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Khan R, Osman H, Lee S, Chen YI, Singh A, Hookey L, Arya N, Causada Calo N, Grover SC, Tepox-Padrón A, Bass S, Cole M, Lei Y, Li S, Mohamed R, Turbide C, Koury HF, Chau M, Howarth M, Cartwright S, Heitman SJ, Forbes N. Post-ERCP cholecystitis: Incidence, characteristics, and outcomes from a prospective multicenter biliary endoscopy registry. Gastrointest Endosc 2024; 99:633-640. [PMID: 38092126 DOI: 10.1016/j.gie.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/21/2023] [Accepted: 12/05/2023] [Indexed: 03/22/2024]
Abstract
BACKGROUND AND AIMS The incidence, risk factors, and outcomes of post-ERCP cholecystitis are poorly described. We aimed to describe cases of post-ERCP cholecystitis from a prospective multicenter registry with protocolized 30-day follow-up. METHODS Patient- and procedure-related data from 7 centers were obtained. The primary outcome was post-ERCP cholecystitis, defined according to a Delphi-based criteria and causal attribution system. Risk factors and outcomes were described for all cases. RESULTS Seventeen cases of post-ERCP cholecystitis were identified among 4428 patients with gallbladders undergoing ERCP between 2018 and 2023 (incidence, 0.38%; 95% confidence interval, 0.20-0.57). In ERCPs with covered metal stenting, 7 of 467 resulted in cholecystitis (incidence, 1.50%; 95% confidence interval, 0.40-2.60). Patients had symptoms at a median of 5 days (interquartile range, 5) after ERCP. Management strategies included cholecystectomy, percutaneous cholecystostomy, and endoscopic stent removal/exchange. CONCLUSIONS Estimates of post-ERCP cholecystitis incidence can inform discussions around procedural risk.
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Affiliation(s)
- Rishad Khan
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Hana Osman
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sangmin Lee
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Yen-I Chen
- Division of Gastroenterology and Hepatology, McGill University, Montreal, Quebec, Canada
| | - Andrew Singh
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, University of British Columbia, Victoria, British Columbia, Canada
| | - Lawrence Hookey
- Division of Gastroenterology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Naveen Arya
- Division of Gastroenterology, Oakville Trafalgar Memorial Hospital, Oakville, Ontario, Canada
| | - Natalia Causada Calo
- Division of Gastroenterology, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Samir C Grover
- Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada
| | - Alejandra Tepox-Padrón
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sydney Bass
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Martin Cole
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Yang Lei
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Suqing Li
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rachid Mohamed
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christian Turbide
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Hannah F Koury
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Millie Chau
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Megan Howarth
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shane Cartwright
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Steven J Heitman
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
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Jairath V, Zou G, Wang Z, Adsul S, Colombel JF, D'Haens GR, Freire M, Moran GW, Peyrin-Biroulet L, Sandborn WJ, Sebastian S, Travis S, Vermeire S, Radulescu G, Sigler J, Hanžel J, Ma C, Sedano R, McFarlane SC, Arya N, Beaton M, Bossuyt P, Danese S, Green D, Harlan W, Horynski M, Klopocka M, Petroniene R, Silverberg MS, Wolanski L, Feagan BG. Determining the optimal treatment target in patients with ulcerative colitis: rationale, design, protocol and interim analysis for the randomised controlled VERDICT trial. BMJ Open Gastroenterol 2024; 11:e001218. [PMID: 38336367 PMCID: PMC10870790 DOI: 10.1136/bmjgast-2023-001218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 12/06/2023] [Indexed: 02/12/2024] Open
Abstract
INTRODUCTION Symptoms, endoscopy and histology have been proposed as therapeutic targets in ulcerative colitis (UC). Observational studies suggest that the achievement of histologic remission may be associated with a lower risk of complications, compared with the achievement of endoscopic remission alone. The actiVE ulcerative colitis, a RanDomIsed Controlled Trial (VERDICT) aims to determine the optimal treatment target in patients with UC. METHODS AND ANALYSIS In this multicentre, prospective randomised study, 660 patients with moderate to severe UC (Mayo rectal bleeding subscore [RBS] ≥1; Mayo endoscopic score [MES] ≥2) are randomly assigned to three treatment targets: corticosteroid-free symptomatic remission (Mayo RBS=0) (group 1); corticosteroid-free endoscopic remission (MES ≤1) and symptomatic remission (group 2); or corticosteroid-free histologic remission (Geboes score <2B.0), endoscopic remission and symptomatic remission (group 3). Treatment is escalated using vedolizumab according to a treatment algorithm that is dependent on the patient's baseline UC therapy until the target is achieved at weeks 16, 32 or 48. The primary outcome, the time from target achievement to a UC-related complication, will be compared between groups 1 and 3 using a Cox proportional hazards model. ETHICS AND DISSEMINATION The study was approved by ethics committees at the country level or at individual sites as per individual country requirements. A full list of ethics committees is available on request. Study results will be disseminated in peer-reviewed journals and at scientific meetings. TRIAL REGISTRATION NUMBER EudraCT: 2019-002485-12; NCT04259138.
