Kubitz
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Düsseldorf.
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Kummer S, Sagir A, Pandey S, Feldkötter M, Habbig S, Hoppe B, Mayatepek E, Oh J. Leberfibrose bei zystischen Nierenerkrankungen-Anwendung der transienten Elastografie (Fibroscan®) zur Erkennung und Quantifizierung. Klin Padiatr 2011. [DOI: 10.1055/s-0031-1273818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Blondin D, Erhardt A, Crynen K, Sagir A, Scherer A, Kröpil P, Häussinger D, Mödder U, Kubitz R. [Diagnosis of focal liver lesions in cirrhotic patients: comparison of contrast-enhanced ultrasound using sulphur hexafluoride (SF6) microbubbles and MRI using Gd-EOB-DTPA]. Z Gastroenterol 2011; 49:23-9. [PMID: 21225534 DOI: 10.1055/s-0029-1245781] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIM The diagnostic accuracies of contrast-enhanced sonography and hepatobiliary contrast-enhanced MRI of the liver in evaluating focal liver lesions in patients with liver cirrhosis were compared. MATERIAL AND METHODS In 33 patients (25 men, 8 women, mean age 63.2 ± 11.2 years) MRI of the liver using Gd-EOB-DTPA (Primovist®, Bayer Schering Pharma, Berlin) was performed. Axial T(2)-weighted, unenhanced T(1)-weighted and enhanced T(1)-weighted scans during arterial, portal venous and late phases were acquired, followed by coronary T(1)-weighted and axial fat-suppressed T(1)-weighted scans 15 minutes post contrast application. In all patients within 4 weeks contrast-enhanced sonography using sulfur hexafluoride microbubbles (SonoVue®, Nycomed, Germany) was obtained. RESULTS Cirrhosis of the liver was related to viral infection in 45.4% and to alcoholism in 39.4%. All hepatic lesions were confirmed by histologic examination. Sensitivity and specificity of MRI were 90.2% and 83.3%, compared to contrast-enhanced sonography with 92.7 % and 50 %, respectively. Positive and negative predictive values were 97.4% and 55.5 % for MRI and 90.5% and 50% for contrast-enhanced sonography, respectively. DISCUSSION In this retrospective study MRI using Gd-EOB-DTPA as well as contrast-enhanced sonography using sulfur hexafluoride microbubbles gave excellent results in detecting HCC in patients suffering from liver cirrhosis. Although the specificity was higher for MRI, the accuracy showed no significant difference between these two imaging techniques.
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Affiliation(s)
- D Blondin
- Institut für Radiologie, Heinrich-Heine-Universität Düsseldorf.
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Erhardt A, Hoernke M, Heinzel-Pleines U, Sagir A, Göbel T, Häussinger D. Retrospective analysis of chronic hepatitis D in a West German University Clinic over two decades: migratory pattern, prevalence and clinical outcome. Z Gastroenterol 2010; 48:813-7. [PMID: 20687016 DOI: 10.1055/s-0028-1109984] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND/AIMS Epidemiology, clinical features and long term-course of chronic hepatitis D were addressed in a non-endemic Central European area. METHODS Sixty-seven patients with chronic hepatitis D were identified among 1307 HBsAg carriers at the university hospital Düsseldorf during two decades (1989 - 2008) and followed for a mean of 7 +/- 6 years. Forty-one of these were treated with IFN-alfa for at least six months. RESULTS Hepatitis D prevalence increased from 4.1 to 6.2 % among HBsAg carriers during the two decades (p < 0.06). Patients originating from the former Soviet Union (32.1 vs. 46.2 %) and Africa (0 vs. 17.9 %) became more frequent whereas the prevalence of patients from Southern Europe declined (46.5 vs.17.9 % p < 0.03). The time span between the diagnosis of hepatitis B and D was 4.8 +/- 7 years (p < 0.0001). A sustained virological response to interferon-alfa was achieved in 19.5 % of the patients. The yearly incidence rates for death, HCC and complications were 3.2 %, 2.7 % and 8 % among patients with liver cirrhosis. Estimated survival and complication-free survival during 12 years were 72 % and 45 % in cirrhotic compared to 100 % in non-cirrhotic patients (p < 0.008 and p < 0.0001, respectively). CONCLUSION Hepatitis D in western Germany appears to be on the increase and has a migration background that should be considered in clinical practice. Clinical outcome and response to IFN are as poor as in endemic regions, indicating the need to improve early diagnosis.
