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Larkin A, Kim JS, Kim N, Baek SH, Yamada S, Park K, Tai K, Yanagi Y, Park JH. Accuracy of artificial intelligence-assisted growth prediction in skeletal Class I preadolescent patients using serial lateral cephalograms for a 2-year growth interval. Orthod Craniofac Res 2024. [PMID: 38321788 DOI: 10.1111/ocr.12764] [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: 01/23/2024] [Indexed: 02/08/2024]
Abstract
OBJECTIVE To investigate the accuracy of artificial intelligence-assisted growth prediction using a convolutional neural network (CNN) algorithm and longitudinal lateral cephalograms (Lat-cephs). MATERIALS AND METHODS A total of 198 Japanese preadolescent children, who had skeletal Class I malocclusion and whose Lat-cephs were available at age 8 years (T0) and 10 years (T1), were allocated into the training, validation, and test phases (n = 161, n = 17, n = 20). Orthodontists and the CNN model identified 28 hard-tissue landmarks (HTL) and 19 soft-tissue landmarks (STL). The mean prediction error values were defined as 'excellent,' 'very good,' 'good,' 'acceptable,' and 'unsatisfactory' (criteria: 0.5 mm, 1.0 mm, 1.5 mm, and 2.0 mm, respectively). The degree of accurate prediction percentage (APP) was defined as 'very high,' 'high,' 'medium,' and 'low' (criteria: 90%, 70%, and 50%, respectively) according to the percentage of subjects that showed the error range within 1.5 mm. RESULTS All HTLs showed acceptable-to-excellent mean PE values, while the STLs Pog', Gn', and Me' showed unsatisfactory values, and the rest showed good-to-acceptable values. Regarding the degree of APP, HTLs Ba, ramus posterior, Pm, Pog, B-point, Me, and mandibular first molar root apex exhibited low APPs. The STLs labrale superius, lower embrasure, lower lip, point of lower profile, B', Pog,' Gn' and Me' also exhibited low APPs. The remainder of HTLs and STLs showed medium-to-very high APPs. CONCLUSION Despite the possibility of using the CNN model to predict growth, further studies are needed to improve the prediction accuracy in HTLs and STLs of the chin area.
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Affiliation(s)
- A Larkin
- Postgraduate Orthodontic Program, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, Arizona, USA
| | - J-S Kim
- Department of Biomedical Engineering, Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - N Kim
- Department of Convergence Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - S-H Baek
- Department of Orthodontics, School of Dentistry, Dental Research Institute, Seoul National University, Seoul, Republic of Korea
| | - S Yamada
- Department of Dental Informatics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - K Park
- Department of Biomedical Engineering, Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - K Tai
- Postgraduate Orthodontic Program, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, Arizona, USA
- Private Practice of Orthodontics, Okayama, Japan
| | - Y Yanagi
- Department of Dental Informatics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - J H Park
- Postgraduate Orthodontic Program, Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, Arizona, USA
- Graduate School of Dentistry, Kyung Hee University, Seoul, Republic of Korea
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Shekhar AC, Larkin A, Fisher B, Mann NC. Aspirin use in ST-elevation myocardial infarction (STEMI) patients transported by emergency medical services (EMS). Am J Emerg Med 2023; 65:200-201. [PMID: 36509606 DOI: 10.1016/j.ajem.2022.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 11/26/2022] [Indexed: 12/05/2022] Open
Affiliation(s)
- Aditya C Shekhar
- Icahn School of Medicine at Mount Sinai, New York City, NY, United States of America.
| | - Angela Larkin
- NEMSIS Technical Assistance Center, The University of Utah, Salt Lake City, UT, United States of America
| | - Benjamin Fisher
- NEMSIS Technical Assistance Center, The University of Utah, Salt Lake City, UT, United States of America
| | - N Clay Mann
- NEMSIS Technical Assistance Center, The University of Utah, Salt Lake City, UT, United States of America; Department of Pediatrics, The University of Utah, Salt Lake City, UT, United States of America
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Skolarus TA, Forman J, Sparks JB, Metreger T, Hawley ST, Caram MV, Dossett LA, Larkin A, Paniagua Cruz A, Makarov DV, Leppert JT, Shelton JB, Stensland KD, Hollenbeck BK, Shahinian V, Wittmann DA, Deolankar V, Sriram S. Unpacking low-value castration practices using behavior specification to guide de-implementation in prostate cancer care. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e17055] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e17055 Background: Many men with prostate cancer will be exposed to ADT at some point during cancer survivorship. Unfortunately, ADT overuse in low-value scenarios is not uncommon (e.g., monotherapy in localized prostate cancer, biochemically-recurrent non-metastatic disease) resulting in more harms than benefits. We conducted an innovative survey study to unpack ADT overuse to inform behavior change and de-implementation strategies. Methods: Our survey used the Theoretical Domains Framework (TDF), and the Capability, Opportunity, Motivation – Behavior (COM-B) Model. The survey was fielded to the Society of Government Service Urologists listserv in December 2020. We stratified respondents based on their likelihood of stopping ADT monotherapy in the case of a localized prostate cancer patient presenting to their office (yes/probably yes, probably no/no), and characterized Likert scale responses to 7 COM-B statements. We used multivariable logistic regression to identify associations between stopping ADT and COM-B responses across a dichotomized Likert scale of “strongly disagree/disagree/neutral” and “agree/strongly agree.”. Results: Our survey was completed by 84 respondents (13% response rate), with 27% indicating ‘probably no’/‘no’ to stopping low-value ADT monotherapy in the case of a localized prostate cancer patient presenting to their office. Our multivariable model identified 2 COM-B statements significantly associated with lower likelihood of stopping low-value ADT. Conclusions: Using an innovative, behavioral theory-informed survey, we identified that providers less likely to stop low-value ADT had greater concern about patient worry and were more interested in providing ADT recommendations consistent with peers, informing de-implementation strategy selection. Clinical trial information: MCT03579680. [Table: see text]
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Affiliation(s)
| | - Jane Forman
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Jordan B. Sparks
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Tabitha Metreger
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Sarah T. Hawley
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Megan Veresh Caram
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan Medical School, Ann Arbor, MI
| | | | - Angela Larkin
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | | | - Danil V. Makarov
- VA New York Harbor Healthcare System and NYU School of Medicine Departments of Urology and Population Health, New York, NY
| | - John T. Leppert
- Surgical Service, Veteran’s Affairs Palo Alto Health Care System, Palo Alto, CA
| | | | - Kristian D. Stensland
- Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, MI
| | - Brent K. Hollenbeck
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Vahakn Shahinian
- Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, MI
| | - Daniela A. Wittmann
- Department of Urology, Dow Division of Health Services Research, University of Michigan Medical School, Ann Arbor, MI
| | - Varad Deolankar
- University of Michigan Ross School of Business, Ann Arbor, MI
| | - S. Sriram
- University of Michigan Ross School of Business, Ann Arbor, MI
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Abstract
Background: The National Emergency Medical Services Information System (NEMSIS) is a federally funded program designed to standardize Emergency Medical Services (EMS) patient care reporting and facilitate state and national data repositories for the assessment and improvement of EMS systems of care. This manuscript characterizes the 2020 submissions to the National EMS Database, detailing the strengths and limitations associated with use of these data for public health surveillance, improving prehospital patient care, critical resource allocation, clinician safety, system quality assurance and research purposes.Methodology: Using the 2020 NEMSIS Public-Release Research Dataset (NEMSIS dataset), we evaluated the dataset completeness (i.e., presence of missing/null values), dataset content and assessed data generalizability. The analysis focused on 911 EMS activations resulting in the treatment and transport of a patient, except for out-of-hospital cardiac arrests for which all patients were included regardless of transport status.Results: In 2020, 43,488,767 EMS activations were reported to the National EMS Database by 12,319 agencies serving 50 states and territories. Of the 19,533,036 911 EMS activations reportedly treating and transporting a patient, the majority were attended by "non-volunteer" clinicians (77%) working in a fire-based EMS agency (35%) certified to offer Advanced Life Support (ALS) Paramedic service (80%) and located in an urban area (82%). 911 call centers most often dispatched EMS for "sick person" (20%), while EMS clinicians most likely reported asthenia (7%) as the patient's primary symptom as well as the clinician's primary impression (6%), and documented "fall on same level, slip, or trip" as the most common cause of injury (37%). The NEMSIS dataset demonstrates some "missingness" and element inconsistencies, but methods may be employed to mitigate these data limitations.Conclusions: The National EMS Database is a free and publicly available resource for evaluating EMS system utilization, response, and prehospital patient care. Understanding the characteristics of the underlying dataset and known data limitations will help ensure proper analysis and reporting of research and quality metrics based on nationally standardized NEMSIS data.
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Affiliation(s)
- Julianne Ehlers
- National Emergency Medical Services (NEMSIS) Technical Assistance Center, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Benjamin Fisher
- National Emergency Medical Services (NEMSIS) Technical Assistance Center, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Skyler Peterson
- National Emergency Medical Services (NEMSIS) Technical Assistance Center, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Mengtao Dai
- National Emergency Medical Services (NEMSIS) Technical Assistance Center, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Angela Larkin
- National Emergency Medical Services (NEMSIS) Technical Assistance Center, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Lauri Bradt
- National Emergency Medical Services (NEMSIS) Technical Assistance Center, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - N Clay Mann
- National Emergency Medical Services (NEMSIS) Technical Assistance Center, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
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Lagisetty P, Garpestad C, Larkin A, Macleod C, Antoku D, Slat S, Thomas J, Powell V, Bohnert ASB, Lin LA. Identifying individuals with opioid use disorder: Validity of International Classification of Diseases diagnostic codes for opioid use, dependence and abuse. Drug Alcohol Depend 2021; 221:108583. [PMID: 33662670 PMCID: PMC8409339 DOI: 10.1016/j.drugalcdep.2021.108583] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Policy evaluations and health system interventions often utilize International Classification of Diseases (ICD) codes of opioid use, dependence, and abuse to identify individuals with opioid use disorder (OUD) and assess receipt of evidence-based treatments. However, ICD codes may not map directly onto the Diagnostic and Statistical Manual of Mental Disorder (DSM-5) OUD criteria. This study investigates the positive predictive value of ICD codes in identifying patients with OUD. METHODS We conducted a clinical chart review on a national sample of 520 Veterans assigned ICD-9 or ICD-10 codes for opioid use, dependence, or abuse from 2012 to 2017. We extracted evidence of DSM-5 OUD criteria and opioid misuse from clinical documentation in the month preceding and three months following initial ICD code listing, and categorized patients into: 1) high likelihood of OUD, 2) limited aberrant opioid use, 3) prescribed opioid use without evidence of aberrant use, and 4) insufficient information. Positive predictive value was calculated as the percentage of individuals with these ICD codes meeting high likelihood of OUD criteria upon chart review. RESULTS Only 57.7 % of patients were categorized as high likelihood of OUD; 16.5 % were categorized as limited aberrant opioid use, 18.9 % prescribed opioid use without evidence of aberrant use, and 6.9 % insufficient information. CONCLUSIONS Patients assigned ICD codes for opioid use, dependence, or abuse often lack documentation of meeting OUD criteria. Many receive long-term opioid therapy for chronic pain without evidence of misuse. Robust methods of identifying individuals with OUD are crucial to improving access to clinically appropriate treatment.
