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Naveed M, Ali I, Aziz T, Ain N, Shabbir MA, Javed K, Alharbi M, Alshammari A, Alasmari AF, Alharbi SA, Alharbi MS. Halogens engineering-based design of agonists for boosting expression of frataxin protein in Friedreich's ataxia. Eur Rev Med Pharmacol Sci 2023; 27:6972-6984. [PMID: 37606107 DOI: 10.26355/eurrev_202308_33269] [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: 08/23/2023]
Abstract
OBJECTIVE Decreased expression of the mitochondrial protein frataxin is the cause of the neurodegenerative disorder Friedreich's ataxia. In patients with cardiac disorders, the death rate of this disease is very high, up to 66%. In order to combat Friedreich ataxia, which is a potentially toxic disorder, de novo drug discovery and design have been created utilizing the approach of compound engineering with halogens. This study aimed to investigate the potential for effective treatment of Friedreich ataxia. MATERIALS AND METHODS The screening of twenty different agonist compounds was carried out in order to find the most promising agonist compound that may be used for molecular docking prediction against the Frataxin Protein. The compound with the lowest binding energies is then optimized by halogens. The final candidate's drug-like properties are identified through Absorption, Distribution, Metabolism, Excretion, and Toxicity (ADMET) profiling. Lipinski's rule of five was checked. Molecular dynamic stimulations were evaluated. RESULTS The most potent agonist compound was identified out of twenty different compounds utilizing a docking approach against the Frataxin Protein. The compound with the lowest binding energies was next subjected to optimization by halogens. The optimized agonist 9-[1-[(1S, 5R)-8, 8-dimethyl-8-azoniabicyclo[3.2.1]octan-3-yl]triazol-4-yl]fluoren-9-ol has higher binding energy of -10.4Kcal/mol with molecular weight of 705.63 g/mol. Drug-like properties are identified through ADMET profiling, having water solubility of about -7.59, skin permeation -7.08 cm/s, bioavailability score 0.17, and high GI absorption. The candidate fulfills the Lipinski rule of five and portrays efficient molecular dynamic stimulations. CONCLUSIONS The selected agonist is one of the most potent compounds in increasing Frataxin protein expression. Furthermore, optimization with halogens can be a productive approach to improve the candidate's drug efficacy. The development of effective medications for the treatment of Friedreich ataxia would be aided by the results of these computational investigations.
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Affiliation(s)
- M Naveed
- Department of Biotechnology, Faculty of Science & Technology, University of Central Punjab, Lahore, Pakistan.
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Alharbi SA, Alshammari FD, Humaida MI, Abdalhabib EK, Babikir Bealy MA, Elkhalifa AEO, Agabeldour AA, Alshammari FF. The cytological pattern of cervical smears of a series of Saudi women in one gynecologic center. Eur Rev Med Pharmacol Sci 2023; 27:6785-6791. [PMID: 37522689 DOI: 10.26355/eurrev_202307_33149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
OBJECTIVE Cervical intraepithelial neoplasia (CIN) is a type of abnormal cervical epithelial development that can lead to cervical malignancy. Thus, the purpose of this study was to examine the cytological pattern of cervical smears from a group of Saudi women who visited a single gynecologic center. PATIENTS AND METHODS From May 2020 to May 2021, 300 women were referred to the cytopathology laboratory and their cytological materials were collected. Because of gynecologic concerns, the women in the study were referred for Pap smears. As part of the obligatory investigations in conjunction with the clinical assessment, a Pap smear is requested. RESULTS CIN of various grades was found in 11% of the women. High-grade Squamous Intraepithelial Lesions (HSIL) were the most detected modifications, followed by Atypical Squamous Cells of Undetermined Significance (ASUS) and Low-grade Squamous Intraepithelial Lesions (LSIL), accounting for 36.4%, 33.3%, and 30.3%, respectively. In 23.7% of the women, inflammatory cell infiltrations were found. Infection with Candida Albicans was identified in 2.3% of the women. In 15.8% of the patients, cytological evidence of bacterial infection was found. CONCLUSIONS The prevalence of CIN has been growing in Saudi Arabia in recent years, implying a probable involvement in the spread of HPV. Most CIN cases associated with middle age point to HPV infection at a younger age. There is no link between estrogen and/or progesterone levels and CIN.
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Affiliation(s)
- S A Alharbi
- Department of Clinical Laboratory Science, College of Applied Medical Sciences, Shaqra University, Al-Quwayiyah, Saudi Arabia.
