1
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Yang F, Labani-Motlagh A, Bohorquez JA, Moreira JD, Ansari D, Patel S, Spagnolo F, Florence J, Vankayalapati A, Sakai T, Sato O, Ikebe M, Vankayalapati R, Dennehy JJ, Samten B, Yi G. Bacteriophage therapy for the treatment of Mycobacterium tuberculosis infections in humanized mice. Commun Biol 2024; 7:294. [PMID: 38461214 PMCID: PMC10924958 DOI: 10.1038/s42003-024-06006-x] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 03/02/2024] [Indexed: 03/11/2024] Open
Abstract
The continuing emergence of new strains of antibiotic-resistant bacteria has renewed interest in phage therapy; however, there has been limited progress in applying phage therapy to multi-drug resistant Mycobacterium tuberculosis (Mtb) infections. In this study, we show that bacteriophage strains D29 and DS6A can efficiently lyse Mtb H37Rv in 7H10 agar plates. However, only phage DS6A efficiently kills H37Rv in liquid culture and in Mtb-infected human primary macrophages. We further show in subsequent experiments that, after the humanized mice were infected with aerosolized H37Rv, then treated with DS6A intravenously, the DS6A treated mice showed increased body weight and improved pulmonary function relative to control mice. Furthermore, DS6A reduces Mtb load in mouse organs with greater efficacy in the spleen. These results demonstrate the feasibility of developing phage therapy as an effective therapeutic against Mtb infection.
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Affiliation(s)
- Fan Yang
- Department of Medicine, The University of Texas at Tyler School of Medicine, Tyler, TX, USA
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - Alireza Labani-Motlagh
- Department of Medicine, The University of Texas at Tyler School of Medicine, Tyler, TX, USA
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
- Center for Discovery and Innovation, Hackensack Meridian Health, Hackensack, NJ, USA
| | - Jose Alejandro Bohorquez
- Department of Medicine, The University of Texas at Tyler School of Medicine, Tyler, TX, USA
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - Josimar Dornelas Moreira
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - Danish Ansari
- Department of Medicine, The University of Texas at Tyler School of Medicine, Tyler, TX, USA
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - Sahil Patel
- Department of Medicine, The University of Texas at Tyler School of Medicine, Tyler, TX, USA
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - Fabrizio Spagnolo
- Life Sciences Department, Long Island University Post, Brookville, NY, USA
| | - Jon Florence
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - Abhinav Vankayalapati
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - Tsuyoshi Sakai
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - Osamu Sato
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - Mitsuo Ikebe
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - Ramakrishna Vankayalapati
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - John J Dennehy
- Biology Department, Queens College of The City University of New York, Flushing, NY, USA.
- The Graduate Center of The City University of New York, New York, NY, USA.
| | - Buka Samten
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX, USA.
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, USA.
| | - Guohua Yi
- Department of Medicine, The University of Texas at Tyler School of Medicine, Tyler, TX, USA.
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX, USA.
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, USA.
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Bohórquez JA, Adduri S, Ansari D, John S, Florence J, Adejare O, Singh G, Konduru N, Jagannath C, Yi G. A Novel Humanized Mouse Model for HIV and Tuberculosis Co-infection Studies. bioRxiv 2024:2024.03.05.583545. [PMID: 38496484 PMCID: PMC10942347 DOI: 10.1101/2024.03.05.583545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Tuberculosis (TB), caused by Mycobacterium tuberculosis (Mtb), continues to be a major public health problem worldwide. The human immunodeficiency virus (HIV) is another equally important life-threatening pathogen. Further, co-infections with HIV and Mtb have severe effects in the host, with people infected with HIV being fifteen to twenty-one times more likely to develop active TB. The use of an appropriate animal model for HIV/Mtb co-infection that can recapitulate the diversity of the immune response in humans would be a useful tool for conducting basic and translational research in HIV/Mtb infections. The present study was focused on developing a humanized mouse model for investigations on HIV-Mtb co-infection. Using NSG-SGM3 mice that can engraft human stem cells, our studies showed that they were able to engraft human CD34+ stem cells which then differentiate into a full-lineage of human immune cell subsets. After co-infection with HIV and Mtb, these mice showed decrease in CD4+ T cell counts overtime and elevated HIV load in the sera, similar to the infection pattern of humans. Additionally, Mtb caused infections in both lungs and spleen, and induced the development of granulomatous lesions in the lungs, detected by CT scan and histopathology. Distinct metabolomic profiles were also observed in the tissues from different mouse groups after co-infections. Our results suggest that the humanized NSG-SGM3 mice are able to recapitulate the effects of HIV and Mtb infections and co-infection in the human host at pathological, immunological and metabolism levels, providing a dependable small animal model for studying HIV/Mtb co-infection.
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Affiliation(s)
- José Alejandro Bohórquez
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
- Department of Medicine, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
| | - Sitaramaraju Adduri
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
| | - Danish Ansari
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
- Department of Medicine, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
| | - Sahana John
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
- Department of Medicine, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
| | - Jon Florence
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
| | - Omoyeni Adejare
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
| | - Gaurav Singh
- Department of Medicine, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
| | - Nagarjun Konduru
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
| | - Chinnaswamy Jagannath
- Department of Pathology and Genomic Medicine, Center for Infectious Diseases and Translational Medicine, Houston Methodist Research Institute, Houston, TX, USA
| | - Guohua Yi
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
- Department of Medicine, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
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Srivastava R, Labani-Motlagh A, Chen A, Bohorquez JA, Qin B, Dodda M, Yang F, Ansari D, Patel S, Ji H, Trasti S, Chao Y, Patel Y, Zou H, Hu B, Yi G. Development of a human glioblastoma model using humanized DRAG mice for immunotherapy. Antib Ther 2023; 6:253-264. [PMID: 38075240 PMCID: PMC10702851 DOI: 10.1093/abt/tbad021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 12/20/2023] Open
Abstract
Glioblastoma (GBM) is the most common and lethal primary brain tumor. The development of alternative humanized mouse models with fully functional human immune cells will potentially accelerate the progress of GBM immunotherapy. We successfully generated humanized DRAG (NOD.Rag1KO.IL2RγcKO) mouse model by transplantation of human DR4+ hematopoietic stem cells (hHSCs), and effectively grafted GBM patient-derived tumorsphere cells to form xenografted tumors intracranially. The engrafted tumors recapitulated the pathological features and the immune cell composition of human GBM. Administration of anti-human PD-1 antibodies in these tumor-bearing humanized DRAG mice decreased the major tumor-infiltrating immunosuppressive cell populations, including CD4+PD-1+ and CD8+PD-1+ T cells, CD11b+CD14+HLA-DR+ macrophages, CD11b+CD14+HLA-DR-CD15- and CD11b+CD14-CD15+ myeloid-derived suppressor cells, indicating the humanized DRAG mice as a useful model to test the efficacy of GBM immunotherapy. Taken together, these results suggest that the humanized DRAG mouse model is a reliable preclinical platform for studying brain cancer immunotherapy and beyond.
