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Aryan M, Qian S, Chen Z, Louissaint J, Qian X, Rosenblatt R, Verna E, Brown R, Wong R, Clark V, Zhang W. Patients with early-stage alcohol-associated liver disease are at increased risk of hospital readmission and death. Eur J Gastroenterol Hepatol 2024; 36:318-325. [PMID: 38179871 DOI: 10.1097/meg.0000000000002701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
BACKGROUND AND AIMS Patients with alcohol use disorder (AUD) can develop alcohol-associated fatty liver disease (AFLD). However, the impact of AFLD on outcomes remains unclear. We studied the impact of AFLD on readmission, 30-day mortality, and overall mortality in patients admitted with AUD. METHODS Hospitalized patients with AUD between 2011 and 2019 at a tertiary medical center were retrospectively evaluated. Our population included patients with AUD with AFLD: AST and ALT elevation and serum bilirubin <3 mg/dl. Patients with AUD without evidence of liver disease served as control and were labeled as no ALD. Patients with alcohol-associated cirrhosis (AC) and alcohol-associated hepatitis (AH) were included for comparison. Kaplan-Meier survival analysis and multivariable regression for predictors of mortality and survival were performed. RESULTS There were 7522 patients of which 32.44% were female with mean age of 51.86 ± 14.41 years. Patient distribution included no ALD (n = 3775), AFLD (n = 2192), AC (n = 1017) and AH (n = 538) groups. Compared to no ALD group, AFLD group was associated with significantly higher 30-day mortality [4.43% vs. 1.56%, hazard ratio (HR): 2.84; P < 0.001], overall mortality [15.97% vs. 12.69%, HR 1.40, P < 0.001], and 30-day readmission [21.85% vs. 18.49%, odds ratio: 1.21; P < 0.01]. CONCLUSION We demonstrated that AFLD is not a benign entity and poses significant mortality risk. Our results suggest that AFLD may be under-recognized and highlight the need for focused management and close follow-up after discharge.
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Affiliation(s)
- Mahmoud Aryan
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama
| | - Steve Qian
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine
| | - Zhiguo Chen
- Department of Biostatistics, University of Florida, Gainesville, Florida
| | - Jeremy Louissaint
- Center for Liver Disease and Liver Transplantation, Columbia University Vagelos College of Physicians and Surgeons
| | - Xia Qian
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine
| | - Russell Rosenblatt
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York
| | - Elizabeth Verna
- Center for Liver Disease and Liver Transplantation, Columbia University Vagelos College of Physicians and Surgeons
| | - Robert Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York
| | - Robert Wong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine and Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Virginia Clark
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine
| | - Wei Zhang
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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King WW, Richhart R, Culpepper T, Mota M, Banerjee D, Ismael M, Chakraborty J, Ladna M, Khan W, Ruiz N, Wilson J, Altshuler E, Clark V, Cabrera R. Adherence to guideline-directed hepatocellular carcinoma screening: A single-center US experience. World J Hepatol 2023; 15:410-418. [PMID: 37034234 PMCID: PMC10075011 DOI: 10.4254/wjh.v15.i3.410] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/16/2023] [Accepted: 02/21/2023] [Indexed: 03/22/2023] Open
Abstract
BACKGROUND The American Association for the Study of Liver Disease recommends screening patients with cirrhosis for hepatocellular carcinoma (HCC) using imaging with or without alpha-fetoprotein every six months. Unfortunately, screening rates remain inadequate.
AIM To assess root causes of screening failure in a subspecialty hepatology clinic.
METHODS The authors identified patients with cirrhosis seen in a subspecialty hepatology clinic and determined whether they underwent appropriate screening, defined as two cross-sectional images between five and seven months apart. The authors characterized the primary driver of screening failure. Finally, other hepatologists were surveyed to determine provider perceptions of screening failure causes.
