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Mettler SK, Nath HP, Grumley S, Orejas JL, Dolliver WR, Nardelli P, Yen AC, Kligerman SJ, Jacobs K, Manapragada PP, Abozeed M, Aziz MU, Zahid M, Ahmed AN, Terry NL, Elalami R, Estépar RSJ, Sonavane S, Billatos E, Wang W, Estépar RSJ, Richards JB, Cho MH, Diaz AA. Silent Airway Mucus Plugs in COPD and Clinical Implications. Chest 2023:S0012-3692(23)05825-7. [PMID: 38013161 DOI: 10.1016/j.chest.2023.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 11/15/2023] [Accepted: 11/21/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Airway mucus plugs are frequently identified on CT scans of patients with COPD with a smoking history without mucus-related symptoms (ie, cough, phlegm [silent mucus plugs]). RESEARCH QUESTION In patients with COPD, what are the risk and protective factors associated with silent airway mucus plugs? Are silent mucus plugs associated with functional, structural, and clinical measures of disease? STUDY DESIGN AND METHODS We identified mucus plugs on chest CT scans of participants with COPD from the COPDGene study. The mucus plug score was defined as the number of pulmonary segments with mucus plugs, ranging from 0 to 18, and categorized into three groups (0, 1-2, and ≥ 3). We determined risk and protective factors for silent mucus plugs and the associations of silent mucus plugs with measures of disease severity using multivariable linear and logistic regression models. RESULTS Of 4,363 participants with COPD, 1,739 had no cough or phlegm. Among the 1,739 participants, 627 (36%) had airway mucus plugs identified on CT scan. Risk factors of silent mucus plugs (compared with symptomatic mucus plugs) were older age (OR, 1.02), female sex (OR, 1.40), and Black race (OR, 1.93) (all P values < .01). Among those without cough or phlegm, silent mucus plugs (vs absence of mucus plugs) were associated with worse 6-min walk distance, worse resting arterial oxygen saturation, worse FEV1 % predicted, greater emphysema, thicker airway walls, and higher odds of severe exacerbation in the past year in adjusted models. INTERPRETATION Mucus plugs are common in patients with COPD without mucus-related symptoms. Silent mucus plugs are associated with worse functional, structural, and clinical measures of disease. CT scan-identified mucus plugs can complement the evaluation of patients with COPD.
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Affiliation(s)
- Sofia K Mettler
- Department of Medicine, Mount Auburn Hospital, Cambridge, MA; Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Hrudaya P Nath
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | - Scott Grumley
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | - José L Orejas
- Harvard Medical School, Boston, MA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - Wojciech R Dolliver
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - Pietro Nardelli
- Harvard Medical School, Boston, MA; Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Andrew C Yen
- Department of Radiology, University of California San Diego, San Diego, CA
| | | | - Kathleen Jacobs
- Department of Radiology, University of California San Diego, San Diego, CA
| | - Padma P Manapragada
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | - Mostafa Abozeed
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | - Muhammad Usman Aziz
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | - Mohd Zahid
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | - Asmaa N Ahmed
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | - Nina L Terry
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | - Rim Elalami
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - Ruben San José Estépar
- Harvard Medical School, Boston, MA; Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | | | - Ehab Billatos
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Wei Wang
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, MA
| | - Raúl San José Estépar
- Harvard Medical School, Boston, MA; Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Jeremy B Richards
- Department of Medicine, Mount Auburn Hospital, Cambridge, MA; Harvard Medical School, Boston, MA
| | - Michael H Cho
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - Alejandro A Diaz
- Harvard Medical School, Boston, MA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
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Manapragada PP, Bhambhvani P. Looking inside AND outside the heart. J Nucl Cardiol 2023; 30:1688-1689. [PMID: 37340231 DOI: 10.1007/s12350-023-03314-3] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 05/16/2023] [Indexed: 06/22/2023]
Affiliation(s)
- Padma P Manapragada
- Division of Cardiothoracic Radiology, The University of Alabama at Birmingham, Birmingham, AL, USA.