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Affiliation(s)
- Vipul Jairath
- Department of Medicine, Division of Gastroenterology; Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
- Alimentiv Inc, London, Ontario, Canada
| | - Guangyong Zou
- Alimentiv Inc, London, Ontario, Canada
- Department of Epidemiology and Biostatistics; Robarts Research Institute, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | | | - Shashi Adsul
- Takeda Pharmaceuticals, Cambridge, Massachusetts, USA
| | - Jean-Frederic Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Geert R D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | | | - Gordon W Moran
- Nottingham Digestive Diseases Biomedical Research Centre, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Laurent Peyrin-Biroulet
- INSERM, NGERE, University of Lorraine, Nancy, France
- Department of Gastroenterology; INFINY Institute; FHU-CURE, Nancy University Hospital, Nancy, France
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | | | - Simon Travis
- Kennedy Institute and Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Séverine Vermeire
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | | | | | - Jurij Hanžel
- Alimentiv Inc, London, Ontario, Canada
- Department of Gastroenterology, University of Ljubljana, Ljubljana, Slovenia
| | - Christopher Ma
- Alimentiv Inc, London, Ontario, Canada
- Division of Gastroenterology & Hepatology, Cumming School of Medicine; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rocio Sedano
- Alimentiv Inc, London, Ontario, Canada
- Department of Medicine, Division of Gastroenterology, University of Western Ontario, London, Ontario, Canada
| | | | - Naveen Arya
- ABP Research Services Corp, Oakville, Ontario, Canada
| | - Melanie Beaton
- Department of Medicine, Division of Gastroenterology, University of Western Ontario, London, Ontario, Canada
| | - Peter Bossuyt
- Imelda GI Clinical Research Center, Imelda Hospital, Bonheiden, Belgium
| | - Silvio Danese
- Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Daniel Green
- Department of Gastroenterology, Taunton Surgical Centre, Oshawa, Ontario, Canada
| | - William Harlan
- Asheville Gastroenterology Associates, Asheville, North Carolina, USA
| | | | - Maria Klopocka
- Department of Gastroenterology and Nutritional Disorders, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
- Gastroenterology Clinic, Dr. Jana Biziel University Hospital n 2 in Bydgoszcz, Bydgoszcz, Poland
| | | | - Mark S Silverberg
- Toronto Immune and Digestive Health Institute, Toronto, Ontario, Canada
| | - Lukasz Wolanski
- Gastroenterological Department, Samodzielny Publiczny Zakład Opieki Zdrowotnej w Łęcznej, Łęcznej, Poland
| | - Brian G Feagan
- Department of Medicine, Division of Gastroenterology; Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
- Alimentiv Inc, London, Ontario, Canada
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Lin K, Arya N, Laughlin B, Zaniletti I, Van Der Walt C, Bhandarkar A, Bydon M, Sio TTW. Characterizing Hospital Admissions after Proton Beam Therapy Using the National Inpatient Sample Database. Int J Radiat Oncol Biol Phys 2023; 117:e407-e408. [PMID: 37785352 DOI: 10.1016/j.ijrobp.2023.06.1548] [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] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) To characterize the diagnoses, comorbidities, and length of stay in patients who received proton beam therapy during their hospital stay as part of their cancer treatment regimen. MATERIALS/METHODS The National Inpatient Sample database was queried using ICD-10 codes to identify all hospitalizations with proton beam therapy between 2016 and 2018. Weighted frequencies for categorical variables and geometric mean with standard error for continuous variables were derived. Generalized linear models for clustered data in SAS v 9.4 (Cary, NC) were used to determine the association between length of stay with patient and hospital baseline characteristics. RESULTS We studied 511 patients, representing a weighted estimate of 2,555 patients from the National Inpatient Sample from 2016 to 2018 who received proton beam therapy during hospitalization. The mean age was 40 years (StdErr = 3.0). The estimated average length of stay was 7.7 days (StdErr = 0.4). The cohort was 53.6% White, 15.3% Black, 10.4% Hispanic, 7.0% Asian or Pacific Islander, and 0.2% Native American. The most frequent diagnoses at admission were encounter for antineoplastic chemotherapy (10.0%), secondary malignant neoplasm of brain (9.2%), secondary malignant neoplasm of bone (9.0%), encounter for antineoplastic radiation therapy (6.1%), and neoplasm-related pain (3.3%). Large- and medium-sized hospitals were associated with significantly longer lengths of stay than small-sized hospitals (p<0.0001 and p = 0.0186, respectively). Compared to private investor-owned (proprietary) hospitals, nonfederal government-owned (public) hospitals are associated with prolonged length of stay (p = 0.0033). Hospital region and patient age, race, sex, comorbidity, and income quartile were not associated with a longer length of stay. CONCLUSION Our findings demonstrate that hospital-level characteristics are more important than patient-level characteristics in predicting length of stay in patients undergoing proton beam therapy while hospitalized. Patients undergoing proton beam therapy while hospitalized at large- and medium-sized hospitals had longer lengths of stay than those at small-sized hospitals. Additionally, publicly owned hospitals were associated with prolonged length of stay compared to private hospitals. The underlying reason for this difference in length of stay is unclear but may suggest different management strategies, protocols, and discharge criteria for patients receiving proton beam therapy in larger and publicly-owned hospitals compared to smaller and privately-owned hospitals. Future investigations should explore the underlying causes for these discrepancies and identify potential strategies to shorten unnecessarily prolonged hospital stays in patients undergoing proton beam therapy.