RESULTS 1034 patients were identified with an average age of 61 years and a mean MELD of 8.1 ± 3.8. Hepatitis C virus was the most common cirrhosis etiology. 489 (47%) underwent appropriate screening. No demographic or clinical differences were detected between those who underwent appropriate screening and those who did not. The most common etiologies of screening failure, in descending order, were: radiology unable to schedule timely imaging, provider did not order imaging, patient canceled follow up appointment, appointments scheduled too far apart, lost to follow up, no-show to radiology appointment, and provider canceled appointment. Hepatologists surveyed believed the most common cause of screening failure was no-show to radiology.
CONCLUSION Rates of screening were poor even in a subspecialty hepatology clinic. Screening failure was mostly due to systemic factors such as radiology availability and time between hepatology appointments rather than individual error.
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Affiliation(s)
- William W King
- Department of Medicine, University of Florida, Gainesville, FL 32610, United States
| | - Raymond Richhart
- Department of Medicine, University of Florida, Gainesville, FL 32610, United States
| | - Tyler Culpepper
- Department of Medicine, University of Florida, Gainesville, FL 32610, United States
| | - Maneola Mota
- Department of Gastroenterology, University of Florida, Gainesville, FL 32610, United States
| | - Debdeep Banerjee
- Department of Medicine, University of Florida, Gainesville, FL 32610, United States
| | - Media Ismael
- Department of Gastroenterology, University of Florida, Gainesville, FL 32610, United States
| | - Joydeep Chakraborty
- Department of Gastroenterology, University of Florida, Gainesville, FL 32610, United States
| | - Michael Ladna
- Department of Hospital Medicine, University of Florida, Gainesville, FL 32610, United States
| | - Walid Khan
- Department of Hospital Medicine, University of Florida, Gainesville, FL 32610, United States
| | - Nicole Ruiz
- Department of Medicine, University of Florida, Gainesville, FL 32610, United States
| | - Jake Wilson
- Department of Medicine, University of Florida, Gainesville, FL 32610, United States
| | - Ellery Altshuler
- Department of Medicine, University of Florida, Gainesville, FL 32610, United States
| | - Virginia Clark
- Department of Gastroenterology, University of Florida, Gainesville, FL 32610, United States
| | - Roniel Cabrera
- Department of Gastroenterology, University of Florida, Gainesville, FL 32610, United States
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Fromme M, Schneider CV, Pereira V, Hamesch K, Pons M, Reichert MC, Benini F, Ellis P, H Thorhauge K, Mandorfer M, Burbaum B, Woditsch V, Chorostowska-Wynimko J, Verbeek J, Nevens F, Genesca J, Miravitlles M, Nuñez A, Schaefer B, Zoller H, Janciauskiene S, Abreu N, Jasmins L, Gaspar R, Liberal R, Macedo G, Mahadeva R, Gomes C, Schneider KM, Trauner M, Krag A, Gooptu B, Thorburn D, Marshall A, Hurst JR, Lomas DA, Lammert F, Gaisa NT, Clark V, Griffiths W, Trautwein C, Turner AM, McElvaney NG, Strnad P. Hepatobiliary phenotypes of adults with alpha-1 antitrypsin deficiency. Gut 2022; 71:415-423. [PMID: 33632708 DOI: 10.1136/gutjnl-2020-323729] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/07/2021] [Accepted: 01/25/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Alpha-1 antitrypsin deficiency (AATD) is a common, potentially lethal inborn disorder caused by mutations in alpha-1 antitrypsin (AAT). Homozygosity for the 'Pi*Z' variant of AAT (Pi*ZZ genotype) causes lung and liver disease, whereas heterozygous 'Pi*Z' carriage (Pi*MZ genotype) predisposes to gallstones and liver fibrosis. The clinical significance of the more common 'Pi*S' variant remains largely undefined and no robust data exist on the prevalence of liver tumours in AATD. DESIGN Baseline phenotypes of AATD individuals and non-carriers were analysed in 482 380 participants in the UK Biobank. 