- Division of Molecular Imaging and Therapeutics, Department of Radiology, The University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Pradeep Bhambhvani
- Division of Molecular Imaging and Therapeutics, Department of Radiology, The University of Alabama at Birmingham, Birmingham, AL, USA
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Diaz AA, Orejas JL, Grumley S, Nath HP, Wang W, Dolliver WR, Yen A, Kligerman SJ, Jacobs K, Manapragada PP, Abozeed M, Aziz MU, Zahid M, Ahmed AN, Terry NL, San José Estépar R, Kim V, Make BJ, Han MK, Sonavane S, Washko GR, Cho M, San José Estépar R. Airway-Occluding Mucus Plugs and Mortality in Patients With Chronic Obstructive Pulmonary Disease. JAMA 2023; 329:1832-1839. [PMID: 37210745 PMCID: PMC10201404 DOI: 10.1001/jama.2023.2065] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 02/07/2023] [Indexed: 05/23/2023]
Abstract
Importance Airway mucus plugs are common in patients with chronic obstructive pulmonary disease (COPD); however, the association of airway mucus plugging and mortality in patients with COPD is unknown. Objective To determine whether airway mucus plugs identified on chest computed tomography (CT) were associated with increased all-cause mortality. Design, Setting, and Participants Observational retrospective analysis of prospectively collected data of patients with a diagnosis of COPD in the Genetic Epidemiology of COPD cohort. Participants were non-Hispanic Black or White individuals, aged 45 to 80 years, who smoked at least 10 pack-years. Participants were enrolled at 21 centers across the US between November 2007 and April 2011 and were followed up through August 31, 2022. Exposures Mucus plugs that completely occluded airways on chest CT scans, identified in medium- to large-sized airways (ie, approximately 2- to 10-mm lumen diameter) and categorized as affecting 0, 1 to 2, or 3 or more lung segments. Main Outcomes and Measures The primary outcome was all-cause mortality, assessed with proportional hazard regression analysis. Models were adjusted for age, sex, race and ethnicity, body mass index, pack-years smoked, current smoking status, forced expiratory volume in the first second of expiration, and CT measures of emphysema and airway disease. Results Among the 4483 participants with COPD, 4363 were included in the primary analysis (median age, 63 years [IQR, 57-70 years]; 44% were women). A total of 2585 (59.3%), 953 (21.8%), and 825 (18.9%) participants had mucus plugs in 0, 1 to 2, and 3 or more lung segments, respectively. During a median 9.5-year follow-up, 1769 participants (40.6%) died. The mortality rates were 34.0% (95% CI, 32.2%-35.8%), 46.7% (95% CI, 43.5%-49.9%), and 54.1% (95% CI, 50.7%-57.4%) in participants who had mucus plugs in 0, 1 to 2, and 3 or more lung segments, respectively. The presence of mucus plugs in 1 to 2 vs 0 and 3 or more vs 0 lung segments was associated with an adjusted hazard ratio of death of 1.15 (95% CI, 1.02-1.29) and 1.24 (95% CI, 1.10-1.41), respectively. Conclusions and Relevance In participants with COPD, the presence of mucus plugs that obstructed medium- to large-sized airways was associated with higher all-cause mortality compared with patients without mucus plugging on chest CT scans.
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Affiliation(s)
- Alejandro A. Diaz
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - José L. Orejas
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Scott Grumley
- Department of Radiology, University of Alabama at Birmingham
| | - Hrudaya P. Nath
- Department of Radiology, University of Alabama at Birmingham
| | - Wei Wang
- Harvard Medical School, Boston, Massachusetts
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Wojciech R. Dolliver
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Andrew Yen
- Department of Radiology, University of California, San Diego
| | - Seth J. Kligerman
- Department of Radiology, University of California, San Diego
- now with Department of Radiology, National Jewish Health, Denver, Colorado
| | - Kathleen Jacobs
- Department of Radiology, University of California, San Diego
| | | | - Mostafa Abozeed
- Department of Radiology, University of Alabama at Birmingham
| | | | - Mohd Zahid
- Department of Radiology, University of Alabama at Birmingham
| | - Asmaa N. Ahmed
- Department of Radiology, University of Alabama at Birmingham
| | - Nina L. Terry
- Department of Radiology, University of Alabama at Birmingham
| | - Ruben San José Estépar
- Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Victor Kim
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Barry J. Make
- Division of Pulmonary, Critical Care and Sleep Medicine at National Jewish Health, Denver, Colorado
| | - MeiLan K. Han
- Division of Pulmonary and Critical Care at the University of Michigan, Ann Arbor
| | | | - George R. Washko
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Michael Cho
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Channing Division of Network Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Raúl San José Estépar
- Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts
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Perchik JD, Wilson CM, Abozeed M, Manapragada PP, Ahmed AN, Singh SP. Adult Partial Anomalous Pulmonary Venous Return Repair and Superior Vena Cava Syndrome: A Delayed Complication of the Warden Procedure. Radiol Cardiothorac Imaging 2022; 4:e220077. [PMID: 36339061 PMCID: PMC9627227 DOI: 10.1148/ryct.220077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 07/13/2022] [Accepted: 09/28/2022] [Indexed: 06/16/2023]
Abstract
The Warden procedure is one of the most common techniques for surgical correction of partial anomalous pulmonary venous return (PAPVR), involving transection and reanastomosis of the superior vena cava (SVC) to the right atrial appendage and baffling of the anomalous pulmonary veins through the atrial septal defect. While the procedure is typically well-tolerated in pediatric patients, adult patients requiring surgical correction of PAPVR are uncommon. The authors report a case of a 33-year-old woman who developed SVC syndrome as a delayed complication of the Warden procedure. Keywords: Cardiac, Congenital, Complications © RSNA, 2022.
