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Hsu E, Nguyen A, Sanjiv N, Desai M, Blaney D, Rowe SG. A case of accommodation-induced lens subluxation with iris displacement causing intermittent angle closure. Am J Ophthalmol Case Rep 2024; 34:102014. [PMID: 38389701 PMCID: PMC10883782 DOI: 10.1016/j.ajoc.2024.102014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 01/26/2024] [Accepted: 02/04/2024] [Indexed: 02/24/2024] Open
Abstract
Purpose To present an uncommon cause of intermittent angle closure in a young adult patient presenting with intermittent headache and blurry vision exacerbated by accommodation. Observations A 37-year-old man reported experiencing intermittent blurry vision, headache, and pain in both eyes associated with prolonged periods of reading beginning at age 17. Serial intraocular pressure (IOP) measurements showed an increase in IOP from 14 to 32 mmHg in the right eye and from 9 to 37 mmHg in the left eye after 145 minutes of sustained accommodation while sitting up. IOP did not normalize after laser peripheral iridotomy but did normalize after clear lens extraction. Conclusions and importance This case characterized a rare presentation of accommodation-induced IOP elevation in a young adult male that resolved only after clear lens extraction. The clinical takeaway was the importance of considering accommodation-associated angle closure in patients presenting with high intraocular pressures, eye strain, and/or headache with accommodative activities. Notable symptoms that should raise suspicion for this syndrome include halos, changes in visual acuity, and headache with accommodation. We suggested that patients presenting with these symptoms be followed closely, with a full glaucoma evaluation including gonioscopy and possible ultrasound biomicroscopy to assess for pediatric eversional angle closure with headache, plateau iris, angle closure glaucoma, and lens-induced angle closure.
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Affiliation(s)
- Eugene Hsu
- Department of Ophthalmology, Boston University Chobanian & Avedisian School of Medicine, 85 East Concord Street, 8th Floor, Boston, MA, 02118, USA
| | - Anh Nguyen
- Department of Ophthalmology, Boston University Chobanian & Avedisian School of Medicine, 85 East Concord Street, 8th Floor, Boston, MA, 02118, USA
| | - Nayan Sanjiv
- Department of Ophthalmology, Boston University Chobanian & Avedisian School of Medicine, 85 East Concord Street, 8th Floor, Boston, MA, 02118, USA
| | - Manishi Desai
- Department of Ophthalmology, Boston University Chobanian & Avedisian School of Medicine, 85 East Concord Street, 8th Floor, Boston, MA, 02118, USA
| | - Daryl Blaney
- Department of Psychiatry, University of Massachusetts Memorial Health - Harrington Hospital, 340 Thompson Road, Webster, MA, 01570, USA
| | - Susannah G Rowe
- Department of Ophthalmology, Boston University Chobanian & Avedisian School of Medicine, 85 East Concord Street, 8th Floor, Boston, MA, 02118, USA
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2
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Pham JP, Zdanska O, Selga M, Javier J, O'Grady A, Chin V, Forstner D, Hsu E, Liu J. Oncolytic viruses to augment PD‐1 inhibition in metastatic cutaneous squamous cell carcinoma. J Dtsch Dermatol Ges 2024. [PMID: 38679789 DOI: 10.1111/ddg.15423] [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: 07/31/2023] [Accepted: 02/29/2024] [Indexed: 05/01/2024]
Affiliation(s)
- James P Pham
- Department of Medical Oncology, The Kinghorn Cancer Centre, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
- School of Clinical Medicine, UNSW Medicine and Health, St Vincent's Clinical Campus, Darlinghurst, NSW, Australia
| | - Oksana Zdanska
- Department of Medical Oncology, The Kinghorn Cancer Centre, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - Mariz Selga
- Department of Medical Oncology, The Kinghorn Cancer Centre, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - Janelle Javier
- Department of Medical Oncology, The Kinghorn Cancer Centre, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - Aaron O'Grady
- Department of Medical Oncology, The Kinghorn Cancer Centre, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - Venessa Chin
- Department of Medical Oncology, The Kinghorn Cancer Centre, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
- School of Clinical Medicine, UNSW Medicine and Health, St Vincent's Clinical Campus, Darlinghurst, NSW, Australia
| | - Dion Forstner
- School of Clinical Medicine, UNSW Medicine and Health, St Vincent's Clinical Campus, Darlinghurst, NSW, Australia
- GenesisCare Radiation Oncology, St Vincent's Clinic, Darlinghurst, NSW, Australia
| | - Eugene Hsu
- School of Clinical Medicine, UNSW Medicine and Health, St Vincent's Clinical Campus, Darlinghurst, NSW, Australia
- Department of Radiology, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - Jia Liu
- Department of Medical Oncology, The Kinghorn Cancer Centre, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
- School of Clinical Medicine, UNSW Medicine and Health, St Vincent's Clinical Campus, Darlinghurst, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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3
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Gordon AS, Shambhu S, Xia Y, Bowers PN, Sloop S, Hsu E. Clinical and healthcare utilization outcomes during the 6 months following COVID infection in children. Pediatr Res 2024; 95:342-349. [PMID: 37587368 DOI: 10.1038/s41390-023-02762-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 05/30/2023] [Accepted: 07/16/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND We aimed to identify the impact of COVID infection in children in the US prior to vaccine availability on clinical and healthcare utilization outcomes within 6 months of infection. METHODS Using claims data from a large national insurer, we identified 223,842 children with a COVID diagnosis in May 2020-March 2021 and matched them to 223,842 children with a COVID test and no diagnosis. We compared the two cohorts' outcomes during the 6 months after infection/test. RESULTS Uncommon acute adverse events occurring in <0.5% of cases, including MIS-C (relative risk (RR) = 45.2), myocarditis (RR = 10.3), acute heart failure (RR = 2.14), sepsis (RR = 2.02), and viral pneumonia (RR = 2.43) were more frequent in the COVID cohort (all p < 0.001). Development of arrhythmias (RR = 1.24, p < 0.001) and atherosclerotic cardiovascular disease (RR = 1.41, p = 0.007) were more common in the COVID group, while behavioral health disorders were less common (RR = 0.94, p < 0.001). Lab testing and imaging were slightly higher in the COVID group (RR ranging 1.05-1.11 depending on the service and timeframe), though medical costs did not increase. CONCLUSION Severe disease and diagnoses of new conditions are rare in children following COVID infection. We observed an increase in cardiac complications, though they may not last long term. IMPACT Few studies have analyzed the association between COVID infection and medium-term outcomes in children. Our study of >447,000 geographically and socioeconomically diverse children in the US found that uncommon acute adverse events, including myocarditis, MIS-C, and acute heart failure, were more frequent in children with COVID than matched controls, and development of arrhythmias and cardiovascular disease were 1.2 and 1.4 times more common, respectively. Six-month healthcare utilization was similar between cohorts. We provide data on the risks of COVID in children, particularly with respect to cardiac complications, that decision makers may find useful when weighing the benefits and harms of preventive measures.
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Affiliation(s)
- Aliza S Gordon
- Public Policy Institute, Elevance Health, Inc., Indianapolis, IN, 46204, USA.
| | - Sonali Shambhu
- Public Policy Institute, Elevance Health, Inc., Indianapolis, IN, 46204, USA
| | - Yaoxuan Xia
- Carelon Research, Wilmington, DE, 19801, USA
| | - Peter N Bowers
- Population Health Management Support, Elevance Health, Inc., Indianapolis, IN, 46204, USA
| | - Sue Sloop
- Health Economics, Elevance Health, Inc., Indianapolis, IN, 46204, USA
| | - Eugene Hsu
- Medicare Clinical Operations, Elevance Health, Inc., Indianapolis, IN, 46204, USA
- Stanford University School of Medicine, Stanford, CA, 94305, USA
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Hsu E, Milstein A, Choudhry N. Biopsychosocial Intervention or Postural Therapy in Patients With Spine Pain-Reply. JAMA 2023; 329:1408-1409. [PMID: 37097357 DOI: 10.1001/jama.2023.3062] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Affiliation(s)
- Eugene Hsu
- Clinical Excellence Research Center, Stanford University School of Medicine, Palo Alto, California
| | - Arnold Milstein
- Clinical Excellence Research Center, Stanford University School of Medicine, Palo Alto, California
| | - Niteesh Choudhry
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Hsu E, Desai M. Glaucoma and Systemic Disease. Life (Basel) 2023; 13:life13041018. [PMID: 37109547 PMCID: PMC10143901 DOI: 10.3390/life13041018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/09/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
Glaucoma is the leading cause of irreversible blindness in the world. Due to its potential to cause permanent vision loss, it is important to understand how systemic conditions and their respective treatments can be associated with or increase the risk for developing glaucoma. In this review, we examined the literature for up-to-date discussions and provided commentary on glaucoma, its pathophysiology, and associated risk factors. We discuss systemic diseases and the impact, risk, and mechanism for developing glaucoma, including pharmacologically induced glaucoma; inflammatory and auto-immune conditions; infectious, dermatologic, cardiovascular, pulmonary, renal, urologic, neurologic, psychiatric and systemic malignancies: intraocular tumors; as well as pediatric, and genetic conditions. The goal of our discussion of systemic conditions including their commonality, mechanisms, treatments, and associations with developing glaucoma is to emphasize the importance of ocular examinations and follow-up with the multidisciplinary teams involved in the care of each patient to prevent unnecessary vision-loss.
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Affiliation(s)
- Eugene Hsu
- Department of Ophthalmology, Boston University School of Medicine, 85 East Concord Street, 8th Floor, Boston, MA 02118, USA
| | - Manishi Desai
- Department of Ophthalmology, Boston University School of Medicine, 85 East Concord Street, 8th Floor, Boston, MA 02118, USA
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Choudhry NK, Fifer S, Fontanet CP, Archer KR, Sears E, Bhatkhande G, Haff N, Ghazinouri R, Coronado RA, Schneider BJ, Butterworth SW, Deogun H, Cooper A, Hsu E, Block S, Davidson CA, Shackelford CE, Goyal P, Milstein A. Effect of a Biopsychosocial Intervention or Postural Therapy on Disability and Health Care Spending Among Patients With Acute and Subacute Spine Pain: The SPINE CARE Randomized Clinical Trial. JAMA 2022; 328:2334-2344. [PMID: 36538309 PMCID: PMC9856689 DOI: 10.1001/jama.2022.22625] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 11/17/2022] [Indexed: 12/24/2022]
Abstract
Importance Low back and neck pain are often self-limited, but health care spending remains high. Objective To evaluate the effects of 2 interventions that emphasize noninvasive care for spine pain. Design, Setting, and Participants Pragmatic, cluster, randomized clinical trial conducted at 33 centers in the US that enrolled 2971 participants with neck or back pain of 3 months' duration or less (enrollment, June 2017 to March 2020; final follow-up, March 2021). Interventions Participants were randomized at the clinic-level to (1) usual care (n = 992); (2) a risk-stratified, multidisciplinary intervention (the identify, coordinate, and enhance [ICE] care model that combines physical therapy, health coach counseling, and consultation from a specialist in pain medicine or rehabilitation) (n = 829); or (3) individualized postural therapy (IPT), a postural therapy approach that combines physical therapy with building self-efficacy and self-management (n = 1150). Main Outcomes and Measures The primary outcomes were change in Oswestry Disability Index (ODI) score at 3 months (range, 0 [best] to 100 [worst]; minimal clinically important difference, 6) and spine-related health care spending at 1 year. A 2-sided significance threshold of .025 was used to define statistical significance. Results Among 2971 participants randomized (mean age, 51.7 years; 1792 women [60.3%]), 2733 (92%) finished the trial. Between baseline and 3-month follow-up, mean ODI scores changed from 31.2 to 15.4 for ICE, from 29.3 to 15.4 for IPT, and from 28.9 to 19.5 for usual care. At 3-month follow-up, absolute differences compared with usual care were -5.8 (95% CI, -7.7 to -3.9; P < .001) for ICE and -4.3 (95% CI, -5.9 to -2.6; P < .001) for IPT. Mean 12-month spending was $1448, $2528, and $1587 in the ICE, IPT, and usual care groups, respectively. Differences in spending compared with usual care were -$139 (risk ratio, 0.93 [95% CI, 0.87 to 0.997]; P = .04) for ICE and $941 (risk ratio, 1.40 [95% CI, 1.35 to 1.45]; P < .001) for IPT. Conclusions and Relevance Among patients with acute or subacute spine pain, a multidisciplinary biopsychosocial intervention or an individualized postural therapy intervention, each compared with usual care, resulted in small but statistically significant reductions in pain-related disability at 3 months. However, compared with usual care, the biopsychosocial intervention resulted in no significant difference in spine-related health care spending and the postural therapy intervention resulted in significantly greater spine-related health care spending at 1 year. Trial Registration ClinicalTrials.gov Identifier: NCT03083886.
