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Qiu Z, Zhao L, Shen JZ, Liang Z, Wu Q, Yang K, Min L, Gimple RC, Yang Q, Bhargava S, Jin C, Kim C, Hinz D, Dixit D, Bernatchez JA, Prager BC, Zhang G, Dong Z, Lv D, Wang X, Kim LJ, Zhu Z, Jones KA, Zheng Y, Wang X, Siqueira-Neto JL, Chavez L, Fu XD, Spruck C, Rich JN. Transcription Elongation Machinery Is a Druggable Dependency and Potentiates Immunotherapy in Glioblastoma Stem Cells. Cancer Discov 2022; 12:502-521. [PMID: 34615656 PMCID: PMC8831451 DOI: 10.1158/2159-8290.cd-20-1848] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [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: 12/23/2020] [Revised: 07/03/2021] [Accepted: 10/01/2021] [Indexed: 11/16/2022]
Abstract
Glioblastoma (GBM) is the most lethal primary brain cancer characterized by therapeutic resistance, which is promoted by GBM stem cells (GSC). Here, we interrogated gene expression and whole-genome CRISPR/Cas9 screening in a large panel of patient-derived GSCs, differentiated GBM cells (DGC), and neural stem cells (NSC) to identify master regulators of GSC stemness, revealing an essential transcription state with increased RNA polymerase II-mediated transcription. The YY1 and transcriptional CDK9 complex was essential for GSC survival and maintenance in vitro and in vivo. YY1 interacted with CDK9 to regulate transcription elongation in GSCs. Genetic or pharmacologic targeting of the YY1-CDK9 complex elicited RNA m6A modification-dependent interferon responses, reduced regulatory T-cell infiltration, and augmented efficacy of immune checkpoint therapy in GBM. Collectively, these results suggest that YY1-CDK9 transcription elongation complex defines a targetable cell state with active transcription, suppressed interferon responses, and immunotherapy resistance in GBM. SIGNIFICANCE: Effective strategies to rewire immunosuppressive microenvironment and enhance immunotherapy response are still lacking in GBM. YY1-driven transcriptional elongation machinery represents a druggable target to activate interferon response and enhance anti-PD-1 response through regulating the m6A modification program, linking epigenetic regulation to immunomodulatory function in GBM.This article is highlighted in the In This Issue feature, p. 275.
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Affiliation(s)
- Zhixin Qiu
- Hillman Cancer Center and Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.,Division of Regenerative Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA 92037, USA
| | - Linjie Zhao
- Hillman Cancer Center and Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.,Division of Regenerative Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA 92037, USA
| | - Jia Z. Shen
- Tumor Initiation and Maintenance Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA
| | - Zhengyu Liang
- Department of Cellular and Molecular Medicine, Institute of Genomic Medicine, University of California, San Diego, La Jolla, CA 92093, USA
| | - Qiulian Wu
- Hillman Cancer Center and Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.,Division of Regenerative Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA 92037, USA
| | - Kailin Yang
- Department of Radiation Oncology, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Lihua Min
- Hillman Cancer Center and Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Ryan C. Gimple
- Division of Regenerative Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA 92037, USA.,Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - Qiyuan Yang
- NOMIS Center for Immunobiology and Microbial Pathogenesis, The Salk Institute for Biological Studies, La Jolla, CA 92037, USA
| | - Shruti Bhargava
- Division of Regenerative Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA 92037, USA
| | - Chunyu Jin
- Howard Hughes Medical Institute, Department of Medicine, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Cheryl Kim
- Flow Cytometry Core Facility, La Jolla Institute for Immunology (LJI), La Jolla, CA 92037, USA
| | - Denise Hinz
- Flow Cytometry Core Facility, La Jolla Institute for Immunology (LJI), La Jolla, CA 92037, USA
| | - Deobrat Dixit
- Division of Regenerative Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA 92037, USA
| | - Jean A. Bernatchez
- Center for Discovery and Innovation in Parasitic Diseases, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA 92037, USA
| | - Briana C. Prager
- Division of Regenerative Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA 92037, USA.,Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - Guoxin Zhang
- Division of Regenerative Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA 92037, USA
| | - Zhen Dong
- Division of Regenerative Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA 92037, USA
| | - Deguan Lv
- Hillman Cancer Center and Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.,Division of Regenerative Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA 92037, USA
| | - Xujun Wang
- SJTU-Yale Joint Center for Biostatistics, School of Life Science and Biotechnology, Shanghai Jiao Tong University, Shanghai 200240, China
| | - Leo J.Y. Kim
- Division of Regenerative Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA 92037, USA.,Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA
| | - Zhe Zhu
- Division of Regenerative Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA 92037, USA
| | - Katherine A. Jones
- Regulatory Biology Laboratory, The Salk Institute for Biological Studies, La Jolla, CA 92037, USA
| | - Ye Zheng
- NOMIS Center for Immunobiology and Microbial Pathogenesis, The Salk Institute for Biological Studies, La Jolla, CA 92037, USA
| | - Xiuxing Wang
- Division of Regenerative Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA 92037, USA.,School of Basic Medical Sciences, Nanjing Medical University, Nanjing, Jiangsu 211166, China
| | - Jair L. Siqueira-Neto
- Center for Discovery and Innovation in Parasitic Diseases, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA 92037, USA
| | - Lukas Chavez
- Department of Medicine, University of California, San Diego, La Jolla, CA 92093, USA
| | - Xiang-Dong Fu
- Department of Cellular and Molecular Medicine, Institute of Genomic Medicine, University of California, San Diego, La Jolla, CA 92093, USA
| | - Charles Spruck
- Tumor Initiation and Maintenance Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, California.
| | - Jeremy N. Rich
- Hillman Cancer Center and Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.,Division of Regenerative Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA 92037, USA.,Sanford Consortium for Regenerative Medicine, La Jolla, CA 92037, USA.,Department of Neurology, University of Pittsburgh, Pittsburgh, PA 15213, USA.,Corresponding Authors: Jeremy N. Rich: ; +1(412) 623-3364; Address: UPMC Hillman Cancer Center, 5115 Centre Ave, Pittsburgh, PA 15232; Charles Spruck: ; +1(858) 401-3459; Address: 10901 N Torrey Pines Rd, La Jolla, CA 92037
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Burkhardt JK, Srinivasan V, Srivatsan A, Albuquerque F, Ducruet AF, Hendricks B, Gross BA, Jankowitz BT, Thomas AJ, Ogilvy CS, Maragkos GA, Enriquez-Marulanda A, Crowley RW, Levitt MR, Kim LJ, Griessenauer CJ, Schirmer CM, Dalal S, Piper K, Mokin M, Winkler EA, Abla AA, McDougall C, Birnbaum L, Mascitelli J, Litao M, Tanweer O, Riina H, Johnson J, Chen S, Kan P. Multicenter Postmarket Analysis of the Neuroform Atlas Stent for Stent-Assisted Coil Embolization of Intracranial Aneurysms. AJNR Am J Neuroradiol 2020; 41:1037-1042. [PMID: 32467183 DOI: 10.3174/ajnr.a6581] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 03/29/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The Neuroform Atlas is a new microstent to assist coil embolization of intracranial aneurysms that recently gained FDA approval. We present a postmarket multicenter analysis of the Neuroform Atlas stent. MATERIALS AND METHODS On the basis of retrospective chart review from 11 academic centers, we analyzed patients treated with the Neuroform Atlas after FDA exemption from January 2018 to June 2019. Clinical and radiologic parameters included patient demographics, aneurysm characteristics, stent parameters, complications, and outcomes at discharge and last follow-up. RESULTS Overall, 128 aneurysms in 128 patients (median age, 62 years) were treated with 138 stents. Risk factors included smoking (59.4%), multiple aneurysms (27.3%), and family history of aneurysms (16.4%). Most patients were treated electively (93.7%), and 8 (6.3%) underwent treatment within 2 weeks of subarachnoid hemorrhage. Previous aneurysm treatment failure was present in 21% of cases. Wide-neck aneurysms (80.5%), small aneurysm size (<7 mm, 76.6%), and bifurcation aneurysm location (basilar apex, 28.9%; anterior communicating artery, 27.3%; and middle cerebral artery bifurcation, 12.5%) were common. A single stent was used in 92.2% of cases, and a single catheter for both stent placement and coiling was used in 59.4% of cases. Technical complications during stent deployment occurred in 4.7% of cases; symptomatic thromboembolic stroke, in 2.3%; and symptomatic hemorrhage, in 0.8%. Favorable Raymond grades (Raymond-Roy occlusion classification) I and II were achieved in 82.9% at discharge and 89.5% at last follow-up. mRS ≤2 was determined in 96.9% of patients at last follow-up. The immediate Raymond-Roy occlusion classification grade correlated with aneurysm location (P < .0001) and rupture status during treatment (P = .03). CONCLUSIONS This multicenter analysis provides a real-world safety and efficacy profile for the treatment of intracranial aneurysms with the Neuroform Atlas stent.