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Affiliation(s)
- Pooja Lagisetty
- Department of Internal Medicine, University of Michigan Medical School, University of Michigan, North Campus Research Center, 2800 Plymouth Rd, Bldg 16, Room 243, Ann Arbor, MI, USA; Center for Clinical Management and Research, North Campus Research Center, Ann Arbor VA, 2800 Plymouth Rd, Bldg 16, Room 243, Ann Arbor, MI 48109, USA.
| | - Claire Garpestad
- University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, USA
| | - Angela Larkin
- Center for Clinical Management and Research, North Campus Research Center, Ann Arbor VA, 2800 Plymouth Rd, Bldg 16, Room 243, Ann Arbor, MI 48109, USA
| | - Colin Macleod
- Department of Internal Medicine, University of Michigan Medical School, University of Michigan, North Campus Research Center, 2800 Plymouth Rd, Bldg 16, Room 243, Ann Arbor, MI, USA
| | - Derek Antoku
- Department of Internal Medicine, University of Michigan Medical School, University of Michigan, North Campus Research Center, 2800 Plymouth Rd, Bldg 16, Room 243, Ann Arbor, MI, USA
| | - Stephanie Slat
- Department of Internal Medicine, University of Michigan Medical School, University of Michigan, North Campus Research Center, 2800 Plymouth Rd, Bldg 16, Room 243, Ann Arbor, MI, USA
| | - Jennifer Thomas
- Department of Internal Medicine, University of Michigan Medical School, University of Michigan, North Campus Research Center, 2800 Plymouth Rd, Bldg 16, Room 243, Ann Arbor, MI, USA
| | - Victoria Powell
- Department of Geriatrics and Palliative Care, University of Michigan Medical School, 1500 E. Medical Center Dr, Ann Arbor, MI, USA
| | - Amy S B Bohnert
- Center for Clinical Management and Research, North Campus Research Center, Ann Arbor VA, 2800 Plymouth Rd, Bldg 16, Room 243, Ann Arbor, MI 48109, USA; Department of Anesthesiology, University of Michigan Medical School, 1500 E. Medical Center Dr., Ann Arbor, MI, USA
| | - Lewei A Lin
- Center for Clinical Management and Research, North Campus Research Center, Ann Arbor VA, 2800 Plymouth Rd, Bldg 16, Room 243, Ann Arbor, MI 48109, USA; Addiction Center, Department of Psychiatry, University of Michigan, North Campus Research Center, 2800 Plymouth Rd, Bldg 16, 2nd Fl, Ann Arbor, MI, USA.
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Min L, Ha JK, Aubert CE, Hofer TP, Sussman JB, Langa KM, Tinetti M, Kim HM, Maciejewski ML, Gillon L, Larkin A, Chan CL, Kerr EA, Bravata D, Cushman WC. A Method to Quantify Mean Hypertension Treatment Daily Dose Intensity Using Health Care System Data. JAMA Netw Open 2021; 4:e2034059. [PMID: 33449097 PMCID: PMC7811181 DOI: 10.1001/jamanetworkopen.2020.34059] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/28/2020] [Indexed: 12/27/2022] Open
Abstract
Importance Simple measures of hypertension treatment, such as achievement of blood pressure (BP) targets, ignore the intensity of treatment once the BP target is met. High-intensity treatment involves increased treatment burden and can be associated with potential adverse effects in older adults. A method was previously developed to identify older patients receiving intense hypertension treatment by low BP and number of BP medications using national Veterans Health Administration and Medicare Part D administrative pharmacy data to evaluate which BP medications a patient is likely taking on any given day. Objective To further develop and validate a method to more precisely quantify dose intensity of hypertension treatment using only health system administrative pharmacy fill data. Design, Setting, and Participants Observational, cross-sectional study of 319 randomly selected older veterans in the national Veterans Health Administration health care system who were taking multiple BP-lowering medications and had a total of 3625 ambulatory care visits from July 1, 2011, to June 30, 2013. Measure development and medical record review occurred January 1, 2017, through November 30, 2018, and data analysis was conducted from December 1, 2019, to August 31, 2020. Main Outcomes and Measures For each BP-lowering medication, a moderate hypertension daily dose (HDD) was defined as half the maximum dose above which no further clinical benefit has been demonstrated by that medication in hypertension trials. Patients' total HDD was calculated using pharmacy data (pharmacy HDDs), accounting for substantial delays in refills (>30 days) when a patient's pill supply was stretched (eg, cutting existing pills in half). As an external comparison, the pharmacy HDDs were correlated with doses manually extracted from clinicians' visit notes (clinically noted HDDs). How well the pharmacy HDDs correlated with clinically noted HDDs was calculated (using C statistics). To facilitate interpretation, HDDs were described in association with the number of medications. Results A total of 316 patients (99.1%) were male; the mean (SD) age was 75.6 (7.2) years. Pharmacy HDDs were highly correlated (r = 0.92) with clinically noted HDDs, with a mean (SD) of 2.7 (1.8) for pharmacy HDDs and 2.8 (1.8) for clinically noted HDDs. Pharmacy HDDs correlated with high-intensity, clinically noted HDDs ranging from a C statistic of 92.8% (95% CI, 92.0%-93.7%) for 2 or more clinically noted HDDs to 88.1% (95% CI, 85.5%-90.6%) for 6 or more clinically noted HDDs. Conclusions and Relevance This study suggests that health system pharmacy data may be used to accurately quantify hypertension regimen dose intensity. Together with clinic-measured BP, this tool can be used in future health system-based research or quality improvement efforts to fine-tune, manage, and optimize hypertension treatment in older adults.
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Affiliation(s)
- Lillian Min
- Veterans Affairs Geriatric Research, Education, and Clinical Center, Veterans Affairs Ann Arbor Medical Center, Ann Arbor, Michigan
- Division of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan, Ann Arbor
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development Center of Innovation, Ann Arbor, Michigan
- Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Jin-Kyung Ha
- Division of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan, Ann Arbor
| | - Carole E. Aubert
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development Center of Innovation, Ann Arbor, Michigan
- Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Healthcare, University of Bern, Bern, Switzerland
| | - Timothy P. Hofer
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development Center of Innovation, Ann Arbor, Michigan
- Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Division of General Internal Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Jeremy B. Sussman
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development Center of Innovation, Ann Arbor, Michigan
- Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Division of General Internal Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Kenneth M. Langa
- Veterans Affairs Geriatric Research, Education, and Clinical Center, Veterans Affairs Ann Arbor Medical Center, Ann Arbor, Michigan
- Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Division of General Internal Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Social Research, University of Michigan, Ann Arbor
| | - Mary Tinetti
- Section of Geriatrics, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Hyungjin Myra Kim
- Consulting for Statistics, Computing & Analytics Research, University of Michigan, Ann Arbor
- Department of Biostatistics, University of Michigan Medical School, Ann Arbor
| | - Matthew L. Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Veterans Affairs Healthcare System, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Leah Gillon
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development Center of Innovation, Ann Arbor, Michigan
| | - Angela Larkin
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development Center of Innovation, Ann Arbor, Michigan
| | - Chiao-Li Chan
- Division of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan, Ann Arbor
| | - Eve A. Kerr
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development Center of Innovation, Ann Arbor, Michigan
- Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Division of General Internal Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Dawn Bravata
- Veterans Affairs Health Services Research and Development Center for Health Information and Communication, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis
- Department of Neurology, Indiana University School of Medicine, Indianapolis
- Center for Health Services Research, Regenstrief Institute, Indianapolis, Indiana
| | - William C. Cushman
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis
- Medical Service, Memphis Veterans Affairs Medical Center, Memphis, Tennessee
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Miech EJ, Larkin A, Lowery JC, Butler AJ, Pettey KM, Rattray NA, Penney LS, Myers J, Damush TM. Correction to: The "State of Implementation" Progress Report (SIPREP): a pilot demonstration of a navigation system for implementation. Implement Sci Commun 2020; 1:108. [PMID: 33303034 PMCID: PMC7712527 DOI: 10.1186/s43058-020-00095-5] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
An amendment to this paper has been published and can be accessed via the original article.