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Alshammari FD, Alharbi SA, Humaida MI, Abdalhabib EK, Babikir Bealy MA, Elkhalifa AEO, Agabeldour AA. Human Papillomavirus genotypes associated with cervical intraepithelial lesions among Saudi women. Eur Rev Med Pharmacol Sci 2022; 26:6367-6373. [PMID: 36111939 DOI: 10.26355/eurrev_202209_29663] [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: 06/15/2023]
Abstract
OBJECTIVE HPV is responsible for over 90% of cervical cancer worldwide. HPV has numerous subtypes with great variety distribution in different geographical regions. Thus, the present study aimed at assessing Human Papillomavirus (HPV) genotypes associated with cervical intraepithelial lesions among Saudi women. PATIENTS AND METHODS The current study collected cervical smears from 300 women transferred to a cytopathology laboratory between May 2020 and May 2021. The studied women were referred to do Pap smear because of gynecologic complaints. RESULTS Positive HPV testing was established in 4.7%. Most positive cases were identified in the age range of 14-50 years, followed by 51-60 years, representing 50% and 35.7%, respectively. The risk of HPV infection was significantly high in the age between 40-50 years, the odds ratio (OR), 95% confidence interval (95% CI), OR (95% CI) = 3.0137 (1.0228 to 8.8797), p = 0.0454, z statistic = 2.001. About 57% of the cases of HPV were found with cytological atypia. The risk of HPV in inducing cytological atypia, the OR (95%CI) = 1.8546 (2.9386 to 27.0952), p = 0.0001, z statistic = 3.862. Inflammatory cells infiltrate was identified in 43% of HPV-positive cases. The risk of HPV in inducing inflammatory changes, the OR (95% CI) = 2.6423 (0.8850 to 7.8887), p = 0.0817, z statistic = 1.741. CONCLUSIONS The prevalence of High-risk human papillomavirus is relatively low in the AL-Madinah area, Saudi Arabia. Cervical cytological atypia corresponds to the positive HR-HPV findings. HR-HPV infection or cervical cytological atypical changes induce inflammatory cell infiltrates. HR-HPV infection is more common among elderly Saudi women.
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Affiliation(s)
- F D Alshammari
- Department of Clinical Laboratory, College of Applied Medical Science, University of Ha'il, Saudi Arabia.
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Alharbi SA, Alfadl AA, Almogbel Y. Polypharmacy and inappropriate prescribing in elderly patients: a retrospective study at Buriadah Central Hospital, Saudi Arabia. Eur Rev Med Pharmacol Sci 2022; 26:3325-3333. [PMID: 35587085 DOI: 10.26355/eurrev_202205_28752] [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: 06/15/2023]
Abstract
OBJECTIVE An increase in life expectancy has been attributed to better access to health care and viable treatment options for diseases where there were none before. However, a multiple-drug regimen increases the risk of inappropriate prescription and drug-related problems. This study aimed to investigate polypharmacy and inappropriate prescription among elderly patients in the Qassim region of Saudi Arabia. PATIENTS AND METHODS This was a retrospective study wherein the electronic files of patients aged ≥ 60 years were reviewed and investigated for polypharmacy and inappropriate drug prescription using Beer's criteria 2019. RESULTS The 1123 patients who met the eligibility criteria were between 60-102 years of age (mean age: 71.9 years). 387 patients (34.46%) used five medications, while the remaining patients used more than five medications. The prevalence of potentially inappropriate medications (PIMs) was 66.25%. The most commonly prescribed PIMs were non-steroidal anti-inflammatory drugs, baclofen, proton pump inhibitors, diuretics, and aspirin (11.3%, 10.6%, 10.1%, 8.46%, and 5.6%, respectively). CONCLUSIONS This study showed a high prevalence of polypharmacy, which consequently led to a high prevalence of PIMs. This is a serious health problem in the elderly population and should be prevented or tackled with caution.
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Affiliation(s)
- S A Alharbi
- Pharmacy Services, Buraidah Central Hospital, Buraidah, Saudi Arabia.