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Affiliation(s)
- A Erhardt
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum der Heinrich-Heine-Universität Düsseldorf.
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Renjhen P, Kumar A, Pattanshetty S, Sagir A, Samarasinghe CM. A study on knowledge, attitude and practice of contraception among college students in Sikkim, India. J Turk Ger Gynecol Assoc 2010; 11:78-81. [PMID: 24591903 DOI: 10.5152/jtgga.2010.03] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [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: 03/05/2010] [Accepted: 04/16/2010] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To assess the knowledge, attitude and practice of contraception among the college students. MATERIALS AND METHODS A cross sectional study was conducted in the Government College, Gangtok, Sikkim, during the month of April 2009 to evaluate the knowledge, attitude and practice of contraception among 156 students enrolled in the first year bachelor course. Descriptive statistics was used for data analysis. RESULTS 98% (153/156) of the students had knowledge about family planning and 86% (134/156) of them had heard about contraceptives. Most of them knew about condoms (85%) and contraceptive pills (40%) but knowledge about permanent methods and Cu-T was poor (average 12%). Most students thought contraceptives were to be used to prevent unwanted pregnancy (35%) and for birth spacing (30%). 11% of students had used some form of contraceptive in the past and 7% were currently users. The most commonly used contraceptives were condoms, followed by combined use of OCP and condom. CONCLUSION The study highlights the need to motivate the youth for effective and appropriate use of contraceptives when required and arrest the trend towards unwanted pregnancy.
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Oette M, Stelzer A, Göbels K, Wettstein M, Sagir A, Feldt T, Häussinger D. Wireless capsule endoscopy for the detection of small bowel diseases in HIV-1-infected patients. Eur J Med Res 2009; 14:191-4. [PMID: 19541574 PMCID: PMC3351976 DOI: 10.1186/2047-783x-14-5-191] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND AIMS In HIV-infected patients, manifestations of the disease are common in the gastrointestinal tract. The objective of our study was to evaluate the diagnostic yield of the Given(R) Video Capsule System (Given Imaging, Yoqneam, Israel) in these patients. METHODS After the exclusion of GI-tract stenosis by anamnestic exploration, 49 patients were included into the study. Stratification: Group A (n = 19): HIV-positive, CD4 cell count < 200/microl, gastrointestinal symptoms present. Group B: HIV-positive, CD subset4 < 200/microl, without gastrointestinal symptoms (n = 19 Group) C: healthy volunteers (n = 11). RESULTS In group A there was a total of 30 pathological findings, 15 of which had therapeutic implications. In group B, there was a total of 22 pathological findings, 5 relevant for therapy. In group C there was a total of 13 pathological findings, 3 with therapeutic relevance. In 89% (group A) vs. 26% (group B), pathological findings were detected distal to the ligament of Treitz (p = 0.001). All capsules were recovered without any complication after 12 to 96 h from the stool. CONCLUSION Wireless capsule endoscopy of the small intestine should be considered for HIV-infected patients with marked immunosuppression and gastrointestinal symptoms.
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Affiliation(s)
- Mark Oette
- Klinik für Allgemeine Innere Medizin, Gastroenterologie und Infektiologie, Krankenhaus der Augustinerinnen, Jakobstr. 27-31, 50678 Köln, Germany.
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Abstract
There is very little literature regarding peripartum cardiomyopathy (PCM) from Asian countries. A study of PCM was conducted at Kasturba Medical College Hospital, Manipal, with special reference to incidence and outcome. The incidence of PCM was 1 case per 1374 live births. Major risk factors for the development of PCM were multiparity and advanced maternal age. Echocardiography is useful in early diagnosis and for follow-up assessment of left ventricular function. Most of the patients noticed good symptomatic improvement at time of discharge and during the follow-up with standard therapy. Clinical improvement was well correlated with improvement of LV function by echocardiography. Significant thrombotic complications were noticed. None of the patients died during the study and follow-up period.