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Affiliation(s)
- K Lin
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ
| | - N Arya
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ
| | - B Laughlin
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - I Zaniletti
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, AZ
| | - C Van Der Walt
- Department of Quantitative Health Sciences, Section of Biostatistics, Mayo Clinic, Scottsdale, AZ
| | - A Bhandarkar
- Mayo Clinic Neuro-Informatics Laboratory, Rochester, MN
| | - M Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Rochester, MN
| | - T T W Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
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Lin K, Arya N, Yu N, Sio T. 9-Year Analysis of Trends in the Radiation Oncology Residency Match. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Li S, Monachese M, Salim M, Arya N, Sahai AV, Forbes N, Teshima C, Yaghoobi M, Chen YI, Lam E, James P. Standard reporting elements for the performance of EUS: Recommendations from the FOCUS working group. Endosc Ultrasound 2021; 10:84-92. [PMID: 33666183 PMCID: PMC8098847 DOI: 10.4103/eus-d-20-00234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background and Objectives Quality indicators for the performance of EUS have been developed to monitor and improve service value and patient outcomes. To support the incorporation of these indicators and standardize EUS documentation, we propose standard EUS reporting elements for endosonographers and endoscopy units. Methods A comprehensive literature search and review was performed to identify EUS quality indicators and key components of high-quality standardized EUS reporting. Guidance statements regarding standard EUS reporting elements were developed and reviewed at the Forum for Canadian Endoscopic Ultrasound (FOCUS) 2019 Annual Meeting. Results EUS reporting elements can be divided into preprocedural, intraprocedural, and postprocedural items. Preprocedural components include the type, indication, and urgency of the procedure and patient clinical information and consent. Intraprocedural components include the adequacy and extent of examination, relevant landmarks, lesion characteristics, sampling method, specimen quality, and intraprocedural adverse events. Postprocedural components include a summary and synthesis of relevant findings as well as recommended management and follow-up. Conclusions Standardizing reporting elements may help improve the care of patients undergoing EUS procedures. Our review provides a practical guide and compilation of recommended reporting elements to ensure ongoing best practices and quality improvement in EUS.
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Affiliation(s)
- Suqing Li
- Division of Gastroenterology and Hepatology, University Health Network, University of Toronto, Toronto, Canada
| | - Marc Monachese
- Division of Gastroenterology and Hepatology, University Health Network, University of Toronto, Toronto, Canada
| | - Misbah Salim
- Division of Gastroenterology and Hepatology, University Health Network, University of Toronto, Toronto, Canada
| | - Naveen Arya
- Division of Gastroenterology, Oakville Trafalgar Memorial Hospital, Oakville, Ontario, Canada
| | - Anand V Sahai
- Division of Gastroenterology, University of Montreal, Montreal, Quebec, Canada
| | - Nauzer Forbes
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, AB, Canada
| | - Christopher Teshima
- Department of Medicine, Division of Gastroenterology, St. Michael's Hospital, University of Calgary, Toronto, Canada
| | - Mohammad Yaghoobi
- Division of Gastroenterology, McMaster University Medical Center, McMaster University, Hamilton, Canada
| | - Yen-I Chen
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Canada
| | - Eric Lam
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
| | - Paul James
- Division of Gastroenterology and Hepatology, University Health Network, University of Toronto, Toronto, Canada
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Scholtes R, Muskiet M, Van Baar M, Greasley P, Karlsson C, Hammarsterdt A, Arya N, Van Raalte D, Heerspink H. Natriuretic effect of 2 weeks of dapagliflozin treatment in patients with type 2 diabetes and preserved kidney function: results of the DAPASALT trial. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.3357] [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] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Sodium glucose co-transporter 2 (SGLT2) inhibitors reduce the risk for heart failure hospitalization, potentially by inducing sodium excretion, osmotic diuresis and plasma volume contraction, leading to more favorable systemic hemodynamic function. However, this hypothesis has never been formally investigated as no studies have assessed cumulative sodium excretion with SGLT2 inhibition during standardized sodium intake.
Methods
We conducted a mechanistic open label study in patients with type 2 diabetes mellitus (T2D) with preserved kidney function, who were receiving a standardized sodium intake (150 mmol/day) to evaluate the acute effects (average day 2–4), effects at steady state (average day 12–14) and effects during three days wash-out of dapagliflozin on sodium balance and blood pressure. Primary outcome measure was 24-hr sodium excretion during the acute phase. Secondary outcomes included 24-hr glucose excretion and 24-hr blood pressure at each time period and sodium excretion at steady state and during follow-up.