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Affiliation(s)
- J-K Burkhardt
- From the Department of Neurosurgery (J.-K.B., V.S., A.S., O.T., J.J., S.C., P.K.), Baylor College of Medicine, Houston, Texas
| | - V Srinivasan
- From the Department of Neurosurgery (J.-K.B., V.S., A.S., O.T., J.J., S.C., P.K.), Baylor College of Medicine, Houston, Texas
| | - A Srivatsan
- From the Department of Neurosurgery (J.-K.B., V.S., A.S., O.T., J.J., S.C., P.K.), Baylor College of Medicine, Houston, Texas
| | - F Albuquerque
- Department of Neurosurgery (F.A., A.F.D., B.H.), Barrow Neurological Institute, Phoenix, Arizona
| | - A F Ducruet
- Department of Neurosurgery (F.A., A.F.D., B.H.), Barrow Neurological Institute, Phoenix, Arizona
| | - B Hendricks
- Department of Neurosurgery (F.A., A.F.D., B.H.), Barrow Neurological Institute, Phoenix, Arizona
| | - B A Gross
- Department of Neurological Surgery (B.A.G.), University of Pittsburgh Medical Center Presbyterian, Pittsburgh, Pennsylvania
| | - B T Jankowitz
- Department of Neurosurgery (B.T.J.), Cooper University, Camden, New Jersey
| | - A J Thomas
- Beth Israel Deaconess Medical Center (A.J.T., C.S.O., G.A.M.), Harvard Medical School, Boston, Massachusetts
| | - C S Ogilvy
- Beth Israel Deaconess Medical Center (A.J.T., C.S.O., G.A.M.), Harvard Medical School, Boston, Massachusetts
| | - G A Maragkos
- Beth Israel Deaconess Medical Center (A.J.T., C.S.O., G.A.M.), Harvard Medical School, Boston, Massachusetts
| | | | - R W Crowley
- Department of Neurosurgery (R.W.C.), Rush Medical College, Chicago, Illinois
| | - M R Levitt
- Department of Neurological Surgery (M.R.L., L.J.K.), University of Washington, Seattle, Washington
| | - L J Kim
- Department of Neurological Surgery (M.R.L., L.J.K.), University of Washington, Seattle, Washington
| | - C J Griessenauer
- Department of Neurosurgery (C.J.G., C.M.S., S.D.), Geisinger Health, Danville, Pennsylvania.,Research Institute of Neurointervention (C.J.G., C.M.S.), Paracelsus Medical University, Salzburg, Austria
| | - C M Schirmer
- Department of Neurosurgery (C.J.G., C.M.S., S.D.), Geisinger Health, Danville, Pennsylvania.,Research Institute of Neurointervention (C.J.G., C.M.S.), Paracelsus Medical University, Salzburg, Austria
| | - S Dalal
- Department of Neurosurgery (C.J.G., C.M.S., S.D.), Geisinger Health, Danville, Pennsylvania
| | - K Piper
- Department of Neurosurgery (K.P., M.M.), University of Southern Florida College of Public Health, Tampa, Florida
| | - M Mokin
- Department of Neurosurgery (K.P., M.M.), University of Southern Florida College of Public Health, Tampa, Florida
| | - E A Winkler
- Department of Neurological Surgery (E.A.W., A.A.A.), University of California, San Francisco, San Francisco, California
| | - A A Abla
- Department of Neurological Surgery (E.A.W., A.A.A.), University of California, San Francisco, San Francisco, California
| | - C McDougall
- Department of Neurosurgery (C.M., L.B., J.M.), University of Texas Health San Antonio, San Antonio, Texas
| | - L Birnbaum
- Department of Neurosurgery (C.M., L.B., J.M.), University of Texas Health San Antonio, San Antonio, Texas
| | - J Mascitelli
- Department of Neurosurgery (C.M., L.B., J.M.), University of Texas Health San Antonio, San Antonio, Texas
| | - M Litao
- Department of Neurosurgery (M.L., O.T., H.R.), NYU Langone Medical Center, New York, New York
| | - O Tanweer
- From the Department of Neurosurgery (J.-K.B., V.S., A.S., O.T., J.J., S.C., P.K.), Baylor College of Medicine, Houston, Texas.,Department of Neurosurgery (M.L., O.T., H.R.), NYU Langone Medical Center, New York, New York
| | - H Riina
- Department of Neurosurgery (M.L., O.T., H.R.), NYU Langone Medical Center, New York, New York
| | - J Johnson
- From the Department of Neurosurgery (J.-K.B., V.S., A.S., O.T., J.J., S.C., P.K.), Baylor College of Medicine, Houston, Texas
| | - S Chen
- From the Department of Neurosurgery (J.-K.B., V.S., A.S., O.T., J.J., S.C., P.K.), Baylor College of Medicine, Houston, Texas
| | - P Kan
- From the Department of Neurosurgery (J.-K.B., V.S., A.S., O.T., J.J., S.C., P.K.), Baylor College of Medicine, Houston, Texas
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de Oliveira DL, Hirotsu C, Kim LJ, Tufik S, Andersen ML. 0875 Sleep Duration As An Independent Factor Associated With Vitamin D Levels In Episono Cohort. Sleep 2018. [DOI: 10.1093/sleep/zsy061.874] [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: 11/14/2022] Open
Affiliation(s)
| | - C Hirotsu
- Universidade Federal de São Paulo, São Paulo, BRAZIL
| | - L J Kim
- Universidade Federal de São Paulo, São Paulo, BRAZIL
| | - S Tufik
- Universidade Federal de São Paulo, São Paulo, BRAZIL
| | - M L Andersen
- Universidade Federal de São Paulo, São Paulo, BRAZIL
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Hirotsu C, Kim LJ, Esteves AM, Bittencourt L, Andersen ML, Tufik S. 0742 EPIDEMIOLOGY OF RESTLESS LEGS SYNDROME AND PERIODIC LIMB MOVEMENT IN THE EPISONO COHORT. Sleep 2017. [DOI: 10.1093/sleepj/zsx050.741] [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: 11/13/2022] Open
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Soterio-Pires JH, Hirotsu C, Kim LJ, Bittencourt L, Tufik S, Andersen ML. The interaction between erectile dysfunction complaints and depression in men: a cross-sectional study about sleep, hormones and quality of life. Int J Impot Res 2016; 29:70-75. [DOI: 10.1038/ijir.2016.49] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 08/09/2016] [Accepted: 10/28/2016] [Indexed: 02/08/2023]
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Levitt MR, McGah PM, Moon K, Albuquerque FC, McDougall CG, Kalani MYS, Kim LJ, Aliseda A. Computational Modeling of Venous Sinus Stenosis in Idiopathic Intracranial Hypertension. AJNR Am J Neuroradiol 2016; 37:1876-1882. [PMID: 27197986 DOI: 10.3174/ajnr.a4826] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 03/31/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE Idiopathic intracranial hypertension has been associated with dural venous sinus stenosis in some patients, but the hemodynamic environment of the dural venous sinuses has not been quantitatively described. Here, we present the first such computational fluid dynamics model by using patient-specific blood pressure measurements. MATERIALS AND METHODS Six patients with idiopathic intracranial hypertension and at least 1 stenosis or atresia at the transverse/sigmoid sinus junction underwent MR venography followed by cerebral venography and manometry throughout the dural venous sinuses. Patient-specific computational fluid dynamics models were created by using MR venography anatomy, with venous pressure measurements as boundary conditions. Blood flow and wall shear stress were calculated for each patient. RESULTS Computational models of the dural venous sinuses were successfully reconstructed in all 6 patients with patient-specific boundary conditions. Three patients demonstrated a pathologic pressure gradient (≥8 mm Hg) across 4 dural venous sinus stenoses. Small sample size precludes statistical comparisons, but average overall flow throughout the dural venous sinuses of patients with pathologic pressure gradients was higher than in those without them (1041.00 ± 506.52 mL/min versus 358.00 ± 190.95 mL/min). Wall shear stress was also higher across stenoses in patients with pathologic pressure gradients (37.66 ± 48.39 Pa versus 7.02 ± 13.60 Pa). CONCLUSIONS The hemodynamic environment of the dural venous sinuses can be computationally modeled by using patient-specific anatomy and physiologic measurements in patients with idiopathic intracranial hypertension. There was substantially higher blood flow and wall shear stress in patients with pathologic pressure gradients.