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Affiliation(s)
| | | | - Ashwini Kumar
- Community Medicine, Kasturba Medical College, Manipal, India
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Sagir A, Adams O, Oette M, Vogel M, Kupfer B, Emmelkamp J, Rockstroh J, Häussinger D. SEN Virus infection in HIV/HCV coinfected patients. Eur J Med Res 2008; 13:495-499. [PMID: 19073384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Chronic Hepatitis C Virus (HCV) infection is currently one of the most relevant coinfections in HIV positive patients. The influence of SEN Virus (SENV) on the outcome of HCV therapy in HIV/HCV coinfected patients who underwent combination therapy with pegylated interferon (PEG-IFN) and ribavirin is unclear. METHODS SENV DNA was determined by polymerase chain reaction in 67 HIV/HCV coinfected patients, 77 HIV monoinfected patients, 95 treatment naive HCV monoinfetcted patients, and 122 healthy blood donors. Quantitative analysis was done for SENV H DNA. RESULTS SENV DNA was detected in 8 of 67 (12%) HIV/HCV coinfected patients, in 9 of 77 (11.7%) HIV monoinfected patients, in 21 of 95 (22%) HCV monoinfected patients, and 12 of 122 (9.8%) healthy blood donors. HIV monoinfected patients showed the highest mean SENV H DNA level. The mean SENV H DNA was significantly lower in HIV/HCV coinfected patients compared to all other groups. The sustained virological response rates to combination therapy of HCV in HIV/HCV coinfected patients did not differ between patients with detectable SENV 5/8 (62.5%) and without SENV 28/59 (47.5%; p = 0.47). We found no significant difference in SENV H DNA pretreatment levels between nonresponders and responders to combination therapy (112 +/- 144 copies vs. 8 +/- 7 copies/ml; p = 0.27). CONCLUSION Coinfection with HCV may reduce SENV H replication in HIV positive patients and results in significantly lower SENV H DNA levels in HIV/HCV coinfected patients. SENV infection has no influence on the outcome of HCV combination therapy in HIV/HCV coinfected patients.
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Affiliation(s)
- A Sagir
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinik Düsseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany.
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Sagir A, Heintges T, Akyazi Z, Oette M, Erhardt A, Häussinger D. Therapy outcome in patients with chronic hepatitis C: role of therapy supervision by expert hepatologists. J Viral Hepat 2007; 14:633-8. [PMID: 17697015 DOI: 10.1111/j.1365-2893.2007.00854.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [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: 12/24/2022]
Abstract
Previous large multicentre trials reported sustained virological response (SVR) rates of 45-80% in chronically infected hepatitis C virus (HCV) patients. However, it is unclear whether such a treatment success is also achieved in daily routine and to what extent it depends on expert hepatological supervision. This was retrospectively analysed in patients presenting at our outpatient department during May 1997 and March 2004 and receiving at least one treatment dose. A total of 302 treatment-naive HCV patients [72% genotypes 1 or 4 (n = 215), 25% genotypes 2/3 (n = 78) and 3% undetermined genotype (n = 9)] were included in the analysis. Out of these, 196 patients consulted an expert hepatologist at least once every 3 months during treatment [regular visitors (RV)], whereas in 106 patients treatment was performed and supervised by a general practitioner (irregular visitors). Both patient groups did not differ in their baseline characteristics. However, the virological response rates at the end of treatment (ETR; 146/196, 74%vs 51/106, 48%, P < 0.001) and 6 months thereafter (SVR; 129/196, 66%vs 36/106, 34%, P < 0.001) were significantly higher in RV. In patients treated with pegylated-interferon (PEG-IFN)/ribavirin, this difference was statistically highly significant (P < 0.001) for HCV genotypes 1 and 4 (treated patients: SVR: 62/101, 61%vs 14/51, 27%, P < 0.001), but not for genotypes 2/3. SVR rates were also significantly better in RV with advanced liver damage [SVR 69% (22/32) vs 25% (5/20), P = 0.004]. In regular and irregular visitors treatment was discontinued in 7% (14/196) and 15% (16/106) respectively (P = 0.015). Patients with unfavourable genotypes 1 and 4 or with advanced liver damage benefit from HCV therapy supervision by a specialist, probably because of less frequent treatment interruptions or dose reductions.