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Affiliation(s)
- Niteesh K. Choudhry
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sheila Fifer
- Clinical Excellence Research Center, Stanford University School of Medicine, Palo Alto, California
| | - Constance P. Fontanet
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kristin R. Archer
- Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Physical Medicine and Rehabilitation, Osher Center for Integrative Health, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ellen Sears
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Gauri Bhatkhande
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Nancy Haff
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Roya Ghazinouri
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Rogelio A. Coronado
- Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Physical Medicine and Rehabilitation, Osher Center for Integrative Health, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Byron J. Schneider
- Department of Physical Medicine & Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Susan W. Butterworth
- Center for Health System Improvement, University of Tennessee Health Science Center, Memphis
| | | | - Angelina Cooper
- HonorHealth Clinical Research Institute, Scottsdale, Arizona
| | - Eugene Hsu
- Clinical Excellence Research Center, Stanford University School of Medicine, Palo Alto, California
| | - Shannon Block
- Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Physical Medicine and Rehabilitation, Osher Center for Integrative Health, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Claudia A. Davidson
- Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Claude E. Shackelford
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Parul Goyal
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Arnold Milstein
- Clinical Excellence Research Center, Stanford University School of Medicine, Palo Alto, California
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Kansara M, Bhardwaj N, Thavaneswaran S, Xu C, Lee JK, Chang L, Madison RW, Lin F, Hsu E, Patel VK, Aleshin A, Oxnard GR, Simes J, Nimeiri H, Thomas DM. Early circulating tumor DNA dynamics as a pan-tumor biomarker for long-term clinical outcome in patients treated with durvalumab and tremelimumab. Mol Oncol 2022; 17:298-311. [PMID: 36426653 PMCID: PMC9892824 DOI: 10.1002/1878-0261.13349] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 10/13/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022] Open
Abstract
There is an urgent need to identify biomarkers of early response that can accurately predict the benefit of immune checkpoint inhibitors (ICI). Patients receiving durvalumab/tremelimumab had tumor samples sequenced before treatment (baseline) to identify variants for the design of a personalized circulating tumor (ctDNA) assay. ctDNA was assessed at baseline and at 4 and/or 8 weeks into treatment. Correlations between ctDNA changes to radiographic response and overall survival (OS) were made to assess potential clinical benefit. 35/40 patients (87.5%) had personalized ctDNA assays designed, and 29/35 (82.9%) had plasma available for baseline analysis, representing 16 unique solid tumor histologies. As early as 4 weeks after treatment, decline in ctDNA from baseline predicted improved OS (P = 0.0144; HR = 9.98) and ctDNA changes on treatment-supported and refined radiographic response calls. ctDNA clearance at any time through week 8 identified complete responders by a median lead time of 11.5 months ahead of radiographic imaging. ctDNA response monitoring is emerging as a dynamic, personalized biomarker method that may predict survival outcomes in patients with diverse solid tumor histologies, complementing and sometimes preceding standard-of-care imaging assessments.
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Affiliation(s)
- Maya Kansara
- The Kinghorn Cancer CentreGarvan Institute of Medical ResearchDarlinghurstNSWAustralia,Faculty of Medicine, St. Vincent's Clinical SchoolUNSW SydneyKensingtonNSWAustralia
| | | | - Subotheni Thavaneswaran
- The Kinghorn Cancer CentreGarvan Institute of Medical ResearchDarlinghurstNSWAustralia,Faculty of Medicine, St. Vincent's Clinical SchoolUNSW SydneyKensingtonNSWAustralia,National Health and Medical Research Council Clinical Trials CentreUniversity of SydneyNSWAustralia
| | - Chang Xu
- Foundation Medicine, Inc.CambridgeMAUSA
| | | | | | | | - Frank Lin
- The Kinghorn Cancer CentreGarvan Institute of Medical ResearchDarlinghurstNSWAustralia,Faculty of Medicine, St. Vincent's Clinical SchoolUNSW SydneyKensingtonNSWAustralia,National Health and Medical Research Council Clinical Trials CentreUniversity of SydneyNSWAustralia
| | - Eugene Hsu
- Radiology DepartmentSt Vincent's HospitalSydneyNSWAustralia
| | | | | | | | - John Simes
- National Health and Medical Research Council Clinical Trials CentreUniversity of SydneyNSWAustralia
| | | | - David M. Thomas
- The Kinghorn Cancer CentreGarvan Institute of Medical ResearchDarlinghurstNSWAustralia,Faculty of Medicine, St. Vincent's Clinical SchoolUNSW SydneyKensingtonNSWAustralia
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8
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Fifer SK, Choundry NK, Brod M, Hsu E, Milstein A. Improving adherence to guidelines for spine pain care: what tools could support primary care clinicians in conforming to guidelines? BMJ Open Qual 2022; 11:bmjoq-2022-001868. [PMID: 35944933 PMCID: PMC9367179 DOI: 10.1136/bmjoq-2022-001868] [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] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 07/27/2022] [Indexed: 11/22/2022] Open
Abstract
Background Spine pain is one of the most common conditions seen in primary care and is often treated with ineffective, aggressive interventions, such as prescription pain medications, imagery and referrals to surgery. Aggressive treatments are associated with negative side effects and high costs while conservative care has lower risks and costs and equivalent or better outcomes. Despite multiple well-publicised treatment guidelines and educational efforts recommending conservative care, primary care clinicians (PCCs) widely continue to prescribe aggressive, low-value care for spine pain. Methods In this qualitative study semistructured interviews were conducted with PCCs treating spine pain patients to learn what prevents clinicians from following guidelines and what tools or support could promote conservative care. Interviews were conducted by telephone, transcribed and coded for thematic analysis. Results Forty PCCs in academic and private practice were interviewed. Key reflections included that while familiar with guidelines recommending conservative treatment, they did not find guidelines useful or relevant to care decisions for individual patients. They believed that there is an insufficient body of real-world evidence supporting positive outcomes for conservative care and guidance recommendations. They indicated that spine pain patients frequently request aggressive care. These requests, combined with the PCCs’ commitment to reaching shared treatment decisions with patients, formed a key reason for pursuing aggressive care. PCCs reported not being familiar with risk-screening tools for spine patients but indicated that such screens might increase their confidence to recommend conservative care to low-risk patients. Conclusions PCCs may be more willing to give conservative, guideline-consistent care for spine pain if they had tools to assist in making patient-specific evaluations and in countering requests for unneeded aggressive care. Such tools would include both patient risk screens and shared decision-making aids that include elements for resolving patient demands for inappropriate care.
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Affiliation(s)
- Sheila Kean Fifer
- School of Medicine, Stanford University, Clinical Excellence Research Center, Palo Alto, California, USA
| | - Niteesh K Choundry
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Meryl Brod
- The Brod Group, Mill Valley, California, USA
| | - Eugene Hsu
- Government Business Division, Elevance Health, Indianapolis, Indiana, USA
| | - Arnold Milstein
- School of Medicine, Stanford University, Clinical Excellence Research Center, Palo Alto, California, USA
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9
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Choudhry NK, Fontanet CP, Ghazinouri R, Fifer S, Archer KR, Haff N, Butterworth SW, Deogun H, Block S, Cooper A, Sears E, Goyal P, Coronado RA, Schneider BJ, Hsu E, Milstein A. Design of the Spine Pain Intervention to Enhance Care Quality And Reduce Expenditure Trial (SPINE CARE) study: Methods and lessons from a multi-site pragmatic cluster randomized controlled trial. Contemp Clin Trials 2021; 111:106602. [PMID: 34688915 DOI: 10.1016/j.cct.2021.106602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 10/14/2021] [Accepted: 10/17/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Low back and neck pain (together, spine pain) are among the leading causes of medical visits, lost productivity, and disability. For most people, episodes of spine pain are self-limited; nevertheless, healthcare spending for this condition is extremely high. Focusing care on individuals at high-risk of progressing from acute to chronic pain may improve efficiency. Alternatively, postural therapies, which are frequently used by patients, may prevent the overuse of high-cost interventions while delivering equivalent outcomes. METHODS The SPINE CARE (Spine Pain Intervention to Enhance Care Quality And Reduce Expenditure) trial is a cluster-randomized multi-center pragmatic clinical trial designed to evaluate the clinical effectiveness and healthcare utilization of two interventions for primary care patients with acute and subacute spine pain. The study was conducted at 33 primary care clinics in geographically distinct regions of the United States. Individuals ≥18 years presenting to primary care with neck and/or back pain of ≤3 months' duration were randomized at the clinic-level to 1) usual care, 2) a risk-stratified, multidisciplinary approach called the Identify, Coordinate, and Enhance (ICE) care model, or 3) Individualized Postural Therapy (IPT), a standardized postural therapy method of care. The trial's two primary outcomes are change in function at 3 months and spine-related spending at one year. 2971 individuals were enrolled between June 2017 and March 2020. Follow-up was completed on March 31, 2021. DISCUSSION The SPINE CARE trial will determine the impact on clinical outcomes and healthcare costs of two interventions for patients with spine pain presenting to primary care. TRIAL REGISTRATION NUMBER NCT03083886.