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Affiliation(s)
- Rashmi Srivastava
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
- John G. Rangos Sr. Research Center, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Alireza Labani-Motlagh
- Department of Medicine, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
| | - Apeng Chen
- State Key Laboratory of Veterinary Etiological Biology, Lanzhou Veterinary Research Institute, Chinese Academy of Agricultural Sciences, Lanzhou 730046, China
| | - Jose Alejandro Bohorquez
- Department of Medicine, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
| | - Bin Qin
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
- John G. Rangos Sr. Research Center, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA
- National Centre for International Research in Cell and Gene Therapy, Academy of Medical Sciences, Zhengzhou University, Zhengzhou, Henan Province 450001, People’s Republic of China
| | - Meghana Dodda
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
- John G. Rangos Sr. Research Center, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Fan Yang
- Department of Medicine, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
| | - Danish Ansari
- Department of Medicine, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
| | - Sahil Patel
- Department of Medicine, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
| | - Honglong Ji
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
| | - Scott Trasti
- Laboratory Animal Resource Center, Texas Tech University Health Sciences Center, Lubbock, TX 79410, USA
| | - Yapeng Chao
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
- John G. Rangos Sr. Research Center, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Yash Patel
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
- John G. Rangos Sr. Research Center, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Han Zou
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
- John G. Rangos Sr. Research Center, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Baoli Hu
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
- John G. Rangos Sr. Research Center, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA
- Cancer Biology Program, UPMC Hillman Cancer Center, Pittsburgh, PA 15232, USA
| | - Guohua Yi
- Department of Medicine, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
- Center for Biomedical Research, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
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Yang B, Mukherjee T, Radhakrishnan R, Paidipally P, Ansari D, John S, Vankayalapati R, Tripathi D, Yi G. HIV-Differentiated Metabolite N-Acetyl-L-Alanine Dysregulates Human Natural Killer Cell Responses to Mycobacterium tuberculosis Infection. Int J Mol Sci 2023; 24:ijms24087267. [PMID: 37108430 PMCID: PMC10138430 DOI: 10.3390/ijms24087267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/09/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
Mycobacterium tuberculosis (Mtb) has latently infected over two billion people worldwide (LTBI) and caused ~1.6 million deaths in 2021. Human immunodeficiency virus (HIV) co-infection with Mtb will affect the Mtb progression and increase the risk of developing active tuberculosis by 10-20 times compared with HIV- LTBI+ patients. It is crucial to understand how HIV can dysregulate immune responses in LTBI+ individuals. Plasma samples collected from healthy and HIV-infected individuals were investigated using liquid chromatography-mass spectrometry (LC-MS), and the metabolic data were analyzed using the online platform Metabo-Analyst. ELISA, surface and intracellular staining, flow cytometry, and quantitative reverse-transcription PCR (qRT-PCR) were performed using standard procedures to determine the surface markers, cytokines, and other signaling molecule expressions. Seahorse extra-cellular flux assays were used to measure mitochondrial oxidative phosphorylation and glycolysis. Six metabolites were significantly less abundant, and two were significantly higher in abundance in HIV+ individuals compared with healthy donors. One of the HIV-upregulated metabolites, N-acetyl-L-alanine (ALA), inhibits pro-inflammatory cytokine IFN-γ production by the NK cells of LTBI+ individuals. ALA inhibits the glycolysis of LTBI+ individuals' NK cells in response to Mtb. Our findings demonstrate that HIV infection enhances plasma ALA levels to inhibit NK-cell-mediated immune responses to Mtb infection, offering a new understanding of the HIV-Mtb interaction and providing insights into the implication of nutrition intervention and therapy for HIV-Mtb co-infected patients.
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Affiliation(s)
- Baojun Yang
- Department of Medicine, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
- Center for Biomedical Research, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
| | - Tanmoy Mukherjee
- Center for Biomedical Research, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
| | - Rajesh Radhakrishnan
- Center for Biomedical Research, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
| | - Padmaja Paidipally
- Center for Biomedical Research, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
| | - Danish Ansari
- Department of Medicine, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
- Center for Biomedical Research, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
| | - Sahana John
- Department of Medicine, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
- Center for Biomedical Research, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
| | - Ramakrishna Vankayalapati
- Center for Biomedical Research, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
| | - Deepak Tripathi
- Center for Biomedical Research, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
| | - Guohua Yi
- Department of Medicine, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
- Center for Biomedical Research, The University of Texas at Tyler School of Medicine, Tyler, TX 75708, USA
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX 75708, USA
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Yang B, Mukherjee T, Radhakrishnan R, Paidipally P, Ansari D, John S, Vankayalapati R, Tripathi D, Yi G. HIV-differentiated metabolite N-Acetyl-L-Alanine dysregulates human natural killer cell responses to Mycobacterium tuberculosis infection. bioRxiv 2023:2023.02.28.530445. [PMID: 36909560 PMCID: PMC10002710 DOI: 10.1101/2023.02.28.530445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Background Mycobacterium tuberculosis ( Mtb ) has latently infected over two billion people worldwide (LTBI) and causes 1.8 million deaths each year. Human immunodeficiency virus (HIV) co-infection with Mtb will affect the Mtb progression and increase the risk of developing active tuberculosis by 10-20 times compared to the HIV-LTBI+ patients. It is crucial to understand how HIV can dysregulate immune responses in LTBI+ individuals. Methods Plasma samples collected from healthy and HIV-infected individuals were investigated by liquid chromatography-mass spectrometry (LC-MS), and the metabolic data were analyzed using an online platform Metabo-Analyst. ELISA, surface and intracellular staining, flow cytometry, quantitative reverse transcription PCR (qRT-PCR) were performed by standard procedure to determine the surface markers, cytokines and other signaling molecule expression. Seahorse extra cellular flux assays were used to measure the mitochondrial oxidative phosphorylation and glycolysis. Results Six metabolites were significantly less abundant, and two were significantly higher in abundance in HIV+ individuals compared to healthy donors. One of the HIV-upregulated metabolites, N-Acetyl-L-Alanine (ALA), inhibits pro-inflammatory cytokine IFN-□ production by NK cells of LTBI+ individuals. ALA inhibits glycolysis of LTBI+ individuals' NK cells in response to Mtb . Conclusions Our findings demonstrate that HIV infection enhances plasma ALA levels to inhibit NK cell-mediated immune responses to Mtb infection, offering a new understanding of the HIV- Mtb interaction and providing the implication of nutrition intervention and therapy for HIV- Mtb co-infected patients.
