1
|
Estrada-Bernal A, Sharma L, Shah FA. "When the Going Gets Tough": Novel Roles for TRPV4 in Stiffness-induced Phagolysosome Maturation. Am J Respir Cell Mol Biol 2024. [PMID: 38502902 DOI: 10.1165/rcmb.2024-0070ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 03/19/2024] [Indexed: 03/21/2024] Open
Affiliation(s)
- Adriana Estrada-Bernal
- University of Pittsburgh, 6614, Division of Pulmonary, Allergy Critical Care, and Sleep Medicine, Pittsburgh, Pennsylvania, United States
| | - Lokesh Sharma
- University of Pittsburgh, 6614, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Pittsburgh, Pennsylvania, United States
| | - Faraaz Ali Shah
- University of Pittsburgh, 6614, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Pittsburgh, Pennsylvania, United States
- VA Pittsburgh Healthcare System, 20096, Pittsburgh, Pennsylvania, United States;
| |
Collapse
|
2
|
Shah FA, Meyer N, Angus DC, Yende S. Reply to Goligher et al.: Physiology Is Vital to Precision Medicine in Acute Respiratory Distress Syndrome and Sepsis. Am J Respir Crit Care Med 2022; 206:121-122. [PMID: 35533404 PMCID: PMC9954328 DOI: 10.1164/rccm.202203-0534le] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Faraaz Ali Shah
- University of PittsburghPittsburgh, Pennsylvania,Veterans Affairs Pittsburgh Healthcare SystemPittsburgh, Pennsylvania
| | - Nuala Meyer
- University of PennsylvaniaPhiladelphia, Pennsylvania
| | | | - Sachin Yende
- University of PittsburghPittsburgh, Pennsylvania,Veterans Affairs Pittsburgh Healthcare SystemPittsburgh, Pennsylvania,Corresponding author (e-mail: )
| |
Collapse
|
3
|
Shah FA, Meyer NJ, Angus DC, Awdish R, Azoulay É, Calfee CS, Clermont G, Gordon AC, Kwizera A, Leligdowicz A, Marshall JC, Mikacenic C, Sinha P, Venkatesh B, Wong HR, Zampieri FG, Yende S. A Research Agenda for Precision Medicine in Sepsis and Acute Respiratory Distress Syndrome: An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2021; 204:891-901. [PMID: 34652268 PMCID: PMC8534611 DOI: 10.1164/rccm.202108-1908st] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: Precision medicine focuses on the identification of therapeutic strategies that are effective for a group of patients based on similar unifying characteristics. The recent success of precision medicine in non-critical care settings has resulted from the confluence of large clinical and biospecimen repositories, innovative bioinformatics, and novel trial designs. Similar advances for precision medicine in sepsis and in the acute respiratory distress syndrome (ARDS) are possible but will require further investigation and significant investment in infrastructure. Methods: This project was funded by the American Thoracic Society Board of Directors. A multidisciplinary and diverse working group reviewed the available literature, established a conceptual framework, and iteratively developed recommendations for the Precision Medicine Research Agenda for Sepsis and ARDS. Results: The following six priority recommendations were developed by the working group: 1) the creation of large richly phenotyped and harmonized knowledge networks of clinical, imaging, and multianalyte molecular data for sepsis and ARDS; 2) the implementation of novel trial designs, including adaptive designs, and embedding trial procedures in the electronic health record; 3) continued innovation in the data science and engineering methods required to identify heterogeneity of treatment effect; 4) further development of the tools necessary for the real-time application of precision medicine approaches; 5) work to ensure that precision medicine strategies are applicable and available to a broad range of patients varying across differing racial, ethnic, socioeconomic, and demographic groups; and 6) the securement and maintenance of adequate and sustainable funding for precision medicine efforts. Conclusions: Precision medicine approaches that incorporate variability in genomic, biologic, and environmental factors may provide a path forward for better individualizing the delivery of therapies and improving care for patients with sepsis and ARDS.
