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Pettit MS, Crowder SL, Ackerman RS, Hafez O, Poch MA, Patel SY. Preoperative Nutritional Status and Enhanced Recovery after Surgery (ERAS) Prior to Radical Cystectomy: A Review of the Literature. Nutr Cancer 2023; 75:1743-1751. [PMID: 37553951 DOI: 10.1080/01635581.2023.2244172] [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] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 07/18/2023] [Accepted: 07/21/2023] [Indexed: 08/10/2023]
Abstract
Preoperative nutritional status is an important and modifiable risk factor of a patient's recovery and outcome after radical cystectomy. There are multiple malnutrition screening tools and treatment options. In this review, we discuss the best indicators of this condition and how to optimize nutrition status prior to radical cystectomy.
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Affiliation(s)
- Matthew S Pettit
- University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Sylvia L Crowder
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Robert S Ackerman
- Department of Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Osama Hafez
- Department of Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Michael A Poch
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Sephalie Y Patel
- Department of Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
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2
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Dahmen AS, Phuoc VH, Cohen JB, Sexton WJ, Patel SY. Bloodless surgery in urologic oncology: A review of hematologic, anesthetic, and surgical considerations. Urol Oncol 2022; 41:192-203. [PMID: 36470804 DOI: 10.1016/j.urolonc.2022.11.010] [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] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/01/2022] [Accepted: 11/11/2022] [Indexed: 12/03/2022]
Abstract
The urologic oncology patient who refuses blood transfusion can present unique challenges in perioperative blood management. Since blood loss and associated transfusion can be expected in many complex urologic oncology surgeries, a multidisciplinary approach may be required for optimal outcomes. Through collaboration with the hematologist, anesthesiologist, and urologist, various techniques can be employed in the perioperative phases to minimize blood loss and the need for transfusion. We review the risks and benefits of these techniques and offer recommendations specific to the urologic oncology patient.
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Affiliation(s)
- Aaron S Dahmen
- Department of Urology, University of Chicago, Chicago, IL
| | - Vania H Phuoc
- Department of Medical Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Jonathan B Cohen
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Wade J Sexton
- Department of Genitourinary Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Sephalie Y Patel
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, Tampa, FL.
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3
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Cohen JB, Patel SY. Parallels between our response to COVID-19 and patient safety. Br J Anaesth 2022; 129:647-649. [PMID: 36030133 PMCID: PMC9340057 DOI: 10.1016/j.bja.2022.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/08/2022] [Accepted: 07/15/2022] [Indexed: 11/24/2022] Open
Abstract
The response to the COVID-19 pandemic and the approach to patient safety share three important concepts: the challenges of preventing rare events, use of rules, and tolerance for uncertainty. We discuss how each of these ideas can be utilised in perioperative safety to create a high-reliability system.
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4
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Cohen JB, Patel SY. The Successful Anesthesia Patient Safety Officer. Anesth Analg 2021; 133:816-820. [PMID: 34280174 DOI: 10.1213/ane.0000000000005637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jonathan B Cohen
- From the Department of Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
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5
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Ackerman RS, Aldawoodi NN, Muncey AR, Patel SY, Coughlin EC, Mhaskar RS. Intravenous versus Volatile Anesthesia and Cancer Outcomes: The Value of Precise Definitions and Pitfalls of Multivariate Analysis. Anesth Analg 2021; 133:e26-e27. [PMID: 34257210 DOI: 10.1213/ane.0000000000005626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Robert S Ackerman
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, Morsani College of Medicine, University of South Florida, Tampa, Florida,
| | - Nasrin N Aldawoodi
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Aaron R Muncey
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Sephalie Y Patel
- Department of Anesthesiology, Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Emily C Coughlin
- Department of Medical Education, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Rahul S Mhaskar
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida
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Muncey AR, Patel SY, Whelan CJ, Ackerman RS, Gatenby RA. The Intersection of Regional Anesthesia and Cancer Progression: A Theoretical Framework. Cancer Control 2021; 27:1073274820965575. [PMID: 33070618 PMCID: PMC7791454 DOI: 10.1177/1073274820965575] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The surgical stress and inflammatory response and volatile anesthetic
agents have been shown to promote tumor metastasis in animal and
in-vitro studies. Regional neuraxial anesthesia protects against these
effects by decreasing the surgical stress and inflammatory response
and associated changes in immune function in animals. However,
evidence of a similar effect in humans remains equivocal due to the
high variability and retrospective nature of clinical studies and
difficulty in directly comparing regional versus general anesthesia in
humans. We propose a theoretical framework to address the question of
regional anesthesia as protective against metastasis. This theoretical construct views the immune system, circulating tumor
cells, micrometastases, and inflammatory mediators as distinct
populations in a highly connected system. In ecological theory, highly
connected populations demonstrate more resilience to local
perturbations but are prone to system-wide shifts compared with their
poorly connected counterparts. Neuraxial anesthesia transforms the
otherwise system-wide perturbations of the surgical stress and
inflammatory response and volatile anesthesia into a comparatively
local perturbation to which the system is more resilient. We propose
this framework for experimental and mathematical models to help
determine the impact of anesthetic choice on recurrence and metastasis
and create therapeutic strategies to improve cancer outcomes after
surgery.