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Yi G, Yang F, Labani-Motlagh A, Moreira JD, Ansari D, Bohorquez JA, Patel S, Spagnolo F, Florence J, Vankayalapati A, Vankayalapati R, Dennehy JJDJ, Samten B. Bacteriophage therapy for the treatment of Mycobacterium tuberculosis infections in humanized mice. bioRxiv 2023:2023.01.23.525188. [PMID: 36747734 PMCID: PMC9900801 DOI: 10.1101/2023.01.23.525188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The continuing emergence of new strains of antibiotic-resistant bacteria has renewed interest in phage therapy; however, there has been limited progress in applying phage therapy to multi-drug resistant Mycobacterium tuberculosis (Mtb) infections. In this study, we tested three bacteriophage strains for their Mtb-killing activities and found that two of them efficiently lysed Mtb H37Rv in 7H10 agar plates. However, only phage DS6A efficiently killed H37Rv in liquid culture and in Mtb-infected human primary macrophages. In subsequent experiments, we infected humanized mice with aerosolized H37Rv, then treated these mice with DS6A intravenously to test its in vivo efficacy. We found that DS6A treated mice showed increased body weight and improved pulmonary function relative to control mice. Furthermore, DS6A reduced Mtb load in mouse organs with greater efficacy in the spleen. These results demonstrated the feasibility of developing phage therapy as an effective therapeutic against Mtb infection.
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7
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Srivastava R, Labani-Motlagh A, Chen A, Yang F, Ansari D, Patel S, Ji H, Trasti S, Dodda M, Patel Y, Zou H, Hu B, Yi G. Development of a human glioblastoma model using humanized DRAG mice for immunotherapy. bioRxiv 2023:2023.02.15.528743. [PMID: 36824969 PMCID: PMC9948970 DOI: 10.1101/2023.02.15.528743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Glioblastoma (GBM) is the most common and lethal primary brain tumor with high mortality rates and a short median survival rate of about 15 months despite intensive multimodal treatment of maximal surgical resection, radiotherapy, and chemotherapy. Although immunotherapies have been successful in the treatment of various cancers, disappointing results from clinical trials for GBM immunotherapy represent our incomplete understanding. The development of alternative humanized mouse models with fully functional human immune cells will potentially accelerate the progress of GBM immunotherapy. In this study, we developed a humanized DRAG (NOD.Rag1KO.IL2RγcKO) mouse model, in which the human hematopoietic stem cells (HSCs) were well-engrafted and subsequently differentiated into a full lineage of immune cells. Using this humanized DRAG mouse model, GBM patient-derived tumorsphere lines were successfully engrafted to form xenografted tumors, which can recapitulate the pathological features and the immune cell composition of human GBM. Importantly, the administration of anti-human PD-1 antibodies in these DRAG mice bearing a GBM patient-derived tumorsphere line resulted in decreasing the major tumor-infiltrating immunosuppressive cell populations, including CD4 + PD-1 + and CD8 + PD-1 + T cells, CD11b + CD14 + HLA-DR + macrophages, CD11b + CD14 + HLA-DR - CD15 - and CD11b + CD14 - CD15 + myeloid-derived suppressor cells, indicating the humanized DRAG mouse model as a useful model to test the efficacy of immune checkpoint inhibitors in GBM immunotherapy. Together, these results suggest that humanized DRAG mouse models are a reliable preclinical platform for brain cancer immunotherapy and beyond.
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Muacevic A, Adler JR, . S, Chawla H, Kaushik S, Khan Z, . R, Chitravanshi S, Kabir U, Ansari D. Comparative Evaluation of Multidetector Computed Tomography and Dual-Energy Computed Tomography Findings in Gastrointestinal Tuberculosis. Cureus 2022; 14:e32149. [PMID: 36608298 PMCID: PMC9806801 DOI: 10.7759/cureus.32149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2022] [Indexed: 12/04/2022] Open
Abstract
AIM To compare multidetector computed tomography (MDCT) and dual-energy computed tomography (DECT) imaging findings in gastrointestinal (GI) tuberculosis. OBJECTIVE To study imaging findings of MDCT and DECT in GI tuberculosis. METHODOLOGY All the patients falling in the sampling frame and fulfilling the eligibility criteria were clinically examined and demographic details, presenting complaints, medical history, history of anti-tubercular treatment (ATT) intake, personal habits, and family history of tuberculosis were noted. All the patients underwent sputum acid-fast bacilli (AFB) assessment. Outcomes of investigations like bronchoscopy and fine-needle aspiration cytology (FNAC)/biopsy were also noted wherever available. Ascitic fluid AFB and culture assessments were also performed wherever feasible. All CT scans were performed on a 384-slice dual-energy CT scanner (Somaton Force, Siemens Healthcare) and all the images were post-processed on a workstation using syngo.via software that allows the analysis of images using three material decompositions. Features like peritonitis, lymph node involvement, GI wall thickening, and solid organ involvement were focused on. Subjective assessment of images of both MDCT and DECT were assessed by two experienced radiologists to prepare the CT diagnosis. The mutual agreement of the two observers was considered final. CONCLUSIONS The findings of the study showed that both MDCT, as well as DECT, were useful in the diagnosis of GI tuberculosis. On the basis of these findings, DECT could be considered to have an edge over MDCT in the diagnosis of GI tuberculosis. Keeping in view the small sample size and high prevalence, further studies on a larger sample size with relaxed sampling criteria are recommended to validate the findings of the present study.
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Vaid PM, Puntambekar AK, Jumle NS, Banale RA, Ansari D, Reddy RR, Unde RR, Namewar NP, Kelkar DA, Shashidhara LS, Koppiker CB, Kulkarni MD. Evaluation of tumor-infiltrating lymphocytes (TILs) in molecular subtypes of an Indian cohort of breast cancer patients. Diagn Pathol 2022; 17:91. [PMID: 36411483 PMCID: PMC9677664 DOI: 10.1186/s13000-022-01271-y] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/21/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Evaluation of tumor-infiltrating lymphocytes (TILs) distribution in an Indian cohort of breast cancer patients for its prognostic significance. METHODS A retrospective cohort of breast cancer patients from a single onco-surgeon's breast cancer clinic with a uniform treatment strategy was evaluated for TILs. Tumor sections were H&E stained and scored for the spatial distribution and percent stromal TILs infiltration by a certified pathologist. The scores were analysed for association with treatment response and survival outcomes across molecular subtypes. RESULTS Total 229 breast cancer tumors were evaluated. Within spatial distribution categories, intra-tumoral TILs were observed to be associated with complete pathological response and lower recurrence frequency for the entire cohort. Subtype-wise analysis of stromal TILs (sTILs) re-enforced significantly higher infiltration in TNBC compared to HER2-positive and ER-positive tumors. A favourable association of higher stromal infiltration was observed with treatment response and disease outcomes, specifically in TNBC. CONCLUSION Intra-tumoral TILs showed a higher proportion with favourable association with better patient outcomes in an Indian cohort, unlike western cohorts where both stromal and intra-tumoral TILs show similar association with prognosis. With further validation, TILs can be developed as a cost-effective surrogate marker for treatment response, especially in a low-resource setting such as India.