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Affiliation(s)
- M R Levitt
- From the Departments of Neurological Surgery (M.R.L., L.J.K.) .,Radiology (M.R.L., L.J.K.).,Mechanical Engineering (M.R.L., P.M.M., A.A.), University of Washington, Seattle, Washington
| | - P M McGah
- Mechanical Engineering (M.R.L., P.M.M., A.A.), University of Washington, Seattle, Washington
| | - K Moon
- Department of Neurosurgery (K.M., F.C.A., C.G.M., M.Y.S.K.), Barrow Neurological Institute, Phoenix, Arizona
| | - F C Albuquerque
- Department of Neurosurgery (K.M., F.C.A., C.G.M., M.Y.S.K.), Barrow Neurological Institute, Phoenix, Arizona
| | - C G McDougall
- Department of Neurosurgery (K.M., F.C.A., C.G.M., M.Y.S.K.), Barrow Neurological Institute, Phoenix, Arizona
| | - M Y S Kalani
- Department of Neurosurgery (K.M., F.C.A., C.G.M., M.Y.S.K.), Barrow Neurological Institute, Phoenix, Arizona
| | - L J Kim
- From the Departments of Neurological Surgery (M.R.L., L.J.K.).,Radiology (M.R.L., L.J.K.)
| | - A Aliseda
- Mechanical Engineering (M.R.L., P.M.M., A.A.), University of Washington, Seattle, Washington
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McGah PM, Nerva JD, Morton RP, Barbour MC, Levitt MR, Mourad PD, Kim LJ, Aliseda A. In vitro validation of endovascular Doppler-derived flow rates in models of the cerebral circulation. Physiol Meas 2015; 36:2301-17. [PMID: 26450643 PMCID: PMC4684705 DOI: 10.1088/0967-3334/36/11/2301] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This study presents validation of endovascular Doppler velocimetry-based volumetric flow rate measurements conducted in a pulsatile flow loop simulating conditions in both the internal carotid and basilar artery. In vitro models of cerebral vessels, each containing an aneurysm, were fabricated from patient anatomies extracted from 3D rotational angiography. Flow velocity measurements were collected with three different experimental techniques: an endovascular Doppler wire, Particle Image Velocimetry, and a time-resolved ultrasonic flow meter. Womersley's theory of pulsatile flow in a cylindrical vessel was used to compute time-resolved volumetric flow rates from the endovascular Doppler velocity. The volumetric flow rates computed from the Doppler measurements were compared to those from the Particle Image Velocimetry profile measurements, and the direct measurements from the ultrasonic flow meter. The study establishes confidence intervals for any systematic or random errors associated with the wire-derived flow rates as benchmarked to the other two modalities. There is an approximately 10% random error in the Doppler-derived peak and time-averaged flow rates. There is a measurable uniform bias, about 15% too low, in the time-averaged Doppler-derived flow rates. There is also a small proportional bias in the peak systolic Doppler-derived flow rates. Potential sources of error are also discussed.
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Affiliation(s)
- P M McGah
- Department of Mechanical Engineering, University of Washington, Stevens Way, Box 352600, Seattle, Washington, US
| | - J D Nerva
- Department of Neurological Surgery, Harborview Medical Center, 325 9th Ave, Box 359924, Seattle, Washington, US
| | - R P Morton
- Department of Neurological Surgery, Harborview Medical Center, 325 9th Ave, Box 359924, Seattle, Washington, US
| | - M C Barbour
- Department of Mechanical Engineering, University of Washington, Stevens Way, Box 352600, Seattle, Washington, US
| | - M R Levitt
- Department of Neurological Surgery, Harborview Medical Center, 325 9th Ave, Box 359924, Seattle, Washington, US
| | - P D Mourad
- Department of Neurological Surgery, Harborview Medical Center, 325 9th Ave, Box 359924, Seattle, Washington, US
| | - L J Kim
- Department of Neurological Surgery, Harborview Medical Center, 325 9th Ave, Box 359924, Seattle, Washington, US
| | - A Aliseda
- Department of Mechanical Engineering, University of Washington, Stevens Way, Box 352600, Seattle, Washington, US
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Creutzfeldt CJ, Tirschwell DL, Kim LJ, Schubert GB, Longstreth WT, Becker KJ. Seizures after decompressive hemicraniectomy for ischaemic stroke. J Neurol Neurosurg Psychiatry 2014; 85:721-5. [PMID: 23918640 DOI: 10.1136/jnnp-2013-305678] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [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] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The risk of seizures after malignant middle cerebral artery (MCA) infarction with decompressive hemicraniectomy (DHC) is uncertain. Also unknown is how this complication influences survivors' recovery and quality of life. METHODS We retrospectively reviewed medical charts of all patients admitted to Harborview Medical Center between 1 January 2002 and 31 June 2011 for space-occupying MCA ischaemic stroke and who underwent DHC. Survivors and their surrogates were invited to participate in a telephone or in-person interview. RESULTS Fifty-five patients were followed for a median of 311 days (IQR 134-727). Twenty-seven patients (49%) had seizures, 25 (45%) developed epilepsy and 21 (38%) achieved moderate disability or better (modified Rankin Scale score ≤3) by 1 year after stroke onset. The only factor significantly associated with seizure occurrence was male gender. Median time from stroke to first seizure was 222 days, with a cluster of first seizures within weeks after cranioplasty; only two of the first seizures occurred right around the time of stroke onset. Follow-up time was significantly longer for patients with seizures (605 days, IQR 297-882) than for those without (221 days, IQR 104-335). Of the 20 patients interviewed, 12 achieved moderate disability or better, 15 experienced a seizure with 6 indicating the seizure was a major drawback. Regardless, all 20 would have chosen DHC again. CONCLUSIONS In this case series, patients were at high risk of developing seizures after malignant MCA stroke with DHC, especially after cranioplasty. Assuming these findings are replicated, means should be sought to reduce the occurrence of this complication.