Results
Seventeen patients with T2D were enrolled (64.7% male, mean ± SD age 64.24±7.33 years, weight 99.54±17.36 kg, eGFR 94.53±10.10 mL/min/1.73m2, HbA1c 7.20±0.63%). Average sodium excretion at baseline was 147±32 mmol/24 hr, which did not significantly change during treatment (Change at day 2–4 [95% CI]: −5.21 [19.54, 9.12] mmol/24 hr; Change at Day 12–14 [95% CI]: 3.69 [−24.82, 32.20] mmol/24 hr). However, sodium excretion was reduced following washout compared to end of treatment (Change at Day 15–17 [95% CI]: −16.72 [−34.11, 0.66] mmol/24 hr). Glucose excretion was significantly increased throughout the study. Systolic blood pressure was 127.0±10.3 mmHg at baseline and significantly reduced at Day 3 [95% CI]: −5.27 [−8.55, −1.99] mmHg and Day 14 [95% CI]: −7.10 [−10.04, −4.16] mmHg compared to baseline and remained lower following washout.
Conclusions
This study shows that, during a standardized sodium intake, the SGLT-2 inhibitor dapagliflozin acutely reduces blood pressure without altering sodium excretion, indicating possible direct vascular effects independent of sodium balance.
Funding Acknowledgement
Type of funding source: Other. Main funding source(s): Astra Zeneca
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Affiliation(s)
- R Scholtes
- Amsterdam UMC - Location VUmc, Amsterdam, Netherlands (The)
| | - M.H.A Muskiet
- Amsterdam UMC - Location VUmc, Amsterdam, Netherlands (The)
| | - M.J.B Van Baar
- Amsterdam UMC - Location VUmc, Amsterdam, Netherlands (The)
| | | | | | | | - N Arya
- Astra Zeneca, London, United Kingdom
| | - D.H Van Raalte
- Amsterdam UMC - Location VUmc, Amsterdam, Netherlands (The)
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Scheerer MF, Kosiborod M, Cavender M, Fu A, Wilding J, Norhammar A, Birkeland K, Jorgensen M, Thuresson M, Arya N, Bodegard J, Hammar N, Holl RW, Fenici P. Positive Einflüsse auf die Hospitalisierung für Herzinsuffizienz (HHI) und Gesamtmortalität bei Neueinstellung auf SGLT-2 Inhibitoren im Vergleich zu anderen Antidiabetika: Gesamtergebnisse von mehr als 300.000 Patienten aus dem klinischen Alltag – CVD-REAL Studie. DIABETOL STOFFWECHS 2017. [DOI: 10.1055/s-0037-1603544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- MF Scheerer
- AstraZeneca GmbH, Medical Affairs, Wedel, Germany
| | - M Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, United States
| | - M Cavender
- University of North Carolina, Chapel Hill, United States
| | - A Fu
- Georgetown University Medical Center, Washington, United States
| | - J Wilding
- University of Liverpool, Liverpool, United Kingdom
| | | | | | - M Jorgensen
- Steno Diabetes Center, Copenhagen, Denmark
- National Institute of Public Health, Southern Denmark University, Copenhagen, Denmark
| | | | - N Arya
- AstraZeneca, Gaithersburg, United States
| | | | - N Hammar
- AstraZeneca Gothenburg, Mölndal, Sweden
| | - RW Holl
- University of Ulm, Ulm, Germany
| | - P Fenici
- AstraZeneca, Cambridge, United Kingdom
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Cooray M, Nistor I, Pham J, Bair D, Arya N. Accuracy of endoscopic ultrasound-fine needle aspiration of solid lesions over time: Experience from a new endoscopic ultrasound program at a Canadian community hospital. Endosc Ultrasound 2017; 6:187-194. [PMID: 28621296 PMCID: PMC5488522 DOI: 10.4103/2303-9027.208177] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 10/26/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES A Canadian Community Hospital launched a new Endoscopic Ultrasound (EUS) Program in 2011. The aim of this study was to report the accuracy of EUS-fine needle aspiration (EUS-FNA) of solid lesions over time as it pertains to cytotechnologists' involvement and learning curves. METHODS The electronic medical records of patients that had a EUS from July 2011 to January 2014 were retrospectively reviewed. Only solid lesions with FNA sampling were included in the study. The primary outcome assessed was the accuracy of specimen acquisition for pathological review. The secondary outcome was diagnostic accuracy. Cases were separated by chronological order into thirds for the assessment of learning curves. Cytotechnologists' involvement was correlated to determine its impact on accuracy. RESULTS Two hundred and seventy-one EUS-FNA procedures were completed for solid lesions. Cytotechnologists' involvement resulted in a specimen acquisition accuracy of 82.6%, compared with 68.8% without a cytotechnologist (P = 0.009; 95% confidence interval [CI] 3.2%-25.0%). Diagnostic accuracy was 74.2% with a cytotechnologist while 62.4% without a cytotechnologist (P = 0.038; 95% CI 0.3%-23.7%). The specimen acquisition accuracy increased from 73.2% from the first third of cases to 92.3% for the last third with a cytotechnologist (P = 0.004; 95% CI 6%-33.0%). Without a cytotechnologist, the specimen accuracy was 67.6% for the first third while 57.7% for the last third of cases (P = 0.434; 95% CI - 33.9-14.4%). In the multivariable regression analysis, after adjusting for other predictors, a present cytotechnologist (P = 0.022) and lesion size 21 mm-30 mm (P = 0.039) and >30 mm (P = 0.001) were significantly associated with increased specimen acquisition accuracy. Only a present cytotechnologist (P = 0.046) was significantly associated with increased diagnostic accuracy. INTERPRETATION Cytotechnologists' involvement significantly improved the accuracy of specimen acquisition. Although accuracy was impacted by a cytotechnologist learning curve, our results highlight the importance of a cytotechnologist being present for EUS-FNA sampling of solid lesions.