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Affiliation(s)
- Pooja M. Vaid
- grid.417959.70000 0004 1764 2413Centre for Translational Cancer Research: a joint initiative of Indian Institute of Science Education and Research (IISER) Pune and Prashanti Cancer Care Mission (PCCM), Pune, India ,grid.449178.70000 0004 5894 7096Department of Biological Sciences, Ashoka University, Sonipat, India
| | | | - Nutan S. Jumle
- grid.414967.90000 0004 1804 743XDepartment of Pathology, Jehangir Hospital, Pune, India
| | - Rituja A. Banale
- grid.417959.70000 0004 1764 2413Centre for Translational Cancer Research: a joint initiative of Indian Institute of Science Education and Research (IISER) Pune and Prashanti Cancer Care Mission (PCCM), Pune, India ,grid.506045.20000 0004 4911 4105Prashanti Cancer Care Mission, Pune, Maharashtra India
| | - Danish Ansari
- grid.417959.70000 0004 1764 2413Centre for Translational Cancer Research: a joint initiative of Indian Institute of Science Education and Research (IISER) Pune and Prashanti Cancer Care Mission (PCCM), Pune, India ,grid.506045.20000 0004 4911 4105Prashanti Cancer Care Mission, Pune, Maharashtra India
| | - Ruhi R. Reddy
- grid.417959.70000 0004 1764 2413Centre for Translational Cancer Research: a joint initiative of Indian Institute of Science Education and Research (IISER) Pune and Prashanti Cancer Care Mission (PCCM), Pune, India ,grid.506045.20000 0004 4911 4105Prashanti Cancer Care Mission, Pune, Maharashtra India
| | - Rohini R. Unde
- grid.417959.70000 0004 1764 2413Centre for Translational Cancer Research: a joint initiative of Indian Institute of Science Education and Research (IISER) Pune and Prashanti Cancer Care Mission (PCCM), Pune, India ,grid.506045.20000 0004 4911 4105Prashanti Cancer Care Mission, Pune, Maharashtra India
| | - Namrata P. Namewar
- grid.417959.70000 0004 1764 2413Centre for Translational Cancer Research: a joint initiative of Indian Institute of Science Education and Research (IISER) Pune and Prashanti Cancer Care Mission (PCCM), Pune, India ,grid.506045.20000 0004 4911 4105Prashanti Cancer Care Mission, Pune, Maharashtra India
| | - Devaki A. Kelkar
- grid.417959.70000 0004 1764 2413Centre for Translational Cancer Research: a joint initiative of Indian Institute of Science Education and Research (IISER) Pune and Prashanti Cancer Care Mission (PCCM), Pune, India ,grid.506045.20000 0004 4911 4105Prashanti Cancer Care Mission, Pune, Maharashtra India
| | - L. S. Shashidhara
- grid.417959.70000 0004 1764 2413Centre for Translational Cancer Research: a joint initiative of Indian Institute of Science Education and Research (IISER) Pune and Prashanti Cancer Care Mission (PCCM), Pune, India ,grid.449178.70000 0004 5894 7096Department of Biological Sciences, Ashoka University, Sonipat, India ,grid.417959.70000 0004 1764 2413Indian Institute of Science Education and Research, Pune, India
| | - Chaitanyanand B. Koppiker
- grid.417959.70000 0004 1764 2413Centre for Translational Cancer Research: a joint initiative of Indian Institute of Science Education and Research (IISER) Pune and Prashanti Cancer Care Mission (PCCM), Pune, India ,grid.506045.20000 0004 4911 4105Prashanti Cancer Care Mission, Pune, Maharashtra India
| | - Madhura D. Kulkarni
- grid.417959.70000 0004 1764 2413Centre for Translational Cancer Research: a joint initiative of Indian Institute of Science Education and Research (IISER) Pune and Prashanti Cancer Care Mission (PCCM), Pune, India ,grid.506045.20000 0004 4911 4105Prashanti Cancer Care Mission, Pune, Maharashtra India
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10
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Busheri L, Nare S, Banale R, Bapat A, Nagarkar M, Vetale D, Joseph R, Suryawanshi S, Alhat R, Thomas G, Navgire R, Ansari D, Unde R, Shaikh S, Gangurde N, Dixit S, Varghese B, Deshmukh C, Kelkar DA, Kulkarni M, Koppiker CB. Cancer Patient Management during COVID-19 Pandemic: An Audit of a Single-Surgeon Unit in a COVID-Hotspot. South Asian J Cancer 2021; 10:39-41. [PMID: 34430517 PMCID: PMC8380147 DOI: 10.1055/s-0041-1731578] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
The report evaluates the effect of coronavirus disease (COVID-19) pandemic on breast cancer treatment and management at a single-surgeon cancer care unit in one of the hotspots of COVID-19 in India. In response to the pandemic, the adjustments were made in the clinical practice to accommodate social distancing. Patient consultations were done over phone call or in-clinic visit with prior appointment to reduce the risk of exposure to COVID-19. Total number of patients that were treated at the clinic and the essential surgeries performed during the pandemic phases are summarized in the report. The methodology adopted here for care and management of the cancer patients can serve as a guiding principle for cancer care units in the country.
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Affiliation(s)
- Laleh Busheri
- Orchid Breast Health Clinic and Prashanti Cancer Care Mission, Pune, Maharashtra, India
| | - Smeeta Nare
- Orchid Breast Health Clinic and Prashanti Cancer Care Mission, Pune, Maharashtra, India
| | - Rituja Banale
- Orchid Breast Health Clinic and Prashanti Cancer Care Mission, Pune, Maharashtra, India
| | - Ashwini Bapat
- Orchid Breast Health Clinic and Prashanti Cancer Care Mission, Pune, Maharashtra, India
| | - Moushumi Nagarkar
- Orchid Breast Health Clinic and Prashanti Cancer Care Mission, Pune, Maharashtra, India
| | - Deepali Vetale
- Orchid Breast Health Clinic and Prashanti Cancer Care Mission, Pune, Maharashtra, India
| | - Rebecca Joseph
- Orchid Breast Health Clinic and Prashanti Cancer Care Mission, Pune, Maharashtra, India
| | - Swapnil Suryawanshi
- Orchid Breast Health Clinic and Prashanti Cancer Care Mission, Pune, Maharashtra, India
| | - Rashmi Alhat
- Orchid Breast Health Clinic and Prashanti Cancer Care Mission, Pune, Maharashtra, India
| | - George Thomas
- Orchid Breast Health Clinic and Prashanti Cancer Care Mission, Pune, Maharashtra, India
| | - Ruth Navgire
- Orchid Breast Health Clinic and Prashanti Cancer Care Mission, Pune, Maharashtra, India
| | - Danish Ansari
- Orchid Breast Health Clinic and Prashanti Cancer Care Mission, Pune, Maharashtra, India
| | - Rohini Unde
- Orchid Breast Health Clinic and Prashanti Cancer Care Mission, Pune, Maharashtra, India
| | - Shahin Shaikh
- Orchid Breast Health Clinic and Prashanti Cancer Care Mission, Pune, Maharashtra, India
| | - Nutan Gangurde
- Orchid Breast Health Clinic and Prashanti Cancer Care Mission, Pune, Maharashtra, India
| | - Santosh Dixit
- Orchid Breast Health Clinic and Prashanti Cancer Care Mission, Pune, Maharashtra, India.,Center for Translational Cancer Research, A Joint Initiative between IISER Pune and Prashanti Cancer Care Mission, Pune, Maharashtra, India
| | - Beenu Varghese
- Orchid Breast Health Clinic and Prashanti Cancer Care Mission, Pune, Maharashtra, India
| | - Chetan Deshmukh
- Orchid Breast Health Clinic and Prashanti Cancer Care Mission, Pune, Maharashtra, India
| | - Devaki A Kelkar
- Orchid Breast Health Clinic and Prashanti Cancer Care Mission, Pune, Maharashtra, India.,Center for Translational Cancer Research, A Joint Initiative between IISER Pune and Prashanti Cancer Care Mission, Pune, Maharashtra, India