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Affiliation(s)
- Edward J Miech
- VA Precision Monitoring to Transform Care (PRIS-M), Quality Enhancement Research Initiative, HSR&D, Richard L. Roudebush VA Medical Center, Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA.
| | - Angela Larkin
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Julie C Lowery
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Andrew J Butler
- School of Health Professions, University of Alabama at Birmingham, Dean's Office, SHPB 630, 1716 9th Avenue South, Birmingham, AL, 35294, USA
| | - Kristin M Pettey
- VA Southeast Network Office (VISN 7), 3700 Crestwood Parkway, NW, Suite 500, Duluth, GA, 30096-5585, USA
| | - Nicholas A Rattray
- VA Precision Monitoring to Transform Care (PRIS-M), Quality Enhancement Research Initiative, HSR&D, Richard L. Roudebush VA Medical Center, Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
| | - Lauren S Penney
- The Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care System, 7400 Merton Minter, San Antonio, TX, 78229, USA
| | - Jennifer Myers
- VA Precision Monitoring to Transform Care (PRIS-M), Quality Enhancement Research Initiative, HSR&D, Richard L. Roudebush VA Medical Center, Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
| | - Teresa M Damush
- VA Precision Monitoring to Transform Care (PRIS-M), Quality Enhancement Research Initiative, HSR&D, Richard L. Roudebush VA Medical Center, Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
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Miech EJ, Larkin A, Lowery JC, Butler AJ, Pettey KM, Rattray NA, Penney LS, Myers J, Damush TM. The "State of Implementation" Progress Report (SIPREP): a pilot demonstration of a navigation system for implementation. Implement Sci Commun 2020; 1:102. [PMID: 33292841 PMCID: PMC7643402 DOI: 10.1186/s43058-020-00085-7] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 10/12/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Implementation of new clinical programs across diverse facilities in national healthcare systems like the Veterans Health Administration (VHA) can be extraordinarily complex. Implementation is a dynamic process, influenced heavily by local organizational context and the individual staff at each medical center. It is not always clear in the midst of implementation what issues are most important to whom or how to address them. In recognition of these challenges, implementation researchers within VHA developed a new systemic approach to map the implementation work required at different stages and provide ongoing, detailed, and nuanced feedback about implementation progress. METHODS This observational pilot demonstration project details how a novel approach to monitoring implementation progress was applied across two different national VHA initiatives. Stage-specific grids organized the implementation work into columns, rows, and cells, identifying specific implementation activities at the site level to be completed along with who was responsible for completing each implementation activity. As implementation advanced, item-level checkboxes were crossed off and cells changed colors, offering a visual representation of implementation progress within and across sites across the various stages of implementation. RESULTS Applied across two different national initiatives, the SIPREP provided a novel navigation system to guide and inform ongoing implementation within and across facilities. The SIPREP addressed different needs of different audiences, both described and explained how to implement the program, made ample use of visualizations, and revealed both what was happening and not happening within and across sites. The final SIPREP product spanned distinct stages of implementation. CONCLUSIONS The SIPREP made the work of implementation explicit at the facility level (i.e., who does what, and when) and provided a new common way for all stakeholders to monitor implementation progress and to help keep implementation moving forward. This approach could be adapted to a wide range of settings and interventions and is planned to be integrated into the national deployment of two additional VHA initiatives within the next 12 months.
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Affiliation(s)
- Edward J Miech
- VA Precision Monitoring to Transform Care (PRIS-M), Quality Enhancement Research Initiative, HSR&D, Richard L. Roudebush VA Medical Center, Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA.
| | - Angela Larkin
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Julie C Lowery
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Andrew J Butler
- School of Health Professions, University of Alabama at Birmingham, Dean's Office, SHPB 630, 1716 9th Avenue South, Birmingham, AL, 35294, USA
| | - Kristin M Pettey
- VA Southeast Network Office (VISN 7), 3700 Crestwood Parkway, NW, Suite 500, Duluth, GA, 30096-5585, USA
| | - Nicholas A Rattray
- VA Precision Monitoring to Transform Care (PRIS-M), Quality Enhancement Research Initiative, HSR&D, Richard L. Roudebush VA Medical Center, Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
| | - Lauren S Penney
- The Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care System, 7400 Merton Minter, San Antonio, TX, 78229, USA
| | - Jennifer Myers
- VA Precision Monitoring to Transform Care (PRIS-M), Quality Enhancement Research Initiative, HSR&D, Richard L. Roudebush VA Medical Center, Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
| | - Teresa M Damush
- VA Precision Monitoring to Transform Care (PRIS-M), Quality Enhancement Research Initiative, HSR&D, Richard L. Roudebush VA Medical Center, Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
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Min L, Ha JK, Hofer TP, Sussman J, Langa K, Cushman WC, Tinetti M, Kim HM, Maciejewski ML, Gillon L, Larkin A, Chan CL, Kerr E. Validation of a Health System Measure to Capture Intensive Medication Treatment of Hypertension in the Veterans Health Administration. JAMA Netw Open 2020; 3:e205417. [PMID: 32729919 PMCID: PMC9374172 DOI: 10.1001/jamanetworkopen.2020.5417] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
IMPORTANCE Blood pressure (BP) targets are the main measure of high-quality hypertension care in health systems. However, BP alone does not reflect intensity of pharmacological treatment, which should be carefully managed in older patients. OBJECTIVES To develop and validate an electronic health record (EHR) data-only algorithm using pharmacy and BP data to capture intensive hypertension care (IHC), defined as 3 or more BP medications and BP less than 120 mm Hg, and to identify conditions associated with greater IHC, either through greater algorithm false-positive IHC, or by contributing clinically to delivering more IHC. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study was conducted among 319 randomly selected patients aged 65 years or older receiving IHC from the Veterans Health Administration (VHA) from July 1, 2011, to June 30, 2013. Data were collected from a total of 3625 primary care visits. Data were analyzed from January 2017 to March 2020. EXPOSURES Calibration and measurement of the algorithm for IHC (algorithm IHC). MAIN OUTCOMES AND MEASURES For each primary care visit, the reference standard, clinical IHC, was determined by detailed review of free-text clinical notes. The correlation in BP medication count between the EHR-only algorithm vs the reference standard and the sensitivity and specificity of the algorithm IHC were calculated. In addition, presence vs absence of contributing conditions acting in combination with hypertension management were measured to examine incidence of IHC associated with contributing conditions, including an acute condition that lowered BP (eg, dehydration), another condition requiring a BP target lower than the standard 140 mm Hg (eg, diabetes), or the patient needing a BP-lowering medication for a nonhypertension condition (eg, β-blocker for atrial fibrillation) resulting in low BP. RESULTS Among 319 patients with 3625 visits (mean [SD] age, 75.6 [7.2] years; 3592 [99.1%] men), 911 visits (25.1%) had clinical IHC by the reference standard. The algorithm for determining medication count was highly correlated with the reference standard (r = 0.84). Sensitivity of detecting clinical IHC was 92.2% (95% CI, 89.3%-95.1%), and specificity was 97.2% (95% CI, 96.1%-98.3%), suggesting that clinical IHC can be identified from routinely collected data. Only 75 visits (2.1%) were algorithm IHC false positives, 55 visits (1.5%) involved IHC with contributing conditions, and 125 visits (3.5%) involved either false-positive or IHC with contributing conditions. Among select contributing conditions, congestive heart failure (37 patients [5.2%]) was most associated with a prespecified combined false-positive or IHC with contributing conditions rate higher than 5%. CONCLUSIONS AND RELEVANCE These findings suggest that health system data can be used reliably to estimate IHC.
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Affiliation(s)
- Lillian Min
- VA Ann Arbor Medical Center VA Geriatric Research, Education, and Clinical Center (GRECC)
- Division of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, MI
- Institute of Healthcare Policy and Innovation (IHPI), University of Michigan, Ann Arbor, Michigan
| | - Jin-Kyung Ha
- Division of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan
| | - Timothy P. Hofer
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, MI
- Institute of Healthcare Policy and Innovation (IHPI), University of Michigan, Ann Arbor, Michigan
- Division of General Internal Medicine, Department of Internal Medicine, University of Michigan
| | - Jeremy Sussman
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, MI
- Institute of Healthcare Policy and Innovation (IHPI), University of Michigan, Ann Arbor, Michigan
- Division of General Internal Medicine, Department of Internal Medicine, University of Michigan
| | - Kenneth Langa
- VA Ann Arbor Medical Center VA Geriatric Research, Education, and Clinical Center (GRECC)
- Institute of Healthcare Policy and Innovation (IHPI), University of Michigan, Ann Arbor, Michigan
- Division of General Internal Medicine, Department of Internal Medicine, University of Michigan
- University of Michigan, Institute for Social Research
| | - William C. Cushman
- Preventive Medicine Section, Memphis VA Medical Center
- Department of Preventive Medicine, University of Tennessee Health Science Center
| | - Mary Tinetti
- Yale School of Medicine, Department of Medicine, Section of Geriatrics
| | - Hyungjin Myra Kim
- Consulting for Statistics, Computing & Analytics Research (CSCAR), University of Michigan, Ann Arbor
- Department of Biostatistics, University of Michigan Medical School
| | - Matthew L. Maciejewski
- ADAPT Center of Innovation Durham, VA Health Care System
- Department of Population Health Sciences, Duke University
| | - Leah Gillon
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, MI
| | - Angela Larkin
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, MI
| | - Chiao-Li Chan
- Division of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan
| | - Eve Kerr
- VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, MI
- Institute of Healthcare Policy and Innovation (IHPI), University of Michigan, Ann Arbor, Michigan
- Division of General Internal Medicine, Department of Internal Medicine, University of Michigan
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Hoolohan C, Larkin A, McLachlan C, Falconer R, Soutar I, Suckling J, Varga L, Haltas I, Druckman A, Lumbroso D, Scott M, Gilmour D, Ledbetter R, McGrane S, Mitchell C, Yu D. Engaging stakeholders in research to address water-energy-food (WEF) nexus challenges. Sustain Sci 2018; 13:1415-1426. [PMID: 30220918 PMCID: PMC6132404 DOI: 10.1007/s11625-018-0552-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 03/16/2018] [Indexed: 06/08/2023]
Abstract
The water-energy-food (WEF) nexus has become a popular, and potentially powerful, frame through which to analyse interactions and interdependencies between these three systems. Though the case for transdisciplinary research in this space has been made, the extent of stakeholder engagement in research remains limited with stakeholders most commonly incorporated in research as end-users. Yet, stakeholders interact with nexus issues in a variety of ways, consequently there is much that collaboration might offer to develop nexus research and enhance its application. This paper outlines four aspects of nexus research and considers the value and potential challenges for transdisciplinary research in each. We focus on assessing and visualising nexus systems; understanding governance and capacity building; the importance of scale; and the implications of future change. The paper then proceeds to describe a novel mixed-method study that deeply integrates stakeholder knowledge with insights from multiple disciplines. We argue that mixed-method research designs-in this case orientated around a number of cases studies-are best suited to understanding and addressing real-world nexus challenges, with their inevitable complex, non-linear system characteristics. Moreover, integrating multiple forms of knowledge in the manner described in this paper enables research to assess the potential for, and processes of, scaling-up innovations in the nexus space, to contribute insights to policy and decision making.