Collapse
|
4
|
Bain W, Yang H, Shah FA, Suber T, Drohan C, Al-Yousif N, DeSensi RS, Bensen N, Schaefer C, Rosborough BR, Somasundaram A, Workman CJ, Lampenfeld C, Cillo AR, Cardello C, Shan F, Bruno TC, Vignali DAA, Ray P, Ray A, Zhang Y, Lee JS, Methé B, McVerry BJ, Morris A, Kitsios GD. COVID-19 versus Non-COVID-19 Acute Respiratory Distress Syndrome: Comparison of Demographics, Physiologic Parameters, Inflammatory Biomarkers, and Clinical Outcomes. Ann Am Thorac Soc 2021; 18:1202-1210. [PMID: 33544045 PMCID: PMC8328355 DOI: 10.1513/annalsats.202008-1026oc] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [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: 08/23/2020] [Indexed: 01/14/2023] Open
Abstract
Rationale: There is an urgent need for improved understanding of the mechanisms and clinical characteristics of acute respiratory distress syndrome (ARDS) due to coronavirus disease (COVID-19).Objectives: To compare key demographic and physiologic parameters, biomarkers, and clinical outcomes of COVID-19 ARDS and ARDS secondary to direct lung injury from other etiologies of pneumonia.Methods: We enrolled 27 patients with COVID-19 ARDS in a prospective, observational cohort study and compared them with a historical, pre-COVID-19 cohort of patients with viral ARDS (n = 14), bacterial ARDS (n = 21), and ARDS due to culture-negative pneumonia (n = 30). We recorded clinical demographics; measured respiratory mechanical parameters; collected serial peripheral blood specimens for measurement of plasma interleukin (IL)-6, IL-8, and IL-10; and followed patients prospectively for patient-centered outcomes. We conducted between-group comparisons with nonparametric tests and analyzed time-to-event outcomes with Kaplan-Meier and Cox proportional hazards models.Results: Patients with COVID-19 ARDS had higher body mass index and were more likely to be Black, or residents of skilled nursing facilities, compared with those with non-COVID-19 ARDS (P < 0.05). Patients with COVID-19 had lower delivered minute ventilation compared with bacterial and culture-negative ARDS (post hoc P < 0.01) but not compared with viral ARDS. We found no differences in static compliance, hypoxemic indices, or carbon dioxide clearance between groups. Patients with COVID-19 had lower IL-6 levels compared with bacterial and culture-negative ARDS at early time points after intubation but no differences in IL-6 levels compared with viral ARDS. Patients with COVID-19 had longer duration of mechanical ventilation but similar 60-day mortality in both unadjusted and adjusted analyses.Conclusions: COVID-19 ARDS bears several similarities to viral ARDS but demonstrates lower minute ventilation and lower systemic levels of IL-6 compared with bacterial and culture-negative ARDS. COVID-19 ARDS was associated with longer dependence on mechanical ventilation compared with non-COVID-19 ARDS. Such detectable differences of COVID-19 do not merit deviation from evidence-based management of ARDS but suggest priorities for clinical research to better characterize and treat this new clinical entity.
Collapse
Affiliation(s)
- William Bain
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Acute Lung Injury Center of Excellence, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania
| | - Haopu Yang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Acute Lung Injury Center of Excellence, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- School of Medicine, Tsinghua University, Beijing, China
| | - Faraaz Ali Shah
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Acute Lung Injury Center of Excellence, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania
| | - Tomeka Suber
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Acute Lung Injury Center of Excellence, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | - Rebecca S. DeSensi
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Acute Lung Injury Center of Excellence, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Nicole Bensen
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Caitlin Schaefer
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Acute Lung Injury Center of Excellence, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brian R. Rosborough
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Acute Lung Injury Center of Excellence, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ashwin Somasundaram
- Division of Hematology-Oncology, Department of Medicine
- Tumor Microenvironment Center, and
- Department of Immunology and
| | - Creg J. Workman
- Tumor Microenvironment Center, and
- Department of Immunology and
| | | | | | - Carly Cardello
- Tumor Microenvironment Center, and
- Department of Immunology and
| | - Feng Shan
- Tumor Microenvironment Center, and
- Department of Immunology and
| | - Tullia C. Bruno
- Tumor Microenvironment Center, and
- Cancer Immunology and Immunotherapy Program, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, Pennsylvania; and
- Department of Immunology and
| | - Dario A. A. Vignali
- Tumor Microenvironment Center, and
- Cancer Immunology and Immunotherapy Program, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, Pennsylvania; and
- Department of Immunology and
| | - Prabir Ray
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Acute Lung Injury Center of Excellence, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Immunology and
| | - Anuradha Ray
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Acute Lung Injury Center of Excellence, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Immunology and