1104 participants of a multinational cohort (586 Pi*ZZ, 239 Pi*SZ, 279 non-carriers) underwent a comprehensive clinical assessment. Associations were adjusted for age, sex, body mass index, diabetes and alcohol consumption. RESULTS Among UK Biobank participants, Pi*ZZ individuals displayed the highest liver enzyme values, the highest occurrence of liver fibrosis/cirrhosis (adjusted OR (aOR)=21.7 (8.8-53.7)) and primary liver cancer (aOR=44.5 (10.8-183.6)). Subjects with Pi*MZ genotype had slightly elevated liver enzymes and moderately increased odds for liver fibrosis/cirrhosis (aOR=1.7 (1.2-2.2)) and cholelithiasis (aOR=1.3 (1.2-1.4)). Individuals with homozygous Pi*S mutation (Pi*SS genotype) harboured minimally elevated alanine aminotransferase values, but no other hepatobiliary abnormalities. Pi*SZ participants displayed higher liver enzymes, more frequent liver fibrosis/cirrhosis (aOR=3.1 (1.1-8.2)) and primary liver cancer (aOR=6.6 (1.6-26.9)). The higher fibrosis burden was confirmed in a multinational cohort. Male sex, age ≥50 years, obesity and the presence of diabetes were associated with significant liver fibrosis. CONCLUSION Our study defines the hepatobiliary phenotype of individuals with the most relevant AATD genotypes including their predisposition to liver tumours, thereby allowing evidence-based advice and individualised hepatological surveillance.
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Affiliation(s)
- Malin Fromme
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Aachen, Germany
| | - Carolin V Schneider
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Aachen, Germany
| | - Vitor Pereira
- Department of Gastroenterology, Centro Hospitalar do Funchal, Madeira, Portugal
| | - Karim Hamesch
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Aachen, Germany
| | - Monica Pons
- Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Universitat Autonoma de Barcelona, Barcelona, Catalunya, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Comunidad de Madrid, Spain
| | - Matthias C Reichert
- Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany
| | - Federica Benini
- Gastroenterology Unit, Department of Medicine, Spedali Civili and University, Brescia, Italy
| | - Paul Ellis
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Katrine H Thorhauge
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Vienna, Austria
| | - Barbara Burbaum
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Aachen, Germany
| | - Vivien Woditsch
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Aachen, Germany
| | - Joanna Chorostowska-Wynimko
- Department of Genetics and Clinical Immunology, National Tuberculosis and Lung Diseases Institute, Warszawa, Poland
| | - Jef Verbeek
- Department of Gastroenterology & Hepatology, KU Leuven University Hospitals Leuven, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Leuven, Flanders, Belgium
| | - Frederik Nevens
- Department of Gastroenterology & Hepatology, KU Leuven University Hospitals Leuven, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Leuven, Flanders, Belgium
| | - Joan Genesca
- Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Universitat Autonoma de Barcelona, Barcelona, Catalunya, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Comunidad de Madrid, Spain
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Alexa Nuñez
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Benedikt Schaefer
- Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Tirol, Austria
| | - Heinz Zoller
- Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Tirol, Austria
| | | | - Nélia Abreu
- Department of Gastroenterology, Centro Hospitalar do Funchal, Madeira, Portugal
| | - Luís Jasmins
- Department of Gastroenterology, Centro Hospitalar do Funchal, Madeira, Portugal
| | - Rui Gaspar
- Gastroenterology Department, Centro Hospitalar de São João, Faculty of Medicine of Porto University, Porto, Portugal
| | - Rodrigo Liberal
- Gastroenterology Department, Centro Hospitalar de São João, Faculty of Medicine of Porto University, Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar de São João, Faculty of Medicine of Porto University, Porto, Portugal
| | - Ravi Mahadeva
- Department of Respiratory Medicine, Cambridge University Hospitals, Cambridge, UK
| | - Catarina Gomes
- Gastroenterology Department, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Porto, Portugal
| | - Kai Markus Schneider
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Aachen, Germany
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Vienna, Austria