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Affiliation(s)
- C J Creutzfeldt
- Department of Neurology and Neurosurgery, University of Washington, Seattle, Washington, USA
| | - D L Tirschwell
- Department of Neurology and Neurosurgery, University of Washington, Seattle, Washington, USA
| | - L J Kim
- Department of Neurology and Neurosurgery, University of Washington, Seattle, Washington, USA
| | - G B Schubert
- Department of Neurology and Neurosurgery, University of Washington, Seattle, Washington, USA
| | - W T Longstreth
- Department of Neurology and Neurosurgery, University of Washington, Seattle, Washington, USA
| | - K J Becker
- Department of Neurology and Neurosurgery, University of Washington, Seattle, Washington, USA
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Levitt MR, McGah PM, Aliseda A, Mourad PD, Nerva JD, Vaidya SS, Morton RP, Ghodke BV, Kim LJ. Cerebral aneurysms treated with flow-diverting stents: computational models with intravascular blood flow measurements. AJNR Am J Neuroradiol 2013; 35:143-8. [PMID: 23868162 DOI: 10.3174/ajnr.a3624] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Computational fluid dynamics modeling is useful in the study of the hemodynamic environment of cerebral aneurysms, but patient-specific measurements of boundary conditions, such as blood flow velocity and pressure, have not been previously applied to the study of flow-diverting stents. We integrated patient-specific intravascular blood flow velocity and pressure measurements into computational models of aneurysms before and after treatment with flow-diverting stents to determine stent effects on aneurysm hemodynamics. MATERIALS AND METHODS Blood flow velocity and pressure were measured in peri-aneurysmal locations by use of an intravascular dual-sensor pressure and Doppler velocity guidewire before and after flow-diverting stent treatment of 4 unruptured cerebral aneurysms. These measurements defined inflow and outflow boundary conditions for computational models. Intra-aneurysmal flow rates, wall shear stress, and wall shear stress gradient were calculated. RESULTS Measurements of inflow velocity and outflow pressure were successful in all 4 patients. Computational models incorporating these measurements demonstrated significant reductions in intra-aneurysmal wall shear stress and wall shear stress gradient and a trend in reduced intra-aneurysmal blood flow. CONCLUSIONS Integration of intravascular dual-sensor guidewire measurements of blood flow velocity and blood pressure provided patient-specific computational models of cerebral aneurysms. Aneurysm treatment with flow-diverting stents reduces blood flow and hemodynamic shear stress in the aneurysm dome.
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Levitt MR, Ghodke BV, Hallam DK, Sekhar LN, Kim LJ. Incidence of microemboli and correlation with platelet inhibition in aneurysmal flow diversion. AJNR Am J Neuroradiol 2013; 34:2321-5. [PMID: 23811975 DOI: 10.3174/ajnr.a3627] [Citation(s) in RCA: 11] [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: 11/07/2022]
Abstract
Flow-diverting stents have been associated with embolic and hemorrhagic complications, but the rate of procedure-related microemboli is unknown. Using transcranial Doppler sonography, we measured the rate of microemboli in 23 patients treated with flow-diverting stents. Patients received preprocedural dual antiplatelet medications and intraprocedural heparinization. Point-of-care platelet reactivity testing was performed before the procedure, and nonresponders (>213 P2Y12/ADP receptor reactivity units) received additional thienopyridine. Transcranial Doppler sonography was performed within 12-24 hours. Microemboli were detected in 3 patients (13%), 2 of whom were initially nonresponders. There was no association between the presence of microemboli and procedural or neurologic complications, aneurysm size, number of stents, or procedure time. Eight procedures (34.8%) required additional thienopyridine for inadequate platelet inhibition, and 3 required further treatment for persistent nonresponse to point-of-care platelet reactivity testing. There were 6 technical and 2 postoperative complications; none were associated with inadequate platelet inhibition or microemboli. The combination of routine point-of-care platelet reactivity testing and postprocedural microembolic monitoring may help identify patients at risk for thromboembolic complications after flow-diverting stents.
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Ramanathan D, Ghodke B, Kim LJ, Hallam D, Herbes-Rocha M, Sekhar LN. Endovascular management of cerebral bypass graft problems: an analysis of technique and results. AJNR Am J Neuroradiol 2011; 32:1415-9. [PMID: 21816916 DOI: 10.3174/ajnr.a2565] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Cerebral bypass grafts may develop generalized graft narrowing or focal stenosis during the perioperative period or later. Endovascular techniques such as PTA and stent placement of graft vessels are potential treatment options. Our objective was to review the safety, indications, technique, and results of endovascular management of graft problems. MATERIALS AND METHODS All patients with cerebral bypass procedures by using graft vessels from 2005 to 2009 were identified from a prospective registry and were studied retrospectively. Patient characteristics, bypass procedures, indications for endovascular interventions, graft patency, and clinical outcomes were reviewed from medical charts and imaging records. RESULTS A total of 79 patients underwent bypass procedures by using graft vessels. Seven patients of this group underwent endovascular interventions for the treatment of graft narrowing. Four of the 7 patients were treated for graft narrowing in the perioperative period (<1 month) with PTA; and 3 of the 7 patients, for late stenosis, 2 with PTA alone and 1 with PTA followed by stent placement. All procedures were immediately successful in improving flow through the graft. In late stenosis, PTA alone provided temporary improvement followed by recurrence, whereas PTA with a stent procedure was effective in the 1 patient long term. CONCLUSIONS PTA is safe and effective in the management of graft spasm in the perioperative period. For late graft stenosis, PTA alone provides only temporary respite, while PTA with stent placement may be an effective solution.
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Affiliation(s)
- D Ramanathan
- Department of Neurological Surgery, University of Washington, Seattle, 98104, USA
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12
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Abstract
FPCT and navigation software on contemporary fluoroscopic units perform imaging of a quality comparable with conventional CT. They can accurately guide percutaneous procedures, providing live instrument visualization and the capability to re-image without patient transfer. FPCT navigation was used in the placement of a ventricular drain in a 62-year-old woman for subarachnoid-related hydrocephalus by using an otherwise standard bedside technique. Ventriculostomy catheter placement was technically successful without complication with a catheter at the foramen of Monro.
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Affiliation(s)
- D L Cooke
- Department of Radiology, University of Washington School of Medicine, 1959 NE Pacific St, NW011, Box 357115, Seattle, WA 98195-7115, USA.
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13
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Bozinov O, Kim LJ, Spetzler RF. Intraoperative angiography for hunterian ligation of a recurrent basilar aneurysm. Zentralbl Neurochir 2007; 68:151-4; discussion 154. [PMID: 17665344 DOI: 10.1055/s-2007-984460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Cerebral aneurysms often recur after selective endovascular treatment with detachable coils and are usually treated by recoiling. Sometimes, however, surgical treatment is required, and application of the clip can be difficult. Evacuation of embolic material risks injuring eloquent structures or perforators, especially in the posterior circulation. In such cases parent vessel occlusion for reversal of flow might be an option. If collateral flow is adequate, an additional bypass is not required. When using this technique, known as Hunterian ligation, intraoperative monitoring such as electrophysiological monitoring and intraoperative angiography can be of great help and are advisable. We describe this procedure and related intraoperative considerations in one case report.
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Affiliation(s)
- O Bozinov
- Department of Neurochirurgie, Philipps Universitaet, Marburg, Germany.
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14
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Kim LJ, Feiz-Erfan I, Clatterbuck RE, Spetzler RF. Spontaneous ventriculostomy in a patient with obstructive hydrocephalus. Acta Neurochir (Wien) 2005; 147:219; discussion 219-20. [PMID: 15570439 DOI: 10.1007/s00701-004-0401-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Spontaneous ventriculostomy related to progressive obstructive hydrocephalus is rare. Radiologic demonstration of such a phenomenon can be delineated with magnetic resonance imaging (MRI) and cine MRI. CASE PRESENTATION A 59-year-old woman with a known tectal glioma and symptoms of chronic hydrocephalus developed progressively worsening headaches. During follow-up, she noted spontaneous relief of her headaches. Follow-up cine MRI demonstrated a spontaneous ventriculostomy via the floor of the third ventricle. INTERPRETATION Clinicians should be aware of spontaneous ventriculostomy demonstrable on cine MRI because it may obviate the need for a CSF diversion procedure.