| | - Yingze Zhang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Acute Lung Injury Center of Excellence, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Janet S. Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Acute Lung Injury Center of Excellence, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Barbara Methé
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Acute Lung Injury Center of Excellence, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Center for Medicine and the Microbiome, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Bryan J. McVerry
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Acute Lung Injury Center of Excellence, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Center for Medicine and the Microbiome, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alison Morris
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Acute Lung Injury Center of Excellence, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Center for Medicine and the Microbiome, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Georgios D. Kitsios
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Acute Lung Injury Center of Excellence, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Center for Medicine and the Microbiome, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| |
Collapse
|
5
|
Abstract
Regulation of endogenous glucose production (EGP) by hormonal, neuronal, and metabolic signaling pathways contributes to the maintenance of euglycemia under normal physiologic conditions. EGP is defined by the generation of glucose from substrates through glycogenolysis and gluconeogenesis, usually in fasted states, for local and systemic use. Abnormal increases in EGP are noted in patients with diabetes mellitus type 2, and elevated EGP may also impact the pathogenesis of nonalcoholic fatty liver disease and congestive heart failure. In this narrative review, we performed a literature search in PubMed to identify recently published English language articles characterizing EGP in critical illness. Evidence from preclinical and clinical studies demonstrates that critical illness can disrupt EGP through multiple mechanisms including increased systemic inflammation, counterregulatory hormone and catecholamine release, alterations in the hypothalamic-pituitary axis, insulin resistance, lactic acidosis, and iatrogenic insults such as vasopressors and glucocorticoids administered as part of clinical care. EGP contributes to hyperglycemia in critical illness when abnormally elevated and to hypoglycemia when abnormally depressed, each of which has been independently associated with increased mortality. Increased EGP may also promote protein catabolism that could worsen critical illness myopathy and impede recovery. Better understanding of the mechanisms and factors contributing to dysregulated EGP in critical illness may help in the development of therapeutic strategies that promote euglycemia, reduce intensive care unit-associated catabolism, and improve patient outcomes.
Collapse
Affiliation(s)
- Nameer Al-Yousif
- Department of Internal Medicine, UPMC Mercy Hospital, Pittsburgh, Pennsylvania, USA
| | - Sagar Rawal
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael Jurczak
- Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hussain Mahmud
- Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Faraaz Ali Shah
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Acute Lung Injury Center of Excellence, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
6
|
Farooq N, Chuan B, Mahmud H, El Khoudary SR, Nouraie SM, Evankovich J, Yang L, Dunlap D, Bain W, Kitsios G, Zhang Y, O’Donnell CP, McVerry BJ, Shah FA. Association of the systemic host immune response with acute hyperglycemia in mechanically ventilated septic patients. PLoS One 2021; 16:e0248853. [PMID: 33755703 PMCID: PMC7987165 DOI: 10.1371/journal.pone.0248853] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 03/07/2021] [Indexed: 12/13/2022] Open
Abstract
Hyperglycemia during sepsis is associated with increased organ dysfunction and higher mortality. The role of the host immune response in development of hyperglycemia during sepsis remains unclear. We performed a retrospective analysis of critically ill adult septic patients requiring mechanical ventilation (n = 153) to study the relationship between hyperglycemia and ten markers of the host injury and immune response measured on the first day of ICU admission (baseline). We determined associations between each biomarker and: (1) glucose, insulin, and c-peptide levels at the time of biomarker collection by Pearson correlation; (2) average glucose and glycemic variability in the first two days of ICU admission by linear regression; and (3) occurrence of hyperglycemia (blood glucose>180mg/dL) by logistic regression. Results were adjusted for age, pre-existing diabetes mellitus, severity of illness, and total insulin and glucocorticoid dose. Baseline plasma levels of ST2 and procalcitonin were positively correlated with average blood glucose and glycemic variability in the first two days of ICU admission in unadjusted and adjusted analyses. Additionally, higher baseline ST2, IL-1ra, procalcitonin, and pentraxin-3 levels were associated with increased risk of hyperglycemia. Our results suggest associations between the host immune response and hyperglycemia in critically ill septic patients particularly implicating the interleukin-1 axis (IL-1ra), the interleukin-33 axis (ST2), and the host response to bacterial infections (procalcitonin, pentraxin-3).