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Affiliation(s)
- C. Hoolohan
- Tyndall Centre for Climate Change Research, University of Manchester, Manchester, UK
| | - A. Larkin
- Tyndall Centre for Climate Change Research, University of Manchester, Manchester, UK
| | - C. McLachlan
- Tyndall Centre for Climate Change Research, University of Manchester, Manchester, UK
| | | | | | | | - L. Varga
- Cranfield University, Cranfield, UK
| | | | | | | | - M. Scott
- University of Glasgow, Glasgow, UK
| | - D. Gilmour
- University of Abertay Dundee, Dundee, UK
| | | | | | | | - D. Yu
- Loughborough University, Loughborough, UK
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11
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Abstract
PURPOSE OF REVIEW We present a review of emerging technologies and how these can transform personal air pollution exposure assessment and subsequent health research. RECENT FINDINGS Estimating personal air pollution exposures is currently split broadly into methods for modeling exposures for large populations versus measuring exposures for small populations. Air pollution sensors, smartphones, and air pollution models capitalizing on big/new data sources offer tremendous opportunity for unifying these approaches and improving long-term personal exposure prediction at scales needed for population-based research. A multi-disciplinary approach is needed to combine these technologies to not only estimate personal exposures for epidemiological research but also determine drivers of these exposures and new prevention opportunities. While available technologies can revolutionize air pollution exposure research, ethical, privacy, logistical, and data science challenges must be met before widespread implementations occur. Available technologies and related advances in data science can improve long-term personal air pollution exposure estimates at scales needed for population-based research. This will advance our ability to evaluate the impacts of air pollution on human health and develop effective prevention strategies.
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Affiliation(s)
- A Larkin
- College of Public Health and Human Sciences, Oregon State University, Milam 20A, Corvallis, OR, 97331, USA
| | - P Hystad
- College of Public Health and Human Sciences, Oregon State University, Milam 20C, Corvallis, OR, 97331, USA.
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Jain S, Larkin A, Chong H. OR063 A case of recurrent splenic lesions in a patient with Vici syndrome. Ann Allergy Asthma Immunol 2017. [DOI: 10.1016/j.anai.2017.08.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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13
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Gregory J, Larkin A, Nicholas M, Winder J, Borromeo M, MacGregor C. ESTABLISHING A RHYTHM: THE DEVELOPMENT OF AN INTER-PROFESSIONAL COMMUNICATION PRACTICE MODEL IN THE CARDIAC SERVICES INTENSIVE CARE [CSICU]. Can J Cardiol 2015. [DOI: 10.1016/j.cjca.2015.07.700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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14
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Garrett M, Hogan N, Larkin A, Saunders J, Jakeman P, Coote S. Exercise in the community for people with minimal gait impairment due to MS: an assessor-blind randomized controlled trial. Mult Scler 2012; 19:782-9. [DOI: 10.1177/1352458512461966] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: While there is an increasing body of evidence supporting the efficacy of exercise in people with multiple sclerosis (MS), additional information on the effectiveness of combining aerobic and resistance training, and yoga is required. Objectives: This study evaluated the effectiveness of community exercise interventions for people with MS having minimal gait impairment. Methods: A multi-centred, block-randomised, assessor-blinded, controlled trial was conducted. Participants were randomised in groups of eight to physiotherapist (PT)-led exercise ( n = 80), yoga ( n = 77), fitness instructor (FI)-led exercise ( n = 86) and they took part in weekly community-based group exercise sessions. Those in the control group were asked not to change of their exercise habits ( n = 71). The primary outcome was the Multiple Sclerosis Impact Scale (MSIS) 29v2 physical component, measured before and after the 10-week intervention. Secondary outcomes were the MSIS 29v2 psychological component, the Modified Fatigue Impact Scale (MFIS) and the 6-Minute Walk Test (6MWT). Results: The group x time interaction approached significance for the MSIS-29v2 physical component ( f = 2.48, p = 0.061) and MFIS total ( f = 2.50, p = 0.06), and it was significant for the MFIS physical subscale ( f = 4.23, p = 0.006). All three exercise interventions led to a statistically significant improvement on the MSIS-29 psychological component and both the MFIS total and physical subscales, which were greater than the control ( p < 0.05). Only the PT-led and FI-led interventions significantly improved the MSIS-29 physical and 6MWT to levels greater than the control ( p < 0.05). Conclusions: This study provides evidence for the positive effect of exercise on the physical impact of MS and fatigue. The group nature of the classes may have contributed to the positive effects seen on the psychological impact of MS.
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Affiliation(s)
| | - N Hogan
- University of Limerick, Ireland
| | - A Larkin
- Multiple Sclerosis Society of Ireland, Galway, Ireland
| | | | | | - S Coote
- University of Limerick, Ireland
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15
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Sharma SK, Almeida FA, Kierstein S, Hortobagyi L, Lin T, Larkin A, Peterson J, Yagita H, Zangrilli JG, Haczku A. Systemic FasL neutralization increases eosinophilic inflammation in a mouse model of asthma. Allergy 2012; 67:328-35. [PMID: 22175699 DOI: 10.1111/j.1398-9995.2011.02763.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2011] [Indexed: 01/23/2023]
Abstract
BACKGROUND Eosinophils and lymphocytes are pathogenically important in allergic inflammation and sensitive to Fas-mediated apoptosis. Fas ligand (FasL) activity therefore should play a role in regulating the allergic immune response. We aimed to characterize the role of FasL expression in airway eosinophilia in Aspergillus fumigatus (Af)-induced sensitization and to determine whether FasL neutralization alters the inflammatory response. METHODS Sensitized Balb/c mice were killed before (day 0) and 1, 7 and 10 days after a single intranasal challenge with Af. Animals received either neutralizing antibody to FasL (clone MFL4) or irrelevant hamster IgG via intraperitoneal injection on days -1 and 5. FasL expression, BAL and tissue inflammatory cell and cytokine profile, and apoptosis were assessed. RESULTS Postchallenge FasL gene expression in BAL cells and TUNEL positivity in the airways coincided with the height of inflammatory cell influx on day 1, while soluble FasL protein was released on day 7, preceding resolution of the inflammatory changes. Although eosinophil numbers showed a negative correlation with soluble FasL levels in the airways, MBP(+) eosinophils remained TUNEL negative in the submucosal tissue, throughout the 10-day period after Af challenge. Systemic FasL neutralization significantly enhanced BAL and tissue eosinophil counts. This effect was associated with increased activation of T cells and release of IL-5, IL-9, and GM-CSF in the BAL fluid of mice, indicating an involvement of pro-eosinophilic survival pathways. CONCLUSIONS FasL activity may play an active role in resolving eosinophilic inflammation through regulating T cells and pro-eosinophilic cytokine release during the allergic airway response.
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Affiliation(s)
| | - F. A. Almeida
- Division of Pulmonary and Critical Care; Thomas Jefferson University; Philadelphia; PA; USA
| | - S. Kierstein
- Pulmonary, Allergy and Critical Care Division; University of Pennsylvania School of Medicine; Philadelphia; PA; USA
| | - L. Hortobagyi
- Pulmonary, Allergy and Critical Care Division; University of Pennsylvania School of Medicine; Philadelphia; PA; USA
| | - T. Lin
- Division of Pulmonary and Critical Care; Thomas Jefferson University; Philadelphia; PA; USA
| | - A. Larkin
- Center for Translational Medicine; Thomas Jefferson University; Philadelphia; PA; USA
| | - J. Peterson
- Center for Translational Medicine; Thomas Jefferson University; Philadelphia; PA; USA
| | - H. Yagita
- Juntendo University School of Medicine; Tokyo; Japan
| | | | - A. Haczku
- Pulmonary, Allergy and Critical Care Division; University of Pennsylvania School of Medicine; Philadelphia; PA; USA
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16
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Lowery J, Hopp F, Subramanian U, Wiitala W, Welsh DE, Larkin A, Stemmer K, Zak C, Vaitkevicius P. Evaluation of a nurse practitioner disease management model for chronic heart failure: a multi-site implementation study. ACTA ACUST UNITED AC 2011; 18:64-71. [PMID: 22277180 DOI: 10.1111/j.1751-7133.2011.00228.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
While disease management appears to be effective in selected, small groups of CHF patients from randomized controlled trials, its effectiveness in a broader CHF patient population is not known. This prospective, quasi-experimental study compared patient outcomes under a nurse practitioner-led disease management model (intervention group) with outcomes under usual care (control group) in both primary and tertiary medical centers. The study included 969 veterans (458 intervention, 511 control) treated for CHF at six VA medical centers. Intervention patients had significantly fewer (p<0.05) CHF and all-cause admissions at one-year follow-up, and lower mortality at both one- and two-year follow-up. These data provide support for the potential effectiveness of the intervention, and suggest that the evidence from RCTs of disease management models for CHF can be translated into clinical practice, even without the benefits of a selected patient population and dedicated resources often found in RCTs.
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Affiliation(s)
- Julie Lowery
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105, USA.