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7
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Patel SY, Kubal TE, Li R, Manley BJ, Gilbert SM, Sexton WJ, Spiess PE, Boulware D, Poch MA. Prevalence of Preoperative Iron Deficiency Anemia: A Case Series Among Patients Undergoing Radical Cystectomy. A A Pract 2021; 15:e01477. [PMID: 33999012 DOI: 10.1213/xaa.0000000000001477] [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: 11/05/2022]
Abstract
Anemia occurs in a significant group of patients with bladder cancer before radical cystectomy. Iron deficiency is a readily identifiable cause of anemia, which can be treated before surgery. The proportion of patients with bladder cancer with iron deficiency anemia is unknown. Laboratory and clinical outcomes were collected on 47 consecutive patients presenting for radical cystectomy. Iron studies found 30% of patients had iron deficiency anemia. These findings present an opportunity to treat anemia before surgery, to reduce blood transfusions during radical cystectomy.
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Affiliation(s)
| | | | - Roger Li
- Department of Genitourinary Oncology
| | | | | | | | | | - David Boulware
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
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Patel SY, Trona N, Alford B, Laborde JM, Kim Y, Li R, Manley BJ, Gilbert SM, Sexton WJ, Spiess PE, Poch MA. Preoperative immunonutrition and carbohydrate loading associated with improved bowel function after radical cystectomy. Nutr Clin Pract 2021; 37:176-182. [PMID: 33900647 DOI: 10.1002/ncp.10661] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Preoperative malnourishment has been consistently associated with poor outcomes after radical cystectomy and other major abdominal surgeries. Most enhanced recovery after surgery (ERAS) studies have examined preoperative nutrition and its relationship to outcomes after gastrointestinal surgery. Although numerous studies have demonstrated the benefits of using an ERAS protocol, this study in unique in comparing 2 ERAS protocols, with and without a nutrition component. METHODS A formalized preoperative nutrition protocol (PNP) recommending use of preoperative immunonutrition and carbohydrate drink was introduced in June 2018. A total of 78 consecutive patients who drank both beverages were compared with 92 historical controls. Multivariable logistic regression analyses were sequentially performed to determine if preoperative nutrition was associated with binary outcome variables (30-day complication, infectious complication, and readmission within 30 days). RESULTS The preoperative nutrition group and control group were statistically similar in distribution of age, sex, American Society of Anesthesiologists physical status classification, clinical stage, and body mass index. Return of bowel function was found to occur earlier in the preoperative nutrition group than in the control group (3.12 vs 3.74 days; relative risk, 0.82; CI, 0.73-0.93; P = .0029). Complications within 30 days were similar in both groups (63.6% vs 55.4%; P = 0.36). Infectious complications (42.9% vs 37%; P = .53) and readmission within 30 days (22.1% vs 15.2%; P = .34) were also similar in both groups. CONCLUSIONS Use of a PNP including immunonutrition and carbohydrate drink may be associated with earlier return of bowel function after radical cystectomy.