Collapse
Affiliation(s)
- Nauman Farooq
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Byron Chuan
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Hussain Mahmud
- Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Samar R. El Khoudary
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Seyed Mehdi Nouraie
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - John Evankovich
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Libing Yang
- School of Medicine, Tsinghua University, Haidian District, Beijing, China
| | - Daniel Dunlap
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - William Bain
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States of America
| | - Georgios Kitsios
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Yingze Zhang
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Christopher P. O’Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Bryan J. McVerry
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Faraaz Ali Shah
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States of America
- * E-mail:
| |
Collapse
|
7
|
Sami A, Shah FA, Abdullah M, Zhou X, Yan Y, Zhu Z, Zhou K. Melatonin mitigates cadmium and aluminium toxicity through modulation of antioxidant potential in Brassica napus L. Plant Biol (Stuttg) 2020; 22:679-690. [PMID: 32003103 DOI: 10.1111/plb.13093] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [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: 07/03/2019] [Accepted: 01/21/2020] [Indexed: 05/03/2023]
Abstract
Melatonin has emerged as an essential molecule in plants, due to its role in defence against metal toxicity. Aluminium (Al) and cadmium (Cd) toxicity inhibit rapeseed seedling growth. In this study, we applied different doses of melatonin (50 and 100 µm) to alleviate Al (25 µm) and Cd (25 µm) stress in rapeseed seedlings. Results show that Al and Cd caused toxicity in rapeseed seedling, as evidenced by a decrease in height, biomass and antioxidant enzyme activity. Melatonin increased the expression of melatonin biosynthesis-related Brassica napus genes for caffeic acid O-methyl transferase (BnCOMT) under Al and Cd stress. The genes BnCOMT-1, BnCOMT-5 and BnCOMT-8 showed up-regulated expression, while BnCOMT-4 and BnCOMT-6 were down-regulated during incubation in water. Melatonin application increased the germination rate, shoot length, root length, fresh and dry weight of seedlings. Melatonin supplementation under Al and Cd stress increased superoxide dismutase, catalase, peroxidase, ascorbate peroxidase, proline, chlorophyll and anthocyanin content, as well as photosynthesis rate. Both Cd and Al treatments significantly increased hydrogen peroxide and malondialdehyde levels in rapeseed seedlings, which were strictly counterbalanced by melatonin. Analysis of Cd and Al in different subcellular compartments showed that melatonin enhanced cell wall and soluble fractions, but reduced the vacuolar and organelle fractions in Al- and Cd-treated seedlings. These results suggest that melatonin-induced improvements in antioxidant potential, biomass, photosynthesis rate and successive Cd and Al sequestration play a pivotal role in plant tolerance to Al and Cd stress. This mechanism may have potential implications in safe food production.
Collapse
Affiliation(s)
- A Sami
- College of Agronomy, Anhui Agricultural University, Hefei, China
| | - F A Shah
- Key Laboratory of High Magnetic Field and Ion Beam Physical Biology, Hefei Institutes of Physical Science, Chinese Academy of Sciences, Hefei, Anhui, China
| | - M Abdullah
- School of Life Sciences, Anhui Agricultural University, Hefei, China
| | - X Zhou
- College of Agronomy, Anhui Agricultural University, Hefei, China
| | - Y Yan
- College of Agronomy, Anhui Agricultural University, Hefei, China
| | - Z Zhu
- College of Agronomy, Anhui Agricultural University, Hefei, China
| | - K Zhou
- College of Agronomy, Anhui Agricultural University, Hefei, China
| |
Collapse
|
8
|
Shah FA, Mahmud H, Gallego-Martin T, Jurczak MJ, O’Donnell CP, McVerry BJ. Therapeutic Effects of Endogenous Incretin Hormones and Exogenous Incretin-Based Medications in Sepsis. J Clin Endocrinol Metab 2019; 104:5274-5284. [PMID: 31216011 PMCID: PMC6763279 DOI: 10.1210/jc.2019-00296] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 02/04/2019] [Accepted: 06/13/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Sepsis, a complex disorder characterized by a dysregulated immune response to an inciting infection, affects over one million Americans annually. Dysglycemia during sepsis hospitalization confers increased risk of organ dysfunction and death, and novel targets for the treatment of sepsis and maintenance of glucose homeostasis are needed. Incretin hormones are secreted by enteroendocrine cells in response to enteral nutrients and potentiate insulin release from pancreatic β cells in a glucose-dependent manner, thereby reducing the risk of insulin-induced hypoglycemia. Incretin hormones also reduce systemic inflammation in preclinical studies, but studies of incretins in the setting of sepsis are limited. METHODS In this bench-to-bedside mini-review, we detail the evidence to support incretin hormones as a therapeutic target in patients with sepsis. We performed a PubMed search using the medical subject headings "incretins," "glucagon-like peptide-1," "gastric inhibitory peptide," "inflammation," and "sepsis." RESULTS Incretin-based therapies decrease immune cell activation, inhibit proinflammatory cytokine release, and reduce organ dysfunction and mortality in preclinical models of sepsis. Several small clinical trials in critically ill patients have suggested potential benefit in glycemic control using exogenous incretin infusions, but these studies had limited power and were performed in mixed populations. Further clinical studies examining incretins specifically in septic populations are needed. CONCLUSIONS Targeting the incretin hormone axis in sepsis may provide a means of not only promoting euglycemia in sepsis but also attenuating the proinflammatory response and improving clinical outcomes.