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Affiliation(s)
- Niteesh K Choudhry
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
| | - Constance P Fontanet
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Roya Ghazinouri
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sheila Fifer
- Clinical Excellence Research Center, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Kristin R Archer
- Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Physical Medicine and Rehabilitation, Osher Center for Integrative Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nancy Haff
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Susan W Butterworth
- Center for Health System Improvement, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Harvinder Deogun
- HonorHealth Clinical Research Institute, Scottsdale, Arizona, USA
| | - Shannon Block
- Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Physical Medicine and Rehabilitation, Osher Center for Integrative Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Angelina Cooper
- HonorHealth Clinical Research Institute, Scottsdale, Arizona, USA
| | - Ellen Sears
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Parul Goyal
- Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rogelio A Coronado
- Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Physical Medicine and Rehabilitation, Osher Center for Integrative Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Byron J Schneider
- Department of Physical Medicine & Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eugene Hsu
- Clinical Excellence Research Center, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Arnold Milstein
- Clinical Excellence Research Center, Stanford University School of Medicine, Palo Alto, CA, USA
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Grivas P, Khaki AR, Wise-Draper TM, French B, Hennessy C, Hsu CY, Shyr Y, Li X, Choueiri TK, Painter CA, Peters S, Rini BI, Thompson MA, Mishra S, Rivera DR, Acoba JD, Abidi MZ, Bakouny Z, Bashir B, Bekaii-Saab T, Berg S, Bernicker EH, Bilen MA, Bindal P, Bishnoi R, Bouganim N, Bowles DW, Cabal A, Caimi PF, Chism DD, Crowell J, Curran C, Desai A, Dixon B, Doroshow DB, Durbin EB, Elkrief A, Farmakiotis D, Fazio A, Fecher LA, Flora DB, Friese CR, Fu J, Gadgeel SM, Galsky MD, Gill DM, Glover MJ, Goyal S, Grover P, Gulati S, Gupta S, Halabi S, Halfdanarson TR, Halmos B, Hausrath DJ, Hawley JE, Hsu E, Huynh-Le M, Hwang C, Jani C, Jayaraj A, Johnson DB, Kasi A, Khan H, Koshkin VS, Kuderer NM, Kwon DH, Lammers PE, Li A, Loaiza-Bonilla A, Low CA, Lustberg MB, Lyman GH, McKay RR, McNair C, Menon H, Mesa RA, Mico V, Mundt D, Nagaraj G, Nakasone ES, Nakayama J, Nizam A, Nock NL, Park C, Patel JM, Patel KG, Peddi P, Pennell NA, Piper-Vallillo AJ, Puc M, Ravindranathan D, Reeves ME, Reuben DY, Rosenstein L, Rosovsky RP, Rubinstein SM, Salazar M, Schmidt AL, Schwartz GK, Shah MR, Shah SA, Shah C, Shaya JA, Singh SRK, Smits M, Stockerl-Goldstein KE, Stover DG, Streckfuss M, Subbiah S, Tachiki L, Tadesse E, Thakkar A, Tucker MD, Verma AK, Vinh DC, Weiss M, Wu JT, Wulff-Burchfield E, Xie Z, Yu PP, Zhang T, Zhou AY, Zhu H, Zubiri L, Shah DP, Warner JL, Lopes G. Association of clinical factors and recent anticancer therapy with COVID-19 severity among patients with cancer: a report from the COVID-19 and Cancer Consortium. Ann Oncol 2021; 32:787-800. [PMID: 33746047 PMCID: PMC7972830 DOI: 10.1016/j.annonc.2021.02.024] [Citation(s) in RCA: 202] [Impact Index Per Article: 67.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/18/2021] [Accepted: 02/28/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Patients with cancer may be at high risk of adverse outcomes from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We analyzed a cohort of patients with cancer and coronavirus 2019 (COVID-19) reported to the COVID-19 and Cancer Consortium (CCC19) to identify prognostic clinical factors, including laboratory measurements and anticancer therapies. PATIENTS AND METHODS Patients with active or historical cancer and a laboratory-confirmed SARS-CoV-2 diagnosis recorded between 17 March and 18 November 2020 were included. The primary outcome was COVID-19 severity measured on an ordinal scale (uncomplicated, hospitalized, admitted to intensive care unit, mechanically ventilated, died within 30 days). Multivariable regression models included demographics, cancer status, anticancer therapy and timing, COVID-19-directed therapies, and laboratory measurements (among hospitalized patients). RESULTS A total of 4966 patients were included (median age 66 years, 51% female, 50% non-Hispanic white); 2872 (58%) were hospitalized and 695 (14%) died; 61% had cancer that was present, diagnosed, or treated within the year prior to COVID-19 diagnosis. Older age, male sex, obesity, cardiovascular and pulmonary comorbidities, renal disease, diabetes mellitus, non-Hispanic black race, Hispanic ethnicity, worse Eastern Cooperative Oncology Group performance status, recent cytotoxic chemotherapy, and hematologic malignancy were associated with higher COVID-19 severity. Among hospitalized patients, low or high absolute lymphocyte count; high absolute neutrophil count; low platelet count; abnormal creatinine; troponin; lactate dehydrogenase; and C-reactive protein were associated with higher COVID-19 severity. Patients diagnosed early in the COVID-19 pandemic (January-April 2020) had worse outcomes than those diagnosed later. Specific anticancer therapies (e.g. R-CHOP, platinum combined with etoposide, and DNA methyltransferase inhibitors) were associated with high 30-day all-cause mortality. CONCLUSIONS Clinical factors (e.g. older age, hematological malignancy, recent chemotherapy) and laboratory measurements were associated with poor outcomes among patients with cancer and COVID-19. Although further studies are needed, caution may be required in utilizing particular anticancer therapies. CLINICAL TRIAL IDENTIFIER NCT04354701.
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Affiliation(s)
- P Grivas
- University of Washington/Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Seattle, USA.
| | - A R Khaki
- University of Washington/Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Seattle, USA; Stanford University, Stanford, USA
| | | | - B French
- Vanderbilt University Medical Center, Nashville, USA
| | - C Hennessy
- Vanderbilt University Medical Center, Nashville, USA
| | - C-Y Hsu
- Vanderbilt University Medical Center, Nashville, USA
| | - Y Shyr
- Vanderbilt University Medical Center, Nashville, USA
| | - X Li
- Vanderbilt University School of Medicine, Nashville, USA
| | | | - C A Painter
- Broad Institute, Cancer Program, Cambridge, USA
| | - S Peters
- Lausanne University, Lausanne, Switzerland
| | - B I Rini
- Vanderbilt University Medical Center, Nashville, USA
| | | | - S Mishra
- Vanderbilt University Medical Center, Nashville, USA
| | - D R Rivera
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, USA
| | - J D Acoba
- University of Hawaii Cancer Center, Honolulu, USA
| | - M Z Abidi
- University of Colorado School of Medicine, Aurora, USA
| | - Z Bakouny
- Dana-Farber Cancer Institute, Boston, USA
| | - B Bashir
- Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, USA
| | | | - S Berg
- Cardinal Bernardin Cancer Center, Loyola University Medical Center, Maywood, USA
| | | | - M A Bilen
- Winship Cancer Institute of Emory University, Atlanta, USA
| | - P Bindal
- Beth Israel Deaconess Medical Center, Boston, USA
| | - R Bishnoi
- University of Florida, Gainesville, USA
| | - N Bouganim
- McGill University Health Centre, Montréal, Canada
| | - D W Bowles
- University of Colorado School of Medicine, Aurora, USA
| | - A Cabal
- University of California San Diego, Moores Cancer Center, La Jolla, USA
| | - P F Caimi
- University Hospitals Seidman Cancer Center, Cleveland, USA; Case Western Reserve University, Cleveland, USA
| | - D D Chism
- Thompson Cancer Survival Center, Knoxville, USA
| | - J Crowell
- St. Elizabeth Healthcare, Edgewood, USA
| | - C Curran
- Dana-Farber Cancer Institute, Boston, USA
| | - A Desai
- Mayo Clinic Cancer Center, Rochester, USA
| | - B Dixon
- St. Elizabeth Healthcare, Edgewood, USA
| | - D B Doroshow
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - E B Durbin
- Markey Cancer Center, University of Kentucky, Lexington, USA
| | - A Elkrief
- McGill University Health Centre, Montréal, Canada
| | - D Farmakiotis
- The Warren Alpert Medical School of Brown University, Providence, USA
| | - A Fazio
- Tufts Medical Center Cancer Center, Boston and Stoneham, USA
| | - L A Fecher
- University of Michigan Rogel Cancer Center, Ann Arbor, USA
| | - D B Flora
- St. Elizabeth Healthcare, Edgewood, USA
| | - C R Friese
- University of Michigan Rogel Cancer Center, Ann Arbor, USA
| | - J Fu
- Tufts Medical Center Cancer Center, Boston and Stoneham, USA
| | - S M Gadgeel
- Henry Ford Cancer Institute/Henry Ford Health System, Detroit, USA
| | - M D Galsky
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - D M Gill
- Intermountain Healthcare, Salt Lake City, USA
| | | | - S Goyal
- George Washington University, Washington DC, USA
| | - P Grover
- University of Cincinnati Cancer Center, Cincinnati, USA
| | - S Gulati
- University of Cincinnati Cancer Center, Cincinnati, USA
| | - S Gupta
- Cleveland Clinic Taussig Cancer Institute, Cleveland, USA
| | | | | | - B Halmos
- Albert Einstein Cancer Center/Montefiore Medical Center, Bronx, USA
| | - D J Hausrath
- Vanderbilt University School of Medicine, Nashville, USA
| | - J E Hawley
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, USA
| | - E Hsu
- Hartford HealthCare, Hartford, USA; University of Connecticut, Farmington, USA
| | - M Huynh-Le
- George Washington University, Washington DC, USA
| | - C Hwang
- Henry Ford Cancer Institute/Henry Ford Health System, Detroit, USA
| | - C Jani
- Mount Auburn Hospital, Cambridge, USA
| | | | - D B Johnson
- Vanderbilt University Medical Center, Nashville, USA
| | - A Kasi
- University of Kansas Medical Center, Kansas City, USA
| | - H Khan
- The Warren Alpert Medical School of Brown University, Providence, USA
| | - V S Koshkin
- University of California, San Francisco, San Francisco, USA
| | - N M Kuderer
- Advanced Cancer Research Group, LLC, Kirkland, USA
| | - D H Kwon
- University of California, San Francisco, San Francisco, USA
| | | | - A Li
- Baylor College of Medicine, Houston, USA
| | | | - C A Low
- Intermountain Healthcare, Salt Lake City, USA
| | | | - G H Lyman
- University of Washington/Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Seattle, USA
| | - R R McKay
- University of California San Diego, Moores Cancer Center, La Jolla, USA
| | - C McNair
- Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, USA
| | - H Menon
- Penn State Health/Penn State Cancer Institute/St. Joseph Cancer Center, Hershey, USA
| | - R A Mesa
- Mays Cancer Center at UT Health San Antonio MD Anderson, San Antonio, USA
| | - V Mico
- Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, USA
| | - D Mundt
- Advocate Aurora Health, Milwaukee, USA
| | - G Nagaraj
- Loma Linda University Cancer Center, Loma Linda, USA
| | - E S Nakasone
- University of Washington/Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Seattle, USA
| | - J Nakayama
- Case Western Reserve University, Cleveland, USA; University Hospitals Cleveland Medical Center, Cleveland, USA
| | - A Nizam
- Cleveland Clinic Taussig Cancer Institute, Cleveland, USA
| | - N L Nock
- University Hospitals Seidman Cancer Center, Cleveland, USA; Case Western Reserve University, Cleveland, USA
| | - C Park
- University of Cincinnati Cancer Center, Cincinnati, USA
| | - J M Patel
- Beth Israel Deaconess Medical Center, Boston, USA
| | - K G Patel
- University of California Davis Comprehensive Cancer Center, Sacramento, USA
| | - P Peddi
- Willis-Knighton Cancer Center, Shreveport, USA
| | - N A Pennell
- Cleveland Clinic Taussig Cancer Institute, Cleveland, USA
| | | | - M Puc
- Virtua Health, Marlton, USA
| | | | - M E Reeves
- Loma Linda University Cancer Center, Loma Linda, USA
| | - D Y Reuben
- Medical University of South Carolina, Charleston, USA
| | | | - R P Rosovsky
- Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | | | - M Salazar
- Mays Cancer Center at UT Health San Antonio MD Anderson, San Antonio, USA
| | | | - G K Schwartz
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, USA
| | - M R Shah
- Rutgers Cancer Institute of New Jersey, New Brunswick, USA
| | - S A Shah
- Stanford University, Stanford, USA
| | - C Shah
- University of Florida, Gainesville, USA
| | - J A Shaya
- University of California San Diego, Moores Cancer Center, La Jolla, USA
| | - S R K Singh
- Henry Ford Cancer Institute/Henry Ford Health System, Detroit, USA
| | - M Smits
- ThedaCare Regional Cancer Center, Appleton, USA
| | | | - D G Stover
- The Ohio State University, Columbus, USA
| | | | - S Subbiah
- Stanley S. Scott Cancer Center, LSU Health Sciences Center, New Orleans, USA
| | - L Tachiki
- University of Washington/Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Seattle, USA
| | - E Tadesse
- Advocate Aurora Health, Milwaukee, USA
| | - A Thakkar
- Albert Einstein Cancer Center/Montefiore Medical Center, Bronx, USA
| | - M D Tucker
- Vanderbilt University Medical Center, Nashville, USA
| | - A K Verma
- Albert Einstein Cancer Center/Montefiore Medical Center, Bronx, USA
| | - D C Vinh
- McGill University Health Centre, Montréal, Canada
| | - M Weiss
- ThedaCare Regional Cancer Center, Appleton, USA
| | - J T Wu
- Stanford University, Stanford, USA
| | | | - Z Xie
- Mayo Clinic Cancer Center, Rochester, USA
| | - P P Yu
- Hartford HealthCare, Hartford, USA
| | - T Zhang
- Duke University, Durham, USA
| | - A Y Zhou
- Siteman Cancer Center, Washington University School of Medicine, St. Louis, USA
| | - H Zhu
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - L Zubiri
- Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - D P Shah
- Mays Cancer Center at UT Health San Antonio MD Anderson, San Antonio, USA
| | - J L Warner
- Vanderbilt University Medical Center, Nashville, USA
| | - GdL Lopes
- University of Miami/Sylvester Comprehensive Cancer Center, Miami, USA
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Zhao R, Cosman R, Aggarwal N, O'Grady A, Hsu E, Ardolino L, Xia H, Chi Y, Qui S, Murad Y, Lee E, Jia W, Joshua AM. Initial results from a first in human trial incorporating accelerated dose titration of a novel immune stimulating oncolytic virus - VG161. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e14574] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e14574 Background: Oncolytic virus (OV) can specifically replicate in cancer cells causing cell lysis. Together with the expression of immune stimulating payloads, OV can induce an anti-tumor immune response. The aim of this study is to assess the safety, tolerability, and PK profile of VG161, a novel HSV-1 OV armed with IL12, IL15 with its receptor α unit, and PD-L1 antagonist (Fc-fused 14 amino acid peptide), after single intra-tumoral injection (IT) in patients with advanced refractory solid tumors. Methods: This is an open label, single-arm, accelerated titration design pilot trial. Based on preclinical NOAEL, the first cohort dose level was calculated as 5×107/subject, followed with 2 cohorts (1×108 and 2×108 PFU), 1-3 patients per cohort. One patient was treated in each cohort and the subsequent cohorts were initiated only after the safety observation of the current cohort was completed (21 days) with no DLT and no > 2 moderate toxicity events deemed possibly, probably, or definitely related to VG161, otherwise, it would be expanded per the 3+3 design. DNA copy number of VG161 was measured with qPCR in the tumor biopsy and blood, in urine for virus shedding, as well as swabs of injection site and mouth. Immune cytokines were measured with MSD assay (electrochemiluminescence detection) in blood. Peripheral lymphocyte subsets were analyzed with flowcytometry. Results: Three patients (1 per cohort) were treated and completed safety observation. No DLT, and 10 AEs (fever, low neutrophils and lymphocytes, etc.) were possibly, probably, or definitely related. Grade 3 fever was the only related SAE, which recovered in 3 days. Dose dependent increase of VG161 DNA copy was detected in the tumor 2-3 days after treatment (C-max: 10, 1000, and 1000000 times increase from low to high dose), in contrast, it remained undetectable in blood, oral swab, and urine. Virus DNA was detected in injection site swab for the patient at the highest dose level but not for those treated at lower dose levels. After dosing, increases of IL-12 (C-max: 2.0, 2.4, and 21 times of baseline), IL-15 (C-max: 1.6, 3.2, and 2.5 times of baseline), IFN-γ (C-max: 49, 638, and 236 times of baseline) and TNF-α (C-max: 2.3, 3.7, and 2.2 times of baseline) from low to high dose were seen. Peripheral lymphocyte subset analysis and immune profiling of injected tumor are ongoing. Interestingly, partial regression of multiple visible non-injected lesions was observed in 1 patient shortly after dosing, however no durable direct or abscopal responses were seen to date. Conclusions: Single IT injection of VG161 up to 2×108 PFU/subject is safe and well tolerated, with no unexpected viral spread or shedding. The post-dose increase in cytokines and the transit regression of non-injected lesions imply the activation of anti-cancer immunity induced by VG161. This holds potential for further dose optimization to assess the safety and efficacy. Clinical trial information: ACTRN12620000244909.
