1
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Maharaj AD, Lubel J, Lam E, Clark PJ, Duncan O, George J, Jeffrey GP, Lipton L, Liu H, McCaughan G, Neo E, Philip J, Strasser SI, Stuart K, Thompson A, Tibballs J, Tu T, Wallace MC, Wigg A, Wood M, Zekry A, Greenhill E, Ioannou LJ, Ahlenstiel G, Bowers K, Clarke SJ, Dev A, Fink M, Goodwin M, Karapetis CS, Levy MT, Muller K, O'Beirne J, Pryor D, Seow J, Shackel N, Tallis C, Butler N, Olynyk JK, Reed‐Cox K, Zalcberg JR, Roberts SK. Monitoring quality of care in hepatocellular carcinoma: A modified Delphi consensus. Hepatol Commun 2022; 6:3260-3271. [PMID: 36153817 PMCID: PMC9592757 DOI: 10.1002/hep4.2089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 07/19/2022] [Indexed: 12/14/2022] Open
Abstract
Although there are several established international guidelines on the management of hepatocellular carcinoma (HCC), there is limited information detailing specific indicators of good quality care. The aim of this study was to develop a core set of quality indicators (QIs) to underpin the management of HCC. We undertook a modified, two-round, Delphi consensus study comprising a working group and experts involved in the management of HCC as well as consumer representatives. QIs were derived from an extensive review of the literature. The role of the participants was to identify the most important and measurable QIs for inclusion in an HCC clinical quality registry. From an initial 94 QIs, 40 were proposed to the participants. Of these, 23 QIs ultimately met the inclusion criteria and were included in the final set. This included (a) nine related to the initial diagnosis and staging, including timing to diagnosis, required baseline clinical and laboratory assessments, prior surveillance for HCC, diagnostic imaging and pathology, tumor staging, and multidisciplinary care; (b) thirteen related to treatment and management, including role of antiviral therapy, timing to treatment, localized ablation and locoregional therapy, surgery, transplantation, systemic therapy, method of response assessment, and supportive care; and (c) one outcome assessment related to surgical mortality. Conclusion: We identified a core set of nationally agreed measurable QIs for the diagnosis, staging, and management of HCC. The adherence to these best practice QIs may lead to system-level improvement in quality of care and, ultimately, improvement in patient outcomes, including survival.
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Affiliation(s)
- Ashika D. Maharaj
- Public Health and Preventative MedicineMonash UniversityMelbourneAustralia
| | - John Lubel
- Alfred Health and Central Clinical SchoolMonash UniversityMelbourneAustralia
| | - Eileen Lam
- Public Health and Preventative MedicineMonash UniversityMelbourneAustralia
| | | | | | - Jacob George
- Storr Liver Centre, Westmead Institute for Medical ResearchWestmead Hospital and University of SydneySydneyAustralia
| | | | - Lara Lipton
- Royal Melbourne HospitalWestern HealthParkvilleAustralia
| | - Howard Liu
- Princess Alexandra HospitalWoolloongabbaAustralia
| | - Geoffrey McCaughan
- Royal Prince Alfred Hospital and Centenary Institute for Medical ResearchNewtownAustralia
| | | | - Jennifer Philip
- St. Vincent's Hospital and University of MelbourneMelbourneAustralia
| | - Simone I. Strasser
- Royal Prince Alfred Hospital and University of SydneyCamperdownAustralia
| | | | | | | | - Thomas Tu
- Sydney Institute for Infectious Diseases and Storr Liver CentreWestmead Hospital, and University of SydneySydneyAustralia
| | - Michael C. Wallace
- Sir Charles Gairdner Hospital and Medical SchoolUniversity of Western AustraliaPerthAustralia
| | - Alan Wigg
- Flinders Medical Centre and Flinders UniversityAdelaideAustralia
| | - Marnie Wood
- Royal Brisbane and Women's HospitalHerstonAustralia
| | - Amany Zekry
- St. George and Sutherland Clinical CampusSt. George HospitalSydneyAustralia
| | - Elysia Greenhill
- Public Health and Preventative MedicineMonash UniversityMelbourneAustralia
| | - Liane J. Ioannou
- Public Health and Preventative MedicineMonash UniversityMelbourneAustralia
| | - Golo Ahlenstiel
- Blacktown Clinical School and HospitalWestern Sydney UniversityPenrithAustralia
| | - Kaye Bowers
- Alfred Health and Department of SurgeryMonash UniversityMelbourneAustralia
| | - Stephen J. Clarke
- Royal North Shore Hospital and University of SydneySt LeonardsAustralia
| | | | - Michael Fink
- Austin Hospital and University of MelbourneHeidelbergAustralia
| | | | | | - Miriam T. Levy
- Department of GastroenterologyLiverpool Hospital, University of New South WalesLiverpoolAustralia
| | - Kate Muller
- Flinders Medical Centre and Flinders UniversityAdelaideAustralia
| | | | - David Pryor
- Princess Alexandra HospitalWoolloongabbaAustralia
| | | | | | | | - Nick Butler
- Princess Alexandra Hospital and University of QueenslandWoolloongabbaAustralia
| | - John K. Olynyk
- Fiona Stanley Hospital and Edith Cowan UniversityMurdochAustralia
| | | | - John R. Zalcberg
- Public Health and Preventative MedicineMonash UniversityMelbourneAustralia
| | - Stuart K. Roberts
- Alfred Health, Gastroenterology Department, and Central Clinical SchoolMonash UniversityMelbourneAustralia
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2
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Howell J, Majumdar A, Fink MA, Byrne M, McCaughan G, Strasser SI, Crawford M, Hodgkinson P, Stuart KA, Tallis C, Chen J, Wigg A, Jones R, Jaques B, Jeffrey G, Adams L, Wallace MC, Munn S, Gane E, Thompson AJ, Gow P. Turning the Tide on Hepatitis C Virus-Related Liver Transplantation: The Return on Investment in Hepatitis C Virus Treatment in Australia and New Zealand. Liver Transpl 2022; 28:236-246. [PMID: 34624175 DOI: 10.1002/lt.26329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/08/2021] [Accepted: 08/31/2021] [Indexed: 01/13/2023]
Abstract
Introduction of universal access to direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) in Australia and New Zealand on March 1st , 2016, has had a major impact on the number of people with chronic HCV infection, but the impact on liver transplantation rates is unknown. We conducted a retrospective registry study including all adult liver transplantations from the Australia and New Zealand Liver and Intestinal Liver Transplant Registry (ANZLITR) data set. Interrupted time series analysis determined the impact of DAAs in 2016 on the number of HCV liver transplantations per year. Cox regression analysis was used to determine the impact of DAAs on post-liver transplantation survival. Between January 1, 1990, and December 31, 2019 5318 adult liver transplantations were performed, and 29% (1531) were for HCV infection. Prior to the introduction of DAAs, there was a mean increase of 3.5 adult liver transplantations performed for HCV per annum, but between 2016 and 2019 there was a mean decrease of 7.9 adult liver transplantations per annum (P < 0.001). Similarly, the proportion of liver transplantations performed for HCV increased from 9% (1990) to 33% in 2016 and then fell to 23% in 2019 (P < 0.001). The number and proportion of patients with HCV added to the liver transplantation waiting list also fell in 2016 (P < 0.001) when compared with other indications. The introduction of DAAs was associated with a 31% reduction in death after liver transplantation, adjusted for age at transplant and hepatocellular carcinoma (HCC; hazard ratio [HR], 0.69; 95% confidence interval [CI], 0.48-0.99; P = 0.047). The number of adult liver transplantations performed for HCV-related liver cirrhosis and HCC has reduced since the introduction of universal access to DAAs in 2016 in Australia and New Zealand.
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Affiliation(s)
- Jess Howell
- Department of Medicine, University of Melbourne, Melbourne, Australia.,Department of Gastroenterology, St. Vincent's Hospital Melbourne, Melbourne, Australia.,Disease Elimination Department, Burnet Institute, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Avik Majumdar
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, Australia.,AW Morrow GE and Liver Centre, University of Sydney, Sydney, Australia
| | - Michael A Fink
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Australia.,Department of Surgery, Austin Health, The University of Melbourne, Melbourne, Australia
| | - Mandy Byrne
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Australia
| | - Geoff McCaughan
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, Australia.,AW Morrow GE and Liver Centre, University of Sydney, Sydney, Australia
| | - Simone I Strasser
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, Australia.,AW Morrow GE and Liver Centre, University of Sydney, Sydney, Australia
| | - Michael Crawford
- Australian National Liver Transplant Unit, Royal Prince Alfred Hospital, Sydney, Australia.,AW Morrow GE and Liver Centre, University of Sydney, Sydney, Australia
| | - Peter Hodgkinson
- Queensland Liver Transplant Service, Princess Alexandra Hospital and Queensland Children's Hospital, Brisbane, Australia
| | - Katherine A Stuart
- Queensland Liver Transplant Service, Princess Alexandra Hospital and Queensland Children's Hospital, Brisbane, Australia
| | - Caroline Tallis
- Queensland Liver Transplant Service, Princess Alexandra Hospital and Queensland Children's Hospital, Brisbane, Australia
| | - John Chen
- South Australian Liver Transplant Unit, Flinders Medical Centre, Adelaide, Australia
| | - Alan Wigg
- South Australian Liver Transplant Unit, Flinders Medical Centre, Adelaide, Australia
| | - Robert Jones
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Australia.,Department of Surgery, Austin Health, The University of Melbourne, Melbourne, Australia
| | - Bryon Jaques
- WA Liver Transplant Service, Sir Charles Gairdner Hospital, Perth, Australia
| | - Gary Jeffrey
- WA Liver Transplant Service, Sir Charles Gairdner Hospital, Perth, Australia.,Medical School, University of Western Australia, Perth, Australia
| | - Leon Adams
- WA Liver Transplant Service, Sir Charles Gairdner Hospital, Perth, Australia.,Medical School, University of Western Australia, Perth, Australia
| | - Michael C Wallace
- WA Liver Transplant Service, Sir Charles Gairdner Hospital, Perth, Australia.,Medical School, University of Western Australia, Perth, Australia
| | - Stephen Munn
- New Zealand Liver Transplant Service, Auckland City Hospital and Starship Children's Hospital, Auckland, New Zealand
| | - Ed Gane
- New Zealand Liver Transplant Service, Auckland City Hospital and Starship Children's Hospital, Auckland, New Zealand.,Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Alex J Thompson
- Department of Medicine, University of Melbourne, Melbourne, Australia.,Department of Gastroenterology, St. Vincent's Hospital Melbourne, Melbourne, Australia
| | - Paul Gow
- Department of Medicine, University of Melbourne, Melbourne, Australia.,Victorian Liver Transplant Unit, Austin Health, Melbourne, Australia
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3
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Wallace MC, Samuelson S, Khoo T, Ooi J, Tibballs J, Ferguson J, Preen DB, Knuiman M, Garas G, MacQuillan G, Adams LA, Jeffrey GP. The MAAPE score in intermediate and advanced hepatocellular carcinoma treated with Yttrium-90 resin microsphere radioembolization. J Gastroenterol Hepatol 2020; 35:1945-1952. [PMID: 32036614 DOI: 10.1111/jgh.15008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 01/06/2020] [Accepted: 02/03/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIM Yttrium-90 resin microsphere radioembolization (RE) is not recommended for routine use in intermediate or advanced hepatocellular carcinoma (HCC) by recent guidelines. This study aims to establish pre-treatment variables which predict survival in HCC patients treated with RE to identify those who will benefit most from it, and to inform patient selection for future trials. METHODS Single center, retrospective study of consecutive patients with HCC treated with RE from 2007 to 2018. Patients included if undergoing their first RE treatment for intermediate or advanced HCC; a Child-Pugh score of B7 or less; and a performance status of 1 or less. Multivariable Cox regression identified variables that were significantly associated with survival. A predictive score was developed based upon coefficients from the fitted Cox regression model, and cubic spline regression was used to identify prognostic groups. RESULTS One hundred thirteen patients with intermediate (53.1%) and advanced HCC (45.1%) followed for a median of 13.2 months were included. Variables associated with superior survival used to derive the MAAPE score were lower Model for End-Stage Liver Disease score (≤ 7), lower Alpha-fetoprotein (≤ 150 IU/L), higher serum Albumin (> 37 g/L), absence of Portal vein tumor thrombus, and better performance status (Eastern Cooperative Oncology Group = 0). Three survival prognostic groups were identified: good (median overall survival 25.0 months), average (15.3 months), and poor (6.3 months) (overall log-rank test, P < 0.001). CONCLUSION The MAAPE score accurately identifies HCC patients in whom RE is safe and effective. This will allow for optimal patient selection for future trials of RE versus systemic therapy.