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Affiliation(s)
- Sephalie Y Patel
- Department of Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Nathaniel Trona
- USF Health Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Brandon Alford
- USF Health Morsani College of Medicine, University of South Florida, Tampa, Florida, USA.,Department of Anesthesiology, University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Jose M Laborde
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Youngchul Kim
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Roger Li
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Brandon J Manley
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Wade J Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Philippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Michael A Poch
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
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10
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Petitt MS, Ackerman RS, Hanna MM, Chen L, Mhaskar RS, Fernandez DC, Patel SY. Anesthetic and analgesic methods for gynecologic brachytherapy: A meta-analysis and systematic review. Brachytherapy 2020; 19:328-336. [DOI: 10.1016/j.brachy.2020.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/30/2019] [Accepted: 01/19/2020] [Indexed: 12/18/2022]
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11
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Patel SY, Ackerman RS, Boulware D, Poch MA. Epidural anesthesia may be associated with increased postoperative complications in the elderly population undergoing radical cystectomy: an analysis from the National Surgical Quality Improvement Project (NSQIP) database. World J Urol 2020; 39:433-441. [PMID: 32318858 DOI: 10.1007/s00345-020-03212-0] [Citation(s) in RCA: 4] [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: 12/21/2019] [Accepted: 04/10/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Epidural anesthesia has been associated with a decrease in cardiopulmonary complications and a decrease in blood loss in orthopedic procedures. Its influence on the outcomes of patients receiving radical cystectomies is unknown. We aim to use the large national database from the National Surgical Quality Improvement Project (NSQIP) to examine whether postoperative complications may be affected by the use of epidural anesthesia during radical cystectomy. METHODS Data were collected from the 2014-2016 participant user files of the NSQIP database. Patients receiving radical cystectomy were identified by CPT code and further stratified by anesthesia type. Demographics, length of stay, and 30-day complications including death were collected and analyzed using univariable and multivariable analysis. RESULTS A total of 6448 patients met the inclusion criteria for analysis. Between 2014 and 2016, 5064 patients received general anesthesia only (GA) and 1384 patients received general and epidural anesthesia (GEA). Statistical analysis showed an overall increase in major complications (17.8% vs 18.5%) in the GEA group (p = 0.0046). Subgroup analysis showed major complications to be more likely in patients older than 75 years receiving GEA instead of GA (p = 0.0301). CONCLUSIONS Elderly patients (age > 75) undergoing radical cystectomy may experience more major complications with the use of epidural anesthesia. This may be due to end-organ effects from the hemodynamic changes of epidural anesthesia which are poorly tolerated in the elderly population. Further single intervention epidural studies need to be performed to isolate the effects of epidural anesthesia on individual surgical procedures.
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Affiliation(s)
- Sephalie Y Patel
- Department of Anesthesiology, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA.
| | - Robert S Ackerman
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA.,Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - David Boulware
- Department of Biostatistics, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Michael A Poch
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
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12
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Ackerman RS, Hirschi M, Trona N, Joyce DM, Evans T, Patel SY. Incidence of Thromboembolic Events in Oncology Patients Receiving Intraoperative Tranexamic Acid During Orthopedic Surgery: A Retrospective Review at a Comprehensive Cancer Center. A A Pract 2020; 14:63-66. [DOI: 10.1213/xaa.0000000000001129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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13
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Sun J, Kirichenko DA, Chung JL, Carr MJ, Eroglu Z, Khushalani NI, Markowitz J, Messina JL, Sondak VK, Zager JS, Patel SY. Perioperative Outcomes of Melanoma Patients Undergoing Surgery After Receiving Immunotherapy or Targeted Therapy. World J Surg 2019; 44:1283-1293. [DOI: 10.1007/s00268-019-05314-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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14
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Affiliation(s)
- Jonathan B Cohen
- From the Department of Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
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15
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Ackerman RS, Tufts CW, DePinto DG, Chen J, Altshuler JR, Serdiuk A, Cohen JB, Patel SY. How Sweet Is This? A Review and Evaluation of Preoperative Carbohydrate Loading in the Enhanced Recovery After Surgery Model. Nutr Clin Pract 2019; 35:246-253. [PMID: 31637778 DOI: 10.1002/ncp.10427] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Preoperative carbohydrate loading is a contemporary element of the enhanced recovery after surgery (ERAS) paradigm. In addition to intraoperative surgical and anesthetic modifications and postoperative care practices, preoperative optimization is essential to good postsurgical outcomes. What was long held as dogma, a period of prolonged fasting prior to the administration of anesthesia, was later re-examined and challenged. Along with the proposed physiologic effects of decreasing the surgical stress response and insulin resistance, preoperative carbohydrate loading was also demonstrated to improve patient satisfaction and well-being, without an increase in perioperative complications. The benefits are most strongly observed in abdominal and cardiac surgery patients, but there has also been data which support its use in other specialties and surgeries. Barriers to the adoption of perioperative carbohydrate loading are few, but importantly include overcoming the inertia to modify older and more restrictive fasting guidelines and achieving the multidisciplinary consensus necessary to implement such changes. Despite these challenges, and with an existing body of evidence supporting its benefits, preoperative carbohydrate loading presents a significant contribution to the ERAS programs.