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Affiliation(s)
- L J Kim
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA
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15
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Huang J, Agus DB, Winfree CJ, Kiss S, Mack WJ, McTaggart RA, Choudhri TF, Kim LJ, Mocco J, Pinsky DJ, Fox WD, Israel RJ, Boyd TA, Golde DW, Connolly ES. Dehydroascorbic acid, a blood-brain barrier transportable form of vitamin C, mediates potent cerebroprotection in experimental stroke. Proc Natl Acad Sci U S A 2001; 98:11720-4. [PMID: 11573006 PMCID: PMC58796 DOI: 10.1073/pnas.171325998] [Citation(s) in RCA: 172] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2001] [Accepted: 06/27/2001] [Indexed: 11/18/2022] Open
Abstract
Neuronal injury in ischemic stroke is partly mediated by cytotoxic reactive oxygen species. Although the antioxidant ascorbic acid (AA) or vitamin C does not penetrate the blood-brain barrier (BBB), its oxidized form, dehydroascorbic acid (DHA), enters the brain by means of facilitative transport. We hypothesized that i.v. DHA would improve outcome after stroke because of its ability to cross the BBB and augment brain antioxidant levels. Reversible or permanent focal cerebral ischemia was created by intraluminal middle cerebral artery occlusion in mice treated with vehicle, AA, or DHA (40, 250, or 500 mg/kg), either before or after ischemia. Given before ischemia, DHA caused dose-dependent increases in postreperfusion cerebral blood flow, with reductions in neurological deficit and mortality. In reperfused cerebral ischemia, mean infarct volume was reduced from 53% and 59% in vehicle- and AA-treated animals, respectively, to 15% in 250 mg/kg DHA-treated animals (P < 0.05). Similar significant reductions occurred in nonreperfused cerebral ischemia. Delayed postischemic DHA administration after 15 min or 3 h also mediated improved outcomes. DHA (250 mg/kg or 500 mg/kg) administered at 3 h postischemia reduced infarct volume by 6- to 9-fold, to only 5% with the highest DHA dose (P < 0.05). In contrast, AA had no effect on infarct volumes, mortality, or neurological deficits. No differences in the incidence of intracerebral hemorrhage occurred. Unlike exogenous AA, DHA confers in vivo, dose-dependent neuroprotection in reperfused and nonreperfused cerebral ischemia at clinically relevant times. As a naturally occurring interconvertible form of AA with BBB permeability, DHA represents a promising pharmacological therapy for stroke based on its effects in this model of cerebral ischemia.
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Affiliation(s)
- J Huang
- Department of Neurological Surgery, College of Physicians and Surgeons, Columbia University, 710 West 168th Street, New York, NY 10032, USA
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16
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Abstract
NFATp is one member of a family of transcriptional activators that regulate the expression of cytokine genes. To study mechanisms of NFATp transcriptional activation, we established a reconstituted transcription system consisting of human components that is responsive to activation by full-length NFATp. The TATA-associated factor (TAF(II)) subunits of the TFIID complex were required for NFATp-mediated activation in this transcription system, since TATA-binding protein (TBP) alone was insufficient in supporting activated transcription. In vitro interaction assays revealed that human TAF(II)130 (hTAF(II)130) and its Drosophila melanogaster homolog dTAF(II)110 bound specifically and reproducibly to immobilized NFATp. Sequences contained in the C-terminal domain of NFATp (amino acids 688 to 921) were necessary and sufficient for hTAF(II)130 binding. A partial TFIID complex assembled from recombinant hTBP, hTAF(II)250, and hTAF(II)130 supported NFATp-activated transcription, demonstrating the ability of hTAF(II)130 to serve as a coactivator for NFATp in vitro. Overexpression of hTAF(II)130 in Cos-1 cells inhibited NFATp activation of a luciferase reporter. These studies demonstrate that hTAF(II)130 is a coactivator for NFATp and represent the first biochemical characterization of the mechanism of transcriptional activation by the NFAT family of activators.
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Affiliation(s)
- L J Kim
- Department of Chemistry and Biochemistry, University of Colorado at Boulder, Boulder, Colorado 80309-0215, USA
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17
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Huang J, Choudhri TF, Winfree CJ, McTaggart RA, Kiss S, Mocco J, Kim LJ, Protopsaltis TS, Zhang Y, Pinsky DJ, Connolly ES. Postischemic cerebrovascular E-selectin expression mediates tissue injury in murine stroke. Stroke 2000; 31:3047-53. [PMID: 11108771] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
BACKGROUND AND PURPOSE Although the deleterious role of several proinflammatory mediators, including P-selectin, in reperfused stroke is well established, the role of E-selectin has not been fully characterized. METHODS E-selectin mRNA expression was studied at 4, 10, and 24 hours after reperfusion with reverse transcription and polymerase chain reaction in mice (n=18) subjected to transient intraluminal middle cerebral artery occlusion (MCAO). Mice received intravenous injection with anti-E-selectin monoclonal antibody (10, 35, or 50 microg), nonimmune IgG, or vehicle immediately before MCAO and 90 minutes later (n=85). Others received anti-E-selectin antibody 3 or 6 hours after MCAO (n=32). Myeloperoxidase activity was measured in sham-operated mice and after 10 hours of reperfusion in saline-, nonimmune IgG-, or anti-E-selectin IgG-treated cohorts (n=17). Serial cerebral blood flow was measured with laser-Doppler flowmetry, and outcomes were assessed by neurological deficits and infarct volumes with the use of planimetric analysis of triphenyltetrazolium chloride-stained sections. RESULTS Upregulated E-selectin expression occurred in the ischemic cerebral vasculature within 4 hours of reperfusion and persisted for 24 hours. Anti-E-selectin antibody increased ischemic cortical cerebral blood flow up to 2.6-fold (P:<0.05). In addition to dose-dependent reductions in neurological deficits (P:<0.05), mortality, and infarct volumes (P:<0.01 for 35 and 50 microg), anti-E-selectin treatment reduced cerebral neutrophil accumulation (P:<0.05) and was neuroprotective even if delayed until 3 hours after ischemia (P:<0. 05). CONCLUSIONS These findings establish a functional role for E-selectin in the pathogenesis of tissue injury after cerebral ischemia and reperfusion and suggest that E-selectin blockade may be clinically useful in the treatment of reperfused stroke.
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Affiliation(s)
- J Huang
- Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
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18
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Tran KM, Frank SM, Raja SN, El-Rahmany HK, Kim LJ, Vu B. Lumbar sympathetic block for sympathetically maintained pain: changes in cutaneous temperatures and pain perception. Anesth Analg 2000; 90:1396-401. [PMID: 10825327 DOI: 10.1097/00000539-200006000-00025] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.1] [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: 11/25/2022]
Abstract
UNLABELLED Lumbar sympathetic block (LSB) is used in the management of sympathetically maintained pain states. We characterized cutaneous temperature changes over the lower extremities after LSB. Additionally, we examined the effects of iohexol, a radio-opaque contrast medium, on temperature changes and pain relief. After institutional review board approval and written, informed consent, 28 LSBs were studied in 17 patients. Iohexol or normal saline was injected in a randomized, double-blinded fashion before bupivacaine. Lower extremity cutaneous temperatures were measured. Pain, allodynia, interference with daily function, and perceived pain relief were reported in a subset of 15 LSBs for 1 wk after the block. The distal lower extremity ipsilateral to the LSB had the greatest magnitude (8.7 degrees +/- 0.8 degrees C) and rate (1.1 degrees +/- 0.2 degrees C/min) of temperature change. The great toe temperature was within 3 degrees C of core temperature within 35 min after LSB. There were no differences in temperature change between the groups. The iohexol group had greater relief of pain until the morning of the first postblock day (P = 0.002) and longer perceived relief of pain (P = 0.01). The maximum temperature of the great toe correlated with allodynia relief (P = 0.0007). Thus clinicians should expect ipsilateral toe temperatures to increase to within approximately 3 degrees C of core temperature. Iohexol does not alter the efficacy of LSB and may improve relief of symptoms. The magnitude of temperature change may predict relief of allodynia. IMPLICATIONS Cutaneous toe temperatures approaching core temperature provide a useful monitor of lumbar sympathetic block and may predict relief of sympathetically maintained pain. Iohexol will not compromise temperature changes or pain relief.