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Affiliation(s)
- A Sagir
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinik Düsseldorf, Moorenstr, Düsseldorf, Germany
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Oette M, Kaiser R, Däumer M, Fätkenheuer G, Rockstroh JK, Knechten H, Mitrenga D, Beerenwinkel N, Sagir A, Pfister H, Häussinger D. [Epidemiology of primary drug resistance in chronically HIV-infected patients in Nordrhein-Westfalen, Germany, 2001-2005]. Dtsch Med Wochenschr 2007; 132:977-82. [PMID: 17457780 DOI: 10.1055/s-2007-979365] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND OBJECTIVE Primary HIV drug resistance, characterized by mutant virus strains in untreated HIV-infected persons, is of significant epidemiological significance. Primary resistance is associated with reduced efficacy of antiretroviral therapy (ART). We determined the prevalence of primary resistance in Nordrhein-Westfalen, Germany. PATIENTS AND METHODS Genotypic resistance testing was performed in a prospective multicenter study in chronically infected previously untreated HIV-positive patients before administration of first-line ART. Mutations were classified according to the International AIDS Society USA guidelines and the geno2pheno interpretation tool. RESULTS Between January 2001 and December 2005, resistance testing was performed in 831 patients. 77.4% were males, the mean age was 39 years (SD: 10.5). The mean duration of diagnosis of HIV infection was 1.6 years (SD: 3.4). 32.4% of patients were at CDC stage C, mean CD4 cell count was 236 /microl (SD: 205), and mean viral load was 206,855 copies/ml (SD: 450,610). In total, resistance-associated mutations were detected in 75 patients (9.0%; 95%CI, 7.1-11.0). After inclusion of mutations E44D and V118I, resistance was identified in 99 patients (11.9%; 95%CI, 9.7-14.1). 5.4% had mutations indicating nucleoside reverse transcriptase inhibitor (NRTI) resistance (95%CI, 3.9-7.0), 3.0% had non-NRTI resistance (95%CI, 1.8-4.2), and 2.4% had protease inhibitor resistance (95%CI, 1.4-3.4), respectively. Two-class resistance was detected in 0.8% (95%CI, 0.2-1.5), three-class resistance in 0.5% (95%CI, 0.01-1.0). Mutations indicating revertant variants of resistant strains were found in 3.9% (95%CI, 2.5-5.2). Considering the variables age, gender, time since diagnosis, CDC stage, CD4 cell count, viral load, HIV subtype, ethnic origin, and HIV transmission group, no significant risk factor for the presence of primary resistance was demonstrated in univariate and mutlivariate analyses. CONCLUSION The prevalence of primary resistant virus strains was about 10% in chronically infected ART-naive HIV-patients in the largest federal state of Germany. The majority of these patients had NRTI-associated resistance. No risk factor for the presence of primary drug resistance was identified. Because of the high prevalence and the possible impact on efficacy of drug treatment, routine genotypic resistance testing should be performed in untreated HIV-positive patients before administration of first-line ART.
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Affiliation(s)
- M Oette
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Düsseldorf.
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Abstract
BACKGROUND AND OBJECTIVE Detection of liver cirrhosis has numerous implications because of the potential sequelae of cirrhosis. Transient elastography (Fibroscan), was evaluated as a novel, non-invasive means of assessing cirrhosis by measuring liver stiffness. METHODS 147 consecutive patients with different forms of liver disease and histologically determined stages of liver fibrosis were prospectively studied by transient elastography. 48 patients had liver cirrhosis. RESULTS The number of transient elastographic measurements per patient was 12+/-4 (range 6 - 30). Valid elastography measurements were available for 135 out of 147 patients (92 %). The results of transient elastography correlated positively with the histological score of liver fibrosis (r = 0.8; 95 % CI: 0.72 - 0.85; p < 0.001). Areas under the receiver operating characteristic curve (AUROC) were 0.91 for > or = F3 fibrosis (95 % CI: 0.85 - 0.96) and 0.94 for cirrhosis (95 % CI: 0.90 - 0.98). Using a cut-off value of 13 kPa for detection of liver cirrhosis a sensitivity of 90 %, a specificity of 82 %, a positive predictive value of 71 % and a negative predictive value of 95 % were obtained. CONCLUSIONS Measuring liver stiffness by transient elastography proved to be an easy method to assess liver cirrhosis. In combination with clinical signs, ultrasound and biochemical markers noninvasive diagnosis of liver cirrhosis will be further improved.