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Affiliation(s)
| | | | - Neha Aggarwal
- Kinghorn Cancer Centre, St Vincents Hospital, Sydney, NSW, Australia
| | - Aaron O'Grady
- The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, NSW, Australia
| | - Eugene Hsu
- St Vincent's Hospital, Sydney, NSW, Australia
| | - Luke Ardolino
- Kinghorn Cancer Centre, St Vincents Hospital, Sydney, NSW, Australia
| | - Huiqun Xia
- Virogin Biotech Canada, Ltd., Vancouver, BC, Canada
| | - Yiting Chi
- Shanghai Virogin Biotech Co., Ltd., Shanghai, China
| | - Shi Qui
- CNBG-Virogin Biotech (Shanghai) Inc., Ltd., Shanghai, China
| | - Yanal Murad
- Virogin Biotech Canada Ltd., Vancouver, BC, Canada
| | - Erica Lee
- Virogin Biotech Canada Ltd., Vancouver, BC, Canada
| | - William Jia
- Virogin Biotech Canada Ltd., Vancouver, BC, Canada
| | - Anthony M. Joshua
- Kinghorn Cancer Centre, St Vincent's Hospital, Darlinghurst, NSW, Australia
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12
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Rosas HD, Hsu E, Mercaldo ND, Lai F, Pulsifer M, Keator D, Brickman AM, Price J, Yassa M, Hom C, Krinsky‐McHale SJ, Silverman W, Lott I, Schupf N. Alzheimer-related altered white matter microstructural integrity in Down syndrome: A model for sporadic AD? Alzheimers Dement (Amst) 2020; 12:e12040. [PMID: 33204811 PMCID: PMC7648416 DOI: 10.1002/dad2.12040] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/14/2020] [Accepted: 02/19/2020] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Virtually all adults with Down syndrome (DS) develop Alzheimer's disease (AD)-associated neuropathology by the age of 40, with risk for dementia increasing from the early 50s. White matter (WM) pathology has been reported in sporadic AD, including early demyelination, microglial activation, loss of oligodendrocytes and reactive astrocytes but has not been extensively studied in the at-risk DS population. METHODS Fifty-six adults with DS (35 cognitively stable adults, 11 with mild cognitive impairment, 10 with dementia) underwent diffusion-weighted magnetic resonance imaging (MRI), amyloid imaging, and had assessments of cognition and functional abilities using tasks appropriate for persons with intellectual disability. RESULTS Early changes in late-myelinating and relative sparing of early-myelinating pathways, consistent with the retrogenesis model proposed for sporadic AD, were associated with AD-related cognitive deficits and with regional amyloid deposition. DISCUSSION Our findings suggest that quantification of WM changes in DS could provide a promising and clinically relevant biomarker for AD clinical onset and progression.
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Affiliation(s)
- H. Diana Rosas
- Department of NeurologyMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
- Department of RadiologyAthinoula Martinos CenterMassachusetts General HospitalHarvard Medical SchoolCharlestownMassachusettsUSA
| | - Eugene Hsu
- Department of NeurologyMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
- Department of RadiologyAthinoula Martinos CenterMassachusetts General HospitalHarvard Medical SchoolCharlestownMassachusettsUSA
| | - Nathaniel D. Mercaldo
- Department of NeurologyMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Florence Lai
- Department of NeurologyMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Margaret Pulsifer
- Department of NeurologyMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - David Keator
- Department of Psychiatry and Human BehaviorUniversity of CaliforniaIrvineCaliforniaUSA
| | - Adam M. Brickman
- G. H. Sergievsky Center and Taub Institute for Research on Alzheimer's Disease and the Aging BrainCollege of Physicians and SurgeonsColumbia UniversityNew YorkNew YorkUSA
- Department of NeurologyCollege of Physicians and SurgeonsColumbia UniversityNew YorkNew YorkUSA
| | - Julie Price
- Department of RadiologyAthinoula Martinos CenterMassachusetts General HospitalHarvard Medical SchoolCharlestownMassachusettsUSA
| | - Michael Yassa
- Department of Neurobiology and BehaviorUniversity of CaliforniaCalifornia, USAIrvine
| | - Christy Hom
- Department of Psychiatry and Human BehaviorUniversity of CaliforniaIrvineCaliforniaUSA
| | | | - Wayne Silverman
- Kennedy Krieger InstituteJohns Hopkins University School of Medicine, BaltimoreMarylandUSA
- Department of PediatricsIrvine Medical CenterUniversity of CaliforniaIrvineCaliforniaUSA
| | - Ira Lott
- Department of PediatricsIrvine Medical CenterUniversity of CaliforniaIrvineCaliforniaUSA
| | - Nicole Schupf
- G. H. Sergievsky Center and Taub Institute for Research on Alzheimer's Disease and the Aging BrainCollege of Physicians and SurgeonsColumbia UniversityNew YorkNew YorkUSA
- Department of NeurologyCollege of Physicians and SurgeonsColumbia UniversityNew YorkNew YorkUSA
- Department of EpidemiologyMailman School of Public HealthColumbia UniversityNew YorkNew YorkUSA
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13
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Elisofon SA, Magee JC, Ng VL, Horslen SP, Fioravanti V, Economides J, Erinjeri J, Anand R, Mazariegos GV, Martin A, Mannino D, Flynn L, Mohammad S, Alonso E, Superina R, Brandt K, Riordan M, Lokar J, Ito J, Elisofon S, Zapata L, Jain A, Foristal E, Gupta N, Whitlow C, Naik K, Espinosa H, Miethke A, Hawkins A, Hardy J, Engels E, Schreibeis A, Ovchinsky N, Kogan‐Liberman D, Cunningham R, Malik P, Sundaram S, Feldman A, Garcia B, Yanni G, Kohli R, Emamaullee J, Secules C, Magee J, Lopez J, Bilhartz J, Hollenbeck J, Shaw B, Bartow C, Forest S, Rand E, Byrne A, Linguiti I, Wann L, Seidman C, Mazariegos G, Soltys K, Squires J, Kepler A, Vitola B, Telega G, Lerret S, Desai D, Moghe J, Cutright L, Daniel J, Andrews W, Fioravanti V, Slowik V, Cisneros R, Faseler M, Hufferd M, Kelly B, Sudan D, Mavis A, Moats L, Swan‐Nesbit S, Yazigi N, Buranych A, Hobby A, Rao G, Maccaby B, Gopalareddy V, Boulware M, Ibrahim S, El Youssef M, Furuya K, Schatz A, Weckwerth J, Lovejoy C, Kasi N, Nadig S, Law M, Arnon R, Chu J, Bucuvalas J, Czurda M, Secheli B, Almy C, Haydel B, Lobritto S, Emand J, Biney‐Amissah E, Gamino D, Gomez A, Himes R, Seal J, Stewart S, Bergeron J, Truxillo A, Lebel S, Davidson H, Book L, Ramstack D, Riley A, Jennings C, Horslen S, Hsu E, Wallace K, Turmelle Y, Nadler M, Postma S, Miloh T, Economides J, Timmons K, Ng V, Subramonian A, Dharmaraj B, McDiarmid S, Feist S, Rhee S, Perito E, Gallagher L, Smith K, Ebel N, Zerofsky M, Nogueira J, Greer R, Gilmour S, Robert C, Cars C, Azzam R, Boone P, Garbarino N, Lalonde M, Kerkar N, Dokus K, Helbig K, Grizzanti M, Tomiyama K, Cocking J, Alexopoulos S, Bhave C, Schillo R, Bailey A, Dulek D, Ramsey L, Ekong U, Valentino P, Hettiarachchi D, Tomlin R. Society of pediatric liver transplantation: Current registry status 2011-2018. Pediatr Transplant 2020; 24:e13605. [PMID: 31680409 DOI: 10.1111/petr.13605] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 08/08/2019] [Accepted: 09/27/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND SPLIT was founded in 1995 in order to collect comprehensive prospective data on pediatric liver transplantation, including waiting list data, transplant, and early and late outcomes. Since 2011, data collection of the current registry has been refined to focus on prospective data and outcomes only after transplant to serve as a foundation for the future development of targeted clinical studies. OBJECTIVE To report the outcomes of the SPLIT registry from 2011 to 2018. METHODS This is a multicenter, cross-sectional analysis characterizing patients transplanted and enrolled in the SPLIT registry between 2011 and 2018. All patients, <18 years of age, received a first liver-only, a combined liver-kidney, or a combined liver-pancreas transplant during this study period. RESULTS A total of 1911 recipients from 39 participating centers in North America were registered. Indications included biliary atresia (38.5%), metabolic disease (19.1%), tumors (11.7%), and fulminant liver failure (11.5%). Greater than 50% of recipients were transplanted as either Status 1A/1B or with a MELD/PELD exception score. Incompatible transplants were performed in 4.1%. Kaplan-Meier estimates of 1-year patient and graft survival were 97.3% and 96.6%. First 30 days of surgical complications included reoperation (31.7%), hepatic artery thrombosis (6.3%), and portal vein thrombosis (3.2%). In the first 90 days, biliary tract complications were reported in 13.6%. Acute cellular rejection during first year was 34.7%. At 1 and 2 years of follow-up, 39.2% and 50.6% had normal liver tests on monotherapy (tacrolimus or sirolimus). Further surgical, survival, allograft function, and complications are detailed.