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Affiliation(s)
- Michael C Wallace
- Medical School, University of Western Australia, Nedlands, Western Australia, Australia.,Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,School of Population and Global Health, University of Western Australia, Nedlands, Western Australia, Australia
| | - Shaun Samuelson
- Department of Radiology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Tiffany Khoo
- Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Jacob Ooi
- Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Jonathan Tibballs
- Department of Radiology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - John Ferguson
- Department of Radiology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - David B Preen
- School of Population and Global Health, University of Western Australia, Nedlands, Western Australia, Australia
| | - Matthew Knuiman
- School of Population and Global Health, University of Western Australia, Nedlands, Western Australia, Australia
| | - George Garas
- Medical School, University of Western Australia, Nedlands, Western Australia, Australia.,Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Gerry MacQuillan
- Medical School, University of Western Australia, Nedlands, Western Australia, Australia.,Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Leon A Adams
- Medical School, University of Western Australia, Nedlands, Western Australia, Australia.,Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Gary P Jeffrey
- Medical School, University of Western Australia, Nedlands, Western Australia, Australia.,Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
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4
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Wallace MC, Sek K, Francis RJ, Samuelson S, Ferguson J, Tibballs J, Asad A, Preen DB, MacQuillan G, Garas G, Adams LA, Jeffrey GP. Baseline and Post-treatment 18F-Fluorocholine PET/CT Predicts Outcomes in Hepatocellular Carcinoma Following Locoregional Therapy. Dig Dis Sci 2020; 65:647-657. [PMID: 31440998 DOI: 10.1007/s10620-019-05781-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 08/07/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS 18F-fluorocholine positron emission tomography/computed tomography (18F-FCH PET/CT) is an emerging functional imaging technique in the diagnosis and management of hepatocellular carcinoma (HCC). The aim of this study was to assess the ability of a pre- and post-treatment 18F-FCH PET/CT to predict prognosis and treatment response in early-stage HCC. METHODS Patients with early- or intermediate-stage HCC planned for locoregional therapy were prospectively enrolled. Baseline demographic and tumor information was collected and baseline and post-treatment 18F-FCH PET/CT performed. Maximum standardized uptake values (SUVmax) were determined for each HCC lesion, and the difference between baseline and post-treatment SUVmax values were compared with progression-free survival outcomes. RESULTS A total of 29 patients with 39 confirmed HCC lesions were enrolled from a single clinical center. Patients were mostly men (89.7%) with hepatitis C or alcohol-related cirrhosis (65.5%) and early-stage disease (89.7%). Per-patient and per-lesion sensitivity of 18F-FCH PET/CT was 72.4% and 59.0%, respectively. A baseline SUVmax < 13 was associated with a superior median progression-free survival compared with an SUVmax of > 13 (17.7 vs. 5.1 months; p = 0.006). A > 45% decrease in SUVmax between baseline and post-treatment 18F-FCH PET/CT ("responders") was associated with a superior mean progression-free survival than a percentage decrease of < 45% ("non-responders," 36.1 vs. 11.6 months; p = 0.034). CONCLUSIONS Baseline and post-treatment 18F-FCH PET/CT predicts outcomes in early-stage HCC undergoing locoregional therapy. This technique may identify patients with an objective response post-locoregional therapy who would benefit from further therapy.
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Affiliation(s)
- Michael C Wallace
- Department of Hepatology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, 6009, WA, Australia. .,Medical School, University of Western Australia, Nedlands, WA, Australia. .,School of Population and Global Health, University of Western Australia, Nedlands, WA, Australia.
| | - Kenny Sek
- Department of Nuclear Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Roslyn J Francis
- Medical School, University of Western Australia, Nedlands, WA, Australia.,Department of Nuclear Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Shaun Samuelson
- Department of Radiology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - John Ferguson
- Department of Radiology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Jonathan Tibballs
- Department of Radiology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Ali Asad
- Department of Medical Technology and Physics, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - David B Preen
- School of Population and Global Health, University of Western Australia, Nedlands, WA, Australia
| | - Gerry MacQuillan
- Department of Hepatology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, 6009, WA, Australia.,Medical School, University of Western Australia, Nedlands, WA, Australia
| | - George Garas
- Department of Hepatology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, 6009, WA, Australia.,Medical School, University of Western Australia, Nedlands, WA, Australia
| | - Leon A Adams
- Department of Hepatology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, 6009, WA, Australia.,Medical School, University of Western Australia, Nedlands, WA, Australia
| | - Gary P Jeffrey
- Department of Hepatology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, 6009, WA, Australia.,Medical School, University of Western Australia, Nedlands, WA, Australia
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5
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Wallace MC, Preen DB, Short MW, Adams LA, Jeffrey GP. Hepatocellular carcinoma in Australia 1982-2014: Increasing incidence and improving survival. Liver Int 2019; 39:522-530. [PMID: 30230194 DOI: 10.1111/liv.13966] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 09/05/2018] [Accepted: 09/06/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS There is a paucity of accurate and current data on hepatocellular carcinoma (HCC) trends in incidence and survival in developed countries. We performed an Australia-wide assessment of HCC epidemiology across a 33-year time span aiming to accurately describe changes in incidence and survival. METHODS Cases of HCC from 1982 to 2014 were identified via the Australian Cancer Database (ACD). Trends in incidence rates were explored using piecewise linear regression. Survival was compared by Kaplan-Meier survival curves and 1-, 3- and 5-year survival probabilities by year of diagnosis. RESULTS Age-adjusted HCC incidence rate increased from 1.38 per 100 000 (95% CI: 1.34-1.43) in 1982 to 4.96 per 100 000 (95% CI: 4.89-5.03, P < 0.001) in 2014 with an average annual percentage increase of 4.46% (95% CI: 4.24%-4.69%). The highest incidence rate in 2014 was in those aged 75-79 (24.31 per 100 000; 95% CI: 19.50-29.12). Almost 80% of cases across the period were men who had significantly higher age-adjusted incidence rates in 2014 than women (8.55 per 100 000 [95% CI: 8.42-8.68] vs 1.65 per 100 000 [95% CI: 1.60-1.70]; P < 0.001). A hepatitis C (HCV) birth cohort effect was identified and associated with rapid increases in HCC incidence when members of the cohort aged and entered into age groups 45-49, 50-54 and 55-59. Median survival increased from 2.10 months (95% CI: 1.57-2.62 months) in those diagnosed between 1982 and 1984 to 12.07 months (95% CI: 11.17-12.97 months) when diagnosed between 2010 and 2014 (P < 0.001). CONCLUSIONS An Australia-wide analysis of HCC epidemiological trends across three decades shows significant and consistent increases in both incidence and survival. LAY SUMMARY There has been a significant increase in hepatocellular cancer (HCC) reported in Australia over the last three decades without evidence of slowing. Across the same time period, a significant improvement in survival has been identified with the average life expectancy after diagnosis now one year. This research lays the foundation for important public health service delivery.
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Affiliation(s)
- Michael C Wallace
- Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,School of Medicine and Pharmacology, University of Western Australia, Nedlands, Western Australia, Australia.,School of Population Health, University of Western Australia, Nedlands, Western Australia, Australia
| | - David B Preen
- School of Population Health, University of Western Australia, Nedlands, Western Australia, Australia
| | - Mark W Short
- Australian Institute of Health and Welfare, Bruce, Australian Capital Territory, Australia
| | - Leon A Adams
- Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,School of Medicine and Pharmacology, University of Western Australia, Nedlands, Western Australia, Australia
| | - Gary P Jeffrey
- Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,School of Medicine and Pharmacology, University of Western Australia, Nedlands, Western Australia, Australia
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6
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Wallace MC, Huang Y, Preen DB, Garas G, Adams LA, MacQuillan G, Tibballs J, Ferguson J, Samuelson S, Jeffrey GP. HKLC Triages More Hepatocellular Carcinoma Patients to Curative Therapies Compared to BCLC and Is Associated with Better Survival. Dig Dis Sci 2017; 62:2182-2192. [PMID: 28547649 DOI: 10.1007/s10620-017-4622-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 05/16/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIMS The Hong Kong Liver Cancer (HKLC) system proposes to triage hepatocellular carcinoma (HCC) patients to more aggressive treatment and may be associated with superior survival compared with the Barcelona Clinic Liver Cancer (BCLC) system. We aimed to identify the influence of adherence to HKLC or BCLC treatment recommendations on survival and time to progression. METHODS We examined a prospectively enrolled cohort of 292 patients undergoing 532 treatment episodes from a single clinical center. RESULTS The BCLC and HKLC systems accurately predicted overall survival and time to progression after each treatment episode (BCLC: p < 0.001; HKLC: p < 0.001). Adherence to treatment recommendations was higher for HKLC than for BCLC (55.6 vs. 47.9%, p = 0.01). Survival was superior with adherence to HKLC recommendations compared to non-adherence (45.3 vs. 27.1 months, p < 0.001). There was no difference in survival in BCLC with adherence compared to non-adherence (34.6 vs. 32.3 months, p = 0.96). The survival benefit was limited to early- and very early stage disease for both HKLC (p < 0.001) and BCLC (p = 0.007). More patients were triaged to curative therapies by HKLC than BCLC (p = 0.004). The use of transarterial chemoembolization instead of ablation or resection in early- and very early stage disease for technical reasons was the major cause for non-recommended treatment and was associated with worse survival (p < 0.001). CONCLUSIONS These data support the use of HKLC in early- and very early stage HCC. Efforts should be made to overcome technical reasons for not performing ablation in early- and very early stage disease.
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Affiliation(s)
- Michael C Wallace
- Department of Hepatology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, WA, 6009, Australia.
- School of Medicine and Pharmacology, University of Western Australia, Nedlands, WA, Australia.