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Affiliation(s)
- A Erhardt
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Heinrich-Heine-Universität, Düsseldorf.
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Erhardt A, Blondin D, Hauck K, Sagir A, Kohnle T, Heintges T, Häussinger D. Response to interferon alfa is hepatitis B virus genotype dependent: genotype A is more sensitive to interferon than genotype D. Gut 2005; 54:1009-13. [PMID: 15951551 PMCID: PMC1774609 DOI: 10.1136/gut.2004.060327] [Citation(s) in RCA: 195] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Current interferon alfa (IFN) treatment of chronic hepatitis B has limited efficacy. The role of hepatitis B virus (HBV) genotypes for response to IFN was investigated. PATIENTS AND METHODS HBV genotype was determined by direct sequencing of the HBV X gene in 165 consecutive patients with chronic replicative hepatitis B treated with standard IFN. HBV genotype A or D was found in 144 cases. RESULTS Sustained response (six months after treatment) to standard IFN therapy was higher in HBV genotype A compared with HBV genotype D infected patients (49% v 26%; p<0.005). Sustained response to IFN was 46% versus 24% (p<0.03) in hepatitis B e antigen (HBeAg) positive hepatitis (n = 99) and 59% versus 29% (p<0.05) in HBeAg negative hepatitis (n = 45) for HBV genotype A compared with HBV genotype D. HBeAg status had no negative impact on IFN response. Multivariate logistic regression identified HBV genotype A and high pretreatment alanine aminotransferase levels (>2 x upper limit of normal) as independent positive predictive parameters of IFN response. CONCLUSIONS The present study indicates that HBV genotypes A and D are important and independent predictors of IFN responsiveness in chronic hepatitis B. HBV genotype adapted treatment regimens may further improve treatment efficacy in chronic hepatitis B.
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Affiliation(s)
- A Erhardt
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Heinrich-Heine-Universität Düsseldorf, Moorenstr 5, D-40225 Düsseldorf, Germany.
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Oette M, Kurowski M, Feldt T, Kroidl A, Sagir A, Vogt C, Wettstein M, Häussinger D. Impact of rosiglitazone treatment on the bioavailability of antiretroviral compounds in HIV-positive patients. J Antimicrob Chemother 2005; 56:416-9. [PMID: 15983027 DOI: 10.1093/jac/dki234] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The insulin-sensitizer rosiglitazone is under investigation for therapy of HIV-associated lipodystrophy syndrome (LDS). Little is known about pharmacological interactions with antiretroviral (ARV) drugs. METHODS Therapeutic drug monitoring (TDM) of ARV drugs was performed in a prospective study before and at day 28 after start of treatment with 4 mg of rosiglitazone for combined LDS. Drug levels were measured in the morning fasting, and 0.5, 1, 2, 4, 6 and 8 h after standardized drug intake. Values were log-transformed for analysis. RESULTS Twelve males and six females were assessed; mean age was 50.7 years and mean CD4 cell count was 496 cells/mm(3). All patients had a viral load below 50 copies/mL, and backbone ARV therapy consisted of two or three nucleoside reverse transcriptase inhibitors in all cases. After administration of rosiglitazone, no significant differences in Cmax, Cmin and AUC were found in cases treated with efavirenz (n = 10) and lopinavir (n = 4). Mean Cmax of nevirapine (n = 4) was reduced significantly [-0.44; 95% confidence interval (CI) -0.86 to -0.01]. Furthermore, there was a consistent trend to a reduction in the geometric mean ratio (GMR) of Cmax, Cmin and AUC (GMR of Cmax 0.95; 95% CI 0.9-1.0; GMR of Cmin 0.89; 95% CI 0.65-1.13; GMR of AUC 0.96; 95% CI 0.91-1.01). CONCLUSIONS Treatment with 4 mg of rosiglitazone for HIV-associated LDS is likely to reduce the bioavailability of nevirapine. Thus, routine TDM is recommended for patients treated with rosiglitazone and nevirapine. A therapy consisting of efavirenz or lopinavir seems to be without negative impact. Further studies on the interaction of rosiglitazone with ARV drugs are necessary.