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Bibek Gooptu
- NIHR Leicester BRC-Respiratory and Leicester Institute of Structural & Chemical Biology, University of Leicester, Leicester, Leicestershire, UK.,London Alpha-1 Antitrypsin Deficiency Service, Royal Free Hospital, London, UK
| | - Douglas Thorburn
- London Alpha-1 Antitrypsin Deficiency Service, Royal Free Hospital, London, UK.,Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Aileen Marshall
- London Alpha-1 Antitrypsin Deficiency Service, Royal Free Hospital, London, UK.,Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - John R Hurst
- London Alpha-1 Antitrypsin Deficiency Service, Royal Free Hospital, London, UK.,UCL Respiratory, Division of Medicine, University College London, London, UK
| | - David A Lomas
- London Alpha-1 Antitrypsin Deficiency Service, Royal Free Hospital, London, UK.,UCL Respiratory, Division of Medicine, University College London, London, UK
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany.,Hannover Medical School (MHH), Hannover, Germany
| | - Nadine T Gaisa
- Institute of Pathology, University Hospital RWTH Aachen, Aachen, Germany
| | - Virginia Clark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
| | - William Griffiths
- Department of Hepatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - Christian Trautwein
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Aachen, Germany
| | - Alice M Turner
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Noel G McElvaney
- Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Pavel Strnad
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Aachen, Germany
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4
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Arab JP, Díaz LA, Baeza N, Idalsoaga F, Fuentes-López E, Arnold J, Ramírez CA, Morales-Arraez D, Ventura-Cots M, Alvarado-Tapias E, Zhang W, Clark V, Simonetto D, Ahn JC, Buryska S, Mehta TI, Stefanescu H, Horhat A, Bumbu A, Dunn W, Attar B, Agrawal R, Haque ZS, Majeed M, Cabezas J, García-Carrera I, Parker R, Cuyàs B, Poca M, Soriano G, Sarin SK, Maiwall R, Jalal PK, Abdulsada S, Higuera-de la Tijera MF, Kulkarni AV, Rao PN, Guerra Salazar P, Skladaný L, Bystrianska N, Prado V, Clemente-Sanchez A, Rincón D, Haider T, Chacko KR, Cairo F, de Sousa Coelho M, Romero GA, Pollarsky FD, Restrepo JC, Castro-Sanchez S, Toro LG, Yaquich P, Mendizabal M, Garrido ML, Narvaez A, Bessone F, Marcelo JS, Piombino D, Dirchwolf M, Arancibia JP, Altamirano J, Kim W, Araujo RC, Duarte-Rojo A, Vargas V, Rautou PE, Issoufaly T, Zamarripa F, Torre A, Lucey MR, Mathurin P, Louvet A, García-Tsao G, González JA, Verna E, Brown RS, Roblero JP, Abraldes JG, Arrese M, Shah VH, Kamath PS, Singal AK, Bataller R. Identification of optimal therapeutic window for steroid use in severe alcohol-associated hepatitis: A worldwide study. J Hepatol 2021; 75:1026-1033. [PMID: 34166722 DOI: 10.1016/j.jhep.2021.06.019] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/18/2021] [Accepted: 06/03/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Corticosteroids are the only effective therapy for severe alcohol-associated hepatitis (AH), defined by a model for end-stage liver disease (MELD) score >20. However, there are patients who may be too sick to benefit from therapy. Herein, we aimed to identify the range of MELD scores within which steroids are effective for AH. METHODS We performed a retrospective, international multicenter cohort study across 4 continents, including 3,380 adults with a clinical and/or histological diagnosis of AH. The main outcome was mortality at 30 days. We used a discrete-time survival analysis model, and MELD cut-offs were established using the transform-the-endpoints method. RESULTS In our cohort, median age was 49 (40-56) years, 76.5% were male, and 79% had underlying cirrhosis. Median MELD at admission was 24 (19-29). Survival was 88% (87-89) at 30 days, 77% (76-78) at 90 days, and 72% (72-74) at 180 days. A total of 1,225 patients received corticosteroids. In an adjusted-survival-model, corticosteroid use decreased 30-day mortality by 41% (hazard ratio [HR] 0.59; 0.47-0.74; p <0.001). Steroids only improved survival in patients with MELD scores between 21 (HR 0.61; 0.39-0.95; p = 0.027) and 51 (HR 0.72; 