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Affiliation(s)
- Mohan Cooray
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - Irina Nistor
- Department of Medicine, Division of Gastroenterology, Oakville-Trafalgar Memorial Hospital, Oakville, Ontario, Canada
| | - Joe Pham
- Department of Medicine, Division of Gastroenterology, Oakville-Trafalgar Memorial Hospital, Oakville, Ontario, Canada
| | - Douglas Bair
- Department of Medicine, Division of Gastroenterology, Oakville-Trafalgar Memorial Hospital, Oakville, Ontario, Canada
| | - Naveen Arya
- Department of Medicine, Division of Gastroenterology, Oakville-Trafalgar Memorial Hospital, Oakville, Ontario, Canada
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S. Jain K, Arya N, N. Inamdar N, B. Auti P, A. Unawane S, H. Puranik H, S. Sanap M, D. Inamke A, J. Mahale V, S. Prajapati C, J. Shishoo C. The Chemistry and Bio-Medicinal Significance of Pyrimidines & Condensed Pyrimidines. Curr Top Med Chem 2016; 16:3133-3174. [DOI: 10.2174/1568026616666160609100410] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 05/30/2016] [Accepted: 05/30/2016] [Indexed: 11/22/2022]
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Affiliation(s)
| | - Anand V Sahai
- Department of Gastroenterology, Centre Hospitalier de l'Universite de Montreal, Montreal, Canada
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Abstract
BACKGROUND Self-expandable metal stents (SEMS) can provide temporary relief of acute large bowel obstructions. Placement of SEMS creates the opportunity for semi-elective 1-stage surgical resections, use of possible adjuvant therapy or palliative relief of malignant obstructions. Our aim was to assess the likelihood of success and possible complication rates of SEMS insertion in a community hospital setting in patients presenting with large bowel obstructions. METHODS We conducted a retrospective chart review at a single community-based hospital. This review addressed the technical success in deployment of the SEMS, clinical success defined by relief of the obstruction, procedure-related complications, surgical interventions and completion of adjuvant therapy for patients with large bowel obstructions. RESULTS In a 34-month period, 16 patients underwent 16 SEMS procedures. The average age of patients was 69.4 years and 7 (44%) were women. Thirteen patients had intrinsic colorectal cancers, 1 had an extracolonic lesion (ovarian cancer) and 2 had strictures due to diverticular disease. Technical success occurred in all 16 patients, but only 15 (94%) had clinical success. No procedure-related deaths (defined as death within 7 days) occurred. Palliative stenting occurred in 5 patients (31%). Eleven patients (69%) eventually had surgery. Stenting allowed a window for neoadjuvant therapy in 4 patients. Ten of 11 patients (91%) had a 1-stage procedure. One patient had a cecal perforation presenting 2 days after SEMS. This patient received a defunctioning ileostomy. CONCLUSION In appropriate patients with large bowel obstructions, SEMS proced ures can be safely and effectively performed in a community-based setting.
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Affiliation(s)
- Naveen Arya
- Oakville Trafalgar Memorial Hospital and the Oakville Endoscopy Centre, Oakville, Ont.