| | - Madhura Kulkarni
- Orchid Breast Health Clinic and Prashanti Cancer Care Mission, Pune, Maharashtra, India.,Center for Translational Cancer Research, A Joint Initiative between IISER Pune and Prashanti Cancer Care Mission, Pune, Maharashtra, India
| | - Chaitanyanand B Koppiker
- Orchid Breast Health Clinic and Prashanti Cancer Care Mission, Pune, Maharashtra, India.,Center for Translational Cancer Research, A Joint Initiative between IISER Pune and Prashanti Cancer Care Mission, Pune, Maharashtra, India
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11
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Byrling J, Hilmersson KS, Ansari D, Andersson R, Andersson B. Thrombospondin-2 as a diagnostic biomarker for distal cholangiocarcinoma and pancreatic ductal adenocarcinoma. Clin Transl Oncol 2021; 24:297-304. [PMID: 34319497 PMCID: PMC8794913 DOI: 10.1007/s12094-021-02685-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/10/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE Distal cholangiocarcinoma and pancreatic ductal adenocarcinoma are malignancies with poor prognoses that can be difficult to distinguish preoperatively. Thrombospondin-2 has been proposed as a novel diagnostic biomarker for early pancreatic ductal adenocarcinoma. The aim of the present study was to evaluate thrombospondin-2 as a diagnostic and prognostic biomarker in combination with current biomarker CA 19-9 for distal cholangiocarcinoma and pancreatic ductal adenocarcinoma. METHODS Thrombospondin-2 was measured in prospectively collected serum samples from patients who underwent surgery with a histopathological diagnosis of distal cholangiocarcinoma (N = 51), pancreatic ductal adenocarcinoma (N = 52) and benign pancreatic diseases (N = 27) as well as healthy blood donors (N = 52) using an enzyme-linked immunosorbent assay. RESULTS Thrombospondin-2 levels (ng/ml) were similar in distal cholangiocarcinoma 55 (41-77) and pancreatic ductal adenocarcinoma 48 (35-80) (P = 0.221). Thrombospondin-2 + CA 19-9 had an area under the curve of 0.92 (95% CI 0.88-0.97) in differentiating distal cholangiocarcinoma and pancreatic ductal adenocarcinoma from healthy donors which was superior to CA 19-9 alone (P < 0.001). The diagnostic value of adding thrombospondin-2 to CA 19-9 was larger in early disease stages. Thrombospondin-2 did not provide additional value to CA 19-9 in differentiating the benign disease group; however, heterogeneity was notable in the benign cohort. Three of five patients with autoimmune pancreatitis patients had greatly elevated thrombospondin-2 levels. Thrombospondin-2 levels had no correlation with prognoses. CONCLUSIONS Serum thrombospondin-2 in combination with CA 19-9 has potential as a biomarker for distal cholangiocarcinoma and pancreatic cancer.
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Affiliation(s)
- J Byrling
- Department of Surgery, Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, 221 85, Lund, Sweden
| | - K S Hilmersson
- Department of Surgery, Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, 221 85, Lund, Sweden
| | - D Ansari
- Department of Surgery, Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, 221 85, Lund, Sweden
| | - R Andersson
- Department of Surgery, Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, 221 85, Lund, Sweden
| | - B Andersson
- Department of Surgery, Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, 221 85, Lund, Sweden.
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12
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Coolen I, Merkley R, Ansari D, Dove E, Dowker A, Mills A, Murphy V, von Spreckelsen M, Scerif G. Domain-general and domain-specific influences on emerging numerical cognition: Contrasting uni-and bidirectional prediction models. Cognition 2021; 215:104816. [PMID: 34224977 DOI: 10.1016/j.cognition.2021.104816] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 06/12/2021] [Accepted: 06/15/2021] [Indexed: 11/26/2022]
Abstract
Domain-general skills such as executive functions (EFs), and domain-specific skills such as non-symbolic number sense and symbolic understanding are often pitted against each other as predictors of emerging maths. Here we aimed to investigate early childhood relations between these foundational skills with a balanced, longitudinal design. One hundred and seventy 3- and 4-year-old-children were tested at two time points, 5 months apart, on four domain-general executive and five domain-specific numeracy tasks. A latent EF factor was a strong predictor of symbolic maths and of their growth. In addition, stronger symbolic maths at Time 1 was correlated with later stronger EF, but symbolic maths did not predict EF growth. Our findings provide novel insights into dynamic interplay between general and specific cognitive skills contributing to preschool maths.
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Affiliation(s)
- I Coolen
- Department of Experimental Psychology, University of Oxford, United Kingdom
| | - R Merkley
- Institute of Cognitive Science, Carleton University, Canada
| | - D Ansari
- Department of Psychology & Faculty of Education, The University of Western Ontario, Canada
| | - E Dove
- Department of Experimental Psychology, University of Oxford, United Kingdom
| | - A Dowker
- Department of Experimental Psychology, University of Oxford, United Kingdom
| | - A Mills
- Department of Experimental Psychology, University of Oxford, United Kingdom
| | - V Murphy
- Oxford Department of Education, University of Oxford, United Kingdom
| | - M von Spreckelsen
- Department of Experimental Psychology, University of Oxford, United Kingdom
| | - G Scerif
- Department of Experimental Psychology, University of Oxford, United Kingdom.
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13
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Kriz D, Ansari D, Andersson R. Potential biomarkers for early detection of pancreatic ductal adenocarcinoma. Clin Transl Oncol 2020; 22:2170-2174. [PMID: 32447642 PMCID: PMC7578134 DOI: 10.1007/s12094-020-02372-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 05/01/2020] [Indexed: 12/12/2022]
Abstract
Pancreatic cancer has the highest mortality amongst all major organ cancers. Early detection is key to reduce deaths related to pancreatic cancer. However, early detection has been challenged by the lack of non-invasive biomarkers with enough sensitivity and specificity to allow for screening. The gold standard is still carbohydrate antigen (CA 19-9), against which all new biomarkers must be evaluated. In this paper, we describe recent progress in the development of new pancreatic cancer biomarkers, focusing on proteins, metabolites, and genetic and epigenetic biomarkers. Although several promising biomarkers have been identified, they are all derived from retrospective studies and additional prospective studies are needed to confirm their clinical validity.
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Affiliation(s)
- D Kriz
- Department of Surgery, Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
| | - D Ansari
- Department of Surgery, Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
| | - R Andersson
- Department of Surgery, Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden.