Collapse
Affiliation(s)
- Faraaz Ali Shah
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Veteran Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Correspondence and Reprint Requests: Faraaz Ali Shah, MD, MPH, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center, 3459 Fifth Avenue NW, 628 MUH, Pittsburgh, Pennsylvania 15213. E-mail:
| | - Hussain Mahmud
- Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Teresa Gallego-Martin
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael J Jurczak
- Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christopher P O’Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Bryan J McVerry
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
9
|
Shah FA, Kitsios GD, Zhang Y, Morris A, Yende S, Huang DT, O'Donnell CP, McVerry BJ. Rationale for and Design of the Study of Early Enteral Dextrose in Sepsis: A Pilot Placebo-Controlled Randomized Clinical Trial. JPEN J Parenter Enteral Nutr 2019; 44:541-547. [PMID: 31148210 DOI: 10.1002/jpen.1608] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 02/04/2019] [Revised: 04/19/2019] [Accepted: 05/03/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Sepsis is characterized by life-threatening organ dysfunction caused by a dysregulated host response to infection and affects over 1 million Americans annually. Loss of glycemic control in sepsis is associated with increased morbidity and mortality, and novel approaches are needed to promote euglycemia and improve outcomes in sepsis. Recent studies from our laboratory demonstrate that early low-level enteral dextrose infusion in septic mice attenuates the systemic inflammatory response and improves glycemic control by inducing intestine-derived incretin hormone secretion. AIM The aim of the Study of Early Enteral Dextrose in Sepsis (SEEDS) is to test the effect of a 24-hour enteral dextrose infusion in critically ill septic patients as a therapeutic agent to decrease systemic inflammation and promote euglycemia. METHODS SEEDS is a single-center, double-blind, randomized, controlled trial that will enroll 60 septic patients admitted to the intensive care units at the University of Pittsburgh Medical Center Health System in Pittsburgh. Participants will be randomized 1:1 to receive enteral dextrose (n = 30) or water (placebo, n = 30) infusion for 24 hours. The primary outcome is the circulating interleukin-6 level measured after the 24-hour infusion compared between dextrose and placebo groups. Secondary outcomes include postinfusion circulating insulin, incretin, and other proinflammatory cytokine levels, as well as incidence of hyperglycemia and hypoglycemia during the infusion period. DISCUSSION This trial will characterize the effects of early enteral dextrose on endogenous endocrine pathways and the systemic inflammatory response in sepsis. The results of this trial will inform future larger interventional studies of early enteral nutrients in critically ill patients with sepsis.