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17
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Eustace AJ, Kennedy S, Larkin A, Mahgoub T, Tryfonopoulos D, O'Driscoll L, Clynes M, Crown J, O'Donovan N. Identification of predictive biomarkers for dasatinib treatment of metastatic melanoma. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.8578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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18
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Browne B, Crown J, Eustace AJ, Kennedy S, O'Brien N, Larkin A, Ballot J, Mahgoub T, Qadir Z, Sclafani F, Madden SF, Kennedy MJ, Duffy MJ, O'Donovan N. IGF1R and phosphorylated IGF1R in HER2-positive breast cancer. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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19
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Eustace AJ, Mahgoub T, Kennedy S, Crown J, Larkin A, Tryfonopoulos D, O'Driscoll L, Clynes M, O'Donovan N. Targeting SRC kinase (SRC) in melanoma cells. J Clin Oncol 2010. [DOI: 10.1200/jco.2010.28.15_suppl.8584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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20
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Larkin A, Friedman K, Mahesh M, Noz M, Wagner S, Wahl R. SU-GG-I-145: Quantifying the Increase in Radiation Exposure Associated with SPECT/CT Compared to SPECT Alone for Routine Nuclear Medicine Examinations. Med Phys 2008. [DOI: 10.1118/1.2961543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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21
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O'Connor U, Dowling A, Larkin A, Sheahan N, Gray L, Gallagher A, O'Reilly G, Kosunen A, Zdesar U, Malone JF. Development of training syllabi for radiation protection and quality assurance of dual-energy X-ray absorptiometry (DXA) systems. Radiat Prot Dosimetry 2008; 129:211-213. [PMID: 18397931 DOI: 10.1093/rpd/ncn088] [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] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
The use of dual-energy X-ray absorptiometry (DXA) scanners for measuring bone mineral density (BMD) is on the increase. A single DXA scan is a relatively low-dose diagnostic X-ray examination; however, radiation protection (RP) issues should not be trivialised. One objective of the EU 6th Framework SENTINEL co-ordination action was to develop training syllabi in RP and quality assurance (QA) for BMD, and this study presents the results. An EU-wide survey was carried out which confirmed that there was a need for an accredited DXA RP training course in many EU states. There is also limited published guidance on acceptance testing/QA for DXA. Two training syllabi were developed: one on RP and one on QA of DXA systems. A training course was delivered in Ireland in 2006 by the Medical Physics & Bioengineering Department of St James's Hospital, Dublin. Following the training course, a PC-based training CD was developed and will be made available. A harmonised approach to training will promote consistent approaches to radiation safety across the EU.
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Affiliation(s)
- U O'Connor
- St James's Hospital, The Haughton Institute, Dublin, Ireland.
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22
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Larkin A, Sheahan N, O'Connor U, Gray L, Dowling A, Vano E, Torbica P, Salat D, Schreiner A, Neofotistou V, Malone JF. QA/acceptance testing of DEXA X-ray systems used in bone mineral densitometry. Radiat Prot Dosimetry 2008; 129:279-283. [PMID: 18381338 DOI: 10.1093/rpd/ncn086] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
New developments in dual energy X-ray absorptiometry (DEXA) imaging technology [fan beam and cone beam (CB)] result in higher exposure levels, shorter scan times, increased patient throughput and increased shielding requirements. This study presents the results of a European survey detailing the number and location of DEXA systems in SENTINEL partner states and the QA (quality assurance) currently performed by physicists and operators in these centres. The results of a DEXA equipment survey based on an in-house developed QA protocol are presented. Measurements show that the total effective dose to the patient from a spine and dual femur DEXA examination on the latest generation DEXA systems is comparable with a few microSv at most. Scatter measurements showed that the use of a mobile lead screen for staff protection was necessary for fan and CB systems. Scattered dose from newer generation systems may also exceed the exposure limits for the general public so structural shielding may also be required. Considerable variation in the magnitude and annual repeatability of half value layer was noted between different models of DEXA scanners. A comparative study of BMD (bone mineral density) accuracy using the European Spine Phantom highlighted a deviation of up to 7% in BMD values between scanners of different manufacturers.
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Affiliation(s)
- A Larkin
- St James's Hospital, Dublin, Ireland, UK.
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23
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Gray L, Dowling A, Gallagher A, Gorman D, O'Connor U, Devine M, Larkin A, Walsh C, Malone JF. Acceptance testing and routine quality control in general radiography: mobile units and film/screen fixed systems. Radiat Prot Dosimetry 2008; 129:276-278. [PMID: 18326885 DOI: 10.1093/rpd/ncn033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
This study presents the findings from acceptance testing and routine quality control (QC) of general radiographic X-ray equipment in Ireland during 2006 and early 2007, including mobile X-ray units and film/screen fixed systems. Acceptance testing and routine QC of the diagnostic X-ray imaging equipment are requirements of European and Irish legislation. One hundred general radiographic X-ray systems were tested within Ireland, 73% of them failed to meet the required QC guidelines, whereby one or more faults were identified. The majority of these failures were minor ones, requiring attention by the suppliers at the next routine service. Significant faults were only identified in seven systems. The suppliers were requested to investigate these issues as soon as possible and take the necessary corrective action. A review of the QC results highlights the need to perform comprehensive acceptance and routine testing of the systems.
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Affiliation(s)
- L Gray
- St James's Hospital/The Haughton Institute, Dublin, Ireland.
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24
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Walsh C, Gorman D, Byrne P, Larkin A, Dowling A, Malone JF. Quality assurance of computed and digital radiography systems. Radiat Prot Dosimetry 2008; 129:271-275. [PMID: 18319281 DOI: 10.1093/rpd/ncn047] [Citation(s) in RCA: 8] [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] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Computed radiography (CR) and digital radiography (DR) are replacing traditional film screen radiography as hospitals move towards digital imaging and picture archiving and communication systems (PACS). Both IPEM and KCARE have recently published quality assurance and acceptance testing guidelines for DR. In this paper, the performance of a range of CR and DR systems is compared. Six different manufacturers are included. Particular attention is paid to the performance of the systems under automatic exposure control (AEC). The patient is simulated using a range of thicknesses of tissue equivalent material. Image quality assessment was based on detector assessment protocols and includes pixel value measures as well as subjective assessment using Leeds Test Objects. The protocols for detector assessment cover a broad range of tests and in general detectors (whether DR or CR) performed satisfactorily. The chief limitation in performing these tests was that not all systems provided ready access to pixel values. Subjective tests include the use of the Leeds TO20. As part of this work, suggested reference values are provided to calculate the TO20 image quality factor. One consequence of moving from film screen to digital technologies is that the dynamic range of digital detectors is much wider, and increased exposures are no longer evident from changes in image quality. As such, AEC is a key parameter for CR and DR. Dose was measured using a standard phantom as a basic means of comparing systems. In order to assess the AEC performance, exit doses were also measured while varying phantom thickness. Signal-to-noise ratios (SNRs) were calculated on a number of systems where pixel values were available. SNR was affected by the selection of acquisition protocol. Comparisons between different technologies and collation of data will help refine acceptance thresholds and contribute to optimising dose and image quality.
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Affiliation(s)
- C Walsh
- Haughton Institute, Dublin 8 & The Adelaide and Meath Hospital incorporating the National Children's Hospital, Dublin.
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25
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Vano E, Järvinen H, Kosunen A, Bly R, Malone J, Dowling A, Larkin A, Padovani R, Bosmans H, Dragusin O, Jaschke W, Torbica P, Back C, Schreiner A, Bokou C, Kottou S, Tsapaki V, Jankowski J, Papierz S, Domienik J, Werduch A, Nikodemova D, Salat D, Kepler K, Bor MD, Vassileva J, Borisova R, Pellet S, Corbett RH. Patient dose in interventional radiology: a European survey. Radiat Prot Dosimetry 2008; 129:39-45. [PMID: 18287189 DOI: 10.1093/rpd/ncn024] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Patient doses for a few common fluoroscopy-guided procedures in interventional radiology (IR) (excluding cardiology) were collected from a few radiological departments in 13 European countries. The major aim was to evaluate patient doses for the basis of the reference levels. In total, data for 20 procedures for about 1300 patients were collected. There were many-fold variations in the number of IR equipment and procedures per population, in the entrance dose rates, and in the patient dose data (total dose area product or DAP, fluoroscopy time and number of frames). There was no clear correlation between the total DAP and entrance dose rate, or between the total DAP and fluoroscopy time, indicating that a number of parameters affect the differences. Because of the limited number of patients, preliminary reference levels were proposed only for a few procedures. There is a need to improve the optimisation of IR procedures and their definitions and grouping, in order to account for their different complexities.
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Affiliation(s)
- E Vano
- Radiology Department, Ciudad Universitaria, Complutense University, Madrid, Spain
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Dowling A, Gallagher A, O'Connor U, Larkin A, Gorman D, Gray L, Malone J. Acceptance testing and QA of interventional cardiology systems. Radiat Prot Dosimetry 2008; 129:291-294. [PMID: 18283061 DOI: 10.1093/rpd/ncn042] [Citation(s) in RCA: 3] [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: 05/25/2023]
Abstract
Interventional cardiology (IC) is a rapidly growing field of medical specialisation. Such procedures are complex and may subject patients and operators to higher levels of risk than those encountered in general radiology. Acceptance testing and quality assurance (QA) of radiological equipment, including IC equipment, is a requirement of the EU Medical Exposures Directive (MED) (97/43/EURATOM). In addition, the MED identifies interventional radiology as an area of special concern. This study presents the results of a survey of 17 IC systems (including several flat panel detector systems) in Irish hospitals. The results of the survey indicate large differences in patient doses between manufacturers for equivalent levels of measured image quality. In addition, all systems were found to have failed one or more acceptance tests, with 60% of systems demonstrating significant problems at acceptance testing. The results of the survey demonstrate the importance of acceptance testing and QA in IC. The results also provide baseline data, which may be used in the development of future QA guidelines.
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Affiliation(s)
- A Dowling
- Department of Medical Physics and Bioengineering, St. James's Hospital, Dublin, Ireland.
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27
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O'Connor U, Dowling A, Gallagher A, Gorman D, Walsh C, Larkin A, Gray L, Devine M, Malone J. Acceptance testing of fluoroscopy systems used for interventional purposes. Radiat Prot Dosimetry 2008; 129:56-58. [PMID: 18285319 DOI: 10.1093/rpd/ncn041] [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] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
This study presents the results of acceptance testing on 18 interventional fluoroscopy systems in Ireland. Acceptance testing and routine quality assurance (QA) of X-ray systems are the requirements of the EU Medical Exposures Directive (MED) and these requirements were subsequently implemented into Irish legislation. The MED states that special consideration should be given to the QA and dose assessment of high dose procedures such as interventional fluoroscopy. Owing to the advances in fluoroscopy technology, it has been found that comprehensive testing of interventional systems proves challenging in a busy hospital environment. A number of recurrent problems have been identified and are presented.
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Affiliation(s)
- U O'Connor
- St James's Hospital/The Haughton Institute, Dublin, Ireland.