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Manapragada PP, Bhambhvani PG. 'Do No Harm': optimizing protocol for FDG PET cardiac viability assessment. J Nucl Cardiol 2022; 29:1992-1994. [PMID: 35737179 DOI: 10.1007/s12350-022-03043-z] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 06/13/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Padma P Manapragada
- Department of Radiology, The University of Alabama at Birmingham, Birmingham, USA
| | - Pradeep G Bhambhvani
- Department of Radiology, The University of Alabama at Birmingham, Birmingham, USA.
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Terry NLJ, Manapragada PP, Aziz MU, Singh SP. Review of pericardial disease on computed tomography. J Med Imaging Radiat Sci 2021; 52:S65-S77. [PMID: 34588141 DOI: 10.1016/j.jmir.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/23/2021] [Accepted: 09/10/2021] [Indexed: 10/20/2022]
Abstract
Echocardiography has long been the mainstay in the evaluation of cardiac and pericardial disease. As computed tomography (CT) has advanced, it has become a valuable partner in the imaging of the pericardium. The advantages of CT include a larger field of view, multiplanar reconstruction and increased discrimination between various soft tissues and fluids. CT is less operator dependent and can more easily, and reproducibly, image areas of the pericardium for which echocardiography has poor windows such as the right pericardium. The introduction of EKG gating has decreased cardiac motion artifact and can allow functional evaluation although echocardiography remains the primary source of real-time imaging of cardiac and valve motion. It is essential for the skilled cardiac imager to understand the strengths and weaknesses of CT and its role in the definition and assessment of pericardial disease.
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Affiliation(s)
- Nina L J Terry
- University of Alabama at Birmingham, Department of Radiology, Birmingham, AL, USA.
| | - Padma P Manapragada
- University of Alabama at Birmingham, Department of Radiology, Birmingham, AL, USA
| | - Muhammad Usman Aziz
- University of Alabama at Birmingham, Department of Radiology, Birmingham, AL, USA
| | - Satinder P Singh
- University of Alabama at Birmingham, Department of Radiology, Birmingham, AL, USA
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Manapragada PP, Aziz MU, Singh SP, Nath H. Cardiac computed tomographic evaluation of coronary artery calcification: A review. J Med Imaging Radiat Sci 2021; 52:S12-S18. [PMID: 34479829 DOI: 10.1016/j.jmir.2021.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/15/2021] [Accepted: 07/16/2021] [Indexed: 01/07/2023]
Abstract
Vascular calcification is most commonly due to atherosclerosis. It has been well documented that absence of coronary calcification on a chest CT (CCT) is associated with low cardiovascular events and good prognosis. High CT calcium scores often result in a higher incidence of cardiovascular events and worse survival. In asymptomatic patients with an intermediate risk for coronary artery disease, numerous studies have shown Coronary Calcium Scoring (CCS) has prognostic relevance and incremental prognostic value over conventional risk stratification. CT detected calcium score plays important role in patient management. This article will review various CT based coronary artery calcium scoring methods.
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Affiliation(s)
- Padma P Manapragada
- The University of Alabama at Birmingham, Department of Diagnostic Radiology, Birmingham, AL, USA.