0.52-0.99; p = 0.041). The maximum effect of corticosteroid treatment (21-30% survival benefit) was observed with MELD scores between 25 (HR 0.58; 0.42-0.77; p <0.001) and 39 (HR 0.57; 0.41-0.79; p <0.001). No corticosteroid benefit was seen in patients with MELD >51. The type of corticosteroids used (prednisone, prednisolone, or methylprednisolone) was not associated with survival benefit (p = 0.247). CONCLUSION Corticosteroids improve 30-day survival only among patients with severe AH, especially with MELD scores between 25 and 39. LAY SUMMARY Alcohol-associated hepatitis is a condition where the liver is severely inflamed as a result of excess alcohol use. It is associated with high mortality and it is not clear whether the most commonly used treatments (corticosteroids) are effective, particularly in patients with very severe liver disease. In this worldwide study, the use of corticosteroids was associated with increased 30-day, but not 90- or 180-day, survival. The maximal benefit was observed in patients with an MELD score (a marker of severity of liver disease; higher scores signify worse disease) between 25-39. However, this benefit was lost in patients with the most severe liver disease (MELD score higher than 51).
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Affiliation(s)
- Juan Pablo Arab
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Luis Antonio Díaz
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Natalia Baeza
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Idalsoaga
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Eduardo Fuentes-López
- Department of Health Sciences, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jorge Arnold
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Servicio Medicina Interna, Hospital El Pino, Santiago, Chile
| | | | - Dalia Morales-Arraez
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
| | - Meritxell Ventura-Cots
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
| | - Edilmar Alvarado-Tapias
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
| | - Wei Zhang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
| | - Virginia Clark
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
| | - Douglas Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Joseph C Ahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Seth Buryska
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Tej I Mehta
- Division of Gastroenterology and Hepatology, Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA; The Johns Hopkins Hospital, Department of Interventional Radiology, Baltimore, MD, USA
| | - Horia Stefanescu
- Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Adelina Horhat
- Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Andreea Bumbu
- Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | | | - Bashar Attar
- Division of Gastroenterology & Hepatology, Cook County Health and Hospital Systems, Chicago, Illinois, USA
| | - Rohit Agrawal
- Division of Gastroenterology and Hepatology, University of Illinois, Chicago, Illinois, USA
| | - Zohaib Syed Haque
- Division of Gastroenterology & Hepatology, Cook County Health and Hospital Systems, Chicago, Illinois, USA
| | - Muhammad Majeed
- Division of Gastroenterology & Hepatology, Cook County Health and Hospital Systems, Chicago, Illinois, USA
| | - Joaquín Cabezas
- Gastroenterology and Hepatology Department, University Hospital Marques de Valdecilla, Santander, Spain; Research Institute Valdecilla (IDIVAL), Santander, Spain
| | - Inés García-Carrera
- Gastroenterology and Hepatology Department, University Hospital Marques de Valdecilla, Santander, Spain; Research Institute Valdecilla (IDIVAL), Santander, Spain
| | - Richard Parker
- Leeds Liver Unit, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Berta Cuyàs
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, CIBERehd, Barcelona, Spain
| | - Maria Poca
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, CIBERehd, Barcelona, Spain
| | - German Soriano
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, CIBERehd, Barcelona, Spain
| | - Shiv K Sarin
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakhi Maiwall
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Prasun K Jalal
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - Saba Abdulsada