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28
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Desrosiers L, Rezk S, Larkin A, Khan A, Li C. Myofibroblastoma of the male breast: a rare entity of increasing frequency that can be diagnosed on needle core biopsy. Histopathology 2007; 51:568-72. [PMID: 17880543 DOI: 10.1111/j.1365-2559.2007.02808.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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29
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O'Driscoll L, Walsh N, Larkin A, Ballot J, Ooi WS, Gullo G, O'Connor R, Clynes M, Crown J, Kennedy S. MDR1/P-glycoprotein and MRP-1 drug efflux pumps in pancreatic carcinoma. Anticancer Res 2007; 27:2115-20. [PMID: 17695494] [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: 05/16/2023]
Abstract
BACKGROUND Pancreatic cancer is one of the most challenging solid organ malignancies. This is due to its aggressiveness, frequent late presentation as advanced disease and chemoresistance. A better understanding of the molecular basis of its drug resistance is needed. MATERIALS AND METHODS In this study, the first of its kind, the expression of both MDR1 P-gp and MRP-1 protein in pancreatic tumour specimens was examined by immunohistochemistry. Expression of these drug efflux pumps was examined using semi-quantitative immunohistochemistry according to the percentage of cells within the tumour, demonstrating another staining intencity. RESULTS Overall, 93.3% of pancreatic carcinomas expressed MDR1 P-gp, approximately 31% co-expressed MRP-1 with MDR1 P-gp, while 6.7% expressed neither of these proteins. CONCLUSION Our results show that drug efflux pumps, in particular that of MDR1 P-gp, are frequently expressed in pancreatic cancer. While a causative role for these efflux pumps in pancreatic cancer chemoresistance cannot necessarily be concluded, the information presented here should be considered when selecting chemotherapy/drug efflux pump inhibitors for future therapies.
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Affiliation(s)
- L O'Driscoll
- National Institute for Cellular Biotechnology, Dublin City University, Dublin, Ireland.
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30
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Roy S, Kenny E, Kennedy S, Larkin A, Ballot J, Perez De Villarreal M, Crown J, O'Driscoll L. MDR1/P-glycoprotein and MRP-1 mRNA and protein expression in non-small cell lung cancer. Anticancer Res 2007; 27:1325-30. [PMID: 17593626] [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: 05/16/2023]
Abstract
BACKGROUND Multiple drug resistance (MDR), both inherent and acquired, is a serious problem in non-small cell lung carcinomas (NSCLC). The purpose of this study was to investigate the prevalence of expression of genes encoding drug efflux pumps, MDR1 and MRP-1, at both the mRNA and protein levels, in this type of cancer. MATERIALS AND METHODS Tumour specimens (38 cases) were analysed using immunohistochemistry and, where possible (30 cases), also using reverse-transcriptase polymerase chain reaction. RESULTS The results from this analysis indicated that either, or both, drug efflux pumps were frequently expressed in NSCLC. Expression of mrp1 was found to be predominant over mdr1 at the mRNA level, while MDR1 P-gp was more frequently detected than MRP-1 protein. In some cases, proteins encoding pumps were detected without corresponding mRNAs--possibly due to differing sensitivities of the analysis techniques. CONCLUSION Future studies of mdr1 and mrp1 using increased-sensitivity qPCR techniques, in parallel with protein analysis, in larger cohorts of cases may help to elucidate the role of drug efflux pumps in NSCLC multiple drug resistance.
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Affiliation(s)
- S Roy
- St. Vincent's University Hospital, Dublin 4, Ireland
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31
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O'Connor R, O'Leary M, Ballot J, Collins CD, Kinsella P, Mager DE, Arnold RD, O'Driscoll L, Larkin A, Kennedy S, Fennelly D, Clynes M, Crown J. A phase I clinical and pharmacokinetic study of the multi-drug resistance protein-1 (MRP-1) inhibitor sulindac, in combination with epirubicin in patients with advanced cancer. Cancer Chemother Pharmacol 2006; 59:79-87. [PMID: 16642371 DOI: 10.1007/s00280-006-0240-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [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: 01/19/2006] [Accepted: 03/20/2006] [Indexed: 12/16/2022]
Abstract
PURPOSE Multi-drug resistance mediated by ATP-binding cassette trans-membrane protein pumps is an important cause of cancer treatment failure. Sulindac has been shown to be a competitive substrate for the clinically important resistance protein, multi-drug resistance protein-1 (MRP-1), and thus might enhance the anti-cancer activity of substrate chemotherapeutic agents, e.g. anthracyclines. METHODS We conducted a dose-escalating, single arm, prospective, open label, non-randomised phase I trial of epirubicin (75 mg/m(2)) in combination with escalating oral doses of sulindac (0-800 mg) in patients with advanced cancer to identify an appropriate dose of sulindac to use in future resistance studies. Anthracycline and sulindac pharmacokinetics were studied in cycles 1 and 3. RESULTS Seventeen patients (8 breast, 3 lung, 2 bowel, 1 melanoma, 1 renal, 1 ovarian and 1 of unknown primary origin, 16/17 having had prior chemotherapy) were enrolled. Eight patients received a full six cycles of treatment; 14 patients received three or more cycles. Dose-limiting toxicity was observed in two patients at 800 mg sulindac (1 renal impairment, 1 fatal haemoptysis in a patient with advanced lung cancer), and sulindac 600 mg was deemed to be the maximum tolerated dose. Sulindac had no effect on epirubicin pharmacokinetics. Among 15 patients with evaluable tumour, two partial responses were seen (malignant melanoma and breast cancer). Four others had prolonged stable disease. CONCLUSION Epirubicin 75 mg/m(2) and sulindac 600 mg are the recommended doses for phase II studies for these agents in combination.
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MESH Headings
- ATP Binding Cassette Transporter, Subfamily B, Member 1/antagonists & inhibitors
- ATP Binding Cassette Transporter, Subfamily B, Member 1/metabolism
- Adult
- Aged
- Anti-Inflammatory Agents, Non-Steroidal/adverse effects
- Anti-Inflammatory Agents, Non-Steroidal/pharmacokinetics
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Antibiotics, Antineoplastic/adverse effects
- Antibiotics, Antineoplastic/therapeutic use
- Chemotherapy, Adjuvant
- Creatinine/blood
- Dose-Response Relationship, Drug
- Drug Resistance, Multiple/drug effects
- Drug Resistance, Neoplasm/drug effects
- Epirubicin/adverse effects
- Epirubicin/therapeutic use
- Female
- Humans
- Immunohistochemistry
- Male
- Middle Aged
- Myocardium/metabolism
- Neoplasms/drug therapy
- Neoplasms/metabolism
- Neoplasms/pathology
- Platelet Count
- Prospective Studies
- Sulindac/adverse effects
- Sulindac/pharmacokinetics
- Sulindac/therapeutic use
- Troponin/metabolism
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Affiliation(s)
- R O'Connor
- The National Institute for Cellular Biotechnology, Dublin City University, Dublin, 9, Ireland.
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32
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Tian C, Larkin A. Deterministic weak localization in periodic structures. Phys Rev Lett 2005; 95:246601. [PMID: 16384403 DOI: 10.1103/physrevlett.95.246601] [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] [Subscribe] [Scholar Register] [Received: 03/14/2005] [Indexed: 05/05/2023]
Abstract
In some perfect periodic structures classical motion exhibits deterministic diffusion. For such systems we present the weak localization theory. As a manifestation for the velocity autocorrelation function a universal power law decay is predicted to appear at four Ehrenfest times. This deterministic weak localization is robust against weak quenched disorders, which may be confirmed by coherent backscattering measurements of periodic photonic crystals.
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Affiliation(s)
- C Tian
- Kavli Institute for Theoretical Physics, University of California, Santa Barbara, California 93106, USA
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33
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James D, Leadbeatter S, Davison A, Coyle T, Larkin A, Smith K, Mayo S, Hunt N. Sci Justice 2005; 45:227-228. [DOI: 10.1016/s1355-0306(05)71669-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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34
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Walsh C, Larkin A, Dennan S, O'Reilly G. Exposure variations under error conditions in automatic exposure controlled film-screen projection radiography. Br J Radiol 2004; 77:931-3. [PMID: 15507417 DOI: 10.1259/bjr/62185486] [Citation(s) in RCA: 6] [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] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Improper automatic exposure control (AEC) termination may result in high overexposures on some radiographic systems. Under AEC, X-ray factors are adjusted automatically to compensate for differences in patient thickness and density. In radiography, AEC is implemented using ionization chambers placed in the film bucky. In this study we deliberately chose incorrect set-up conditions and assessed the response of the AEC system. Two types of incorrect set-up were studied: (1) incorrect selection of bucky radiation detector and (2) simulated misalignment between the X-ray field and light field. The systems tested varied in age from 1 year to in excess of 10 years. In the first test, overexposures of 90 mGy were recorded. Two systems did not meet EC guidelines for improper AEC termination. The second test, misalignment of the X-ray field, was observed to affect the exposure delivered by approximately +/-22%. The maximum dose increase observed, with a chest phantom in the beam, was 165 microGy. Misalignments also resulted in reduced exposures, which may impact on image quality.
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Affiliation(s)
- C Walsh
- St. James's Hospital, Dublin 8, Ireland
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35
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Abstract
Quantum kicked rotor was recently realized in experiments with cold atomic gases and standing optical waves. As predicted, it exhibits dynamical localization in the momentum space. Here we consider the weak-localization regime concentrating on the Ehrenfest time scale. The latter accounts for the spread time of a minimal wave packet and is proportional to the logarithm of the Planck constant. We show that the onset of the dynamical localization is essentially delayed by four Ehrenfest times, and give quantitative predictions suitable for an experimental verification.
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Affiliation(s)
- C Tian
- Department of Physics, University of Minnesota, Minneapolis, MN 55455, USA
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36
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Li Y, Li H, Bassi R, Ludwig D, Witte L, Meyer D, Larkin A, Zhu Z, Senter P, Hicklin D. 308 Inhibition of FLT3-expressing leukemia cells by a monoclonal antibody-auristatin conjugate. EJC Suppl 2004. [DOI: 10.1016/s1359-6349(04)80316-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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37
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Abstract
Fibre mapping, more commonly known as one-to-one taping, was developed in Germany approximately twenty years ago. The technique facilitates the distribution of fibres on a surface to be recorded. The impact of this technique on the investigation of serious crime has been reported in the European Fibre Group on several occasions. This paper represents a case study of the application of the technique. It is believed to be the first time that this technique has been successfully applied in the United Kingdom.