Collapse
Affiliation(s)
- Faraaz Ali Shah
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Veteran Affairs, Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Georgios D Kitsios
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yingze Zhang
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alison Morris
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sachin Yende
- Veteran Affairs, Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David T Huang
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christopher P O'Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Bryan J McVerry
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
10
|
Abstract
In lamellar bone, a network of highly oriented interconnected osteocytes is organized in concentric layers. Through their cellular processes contained within canaliculi, osteocytes are highly mechanosensitive and locally modulate bone remodeling. We review the recent developments demonstrating the significance of the osteocyte lacuno-canalicular network in bone maintenance around implant biomaterials. Drilling during implant site preparation triggers osteocyte apoptosis, the magnitude of which correlates with drilling speed and heat generation, resulting in extensive remodeling and delayed healing. In peri-implant bone, osteocytes physically communicate with implant surfaces via canaliculi and are responsive to mechanical loading, leading to changes in osteocyte numbers and morphology. Certain implant design features allow peri-implant osteocytes to retain a less aged phenotype, despite highly advanced extracellular matrix maturation. Physicochemical properties of anodically oxidized surfaces stimulate bone formation and remodeling by regulating the expression of RANKL (receptor activator of nuclear factor-κB ligand), RANK, and OPG (osteoprotegerin) from implant-adherent cells. Modulation of certain osteocyte-related molecular signaling mechanisms (e.g., sclerostin blockade) may enhance the biomechanical anchorage of implants. Evaluation of the peri-implant osteocyte lacuno-canalicular network should therefore be a necessary component in future investigations of osseointegration to more completely characterize the biological response to materials for load-bearing applications in dentistry and orthopedics.
Collapse
Affiliation(s)
- F A Shah
- 1 Department of Biomaterials, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - P Thomsen
- 1 Department of Biomaterials, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - A Palmquist
- 1 Department of Biomaterials, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| |
Collapse
|
11
|
Shah FA, Singamsetty S, Guo L, Chuan BW, McDonald S, Cooper BA, O'Donnell BJ, Stefanovski D, Wice B, Zhang Y, O'Donnell CP, McVerry BJ. Stimulation of the endogenous incretin glucose-dependent insulinotropic peptide by enteral dextrose improves glucose homeostasis and inflammation in murine endotoxemia. Transl Res 2018; 193:1-12. [PMID: 29222967 PMCID: PMC5826869 DOI: 10.1016/j.trsl.2017.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 10/20/2017] [Accepted: 11/08/2017] [Indexed: 12/11/2022]
Abstract
Loss of glucose homeostasis during sepsis is associated with increased organ dysfunction and higher mortality. Novel therapeutic strategies to promote euglycemia in sepsis are needed. We have previously shown that early low-level intravenous (IV) dextrose suppresses pancreatic insulin secretion and induces insulin resistance in septic mice, resulting in profound hyperglycemia and worsened systemic inflammation. In this study, we hypothesized that administration of low-level dextrose via the enteral route would stimulate intestinal incretin hormone production, potentiate insulin secretion in a glucose-dependent manner, and thereby improve glycemic control in the acute phase of sepsis. We administered IV or enteral dextrose to 10-week-old male C57BL/6J mice exposed to bacterial endotoxin and measured incretin hormone release, glucose disposal, and proinflammatory cytokine production. Compared with IV administration, enteral dextrose increased circulating levels of the incretin hormone glucose-dependent insulinotropic peptide (GIP) associated with increased insulin release and insulin sensitivity, improved mean arterial pressure, and decreased proinflammatory cytokines in endotoxemic mice. Exogenous GIP rescued glucose metabolism, improved blood pressure, and increased insulin release in endotoxemic mice receiving IV dextrose, whereas pharmacologic inhibition of GIP signaling abrogated the beneficial effects of enteral dextrose. Thus, stimulation of endogenous GIP secretion by early enteral dextrose maintains glucose homeostasis and attenuates the systemic inflammatory response in endotoxemic mice and may provide a therapeutic target for improving glycemic control and clinical outcomes in patients with sepsis.
Collapse
Affiliation(s)
- Faraaz Ali Shah
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pa.