- School of Population Health, University of Western Australia, Nedlands, WA, Australia.
| | - Yi Huang
- School of Medicine and Pharmacology, University of Western Australia, Nedlands, WA, Australia
| | - David B Preen
- School of Population Health, University of Western Australia, Nedlands, WA, Australia
| | - George Garas
- Department of Hepatology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, WA, 6009, Australia
| | - Leon A Adams
- Department of Hepatology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, WA, 6009, Australia
- School of Medicine and Pharmacology, University of Western Australia, Nedlands, WA, Australia
| | - Gerry MacQuillan
- Department of Hepatology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, WA, 6009, Australia
- School of Medicine and Pharmacology, University of Western Australia, Nedlands, WA, Australia
| | - Jonathan Tibballs
- Department of Radiology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - John Ferguson
- Department of Radiology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Shaun Samuelson
- Department of Radiology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Gary P Jeffrey
- Department of Hepatology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, WA, 6009, Australia
- School of Medicine and Pharmacology, University of Western Australia, Nedlands, WA, Australia
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7
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Hicks DF, Goossens N, Blas-García A, Tsuchida T, Wooden B, Wallace MC, Nieto N, Lade A, Redhead B, Cederbaum AI, Dudley JT, Fuchs BC, Lee YA, Hoshida Y, Friedman SL. Transcriptome-based repurposing of apigenin as a potential anti-fibrotic agent targeting hepatic stellate cells. Sci Rep 2017; 7:42563. [PMID: 28256512 PMCID: PMC5335661 DOI: 10.1038/srep42563] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [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: 11/30/2016] [Accepted: 01/10/2017] [Indexed: 02/07/2023] Open
Abstract
We have used a computational approach to identify anti-fibrotic therapies by querying a transcriptome. A transcriptome signature of activated hepatic stellate cells (HSCs), the primary collagen-secreting cell in liver, and queried against a transcriptomic database that quantifies changes in gene expression in response to 1,309 FDA-approved drugs and bioactives (CMap). The flavonoid apigenin was among 9 top-ranked compounds predicted to have anti-fibrotic activity; indeed, apigenin dose-dependently reduced collagen I in the human HSC line, TWNT-4. To identify proteins mediating apigenin's effect, we next overlapped a 122-gene signature unique to HSCs with a list of 160 genes encoding proteins that are known to interact with apigenin, which identified C1QTNF2, encoding for Complement C1q tumor necrosis factor-related protein 2, a secreted adipocytokine with metabolic effects in liver. To validate its disease relevance, C1QTNF2 expression is reduced during hepatic stellate cell activation in culture and in a mouse model of alcoholic liver injury in vivo, and its expression correlates with better clinical outcomes in patients with hepatitis C cirrhosis (n = 216), suggesting it may have a protective role in cirrhosis progression.These findings reinforce the value of computational approaches to drug discovery for hepatic fibrosis, and identify C1QTNF2 as a potential mediator of apigenin's anti-fibrotic activity.
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Affiliation(s)
- Daniel F. Hicks
- Division of Liver Diseases, Department of Medicine, Liver Cancer Program, Tisch Cancer Institute, Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Nicolas Goossens
- Division of Liver Diseases, Department of Medicine, Liver Cancer Program, Tisch Cancer Institute, Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, USA
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Ana Blas-García
- Division of Liver Diseases, Department of Medicine, Liver Cancer Program, Tisch Cancer Institute, Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, USA
- Department of Pharmacology, University of Valencia-FISABIO, Valencia, Spain
| | - Takuma Tsuchida
- Division of Liver Diseases, Department of Medicine, Liver Cancer Program, Tisch Cancer Institute, Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, USA
- Research Division, Mitsubishi Tanabe Pharma Corporation, Saitama, Japan
| | - Benjamin Wooden
- Division of Liver Diseases, Department of Medicine, Liver Cancer Program, Tisch Cancer Institute, Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Michael C. Wallace
- Division of Liver Diseases, Department of Medicine, Liver Cancer Program, Tisch Cancer Institute, Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, USA
- University of Western Australia, West Leederville, WA, Australia
| | - Natalia Nieto
- Department of Pathology, University of Illinois at Chicago, Chicago, USA
| | - Abigale Lade
- Division of Liver Diseases, Department of Medicine, Liver Cancer Program, Tisch Cancer Institute, Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Benjamin Redhead
- Department of Genetics and Genomics Sciences, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Arthur I Cederbaum
- Department of Pharmacology and Systems Therapeutics, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Joel T. Dudley
- Department of Genetics and Genomics Sciences, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Bryan C. Fuchs
- Division of Surgical Oncology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, USA
| | - Youngmin A. Lee
- Division of Liver Diseases, Department of Medicine, Liver Cancer Program, Tisch Cancer Institute, Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Yujin Hoshida
- Division of Liver Diseases, Department of Medicine, Liver Cancer Program, Tisch Cancer Institute, Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Scott L. Friedman
- Division of Liver Diseases, Department of Medicine, Liver Cancer Program, Tisch Cancer Institute, Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, USA
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8
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Wallace MC, Hamesch K, Lunova M, Kim Y, Weiskirchen R, Strnad P, Friedman SL. Standard operating procedures in experimental liver research: thioacetamide model in mice and rats. Lab Anim 2015; 49:21-9. [PMID: 25835735 DOI: 10.1177/0023677215573040] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In addition to carbon tetrachloride (CCl4), thioacetamide (TAA) represents a second widely used model for the induction of experimental liver fibrosis, but can also be employed for the development of acute liver failure and liver tumours. While TAA itself is not hepatotoxic, its reactive metabolites covalently bind to proteins and lipids thereby causing oxidative stress and centrilobular necrosis. Compared with CCl4, TAA leads to more periportal infiltrates and more pronounced ductal proliferation. While TAA has been shown to induce liver fibrosis development in several different mouse strains, wide variations in the administration routes, doses and treatment durations have been reported. Therefore, an adoption of a universal standard operating procedure for the administration of TAA is urgently needed. For that purpose, we are presenting here two TAA models (intraperitoneal administration of 150 mg/kg of TAA three times per week for 11 weeks in rats, and TAA administration in drinking water at 300 mg/L for 2-4 months in mice) with which we have had success in reliably and reproducibly developing chronic liver injury and fibrosis.
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Affiliation(s)
- M C Wallace
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - K Hamesch
- Department of Internal Medicine III, RWTH University Hospital Aachen, Aachen, Germany
| | - M Lunova
- Department of Internal Medicine III, RWTH University Hospital Aachen, Aachen, Germany
| | - Y Kim
- Kyung Hee Medical Center, Seoul, Korea
| | - R Weiskirchen
- Institute of Molecular Pathobiochemistry, Experimental Gene Therapy and Clinical Chemistry, RWTH University Hospital Aachen, Aachen, Germany
| | - P Strnad
- Department of Internal Medicine III, RWTH University Hospital Aachen, Aachen, Germany Interdisciplinary Center for Clinical Research (IZKF), RWTH University Aachen, Aachen, Germany
| | - S L Friedman
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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9
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Abstract
Primary liver cancer, the majority of which are hepatocellular carcinomas, is now the second leading cause of cancer death worldwide. Hepatocellular carcinoma is a unique cancer that typically arises in the setting of chronic liver disease at a rate dependent upon the complex interplay between the host, disease and environmental factors. Infection with chronic hepatitis B or C virus is currently the dominant risk factor worldwide. However, changing lifestyle and environmental factors in western countries plus rising neonatal hepatitis B vaccination rates and decreasing exposure to dietary aflatoxins in developing countries are driving an evolution of the epidemiology of this cancer. An understanding of this change is crucial in combating the rising incidence currently being seen in western regions and will underpin the efforts to reduce the mortality rates associated with this cancer.
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Affiliation(s)
- Michael C Wallace
- University of Western Australia, School of Medicine and Pharmacology, 35 Stirling Highway, Crawley, Perth, Western Australia, Australia
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10
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Abstract
Reversibility of hepatic fibrosis and cirrhosis following antiviral therapy for hepatitis B or C has advanced the prospect of developing antifibrotic therapies for patients with chronic liver diseases, especially non-alcoholic steatohepatitis. Mechanisms of fibrosis have focused on hepatic stellate cells, which become fibrogenic myofibroblasts during injury through 'activation', and are at the nexus of efforts to define novel drug targets. Recent studies have clarified pathways of stellate cell gene regulation and epigenetics, emerging pathways of fibrosis regression through the recruitment and amplification of fibrolytic macrophages, nuanced responses of discrete inflammatory cell subsets and the identification of the 'ductular reaction' as a marker of severe injury and repair. Based on our expanded knowledge of fibrosis pathogenesis, attention is now directed towards strategies for antifibrotic therapies and regulatory challenges for conducting clinical trials with these agents. New therapies are attempting to: 1) Control or cure the primary disease or reduce tissue injury; 2) Target receptor-ligand interactions and intracellular signaling; 3) Inhibit fibrogenesis; and 4) Promote resolution of fibrosis. Progress is urgently needed in validating non-invasive markers of fibrosis progression and regression that can supplant biopsy and shorten the duration of clinical trials. Both scientific and clinical challenges remain, however the past three decades of steady progress in understanding liver fibrosis have contributed to an emerging translational success story, with realistic hopes for antifibrotic therapies to treat patients with chronic liver disease in the near future.
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Affiliation(s)
- Youngmin A Lee
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Michael C Wallace
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Scott L Friedman
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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11
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Abstract
The last decade has seen a rapid expansion in our understanding of the mechanisms leading to hepatic stellate cell activation. The classic activation pathway of initiation, perpetuation and regression remains as a useful model; however, the emergence of several new pathways and mediators has revealed a deeper complexity than previously appreciated. Although core fibrogenic pathways exist across organs and disease types, there is accumulating evidence for disease- and context-specific mechanisms that may modulate or drive hepatic fibrogenesis. Hence, a "one size fits all" approach to antifibrotic therapy may not be appropriate for all disease settings. The authors present a focused and concise update of the most recent advances in our understanding of hepatic stellate cell activation pathways, while highlighting several challenges that may be constraining progress. This summary provides a foundation to further expand our knowledge of this unique cell type and its contributions to human liver disease.
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Affiliation(s)
- Michael C Wallace
- Division of Liver Diseases, Mount Sinai School of Medicine, New York, New York
| | - Scott L Friedman
- Division of Liver Diseases, Mount Sinai School of Medicine, New York, New York
| | - Derek A Mann
- Fibrosis Laboratory, Institute of Cellular Medicine, New Castle University, Newcastle upon Tyne, United Kingdom
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12
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Woodrow SI, O'Kelly C, Hamstra SJ, Wallace MC. Unemployment in an Underserviced Specialty?: The Need for Co-ordinated Workforce Planning in Canadian Neurosurgery. Can J Neurol Sci 2014; 33:170-4. [PMID: 16736725 DOI: 10.1017/s0317167100004923] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
ABSTRACT:Background:A recent report suggested that newly trained Canadian neurosurgeons are experiencing difficulty finding employment in Canada. Such occurrences, in combination with recent certification restrictions imposed in the US, have resulted in increasing concern that we will shortly be seeing a surplus of graduating neurosurgeons in Canada. The purpose of this study was to develop a better understanding of training and employment patterns in the Canadian neurosurgical workforce.Methods:Using a database provided by the Royal College of Physicians and Surgeons of Canada, the current practice location of recent (1990-2002) neurosurgical certificants and a list of all neurosurgeons practicing in Canada were generated. From these data the number of surgeons per 100,000 patient population, and the number of residents required to maintain this workforce were determined.Results:Practice location could be identified for 183/189 individuals who passed their qualifying examination in neurosurgery during this time. Only 45% of them are currently practicing in Canada. The current service ratio for this specialty is 0.65 per 100,000 population overall. Although 14.6 residents/ year are being trained, only 6.5/ year are required to maintain the existing neurosurgical workforce.Conclusion:Our data supports the concern about an imminent employment crisis for young neurosurgeons in Canada with more than twice the required number of residents being trained. However, this shortfall of staff positions is at a time when the specialty may be underservicing the country's population. These results highlight the necessity for more cohesive workforce planning in Canada, and in particular, ensuring the appropriate balance between training and need.