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12
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Arya N, Howard J, Isaacs S, Mcallister M, Murphy S, Rapport D, Waltner-Toews D. Time for an ecosystem approach to public health? Lessons from two infectious disease outbreaks in Canada. Glob Public Health 2009; 4:31-49. [DOI: 10.1080/17441690701438128] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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13
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Sharif MA, Bayraktutan U, Arya N, O'Donnell ME, Badger SA, Young IS, Soong CV. Smoking impairs endothelial function in human saphenous vein in an ex vivo model. Ann Vasc Surg 2008; 23:116-21. [PMID: 18640818 DOI: 10.1016/j.avsg.2008.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2008] [Revised: 04/18/2008] [Accepted: 04/30/2008] [Indexed: 10/21/2022]
Abstract
The aim of this ex vivo experimental study was to assess the effect of smoking, diabetes mellitus, and hypertension on endothelial function in human saphenous vein, a commonly used conduit for coronary and peripheral arterial bypass surgery. A segment of long saphenous vein harvested during infrainguinal bypass surgery was mounted in an organ bath for isometric tension studies. Vein rings were precontracted to submaximal contraction with phenylephrine, followed by endothelium-dependent relaxation with acetylcholine. Long saphenous vein segments were collected from 26 patients, including five females, with a mean age of 66.4 years (range 48-92). Current smokers had impaired endothelium-dependent relaxation compared to ex- and nonsmokers (10.2%, n=13, vs. 32.9%, n=13; p<0.010). However, ex-smokers and nonsmokers did not have a significant difference in relaxant responses to acetylcholine (29.1%, n=8, vs. 24.6%, n=5; p=nonsignificant [ns]). Similarly, diabetic and nondiabetic patients did not show a significant difference in endothelium-dependent relaxation (23.1%, n=10, vs. 15.6%, n=16; p=ns). The relaxant responses in hypertensive and normotensive patients were not different (20.4%, n=12, vs. 22.5%, n=14; p=ns). Smoking has a deleterious effect on the endothelial function of saphenous vein, and smoking cessation may improve the long-term durability of saphenous vein used as a bypass graft in patients undergoing arterial reconstruction.
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Affiliation(s)
- M A Sharif
- Department of Vascular and Endovascular Surgery, Belfast City Hospital, Belfast, United Kingdom.
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14
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Sharif MA, Arya N, Soong CV, Lau LL, O'Donnell ME, Blair PH, McKinley AG. Validity of the Hardman Index to Predict Outcome in Ruptured Abdominal Aortic Aneurysm. Ann Vasc Surg 2007; 21:34-8. [PMID: 17349333 DOI: 10.1016/j.avsg.2006.08.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2005] [Revised: 08/08/2006] [Accepted: 08/10/2006] [Indexed: 11/21/2022]
Abstract
This study assessed the validity of the Hardman index in predicting outcome following open repair of ruptured abdominal aortic aneurysm and whether this scoring system can be used reliably to select patients for surgical repair. Patients undergoing open repair of ruptured abdominal aortic aneurysm in two university teaching hospitals over a 5-year period were identified from a computerized hospital database. Thirty-day mortality was the main outcome measure. Five Hardman index factors were calculated and related to outcome retrospectively. There were 178 patients with a mean age of 73.9 years (range 51-94) and a male to female ratio of 5.4:1. The overall in-hospital mortality was 57.3% (102/178). Univariate analysis of risk factors showed that age >76 years (P = 0.007, odds ratio [OR] 2.34, 95% confidence interval [CI] 1.26-4.37) and electrocardiograghic evidence of ischemia on admission (P = 0.002, OR 3.75, 95% CI 1.57-8.93) were associated with high mortality. However, loss of consciousness (P = 0.155, OR 1.56, 95% CI 0.85-2.86), hemoglobin <9 g/dL (P = 0.118, OR 1.89, 95% CI 0.85-4.22), and serum creatinine >0.19 mmol/L (P = 0.691, OR 1.25, 95% CI 0.42-3.70) were not significant predictors of mortality. Using a multivariate analysis, age >76 years (P = 0.043, OR 2.29, 95% CI 1.03-5.11) and myocardial ischemia (P = 0.029, OR 2.93, 95% CI 1.12-7.67) were again found to be the significant predictors of mortality. The operative mortality was 44%, 46%, 68%, 79%, and 100% for Hardman scores of 0, 1, 2, 3, and 4, respectively. No patient had a score of 5. The Hardman index is not a reliable predictor of outcome following repair of ruptured abdominal aortic aneurysm. High-risk patients may still survive and should not be denied surgical repair based on the scoring system alone. Further evaluation of the risk factors is required to reliably and justifiably exclude those patients in whom the intervention is inappropriate.
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Affiliation(s)
- M A Sharif
- Department of Vascular and Endovascular Surgery, Belfast City Hospital, Belfast, Northern Ireland, UK.
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15
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Abogunrin FA, Arya N, Somerville JE, Refsum S. Solitary caecal diverticulitis--a rare cause of right iliac fossa pain. Ulster Med J 2005; 74:132-3. [PMID: 16235768 PMCID: PMC2475384] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Autonomic dysreflexia is an important clinical diagnosis that requires prompt treatment to avoid devastating complications. The condition may present itself to all members of medical and surgical specialties, who may not be accustomed to treating it. It is the clinician's responsibility to have a basic understanding of the pathophysiology of the condition and the simple steps required to treat it.