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Affiliation(s)
- K M Tran
- The Johns Hopkins University School of Medicine, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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19
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Cattaneo CG, Frank SM, Hesel TW, El-Rahmany HK, Kim LJ, Tran KM. The accuracy and precision of body temperature monitoring methods during regional and general anesthesia. Anesth Analg 2000; 90:938-45. [PMID: 10735803 DOI: 10.1097/00000539-200004000-00030] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED We tested the hypotheses that accuracy and precision of available temperature monitoring methods are different between spinal anesthesia (SA) and general anesthesia (GA), and that patients receiving SA are at equal risk for hypothermia as those receiving GA. Patients scheduled for radical retropubic prostatectomy were enrolled. Either GA (n = 16) or SA (n = 16) was given according to patient and clinician preference. Temperatures were monitored with thermocouple probes at the tympanic membrane, axilla, rectum, and forehead skin surface. Tympanic temperatures were also measured with an infrared device, and forehead skin temperatures were monitored with two brands of liquid crystal thermometer strips. Accuracy and precision of these monitoring methods were determined by using tympanic membrane temperature, measured by thermocouple, as the reference core temperature (T(c)). At the end of surgery, T(c) was similar between SA (35.0 +/- 0.1 degrees C) and GA (35.2 +/- 0.1 degrees C) (P = 0.44). Accuracy and precision of each temperature monitoring method were similar between SA and GA. Rectal temperature monitoring offered the greatest combination of accuracy and precision. All other methods underestimated T(c). These findings suggest that patients receiving SA or GA are at equal and significant risk for hypothermia, and should have their temperatures carefully monitored, recognizing that most monitoring methods underestimate T(c). IMPLICATIONS Body temperature should be monitored during spinal anesthesia because patients are at significant risk for hypothermia. Rectal temperature is a valid method of measuring core temperature, whereas other methods tend to underestimate true core temperature.
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Affiliation(s)
- C G Cattaneo
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA.
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20
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Poisik A, Heyer EJ, Solomon RA, Quest DO, Adams DC, Baldasserini CM, McMahon DJ, Huang J, Kim LJ, Choudhri TF, Connolly ES. Safety and efficacy of fixed-dose heparin in carotid endarterectomy. Neurosurgery 1999; 45:434-41; discussion 441-2. [PMID: 10493364 PMCID: PMC2777760 DOI: 10.1097/00006123-199909000-00003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Although fixed dosage of heparin is frequently used during vascular surgery, there are very few studies that document the appropriateness of this type of dosing. We have undertaken a prospective study to determine the physiological response to a fixed dose of heparin, using a conventional measure of anticoagulation, and have correlated this measure with complications. METHODS We studied 140 consecutive patients undergoing elective carotid endarterectomy. Serial activated clotting times (ACT values) were obtained in duplicate before administration of heparin, 15 minutes after application of a carotid artery cross-clamp, and 1 hour after administration of 5000 U of heparin by intravenous bolus. Postoperatively, patients were assessed for new neurological deficits (transient ischemic attack and stroke) and neck hematomas. A battery of neuropsychometric tests was performed in 49 patients at baseline and on the day after carotid endarterectomy to identify subtle new neurological deficits. RESULTS ACT values were found to be highly reproducible, with less than a 1.5% difference between duplicate baseline samples. Although all patients received 5000 U of heparin, the dose received per kilogram of body weight varied considerably (44-116 U/kg), as did ACT values at both 15 minutes (178-423 s) and 1 hour (173-390 s). Nevertheless, there was a significant correlation between heparin dose per kilogram and ACT values at 15 minutes (r = 0.45) and at 1 hour (r = 0.38) postinfusion, as well as ACT ratios (final ACT/initial ACT) at 15 minutes (r = 0.43) and at 1 hour (r = 0.34) after heparin bolus. Eight patients (5.7%) developed postoperative wound hematomas, one of which (0.7%) required reoperation. No patient had a stroke, but one patient had a transient ischemic attack, and 19 (39%) of 49 patients demonstrated significant early postoperative neuropsychometric deficits. Although the incidence of neck hematoma was not influenced by the heparin dose (P = 0.23), the ACT value at 15 minutes (P = 0.71) or 1 hour (P = 0.61), or the ACT ratio (P = 0.68), the only severe hematoma requiring reoperation occurred when the maximal ACT value was more than 400 seconds. Although performance on neuropsychometric tests did not appear to be statistically influenced by heparin dosing, the ACT value, or the degree of ACT elevation, there was a trend for deficits to be associated with lower heparin doses. CONCLUSION Fixed heparin dosing achieves safe and efficacious anticoagulation in the great majority of patients having carotid endarterectomy, with 5000 U expected to result in 15-minute and 1-hour ACT values of 175 to 425 seconds and 170 to 390 seconds, respectively. Although weight-based heparin dosing may reduce the incidence of subtle complications (hematoma formation or decline on neuropsychometric tests) and may result in more predictable 15-minute and 1-hour ACT values (85 U/kg; 225-375 and 200-340 s, respectively), no statistically compelling clinical advantage could be demonstrated. Therefore, either weight-based or fixed dosing is acceptable, with both obviating the need for routine pre-clamp ACT confirmation, thereby saving operative time and expense.
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Affiliation(s)
- A Poisik
- Department of Anesthesiology, Columbia University, New York, New York, USA
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21
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Huang J, Kim LJ, Poisik A, Pinsky DJ, Connolly ES. Titration of postischemic cerebral hypoperfusion by variation of ischemic severity in a murine model of stroke. Neurosurgery 1999; 45:328-33. [PMID: 10449078 DOI: 10.1097/00006123-199908000-00027] [Citation(s) in RCA: 24] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Murine models using intraluminal occluding sutures to establish transient focal cerebral ischemia are becoming increasingly widespread, because of advances in transgenic technology and the advent of cerebroprotective strategies to ameliorate postischemic cerebrovascular no-reflow. We hypothesize that the degree of postischemic hypoperfusion is directly related to the severity of the initial ischemic insult. METHODS Transient ischemia of 45-minute duration was produced using middle cerebral artery occlusion with 10-0 (n = 5), 9-0 (n = 5), 8-0 (n = 6), 7-0 (n = 8), 6-0 (n = 30), or 5-0 (n = 5) sutures. In separate experiments, transient vessel occlusion with 6-0 sutures was performed for 15 (n = 17), 30 (n = 16), or 45 (n = 30) minutes. Sequential laser Doppler measurements of relative cerebral blood flow were obtained, and stroke severity was assessed using neurological deficit scores and infarction volumes. RESULTS Although relative cerebral blood flow at the time of occlusion and 24 hours thereafter was diminished in parallel with increasing suture diameters, only the use of larger sutures resulted in postischemic no-reflow. As the suture diameter was increased, the resultant reflow was decreased and the stroke outcome worsened. A more than twofold increase in infarction volume (8.0 +/- 3 versus 19.7 +/- 3%, P < 0.05) resulted when ischemia duration was increased from 30 to 45 minutes. CONCLUSION Titration of the initial ischemic insult leads to corresponding variations in the magnitude of postischemic no-reflow and tissue damage. Therefore, critical control of the severity of the initial injury in studies using intraluminal suture occlusion is warranted.