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Affiliation(s)
- S I Woodrow
- Department of Surgery, Wilson Centre for Research in Education, Faculty of Medicine, University of Toronto, Toronto, ON
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13
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Abstract
Hepatocellular carcinoma is an emerging worldwide health threat that has few curative treatment options and poor overall survival. Progressive hepatic fibrosis is a common pathway for all forms of chronic liver disease and is closely linked epidemiologically to hepatocellular carcinoma risk. However, the molecular events that predispose a fibrotic liver to cancer development remain elusive. Nonetheless, a permissive hepatic microenvironment provides fertile soil for transition of damaged hepatocytes into hepatocellular carcinoma. Key predisposing features include alterations in the extracellular matrix, bidirectional signaling pathways between parenchymal and nonparenchymal cells, and immune dysfunction. Emerging research into the contributions of autophagy, tumor-associated fibroblasts, and hepatocellular carcinoma progenitor cells to this dangerous milieu also provides new mechanistic underpinnings to explain the contribution of fibrosis to cancer. As effective antifibrotic therapies are developed, these approaches could attenuate the rising surge of hepatocellular carcinoma associated with chronic liver disease.
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Affiliation(s)
- Michael C. Wallace
- *Division of Liver Diseases, Mount Sinai School of Medicine, New York, NY, USA
- †School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia
| | - Scott L. Friedman
- *Division of Liver Diseases, Mount Sinai School of Medicine, New York, NY, USA
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Wallace MC, James AL, Marshall M, Kontorinis N. Resolution of severe hepato-pulmonary syndrome following transjugular portosystemic shunt procedure. BMJ Case Rep 2012; 2012:bcr.02.2012.5811. [PMID: 22669921 DOI: 10.1136/bcr.02.2012.5811] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The hepato-pulmonary syndrome (HPS) is a relatively common complication of hepatic disease that leads to hypoxaemia and dyspnoea secondary to pulmonary shunting. A number of pharmacological therapies have been trialled, yet liver transplantation remains the only definitive treatment. The use of a transjugular intrahepatic portosystemic shunt (TIPS) to reduce portal hypertension and improve oxygenation remains controversial in HPS due to the lack of large clinical series or randomised controlled trials. We present a case of HPS successfully treated with TIPS and review the relevant literature.
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Affiliation(s)
- Michael C Wallace
- Department of Gastroenterology and Hepatology, Royal Perth Hospital, Perth, Western Australia, Australia.
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15
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Abstract
Bleeding from the GI tract is a commonly encountered clinical problem after percutaneous coronary intervention. The GI tract is likely to become the most commonly encountered site of bleeding as cardiologists adopt smaller access sheath sizes, percutaneous closure devices and a radial artery approach, further reducing access-site bleeding. To appropriately manage gastrointestinal bleeding in this setting, the clinician must strike a balance between arresting hemorrhage and preventing ischemic coronary complications. To do so, an appreciation of both cardiovascular and gastrointestinal issues is required. This review aims to provide the required knowledge, as well as a series of recommendations from our practice, to assist in the management of this potentially fatal complication.
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Affiliation(s)
- Michael C Wallace
- Department of Gastroenterology and Hepatology, Royal Perth Hospital, Perth, WA 6001, Australia.
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16
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Ebinu JO, Matouk CC, Wallace MC, Terbrugge KG, Krings T. Hydrocephalus secondary to hydrodynamic disequilibrium in an adult patient with a choroidal-type arteriovenous malformation. Interv Neuroradiol 2011; 17:212-6. [PMID: 21696661 DOI: 10.1177/159101991101700212] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Accepted: 02/01/2011] [Indexed: 11/15/2022] Open
Abstract
We describe an adult patient with an unruptured choroidal-type arteriovenous malformation (AVM) associated with progressive hydrocephalus. There was no evidence of mechanical obstruction of the ventricular system by the AVM nidus itself or a draining vein. However significant reflux into periventricular and transmedullary veins was demonstrated. Following partial targeted embolization of the AVM, no further reflux was observed, the patient's clinical deficits resolved, and the hydrocephalus improved. We suggest a hydrodynamic disorder as a potential pathomechanism of hydrocephalus in this adult patient with an unruptured AVM.
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Affiliation(s)
- J O Ebinu
- Departments of Surgery and Medical Imaging, The University of Toronto Brain Vascular Malformation Study Group, The Toronto Hospital, Western Division, ON, Canada
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17
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Faughnan ME, Palda VA, Garcia-Tsao G, Geisthoff UW, McDonald J, Proctor DD, Spears J, Brown DH, Buscarini E, Chesnutt MS, Cottin V, Ganguly A, Gossage JR, Guttmacher AE, Hyland RH, Kennedy SJ, Korzenik J, Mager JJ, Ozanne AP, Piccirillo JF, Picus D, Plauchu H, Porteous MEM, Pyeritz RE, Ross DA, Sabba C, Swanson K, Terry P, Wallace MC, Westermann CJJ, White RI, Young LH, Zarrabeitia R. International guidelines for the diagnosis and management of hereditary haemorrhagic telangiectasia. J Med Genet 2009; 48:73-87. [PMID: 19553198 DOI: 10.1136/jmg.2009.069013] [Citation(s) in RCA: 652] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND HHT is an autosomal dominant disease with an estimated prevalence of at least 1/5000 which can frequently be complicated by the presence of clinically significant arteriovenous malformations in the brain, lung, gastrointestinal tract and liver. HHT is under-diagnosed and families may be unaware of the available screening and treatment, leading to unnecessary stroke and life-threatening hemorrhage in children and adults. OBJECTIVE The goal of this international HHT guidelines process was to develop evidence-informed consensus guidelines regarding the diagnosis of HHT and the prevention of HHT-related complications and treatment of symptomatic disease. METHODS The overall guidelines process was developed using the AGREE framework, using a systematic search strategy and literature retrieval with incorporation of expert evidence in a structured consensus process where published literature was lacking. The Guidelines Working Group included experts (clinical and genetic) from eleven countries, in all aspects of HHT, guidelines methodologists, health care workers, health care administrators, HHT clinic staff, medical trainees, patient advocacy representatives and patients with HHT. The Working Group determined clinically relevant questions during the pre-conference process. The literature search was conducted using the OVID MEDLINE database, from 1966 to October 2006. The Working Group subsequently convened at the Guidelines Conference to partake in a structured consensus process using the evidence tables generated from the systematic searches. RESULTS The outcome of the conference was the generation of 33 recommendations for the diagnosis and management of HHT, with at least 80% agreement amongst the expert panel for 30 of the 33 recommendations.
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Affiliation(s)
- M E Faughnan
- Division of Respirology, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
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18
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da Costa L, Thines L, Dehdashti AR, Wallace MC, Willinsky RA, Tymianski M, Schwartz ML, ter Brugge KG. Management and clinical outcome of posterior fossa arteriovenous malformations: report on a single-centre 15-year experience. J Neurol Neurosurg Psychiatry 2009; 80:376-9. [PMID: 19028763 DOI: 10.1136/jnnp.2008.152710] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [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] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Posterior fossa brain arteriovenous malformations (PFbAVMs) are rare lesions. Management is complicated by eloquence of adjacent neurological structures, multimodality treatment is often necessary, and obliteration is not always possible. We describe a 15-year experience in the management of posterior fossa brain AVMs with a focus on clinical outcome. METHODS From 1989 to 2004, prospectively collected information on 106 patients with diagnosis of a PFbAVMs was obtained. Clinical and angioarchitectural characteristics, management options and complications are described and reviewed to evaluate their impact on final outcome as measured by the Modified Rankin Score (mRS). RESULTS Ninety-eight patients were followed for an average of 3.3 years (1-14.6). The male-to-female ratio was 1:1. Ninety-five out of 98 patients (96.9%) were symptomatic at presentation, with 61 (62.2%) intracranial haemorrhages. Sixty-two patients were treated (46 cerebellar, 16 brainstem). Ten haemorrhages occurred in follow-up (4.1%/year). The mRS was obtained in 62 patients and was classified as low (good, mRS<or=2) or high (poor, mRS>or=3). Haemorrhage was the only predictor of poor mRS at presentation (p = 0.0229). A poor clinical outcome was correlated with the presence of AA (p = 0.0276), a poor initial mRS (p<0.0001) and the number of treatments needed (p = 0.0434). Patients were significantly more likely to improve than to deteriorate over time (p = 0.0201). CONCLUSION The final clinical outcome in PFbAVMs relates directly with the presence of associated aneurysms, number of treatments needed to obliterate the AVM and mRS at presentation. Despite the fact that patients tend to improve after brain AVM haemorrhage, the relationship of MRS at presentation and final outcome suggests that an expedited, more definitive treatment is probably a better choice, especially in patients with good grades after the initial bleeding.
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Affiliation(s)
- L da Costa
- Department of Medical Imaging, Division of Neuroradiology, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada.
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19
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da Costa LB, Terbrugge K, Farb R, Wallace MC. Surgical disconnection of cortical venous reflux as a treatment for Borden type II dural arteriovenous fistulae. Acta Neurochir (Wien) 2007; 149:1103-8; discussion 1108. [PMID: 17914598 DOI: 10.1007/s00701-007-1316-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2006] [Accepted: 06/21/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The presence of cortical venous reflux is recognized as an indicator of increased risk of intracranial hemorrhage and neurological deficits in cranial dural arteriovenous fistulas. Its disconnection is well accepted as a treatment for fistulas with direct cortical reflux (Borden type III), but the role of disconnection of the cortical venous reflux in the management of fistulas that involve the venous sinus and cortical venous reflux (Borden type II) is still a matter of debate. We analyze the experience of the Toronto Brain Vascular Malformation Study Group in the management of these lesions by simple cortical venous reflux disconnection and its impact in the future risk of bleeding. METHODS From June 1984 to August 2004, 347 patients with dural arteriovenous fistulas, either cranial or spinal, were evaluated by the group. Fifty-three patients had a Borden type II dural arteriovenous fistulas. Twenty-five patients were submitted to simple surgical disconnection of the dural arteriovenous fistulas, two were lost for follow-up. There were 15 females and 8 males, with mean age at diagnosis of 53.9 years. Follow-up time was 112.6 patient-years, from 2 months to 11 years, mean 4.9 years. Endovascular treatment was attempted in all patients, but no disconnection was possible. Twelve patients had their fistulas completely occluded by endovascular means, but are not analyzed here. There were four complications from the 93 endovascular procedures, and 3 from the 27 surgical procedures. Two patients required a repeated surgical procedure. No episode of intracranial hemorrhage or worsening neurological deficit was seen after disconnection of the cortical venous reflux in 4.9 years of follow-up. CONCLUSION Simple surgical disconnection of the cortical venous reflux maybe an option in the management of patients with Borden type II dural arteriovenous fistulas. This procedure is a much smaller surgical undertaking and is associated with fewer complications than attempts to resect or pack the whole fistula, especially if located in the skull base.
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Affiliation(s)
- L B da Costa
- Toronto Brain Vascular Malformation Study Group, Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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20
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Taplin MA, Anthony R, Tymianski M, Wallace MC, Rutka JA. Transmastoid partial labyrinthectomy for brainstem vascular lesions: clinical outcomes and assessment of postoperative cochleovestibular function. Skull Base 2007; 16:133-43. [PMID: 17268586 PMCID: PMC1586170 DOI: 10.1055/s-2006-949514] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To discuss the transmastoid partial labyrinthectomy approach for brainstem vascular lesions, with respect to hearing and balance preservation. DESIGN Retrospective case series. SETTING Tertiary referral center (University Health Network, Toronto). PARTICIPANTS Nine consecutive surgical patients between 1999 and 2004. MAIN OUTCOME MEASURES Clinical, audiometric, and electrophysiological vestibular data. RESULTS Nine transmastoid partial labyrinthectomy procedures (all females) were performed. In seven patients the underlying pathology was an intra-axial brainstem cavernous malformation. Two patients were treated for a basilar artery aneurysm. All patients had progressive neurological signs. Serviceable hearing (pure tone average (PTA): < 50 dB; speech discrimination score (SDS): > 50%) was preserved in seven patients. Partial vestibular function (clinical and electrophysiological) was maintained in most patients. CONCLUSIONS The partial labyrinthectomy approach to the skull base provides excellent exposure while preserving cochleovestibular function in most patients.