| | - Muhammad Usman Aziz
- The University of Alabama at Birmingham, Department of Diagnostic Radiology, Birmingham, AL, USA
| | - Satinder P Singh
- The University of Alabama at Birmingham, Department of Diagnostic Radiology, Birmingham, AL, USA
| | - Hrudaya Nath
- The University of Alabama at Birmingham, Department of Diagnostic Radiology, Birmingham, AL, USA
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8
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Choudhary G, Manapragada PP, Wallace E, Bhambhvani P. Utility of Scintigraphy in Assessment of Noninfectious Complications of Peritoneal Dialysis. J Nucl Med Technol 2019; 47:163-168. [PMID: 30700534 DOI: 10.2967/jnmt.118.223156] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 11/26/2018] [Indexed: 11/16/2022] Open
Abstract
Dialysis is an artificial process to remove waste products and excess water from the body in patients with kidney failure. Two main types of dialysis are available. Hemodialysis, which uses an artificial filtration apparatus, is usually done at specialized centers but can be done in a patient's home. Peritoneal dialysis functions by placing dialysis fluid, also called dialysate, into the peritoneal cavity, allowing for solute to be removed from the peritoneal capillaries through diffusion across a chemical gradient into the dialysate and removal of water through an osmotic gradient created by hypertonic dextrose. Peritoneal dialysis can be either automated, which is done with the help of a machine called a cycler, or continuous ambulatory, which is a process involving multiple exchanges a day and is performed using only gravity to infuse and drain the solution from the peritoneal cavity. For many reasons, the number of people using home dialysis has recently started to rise, with the largest increase in the United States occurring after the implementation of the prospective bundled payment system for end-stage renal disease. With the increased use of home dialysis, potential complications will increase as well. It is imperative that our health-care system be poised not only to increase the number of home dialysis patients but also to diagnose and manage any complications. Nuclear imaging is a commonly available modality to detect various complications related to peritoneal dialysis. In this review article, we discuss the role of peritoneal scintigraphy in detecting some noninfectious peritoneal dialysis complications, with emphasis on scintigraphy technique; imaging time points; the role of planar, SPECT, and SPECT/CT imaging; and the clinical indications, with illustrative case examples.
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Affiliation(s)
- Gagandeep Choudhary
- Division of Molecular Imaging and Therapeutics, Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama; and
| | - Padma P Manapragada
- Division of Molecular Imaging and Therapeutics, Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama; and
| | - Eric Wallace
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Pradeep Bhambhvani
- Division of Molecular Imaging and Therapeutics, Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama; and
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Manapragada PP. Molecular Imaging in Management of Breast Cancer. Semin Roentgenol 2018; 53:301-310. [PMID: 30449348 DOI: 10.1053/j.ro.2018.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ahmad I, Guroji P, DeBrot AH, Manapragada PP, Katiyar SK, Elmets CA, Yusuf N. Loss of INK4a/Arf gene enhances ultraviolet radiation-induced cutaneous tumor development. Exp Dermatol 2017; 26:1018-1025. [PMID: 28418604 DOI: 10.1111/exd.13356] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2017] [Indexed: 12/22/2022]
Abstract
The CDKN2A locus encodes for tumor suppressor genes p16INK4a and p14Arf which are frequently inactivated in human skin tumors. The purpose of this study was to determine the relationship between loss of INK4a/Arf activity and inflammation in the development of ultraviolet (UV) radiation-induced skin tumors. Panels of INK4a/Arf-/- mice and wild-type (WT) mice were treated with a single dose of UVB (200 mJ/cm2 ). For long-term studies, these mice were irradiated with UVB (200 mJ/cm2 ) three times weekly for 30 weeks. At the end of the experiment, tissues were harvested from mice and assayed for inflammatory biomarkers and cytokines. A single dose of UVB resulted in a significant increase in reactive oxygen species (ROS) and 8-dihydroxyguanosine (8-oxo-dG) lesions in INK4a/Arf-/- mice compared to WT mice. When subjected to chronic UVB, we found that 100% of INK4a/Arf-/- mice had tumors, whereas there were no tumors in WT controls after 24 weeks of UVB exposure. The increase in tumor development correlated with a significant increase in nuclear factor (NF)-κB, cyclooxygenase-2 (COX-2), prostaglandin E2 (PGE2 ) and its receptors both in UVB-exposed skin and in the tumors. A significant increase was seen in inflammatory cytokines in skin samples of INK4a/Arf-/- mice following treatment with chronic UVB radiation. Furthermore, significantly more CD11b+ Gr1+ myeloid cells were present in UVB-exposed INK4a/Arf-/- mice compared to WT mice. Our data indicate that by targeting UVB-induced inflammation, it may be possible to prevent UVB-induced skin tumors in individuals that carry CDKN2A mutation.
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Affiliation(s)
- Israr Ahmad
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Purushotham Guroji
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Amanda H DeBrot
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Padma P Manapragada
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Santosh K Katiyar
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA.,Veteran Affairs Medical Center, Birmingham, AL, USA.,Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Craig A Elmets
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA.,Veteran Affairs Medical Center, Birmingham, AL, USA.,Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nabiha Yusuf
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA.,Veteran Affairs Medical Center, Birmingham, AL, USA.,Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
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