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Affiliation(s)
- Scott A Elisofon
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts
| | - John C Magee
- Division of Surgery, University of Michigan Transplant Center, Ann Arbor, Michigan
| | - Vicky L Ng
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Transplant and Regenerative Medicine Center, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Simon P Horslen
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Vicki Fioravanti
- Section of Hepatology and Liver Transplantation, Children's Mercy Hospital, Kansas City, Missouri
| | | | | | | | - George V Mazariegos
- Division of Pediatric Transplant Surgery, Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
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Cooper T, Schmutz B, Hsu E, Lynham A. Magnetic resonance imaging for three-dimensional printing of the bony orbit: is clinical use imminent? Int J Oral Maxillofac Surg 2019; 49:483-490. [PMID: 31402077 DOI: 10.1016/j.ijom.2019.07.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/28/2019] [Accepted: 07/18/2019] [Indexed: 10/26/2022]
Abstract
The aim of this study was to examine the accuracy of three dimensionally (3D) printed models of the bony orbit derived from magnetic resonance imaging (MRI) for the purpose of preoperative plate bending in the setting of orbital blowout fracture. Retrospective computed tomography (CT) and MRI data from patients with suspected orbital fractures were used. Virtual models were manually generated and analysed for spatial accuracy of the fracture margins. 3D-printed models were produced and orbital fan plates bent by a single operator. The plates were then digitized and analysed for spatial discrepancy using reverse engineering software. Seven orbital blowout fractures were evident in six orbits. Analysis of the virtual models revealed high congruence between blowout fracture margins on CT and MRI (n=7, average deviation 0.85mm). Three zygomaticomaxillary complex fractures were seen, for which MRI did not demonstrate the same accuracy. For plates bent to the 3D-printed models of blowout fractures (n=6), no significant difference was found between those bent to CT versus those bent to MRI when compared for average surface and average border deviation (Wilcoxon signed rank test). Orbital blowout fractures can be defined on MRI with clinically acceptable accuracy. 3D printing of orbital biomodels from MRI for bending reconstructive plates is an acceptable and accurate technique.
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Affiliation(s)
- T Cooper
- Department of Oral and Maxillofacial Surgery, Royal Perth Hospital, Perth, Western Australia, Australia.
| | - B Schmutz
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - E Hsu
- Department of Oral and Maxillofacial Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - A Lynham
- School of Medicine, University of Queensland, Brisbane, Australia
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Sathishkumar M, Janecek J, Phelan M, Keator D, Doran E, Hom C, Nguyen D, Hsu E, Igwe KC, Banerjee A, Rosas HD, Lai F, Brickman AM, Schupf N, Silverman W, Lott IT, Yassa MA. P4-331: MEDIAL TEMPORAL LOBE STRUCTURAL DEFICITS ASSOCIATED WITH ALZHEIMER'S DEMENTIA IN INDIVIDUALS WITH DOWN SYNDROME. Alzheimers Dement 2019. [DOI: 10.1016/j.jalz.2019.06.4001] [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] [Indexed: 10/25/2022]
Affiliation(s)
| | | | | | | | - Eric Doran
- University of California; Irvine School of Medicine; Irvine CA USA
| | - Christy Hom
- University of California, Irvine; Irvine CA USA
| | - Dana Nguyen
- University of California, Irvine; Irvine CA USA
| | - Eugene Hsu
- Massachusetts General Hospital; Boston MA USA
| | - Kay C. Igwe
- Columbia University Medical Center; NY NY USA
| | | | - H. Diana Rosas
- MGH/MIT/HMS Athinoula A. Martinos Center for Biomedical Imaging; Massachusetts General Hospital, Harvard Medical School; Charlestown MA USA
| | | | | | - Nicole Schupf
- Columbia University Irving Medical Center; NY NY USA
| | | | - Ira T. Lott
- University of California; Irvine School of Medicine; Irvine CA USA
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Rosas HD, Mercaldo N, Hsu E, Brickman AM, Pulsifer M, Pang D, Jordan C, Doran E, Yassa MA, Keator D, Sathishkumar M, Price JC, Krinsky-McHale SJ, Silverman W, Lott IT, Schupf N, Lai F. P1-358: ALZHEIMER'S RELATED ALTERED MICROSTRUCTURE INTEGRITY IN DOWN SYNDROME. Alzheimers Dement 2019. [DOI: 10.1016/j.jalz.2019.06.913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- H. Diana Rosas
- Massachusetts General Hospital; Charlestown MA USA
- Harvard Medical School; Boston MA USA
- MGH/MIT/HMS Athinoula A. Martinos Center for Biomedical Imaging; Massachusetts General Hospital, Harvard Medical School; Charlestown MA USA
| | | | - Eugene Hsu
- Massachusetts General Hospital; Boston MA USA
| | | | - Margaret Pulsifer
- Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Deborah Pang
- NYS Institute for Basic Research; Staten Island NY USA
| | | | - Eric Doran
- University of California; Irvine School of Medicine; Irvine CA USA
| | | | | | | | | | | | | | - Ira T. Lott
- University of California; Irvine School of Medicine; Irvine CA USA
| | - Nicole Schupf
- Columbia University Irving Medical Center; New York NY USA
| | - Florence Lai
- Massachusetts General Hospital; Boston MA USA
- Harvard Medical School; Boston MA USA
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17
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Xu K, Lo A, Chin V, Gzell C, O’Connor C, Forstner D, Gallagher R, Bova R, Crawford J, Harvey R, Lochhead A, Earls P, Qiu M, Hsu E, Bigg-Wither G, Chan L, Bao H, Foltyn P, Sim HW, Prawira A. Development of overall survival (OS) and progression free survival (PFS) nomograms for Australian patients with locoregionally advanced oropharyngeal squamous cell carcinoma (LA OPSCC). Ann Oncol 2018. [DOI: 10.1093/annonc/mdy287.049] [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: 11/14/2022] Open
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Bhatia KD, Henderson LA, Hsu E, Yim M. Reduced integrity of the uncinate fasciculus and cingulum in depression: A stem-by-stem analysis. J Affect Disord 2018; 235:220-228. [PMID: 29656270 DOI: 10.1016/j.jad.2018.04.055] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 03/21/2018] [Accepted: 04/04/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The subgenual cingulate gyrus (Brodmann's Area 25: BA25) is hypermetabolic in depression and has been targeted successfully with deep brain stimulation. Two of the white matter tracts that play a role in treatment response are the uncinate fasciculus (UF) and the cingulum bundle. The UF has three prefrontal stems, the most medial of which extends from BA25 (which deals with mood regulation) and the most lateral of which extends from the dorso-lateral prefrontal cortex (concerned with executive function). The cingulum bundle has numerous fibers connecting the lobes of the cerebrum, with the longest fibers extending from BA25 to the amygdala. We hypothesize that there is reduced integrity in the UF, specific to the medial prefrontal stems, as well as in the subgenual and amygdaloid fibers of the cingulum bundle. Our secondary hypothesis is that these changes are present from the early stages of depression. OBJECTIVE Compare the white matter integrity of stems of the UF and components of the cingulum bundle in first-onset depressed, recurrent/chronic depressed, and non-depressed control subjects. METHODS Depressed patients (n = 103, first-onset = 57, chronic = 46) and non-depressed control subjects (n = 74) underwent MRI with 32-directional DTI sequences. The uncinate fasciculi and cingulum bundles were seeded, and the fractional anisotropy (FA) measured in each of the three prefrontal stems and the body of the UF, as well as the subgenual, body, and amygdaloid fiber components of the cingulum bundle. FA measurements were compared between groups using ANOVA testing with post-hoc Tukey analysis. RESULTS There were significant reductions in FA in the subgenual and polar stems of the UF bilaterally, as well as the subgenual and amygdaloid fibers of the cingulum bundle, in depressed patients compared with controls (p < 0.001). There was no significant difference seen in the lateral UF stem or the main body of the cingulum. No significant difference was demonstrated in any of the tracts between first-onset and chronic depression patients. CONCLUSION Depressed patients have reduced white matter integrity in the subgenual and polar stems of the uncinate fasciculi but not the lateral stems, as well as in the subgenual and amygdaloid cingulum fibers. These changes are present from the first-onset of the disease.
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Affiliation(s)
- Kartik D Bhatia
- Department of Anatomy and Histology, University of Sydney, Camperdown, NSW 2050, Australia.
| | - Luke A Henderson
- Department of Anatomy and Histology, University of Sydney, Camperdown, NSW 2050, Australia
| | - Eugene Hsu
- Department of Medical Imaging, St Vincent's Hospital, Darlinghurst, NSW 2010, Australia
| | - Mark Yim
- Department of Psychiatry, St Vincent's Clinic, Darlinghurst, NSW 2010, Australia
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Bhatia K, Henderson L, Yim M, Hsu E, Dhaliwal R. Diffusion Tensor Imaging Investigation of Uncinate Fasciculus Anatomy in Healthy Controls: Description of a Subgenual Stem. Neuropsychobiology 2018; 75:132-140. [PMID: 29332063 DOI: 10.1159/000485111] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 11/08/2017] [Indexed: 11/19/2022]
Abstract
The uncinate fasciculus is the largest white matter association tract connecting the prefrontal cortex and the anteromedial temporal lobe. The traditional anatomical description outlines a temporal stem that hooks around the posterior insula, a subinsular body, and 2 prefrontal stems extending to the lateral orbital gyri and the frontopolar cortex. Recent imaging studies of the white matter tracts deep to the subgenual cingulate gyrus (Brodmann area 25: BA25) suggest the presence of white matter fibers extending from BA25 to the amygdala, via a route that would run in close proximity to the uncinate fasciculus, that are of functional importance in mood disorders. We hypothesized that these fibers represent a third, medial prefrontal stem of the uncinate fasciculus. Using diffusion tensor imaging in 74 healthy volunteer humans, we seeded the uncinate fasciculus using 2 regions of interest centered over the temporal stem and the caudal body of the uncinate fasciculus in the coronal plane at the level of the anterior commissure. A medial prefrontal stem extending to the subgenual cingulate gyrus was demonstrated in 65/74 left and 70/74 right cerebral hemispheres, and had a mean fractional anisotropy value of 0.43 (95% CI 0.40-0.47). The medial subgenual stem fibers were inseparable from the caudal body and temporal stem of the main uncinate fasciculus and followed the same hook-shaped morphology. A probable medial subgenual prefrontal stem of the uncinate fasciculus was demonstrated in a cohort of healthy volunteers and is of potential significance in our understanding of neuropsychiatry and mood disorders.
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Affiliation(s)
- Kartik Bhatia
- Medical Imaging, St. Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Luke Henderson
- Department of Anatomy, University of Sydney, Camperdown, New South Wales, Australia
| | - Mark Yim
- Department of Psychiatry (Adolescent Unit), St. Vincent's Clinic, Darlinghurst, New South Wales, Australia
| | - Eugene Hsu
- Medical Imaging, St. Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Rajiv Dhaliwal
- Department of Surgery, University of Sydney, Camperdown, New South Wales, Australia
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Bhatia KD, Henderson LA, Hsu E, Yim M. Subcaudate Tractotomy White Matter Anatomy and Variability: A Diffusion Tensor Imaging Study. Stereotact Funct Neurosurg 2018; 96:71-82. [PMID: 29768273 DOI: 10.1159/000488359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 03/06/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Subcaudate tractotomy is a functional ablative procedure performed for treatment-resistant psychiatric disease, targeting the white matter tracts ventral to the head of the caudate nucleus. The white matter anatomy of this region has extensive interindividual variability, and this is thought to impact upon the treatment response to ablative and deep brain stimulation procedures. OBJECTIVE We aim to assess in detail the white matter tract anatomy and topographic variability underlying subcaudate tractotomy. METHODS 74 non-depressed adult volunteers underwent MRI including diffusion tensor imaging. Individualized regions of interest were formed in both hemispheres using native non-normalized data to simulate a subcaudate tractotomy. Tractography and analysis were performed and the exact tract locations measured including mean distances and standard deviations to assess variability. RESULTS The cingulum bundle, uncinate fasciculus, corticostriatal fibres, and corticothalamic fibres were consistently demonstrated. The location of the cingulum bundle was consistent across subjects, but there was extensive interindividual variability in the topographic location of the other tracts. CONCLUSION We have demonstrated a detailed analysis of the white matter tracts and their anatomical variability underlying subcaudate tractotomy. This has significant implications for neurosurgical targeting.