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Affiliation(s)
- T Coyle
- Forensic Alliance, F5, Culham Science Centre, Abingdon OX14 3ED, United Kingdom
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38
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O'Driscoll L, Cronin D, Kennedy SM, Purcell R, Linehan R, Glynn S, Larkin A, Scanlon K, McDermott EW, Hill AD, O'Higgins NJ, Parkinson M, Clynes M. Expression and prognostic relevance of Mcl-1 in breast cancer. Anticancer Res 2004; 24:473-82. [PMID: 15152946] [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: 04/29/2023]
Abstract
BACKGROUND Bcl-2, an anti-apoptotic protein, is frequently associated with favourable prognosis in breast cancer. The potential role of mcl-1, another bcl-2 family member, in breast cancer has not yet been defined. PATIENTS AND METHODS This study examined the expression of mcl-1 and bcl-2 in 170 cases of invasive primary breast carcinoma, using reverse-transcriptase polymerase chain reaction and immunohistochemical analyses. RESULTS Expression of bcl-2 mRNA and protein were found to be favourably associated with outcome for patients, supporting a prognostic role for bcl-2 in breast cancer, whereas mcl-1 expression, at the mRNA or protein level, did not correlate with tumour size, grade, lymph node or ER status, age of patient at diagnosis, or disease outcome. CONCLUSION As these analyses of mcl-1 expression may have co-detected mcl-1(S/deltaTM) (a more recently identified, shorter variant, that may be pro-apoptotic) with the anti-apoptotic wild-type of mcl-1, it is possible that future studies may indicate some significant clinical correlations if the isoforms can be independently investigated.
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Affiliation(s)
- L O'Driscoll
- National Institute for Cellular Biotechnology, Dublin City University, Glasnevin, Dublin 9, Ireland.
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39
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Gompels MM, Hodges E, Lock RJ, Angus B, White H, Larkin A, Chapel HM, Spickett GP, Misbah SA, Smith JL. Lymphoproliferative disease in antibody deficiency: a multi-centre study. Clin Exp Immunol 2003; 134:314-20. [PMID: 14616793 PMCID: PMC1808874 DOI: 10.1046/j.1365-2249.2003.02253.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We have undertaken a retrospective study of antibody deficient patients, with and without lymphoma, and assessed the ability of specific polymerase chain reaction (PCR) primers to determine if the detection of clonal lymphocyte populations correlates with clinical and immunohistochemical diagnosis of lymphoma. We identified 158 cases with antibody deficiency presenting during the past 20 years. Paraffin-embedded biopsy specimens or slides were available for analysis in a cohort of 34 patients. Of these patients, 29 had common variable immunodeficiency, one X-linked agammaglobulinaemia, one X-linked immunoglobulin deficiency of uncertain cause and three isolated IgG subclass deficiency. We have confirmed that lymphoma in antibody deficiency is predominantly B cell in origin. Clonal lymphocyte populations were demonstrated in biopsies irrespective of histology (16/19 with lymphoma and 11/15 without). Isolated evidence of clonality in biopsy material is therefore an insufficient diagnostic criterion to determine malignancy. Furthermore, our data suggest that clonal expansions are rarely the result of Epstein-Barr virus-driven disease.
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Affiliation(s)
- M M Gompels
- Immunology and Immunogenetics, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
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40
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Connolly L, Moran E, Larkin A, Scheffer G, Scheper R, Sarkadi B, Kool M, Clynes M. A new monoclonal antibody, P2A8(6), that specifically recognizes a novel epitope on the multidrug resistance-associated protein 1 (MRP1), but not on MRP2 nor MRP3. Hybrid Hybridomics 2002; 20:333-41. [PMID: 11839251 DOI: 10.1089/15368590152740734] [Citation(s) in RCA: 6] [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] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Multidrug resistance (MDR) is a major problem in the chemotherapeutic treatment of cancer. Overexpression of the multidrug resistance-associated protein 1 (MRP1), is associated with MDR in certain tumors. A number of MRP1-specific MAbs, which facilitate both clinical and experimental investigations of this protein, are available. To add to this panel of existing antibodies, we have now generated an additional MRP1-specific monoclonal antibody (MAb), P2A8(6), which detects a unique heat stable epitope on the MRP1 molecule. Female Wistar rats were immunized via footpad injections with a combination of two short synthetic peptides corresponding to amino acids 235-246 (peptide A) and 246-260 (peptide B) of the MRP1 protein. Immune reactive B cells were then isolated from the popliteal lymph nodes for fusion with SP2/O-Ag14 myeloma cells. Resultant hybridoma supernatants were screened for MRP1-specific antibody production. Antibody P2A8(6) was characterized by Western blotting and immunocytochemistry on paired multidrug resistant (MRP1 overexpressing) and sensitive parental cell lines. The antibody detects a protein of 190 kDa in MRP1-expressing cell lines but not in MRP2- or MRP3-transfected cell lines. P2A8(6) stains drug-selected and MRP1-transfected cell lines homogeneously by immunocytochemistry and recognizes MRP1 by immunohistochemistry on formalin-fixed paraffin wax-embedded tissue sections. Peptide inhibition studies confirm that P2A8(6) reacts with peptide B (amino acids 246-260), therefore recognizing a different epitope from that of all currently available MRP1 MAbs. This new MAb, chosen for its specificity to the MRP1 protein, may be a useful addition to the currently available range of MRP1-specific MAbs.
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Affiliation(s)
- L Connolly
- National Cell and Tissue Culture Centre/Bioresearch Ireland, D.C.U., Glasnevin, Dublin 9, Ireland
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41
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Agam O, Aleiner I, Larkin A. Shot noise in chaotic systems: "classical" to quantum crossover. Phys Rev Lett 2000; 85:3153-3156. [PMID: 11019289 DOI: 10.1103/physrevlett.85.3153] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/1999] [Revised: 07/06/2000] [Indexed: 05/23/2023]
Abstract
This paper is devoted to study of the classical-to-quantum crossover of the shot noise in chaotic systems. This crossover is determined by the ratio of the particle dwell time in the system, tau(d), to the characteristic time for diffraction t(E) approximately lambda(-1)|lnh, where lambda is the Lyapunov exponent. The shot noise vanishes when t(E)>>tau(d), while it reaches a universal value in the opposite limit. Thus, the Lyapunov exponent of chaotic mesoscopic systems may be found by shot noise measurements.
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Affiliation(s)
- O Agam
- The Racah Institute of Physics, The Hebrew University, Jerusalem 91904, Israel
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42
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Craig R, Larkin A, Mingo AM, Thuerauf DJ, Andrews C, McDonough PM, Glembotski CC. p38 MAPK and NF-kappa B collaborate to induce interleukin-6 gene expression and release. Evidence for a cytoprotective autocrine signaling pathway in a cardiac myocyte model system. J Biol Chem 2000; 275:23814-24. [PMID: 10781614 DOI: 10.1074/jbc.m909695199] [Citation(s) in RCA: 280] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
In cardiac myocytes, the stimulation of p38 MAPK by the MAPKK, MKK6, activates the transcription factor, NF-kappaB, and protects cells from apoptosis. In the present study in primary neonatal rat cardiac myocytes, constitutively active MKK6, MKK6(Glu), bound to IkappaB kinase (IKK)-beta and stimulated its abilities to phosphorylate IkappaB and to activate NF-kappaB. MKK6(Glu) induced NF-kappaB-dependent interleukin (IL)-6 transcription and IL-6 release in a p38-dependent manner. IL-6 protected myocardial cells against apoptosis. Like IL-6, TNF-alpha, which activates both NF-kappaB and p38, also induced p38-dependent IL-6 expression and release and protected myocytes from apoptotis. While TNF-alpha was relatively ineffective, IL-6 activated myocardial cell STAT3 by about 8-fold, indicating a probable role for this transcription factor in IL-6-mediated protection from apoptosis. TNF-alpha-mediated IL-6 induction was inhibited by a kinase-inactive form of the MAPKKK, TGF-beta activated protein kinase (Tak1), which is known to activate p38 and NF-kappaB in other cell types. Thus, by stimulating both p38 and NF-kappaB, Tak1-activating cytokines, like TNF-alpha, can induce IL-6 expression and release. Moreover, the myocyte-derived IL-6 may then function in an autocrine and/or paracrine fashion to augment myocardial cell survival during stresses that activate p38.
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Affiliation(s)
- R Craig
- SDSU Heart Institute and The Department of Biology, San Diego State University, San Diego, California 92182, USA
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43
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Coulthard P, Bridgman C, Larkin A, Worthington H, Coulthard DP. Appropriateness of a Resuscitation Council (UK) advanced life support course for primary care dentists. Br Dent J 2000. [DOI: 10.1038/sj.bdj.4800523a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Coulthard P, Bridgman CM, Larkin A, Worthington HV. Appropriateness of a Resuscitation Council (UK) advanced life support course for primary care dentists. Br Dent J 2000; 188:507-12. [PMID: 10859850 DOI: 10.1038/sj.bdj.4800523] [Citation(s) in RCA: 7] [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] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To investigate whether a standard Resuscitation Council (UK) ALS course is appropriate for primary care dentists or whether a course should be specifically designed for dentists. DESIGN Opinions canvassed by pre-course expectation and post-course evaluation questionnaires. SUBJECTS 23 West Pennine primary care dentists providing a general anaesthetic or conscious sedation service who attended an ALS course. RESULTS Knowledge and skills were rated on a 5-point scale from 1 (not important at all) to 5 (extremely important). Basic airway management (mean = 5) and anaphylaxis (mean = 4.9) scored the highest on the 'expectation' questionnaire. Rhythm recognition (P < 0.001), defibrillation (P = 0.007) and arrest algorithms (P = 0.047) were rated as significantly more important after the course than before. Knowledge about rhythm disorder management, cardiac pacing, post-resuscitation care, blood gas interpretation and bereavement were not considered to be so important either before or after the course. CONCLUSIONS Despite rating some aspects as unimportant, all dentists stated that this course had been appropriate. They did not want a specially designed ALS course for dentistry. Taking exactly the same recognised course and assessments as other healthcare professionals and gaining the same certification was felt to be important to this group of dentists.