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Affiliation(s)
- Michael A. Taplin
- Department of Otolaryngology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Richard Anthony
- Department of Otolaryngology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Michael Tymianski
- Department of Neurosurgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Michael C. Wallace
- Department of Neurosurgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - John A. Rutka
- Department of Otolaryngology, University Health Network, University of Toronto, Toronto, Ontario, Canada
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21
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Verlaan DJ, Dubé MP, St-Onge J, Noreau A, Roussel J, Satgé N, Wallace MC, Rouleau GA. A new locus for autosomal dominant intracranial aneurysm, ANIB4, maps to chromosome 5p15.2-14.3. J Med Genet 2006; 43:e31. [PMID: 16740915 PMCID: PMC2564548 DOI: 10.1136/jmg.2005.033209] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Intracranial aneurysms (IA) are dilatations of intracranial arteries that occur most commonly at arterial bifurcations. Unruptured IA are present in approximately 1-2% of the population aged over 30 years of age. Aneurysms are only rarely symptomatic unless they rupture, which typically results in a subarachnoid haemorrhage associated with high morbidity and mortality. METHODS A large French Canadian (FC) family (Aneu60) was identified which contained 12 affected individuals with intracranial aneurysms. Nine of the affected patients and three unaffected individuals were sent for an 8 cM genome-wide scan. Multipoint and two-point methods were used to analyse the scan data by using a dominant parametric model. RESULTS We identified an IA susceptibility locus (ANIB4) located on chromosome 5p15.2-14.3. The locus was found by genome-wide linkage analysis and follow up analyses provided a maximum multipoint LOD score of 3.57 over the region. An identical haplotype segment of 7.2 Mb was found in a second FC pedigree and contributes to the refinement of the candidate gene interval. CONCLUSIONS Our results indicate that there is a major gene locus on chromosome 5p.
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22
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da Costa LB, Wallace MC, Montanera W. Shotgun pellet embolization to the posterior cerebral circulation. AJNR Am J Neuroradiol 2006; 27:261-3. [PMID: 16484388 PMCID: PMC8148771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
The embolization of missiles to the intracranial circulation is a rare event. We describe here a case of a man shot by a shotgun, presenting with a posterior fossa stroke and occlusion of the superior cerebellar artery by a metallic pellet. To our knowledge, this is the third case of posterior fossa circulation pellet emboli.
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Affiliation(s)
- L B da Costa
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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23
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Mascia L, Fedorko L, terBrugge K, Filippini C, Pizzio M, Ranieri VM, Wallace MC. The accuracy of transcranial Doppler to detect vasospasm in patients with aneurysmal subarachnoid hemorrhage. Intensive Care Med 2003; 29:1088-94. [PMID: 12774157 DOI: 10.1007/s00134-003-1780-5] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2002] [Accepted: 03/27/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To examine the accuracy of transcranial Doppler to detect cerebral vasospasm in a patient population with aneurysmal subarachnoid hemorrhage. DESIGN Prospective blind comparison of transcranial Doppler with cerebral angiography. Diagnostic accuracy of transcranial Doppler was assessed using receiver operating characteristic (ROC) analysis and likelihood ratios. Sensitivity and specificity were calculated using directly measured middle cerebral artery diameter as reference standard. SETTING Intensive Care Unit of a large university teaching hospital. PATIENTS AND PARTICIPANTS Twenty-two patients with subarachnoid hemorrhage were included. Patients underwent angiography on admission and after 8 days to diagnose vasospasm and were defined as having clinical vasospasm, angiographic vasospasm, or no vasospasm. MEASUREMENTS AND RESULTS Sensitivity and specificity were 1.00 and 0.75 for angiographic vasospasm and both equal to 1.00 for clinical vasospasm diagnosis. A transcranial Doppler mean velocity threshold value of 100 cm/s for angiographic vasospasm and 160 cm/s for clinical vasospasm detection were chosen by ROC analysis. CONCLUSIONS A Transcranial Doppler mean velocity threshold of 160 cm/s, calculated by the ROC analysis, accurately detects clinical vasospasm. A daily transcranial Doppler examination performed by a trained operator should be routinely used to provide early identification of patients at high risk and to orient therapeutic decisions.
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Affiliation(s)
- L Mascia
- Dipartimento di Discipline Medico-Chirurgiche, Sezione di Anestesiologia e Rianimazione, Ospedale S. Giovanni Battista, Università di Torino, Corso Dogliotti 14, 10126, Torino, Italy.
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Sneddon AA, Koll M, Wallace MC, Jones J, Miell JP, Garlick PJ, Preedy VR. Acute alcohol administration inhibits the refeeding response after starvation in rat skeletal muscle. Am J Physiol Endocrinol Metab 2003; 284:E874-82. [PMID: 12388171 DOI: 10.1152/ajpendo.00209.2002] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This study determined whether an acute alcohol dose could inhibit the refeeding response in starved muscle. Rats starved for 24 h were pretreated with alcohol or saline before refeeding by intragastric or intravenous infusion of enteral diet (ENT), total parenteral nutrition (TPN), or saline. Refeeding by TPN or ENT stimulated increases in the fractional rate of protein synthesis (k(s)) in skeletal muscle. Alcohol prevented the increase in k(s) when refeeding occurred intragastrically (TPN or ENT) (P < 0.001) but not intravenously (TPN). Upon intragastric refeeding, alcohol inhibited the increase in both eukaryotic initiation factor 4E-binding protein-1 (4E-BP1) and p70 S6 kinase (p70(S6K)) phosphorylation in plantaris but caused only partial inhibition in soleus muscle (ENT only). When rats were refed intravenously, alcohol had no effect on the increased 4E-BP1 or p70(S6K) phosphorylation in either muscle. Plasma insulin levels were augmented by alcohol. Alcohol-related changes in plasma amino acid concentrations were similar irrespective of the route of feeding, whereas IGF-I levels showed differential changes. This is the first study to demonstrate that acute alcohol ingestion impedes the starved-to-fed response in skeletal muscle.
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Affiliation(s)
- A A Sneddon
- Rowett Research Institute, Bucksburn, Aberdeen AB21 9SB, Scotland, UK.
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Abstract
The effects of transient cerebral ischemia on phosphorylation of the NR1 subunit of the NMDA receptor by protein kinase C (PKC) and protein kinase A (PKA) were investigated. Adult rats received 15 min of cerebral ischemia followed by various times of recovery. Phosphorylation was examined by immunoblotting hippocampal homogenates with antibodies that recognized NR1 phosphorylated on the PKC phosphorylation sites Ser890 and Ser896, the PKA phosphorylation site Ser897, or dually phosphorylated on Ser896 and Ser897. The phosphorylation of all sites examined increased following ischemia. The increase in phosphorylation by PKC was greater than by PKA. The ischemia-induced increase in phosphorylation was predominantly associated with the population of NR1 that was insoluble in 1% deoxycholate. Enhanced phosphorylation of NR1 by PKC and PKA may contribute to alterations in NMDA receptor function in the postischemic brain.
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Affiliation(s)
- H H Cheung
- Centre for the Neurobiology of Stress, Division of Life Sciences, University of Toronto at Scarborough, Toronto, Ontario, Canada
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Shehab ZP, Walsh RM, Thorp MA, Wallace MC, Tymianski M, Rutka JA. Partial labyrinthectomy approach for brainstem vascular lesions. J Otolaryngol 2001; 30:224-30. [PMID: 11771034 DOI: 10.2310/7070.2001.20167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Conventional wisdom has typically dictated that the bony labyrinth is an inviolate structure. This notion, however, was successfully challenged following the introduction of the partial labyrinthectomy approach, which was primarily used for the surgical management of cerebellopontine and petrous apex meningiomas. In this article, we discuss an extension of the technique of partial labyrinthectomy in a series of patients that has been used for the treatment of brainstem vascular lesions. We believe that this technique provides superior exposure to the brain stem when compared with conventional retrosigmoid and retrolabyrinthine approaches while reducing the inherent morbidity seen in transotic or petrosectomy approaches.
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Affiliation(s)
- Z P Shehab
- Department of Otolaryngology, University Health Network, University of Toronto, Ontario
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Abstract
Cerebral ischemia results in activation of the mitogen-activated protein kinase pathway and increased tyrosine phosphorylation of proteins associated with postsynaptic densities (PSDs). The authors investigated the possible relation between these events by determining the effect of ischemia on tyrosine phosphorylation of the brain-specific, PSD-enriched, Ras-GTPase activating protein, SynGAP. Transient (15 minutes) global ischemia was produced in rats by 4-vessel occlusion and PSDs prepared from forebrains immediately after ischemia or at 20 minutes, 1 hour, or 24 hours of reperfusion. Tyrosine phosphorylation of SynGAP was elevated relative to sham-operated controls by 20 minutes of reperfusion and remained elevated for at least 24 hours. Tyrosine phosphorylation of SynGAP also increased in CA1 and CA3/DG subfields of the hippocampus. Enhanced tyrosine phosphorylation of SynGAP was not accompanied by a change in PSD RasGAP activity. SynGAP bound to the SH2 domains of Src and Fyn in a tyrosine phosphorylation-dependent fashion, and this interaction increased after ischemia. SynGAP binds to the PDZ domains of PSD-95/SAP90 and coimmunoprecipitated with PSD-95. The coimmunoprecipitation of SynGAP with PSD-95 decreased after ischemia. The results indicate that changes in the properties and interactions of SynGAP may be involved in the neuropathology of ischemia.
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Affiliation(s)
- L Pei
- Center for the Neurobiology of Stress, Division of Life Sciences, University of Toronto at Scarborough, Ontario, Canada
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Abstract
This report describes the evaluation of a curriculum-integrated programme designed to help students develop an awareness of the nursing literature, the skills to locate and retrieve it, and skills required in its evaluation; in other words'information literacy'. Positive changes in student performance on objective measures of information-literacy skills were revealed as well as a significant increase in the levels of confidence of the student in performing those skills. Students who had undertaken the information-literacy programme ('programme' students) performed better on a range of objective measures of information literacy, as well as reporting higher levels of confidence in these skills, than students who had not participated in the programme ('non-programme' students). Evaluation of this programme provides evidence of the potential usefulness of a curriculum-integrated approach for the development of information-literacy skills within nursing education. With these underlying skills, students will be better equipped to consolidate and extend their key information-literacy skills to include research appreciation and application. These are vital for effective lifelong learning and a prerequisite to evidence-based practice.
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Affiliation(s)
- A Shorten
- Lecturer Department of Nursing, University of Wollongong, NSW, Australia.
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Al-Yamany M, Terbrugge KG, Willinsky R, Montanera W, Tymianski M, Wallace MC. Palliative embolisation of brain arteriovenous malformations presenting with progressive neurological deficit. Interv Neuroradiol 2001; 6:177-83. [PMID: 20667196 DOI: 10.1177/159101990000600302] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2000] [Accepted: 08/31/2000] [Indexed: 11/16/2022] Open
Abstract
SUMMARY Large arteriovenous malformations (AVMs) located in eloquent areas of the brain are generally considered incurable because of the high morbidity and mortality associated with their treatment. When these patients develop a progressive neurological deficit they in time often become severely disabled. This report presents the results of palliative embolisation in this subgroup of patients. Analysis of our data-base of 714 patients with known brain AVMs revealed 17 patients who presented with progressive neurological deficit and who underwent palliative embolisation as the therapeutic modality of choice for management of their AVM. One patient was excluded due to lack of follow-up and two were excluded because they later received radiation therapy. Following embolisation 43% had improvement of their neurological deficit, 50% stabilized and 7% continued to deteriorate and these clinical results persisted for an average of more than 2 years follow-up. Transient neurological morbidity associated with embolisation treatment was 7% and there was no permanent morbidity and no mortality. Palliative embolisation of brain AVMs presenting with progressive neurological deficits arrested deterioration in more than 90% of patients and was associated with low morbidity and no mortality.