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Alharbi SA, Ovchinnikov DA, Wolvetang E. Leucine-rich repeat-containing G protein-coupled receptor 5 marks different cancer stem cell compartments in human Caco-2 and LoVo colon cancer lines. World J Gastroenterol 2021; 27:1578-1594. [PMID: 33958845 PMCID: PMC8058648 DOI: 10.3748/wjg.v27.i15.1578] [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] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/22/2021] [Accepted: 02/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Colon cancer cell lines are widely used for research and for the screening of drugs that specifically target the stem cell compartment of colon cancers. It was reported that colon cancer carcinoma specimens contain a subset of leucine-rich repeat-containing G protein-coupled receptor 5 (LGR5)-expressing stem cells, these so-called “tumour-initiating” cells, reminiscent in their properties of the normal intestinal stem cells (ISCs), may explain the apparent heterogeneity of colon cancer cell lines. Also, colon cancer is initiated by aberrant Wnt signaling in ISCs known to express high levels of LGR5. Furthermore, in vivo reports demonstrate the clonal expansion of intestinal adenomas from a single LGR5-expressing cell.
AIM To investigate whether colon cancer cell lines contain cancer stem cells and to characterize these putative cancer stem cells.
METHODS A portable fluorescent reporter construct based on a conserved fragment of the LGR5 promoter was used to isolate the cell compartments expressing different levels of LGR5 in two widely used colon cancer cell lines (Caco-2 and LoVo). These cells were then characterized according to their proliferation capacity, gene expression signatures of ISC markers, and their tumorigenic properties in vivo and in vitro.
RESULTS The data revealed that the LGR5 reporter can be used to identify and isolate a classical intestinal crypt stem cell-like population from the Caco-2, but not from the LoVo, cell lines, in which the cancer stem cell population is more akin to B lymphoma Moloney murine leukemia virus insertion region 1 homolog (+4 crypt) stem cells. This sub-population within Caco-2 cells exhibits an intestinal cancer stem cell gene expression signature and can both self-renew and generate differentiated LGR5 negative progeny. Our data also show that cells expressing high levels of LGR5/enhanced yellow fluorescent protein (EYFP) from this cell line exhibit tumorigenic-like properties in vivo and in vitro. In contrast, cell compartments of LoVo that are expressing high levels of LGR5/EYFP did not show these stem cell-like properties. Thus, cells that exhibit high levels of LGR5/EYFP expression represent the cancer stem cell compartment of Caco-2 colon cancer cells, but not LoVo cells.
CONCLUSION Our findings highlight the presence of a spectrum of different ISC-like compartments in different colon cancer cell lines. Their existence is an important consideration for their screening applications and should be taken into account when interpreting drug screening data. We have generated a portable LGR5-reporter that serves as a valuable tool for the identification and isolation of different colon cancer stem cell populations in colon cancer lines.
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Affiliation(s)
- Samah Abdulaali Alharbi
- Physiology Department, College of Medicine, Umm Al-Qura University, Makkah 24231, Saudi Arabia
- Department of Stem Cell Engineering Group, Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, Brisbane 4072, QLD, Australia
| | - Dmitry A Ovchinnikov
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, Brisbane 4072, QLD, Australia
| | - Ernst Wolvetang
- Department of Stem Cell Engineering Group, Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, Brisbane 4072, QLD, Australia
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Alahmadi TA, Alharbi SA, Almoallim HS, Damra E, Salmen SH. Isolation of filter passing bacteria from a range of dental clinic surfaces. Proceedings of the Estonian Academy of Sciences 2021. [DOI: 10.3176/proc.2021.1.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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El-Kott AF, Shati AA, Al-Kahtani MA, Alharbi SA. Kaempferol Induces Cell Death in A2780 Ovarian Cancer Cells and Increases Their Sensitivity to Cisplatin by Activation of Cytotoxic Endoplasmic Reticulum-Mediated Autophagy and Inhibition of Protein Kinase B. Folia Biol (Praha) 2020; 66:36-46. [PMID: 32512657] [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: 06/11/2023]
Abstract
This study investigated whether kaempferol could inhibit ovarian cancer (OC) by activation of endoplasmic reticulum (ER) stress and autophagy, and tested its effect on the sensitivity of OC cells to cisplatin (cis-diamminedichloroplatinum, DPP). To study the effect of kaempferol on activation of ER stress and autophagy and find out whether its mechanism of action involves calcium (Ca2+), A2780 OC cells were cultured in DMEM/F12 for 24 h with or without kaempferol (40 μmol/l) in the presence or absence of autophagy or ER stress inhibitors or a calcium chelator. To study the effect of kaempferol on the sensitivity of OC cells to DPP and the potential involvement of modulation of protein kinase B (Akt) expression, A2780 OC were incubated with kaempferol and increasing concentrations of DPP (0-20 μmol/l) and then with kaempferol at its predetermined IC50 (6.8 μmol/l). Compared to control cells, kaempferol increased cell apoptosis (158 %) and decreased viability (53.17 %) and proliferation (49.17 %) of A2780 OC cells. Concomitantly, it increased the protein levels of GRP78, PERK, ATF6, IRE-1, LC3II, beclin 1, and caspase 4, thus suggesting activation of cytotoxic autophagy. This was mediated by increasing intracellular Ca+2 levels. In addition, kaempferol increased the sensitivity of A2780 cells to DPP (IC50 from 6.867 ± 0.99 to 3.73 ± 0.59 μmol/l) by decreasing the protein levels of p-Akt (0.31 ± 0.09 vs 0.12 ± 0.005). In conclusion, the findings of this study encourage the use of kaempferol alone or in combination with DPP to inhibit tumorigenesis of ovarian cells.