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45
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Hill BT, Moran E, Etiévant C, Perrin D, Masterson A, Larkin A, Whelan RD. Low-dose twice-daily fractionated X-irradiation of ovarian tumor cells in vitro generates drug-resistant cells overexpressing two multidrug resistance-associated proteins, P-glycoprotein and MRP1. Anticancer Drugs 2000; 11:193-200. [PMID: 10831278 DOI: 10.1097/00001813-200003000-00007] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Failure of chemotherapy is frequently observed in patients previously treated with radiotherapy. To establish a cellular model for examining this resistance phenotype a series of mammalian tumor cell lines were exposed in vitro to fractionated X-irradiation and were then shown to express resistance to multiple antitumor drugs, including vincristine, etoposide and cisplatin. In these experiments the radiation was delivered as 10 fractions of 5 Gy (dose resulting in 1 log cell kill) given intermittently over several months. We now report that a comparable multidrug-resistance profile is expressed by human SK-OV-3 human ovarian tumor cells exposed in vitro to low dose (2 Gy) twice-daily fractions of X-rays given for 5 days on two consecutive weeks, essentially mimicking clinical practice, involving an overexpression of two MDR-associated proteins, P-glycoprotein and the multidrug resistance protein 1 (MRP1), with the latter being readily detectable by immunocytochemistry.
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Affiliation(s)
- B T Hill
- Division de Cancérologie, Centre de Recherche Pierre Fabre, Castres, France.
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46
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Abstract
Indigo dye is used to dye denim and other fabrics. It is now accepted that if this is co-extracted with the DNA, it may inhibit PCR amplification. A simple, improved method is described for the extraction of DNA from bloodstained denim for PCR amplification and short tandem repeat (STR) analysis. The DNA was extracted by constructing a blotting system using capillary action to draw a saline solution through the denim. The transferred material was collected onto nylon membranes and these were processed by chelex extraction. A variety of coloured denim substrates and other heavily dyed fabrics, including case work samples were used. In all cases the DNA was extracted, amplified and typed correctly.
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Affiliation(s)
- A Larkin
- Institute of Environmental Science and Research Ltd., ESR-Forensic, Mount Albert Science Centre, Private Bag 92-021, Auckland, New Zealand
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Larkin A, Moran E, Alexander D, Clynes M. Preliminary immunocytochemical studies of MDR-1 and MDR-3 Pgp expression in B-cell leukaemias. Adv Exp Med Biol 1999; 457:65-70. [PMID: 10500781 DOI: 10.1007/978-1-4615-4811-9_8] [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: 02/14/2023]
Abstract
P-glycoproteins (Pgps) belong to the family of ATP binding cassette (ABC) transporter proteins. In humans two Pgp genes have been identified; mdr-1 and mdr-3. Classical Multiple Drug Resistance (MDR) is associated with over expression of the mdr-1 gene product, P-170. No role for mdr-3 in MDR has yet been proven. However there is evidence that mdr-3 overexpression may be associated with drug resistance in certain B-cell lymphocytic leukaemias. In an immunocytochemical study we have looked at a selection of B-cell leukaemias for mdr-1 and mdr-3 encoded Pgp expression using monoclonal antibodies specific for the mdr-1 and mdr-3 encoded gene products. In B-CLL patients a differential pattern of MDR-3 positive staining was observed; suggesting that MDR-3 positivity may be associated with a more malignant phenotype in B-CLL. This pattern was not observed with MDR-1 positivity. We also observed MDR-3 positivity in an AML stage M5a patient which is the first report of MDR-3 Pgp expression being detected in AML; suggesting that MDR-3 Pgp expression may be limited to particular subtypes of this disease. Results from B-NHL cases were inconclusive with varying expression of MDR-1 and MDR-3 Pgps observed. Work is currently underway to further explain the significance of these findings.
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MESH Headings
- ATP Binding Cassette Transporter, Subfamily B/analysis
- ATP Binding Cassette Transporter, Subfamily B/genetics
- ATP Binding Cassette Transporter, Subfamily B, Member 1/analysis
- ATP Binding Cassette Transporter, Subfamily B, Member 1/genetics
- ATP-Binding Cassette Transporters/analysis
- ATP-Binding Cassette Transporters/genetics
- Drug Resistance, Multiple
- Genes, MDR
- Humans
- Immunohistochemistry/methods
- Leukemia, B-Cell/genetics
- Leukemia, B-Cell/pathology
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Leukemia, Myeloid, Acute/pathology
- Lymphoma, B-Cell/genetics
- Lymphoma, B-Cell/pathology
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Affiliation(s)
- A Larkin
- National Cell and Tissue Culture Centre, Bioresearch Ireland, Dublin City University, Ireland
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Abstract
The MDR-3-encoded P-glycoprotein (Pgp) is highly expressed in liver and is thought to function as a hepatic transporter of phospholipids into bile. However its role, if any, in other tissues remains undefined. Although transfection experiments have indicated that it may be unable to confer drug resistance, there is evidence that it may be involved in drug resistance in certain B-cell leukaemias. To date, most work on clinical samples has been performed at the mRNA level; limited work has been performed using polyclonal antibodies raised to MDR-3 and mdr-2 (the murine equivalent of MDR-3). We have generated a new monoclonal antibody, termed 6/1G, which specifically recognises the human MDR-3 gene-encoded product. Antibody 6/1G was produced by in vitro immunisation of spleen cells from BALB/c mice with a synthetic 12-amino acid peptide. Cells from MDR-3 transgenic mice showed consistent membranous staining with antibody 6/1G. Immunoblotting with 6/1G identified a band at 170 kDa on lysates of MDR-3 transgenic cells. Preliminary results with a range of B-cell leukaemias suggest that MDR-3 Pgp positivity may be a marker for a more malignant phenotype in B-CLL. Antibody 6/1G may be useful in defining a role for MDR-3 in malignancy and drug resistance, as well as in certain liver diseases such as progressive familial intracholeostasis.
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Affiliation(s)
- A Larkin
- National Cell and Tissue Culture Centre, Bioresearch Ireland, Dublin City University, Glasnevin, Dublin, Ireland.
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Dinh HK, Larkin A, Gatlin L, Piepmeier E. Rat ultrasound model for measuring pain resulting from intramuscularly injected antimicrobials. PDA J Pharm Sci Technol 1999; 53:40-3. [PMID: 10343507] [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: 02/12/2023]
Abstract
Rats emit ultrasonic vocalizations in situations involving anxiety or stress, defense, and submission. This study demonstrates the use of ultrasonic vocalizations as a quantitative measure of pain associated with intramuscular (i.m.) injections. Intramuscularly administered cephalosporins used in a comparative evaluation of pain in humans were chosen to validate this rat model. Three groups of four rats each received an intramuscular injection of either drug first, and then placebo, or placebo and then drug. The three drugs used in this study were cefonicid, cefoxitin, and cefamandole; saline was used as the placebo. Ultrasonic vocalizations were measured from 20 kHz to 100 kHz. The number of vocalizations ranged from 50 milliseconds to 500 milliseconds and most of the vocalizations occurred between 60 kHz and 80 kHz. Rats injected with cefoxitin, cefamandole, cefonicid, and saline vocalized an average of 36 +/- 11, 33 +/- 9, 28 +/- 7, and 11 +/- 6 times respectively. The response to all three antimicrobials differed significantly when compared with placebo (p < 0.01), however, there was no significant difference between the number of vocalizations for each antimicrobial injection. Further research may allow the correlation of the total duration of each vocalization, with the individual frequencies such as the 22 kHz and the 55 kHz components and with the amount of pain associated with the injection. This correlation could then be used to further identify differences in the amount of pain associated with each antimicrobial injection without increasing the sample size.
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Affiliation(s)
- H K Dinh
- Department of Pharmaceutics, University of Texas at Austin 78712-1074, USA
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Moran E, Larkin A, Cleary I, Barnes C, Kennedy SM, Kelehan P, Clynes M. Monoclonal antibodies raised to paraffin wax embedded archival tissue; feasibility study of their potential to detect novel antigenic markers. J Immunol Methods 1998; 219:151-9. [PMID: 9831396 DOI: 10.1016/s0022-1759(98)00134-3] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A study to determine the feasibility of using archival paraffin wax embedded tissue to generate monoclonal antibodies is described. Specifically, monoclonal antibodies were raised to paraffin wax embedded normal human kidney tissue to test the possibility of producing antibodies to such tissue samples prior to attempting generation of antibodies to valuable archival tissue. Multiple sections (10 x 5 microm) were pooled and dewaxed as for immunohistochemical procedures and combined with Freund's adjuvant for immunization of BALB/c mice in vivo. Immunized spleen cells were fused with SP2 myeloma cells and subsequent clones screened on paraffin wax embedded normal human kidney sections, a range of cell lines and normal mouse tissue. Supernatants from 11 wells (from a total of 90 wells screened) showed different staining patterns on sections of paraffin wax embedded kidney. One clone, 1/11C, (isotype IgG1) which exhibited strong staining on all kidney tubules by immunohistochemical studies (glomeruli interstitium and vessels were unstained) and identified a band at 52 kDa on immunoblots of dewaxed kidney tissue (as used for immunogen) was chosen for further characterization. Immunoblotting of five mammalian cell lines showed differential expression of this 52 kDa band (distinct expression on 3/5, weak expression on 2/5 cell lines) whereas, all cell lines displayed a band at 44 kDa and a third band at 70 kDa was observed on 2/5 cell lines. In mouse tissue extracts, the 52 kDa band was identified in kidney tissue only (not in the lung, liver or spleen) with the 44 kDa and 70 kDa bands weakly expressed in all tissues. This preliminary investigation of a novel approach to identifying possible new antigenic markers or producing monoclonal antibodies which react better to known antigens on sections of paraffin wax embedded tissue showed that this method is feasible. The need to have a comprehensive screening system in place and the ability to identify potentially useful clones after the initial screening is paramount due to the relative scarcity of screening material (archival tissue sections) and the tedious nature of the screening method.
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Affiliation(s)
- E Moran
- National Cell and Tissue Culture Centre, BioResearch Ireland, Dublin City University, Ireland.
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