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14
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Abstract
BACKGROUND AND AIMS Patients undergoing surgery are prone to infections, either at the site of surgery (superficial or organ-space) or at remote sites (e.g. pneumonia or urinary tract). Surgical site infections are associated with substantial morbidity and mortality, increased length of hospital stay and represent a huge burden to the health economy across all healthcare systems. Here we discuss recent advances and challenges in the field of surgical site infections. MATERIAL AND METHODS Review of pertinent English language literature. RESULTS Numerous guidelines and recommendations have been published in order to prevent surgical site infections. Compliance with these evidence-based guidelines vary and has not resulted in any major decrease in the surgical site infection rate. To date, most efforts to reduce surgical site infection have focused on the role of the surgeon, but a more comprehensive approach is necessary. CONCLUSION Surgical site infections need to be addressed in a structured way, including checklists, audits, monitoring, and measurements. All stakeholders, including the medical profession, the society, and the patient, need to work together to reduce surgical site infections. Most surgical site infections are preventable-and we need a paradigm shift to tackle the problem.
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Affiliation(s)
- R Andersson
- Department of Surgery, Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
| | - K Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - D Ansari
- Department of Surgery, Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
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15
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Abstract
BACKGROUND AND AIMS Routine drainage after pancreatoduodenectomy is a controversial issue. In this article, we present and discuss the current evidence on abdominal drains in pancreatic surgery. MATERIAL AND METHODS Review of the pertinent English-language literature. RESULTS There is a growing body of evidence showing a lack of benefit of prophylactic drainage after pancreatoduodenectomy. Randomized trials have reported similar outcomes with or without routine drains. If drains were used, early removal was found to be superior to late removal in patients with a low risk of postoperative pancreatic fistula. Consequently, criteria for early drain removal have been developed based on the measurement of drain amylase levels. On the contrary, there exists a subgroup of patients where drains may have a role. In patients with high risk of pancreatic fistula formation, such as those having a soft pancreatic texture, small pancreatic duct and high body mass index, the placement of drains may give sentinel information about future clinical deterioration. The drain may thus help reduce failure-to-rescue rates. CONCLUSION Despite much research, there are many unanswered questions regarding drains in pancreatic surgery. It is evident that routine drainage should be abandoned for a more selective strategy. Furthermore, what is needed is a postoperative warning score that early on can identify patients at risk of a pancreatic fistula, without the routine placement of drains.
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Affiliation(s)
- R Andersson
- Surgery, Department of Clinical Sciences, Lund, Lund University, Skane University Hospital, Lund, Sweden
| | - K Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - D Ansari
- Surgery, Department of Clinical Sciences, Lund, Lund University, Skane University Hospital, Lund, Sweden
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16
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Williamsson C, Karlsson T, Westrin M, Ansari D, Andersson R, Tingstedt B. Sustainability of an Enhanced Recovery Program for Pancreaticoduodenectomy with Pancreaticogastrostomy. Scand J Surg 2018; 108:17-22. [PMID: 29756520 DOI: 10.1177/1457496918772375] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND: Enhanced recovery program for pancreaticoduodenectomy have become standard care. Little is known about adherence rates and sustainability of the program, especially when pancreaticogastrostomy is used in reconstruction. The aim of this study was, therefore, to evaluate adherence rates and continued outcome, after implementation of an enhanced recovery program. METHODS: Consecutive patients undergoing pancreaticoduodenectomy at the Department of Surgery, Skåne University Hospital, Lund, Sweden were followed, after implementation of enhanced recovery program, October 2012. In April 2015, some items in the enhanced recovery program were modified, namely earlier removal of nasogastric tubes and abdominal drain. The patients were analyzed in three groups, the implementation group (control) and two post-implementation groups; intermediate and modified group. Sustainability was assessed according to length of stay and adherence rate. RESULTS: In total, 160 patients were identified. The overall protocol adherence rate increased from 65% to 72%, p = 0.035. While the pre- and intraoperative protocol items were fulfilled to more than >90%, the postoperative were lower, but increasing over time; 48%, 50%, and 58%, p = 0.033. Postoperative complications and hospital length of stay did not change significantly. CONCLUSION: The positive outcome of an enhanced recovery program for pancreaticoduodenectomy was reasonably well sustained. Compliance with the protocol has increased, but strict adherence remains a challenge, especially with the postoperative items.
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Affiliation(s)
- C Williamsson
- 1 Department of Surgery, Skåne University Hospital, Lund, Sweden.,2 Department of Clinical Sciences, Lund University, Lund, Sweden
| | - T Karlsson
- 1 Department of Surgery, Skåne University Hospital, Lund, Sweden.,2 Department of Clinical Sciences, Lund University, Lund, Sweden
| | - M Westrin
- 1 Department of Surgery, Skåne University Hospital, Lund, Sweden.,2 Department of Clinical Sciences, Lund University, Lund, Sweden
| | - D Ansari
- 1 Department of Surgery, Skåne University Hospital, Lund, Sweden.,2 Department of Clinical Sciences, Lund University, Lund, Sweden
| | - R Andersson
- 1 Department of Surgery, Skåne University Hospital, Lund, Sweden.,2 Department of Clinical Sciences, Lund University, Lund, Sweden
| | - B Tingstedt
- 1 Department of Surgery, Skåne University Hospital, Lund, Sweden.,2 Department of Clinical Sciences, Lund University, Lund, Sweden
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17
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Aronsson L, Andersson B, Andersson R, Tingstedt B, Bratlie SO, Ansari D. Intraductal Papillary Mucinous Neoplasms of The Pancreas: A Nationwide Registry-Based Study. Scand J Surg 2018; 107:302-307. [PMID: 29637834 DOI: 10.1177/1457496918766727] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND AIMS: To investigate the paraclinical and pathological features of surgically resected intraductal papillary mucinous neoplasms in Sweden. MATERIALS AND METHODS: A review of prospectively collected data on patients undergoing pancreatic resection for a histopathologically verified intraductal papillary mucinous neoplasm between 2010 and 2016 was performed using the Swedish National Registry for Pancreatic and Periampullary Cancer. RESULTS: A total of 3038 pancreatic resections were performed during the study period, of which 251 (8.3%) were due to intraductal papillary mucinous neoplasms. The intraductal papillary mucinous neoplasm cases comprised 227 noninvasive and 24 invasive lesions. There was an annual increase in the number of resected intraductal papillary mucinous neoplasms, from 13 in 2010 to 56 in 2016, and an increase in the proportion of intraductal papillary mucinous neoplasm to the total number of pancreatic resections (4.7%-11%). Biliary obstruction was the only independent predictor of invasive disease, with odds ratio 3.106 (p = 0.030). There was no difference in survival between low-, intermediate-, and high-grade dysplastic lesions (p = 0.417). However, once invasive, the prognosis was severely impacted (p < 0.001). Three-year survival was 90% for noninvasive intraductal papillary mucinous neoplasm and 39% for invasive intraductal papillary mucinous neoplasm. Survival was better in lymph node negative invasive intraductal papillary mucinous neoplasm (p = 0.021), but still dismal compared to noninvasive lesions (p < 0.001). CONCLUSION: The number of surgically resected intraductal papillary mucinous neoplasms is increasing in Sweden. Biliary obstruction is associated with invasive disease. Low-to-high-grade dysplastic intraductal papillary mucinous neoplasm has an excellent prognosis, while invasive intraductal papillary mucinous neoplasm has a poor survival rate.