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Affiliation(s)
- M Oette
- Clinic for Gastroenterology, Hepatology, and Infectious Diseases, University Clinic Düsseldorf, Moorenstr. 5, 40225 Düsseldorf.
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Feldt T, Oette M, Kroidl A, Göbels K, Leidel R, Sagir A, Kuschak D, Häussinger D. Atazanavir for treatment of HIV infection in clinical routine: efficacy, pharmacokinetics and safety. Eur J Med Res 2005; 10:7-10. [PMID: 15737947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023] Open
Abstract
INTRODUCTION Atazanavir (ATV) is a novel protease inhibitor that has been recently introduced into therapy of HIV infection. Currently there is little data on ATV therapy from daily practice. METHODS In this retrospective study, we report on ATV efficacy and safety in clinical routine. Drug monitoring was performed consisting of unscheduled single measurements and a 4-hour-profile. Trough concentration of >80 ng/ml and peak concentration of 2000-6000 ng/ml were regarded as sufficient. RESULTS Between May 2003 and April 2004, ATV treatment was started in 42 patients, mean observation time was 32 weeks (6-53). Mean age was 45.6 years, 38% had prior AIDS, viral load was undetectable in 73%. Important side effects were minor or moderate diarrhea (27%) and fatigue (15%). ATV was discontinued in 10% due to side effects or malignant diseases. No significant influence on mean values of cholesterol, triglycerides, liver enzymes, CD4-cell-count, and HI-viral load was seen. Virologic failure occurred in 13% of patients, all of them were PI-experienced. Pharmacokinetic data are available for 32 patients, all patients had sufficient trough levels. 30% with unboosted ATV and 21% with boosted ATV had peak plasma concentrations below the level defined as sufficient. Mean trough levels, plasma profile and AUC did not differ significantly between groups with non-boosted versus boosted ATV regimes but showed a wide inter-patient variability. CONCLUSIONS ATV treatment of HIV-infected patients with or without a RTV booster was safe and effective in clinical routine. Drug levels were sufficient in the majority of cases. The variability of pharmacokinetic results in our sample supports therapeutic drug monitoring in patients treated with ATV.
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Affiliation(s)
- T Feldt
- Clinic for Gastroenterology, Hepatology, and Infectious Diseases, University Clinic of Düsseldorf, Moorenstr. 5, D-40225 Düsseldorf, Germany
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Sagir A, Avci A, Erhardt A, Lörke J, Heintges T, Häussinger D. [New approaches in the treatment of hepatitis B]. Dtsch Med Wochenschr 2004; 129:1203-8. [PMID: 15160325 DOI: 10.1055/s-2004-824872] [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] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- A Sagir
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Düsseldorf, Duesseldorf
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Abstract
Cytochrome P450 3A (CYP3A) is involved in biotransformation of more than half of all drugs currently available. Drug interactions by inhibition of CYP3A are of major interest in patients receiving combinations of drugs. Some interactions with CYP3A inhibitors also involve inhibition of the multidrug export pump, P-glycoprotein. An increasing number of adverse drug reactions might be avoided on the basis of knowledge about CYP3A substrates and inhibitors. This article summarizes some examples of such interactions relevant to gastroenterologists. Serious cases by coadministration of CYP3A inhibitors resulting in acute hepatitis, hypotension, rhabdomyolyis, torsade de pointes, sedation, or ergotism are presented: interactions with azole antifungals (ketoconazole, itraconazole, fluconazole), HIV protease inhibitors (ritonavir, indinavir, saquinavir, nelfinavir), macrolide antibiotics (clarithromycin, erythromycin), and grapefruit juice. In addition, 1 case is reported who presented the highest trough levels of the CYP3A substrate budesonide in serum ever measured. Practitioners have to be aware of the high potential of metabolic drug interactions when they prescribe a CYP3A inhibitor. It is wise to check carefully comedication in patients complaining of side effects with substrates of CYP3A.