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Affiliation(s)
- J Huang
- Department of Neurological Surgery, The Neurological Institute, Columbia University, College of Physicians and Surgeons, New York, New York 10032, USA
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22
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Huang J, Kim LJ, Mealey R, Marsh HC, Zhang Y, Tenner AJ, Connolly ES, Pinsky DJ. Neuronal protection in stroke by an sLex-glycosylated complement inhibitory protein. Science 1999; 285:595-9. [PMID: 10417391 DOI: 10.1126/science.285.5427.595] [Citation(s) in RCA: 257] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Glycoprotein adhesion receptors such as selectins contribute to tissue injury in stroke. Ischemic neurons strongly expressed C1q, which may target them for complement-mediated attack or C1qRp-mediated clearance. A hybrid molecule was used to simultaneously inhibit both complement activation and selectin-mediated adhesion. The extracellular domain of soluble complement receptor-1 (sCR1) was sialyl Lewis x glycosylated (sCR1sLex) to inhibit complement activation and endothelial-platelet-leukocyte interactions. sCR1 and sCR1sLex colocalized to ischemic cerebral microvessels and C1q-expressing neurons, inhibited neutrophil and platelet accumulation, and reduced cerebral infarct volumes. Additional benefit was conferred by sialyl Lewis x glycosylation of the unmodified parent sCR1 molecule.
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Affiliation(s)
- J Huang
- Columbia University, College of Physicians and Surgeons, 630 West 168th Street, New York, NY 10032, USA
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23
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Choudhri TF, Hoh BL, Prestigiacomo CJ, Huang J, Kim LJ, Schmidt AM, Kisiel W, Connolly ES, Pinsky DJ. Targeted inhibition of intrinsic coagulation limits cerebral injury in stroke without increasing intracerebral hemorrhage. J Exp Med 1999; 190:91-9. [PMID: 10429673 PMCID: PMC2195562 DOI: 10.1084/jem.190.1.91] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.1] [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: 12/10/1998] [Accepted: 04/27/1999] [Indexed: 11/23/2022] Open
Abstract
Agents that restore vascular patency in stroke also increase the risk of intracerebral hemorrhage (ICH). As Factor IXa is a key intermediary in the intrinsic pathway of coagulation, targeted inhibition of Factor IXa-dependent coagulation might inhibit microvascular thrombosis in stroke without impairing extrinsic hemostatic mechanisms that limit ICH. A competitive inhibitor of native Factor IXa for assembly into the intrinsic Factor X activation complex, Factor IXai, was prepared by covalent modification of the Factor IXa active site. In a modified cephalin clotting time assay, in vivo administration of Factor IXai caused a dose-dependent increase in time to clot formation (3.6-fold increase at the 300 micrograms/kg dose compared with vehicle-treated control animals, P < 0.05). Mice given Factor IXai and subjected to middle cerebral artery occlusion and reperfusion demonstrated reduced microvascular fibrin accumulation by immunoblotting and immunostaining, reduced 111In-labeled platelet deposition (42% decrease, P < 0.05), increased cerebral perfusion (2.6-fold increase in ipsilateral blood flow by laser doppler, P < 0.05), and smaller cerebral infarcts than vehicle-treated controls (70% reduction, P < 0.05) based on triphenyl tetrazolium chloride staining of serial cerebral sections. At therapeutically effective doses, Factor IXai was not associated with increased ICH, as opposed to tissue plasminogen activator (tPA) or heparin, both of which significantly increased ICH. Factor IXai was cerebroprotective even when given after the onset of stroke, indicating that microvascular thrombosis continues to evolve (and may be inhibited) even after primary occlusion of a major cerebrovascular tributary.
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Affiliation(s)
- T F Choudhri
- Department of Neurological Surgery, University College of Physicians and Surgeons, New York 10032, USA
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24
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Connolly ES, Poisik A, Winfree CJ, Kim LJ, Huang J, McMahon DJ, Solomon RA. Cigarette smoking and the development and rupture of cerebral aneurysms in a mixed race population: implications for population screening and smoking cessation. J Stroke Cerebrovasc Dis 1999; 8:248-53. [PMID: 17895172 DOI: 10.1016/s1052-3057(99)80074-3] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/1998] [Accepted: 11/19/1998] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Despite advances in the treatment of aneurysmal subarachnoid hemorhage (aSAH), major additional reductions in morbidity will require the identifications of unruptured aneurysms with a high propensity for bleeding. As screening the entire population is currently not cost-effective, risk factors for the presence of unruptured aneurysms must be identified, and if possible, these risk factors should be modified to reduce disease prevalence. METHODS To examine whether cigarette smoking independent of arterial hypertension is a risk factor for the development of cerebral aneurysms rather than just being associated with aSAH and to determine whether smoking cessation decreases this risk, we conducted a case-control study comparing the prevalence and degree of smoking in a consecutive series of patients undergoing surgery for ruptured or unruptured aneurysm with age-, sex-, race-, and geographically matched control subjects culled from the New York Healthy Heart Study. RESULTS Hypertension alone carries little additional risk for the development of ruptured or unruptured aneurysms. Smoking is a risk factor for not only aneurysmal subarachnoid hemorrhage (Relative Risk [RR]=2.83) but also aneurysm formation (RR=2.33). Coexistent hypertension increases the risk of smoking only minimally. Younger smokers are at threefold higher risk than middle-aged ones. Smoking cessation appears to reduce risk of aneurysmal rupture. The effect of smoking on aneurysm formation and rupture may be dose-dependent. CONCLUSIONS Together these data suggest that smoking, independent of hypertension, plays a critical role in aneurysm development, especially in younger patients, but that physiological mechanisms exist for repair of the damage induced by this toxic insult if cessation is possible.
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Affiliation(s)
- E S Connolly
- Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, NY, USA
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Huang J, Kim LJ, Poisik A, Pinsky DJ, Connolly ES. Does poly-L-lysine coating of the middle cerebral artery occlusion suture improve infarct consistency in a murine model? J Stroke Cerebrovasc Dis 1998; 7:296-301. [PMID: 17895104 DOI: 10.1016/s1052-3057(98)80046-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/1998] [Accepted: 04/17/1998] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND PURPOSE Rodent models of stroke that employ an intraluminal suture to cause focal cerebral ischemia are associated with some variability of resultant infarct volumes, thus requiring increased numbers of animals to determine significant differences between experimental groups. A recent modification of the occluding suture by coating with poly-L-lysine has been shown to create more uniform infarct volumes in rats. METHODS To evaluate the utility of this modification in murine models of both transient and permanent focal cerebral ischemia, male C57B16J mice were subjected to reversible middle cerebral artery occlusion (MCAo) for 45 minutes (n=42), or to permanent MCAo (n=25), with an intraluminal monofilament suture. Three types of sutures were used: untreated, partially coated, and completely coated with poly-L-lysine. Relative changes in regional cerebral blood flow, severity of neurological deficits, and infarct volumes were measured 24 hours after the ischemic injury. RESULTS Animals subjected to 45 minutes of temporary occlusion with completely coated poly-L-lysine sutures had infarct volumes of 13.8%+/-5% compared with infarct volumes of 7.2%+/-4% in those subjected to partially coated sutures and 22.4%+/-6% in the group occluded with untreated sutures (P=ns). Use of completely coated sutures resulted in significantly less reperfusion following suture removal. Control animals undergoing permanent occlusion with untreated sutures had infarct volumes of 17%+/-7% compared with 14.1%+/-5% using completely coated sutures and 6.5%+/-3% in animals with partially coated sutures (P=ns). There were no significant differences in cerebral blood flow between the experimental groups undergoing permanent MCAo. CONCLUSIONS Poly-L-lysine coating of intraluminal sutures does not increase the consistency of infarct volumes in a murine model of temporary/permanent MCAo. These findings are in marked contrast to findings in rats.