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Affiliation(s)
- Kartik D Bhatia
- Department of Anatomy, University of Sydney, Camperdown, New South Wales, Australia
| | - Luke A Henderson
- Department of Anatomy, University of Sydney, Camperdown, New South Wales, Australia
| | - Eugene Hsu
- Department of Medical Imaging, St. Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Mark Yim
- Department of Psychiatry, St. Vincent's Clinic, Darlinghurst, New South Wales, Australia
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Okita T, Hsu E, Aizawa K, Nakada H, Toya W, Matsui K. Quantitative Survey of Laypersons' Attitudes Toward Organ Transplantation in Japan. Transplant Proc 2018; 50:3-9. [PMID: 29407326 DOI: 10.1016/j.transproceed.2017.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 09/25/2017] [Accepted: 11/03/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND In comparison with foreign countries, living-organ transplantations (LOT) have been performed more frequently than dead organ transplants, including brain-dead organ transplantation (BOT) in Japan. This situation has given rise to organ transplantation tourism. Therefore, we clarify laypersons' preferences regarding organ transplantation that are producing the current situation in Japan, to suggest a possible framework for further efforts. METHODS Voluntary completion of a quantitative and anonymous survey was promoted online (a sample size of 1030). The questionnaire had two types of variables concerning demographic characteristics and organ transplantation-related issues. RESULTS LOT was favored over BOT. However, for willingness to donate to family members, the participants showed a significantly more positive attitude toward brain-dead organ donors (BODs) than living organ donors (LODs). In the evaluation of each transplantation technology, BOT and LOT were positioned in the middle, between transplantation that does not depend on others and the utilization of animal organs. CONCLUSIONS Although LOT was favored over BOT, for participants hypothesized to be in a position to donate and receive organs, BODs received a conversely better reputation than LODs. Our survey and discussion suggest that the present conditions of organ transplantation in Japan might be because there is a lack of deliberation on transplantation tourism and LOT. Therefore, more surveys concerning LOT cases and the implications of avoidance of organs from brain-dead bodies, coupled with more discussions based on these surveys, are necessary to formulate a Japanese transplantation policy for the future.
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Affiliation(s)
- T Okita
- Department of Medical Ethics, Tohoku University Graduate School of Medicine, Sendai, Japan; Office for Research Ethics & Bioethics, National Cerebral and Cardiovascular Center, Suita, Japan.
| | - E Hsu
- Office for Research Ethics & Bioethics, National Cerebral and Cardiovascular Center, Suita, Japan; Fulbright, Washington, DC
| | - K Aizawa
- Office for Research Ethics & Bioethics, National Cerebral and Cardiovascular Center, Suita, Japan
| | - H Nakada
- Department of Intellectual Asset Management, National Cerebral and Cardiovascular Center, Suita, Japan; Bioethics Section, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan
| | - W Toya
- Office for Research Ethics & Bioethics, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Philosophy, University of Bergen, Bergen, Norway
| | - K Matsui
- Office for Research Ethics & Bioethics, National Cerebral and Cardiovascular Center, Suita, Japan
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22
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Cho H, David MC, Lynham AJ, Hsu E. Effectiveness of irrigation with chlorhexidine after removal of mandibular third molars: a randomised controlled trial. Br J Oral Maxillofac Surg 2017; 56:54-59. [PMID: 29223633 DOI: 10.1016/j.bjoms.2017.11.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 11/21/2017] [Indexed: 11/29/2022]
Abstract
To evaluate the effect of postoperative irrigation with chlorhexidine on inflammatory complications after the extraction of lower third molars under local anaesthesia, we recruited 100 patients to participate in a controlled, single-blind, randomised clinical trial. They were assigned to one of two groups: the intervention group (postoperative irrigation of the surgical site with chlorhexidine for seven days) or the control group (postoperative chlorhexidine mouth rinse for seven days). The primary outcome variables were pain, swelling, trismus, infection, and alveolar osteitis. The secondary outcome variables were wound dehiscence and food impaction. A total of 95 participants completed the study (47 in the irrigation group and 48 in the rinse group). In the irrigation group, alveolar osteitis and facial swelling had reduced significantly at seven days postoperatively (both p<0.01). Pain scores had also reduced significantly at seven days (p<0.01), but not at 48hours, and patients had lower levels of food impaction (p<0.01) and less severe symptoms (p=0.02). Routine irrigation with chlorhexidine after the extraction of third molars helps to reduce pain and lowers the incidence of alveolar osteitis.
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Affiliation(s)
- H Cho
- School of Medicine, The University of Queensland, Brisbane, Australia.
| | - M C David
- School of Public Health, The University of Queensland, Brisbane, Australia
| | - A J Lynham
- School of Medicine, The University of Queensland, Brisbane, Australia
| | - E Hsu
- Maxillofacial Unit, Royal Brisbane and Women's Hospital, Brisbane, Australia
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Crist J, Hodge JR, Frick M, Leung FP, Hsu E, Gi MT, Venkatesh SK. Magnetic Resonance Imaging Appearance of Schwannomas from Head to Toe: A Pictorial Review. J Clin Imaging Sci 2017; 7:38. [PMID: 29114437 PMCID: PMC5651654 DOI: 10.4103/jcis.jcis_40_17] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [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: 05/28/2017] [Accepted: 08/22/2017] [Indexed: 11/08/2022] Open
Abstract
Schwannomas are benign soft-tissue tumors that arise from peripheral nerve sheaths throughout the body and are commonly encountered in patients with neurofibromatosis Type 2. The vast majority of schwannomas are benign, with rare cases of malignant transformation reported. In this pictorial review, we discuss the magnetic resonance imaging (MRI) appearance of schwannomas by demonstrating a collection of tumors from different parts of the body that exhibit similar MRI characteristics. We review strategies to distinguish schwannomas from malignant soft-tissue tumors while exploring the anatomic and histologic origins of these tumors to discuss how this correlates with their imaging findings. Familiarity with the MRI appearance of schwannomas can help aid in the differential diagnosis of soft-tissue masses, especially in unexpected locations.
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Affiliation(s)
- Jamie Crist
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jacob R Hodge
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew Frick
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Eugene Hsu
- Department of Radiology, St. Vincent's Hospital, Sydney, Australia
| | - Ming Tye Gi
- Department of Diagnostic Imaging, National University Hospital, NUHS, Singapore
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Cho H, Lynham AJ, Hsu E. Postoperative interventions to reduce inflammatory complications after third molar surgery: review of the current evidence. Aust Dent J 2017; 62:412-419. [DOI: 10.1111/adj.12526] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2017] [Indexed: 12/26/2022]
Affiliation(s)
- H Cho
- School of Medicine; The University of Queensland; Brisbane Queensland Australia
| | - AJ Lynham
- School of Medicine; The University of Queensland; Brisbane Queensland Australia
| | - E Hsu
- Maxillofacial Unit; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
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Hurrell M, McNamara Z, Hsu E. Peripheral odontoameloblastoma in an elderly man: a case report and literature review. Int J Oral Maxillofac Surg 2017. [DOI: 10.1016/j.ijom.2017.02.1030] [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]
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Brierly G, Bray L, Theodoropoulos C, Saifzadeh S, Hsu E, Nikolarakos D, Woodruff M, Hutmacher D. A pilot study into prevention of antiresorptive drug-related osteonecrosis of the jaw in a porcine animal model. Int J Oral Maxillofac Surg 2017. [DOI: 10.1016/j.ijom.2017.02.686] [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: 11/28/2022]
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Yu C, Boshell D, Jabbour A, Fulde G, Preicz P, Milner B, Hsu E, McCrohon J, Sammel N, Feneley M. Coronary Computed Tomographic Angiography Oriented Assessment Pathway Versus Standard Assessment of Chest Pain in Real World Practice. Heart Lung Circ 2016. [DOI: 10.1016/j.hlc.2016.06.523] [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: 10/21/2022]
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Abstract
There continues to be an unmet need for safe and effective pain medications. Opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) dominate the clinical landscape despite limited effectiveness and considerable side-effect profiles. Although significant advancements have identified myriad potential pain targets over the past several decades, the majority of new pain pharmacotherapies have failed to come to market. The discovery of nerve growth factor (NGF) and its interaction with tropomyosin receptor kinase A (trkA) have been well characterized as important mediators of pain initiation and maintenance, and pharmacotherapies targeting this pathway have the potential to be considered promising methods in the treatment of a variety of nociceptive and neuropathic pain conditions. Several methodologic approaches, including sequestration of free NGF, prevention of NGF binding and trkA activation, and inhibition of trkA function, have been investigated in the development of new pharmacotherapies. Among these, NGF-sequestering antibodies have exhibited the most promise in clinical trials. However, in 2010, reports of rapid joint destruction leading to joint replacement prompted the US Food and Drug Administration (FDA) to place a hold on all clinical trials involving anti-NGF antibodies. Although the FDA has since lifted this hold and a number of new trials are under way, the long-term efficacy and safety profile of anti-NGF antibodies are yet to be established.
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Affiliation(s)
- David S Chang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eugene Hsu
- Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Daniel G Hottinger
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steven P Cohen
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Bhatia KD, Ambati C, Dhaliwal R, Paschkewitz R, Hsu E, Ho B, Young A, Emmett L. SPECT-CT/VQ versus CTPA for diagnosing pulmonary embolus and other lung pathology: Pre-existing lung disease should not be a contraindication. J Med Imaging Radiat Oncol 2016; 60:492-7. [PMID: 27461384 DOI: 10.1111/1754-9485.12471] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 04/11/2016] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Single Photon Emission Computed Tomography-Ventilation-Perfusion (SPECT-VQ) with low-dose CT (SPECT-CT/VQ) has equivalent diagnostic accuracy to CTPA for diagnosing pulmonary embolus (PE) while using lower radiation doses, but is underutilized owing to perceived inaccuracy of scintigraphy in the setting of pre-existing lung disease. This study assesses the accuracy of SPECT-CT/VQ compared with CTPA for the diagnosis of PE, including in patients with pre-existing lung disease. METHODS Retrospective non-inferiority cohort study of all patients who underwent SPECT-CT/VQ scanning at St Vincent's Hospital, NSW, from June 2012 to November 2013, who also had a CTPA within the same admission and <72 h apart (n = 102). RESULTS SPECT-CT/VQ had 100% sensitivity and 94.4% specificity when compared with CTPA. Of the 102 patients, 14 were lung transplant patients, and 27 had other pre-existing lung disease (41/102, 40.2%), with SPECT-CT/VQ having a sensitivity of 100% and specificity of 97.2% in this patient group. Non-inferiority of SPECT-CT/VQ was demonstrated at a significance level of 0.005. CONCLUSION SPECT-CT/VQ has high sensitivity and specificity for diagnosing PE compared with CTPA, even among patients with pre-existing lung disease, with lower radiation doses.