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Affiliation(s)
- Robert S Ackerman
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Christopher W Tufts
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David G DePinto
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jeffrey Chen
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jaclyn R Altshuler
- Department of Anesthesiology, Baylor College of Medicine, Houston, Texas, USA
| | - Andrew Serdiuk
- Department of Anesthesiology, H. Lee Moffitt Cancer Center, Tampa, Florida, USA
| | - Jonathan B Cohen
- Department of Anesthesiology, H. Lee Moffitt Cancer Center, Tampa, Florida, USA
| | - Sephalie Y Patel
- Department of Anesthesiology, H. Lee Moffitt Cancer Center, Tampa, Florida, USA
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16
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Aldawoodi NN, Escher AR, Ninan D, Patel SY. Transesophageal Echocardiography During Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy: A Novel Approach. Cureus 2019; 11:e5062. [PMID: 31328075 PMCID: PMC6624119 DOI: 10.7759/cureus.5062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an extensive, lengthy procedure for patients with peritoneal metastases. It is associated with fairly high morbidity and mortality as compared with other non-vascular intra-abdominal surgeries. Fluid and hemodynamic management is challenging and not well established, particularly in patients with a low ejection fraction (EF). This case details the successful intraoperative anesthetic management of a patient with an ejection fraction of 20% undergoing CRS/HIPEC using the addition of intraoperative transesophageal echocardiography (TEE) as an adjunct to central venous pressure (CVP), urine output (UOP), and calculated stroke volume variation (SVV) for goal-directed resuscitation and blood pressure support.
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Affiliation(s)
- Nasrin N Aldawoodi
- Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Allan R Escher
- Anesthesiology / Pain Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - David Ninan
- Anesthesiology, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Sephalie Y Patel
- Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
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Abstract
Hypotension during thoracic surgery is traditionally attributed to intrathoracic causes such as pulmonary bleeding, ventilation, causing decreased venous return, and a decrease in myocardial contractility. We present a case of unexplained hypotension presenting at the end of left-sided thoracic surgery. The cause of hypotension was ultimately found to be due to intra-abdominal bleeding from a splenic injury. This case reminds the anesthesiologist to be vigilant of non-thoracic causes of hypotension during left-sided lung surgery.
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Affiliation(s)
- Jonathan B Cohen
- Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | | | - Sephalie Y Patel
- Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Jinhong Liu
- Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
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18
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Chipollini J, Alford B, Boulware DC, Forget P, Gilbert SM, Lockhart JL, Pow-Sang JM, Sexton WJ, Spiess PE, Poch MA, Patel SY. Epidural anesthesia and cancer outcomes in bladder cancer patients: is it the technique or the medication? A matched-cohort analysis from a tertiary referral center. BMC Anesthesiol 2018; 18:157. [PMID: 30390636 PMCID: PMC6215353 DOI: 10.1186/s12871-018-0622-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/19/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The perioperative period can be a critical period with long-term implications on cancer-related outcomes. In this study, we evaluate the influence of regional anesthesia on cancer-specific outcomes in a radical cystectomy (RC) cohort of patients. METHODS We performed a retrospective analysis of patients with clinically-nonmetastatic urothelial carcinoma of the bladder who underwent RC at our institution from 2008 to 2012. Patients were retrospectively registered and stratified based on two anesthetic techniques: perioperative epidural analgesia with general anesthesia (epidural) versus general anesthesia alone (GA). Epidural patients received a sufentanil-based regimen (median intraoperative sufentanil dose 50 mcg (45,85). Propensity-score was used to make 1:1 case-control matching. Cumulative risk of recurrence with competing risks was calculated based on anesthetic technique. Kaplan-Meier curves were used to compare recurrence-free (RFS) and cancer-specific survival (CSS). Univariable and multivariable analyses were performed with Cox proportional hazard regression models for RFS and CSS. RESULTS Only patients with complete data on anesthetic technique were included. Out of 439 patients, 215-pair samples with complete follow-up were included in the analysis. Median follow-up was 41.4 months (range: 0.20-101). Patients with epidurals received higher median total intravenous morphine equivalents (ivMEQ) versus those in the GA group (75 (11-235) vs. 50 ivMEQ (7-277), p < 0.0001). Cumulative risk of recurrence at two years was 25.2% (19.6, 31.2) for epidural patients vs. 20.0% (15.0, 25.7) for GA patients (Gray test p = 0.0508). Epidural analgesic technique was a significant predictor of worse RFS (adjusted HR = 1.67, 1.14-2.45; p = 0.009) and CSS (HR = 1.53, 1.04-2.25; p = 0.030) on multivariable analyses. CONCLUSIONS Epidural anesthesia using sufentanil was associated with worse recurrence and disease-free survival in bladder cancer patients treated with surgery. This may be due use of epidural sufentanil or due to the increased total morphine equivalents patient received as a consequence of this drug.
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Affiliation(s)
- Juan Chipollini
- Department of Genitourinary Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Brandon Alford
- Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, Tampa, FL, 33612, USA
| | - David C Boulware
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Patrice Forget
- Department of Anesthesiology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Scott M Gilbert
- Department of Genitourinary Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Jorge L Lockhart
- Department of Genitourinary Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Julio M Pow-Sang
- Department of Genitourinary Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Wade J Sexton
- Department of Genitourinary Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Philippe E Spiess
- Department of Genitourinary Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Michael A Poch
- Department of Genitourinary Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - Sephalie Y Patel
- Department of Anesthesiology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA.