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Affiliation(s)
- J Huang
- Department of Neurological Surgery, Columbia University, College of Physicians and Surgeons, New York, NY, USA
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Kim LJ, Chen JM, Zucker HA, Benvenisty AI, Todd GJ, Nowygrod R. A novel case of pediatric abdominal aortic aneurysm with visceral arterial stenoses. J Vasc Surg 1997; 25:778-83. [PMID: 9129640 DOI: 10.1016/s0741-5214(97)70311-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- L J Kim
- Division of Vascular Surgery and Pediatric Cardiology, Columbia-Presbyterian Medical Center, New York, NY, USA
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Swaminathan S, Siddiqui AU, Gerst N, Pinkerton FD, Kisic A, Kim LJ, Wilson WK, Schroepfer GJ. Inhibitors of sterol synthesis. Metabolism-based design and construction of a new analog of 3 beta-hydroxy-5 alpha-cholest-8(14)-en-15-one and its effects in cultured mammalian cells and in rats. J Lipid Res 1995. [DOI: 10.1016/s0022-2275(20)40062-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Swaminathan S, Siddiqui AU, Gerst N, Pinkerton FD, Kisic A, Kim LJ, Wilson WK, Schroepfer GJ. Inhibitors of sterol synthesis. Metabolism-based design and construction of a new analog of 3 beta-hydroxy-5 alpha-cholest-8(14)-en-15-one and its effects in cultured mammalian cells and in rats. J Lipid Res 1995; 36:767-86. [PMID: 7616123] [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: 01/26/2023] Open
Abstract
3 beta-Hydroxy-5 alpha-cholest-8(14)-en-15-one (I) is a potent regulator of cholesterol metabolism. In the present study, the 7 alpha-methyl-25,26,26,26,27,27,27-heptafluoro analog (X) of I has been synthesized with the goal of blocking not only the side chain oxidation of I but also its conversion to cholesterol. X was prepared in seven steps from the known 7 alpha-methyl analog (IX) of I. Treatment of the acetate of IX with a mixture of trifluoroacetic anhydride, hydrogen peroxide, and sulfuric acid gave 3 beta-acetoxy-7 alpha-methyl-24-hydroxy-5 alpha-chol-8(14)-en-15-one (XII) in remarkably high (68%) yield. Dehydration of XII via the orthonitrophenylselenide to the 23-ene, followed by addition of (CF3)2CFI gave (23R)-3 beta-acetoxy-7 alpha-methyl-23-iodo-25,26,26,26,27,27,27-heptafluoro-5 alpha-cholest-8(14)-en-15-one (XV). Reductive deiodination of XV with tributyltin hydride, followed by hydrolysis of the acetate gave 3 beta-hydroxy-7 alpha-methyl-25,26,26,26,27,27,27-heptafluoro-5 alpha-cholest-8(14)-en-15-one (X). The F7-7 alpha-methyl-15-ketosterol X lowered the levels of 3-hydroxy-3-methylglutaryl coenzyme A reductase activity in CHO-K1 cells with a potency equivalent to that of I. X showed significant hypocholesterolemic action upon oral administration to rats, with a potency far in excess of the 7 alpha-methyl-15-ketosterol IX lacking the F7 substitution. In marked contrast to I, X showed little or no suppression of food consumption in rats. Upon oral administration of X to rats, low levels of X (relative to cholesterol), characterized by chromatographic and gas chromatography-mass spectrometric methodologies, were observed in serum, liver, and small intestine. No material was observed with the expected properties of F7-7-methylcholesterol (or potential intermediates in its possible formation from X). In contrast to I, X lowered serum cholesterol levels at dosages at which no effect on food consumption was observed.
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Affiliation(s)
- S Swaminathan
- Department of Biochemistry, Rice University, Houston, TX 77251, USA
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Siddiqui AU, Gerst N, Kim LJ, Pinkerton FD, Kisic A, Wilson WK, Schroepfer GJ. Inhibitors of sterol synthesis: effects of a 7 alpha-alkyl analog of 3 beta-hydroxy-5 alpha-cholest-8(14)-en-15-one on 3-hydroxy-3-methylglutaryl coenzyme A reductase activity in cultured mammalian cells and on serum cholesterol levels and other parameters in rats. Chem Phys Lipids 1994; 70:163-78. [PMID: 8033288 DOI: 10.1016/0009-3084(94)90084-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The 7 alpha-methyl analog (II) of 3 beta-hydroxy-5 alpha-cholest-8(14)-en-15- one (I) was prepared by chemical synthesis and evaluated with respect to its effects on HMG-CoA reductase activity in CHO-K1 cells and on serum cholesterol levels in rats. The 7 alpha-methyl substitution had no detectable effect on the potency of I in lowering HMG-CoA reductase activity in the cultured cells. In contrast, the 7 alpha-methyl substitution had a marked effect on the action of I in the suppression of food consumption in rats. Whereas II was less potent than I in lowering serum cholesterol levels in rats, it did so at dosage levels at which only slight or moderate effects on food consumption were observed. Full 1H and 13C-NMR assignments for II and intermediates in its synthesis have been presented. Conformational analysis, based on 1H-1H coupling constants, NMR shieldings and force-field calculations, indicated that the 7 alpha-methyl substitution had virtually no effect on the conformation of the 15-ketosterol apart from minor distortions of ring B.
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Affiliation(s)
- A U Siddiqui
- Department of Biochemistry and Cell Biology, Rice University, Houston, Texas 77251-1892
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Cera LM, Artwohl JE, Wright MF, Kim LJ. Immunohistochemical detection of localized Sendai virus antigen in preserved mouse tissue. Lab Anim Sci 1994; 44:88-90. [PMID: 8007672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- L M Cera
- Department of Comparative Medicine, Loyola University, Maywood, IL
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Artwohl JE, Cera LM, Wright MF, Medina LV, Kim LJ. The efficacy of a dirty bedding sentinel system for detecting Sendai virus infection in mice: a comparison of clinical signs and seroconversion. Lab Anim Sci 1994; 44:73-5. [PMID: 8007667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- J E Artwohl
- Biologic Resources Laboratory, University of Illinois, Chicago
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de Souza MS, Smith AL, Beck DS, Kim LJ, Hansen GM, Barthold SW. Variant responses of mice to Borrelia burgdorferi depending on the site of intradermal inoculation. Infect Immun 1993; 61:4493-7. [PMID: 8406842 PMCID: PMC281186 DOI: 10.1128/iai.61.10.4493-4497.1993] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
C3H/He mice inoculated intradermally at one of two sites with Borrelia burgdorferi responded differently to infection. Shoulder-inoculated mice developed spirochetemia, B. burgdorferi-specific antibody, and arthritis earlier than foot-inoculated mice. Lymphocyte populations derived from spleen tissue were elevated in the shoulder- but not the foot-inoculated mice, and those from lymph nodes were increased in both groups. Lymphocytes derived from blood and spleen tissue showed impaired proliferative responses to all mitogens for shoulder-inoculated mice only, whereas proliferation of lymph node cells was not affected, regardless of route. These results demonstrate that the site of initial B. burgdorferi inoculation is an important determinant in the pathogenesis of B. burgdorferi infection.
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Affiliation(s)
- M S de Souza
- Section of Comparative Medicine, Yale University School of Medicine, New Haven, Connecticut 06510
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