| | - Srikanth Singamsetty
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pa
| | - Lanping Guo
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pa
| | - Byron W Chuan
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pa
| | | | - Bryce A Cooper
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pa
| | - Brett J O'Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pa
| | - Darko Stefanovski
- School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Burton Wice
- Division of Endocrinology, Metabolism, and Lipid Research, Washington University, St. Louis, Mo
| | - Yingze Zhang
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pa
| | - Christopher P O'Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pa
| | - Bryan J McVerry
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pa
| |
Collapse
|
12
|
Singamsetty S, Shah FA, Guo L, Watanabe Y, McDonald S, Sharma R, Zhang Y, Alonso LC, O'Donnell CP, McVerry BJ. Early initiation of low-level parenteral dextrose induces an accelerated diabetic phenotype in septic C57BL/6J mice. Appl Physiol Nutr Metab 2015; 41:12-9. [PMID: 26624964 DOI: 10.1139/apnm-2015-0213] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Development of hyperglycemia during sepsis is associated with increased morbidity and mortality. Nutritional support is common practice in the intensive care unit, but the metabolic effects are not well understood. The purpose of this study is to determine the effect of early low-level calorie provision on the development of hyperglycemia in a clinically relevant murine model of sepsis. C57BL/6J mice underwent femoral arterial and venous catheterization followed by cecal ligation and puncture (CLP) or sham surgery and low-dose intravenous dextrose or saline infusion. Blood glucose, plasma insulin, and cytokines were measured after 24 h. Additional septic mice underwent hyperinsulinemic-euglycemic clamps or received intravenous insulin concurrent with dextrose to determine whole-body insulin sensitivity and test the efficacy of insulin to reverse hyperglycemia. Neither dextrose infusion nor CLP alone induced hyperglycemia. Early initiation of low-level dextrose in septic mice produced a variable glycemic response: 49% maintained euglycemia (blood glucose < 200) and 27% developed severe hyperglycemia (blood glucose ≥ 600). Hyperglycemia was associated with increased inflammation and reduced insulin secretion and sensitivity compared with control mice or CLP mice maintaining euglycemia. Insulin prevented the progression to severe hyperglycemia but was ineffective in reestablishing glycemic control once hyperglycemia had developed. In conclusion, early initiation of clinically relevant low-level dextrose (∼ 20% daily caloric requirements) precipitated hyperglycemia akin to an acute diabetic phenotype in septic mice characterized by decreased insulin sensitivity, decreased insulin secretion, and an increased inflammatory response.
Collapse
Affiliation(s)
- Srikanth Singamsetty
- a Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Faraaz Ali Shah
- a Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Lanping Guo
- a Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Yoshio Watanabe
- a Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Sherie McDonald
- a Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Rohit Sharma
- b Division of Endocrinology and Metabolism, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Yingze Zhang
- a Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Laura C Alonso
- b Division of Endocrinology and Metabolism, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Christopher P O'Donnell
- a Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Bryan J McVerry
- a Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| |
Collapse
|
13
|
|
14
|
Shah FA, Pike F, Alvarez K, Angus D, Newman AB, Lopez O, Tate J, Kapur V, Wilsdon A, Krishnan JA, Hansel N, Au D, Avdalovic M, Fan VS, Barr RG, Yende S. Bidirectional relationship between cognitive function and pneumonia. Am J Respir Crit Care Med 2013; 188:586-92. [PMID: 23848267 PMCID: PMC3827700 DOI: 10.1164/rccm.201212-2154oc] [Citation(s) in RCA: 131] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
RATIONALE Relationships between chronic health conditions and acute infections remain poorly understood. Preclinical studies suggest crosstalk between nervous and immune systems. OBJECTIVES To determine bidirectional relationships between cognition and pneumonia. METHODS We conducted longitudinal analyses of a population-based cohort over 10 years. We determined whether changes in cognition increase risk of pneumonia hospitalization by trajectory analyses and joint modeling. We then determined whether pneumonia hospitalization increased risk of subsequent dementia using a Cox model with pneumonia as a time-varying covariate. MEASUREMENTS AND MAIN RESULTS Of the 5,888 participants, 639 (10.9%) were hospitalized with pneumonia at least once. Most participants had normal cognition before pneumonia. Three cognition trajectories were identified: no, minimal, and severe rapid decline. A greater proportion of participants hospitalized with pneumonia were on trajectories of minimal or severe decline before occurrence of pneumonia compared with those never hospitalized with pneumonia (proportion with no, minimal, and severe decline were 67.1%, 22.8%, and 10.0% vs. 76.0%, 19.3%, and 4.6% for participants with and without pneumonia, respectively; P < 0.001). Small subclinical changes in cognition increased risk of pneumonia, even in those with normal cognition and physical function before pneumonia (β = -0.02; P < 0.001). Participants with pneumonia were subsequently at an increased risk of dementia (hazard ratio, 2.24 [95% confidence interval, 1.62-3.11]; P = 0.01). Associations were independent of demographics, health behaviors, other chronic conditions, and physical function. Bidirectional relationship did not vary based on severity of disease, and similar associations were noted for those with severe sepsis and other infections. CONCLUSIONS A bidirectional relationship exists between pneumonia and cognition and may explain how a single episode of infection in well-appearing older individuals accelerates decline in chronic health conditions and loss of functional independence.