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Affiliation(s)
- A F El-Kott
- Biology Department, College of Science, King Khalid University, Abha, Saudi Arabia
- Zoology Department, College of Science, Damanhour University, Damanhour, Egypt
| | - A A Shati
- Biology Department, College of Science, King Khalid University, Abha, Saudi Arabia
| | - M A Al-Kahtani
- Biology Department, College of Science, King Khalid University, Abha, Saudi Arabia
| | - S A Alharbi
- Department of Physiology, College of Medicine, Umm Al-Qura University, Mekkah, Saudi Arabia
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Perumal Samy R, Manikandan J, Pachiappan A, Ooi EE, Aw LT, Stiles BG, Franco OL, Kandasamy M, Mathi KM, Rane G, Siveen KS, Arunachalam C, Zayed ME, Alharbi SA, Kumar AP, Sethi G, Lim LHK, Chow VT. Gene Microarray Analyses of Daboia russelli russelli Daboiatoxin Treatment of THP-1 Human Macrophages Infected with Burkholderia pseudomallei. Curr Mol Med 2015; 15:961-74. [PMID: 26592245 DOI: 10.2174/1566524016666151123114123] [Citation(s) in RCA: 2] [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] [Received: 02/14/2015] [Revised: 10/24/2015] [Accepted: 11/18/2015] [Indexed: 11/22/2022]
Abstract
Burkholderia pseudomallei is the causative agent of melioidosis and represents a potential bioterrorism threat. In this study, the transcriptomic responses of B. pseudomallei infection of a human macrophage cell model were investigated using whole-genome microarrays. Gene expression profiles were compared between infected THP-1 human monocytic leukemia cells with or without treatment with Daboia russelli russelli daboiatoxin (DRRDbTx) or ceftazidime (antibiotic control). Microarray analyses of infected and treated cells revealed differential upregulation of various inflammatory genes such as interleukin-1 (IL-1), IL-6, tumor necrosis factor-alpha (TNF-α), cyclooxygenase (COX-2), vascular endothelial growth factor (VEGF), chemokine C-X-C motif ligand 4 (CXCL4), transcription factor p65 (NF-kB); and several genes involved in immune and stress responses, cell cycle, and lipid metabolism. Moreover, following DRR-DbTx treatment of infected cells, there was enhanced expression of the tolllike receptor 2 (TLR-2) mediated signaling pathway involved in recognition and initiation of acute inflammatory responses. Importantly, we observed that highly inflammatory cytokine gene responses were similar in infected cells exposed to DRR-DbTx or ceftazidime after 24 h. Additionally, there were increased transcripts associated with cell death by caspase activation that can promote host tissue injury. In summary, the transcriptional responses during B. pseudomallei infection of macrophages highlight a broad range of innate immune mechanisms that are activated within 24 h post-infection. These data provide insights into the transcriptomic kinetics following DRR-DbTx treatment of human macrophages infected with B. pseudomallei.
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Affiliation(s)
- R Perumal Samy
- Department of Physiology, NUS Immunology Programme, Centre for Life Sciences, Yong Loo Lin School of Medicine, National University of Singapore, 28 Medical Drive, 117456, Singapore.