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Affiliation(s)
- A Sagir
- Klinik für Gastroenterologie, Hepatologie und Infektiologie des Universitätsklinikums Düsseldorf, Deutschland
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Erhardt A, Knuth R, Sagir A, Kirschberg O, Heintges T, Häussinger D. Socioepidemiological data on hepatitis delta in a German university clinic--increase in patients from Eastern Europe and the former Soviet Union. Z Gastroenterol 2003; 41:523-6. [PMID: 12806537 DOI: 10.1055/s-2003-39648] [Citation(s) in RCA: 22] [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] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIMS The relevance of chronic hepatitis delta results from its high morbidity leading frequently to rapid cirrhosis progression. The aim of the present study was the socioepidemiological characterization of patients with hepatitis delta, in order to identify patients at risk for hepatitis delta. PATIENTS AND METHODS Clinical parameters of 36 consecutive patients with chronic hepatitis delta, seen between 1989 and 2002 at the University Hospital in Düsseldorf, were evaluated for the present study. Socioepidemiological parameters, available in 31 of these patients who returned a questionnaire, were compared to data of the population of Nordrhein-Westfalen (NRW). RESULTS Liver cirrhosis was found in 33.3% of patients. There was a mean delay of 3 years between the diagnosis of hepatitis B and D. Patients with delta hepatitis were characterized by lower education, were more frequently unemployed, exhibited less qualified work and had less property compared to the population of NRW. 86.1% of hepatitis delta patients were immigrants to Germany. Before 1995 hepatitis delta infections were mainly seen in patients from Southern Europe (75%), whereas after 1996 predominantly patients from Eastern Europe and the former Soviet Union (53.6%; p < 0.04) contributed to the newly diagnosed cases of hepatitis delta. CONCLUSIONS The present data underline that hepatitis delta is a severe disease. It seems reasonable to intensify screening for hepatitis delta among patients with low socioeconomic status, especially among immigrants of Eastern Europe and the former Soviet Union.
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Affiliation(s)
- A Erhardt
- Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum der Heinrich-Heine-Universität Düsseldorf. erhardt@uni-duesseldorf-de
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Richter J, Sagir A, Schöneberg I, Alpers K, Häussinger D. Malaria and tourism: retrospective analysis of German malaria cases imported from the Dominican Republic. Euro Surveill 2001; 6:65-6. [PMID: 11679686 DOI: 10.2807/esm.06.04.00214-en] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report on malaria acquired by German tourists to formerly non-endemic tourist resorts in the Dominican Republic between July 1999 and March 2000. Falciparum malaria is endemic in the western provinces and the hinterland of the Dominican Republic. By contrast, the risk of contracting malaria has always been considered so low in the main tourist resorts in the eastern part of the country that antimalarial chemoprophylaxis was not recommended.
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Affiliation(s)
- J Richter
- Heinrich-Heine-Universität Dusseldorf, Alemania
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Erhardt A, Sagir A, Guillevin L, Neuen-Jacob E, Häussinger D. Successful treatment of hepatitis B virus associated polyarteritis nodosa with a combination of prednisolone, alpha-interferon and lamivudine. J Hepatol 2000; 33:677-83. [PMID: 11059878 DOI: 10.1034/j.1600-0641.2000.033004677.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [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: 12/04/2022]
Abstract
Therapy of hepatitis B virus (HBV)-associated poly-arteritis nodosa is still evolving. Here we report a successful treatment with a short-term steroid administration in combination with a-interferon and lamivudine and a complete sequence analysis of the HBV genome. A 58-year-old man presented with the symptoms of mononeuritis multiplex associated in time with the onset of highly replicative hepatitis B. Polyarteritis nodosa was confirmed by biopsy. During an initial course with alpha-interferon and prednisolone no clinical improvement or hepatitis B virus seroconversion was observed. After addition of lamivudine to the protocol with fast tapering of prednisolone, HBV DNA fell to undetectable levels within 1 month and liver transaminases normalized. After 6 months of treatment HBeAg seroconversion took place, followed by HBsAg seroconversion 2 months later. Clinical symptoms of polyarteritis improved. No relapse of polyarteritis or hepatitis B was seen during the follow up of 9 months. Complete sequence analysis of the HBV genome revealed 6 nucleotide mutations but none in a relevant antigenic epitope. The present protocol of short-term prednisolone administration combined with alpha-interferon and lamivudine was effective for the treatment of HBV-related polyarteritis nodosa and may be a promising new therapeutic approach.
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Affiliation(s)
- A Erhardt
- Klinik für Gastroenterologie, Hepatologie und Infektologie, Heinrich-Heine-University, Düsseldorf Germany.
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