Collapse
Affiliation(s)
- Faraaz Ali Shah
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center, PA, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Arshad M, Khan ZM, Khalil-ur-Rehman, Shah FA, Rajoka MI. Optimization of process variables for minimization of byproduct formation during fermentation of blackstrap molasses to ethanol at industrial scale. Lett Appl Microbiol 2009; 47:410-4. [PMID: 19146530 DOI: 10.1111/j.1472-765x.2008.02446.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIMS To investigate the effect of molasses concentration, initial pH of molasses medium, and inoculum's size to maximize ethanol and minimize methanol, fusel alcohols, acetic acid and aldehydes in the fermentation mash in industrial fermentors. METHODS AND RESULTS Initial studies to optimize temperature, nitrogen source, phosphorous source, sulfur supplement and minerals were performed. The essential nutrients were urea (2 kg in 60 m(3)), 0.5 l each of commercial phosphoric acid and sulfuric acid (for pH control) added at the inoculum preparation stage only. Yields of ethanol, methanol, fusel alcohols, total acids and aldehydes per 100-l fermentation broth were monitored. Molasses at 29 degrees Brix (degree of dissolved sugars in water), initial pH 4.5, inoculum size 30% (v/v) and anaerobic fermentation supported maximum ethanol (7.8%) with Y(P/S) = 238 l ethanol per tonne molasses (96.5% yield) (8.2% increase in yield), and had significantly lower values of byproducts than those in control experiments. CONCLUSIONS Optimization of process variables resulted in higher ethanol yield (8.2%) and reduced yield of methanol, fusel alcohols, acids and aldehydes. SIGNIFICANCE AND IMPACT OF THE STUDY More than 5% substrate is converted into byproducts. Eliminating or reducing their formation can increase ethanol yield by Saccharomyces cerevisiae, decrease the overall cost of fermentation process and improve the quality of ethanol.
Collapse
Affiliation(s)
- M Arshad
- Alcohol Division, Shakargnaj Mills Ltd., Jhang, Punjab, Pakistan
| | | | | | | | | |
Collapse
|
16
|
Dave AN, Shah FA, Sagar RP, Raval HB, Patel CB, Agrawal GR. Ovarian yolk sac tumor. Indian J Radiol Imaging 2005. [DOI: 10.4103/0971-3026.28788] [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: 11/04/2022] Open
|
17
|
Abstract
Aspiration and/or ingestion of foreign bodies is a common occurrence. Six cases of scarf pin aspiration are described. Scarf pin inhalation as a cultural and ethnic hazard in an Arab woman is highlighted. [Editorial comment: The authors illustrate the dangers of holding a straight pin in the mouth. Management of these sharp, potentially penetrating foreign bodies is described.]
Collapse
Affiliation(s)
- P S Murthy
- Department of Ear Nose Throat, Ibri Regional Referral Hospital, Post Box no. 46, Postal Code 516, Sultanate of Oman
| | | | | | | | | |
Collapse
|
18
|
Abstract
Adeno-tonsillar hypertrophy, with signs of upper airway obstruction is a common presentation in ENT clinics. Recently it is identified as a major cause of sleep apnea syndrome. Several isolated case reports of pulmonary hypertension and corpulmonale appeared in the literature. The authors report two such children aged less than 2 years with cardio-pulmonary changes occurring secondary to chronic adeno-tonsillar hypertrophy that were successfully treated with the surgical removal.
Collapse
Affiliation(s)
- S Ramakrishna
- Department of ENT, Ibri Regional Referral Hospital, P.B. No. 46, P.C. 516, Sultanate of Oman, Oman
| | | | | | | | | | | | | |
Collapse
|
19
|
Abstract
Treacher Collins syndrome presents with cranio-facial deformities of variable expressions and severity, but rarely is it associated with acute airway obstruction of such severity that it necessitates surgical intervention. The authors describe their experience with such a neonate, who presented with acute airway obstruction successfully managed with a tracheostomy. The relevant English literature is reviewed.
Collapse
Affiliation(s)
- F A Shah
- ENT Department, Ibri Regional Referral Hospital, P.B. No. 46, P.C. 516, Ibri, Oman
| | | | | | | | | | | |
Collapse
|