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El-kersh TA, Al-akeel RA, Al-sheikh YA, Alharbi SA. Isolation and distribution of mosquito-larvicidal cry genes in Bacillus thuringiensis strains native to Saudi Arabia. Trop Biomed 2014; 31:616-632. [PMID: 25776587] [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: 06/04/2023]
Abstract
A total of 157 environmental samples were collected from 11 ecological regions across Saudi Arabia to isolate native Bacillus thuringiensis (Bt) strains. Bt isolates (n=103) were recovered by the 50% (v/v) ethanol treatment method with Bt index range of 0.01 to 0.4. Most of Bt isolates showed spherical crystals (54%), while, irregular, bi-pyramidal, and spore-attached crystal constituted 27, 16 and 3% respectively. PCR analysis with eight general and specific dipteran primers of Cry and Cyt genes, revealed positive amplification for cry4 & cyt1, and cry4A, cry4B and cyt2, and cry 10 and cry 11 genes in 28%, 26%, 22%, and 25% of tested strains respectively; whereas cry2 gene was not detected except with the reference Bt kurstaki HD-1 strain. Bioassays against Aedes caspuis and Culex pipiens larvae indicated that 11 strains displayed better larvicidal activity compared with Bacillus thuringiensis H14 (Bti) reference (LC50 0.6 μg/ml) strain against Ae. caspuis, but only two strains (620A & 633R1, LC50 of 0.09 μg/ml & 0.064 μg/ml) that gave significant enhancement. Additionally, one strain (633R1) showed LC50 similar to that of Bti H14 (LC50 0.064 μg/ml) against Cx. pipiens. With the exception of cyt primers, sequenced DNA of all positive primers amplicons revealed 95 to 99% identity in GenBank with Bacillus thuringiensis subsp. israelensis plasmid pBtoxis and also correlated with its SDS-PAGE expressed protein profiles analysis. It is hoped that our wild bio-insecticide Bt strains can be explored in future in the control of mosquito-vector borne diseases in Saudi Arabia.
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Affiliation(s)
- T A El-kersh
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Saud University, Riyadh 11433, P.O. Box 10219
| | - R A Al-akeel
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Saud University, Riyadh 11433, P.O. Box 10219
| | - Y A Al-sheikh
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Saud University, Riyadh 11433, P.O. Box 10219
| | - S A Alharbi
- Yanbu General Hospital, Yanbu City, Ministry of Health, Saudi Arabia
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Alharbi SA, Mahmoud FF, Al Awadi A, Al Jumma RA, Khodakhast F, Alsulaiman SM. Association of MHC class I with spondyloarthropathies in Kuwait. Eur J Immunogenet 1996; 23:67-70. [PMID: 8834924 DOI: 10.1111/j.1744-313x.1996.tb00265.x] [Citation(s) in RCA: 14] [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] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This study is the first to assess the prevalence of HLA B27 in Kuwaiti patients with ankylosing spondylitis (AS) or related spondyloarthropathies compared to healthy controls. Positive HLA B27 was found in nine (25.7%) of 35 patients, but only in 22 (4%) of 544 controls (P = 0.000). A significant difference in Cw2 and Cw6 between patients and controls was also found (P < 0.01 and 0.000, respectively), suggesting a linkage disequilibrium between B27 and Cw2 (P < 0.000) in the Kuwaiti population. These findings suggest that B27-positive Kuwaitis are at high risk of developing AS and spondyloarthropathies, especially if they carry Cw2 and Cw6: The importance of HLA Cw loci is becoming increasingly apparent in disease association studies.
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Affiliation(s)
- S A Alharbi
- Immunotherapy Immunogenetic Laboratory, Kuwait University
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Levy EM, Alharbi SA, Grindlinger G, Black PH. Changes in mitogen responsiveness lymphocyte subsets after traumatic injury: relation to development of sepsis. Clin Immunol Immunopathol 1984; 32:224-33. [PMID: 6234119 DOI: 10.1016/0090-1229(84)90123-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Head injury and multiple trauma patients were evaluated for mitogen responsiveness and lymphocyte subset frequencies within the first few days after injury. The profile obtained was compared to the patient's clinical course to see if there was a relation between early immune abnormalities and the subsequent development of unanticipated sepsis. Lymphocytes from multiple trauma patients were generally hyporesponsive to in vitro stimulation with a suboptimal dose of the mitogen phytohemagglutinin (PHA). In contrast, the response of head injured patients was comparable to that of the control group. There was a significant decrease in the relative number of multiple trauma patient's T4 (29.3 vs 48.6%) and T11 (48.9 vs 74.7%) positive populations (P less than 0.01). There was no change in the percentage of T8-positive cells (19.0 vs 20.5%). Patients with head injuries also had a decrease in T4-positive cells (35.9%). The percentage of cells with B cell and natural killer (NK) markers remained normal. Thus trauma patients appeared to have an increase in null cells. Six patients whose PHA responses were among the lowest developed sepsis early after trauma. The changes in subset distributions although possibly contributing to a decreased responsiveness did not predict the ability to respond to PHA or the development of sepsis.
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