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Ackerman RS, Cohen JB, Getting REG, Patel SY. Are you seeing this: the impact of steep Trendelenburg position during robot-assisted laparoscopic radical prostatectomy on intraocular pressure: a brief review of the literature. J Robot Surg 2018; 13:35-40. [PMID: 30047103 DOI: 10.1007/s11701-018-0857-7] [Citation(s) in RCA: 4] [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: 05/11/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
Abstract
With the increasing popularity, frequency, and acceptance of the robotic-assisted laparoscopic radical prostatectomy procedure, an awareness of unique intra- and postoperative complications is heightened, including that of increases in intraocular pressure. The steep Trendelenburg positioning required for operative exposure has been shown to increase this value. While the literature is infrequent and undeveloped, certain anesthetic parameters including deep neuromuscular blockade, modified positioning, and the use of dexmedetomidine have been shown to have mild-to-modest decreases in intraocular pressure for baseline. In the four randomized control trials and four observational studies that were found via PubMed/Medline search, the aforementioned techniques demonstrate some preliminary evidence of operative considerations in this unique patient population. These modifications may prove to have even greater significance in patients with pre-existing ophthalmologic pathologies, such as glaucoma, which were excluded from the studies' analyses. This review summarizes the early literature obtained in this subject, with the intent of emphasizing the initial hypotheses and identifying areas for future study.
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Affiliation(s)
- Robert S Ackerman
- University of South Florida Morsani College of Medicine, 12901 Bruce B Downs Boulevard, Tampa, FL, 33612, USA.,Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - Jonathan B Cohen
- Department of Anesthesiology, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | | | - Sephalie Y Patel
- Department of Anesthesiology, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA.
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Evans T, Hanna M, Hafez O, Patel SY. Use of Laryngeal Mask Airway to Preoxygenate and Ventilate Through a Laryngeal Stoma in a Patient Undergoing General Anesthesia. A A Pract 2018; 10:296-297. [DOI: 10.1213/xaa.0000000000000690] [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: 11/05/2022]
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Abstract
High dose rate interstitial brachytherapy is a commonly performed procedure for carcinoma of the lower lip. Placement of the brachytherapy catheters can be painful and may require monitored anesthesia care or general anesthesia. We present the use of bilateral mental nerve blocks with minimal sedation to facilitate placement of brachytherapy catheters.
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Affiliation(s)
- Osama Hafez
- From the Department of Anesthesiology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Robert S Ackerman
- University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Trip Evans
- From the Department of Anesthesiology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Sephalie Y Patel
- From the Department of Anesthesiology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Devang M Padalia
- From the Department of Anesthesiology, H. Lee Moffitt Cancer Center, Tampa, Florida
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22
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Slongo J, Cohen JB, Patel SY, Sexton WJ, Gonzalez RD, Spiess PE. MP80-16 FAVORABLE OUTCOMES OF THE INSTITUTION OF A MASSIVE TRANSFUSION PROTOCOL IN PATIENTS UNDERGOING MAJOR UROLOGIC ONCOLOGY SURGERY WITH HIGH ANTICIPATED BLOOD LOSS. J Urol 2018. [DOI: 10.1016/j.juro.2018.02.2704] [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: 11/25/2022]
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23
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Patel SY, Edwards DA, Boulware DC, Serdiuk A, Cook SJ, Benson K, Rice MJ. A novel approach to improving efficiency and cost saving in preoperative blood preparation. Transfusion 2017; 57:3035-3039. [PMID: 28940392 DOI: 10.1111/trf.14331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 07/31/2017] [Accepted: 07/31/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Preoperative ordering of blood products has been an area of optimization due to considerable variability among physicians; overpreparation can lead to extra costs and underpreparation of blood can potentially compromise patient safety. STUDY DESIGN AND METHODS We examined the potential cost savings of extending the storage interval of a presurgical type-and-screen sample from 7 to 14 days, thereby reducing the need for a new specimen on the day of surgery. RESULTS Sensitivity analysis showed annual cost savings for our institution to be an estimated $38,770 ($22,420-$73,120). CONCLUSION These results are even more robust when incorporating the additional potential savings from improved operating room efficiency.