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Affiliation(s)
- J Bycroft
- Institute of Urology, UCL, London, UK
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17
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Tang SJ, Zanati S, Dubcenco E, Monkewich G, Arya N, Cirocco M, Kandel G, Kortan P, Haber GB, Marcon NE. Capsule endoscopy regional transit abnormality revisited. Gastrointest Endosc 2004; 60:1029-32. [PMID: 15605032 DOI: 10.1016/s0016-5107(04)02194-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Shou-jiang Tang
- Center for Therapeutic Endoscopy and Endoscopic Oncology, Victoria Wing 16-062, St. Michael's Hospital, Toronto, Ontario M5B 1W8, Canada
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18
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Shergill NK, Chan W, Arya N, Damani N. Pre-admission clinic: a pain in the neck. Hosp Med 2004; 65:757. [PMID: 15624456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
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Abstract
BACKGROUND Choledocholithiasis and intrahepatic bile duct stones pose a significant health hazard, especially in the elderly. The large stone not removable with conventional endoscopic techniques, can be effectively and safely managed with electrohydraulic lithotripsy (EHL). METHODS This study is a retrospective review of consecutive patients at the Wellesley Central Hospital and St. Michael's Hospital, who underwent peroral endoscopic fragmentation of bile duct stones with EHL under direct cholangioscopic control using a "mother-baby" endoscopic system between October 1990 and March 2002. RESULTS To date, 111 patients have been analyzed. Of the 111 patients reviewed, 94 patients have had complete records and were included in this study. Mean follow-up was 26.2 months (range 0-80). Prior to EHL, 93 of 94 patients (99%) had endoscopic retrograde cholangiopancreatography (ERCP) and failed standard stone extraction techniques (mean 1.9 ERCPs/patient, range 0-5). Indications for EHL were large stones (81 patients) or a narrow caliber bile duct below a stone of average size (13 patients). Successful fragmentation (61 complete, 28 partial) was achieved in 89 of 93 patients (96%) (1 patient was excluded from analysis due to a broken endoscope). Fragmentation failures were due to targeting problems (2 patients) and hard stones (2 patients). Seventy-six percent of patients required 1 EHL session, 14% required 2 sessions, and 10% required 3 or more. All patients with successful stone fragmentation required post-EHL balloon or basket extraction of fragments. Complications included: cholangitis and/or jaundice (13 patients); mild hemobilia (1 patient); mild post-ERCP pancreatitis (1 patient); biliary leak (1 patient); and bradycardia (1 patient). There were no deaths related to EHL. Final stone clearance was achieved in 85 of 94 patients (90%). CONCLUSIONS EHL via peroral endoscopic choledochoscopy is a highly successful and safe technique for use in the management of difficult choledocholithiasis and intrahepatic stones. This study has shown a stone fragmentation rate of 96% (89 of 93 patients), and a final stone clearance rate of 90% (85 of 94 patients).
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Affiliation(s)
- Naveen Arya
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Abstract
Patients with functioning renal transplant who develop abdominal aortic aneurysm can safely be treated with endovascular repair. Endovascular repair of aneurysm avoids renal ischemia associated with cross-clamping of aorta.
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Affiliation(s)
- M Rao
- Ulster Hospital, Dundonald, Northern Ireland, UK
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Abstract
Colonoscopy continues to be the primary tool for diagnostic evaluation and management of lower gastrointestinal bleeding (LGIB). With the advent of newer endoscopy delivery therapeutic modalities, the treatment of LGIB has changed dramatically over the decades. The most dramatic change has been the role of surgery, which has been substantially reduced due to the therapeutic colonoscopy. This article reviews recent advances in the endoscopic treatment options in LGIB of the colon and rectum.
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Affiliation(s)
- Naveen Arya
- The Centre for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, 16-062 Cardinal Carter Wing, 30 Bond Street, Toronto, ON M5B 1W8, Canada.
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McFall B, Arya N, Soong C, Lee B, Hannon R. Crutch induced axillary artery injury. Ulster Med J 2004; 73:50-2. [PMID: 15244127 PMCID: PMC2475443] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- B McFall
- Department of Vascular Surgery, Belfast City Hospital, 91 Lisburn Road, Belfast BT9 7AB
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Arya N, Hawe MJG, Ozo C. Diclofenac suppositories and acute ischaemic proctitis. Ulster Med J 2004; 73:63-4. [PMID: 15244131 PMCID: PMC2475450] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- N Arya
- Department of Surgery, Mid Ulster Hospital, Magherafelt, Co. Londonderry BT45 5EX
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Arya N, Rao M, Lee B, Hannon RJ, Soong CV. Treatment of co-existing thoracic and abdominal aortic aneurysms using combined endoluminal stent grafts and conventional surgery. Ulster Med J 2003; 72:126-8. [PMID: 14696828 PMCID: PMC2475434] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- N Arya
- Regional Vascular and Endovascular Surgery Unit, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB
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Arya N, Chakrabrati S, Hegele RA, Adams PC. HFE S65C variant is not associated with increased transferrin saturation in voluntary blood donors. Blood Cells Mol Dis 1999; 25:354-7. [PMID: 10660483 DOI: 10.1006/bcmd.1999.0264] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [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: 11/22/2022]
Abstract
Two amino acid variants in the HFE gene, C282Y and H63D, have been reported in most cases of hereditary hemochromatosis. A recently discovered novel amino acid variant of HFE, namely S65C, has been implicated to be responsible for a mild form of iron overload. We determined genotypes of the HFE S65C variant in 230 voluntary blood donors with a transferrin saturation >45%, who did not carry the HFE C282Y variant. The control group consisted of 248 first time blood donors who had a transferrin saturation < 45%. We also determined genotypes of the HFE H63D variant in the two groups. For the HFE S65C variant, the frequency of the HFE C65 allele was 1. 7% and 2.2% in the high and low transferrin saturation groups, respectively (p = 0.65). In contrast, for the HFE H63D variant, the frequency of the HFE D63 allele was 24.8% and 14.7% in the high and low transferrin saturation groups, respectively (p = 0.0009). This study demonstrates no association of the HFE C65 allele with the phenotype of high transferrin saturation. The results do not support the use of DNA genotyping for the HFE S65C mutation in population screening studies for hemochromatosis.