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Affiliation(s)
- Kartik Dev Bhatia
- Department of Medical Imaging, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Chaitanya Ambati
- Department of Medical Imaging, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Rajiv Dhaliwal
- Department of Medical Imaging, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Royce Paschkewitz
- Department of Medical Imaging, St Vincent's Hospital, Darlinghurst, New South Wales, Australia.,Department of Radiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Eugene Hsu
- Department of Medical Imaging, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Bao Ho
- Department of Medical Imaging, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Andy Young
- Department of Medical Imaging, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Louise Emmett
- Department of Medical Imaging, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
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Kuhtreiber WM, Washer SLL, Hsu E, Zhao M, Reinhold P, Burger D, Zheng H, Faustman DL. Low levels of C-peptide have clinical significance for established Type 1 diabetes. Diabet Med 2015; 32:1346-53. [PMID: 26172028 PMCID: PMC4578991 DOI: 10.1111/dme.12850] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2015] [Indexed: 01/07/2023]
Abstract
AIM To determine whether the low C-peptide levels (< 50 pmol/l) produced by the pancreas for decades after onset of Type 1 diabetes have clinical significance. METHODS We evaluated fasting C-peptide levels, duration of disease and age of onset in a large cross-sectional series (n = 1272) of people with Type 1 diabetes. We then expanded the scope of the study to include the relationship between C-peptide and HbA1c control (n = 1273), as well as diabetic complications (n = 324) and presence of hypoglycaemia (n = 323). The full range of C-peptide levels was also compared with 1,5-Anhydroglucitol, a glucose responsive marker. RESULTS C-peptide levels declined for decades after diagnosis, and the rate of decline was significantly related to age of onset (P < 0.0001), after adjusting for disease duration. C-peptide levels > 10 pmol/l were associated with protection from complications (e.g. nephropathy, neuropathy, foot ulcers and retinopathy; P = 0.03). Low C-peptide levels were associated with poor metabolic control measured by HbA1c (P < 0.0001). Severe hypoglycaemia was associated with the lowest C-peptide levels compared with mild (P = 0.049) or moderate (P = 0.04) hypoglycaemia. All levels of measurable C-peptide were responsive to acute fluctuations in blood glucose levels as assessed by 1,5-Anhydroglucitol (P < 0.0001). CONCLUSIONS Low C-peptide levels have clinical significance and appear helpful in characterizing groups at-risk for faster C-peptide decline, complications, poorer metabolic control and severe hypoglycaemia. Low C-peptide levels may be a biomarker for characterizing at-risk patients with Type 1 diabetes.
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Affiliation(s)
- W M Kuhtreiber
- Immunobiology Laboratory, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | - S L L Washer
- Immunobiology Laboratory, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | | | - M Zhao
- Immunobiology Laboratory, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | - P Reinhold
- Immunobiology Laboratory, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | - D Burger
- Immunobiology Laboratory, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | - H Zheng
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA, USA
| | - D L Faustman
- Immunobiology Laboratory, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
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Abstract
Profound immunological changes occur as tadpoles metamorphose into adult amphibians. These include the expression of a different antibody repertoire, a lessening of skin graft tolerance, the appearance on leukocytes of class I MHC antigens. Here Martin Flajnik and his colleagues review what is known of these changes in Xenopus and speculate on how they may occur.
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Jamison DE, Hsu E, Cohen SP. Epidural adhesiolysis: an evidence-based review. J Neurosurg Sci 2014; 58:65-76. [PMID: 24819483] [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: 06/03/2023]
Abstract
First described over 25 years ago, epidural lysis of adhesions (LOA) involves the mechanical dissolution of epidural scar tissue, which may directly alleviate pain and facilitate the spread of analgesic substances to area(s) of pain generation. Although it most commonly performed for lumbar failed back surgery syndrome, there is a growing body of evidence that suggests it may be effective for spinal stenosis and radicular pain stemming from a herniated disc. There is weak positive evidence that LOA is more effective than conventional caudal epidural steroid injections for failed back surgery syndrome and spinal stenosis, and that LOA is more effective than sham adhesiolysis and conservative management for lumbosacral radiculopathy. For cervical disc herniation and spinal stenosis, there is only anecdotal evidence suggesting effectiveness and safety. Factors that may contribute to the enhanced efficacy compared to traditional epidural steroid administration include the high volume administered, the use of hypertonic saline, and to a lesser extent the use of hyaluronidase and a navigable catheter to mechanically disrupt scar tissue and guide medication administration. Although LOA is widely considered a safe intervention, the complication rates are higher than for conventional epidural steroid injection.
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Affiliation(s)
- D E Jamison
- Department of Anesthesiology Walter Reed National Military Medical Center Bethesda, MD, USA2 Department of Anesthesiology and Critical Care Medicine Johns Hopkins School of Medicine, Baltimore, MD, USA3 Department of Anesthesiology and Critical Care Medicine and Physical Medicine and Rehabilitation Johns Hopkins School of Medicine and Depts. of Anesthesiology and Physical Medicine & Rehabilitation,Uniformed Services University of the Health Sciences Bethesda, MD, USA -
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Hamid KS, Nwachukwu BU, Hsu E, Edgerton CA, Hobson DR, Lang JE. Orthopedic resident work-shift analysis: are we making the best use of resident work hours? J Surg Educ 2014; 71:216-221. [PMID: 24602713 DOI: 10.1016/j.jsurg.2013.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 05/27/2013] [Accepted: 07/06/2013] [Indexed: 06/03/2023]
Abstract
BACKGROUND Surgery programs have been tasked to meet rising demands in patient surgical care while simultaneously providing adequate resident training in the midst of increasing resident work-hour restrictions. The purpose of this study was to quantify orthopedic surgery resident workflow and identify areas needing improved resident efficiency. We hypothesize that residents spend a disproportionate amount of time involved in activities that do not relate directly to patient care or maximize resident education. METHODS We observed 4 orthopedic surgery residents on the orthopedic consult service at a major tertiary care center for 72 consecutive hours (6 consecutive shifts). We collected minute-by-minute data using predefined work-task criteria: direct new patient contact, direct existing patient contact, communications with other providers, documentation/administrative time, transit time, and basic human needs. A seventh category comprised remaining less-productive work was termed as standby. RESULTS In a 720-minute shift, residents spent on an average: 191 minutes (26.5%) performing documentation/administrative duties, 167.0 minutes (23.2%) in direct contact with new patient consults, 129.6 minutes (17.1%) in communication with other providers regarding patients, 116.2 (16.1%) minutes in standby, 63.7 minutes (8.8%) in transit, 32.6 minutes (4.5%) with existing patients, and 20 minutes (2.7%) attending to basic human needs. Residents performed an additional 130 minutes of administrative work off duty. Secondary analysis revealed residents were more likely to perform administrative work rather than directly interact with existing patients (p = 0.006) or attend to basic human needs (p = 0.003). CONCLUSIONS Orthopedic surgery residents spend a large proportion of their time performing documentation/administrative-type work and their workday can be operationally optimized to minimize nonvalue-adding tasks. Formal workflow analysis may aid program directors in systematic process improvements to better align resident skills with tasks. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Kamran S Hamid
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.
| | | | - Eugene Hsu
- Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Colston A Edgerton
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - David R Hobson
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Jason E Lang
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
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Hsu E, Atanelov L, Plunkett AR, Chai N, Chen Y, Cohen SP. Epidural lysis of adhesions for failed back surgery and spinal stenosis: factors associated with treatment outcome. Anesth Analg 2014; 118:215-24. [PMID: 24356168 DOI: 10.1213/ane.0000000000000042] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Failed back surgery syndrome (FBSS) is a challenging problem. One treatment advocated to treat FBSS is epidural lysis of adhesions (LOA). The results of studies examining LOA for FBSS have been mixed, but are limited because no study has ever sought to identify factors associated with outcomes. METHODS We performed this multicenter, retrospective study in 115 patients who underwent LOA for FBSS (n = 104) or spinal stenosis (n = 11) between 2004 and 2007. Twenty-seven demographic, clinical, and procedural variables were extracted from medical records and correlated with the outcome, defined as ≥50% pain relief lasting ≥1 month. Univariable analysis was performed, followed by multivariable logistic regression. RESULTS Overall, 48.7% (95% confidence interval [CI], 39.3%-58.1%) of patients experienced a positive outcome. In univariable analysis, those who had a positive outcome were older (mean age 64.1 years; 95% CI, 59.7-68.6 vs 57.2; 95% CI, 53.0-61.4 years; P = 0.02), while higher baseline numerical rating scale pain scores were associated with a negative outcome (mean 6.7 years; 95% CI, 6.0-7.3 vs 7.5; 95% CI, 6.9-8.0; P = 0.07). Use of hyaluronidase did not correlate with outcomes in univariable analysis (odds ratio [OR], 1.2; 95% CI, 0.6-2.5; P = 0.65). In multivariable analysis, age ≥81 years (OR, 7.8; 95% CI, 1.4-53.7), baseline numerical rating scale score ≤9 (OR, 4.4; 95% CI, 1.4-16.3, P = 0.02), and patients on or seeking disability or worker's compensation (OR, 4.4; 95% CI, 1.1-19.5, P = 0.04) were significantly more likely to experience a positive outcome. CONCLUSIONS Considering our modest success rate, selecting patients for epidural LOA based on demographic and clinical factors may help better select treatment candidates. Procedural factors such as the use of hyaluronidase that increase risks and costs did not improve outcomes, so further research is needed before these become standard practice.
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Affiliation(s)
- Eugene Hsu
- From the *Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine; †Department of Physical Medicine & Rehabilitation, Johns Hopkins School of Medicine; ‡Department of Anesthesia & Operative Services, Womack Army Medical Center, Fort Bragg, North Carolina; §Department of Neurology, Johns Hopkins School of Medicine; ‖Johns Hopkins School of Medicine; ¶Departments of Anesthesiology and Critical Care Medicine & Physical Medicine and Rehabilitation; at Uniformed Services University of the Health Sciences
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Hsu E, Lin D, Evans SJ, Hamid KS, Frick KD, Yang T, Pronovost PJ, Pham JC. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual 2013; 29:13-9. [PMID: 23652336 DOI: 10.1177/1062860613486173] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A complete understanding of the financial impact of patient safety interventions must consider the economic incentives of both payers and providers within the current fee-for-service payment model. This study evaluated the impact of a central line-associated bloodstream infection (CLABSI) initiative on costs, reimbursements, and margins for 1 Hawaii hospital and its payers. Intensive care unit patients (January 2009-December 2011) who developed a CLABSI were compared to matched controls. Mean hospital cost, reimbursement, and margin was $222 692 versus $80 144 (P = .01), $259 433 versus $72 543 (P < .01), and $54 906 versus $6506 (P < .01), respectively. Although hospitals and payers reduce costs by preventing CLABSIs, hospitals also would decrease their margins, which creates a perverse incentive to have more line infections. An optimal reimbursement system must reward hospitals and payers for preventing harm rather than treating illness. This study highlights the critical role that health care payers have as patient safety advocates, financial sponsors, and facilitators.
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Affiliation(s)
- Eugene Hsu
- 1Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD
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Abstract
Postamputation pain (PAP) is highly prevalent after limb amputation but remains an extremely challenging pain condition to treat. A large part of its intractability stems from the myriad pathophysiological mechanisms. A state-of-art understanding of the pathophysiologic basis underlying postamputation phenomena can be broadly categorized in terms of supraspinal, spinal, and peripheral mechanisms. Supraspinal mechanisms involve somatosensory cortical reorganization of the area representing the deafferentated limb and are predominant in phantom limb pain and phantom sensations. Spinal reorganization in the dorsal horn occurs after deafferentataion from a peripheral nerve injury. Peripherally, axonal nerve damage initiates inflammation, regenerative sprouting, and increased "ectopic" afferent input which is thought by many to be the predominant mechanism involved in residual limb pain or neuroma pain, but may also contribute to phantom phenomena. To optimize treatment outcomes, therapy should be individually tailored and mechanism based. Treatment modalities include injection therapy, pharmacotherapy, complementary and alternative therapy, surgical therapy, and interventions aimed at prevention. Unfortunately, there is a lack of high quality clinical trials to support most of these treatments. Most of the randomized controlled trials in PAP have evaluated medications, with a trend for short-term Efficacy noted for ketamine and opioids. Evidence for peripheral injection therapy with botulinum toxin and pulsed radiofrequency for residual limb pain is limited to very small trials and case series. Mirror therapy is a safe and cost-effective alternative treatment modality for PAP. Neuromodulation using implanted motor cortex stimulation has shown a trend toward effectiveness for refractory phantom limb pain, though the evidence is largely anecdotal. Studies that aim to prevent PA P using epidural and perineural catheters have yielded inconsistent results, though there may be some benefit for epidural prevention when the infusions are started more than 24 hours preoperatively and compared with nonoptimized alternatives. Further investigation into the mechanisms responsible for and the factors associated with the development of PAP is needed to provide an evidence-based foundation to guide current and future treatment approaches.