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Affiliation(s)
- Sephalie Y Patel
- Department of Anesthesiology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - David A Edwards
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - David C Boulware
- Department of Biostatistics, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Andrew Serdiuk
- Department of Anesthesiology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Susan J Cook
- Blood Bank, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Kaaron Benson
- Department of Hematopathology and Laboratory Medicine, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Mark J Rice
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
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24
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Kienzler AK, Hargreaves CE, Patel SY. The role of genomics in common variable immunodeficiency disorders. Clin Exp Immunol 2017; 188:326-332. [PMID: 28236292 DOI: 10.1111/cei.12947] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2017] [Indexed: 01/16/2023] Open
Abstract
The advent of next-generation sequencing (NGS) and 'omic' technologies has revolutionized the field of genetics, and its implementation in health care has the potential to realize precision medicine. Primary immunodeficiencies (PID) are a group of rare diseases which have benefited from NGS, with a massive increase in causative genes identified in the past few years. Common variable immunodeficiency disorders (CVID) are a heterogeneous form of PID and the most common form of antibody failure in children and adults. While a monogenic cause of disease has been identified in a small subset of CVID patients, a genomewide association study and whole genome sequencing have found that, in the majority, a polygenic cause is likely. Other NGS technologies such as RNA sequencing and epigenetic studies have contributed further to our understanding of the contribution of altered gene expression in CVID pathogenesis. We believe that to unravel further the complexities of CVID, a multi-omic approach, combining DNA sequencing with gene expression, methylation, proteomic and metabolomics data, will be essential to identify novel disease-associated pathways and therapeutic targets.
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Affiliation(s)
- A-K Kienzler
- NIHR Oxford Biomedical Research Centre, Clinical Immunology Group, Oxford, UK
| | - C E Hargreaves
- NIHR Oxford Biomedical Research Centre, Clinical Immunology Group, Oxford, UK
| | - S Y Patel
- NIHR Oxford Biomedical Research Centre, Clinical Immunology Group, Oxford, UK
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25
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Chipollini J, Tang DH, Hussein K, Patel SY, Garcia-Getting RE, Pow-Sang JM, Gilbert SM, Sexton WJ, Spiess PE, Poch MA. Does Implementing an Enhanced Recovery After Surgery Protocol Increase Hospital Charges? Comparisons From a Radical Cystectomy Program at a Specialty Cancer Center. Urology 2017; 105:108-112. [PMID: 28342928 DOI: 10.1016/j.urology.2017.03.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 02/21/2017] [Accepted: 03/15/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To compare perioperative charges induced at the initial phase of a standardized enhanced recovery after surgery (ERAS) program from a tertiary referral center. METHODS A multidisciplinary ERAS protocol was implemented in our department on July 2015. During the subsequent year, all patients were treated according to this protocol (ERAS group). The patients were compared in terms of real in-hospital charges per surgical episode with a control group consisting of consecutive patients before the start of ERAS. Individual charges were analyzed per sample population and compared with the Wilcoxon rank-sum test or t test. Additionally, cost variances for each group were evaluated. RESULTS A total of 257 consecutive patients were evaluated of which the last 112 were ERAS patients. The median length of stay for each group was 6 days (P = .748). ERAS patients incurred higher medication charges ($1939 vs $1729, P = .036). Control patients incurred higher supplies ($861 vs $692), treatment ($90 vs $72), and miscellaneous charges ($537 vs $388) (all, P < .001). The median total charges per patient were $59,539 for the control group and $60,655 for the ERAS group (P = .175). ERAS adoption significantly reduced variance in billed charges (P < .001). CONCLUSION ERAS implementation did not significantly increase expenditure for cystectomy patients. ERAS showed decreased variance in charges likely due to standardization of care while eliciting savings in supplies, treatment, and miscellaneous costs.
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Affiliation(s)
- Juan Chipollini
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL
| | - Dominic H Tang
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL
| | - Karim Hussein
- Morsani College of Medicine, University of South Florida, Tampa, FL
| | | | | | - Julio M Pow-Sang
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL
| | - Scott M Gilbert
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL
| | - Wade J Sexton
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL
| | - Philippe E Spiess
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL
| | - Michael A Poch
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL.
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Chipollini JJ, Tang DH, Patel SY, Garcia-Getting RE, Gilbert SM, Pow-Sang JM, Sexton WJ, Spiess PE, Poch MA. Perioperative Transfusion of Leukocyte-depleted Blood Products in Contemporary Radical Cystectomy Cohort Does Not Adversely Impact Short-term Survival. Urology 2016; 103:142-148. [PMID: 28011275 DOI: 10.1016/j.urology.2016.12.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 11/30/2016] [Accepted: 12/06/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate the effect of leukoreduced-only perioperative blood transfusion (PBT) and corresponding survival outcomes in a radical cystectomy cohort of patients. MATERIALS AND METHODS We analyzed data from 1026 patients who underwent radical cystectomy at our institution. PBT was defined as transfusion in the intraoperative or within the postoperative hospitalization period. Multivariable analyses using Cox proportional hazards were performed to measure the association between PBT, patient variables, and 3 primary end points: recurrence-free survival, disease-specific survival, and overall survival. Kaplan-Meier curves estimated survival times and were compared with log-rank test. RESULTS Overall, of a total of 1026 patients, 341 (33.2%) received leukoreduced PBT. The median follow-up was 27.5 months. Transfused patients were more likely to be female, had higher estimated blood loss, lower preoperative hemoglobin, were more likely to have received neoadjuvant chemotherapy, or had undergone a continent urinary diversion. Higher pathologic tumor and nodal stage were observed more frequently in patients who received PBT. On multivariable analysis, PBT was not associated with worse recurrence-free survival, disease-specific survival, and overall survival (all P > .05). Kaplan-Meier curves did not show any significant differences (all P > .05) between the transfused and nontransfused groups. In addition, no differences were found in regard to timing of transfusion, that is, intraoperative vs postoperative, in distinct analysis. CONCLUSION No significant association was found between leukoreduced PBT and worse survival outcomes at short-term follow-up in a contemporary cohort of cystectomy patients. Prospective long-term follow-up is warranted.