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Affiliation(s)
- L Aronsson
- 1 Departments of Clinical Sciences and Surgery, Lund University and Skane University Hospital, Lund, Sweden
| | - B Andersson
- 1 Departments of Clinical Sciences and Surgery, Lund University and Skane University Hospital, Lund, Sweden
| | - R Andersson
- 1 Departments of Clinical Sciences and Surgery, Lund University and Skane University Hospital, Lund, Sweden
| | - B Tingstedt
- 1 Departments of Clinical Sciences and Surgery, Lund University and Skane University Hospital, Lund, Sweden
| | - S O Bratlie
- 2 Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - D Ansari
- 1 Departments of Clinical Sciences and Surgery, Lund University and Skane University Hospital, Lund, Sweden
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18
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Ansari D, Tingstedt B, Lindell G, Keussen I, Ansari D, Andersson R. Hemorrhage after Major Pancreatic Resection: Incidence, Risk Factors, Management, and Outcome. Scand J Surg 2017; 106:47-53. [PMID: 26929287 DOI: 10.1177/1457496916631854] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
BACKGROUND AND AIMS Hemorrhage is a rare but dreaded complication after pancreatic surgery. The aim of this study was to examine the incidence, risk factors, management, and outcome of postpancreatectomy hemorrhage in a tertiary care center. MATERIALS AND METHODS A retrospective observational study was conducted on 500 consecutive patients undergoing major pancreatic resections at our institution. Postpancreatectomy hemorrhage was defined according to the International Study Group of Pancreatic Surgery criteria. RESULTS A total of 68 patients (13.6%) developed postpancreatectomy hemorrhage. Thirty-four patients (6.8%) had a type A, 15 patients (3.0%) had a type B, and the remaining 19 patients (3.8%) had a type C bleed. Postoperative pancreatic fistula Grades B and C and bile leakage were significantly associated with severe postpancreatectomy hemorrhage on multivariable logistic regression. For patients with postpancreatectomy hemorrhage Grade C, the onset of bleeding was in median 13 days after the index operation, ranging from 1 to 85 days. Twelve patients (63.2%) had sentinel bleeds. Surgery lead to definitive hemostatic control in six of eight patients (75.0%). Angiography was able to localize the bleeding source in 8/10 (80.0%) cases. The success rate of angiographic hemostasis was 8/8. (100.0%). The mortality rate among patients with postpancreatectomy hemorrhage Grade C was 2/19 (10.5%), and both fatalities occurred late as a consequence of eroded vessels in association with pancreaticogastrostomy. CONCLUSION Delayed hemorrhage is a serious complication after major pancreatic surgery.Sentinel bleed is an early warning sign. Postoperative pancreatic fistula and bile leakage are important risk factors for severe postpancreatectomy hemorrhage.
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Affiliation(s)
- D Ansari
- 1 Department of Surgery, Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
| | - B Tingstedt
- 1 Department of Surgery, Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
| | - G Lindell
- 1 Department of Surgery, Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
| | - I Keussen
- 2 Department of Radiology, Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
| | - D Ansari
- 3 Department of Cardiothoracic Surgery, Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
| | - R Andersson
- 1 Department of Surgery, Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
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19
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Ansari D, Bauden M, Bergström S, Rylance R, Marko-Varga G, Andersson R. Relationship between tumour size and outcome in pancreatic ductal adenocarcinoma. Br J Surg 2017; 104:600-607. [PMID: 28177521 DOI: 10.1002/bjs.10471] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/10/2016] [Accepted: 11/28/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND The size of pancreatic ductal adenocarcinoma (PDAC) at diagnosis is an indicator of outcome. Previous studies have focused mostly on patients with resectable disease. The aim of this study was to investigate the relationship between tumour size and risk of metastasis and death in a large PDAC cohort, including all stages. METHODS Patients diagnosed with PDAC between 1988 and 2013 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Tumour size was defined as the maximum dimension of the tumour as provided by the registry. Metastatic spread was assessed, and survival was calculated according to size of the primary tumour using the Kaplan-Meier method. Cox proportional regression modelling was used to adjust for known confounders. RESULTS Some 58 728 patients were included. There were 187 patients (0·3 per cent) with a tumour size of 0·5 cm or less, in whom the rate of distant metastasis was 30·6 per cent. The probability of tumour dissemination was associated with tumour size at the time of diagnosis. The association between survival and tumour size was linear for patients with localized tumours, but stochastic in patients with regional and distant stages. In patients with resected tumours, increasing tumour size was associated with worse tumour-specific survival, whereas size was not associated with survival in patients with unresected tumours. In the adjusted Cox regression analysis, the death rate increased by 4·1 per cent for each additional 1-cm increase in tumour size. CONCLUSION Pancreatic cancer has a high metastatic capacity even in small tumours. The prognostic impact of tumour size is restricted to patients with localized disease.
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Affiliation(s)
- D Ansari
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund University, Lund, Sweden
| | - M Bauden
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund University, Lund, Sweden
| | - S Bergström
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund University, Lund, Sweden
| | - R Rylance
- National Registry Centre, Skåne University Hospital, Lund University, Lund, Sweden
| | - G Marko-Varga
- Department of Biomedical Engineering, Clinical Protein Science and Imaging, Lund University, Lund, Sweden
| | - R Andersson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund University, Lund, Sweden
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Kristl T, Bauden M, Ansari D, Andersson R, Marko-Varga G. Comprehensive analysis of histone related modifications of formaldehyde fixed paraffin embedded and fresh frozen pancreatic tumor xenografts using LC-MS/MS. Ann Oncol 2016. [DOI: 10.1093/annonc/mdw363.74] [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: 11/12/2022] Open
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Ansari D, Stehlik J, Lund L, Andersson B, Edwards L, Nilsson J. Induction Immunosuppression Strategies and Long-Term Outcomes after Heart Transplantation. J Heart Lung Transplant 2016. [DOI: 10.1016/j.healun.2016.01.171] [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: 10/22/2022] Open
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Chapman CS, Gallivan JP, Wood DK, Milne JL, Ansari D, Culham JC, Goodale MA. Counting on the motor system: Rapid action planning reveals the format- and magnitude-dependent extraction of numerical quantity. J Vis 2014; 14:30. [DOI: 10.1167/14.3.30] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Ansari D, Rosendahl A, Elebro J, Andersson R. Systematic review of immunohistochemical biomarkers to identify prognostic subgroups of patients with pancreatic cancer. Br J Surg 2011; 98:1041-55. [PMID: 21644238 DOI: 10.1002/bjs.7574] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) carries a dismal prognosis. There is a need to identify prognostic subtypes of PDAC to predict clinical and therapeutic outcomes accurately, and define novel therapeutic targets. The purpose of this review was to provide a systematic summary and review of available data on immunohistochemical (IHC) prognostic and predictive markers in patients with PDAC. METHODS Relevant articles in English published between January 1990 and June 2010 were obtained from PubMed searches. Other articles identified from cross-checking references and additional sources were reviewed. The inclusion was limited to studies evaluating IHC markers in a multivariable setting. RESULTS Database searches identified 76 independent prognostic and predictive molecular markers implicated in pancreatic tumour growth, apoptosis, angiogenesis, invasion and resistance to chemotherapy. Of these, 11 markers (Ki-67, p27, p53, transforming growth factor β1, Bcl-2, survivin, vascular endothelial growth factor, cyclo-oxygenase 2, CD34, S100A4 and human equilibrative nucleoside transporter 1) provided independent prognostic or predictive information in two or more separate studies. CONCLUSION None of the molecular markers described can be recommended for routine clinical use as they were identified in small cohorts and there were inconsistencies between studies. Their prognostic and predictive values need to be validated further in prospective multicentre studies in larger patient populations. A panel of molecular markers may become useful in predicting individual patient outcome and directing novel types of intervention.