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Affiliation(s)
- Eugene Hsu
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Steven P Cohen
- Johns Hopkins School of Medicine and Uniformed Services, University of the Health Sciences, Bethesda, MD, USA
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Drakos S, Verma D, Abdulla O, Kfoury A, Stehlik J, Selzman C, Reid B, Gilbert E, Alharethi R, Myrick C, Budge D, Russel G, Clayson S, Bull D, Hammond E, Hsu E, Li D. 565 Characterization of the Failing Human Heart Via Diffusion Tensor Imaging: An Ex-Vivo Study. J Heart Lung Transplant 2011. [DOI: 10.1016/j.healun.2011.01.577] [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] Open
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Druce Batstone M, Hsu E. 47 Manual reduction versus IMF for fixation of mandibular fractures. A randomised double blinded prospective trial. Br J Oral Maxillofac Surg 2010. [DOI: 10.1016/s0266-4356(10)60048-4] [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: 10/19/2022]
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Abstract
The objective of this study is to provide a calculation of recycling rates of waste home appliances in Taiwan, for the EPA to amend these rates in order to increase the recycling efficiency. The recycling rate is calculated by a formula according to the statistical results obtained through: (1) an estimation of domestic use of home appliances using time series analysis with multiplicative seasonal ARIMA model, (2) a further estimation of generated waste home appliances based upon the estimated domestic use and the corresponding distribution of lifetime span, and (3) a cost analysis of recycling home appliances based on a sampling survey with stratified systematic sampling conducted among collectors and a survey on five recycling plants of waste home appliances. The suggested recycling rates in this study finally used by the EPA show that all of the recycling rates have increased compared with the rates in previous years. This study also implies that amending the recycling rates may only solve some recycling problems temporarily; however, the recycling system of waste home appliances in Taiwan has to be reformed to increase the recycling efficiency for the long term.
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Affiliation(s)
- E Hsu
- Department of Statistics, National Taipei University, 67 Section 3, Min-Sheng East Road, Taipei 104, Taiwan.
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Hsu E. A Prospective Randomized Controlled Trial of Acupressure vs Sham for Pregnancy-related Nausea and Vomiting in the Emergency Department. Acad Emerg Med 2003. [DOI: 10.1197/aemj.10.5.437] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Wong LJ, Wang J, Zhang YH, Hsu E, Heim RA, Bowman CM, Woo MS. Improved detection of CFTR mutations in Southern California Hispanic CF patients. Hum Mutat 2001; 18:296-307. [PMID: 11668613 DOI: 10.1002/humu.1191] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene cause cystic fibrosis (CF), a common autosomal recessive disease in Caucasians. The broad mutation spectrum varies among different patient groups. Current molecular diagnoses are designed to detect 80-97% of CF chromosomes in Caucasians and Ashkenazi Jews but have a much lower detection rate in Hispanic CF patients. Grebe et al. [1994] reported a 58% detection rate in Hispanic patients. Since then, there has been no large-scale, complete mutational analysis of Hispanic CF patients. In this study, the mutations in 62 Hispanic patients from southern California were investigated. The entire coding and flanking intronic regions of the CFTR gene were analyzed by temporal temperature gradient gel electrophoresis (TTGE) followed by sequencing to identify the mutations. Eleven novel mutations were discovered in this patient group: 3876delA, 406-1G>A, 935delA, 663delT, 3271delGG, 2105-2117del13insAGAAA, 3199del6, Q179K, 2108delA, 3171delC, and 3500-2A>T. Among the mutations, seven were out-of-frame insertions and deletions that result in truncated proteins, two were splice-site mutations, one was an in-frame 6 bp deletion, and one was a missense mutation that involved the non-conservative change of glutamine-179 to lysine. All patients presented severe classical clinical course with pancreatic insufficiency and poor growth, consistent with the nature of truncation mutation. The results indicate that TTGE screening following the analysis of recurrent mutations will substantially improve the mutation detection rate for Hispanic CF patients from southern California.
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Affiliation(s)
- L J Wong
- Institute for Molecular and Human Genetics, Georgetown University Medical Center, Washington, DC, USA.
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Abstract
UNLABELLED In complex emergencies, especially those involving famine and/or widespread food insecurity, assessments of malnutrition are critical to understanding the population's health status and to assessing the effectiveness of relief interventions. Although the Democratic People's Republic of Korea (DPRK) has benefited from some of the largest, most sustained appeals in the history of the World Food Program (WFP), the government in Pyongyang has placed restrictions on international efforts to gather data on the health and nutritional status of the affected population. QUESTION Lacking direct means to assess the nutritional status of the North Korean populace, what other methodologies could be employed to measure the public health impacts of chronic food shortage? The paper begins with a review of methods for assessing nutritional status, particularly in emergencies; a brief history of the North Korean food crisis (1995-2001), and a review of the available nutritional and health data on the DPRK. The main focus of the paper is on the results of a survey of 2,692 North Korean adult migrants in China. Recognizing certain biases and limitations, the study suggests that sample households have experienced an overall decline in food security, as evidenced by both the decline in government rations from an average of 120 grams per person per day to less than 60 grams per day, and by the increase in the percentage of households relying on foraging or bartering of assets as their principal source of food. It also is apparent that the period 1995-1998 has been marked by elevated household mortality, declining fertility, and steadily rising out-migration. Taken together, the signs point toward famine, whether that is defined as a discrete event--that is, as a regional failure in food production or distribution leading to elevated mortality from starvation and associated disease--or as a more complex social process whose sub-states include not only elevated mortality, but declining fertility, eating of alternative 'famine foods', transfer of assets, and the uprooting and separation of families.
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Affiliation(s)
- W C Robinson
- Johns Hopkins University, Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA.
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Diao J, Khine AA, Sarangi F, Hsu E, Iorio C, Tibbles LA, Woodgett JR, Penninger J, Richardson CD. X protein of hepatitis B virus inhibits Fas-mediated apoptosis and is associated with up-regulation of the SAPK/JNK pathway. J Biol Chem 2001; 276:8328-40. [PMID: 11099494 DOI: 10.1074/jbc.m006026200] [Citation(s) in RCA: 141] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The X protein from a chronic strain of hepatitis B virus (HBx) was determined to inhibit Fas-mediated apoptosis and promote cell survival. Fas-mediated apoptosis is the major cause of hepatocyte damage during liver disease. Experiments demonstrated that cell death caused by anti-Fas antibodies was blocked by the expression of HBx in human primary hepatocytes and mouse embryo fibroblasts. This effect was also observed in mouse erythroleukemia cells that lacked p53, indicating that protection against Fas-mediated apoptosis was independent of p53. Components of the signal transduction pathways involved in this protection were studied. The SAPK/JNK pathway has previously been suggested to be a survival pathway for some cells undergoing Fas-mediated apoptosis, and kinase assays showed that SAPK activity was highly up-regulated in cells expressing the HBx protein. Normal mouse fibroblasts expressing HBx were protected from death, whereas identical fibroblasts lacking the SEK1 component from the SAPK pathway succumbed to Fas-mediated apoptosis, whether HBx was present or not. Assays showed that caspase 3 and 8 activities and the release of cytochrome c from mitochondria were inhibited, in the presence of HBx, following stimulation with anti-Fas antibodies. Coprecipitation and confocal immunofluorescence microscopy experiments demonstrated that HBx localizes with a cytoplasmic complex containing MEKK1, SEK1, SAPK, and 14-3-3 proteins. Finally, mutational analysis of HBx demonstrated that a potential binding region for 14-3-3 proteins was essential for induction of SAPK/JNK activity and protection from Fas-mediated apoptosis.
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Affiliation(s)
- J Diao
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario M5G 2M9, Canada
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Wong LJ, Wang J, Woo M, Hsu E, Bowman CM. A novel mutation detected by temporal temperature gradient gel electrophoresis led to the confirmative prenatal diagnosis of a Hispanic CF family. Prenat Diagn 2000; 20:807-10. [PMID: 11038458 DOI: 10.1002/1097-0223(200010)20:10<807::aid-pd929>3.0.co;2-a] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Mutational analysis of 30 recurrent known mutations detects only about 58% of Hispanic cystic fibrosis (CF) chromosomes. The low mutation detection rate has greatly hindered prenatal diagnosis and carrier testing of Hispanic families who have multiple affected children with unidentified cystic fibrosis transmembrane conductance regulator (CFTR) mutations. We recently employed a temporal temperature gradient gel electrophoresis (TTGE) method to effectively scan unknown mutations in the entire CFTR gene. A novel mutation, 2105-2117 del13insAGAAA was identified in a Hispanic family heterozygous for delta F508. The discovery of the devastating mutation facilitated the prenatal diagnosis for this family who already had two severely affected children. The fetus was found to be a compound heterozygote of delta F508/2105-2117 del13insAGAAA. This case emphasizes the importance of whole gene mutational analysis in patients with a clinical diagnosis of CF, but without the identifiable DNA mutations by routine mutation analysis. Finding of CF mutations in the patient would allow proper genetic counselling and prenatal and carrier detection of at-risk family members.
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Affiliation(s)
- L J Wong
- Institute for Molecular and Human Genetics, Georgetown University Medical Center, M4000, 3800 Reservoir Rd, NW, Washington, DC 20007, USA.
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Affiliation(s)
- S S Lee
- Department of Physiology and Pharmacology, State University of New York, Health Science Center at Brooklyn 11203-2098, USA
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Abstract
A retrospective review of 36 children diagnosed with medulloblastoma in the Ottawa area between 1974 and 1997 was completed (mean age 7.8+/-4.2 years, range 1.2-15.3 years). Via a suboccipital approach, complete tumor resection was achieved in 75% and subtotal resection (>90%) in 25%, without any operative mortality. The tumor was located in the vermis in 39% and in the cerebellar hemisphere in 11%; it occupied both locations in 50%. In 47% of the children a ventriculoperitoneal shunt was required. Postoperatively, craniospinal radiation at 3600 cGy with a boost to the posterior fossa was administered. Chemotherapy was used in 56%. The 1-year survival rate was 92%, and survival plateaued at 54% at 5 years. Children less than 3 years of age fared worse than those over 3 years old. While the male-to-female ratio was 1.6:1, there was no gender difference in survival. Chang's classification was used to grade the tumors. T stage did not have an impact on survival, but M stage did. No statistically significant difference in survival was found between the patients who had a total resection and those who had a subtotal resection. There was no difference in survival in terms of tumor location, hydrocephalus or ventriculoperitoneal shunt. Chemotherapy showed no survival benefit. The recurrence rate was 26%, and its timing followed Collin's law. Recurrence led to death within 1-9 months. GH deficiency was diagnosed in 5 patients and hypothyroidism in 4 patients. The mean follow-up time was 4.4+/-3.7 years, with a range of 2.5 months to 16.5 years. Fourteen patients died, 5 were lost to follow-up, and 7 were transferred to adult care without persistent disease. Ten children are presently being followed up by the Neuro-oncology Clinic. Four children continue to be followed through psychology services. Our results are comparable to those in larger series, and are similar to those of the Montreal Children's Hospital.
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Affiliation(s)
- A Modha
- Division of Neurosurgery, Children's Hospital of Eastern Ontario, Ottawa, Canada
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Abstract
Studies on the terminology of expert knowledge tend to neglect the relevance of sociological data, in spite of general acceptance that knowledge and social practice are interdependent. This paper explores expert knowledge and practice by examining 'styles of knowing' and how they differ according to the ways in which experts establish their authority. For assessing medical authority in microsocial settings, the author takes recourse to Weber's three ideal types. The study shows that for a charismatic healer who seeks to reach mutual consensus with his clientele vagueness in terminology can be useful. When, however, medical authority depends on recognition by superiors and peers in modern bureaucratic institutions, vague terms tend to be avoided. So, the same term that a charismatic healer may refer to in a vague sense becomes more explicitly defined in the bureaucratic setting. Its sense is more clearly delimited and denotational qualities are emphasized. In institutions where traditional authority prevails, like those of the literate elite in highly stratified traditional societies, the technical terminology is not only vague, but notoriously polysemous. The article draws on ethnographic data of Chinese medicine and qigong therapy as practised in the late eighties in Kunming city, the capital of Yunnan province in the People's Republic of China, but it is meant to contribute in a more general way to an exploration of the ways in which claims to medical authority interrelate with word meaning, language use, and 'styles of knowing'. The term investigated, shen, refers to the spiritual, a domain of human experience that is widely acknowledged by traditional medical practitioners, but difficult to evaluate by sociological analysis.
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Affiliation(s)
- E Hsu
- Faculty of Oriental Studies, University of Cambridge, UK
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