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Affiliation(s)
- Juan J Chipollini
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL
| | - Dominic H Tang
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL
| | | | | | - Scott M Gilbert
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL
| | - Julio M Pow-Sang
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL
| | - Wade J Sexton
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL
| | - Philippe E Spiess
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL
| | - Michael A Poch
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL.
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Dhalla F, Fox H, Davenport EE, Sadler R, Anzilotti C, van Schouwenburg PA, Ferry B, Chapel H, Knight JC, Patel SY. Chronic mucocutaneous candidiasis: characterization of a family with STAT-1 gain-of-function and development of an ex-vivo assay for Th17 deficiency of diagnostic utility. Clin Exp Immunol 2016; 184:216-27. [PMID: 26621323 PMCID: PMC4837241 DOI: 10.1111/cei.12746] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 11/02/2015] [Accepted: 11/25/2015] [Indexed: 01/30/2023] Open
Abstract
Chronic mucocutaneous candidiasis (CMC) is characterized by recurrent and persistent superficial infections, with Candida albicans affecting the mucous membranes, skin and nails. It can be acquired or caused by primary immune deficiencies, particularly those that impair interleukin (IL)−17 and IL‐22 immunity. We describe a single kindred with CMC and the identification of a STAT1 GOF mutation by whole exome sequencing (WES). We show how detailed clinical and immunological phenotyping of this family in the context of WES has enabled revision of disease status and clinical management. Together with analysis of other CMC cases within our cohort of patients, we used knowledge arising from the characterization of this family to develop a rapid ex‐vivo screening assay for the detection of T helper type 17 (Th17) deficiency better suited to the routine diagnostic setting than established in‐vitro techniques, such as intracellular cytokine staining and enzyme‐linked immunosorbent assay (ELISA) using cell culture supernatants. We demonstrate that cell surface staining of unstimulated whole blood for CCR6+CXCR3–CCR4+CD161+ T helper cells generates results that correlate with intracellular cytokine staining for IL‐17A, and is able to discriminate between patients with molecularly defined CMC and healthy controls with 100% sensitivity and specificity within the cohort tested. Furthermore, removal of CCR4 and CD161 from the antibody staining panel did not affect assay performance, suggesting that the enumeration of CCR6+CXCR3–CD4+ T cells is sufficient for screening for Th17 deficiency in patients with CMC and could be used to guide further investigation aimed at identifying the underlying molecular cause.
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Affiliation(s)
- F Dhalla
- Department of Clinical Immunology, John Radcliffe Hospital, Oxford, UK
| | - H Fox
- Department of Clinical Laboratory Immunology, Churchill Hospital, Oxford, UK
| | - E E Davenport
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - R Sadler
- Department of Clinical Laboratory Immunology, Churchill Hospital, Oxford, UK
| | - C Anzilotti
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - P A van Schouwenburg
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - B Ferry
- Department of Clinical Laboratory Immunology, Churchill Hospital, Oxford, UK
| | - H Chapel
- Department of Clinical Immunology, John Radcliffe Hospital, Oxford, UK.,NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - J C Knight
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - S Y Patel
- Department of Clinical Immunology, John Radcliffe Hospital, Oxford, UK.,NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Arnold SJ, Hodgson T, Misbah SA, Patel SY, Cooper SM, Venning VA. Three difficult cases: the challenge of autoimmunity, immunodeficiency and recurrent infections in patients with Good syndrome. Br J Dermatol 2015; 172:774-7. [PMID: 25059810 DOI: 10.1111/bjd.13293] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2014] [Indexed: 11/28/2022]
Abstract
Good syndrome (GS) is a rare, adult-acquired primary combined immunodeficiency syndrome arising in the context of previous or current thymoma. Patients with GS frequently develop recurrent sinopulmonary infections and are also at high risk of autoimmune manifestations, including skin conditions such as lichen planus. We report three middle-aged patients with GS complicated by multiple autoimmune and infectious manifestations. The combination of immunodeficiency, autoimmunity and recurrent infections seen in patients with GS continues to present a management challenge, particularly in patients with oral mucosal disease and recurrent candidiasis. Clinicians should be prompted to investigate an underlying immunodeficiency in patients with multiple autoimmune conditions and recurrent sinopulmonary infections.