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Affiliation(s)
- M Al-Yamany
- Radiology and Surgery, University of Toronto, Head Division of Interventional and Diagnostic Neuroradiology, The Western Hospital, University Health Network,Toronto, Ontario, Canada -
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Willinsky R, Goyal M, Terbrugge K, Montanera W, Wallace MC, Tymianski M. Embolisation of Small (< 3 cm) Brain Arteriovenous Malformations. Correlation of Angiographic Results to a Proposed Angioarchitecture Grading System. Interv Neuroradiol 2001; 7:19-27. [PMID: 20663327 DOI: 10.1177/159101990100700102] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2001] [Accepted: 02/15/2001] [Indexed: 11/17/2022] Open
Abstract
SUMMARY The role of embolisation in the treatment of small < 3cm) brain arteriovenous malformations (AVMs) has not been elucidated. We reviewed our experience using embolisation in the treatment of small AVMs and correlated a proposed grading system based on the angioarchitecture to the percentage obliteration achieved by embolisation. Eighty-one small AVMs in 80 patients were embolised from 1984 to 1999. The age range was from 3 to 72 years. The AVMs were given a score from 0 to 6 based on the angioarchitecture. The assigned scores were as follows: nidus (fistula = 0, < 1 cm = 1, 1-3 cm = 2), type offeeding arteries (cortical = 0, perforator or choroidal = 1), number of feeding arteries (single = 0, multiple = 2) and number of draining veins (single = 0, multiple = 1). Angiographic results based on percentage obliteration were grouped into three categories: complete, 66-99%, and 0-65%. The goal of embolisation was cure in 27 AVMs, pre-surgical in 23, pre-radiosurgery in 26, and elimination of an aneurysm in five. Embolisation achieved complete obliteration in 22 (27%) of the 81 AVMs. In the AVMs where the goal was cure, 19 (70%) of 27 were completely obliterated. In the AVMs with angioarchitecture scores of 0-2, 12 (86%) of 14 were cured, with scores of 3-4, 8 (34%) of 24 were cured and with scores of 5-6, 2 (4%) of 44 were cured. Embolisation resulted in transient morbidity of 5.0%, permanent morbidity of 2.5%, and mortality of 1.2%. There were no complications in AVMs with scores of 0-2. Embolisation is an effective treatment of small AVMs when the angioarchitecture is favourable (scores 0-2). This includes pure fistulas and AVMs with a single, pial, feeding artery.
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Affiliation(s)
- R Willinsky
- Department of Medical Imaging, The Toronto Western Hospital, University Health Network, The Brain Vascular Malformation Study Group, University of Toronto; Toronto, Canada -
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31
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Mascia L, Fedorko L, Stewart DJ, Mohamed F, terBrugge K, Ranieri VM, Wallace MC. Temporal relationship between endothelin-1 concentrations and cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage. Stroke 2001; 32:1185-90. [PMID: 11340231 DOI: 10.1161/01.str.32.5.1185] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.1] [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: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Endothelin 1 (ET-1) is a potent vasoconstrictor that may play a role in cerebral vasospasm following subarachnoid hemorrhage (SAH). However, data regarding its pathogenic role in the development of vasospasm are controversial. We planned a prospective, observational clinical study to investigate the temporal relationship between increased ET-1 production and cerebral vasospasm or other neurological sequelae after SAH. METHODS ET-1 levels in cerebrospinal fluid (CSF) were measured in 20 SAH patients from admission (within 24 hours from the bleeding) until day 7. Patients received a daily transcranial Doppler study and a neurological evaluation. On day 7, angiography was performed to verify the degree and extent of vasospasm. Patients were then classified as having (1) clinical vasospasm, (2) angiographic vasospasm, (3) no vasospasm, or (4) poor neurological condition without significant vasospasm (low Glasgow Coma Scale score [GCS]). RESULTS On admission, ET-1 levels were increased in the low-GCS group compared with the other groups (P=0.04). On day 4 ET-1 levels were not significantly different among groups, whereas on day 7 ET-1 levels were significantly increased in both the clinical vasospasm and low-GCS groups compared with the angiographic vasospasm and no vasospasm groups (P<0.005). Moreover, when the low-GCS group was excluded, there was a significant relationship between vasospasm grade and CSF ET-1 levels (R(2)=0.73). CONCLUSIONS CSF ET-1 levels were markedly elevated in patients with clinical manifestations of vasospasm (day 7) and with a poor neurological condition not related to vasospasm. However, ET-1 levels were low in clinical vasospasm patients before clinical symptoms were evident (day 4) and remained low in angiographic vasospasm patients throughout the study period. Thus, our data suggest that CSF ET-1 levels are increased in conditions of severe neuronal damage regardless whether this was due to vasospasm or to the primary hemorrhagic event. In addition, CSF ET-1 levels paralleled the neurological deterioration but were not predictive of vasospasm.
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Affiliation(s)
- L Mascia
- Department of Anaesthesia, Toronto General Hospital, University of Toronto, Toronto, Canada.
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32
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Abstract
The anterior cerebral artery (ACA) is a major vessel responsible for the blood supply to the interhemispheric region. The ACA segment after the anterior communicating artery (AComA) origin is called the distal ACA and has central and cortical branches. The cortical branches are distributed in the different regions of the orbital and medial part of the brain. The objects of this study are the anatomical variations found in the distal ACA. In 76 hemispheres the ACA distal branches were injected with latex and dissected under microscope magnification. Vessel diameters and distances between vessel origins and anterior communicating artery were recorded and analyzed. Microsurgical dissection was carried out to demonstrate anatomic variations of these vessels. Average diameter of ACA at origin was 2.61 +/- 0.34 mm and average diameter of cortical branches diameter ranged from 0.79 +/- 0.27 mm to 1.84 +/- 0.3 mm. Distances between vessel origin and AComA ranged from 7.68 +/- 3.91 mm (orbitofrontal) to 112.6 +/- 11.63 mm (inferior internal parietal). This study found anatomical variations: a single (azygos) ACA was present in one case and three in three cases. Crossing branches of the distal ACA to the contralateral hemisphere were present in 26% of the cases. In some cases a single ACA may supply the posterior hemispheric region through crossing branches. This calls attention to potential bilateral brain infarcts due to a single unilateral ACA occlusion.
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Affiliation(s)
- M A Stefani
- Department of Morphological Sciences, Laboratory of Neuroanatomy, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
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Abstract
This paper describes an evaluation of a curriculum-integrated information literacy programme in an undergraduate nursing course. The aim of the programme was to provide students with an awareness of the discipline's literature and the skills to locate and retrieve the literature. A multidimensional process for determining nursing students' development was utilised in the evaluation of the programme. Pre- and post-programme questionnaires were distributed to a cohort of students who undertook the programme. A cohort of more senior students who had not undertaken the information literacy programme was utilised as a comparison group. Questionnaire results were analysed using a range of inferential statistics. This paper will focus on two main findings related to objective measures of information literacy skills. These include pre-programme/post-programme change in student performance and differences in student performance between those who undertook the programme and those who did not. The programme demonstrated its effectiveness in developing information literacy skills, however the challenge remains for both academics and students to ensure that these skills are consolidated and extended for effective life-long learning.
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Affiliation(s)
- M C Wallace
- Department of Nursing, University of Wollongong, Northfields Avenue, Wollongong, NSW, 2522, Australia
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Cheung HH, Takagi N, Teves L, Logan R, Wallace MC, Gurd JW. Altered association of protein tyrosine kinases with postsynaptic densities after transient cerebral ischemia in the rat brain. J Cereb Blood Flow Metab 2000; 20:505-12. [PMID: 10724115 DOI: 10.1097/00004647-200003000-00009] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Transient cerebral ischemia results in an increase in the tyrosine phosphorylation of proteins associated with postsynaptic densities (PSDs). The authors investigated the possible mechanisms behind this increase by analyzing isolated PSDs for protein tyrosine kinase activity and for the presence of specific tyrosine kinases. Transient (15 minutes) global ischemia was produced in adult rats by four-vessel occlusion, and PSDs were isolated immediately after ischemia or after 20 minutes or 6 hours of reperfusion. Tyrosine phosphorylation of several PSD proteins, including the N-methyl-D-aspartate (NMDA) receptor subunits NR2A and NR2B, was enhanced relative to shams after 20 minutes of reperfusion and underwent a further increase between 20 minutes and 6 hours. The ability of intrinsic PSD tyrosine kinase to phosphorylate PSD proteins, including the NMDA receptor, increased threefold after ischemia. Whereas PSD-associated proline-rich tyrosine kinase 2 (PYK2) and gp145TrkB were elevated immediately after the ischemic event, increases in Src and Fyn were not apparent until 6 hours of reperfusion. The level of PSD-associated pp125FAK decreased after ischemia. The results demonstrate that ischemia results in selective changes in the association of protein tyrosine kinases with the PSD which may account for ischemia-induced increases in the tyrosine phosphorylation of PSD proteins.
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Affiliation(s)
- H H Cheung
- Division of Life Sciences, University of Toronto at Scarborough, Ontario, Canada
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Walsh RM, Tymianski M, Wallace MC, Bath AP, Bance ML, Rutka JA. The transmastoid partial labyrinthectomy approach to medial skull base lesions. Rev Laryngol Otol Rhinol (Bord) 2000; 121:13-20. [PMID: 10865478] [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] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
INTRODUCTION It has long been thought that surgical disruption of the membranous labyrinth invariably results in sensorineural hearing loss and balance dysfunction. Recent evidence suggests that the inner ear can withstand such manipulation without loss of function. The technique of transmastoid partial labyrinthectomy has recently been described as a means of providing access to lesions of the medial skull base by removing part of the labyrinth and at the same time attempting to preserve hearing and vestibular function of the lateral semicircular canal (LSCC) and otolithic organs. PROCEDURE An extended cortical mastoidectomy is performed and the posterior and middle cranial fossa dura are exposed widely. The posterior and superior semicircular canals are occluded at their ampullated ends and at the crus commune, and then resected. The LSCC and vestibule are left undisturbed. The petrous apex is removed and the medial end of the internal auditory canal is exposed. Posterior cranial fossa dural flaps are raised allowing access to the brainstem, petro-clival area and cerebellopontine angle. Temporal and suboccipital craniotomies can be performed, as required. RESULTS Four patients underwent this procedure by a joint Otolaryngological-Neurosurgical team for access to the following lesions: three intra-axial pontine cavernomas and a basilar artery aneurysm. The preliminary hearing and balance results are discussed. CONCLUSIONS The partial labyrinthectomy approach provides improved access to certain lesions of the medial skull base and requires less brain retraction compared with the retrolabyrinthine approach. It also has the potential to preserve serviceable hearing.