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Affiliation(s)
- D Ansari
- Department of Surgery, Lund University and Skåne University Hospital Lund, Lund, Sweden
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Abstract
Abstract
Background
Haemorrhage is a rare, potentially fatal complication in acute pancreatitis (AP). The aim was to investigate the incidence, management and outcome related to this complication.
Methods
The medical records of all patients with AP who presented to a single hospital between January 1994 and July 2009 were reviewed retrospectively. Patients who developed at least one in-hospital episode of major haemorrhage were selected. The aetiology, patient characteristics, occurrence of sentinel bleeding, clinical management and outcome were recorded.
Results
Fourteen (1·0 per cent) of 1356 patients diagnosed with AP developed major haemorrhage. Angiography established the diagnosis in four of six patients. Embolization was successful in one patient. Surgery was performed in two patients. Sentinel bleeding occurred in three of four patients with major postoperative bleeding. The overall mortality rate was 36 per cent (5 of 14 patients). Haemorrhage presenting after more than 7 days was associated with a higher mortality rate of 80 per cent (4 of 5 patients). A fatal outcome was at least three times more likely in patients with severe AP and haemorrhagic complications than in those with severe AP but no bleeding.
Conclusion
Major haemorrhagic complications of AP are rare, but clinically important. Major postoperative bleeding is often preceded by sentinel bleeding. Intra-abdominal haemorrhage presenting more than 1 week after disease onset is a highly fatal complication.
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Affiliation(s)
- E Andersson
- Department of Surgery, Clinical Sciences Lund, Lund University and Lund University Hospital, SE-221 85 Lund, Sweden
| | - D Ansari
- Department of Surgery, Clinical Sciences Lund, Lund University and Lund University Hospital, SE-221 85 Lund, Sweden
| | - R Andersson
- Department of Surgery, Clinical Sciences Lund, Lund University and Lund University Hospital, SE-221 85 Lund, Sweden
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van Eimeren L, Grabner RH, Koschutnig K, Reishofer G, Ebner F, Ansari D. Structure-function relationships underlying calculation: a combined diffusion tensor imaging and fMRI study. Neuroimage 2010; 52:358-63. [PMID: 20382234 DOI: 10.1016/j.neuroimage.2010.04.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2009] [Revised: 03/26/2010] [Accepted: 04/01/2010] [Indexed: 11/18/2022] Open
Abstract
Both neuropsychological and functional neuroimaging studies have identified brain regions that are critical for the neurocognitive processes related to the calculation of arithmetic problems. In particular, the left angular gyrus (lAG) has been repeatedly implicated in arithmetic problem solving and found to be most activated during the retrieval of arithmetic facts. While significant progress has been made in determining the functional role of specific grey matter areas underlying calculation, very little is known about the relationship between these activated regions and their underlying white matter structures. In this study, we collected both diffusion tensor imaging (DTI) and functional magnetic resonance imaging (fMRI) data while participants performed a mental arithmetic task. Fractional anisotropy (FA) values were extracted from predefined, hypothesis-driven, white matter regions and correlated with fMRI activation values, which were extracted from anatomically defined grey matter regions. Results indicated structure-function relationships on multiple levels. Specifically, a link between the integrity of the left superior corona radiata (SCR) and neural activity in the lAG during calculation was observed, which was found to be particularly strong for problems that have a high probability of being solved via the retrieval of arithmetic facts (problems with a relatively small problem size). The findings reported provide a link between functional activation and structural integrity of grey and white matter regions in the left temporoparietal cortex, thereby contributing to our understanding of the role of both the function and structure of this brain region in calculation.
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Affiliation(s)
- L van Eimeren
- Department of Psychology, University of Western Ontario, Ontario, Canada
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Terracciano A, Martin B, Ansari D, Tanaka T, Ferrucci L, Maudsley S, Mattson MP, Costa PT. Plasma BDNF concentration, Val66Met genetic variant and depression-related personality traits. Genes Brain Behav 2010; 9:512-8. [PMID: 20345896 DOI: 10.1111/j.1601-183x.2010.00579.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Brain-derived neurotrophic factor (BDNF) regulates synaptic plasticity and neurogenesis, and BDNF plasma and serum levels have been associated with depression, Alzheimer's disease, and other psychiatric and neurodegenerative disorders. In a relatively large community sample, drawn from the Baltimore Longitudinal Study of Aging (BLSA), we examine whether BDNF plasma concentration is associated with the Val66Met functional polymorphism of the BDNF gene (n = 335) and with depression-related personality traits assessed with the NEO-PI-R (n = 391). Plasma concentration of BDNF was not associated with the Val66Met variant in either men or women. However, in men, but not in women, BDNF plasma level was associated with personality traits linked to depression. Contrary to the notion that low BDNF is associated with negative outcomes, we found lower plasma levels in men who score lower on depression and vulnerability to stress (two facets of Neuroticism) and higher on Conscientiousness and Extraversion. These findings challenge the prevailing hypothesis that lower peripheral levels of BDNF are a marker of depression.
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Affiliation(s)
- A Terracciano
- Laboratory of Personality and Cognition, National Institute on Aging, Baltimore, MD 21224, USA.
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van Eimeren L, Ansari D, Grabner RH, Bosma R, Koschutnig K, Reishofer G, Ebner F, Neuper C. White matter microstructure integrity of the left superior corona radiata is related to activation differences in the left angular gyrus during calculation. Neuroimage 2009. [DOI: 10.1016/s1053-8119(09)71011-0] [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: 11/24/2022] Open
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Ansari D, Grabner RH, Koschutnig K, Reishofer G, Ebner F, Neuper C. Individual differences in mathematical competence modulate brain responses to arithmetic errors: an fMRI study. Neuroimage 2009. [DOI: 10.1016/s1053-8119(09)70692-5] [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] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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