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Affiliation(s)
- N Arya
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
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26
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Affiliation(s)
- N Arya
- Department of General Surgery, Noble's Hospital, Douglas, UK
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Abstract
Patients with blunt abdominal trauma (BAT) often have equivocal signs of intra-abdominal injury. Diagnostic peritoneal lavage (DPL) has been the 'gold standard' for evaluating these patients, the use of ultrasound (US) being a recent phenomenon. Seventy-three patients with BAT and equivocal physical signs were subjected to both DPL and US for detection of intra-abdominal injury. Based on clinical status, DPL and US findings, the patients underwent laparotomy or non-operative management. DPL was positive in 35 patients. There was one false positive and one false negative result (sensitivity 97.1%, specificity 97.4%, accuracy 97.3%). US was positive in 31 patients. There were 5 false positive and 4 false negative results (sensitivity 86.7%, specificity 88.4%, accuracy 87.7%). Solid viscus injury was documented at laparotomy in 24 patients. DPL failed to detect one pancreatic injury, while US failed to detect 4 splenic and 2 liver injuries. US additionally detected a single case of haemopericardium. Although DPL outperformed US in this study, US can complement DPL in defining the organs injured and in follow up of patients undergoing non-operative management for BAT.
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Affiliation(s)
- G Singh
- Department of Surgery, PostGraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Abstract
Storage of red blood cells in preservative medium is associated with metabolic, biochemical and molecular changes to erythrocytes collectively referred to as the "storage lesion." In addition to corpuscular injury, bioreactive substances including cytokines and lipids accumulate in the medium during storage. We review evidence for those storage related changes and potential clinical implications for red blood cell transfusion.
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Affiliation(s)
- I Chin-Yee
- Department of Haematology, London Health Sciences Centre, University of Western Ontario, Canada.
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Wright JF, Blanchette VS, Wang H, Arya N, Petric M, Semple JW, Chia WK, Freedman J. Characterization of platelet-reactive antibodies in children with varicella-associated acute immune thrombocytopenic purpura (ITP). Br J Haematol 1996; 95:145-52. [PMID: 8857953 DOI: 10.1046/j.1365-2141.1996.d01-1872.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.4] [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: 02/02/2023]
Abstract
Biochemical analyses were performed on blood samples obtained from two children (P1, P2) who presented with acute immune thrombocytopenic purpura (ITP) following a recent varicella zoster virus (VZV) infection. Patient sera had antibodies that were reactive with normal blood-group O platelets as measured by flow-cytometric assay. Western blot analysis of electrophoretically separated normal blood-group O platelets under reducing and non-reducing conditions demonstrated that these sera were reactive with platelet antigens of approximately 50 and approximately 110 kD, respectively. These 50/110 kD antigens were not reactive with seven sera from acute ITP patients whose illness was not preceded by VZV infection, with serum from a patient with a prior history of VZV and no thrombocytopenia, nor with normal healthy control sera. VZV antibodies (IgG and IgM), isolated from patient sera by affinity chromatography using immobilized purified VZV glycoproteins, were found to bind to gel-filtered autologous platelets and with normal blood-group O platelets, as analysed by flow cytometry. No binding was observed using antibodies similarly prepared from healthy volunteer sera. To investigate their ability to sensitize platelets to complement activation, affinity-purified VZV antibodies were incubated with platelets and then with purified complement components C1 and 125 I-labelled C4. Platelets reacted with VZV-specific antibodies from the two patients and showed increases of 2.3-2.4-fold of platelet-surface deposition of 125 I-C4b, compared to controls. These data provide evidence that virus-specific antibodies occurring in children with varicella-associated acute ITP cross-react with normal platelet antigens, and may contribute to platelet clearance.
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Affiliation(s)
- J F Wright
- Canadian Red Cross Society, Toronto Centre, Ontario, Canada
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Murthy SSN, Paikaray A, Arya N. Molecular relaxation and excess entropy in liquids and their connection to the structure of glass. J Chem Phys 1995. [DOI: 10.1063/1.469232] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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