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Affiliation(s)
- R M Walsh
- University Health Network, Toronto General Hospital, Ontario, Canada
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Abstract
The postsynaptic density (PSD) is a cytoskeletal specialization involved in the anchoring of neurotransmitter receptors and in regulating the response of postsynaptic neurons to synaptic stimulation. The postsynaptic protein PSD-95 binds to NMDA receptor subunits NR2A and NR2B and to signaling molecules such as neuronal nitric oxide synthase and p135synGAP. We investigated the effects of transient cerebral ischemia on protein interactions involving PSD-95 and the NMDA receptor in the rat hippocampus. Ischemia followed by reperfusion resulted in a decrease in the solubility of the NMDA receptor and PSD-95 in 1% sodium deoxycholate, the decrease being greater in the vulnerable CA1 hippocampal subfield than in the less sensitive CA3/dentate gyrus regions. Solubilization of the kainic acid receptor GluR6/7 and the PSD-95 binding proteins, neuronal nitric oxide synthase and p135synGAP, also decreased following ischemia. The association between PSD-95 and NR2A and NR2B, as indicated by coimmunoprecipitation, was less in postischemic samples than in sham-operated controls. Ischemia also resulted in a decrease in the size of protein complexes containing PSD-95, but had only a small effect on the size distribution of complexes containing the NMDA receptor. The results indicate that molecular interactions involving PSD-95 and the NMDA receptor are modified by an ischemic challenge.
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Affiliation(s)
- N Takagi
- Division of Life Sciences, University of Toronto at Scarborough, Ontario, Canada
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37
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Affiliation(s)
- M Al-Yamany
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada.
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Ferguson GG, Eliasziw M, Barr HW, Clagett GP, Barnes RW, Wallace MC, Taylor DW, Haynes RB, Finan JW, Hachinski VC, Barnett HJ. The North American Symptomatic Carotid Endarterectomy Trial : surgical results in 1415 patients. Stroke 1999; 30:1751-8. [PMID: 10471419 DOI: 10.1161/01.str.30.9.1751] [Citation(s) in RCA: 698] [Impact Index Per Article: 27.9] [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: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE This study reports the surgical results in those patients who underwent carotid endarterectomy in the North American Symptomatic Carotid Endarterectomy Trial (NASCET). METHODS The rates of perioperative stroke and death at 30 days and the final assessment of stroke severity at 90 days were calculated. Regression modeling was used to identify variables that increased or decreased perioperative risk. Nonoutcome surgical complications were summarized. The durability of carotid endarterectomy was examined. RESULTS In 1415 patients there were 92 perioperative outcome events, for an overall rate of 6.5%. At 30 days the results were as follows: death, 1.1%; disabling stroke, 1.8%; and nondisabling stroke, 3.7%. At 90 days, because of improvement in the neurological status of patients judged to have been disabled at 30 days, the results were as follows: death, 1.1%; disabling stroke, 0.9%; and nondisabling stroke, 4.5%. Thirty events occurred intraoperatively; 62 were delayed. Most strokes resulted from thromboembolism. Five baseline variables were predictive of increased surgical risk: hemispheric versus retinal transient ischemic attack as the qualifying event, left-sided procedure, contralateral carotid occlusion, ipsilateral ischemic lesion on CT scan, and irregular or ulcerated ipsilateral plaque. History of coronary artery disease with prior cardiac procedure was associated with reduced risk. The risk of perioperative wound complications was 9.3%, and that of cranial nerve injuries was 8.6%; most were of mild severity. At 8 years, the risk of disabling ipsilateral stroke was 5.7%, and that of any ipsilateral stroke was 17.1%. CONCLUSIONS The overall rate of perioperative stroke and death was 6.5%, but the rate of permanently disabling stroke and death was only 2.0%. Other surgical complications were rarely clinically important. Carotid endarterectomy is a durable procedure.
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Affiliation(s)
- G G Ferguson
- John P. Robarts Research Institute, London, Ontario, Canada. gary.
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Abstract
Because of its potential for augmentation of blood flow and protection of neurons after neurological insult, nimodipine has been investigated as a treatment of spinal cord injury (SCI). The results have been inconsistent, possibly because of poor delivery of nimodipine to the injured spinal cord. The following study was designed to determine the delivery of nimodipine to the injured spinal cord. It was also hoped that information about the temporal and spatial pattern of binding of nimodipine after SCI might further elucidate the relationship between calcium channel activation and injury. Fourteen female Wistar rats were divided into three groups: control (n = 3), 30 min post-SCI (n = 6); and 4 h post-SCI (n = 5). The injury was produced by acute clip compression for 1 min at T1. [3H]Nimodipine was administered 5 min after laminectomy in the control group, and at the above-specified times after injury in the SCI groups. The drug was then allowed to equilibrate for 30 min before the animals were killed. The spatial patterns and concentrations of [3H]nimodipine in various segments of the spinal cord were autoradiographically determined. The highest concentrations of [3H]nimodipine were at the injury site after SCI. Also, the mean [3H]nimodipine concentrations in all sites in each animal were higher in the injury groups than in the control group (p < 0.05). This study indicates that delivery of this agent to the injured cord is possible, and provides evidence of widespread Ca2+ channel activation in the first 4 h after injury.
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Affiliation(s)
- I B Ross
- Section of Neurosurgery, University of Manitoba, Winnipeg, Canada.
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Takagi N, Cheung HH, Bissoon N, Teves L, Wallace MC, Gurd JW. The effect of transient global ischemia on the interaction of Src and Fyn with the N-methyl-D-aspartate receptor and postsynaptic densities: possible involvement of Src homology 2 domains. J Cereb Blood Flow Metab 1999; 19:880-8. [PMID: 10458595 DOI: 10.1097/00004647-199908000-00007] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Transient ischemia increases tyrosine phosphorylation of N-methyl-D-aspartate (NMDA) receptor subunits NR2A and NR2B in the rat hippocampus. The authors investigated the effects of this increase on the ability of the receptor subunits to bind to the Src homology 2 (SH2) domains of Src and Fyn expressed as glutathione-S-transferase-SH2 fusion proteins. The NR2A and NR2B bound to each of the SH2 domains and binding was increased approximately twofold after ischemia and reperfusion. Binding was prevented by prior incubation of hippocampal homogenates with a protein tyrosine phosphatase or by a competing peptide for the Src SH2 domain. Ischemia induced a marked increase in the tyrosine phosphorylation of several proteins in the postsynaptic density (PSD), including NR2A and NR2B, but had no effect on the amounts of individual NMDA receptor subunits in the PSD. The level of Src and Fyn in PSDs, but not in other subcellular fractions, was increased after ischemia. The ischemia-induced increase in the interaction of NR2A and NR2B with the SH2 domains of Src and Fyn suggests a possible mechanism for the recruitment of signaling proteins to the PSD and may contribute to altered signal transduction in the postischemic hippocampus.
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Affiliation(s)
- N Takagi
- Division of Life Sciences, University of Toronto at Scarborough, West Hill, Ontario, Canada
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Redekop G, Willinsky R, Montanera W, TerBrugge K, Tymianski M, Wallace MC. Endovascular occlusion of basilar bifurcation aneurysms with electrolytically detachable coils. Can J Neurol Sci 1999; 26:172-81. [PMID: 10451739 DOI: 10.1017/s0317167100000214] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECT To describe the clinical and angiographic results of endovascular occlusion of basilar bifurcation aneurysms with electrolytically detachable coils, and to identify factors which should be considered in deciding upon surgical or endovascular treatment. METHODS We report our experience with 40 patients in whom occlusion of basilar bifurcation aneurysms with electrolytically detachable coils was attempted. All patients underwent superselective angiography and attempted embolization with Guglielmi detachable coils (GDCs). Angiographic and clinical results were prospectively recorded. Twenty-eight aneurysms presented with subarachnoid hemorrhage (SAH), 2 were symptomatic and 10 were incidental. RESULTS Coils were not placed in 10 patients (25%) because of unfavorable anatomy. Complete aneurysm occlusion was achieved at the time of the initial procedure in 13 (32.5%), small neck remnants were present in 13 (32.5%), and in 4 (10.0%) there was obvious residual contrast filling of the aneurysm body. Of 23 patients successfully coiled after SAH, 20 were Grade 1 to 3 and 3 were grade 4 or 5 at the time of treatment. Eighteen (78%) made a good recovery. Procedural mortality was 2.5% and permanent morbidity was 7.5%. There were no permanent complications in patients with unruptured aneurysms. Complete aneurysm occlusion was possible in 10 (56%) of 18 aneurysms with small necks and 3 (14%) of 22 with large necks. Follow-up angiography in 25 of 28 surviving patients (mean, 12 months) demonstrated stability of all completely occluded aneurysms. Incompletely coiled aneurysms had variable results on follow-up angiograms: 15.4% improved, 69.2% worsened, and 15.4% were stable. No aneurysm bled after treatment during clinical follow-up averaging 22 months. CONCLUSIONS Endovascular treatment of basilar bifurcation aneurysms appears to prevent early aneurysm rebleeding with acceptable rates of morbidity and mortality, but long-term follow-up is required.
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Affiliation(s)
- G Redekop
- Department of Medical Imaging, Toronto Hospital, Canada
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Zhang L, Zhang Y, Tian GF, Wallace MC, Eubanks JH. Reversible attenuation of glutamatergic transmission in hippocampal CA1 neurons of rat brain slices following transient cerebral ischemia. Brain Res 1999; 832:31-9. [PMID: 10375649 DOI: 10.1016/s0006-8993(99)01458-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The present experiments were conducted to determine the time course of synaptic dysfunction in the vulnerable regions of the post-ischemia hippocampus. Following transient cerebral ischemia, neurons in the CA1 subfield of the hippocampus undergo a delayed degeneration that develops about 48 h after reperfusion. We have shown previously that CA1 glutamatergic transmission is decreased in the CA1 subfield well before any morphological deterioration of the CA1 cells is visible under the light microscope. However, it is unknown whether a time window exists after insult in which attenuated synaptic activity may be restored to normal levels. We show here that evoked CA1 somatic population spikes and dendritic field potential responses decline progressively after reperfusion in the CA1 subfield, such that by 72 h post-insult, the challenged neurons are unable to elicit evoked excitatory responses. This attenuation of synaptic transmission was confined to the vulnerable neurons of the hippocampus, however, as the evoked responses in the dentate gyrus displayed amplitudes that were not significantly diminished from sham control after challenge. In brain slices obtained from 24 h post-ischemia rats with significantly impaired CA1 somatic responses, the application of 5 or 50 microM of the potassium channel blocker 4-aminopyridine (4-AP) restored the magnitude of the evoked excitatory response to control values. At 36 h post-ischemia, the decreased CA1 evoked responses could be partially improved by 4-AP, but not to control levels. Based upon these results, we conclude that the decreased CA1 synaptic activity at 24 h post-ischemia is potentially reversible, and suggest that 4-AP improves the CA1 synaptic responses at least in part by improving transmitter release at post-ischemia glutamatergic synapses.
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Affiliation(s)
- L Zhang
- Playfair Neuroscience Unit, 399 Bathurst Street, Toronto, Ontario, Canada
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Norris JS, Valiante TA, Wallace MC, Willinsky RA, Montanera WJ, terBrugge KG, Tymianski M. A simple relationship between radiological arteriovenous malformation hemodynamics and clinical presentation: a prospective, blinded analysis of 31 cases. J Neurosurg 1999; 90:673-9. [PMID: 10193612 DOI: 10.3171/jns.1999.90.4.0673] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors sought to establish prospectively whether there is a simple relationship between radiological features of brain arteriovenous malformation (AVM) hemodynamics and a patient's clinical presentation. METHODS Thirty-one consecutive patients with AVMs underwent cerebral angiography at 3.8 frames/second during each standardized injection of contrast material. Contrast dilution curves were derived from the image sequences by using regions of interest (ROIs) traced on arteries feeding and veins draining the AVM nidus. Angiographic parameters were then analyzed in a blinded fashion. These parameters included the times required to reach the peak contrast density, the contrast decay time, and fractions thereof, in the ROI for each vessel. The authors determined whether these parameters, the arteriovenous transit time, and/or AVM size were related to patients' presentation with hemorrhage (11 patients), seizure (11 patients), or other clinical symptoms (nine patients). Statistically significant results were found only in analyses of arterial phase times to reach peak contrast density. Analyses of venous parameters, AVM size, and nidus transit time showed trends but no statistical significance. Arterial filling with contrast material was significantly slower in patients presenting with hemorrhage (mean 50%, 80%, and 100% of time to peak +/- standard error [SE] = 1.19+/-0.13, 1.97+/-0.18, and 3.04+/-0.34 seconds, respectively) compared with patients presenting with seizures (mean 50%, 80%, and 100% of time to peak +/- SE = 0.80+/-0.12, 1.32+/-0.18, and 1.95+/-0.29 seconds, respectively) according to analysis of variance (p<0.05) and post-hoc t-tests (p<0.05) for each parameter. Patients who presented with other symptoms had intermediate arterial filling times. CONCLUSIONS These simple hemodynamic parameters, which can be obtained without added risk to the patient, may help identify a subset of individuals in whom AVMs pose a higher risk of future hemorrhage and who may therefore warrant more expeditious treatment.