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Affiliation(s)
- S J Arnold
- Department of Dermatology, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LE, U.K
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Suchanek O, Sadler R, Bateman EA, Patel SY, Ferry BL. Immunophenotyping of putative human B1 B cells in healthy controls and common variable immunodeficiency (CVID) patients. Clin Exp Immunol 2013; 170:333-41. [PMID: 23121674 DOI: 10.1111/j.1365-2249.2012.04656.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
B1 B cells represent a unique subset of B lymphocytes distinct from conventional B2 B cells, and are important in the production of natural antibodies. A potential human homologue of murine B1 cells was defined recently as a CD20(+) CD27(+) CD43(+) cell. Common variable immunodeficiency (CVID) is a group of heterogeneous conditions linked by symptomatic primary antibody failure. In this preliminary report, we examined the potential clinical utility of introducing CD20(+) CD27(+) CD43(+) B1 cell immunophenotyping as a routine assay in a diagnostic clinical laboratory. Using a whole blood assay, putative B1 B cells in healthy controls and in CVID patients were measured. Peripheral blood from 33 healthy donors and 16 CVID patients were stained with relevant monoclonal antibodies and underwent flow cytometric evaluation. We established a rapid, whole blood flow cytometric assay to investigate putative human B1 B cells. Examination of CD20(+) CD27(+) CD43(+) cells is complicated by CD3(+) CD27(+) CD43(hi) T cell contamination, even when using stringent CD20 gating. These can be excluded by gating on CD27(+) CD43(lo-int) B cells. Although proportions of CD20(+)CD27(+)CD43(lo–int) cells within B cells in CVID patients were decreased by 50% compared to controls (P < 0·01), this was not significant when measured as a percentage of all CD27(+) B cells (P = 0·78) [corrected]. Immunophenotypic overlap of this subset with other innate-like B cells described recently in humans is limited. We have shown that putative B1 B cell immunophenotyping can be performed rapidly and reliably using whole blood. CD20(+) CD27(+) CD43(lo-int) cells may represent a distinct B1 cell subset within CD27(+) B cells. CVID patients were not significantly different from healthy controls when existing CD27(+) B cell deficiencies were taken into account.
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Affiliation(s)
- O Suchanek
- Clinical Laboratory Immunology, Oxford University Hospitals, Oxford, UK
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Abstract
Individuals with impaired cell mediated immunity exhibit increased susceptibility to infections caused by poorly pathogenic mycobacteria (non-tuberculous mycobacteria and BCG), as well as salmonella species. However, these infections may also occur in a disseminated, fatal form, sometimes with a familial distribution, in the absence of any recognised primary or secondary immunodeficiency. Genetic analysis of affected families has defined mutations in seven different genes participating in the interleukin 12 (IL12) dependent, high output interferon gamma (IFNgamma) pathway. The first category of defect is mutations in the IFNgammaR1 or R2 genes, resulting in defective expression or function of the IFNgamma receptor. The second category of mutations abrogates the cell surface expression IL12Rbeta1gene, resulting in the inability to respond to IL12. The third category of defect is the inability to produce IL12, due to deletion within the gene coding for the inducible chain of IL12 (IL12-p40). Patients with X-linked recessive mutations of the gene encoding the NFkappaB essential modulator may also develop mycobacterial infections, although they usually have a more complex phenotype and are susceptible to a broad spectrum of pathogens. Mutations of the gene encoding the signal transducing molecule STAT1, which impairs the ability to respond to IFNgamma, and mutations of the gene encoding TYK2 (which is associated with a failure to respond to IL12), are both rare genetic defects predisposing to mycobacterial infections. This review summarises the clinical spectrum seen in this group of patients and indicates a strategy for the identification of putative genetic defects in the type-1 cytokine pathway.
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Affiliation(s)
- S Y Patel
- Department of Clinical Biochemistry and Clinical Immunology, Addenbrooke's Hospital, Cambridge, UK
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Patel SY, Kumararatne DS. From black magic to science: understanding the rationale for the use of intravenous immunoglobulin to treat inflammatory myopathies. Clin Exp Immunol 2001; 124:169-71. [PMID: 11422191 PMCID: PMC1906060 DOI: 10.1046/j.1365-2249.2001.01565.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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