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Affiliation(s)
- J S Norris
- University of Toronto Brain Vascular Malformation Study Group, Ontario, Canada
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Wigle D, Ho W, Lo D, Francis J, Eubanks JH, Wallace MC. Altered expression levels of SEF-2 and p112 in the rat hippocampus after transient cerebral ischemia: identification by mRNA differential display. J Cereb Blood Flow Metab 1999; 19:435-42. [PMID: 10197513 DOI: 10.1097/00004647-199904000-00009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The authors used mRNA differential display to identify genes whose expression levels are altered in the adult rat hippocampus 24 hours after global ischemia. At this time after challenge, the basic helix-loop-helix transcription factor, SEF-2, and the 26S proteasome complex subunit, p112, were identified as genes whose expression levels are decreased and increased, respectively, in the hippocampus. To determine the spatial and temporal patterns of expression change for each gene, the authors antisense in situ hybridization to paired brain sections of sham-operated and global ischemia-challenged rats at 6, 12, and 24 hours after reperfusion SEF-2 expression was not significantly altered from that of sham-operated controls in any hippocampal subfield at or before 12 hours after challenge. At 24 hours after ischemia, however, SEF-2 expression levels were significantly diminished in the vulnerable CA1 subfield, but not in the less vulnerable CA3 or dentate granule cell subfields. The proteasome p112 subunit gene displayed no change in expression levels at 6 hours after insult; however, an elevated expression was observed at 12 hours after challenge in the dentate granule cell subfield. By 24 hours after challenge, p112 expression was significantly elevated in both the CA1 and dentate granule cell subfields. These results demonstrate that a member of the basic helix-loop-helix family of transcription factors, SEF-2, and the major subunit of the 26S proteasome complex, p112, display altered gene expression in the hippocampus after transient cerebral ischemia.
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Affiliation(s)
- D Wigle
- Playfair Neuroscience Unit, University of Toronto, Ontario, Canada
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Wallace MC, Shorten A, Crookes PA, McGurk C, Brewer C. Integrating information literacies into an undergraduate nursing programme. Nurse Educ Today 1999; 19:136-141. [PMID: 10335196 DOI: 10.1054/nedt.1999.0621] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The development of support for a more research-based approach to care has created the imperative for nursing education to tackle the issue of information literacy. Information literacy means the ability to locate, evaluate and apply information in critical thinking and problem solving. This paper outlines and provides a rationale for a curriculum-integrated information literacy programme, implemented in the pre-registration Bachelor of Nursing course at the University of Wollongong, NSW, Australia. It also describes a multidimensional evaluation process for determining nursing students' growth in cognitive and affective domains. Results of the programme evaluation will be featured in a future paper.
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Affiliation(s)
- M C Wallace
- Faculty Librarian, Health and Behavioural Sciences, University of Wollongong, NSW, Australia
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Francis J, Zhang Y, Ho W, Wallace MC, Zhang L, Eubanks JH. Decreased hippocampal expression, but not functionality, of GABA(B) receptors after transient cerebral ischemia in rats. J Neurochem 1999; 72:87-94. [PMID: 9886058 DOI: 10.1046/j.1471-4159.1999.0720087.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [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: 11/20/2022]
Abstract
We have examined the effects of transient global ischemia on both the gene expression levels and the functionality of GABA(B) receptors in rat brain, using antisense in situ hybridization and electrophysiological evaluations. At the level of gene expression, no significant change in GABA(B) receptor expression was observed in any hippocampal subfield at either 6 or 12 h after challenge. At 24 h postchallenge, however, a significant decrease in GABA(B) receptor expression was observed in both the CA1 and CA3 subfields, whereas no change was observed in the dentate granule cell layer. Although expression in both the vulnerable CA1 and less vulnerable CA3 subfields was diminished at this time postchallenge, there was no significant difference in the degree of the diminished expression between these subfields. At the functional level, the dose-dependent ability of baclofen (1-100 microM) to inhibit an evoked excitatory postsynaptic potential (f-EPSP) in the CA1 subfield was evaluated at 24 h postischemia, in comparison with the dose-response observed in sham-operated subjects. No significant differences were observed in the efficacy of GABA(B) receptor-mediated inhibition of the elicited f-EPSP at any of the baclofen concentrations examined. These data demonstrate that although the mRNA expression levels for the GABA(B) receptor are diminished in both vulnerable and less vulnerable neurons of Ammon's horn at 24 h following transient global ischemia, the functionality of the GABA(B) receptor system is maintained at this time postchallenge.
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Affiliation(s)
- J Francis
- Playfair Neuroscience Unit, Toronto Western Hospital, Bloorview Epilepsy Research Program, University of Toronto, Ontario, Canada
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Stiver SI, Porter PJ, Willinsky RA, Wallace MC. Acute human histopathology of an intracranial aneurysm treated using Guglielmi detachable coils: case report and review of the literature. Neurosurgery 1998; 43:1203-8. [PMID: 9802864 DOI: 10.1097/00006123-199811000-00106] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE AND IMPORTANCE This case study provided us with the opportunity to explore the histopathological effects of Guglielmi detachable coil (GDC) therapy on the aneurysm orifice and parent vessel-aneurysm neck interface. This type of study is important to the understanding of the mechanisms of obliteration of aneurysms by GDCs. CLINICAL PRESENTATION The patient presented with a Hunt and Hess Grade III subarachnoid hemorrhage that occurred secondary to the rupture of a small anterior communicating artery aneurysm. INTERVENTION The aneurysm was successfully coiled without complication, but the patient died 36 hours later. We examined the gross and microscopic pathological findings of this GDC-treated anterior communicating artery aneurysm 36 hours after coiling. A discrete membrane composed of fibrin had formed completely across the aneurysm orifice, excluding the aneurysm sac from the circulation. This membrane was contiguous with the parent vessel. CONCLUSION This case represents one of the first examples in humans of the formation of a membrane over the aneurysm orifice after GDC therapy. The formation of this membrane, shown to be composed of fibrin, was found at 36 hours after coiling, which is the earliest time frame at which membrane formation has been noted in either humans or animal models. This fibrin membrane may function both as a scaffold for subsequent endothelialization across the aneurysm neck as well as to isolate the aneurysm from the parent circulation, permitting thrombus within the aneurysm sac to mature to an endovascular scar. The factors contributing to the formation of this membrane and its clinical implications are discussed.
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Affiliation(s)
- S I Stiver
- Department of Surgery, The Toronto Hospital, Ontario, Canada
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Hsu JC, Zhang Y, Takagi N, Gurd JW, Wallace MC, Zhang L, Eubanks JH. Decreased expression and functionality of NMDA receptor complexes persist in the CA1, but not in the dentate gyrus after transient cerebral ischemia. J Cereb Blood Flow Metab 1998; 18:768-75. [PMID: 9663507 DOI: 10.1097/00004647-199807000-00008] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The authors investigated the gene expression of the NR2A and NR2B subunits of N-methyl-D-aspartate (NMDA) receptor and the functional electrophysiologic activity of NMDA receptor complexes in the vulnerable CA1 and less vulnerable dentate gyrus subfields of the rat hippocampus at different times after transient cerebral ischemia. Decreased expression for both subtypes was observed in both the CA1 subfield and dentate granule cell layer at early times after challenge; however, the decreased expression in the dentate granule cell layer was reversible because mRNA levels for both the NR2A and NR2B subtypes recovered to, or surpassed, sham-operated mRNA levels by 3 days postchallenge. No recovery of expression for either subtype was observed in the CA1 subfield. The functional activity of NMDA receptor complexes, as assessed by slow field excitatory postsynaptic potentiations (slow f-EPSP) in CA1 pyramidal neurons, was maintained at 6 hours postchallenge; however, this activity was diminished greatly by 24 hours postchallenge, and absent at 7 days postchallenge. A similar pattern was observed for the non-NMDA receptor-mediated fast f-EPSP. In dentate granule neurons, however, no significant change in NMDA receptor-mediated slow f-EPSP from sham control was observed at any time after insult. The non-NMDA receptor-generated fast f-EPSPs also were maintained at all times postinsult in the dentate gyrus. These results illustrate that the activity of NMDA receptors remains functional in dentate granule neurons, but not in the pyramidal neurons of the CA1 subfield, at early and intermediate times after transient cerebral ischemia, and suggest that there is a differential effect of ischemia on the glutamatergic transmission systems in these two hippocampal subfields.
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Affiliation(s)
- J C Hsu
- Playfair Neuroscience Unit, and Department of Anesthesia, University of Toronto, Ontario, Canada
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Norris JS, Wallace MC. Pediatric intracranial aneurysms. Neurosurg Clin N Am 1998; 9:557-63. [PMID: 9668187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Pediatric intracranial aneurysms are uncommon. There are several differences between childhood and adult aneurysms, but the evaluation and management of childhood aneurysms is similar to that in adults. This article will review the incidence, pathology, clinical features, management, and expected outcome of childhood aneurysms.
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Affiliation(s)
- J S Norris
- Division of Neurosurgery, Toronto Hospital (Western Division), Ontario, Canada
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Mingo NS, Cottrell G, Zhang L, Wallace MC, Burnham WM, Eubanks JH. Kainic acid-induced generalized seizures alter the regional hippocampal expression of the rat m1 and m3 muscarinic acetylcholine receptor genes. Epilepsy Res 1997; 29:71-9. [PMID: 9416461 DOI: 10.1016/s0920-1211(97)00067-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We investigated the gene expression responses using in situ hybridization with radiolabelled riboprobes for the m1 and m3 subtypes of muscarinic cholinergic receptors in the rat hippocampus following a brief (5-min) kainic acid-induced behavioral seizure. The kainic acid was intraperitoneally administered, and the ensuing generalized convulsive seizure terminated with diazepam. Our results demonstrate that the expression of the m1 subtype was significantly reduced in the CA1, CA3 and the dentate granule cells by 3 h after the administration of kainic acid while no significant change was observed in any hippocampal subfield for the m3 subtype. By 6 h post challenge, the m1 subtype was still decreased in all hippocampal subfields examined, while the m3 subtype remained unchanged from vehicle injected control. At 24 h post challenge, both the m1 and m3 subtypes were significantly reduced in the CA1 and CA3 subfields; the expression of the m1 subtype in the dentate granule cells, however, had recovered to levels indistinguishable from vehicle-injected control. These results demonstrate that epileptiform activity induced by kainic acid administration promotes alterations in the expression levels for both the m1 and m3 muscarinic receptor genes, and suggest that the activity of this neuromodulatory system in the hippocampus may be altered through activity-dependent mechanisms at early times following seizures.
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Affiliation(s)
- N S Mingo
- Playfair Neuroscience Unit, Toronto, Ontario, Canada
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