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | | | - Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - P Nagaraja Rao
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | | | - Lubomir Skladaný
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University, Slovak Republic; F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | - Natália Bystrianska
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University, Slovak Republic; F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | | | - Ana Clemente-Sanchez
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA; Liver Unit, Department of Digestive Diseases Hospital General Universitario Gregorio Marañón Madrid, Spain; CIBERehd Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas Madrid, Spain
| | - Diego Rincón
- Liver Unit, Department of Digestive Diseases Hospital General Universitario Gregorio Marañón Madrid, Spain; CIBERehd Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas Madrid, Spain
| | - Tehseen Haider
- Division of Gastroenterology and Hepatology, Montefiore Medical Center, Bronx, NY, USA
| | - Kristina R Chacko
- Division of Gastroenterology and Hepatology, Montefiore Medical Center, Bronx, NY, USA
| | - Fernando Cairo
- Liver Transplant Unit, Hospital El Cruce, Florencio Varela, Buenos Aires, Argentina
| | | | - Gustavo A Romero
- Sección Hepatología, Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Buenos Aires, Argentina
| | - Florencia D Pollarsky
- Sección Hepatología, Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Buenos Aires, Argentina
| | - Juan Carlos Restrepo
- Unidad de Hepatología del Hospital Pablo Tobon Uribe, Grupo de Gastrohepatología de la Universidad de Antioquia, Medellín, Colombia
| | - Susana Castro-Sanchez
- Unidad de Hepatología del Hospital Pablo Tobon Uribe, Grupo de Gastrohepatología de la Universidad de Antioquia, Medellín, Colombia
| | - Luis G Toro
- Hepatology and Liver Transplant Unit, Hospitales de San Vicente Fundación de Medellín y Rionegro, Colombia
| | - Pamela Yaquich
- Departamento de Gastroenterología, Hospital San Juan de Dios, Santiago, Chile
| | - Manuel Mendizabal
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Buenos Aires, Argentina
| | | | - Adrián Narvaez
- Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Fernando Bessone
- Hospital Provincial del Centenario, Universidad Nacional de Rosario, Rosario, Argentina
| | | | - Diego Piombino
- Servicio de Medicina Interna del Hospital de Emergencias Dr Clemente Alvarez de Rosario, Santa Fe, Argentina
| | - Melisa Dirchwolf
- Unidad de Hígado, Hospital Privado de Rosario, Rosario, Argentina
| | - Juan Pablo Arancibia
- Departamento de Gastroenterología y Hepatología, Clínica Santa María, Santiago, Chile
| | - José Altamirano
- Department of Internal Medicine, Hospital Quironsalud, Barcelona, Spain
| | - Won Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, South Korea
| | - Roberta C Araujo
- Gastroenterology Division, Ribeirão Preto Medical School, University of São Paulo, 14048-900 Ribeirão Preto, SP, Brazil
| | - Andrés Duarte-Rojo
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
| | - Victor Vargas
- Liver Unit, Hospital Vall d'Hebron, Universitat Autonoma Barcelona, CIBEREHD, Barcelona, Spain
| | - Pierre-Emmanuel Rautou
- Université de Paris, Centre de recherche sur l'inflammation, Inserm, U1149, CNRS, ERL8252, F-75018 Paris, France; Service d'Hépatologie, DHU Unity, DMU Digest, Hôpital Beaujon, AP-HP, Clichy, France; Centre de Référence des Maladies Vasculaires du Foie, French Network for Rare Liver Diseases (FILFOIE), European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Belgium
| | - Tazime Issoufaly
- Université de Paris, Centre de recherche sur l'inflammation, Inserm, U1149, CNRS, ERL8252, F-75018 Paris, France; Service d'Hépatologie, DHU Unity, DMU Digest, Hôpital Beaujon, AP-HP, Clichy, France; Centre de Référence des Maladies Vasculaires du Foie, French Network for Rare Liver Diseases (FILFOIE), European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Belgium
| | | | - Aldo Torre
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubiràn", Mexico City, Mexico
| | - Michael R Lucey
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Philippe Mathurin
- Hôpital Claude Huriez, Services des Maladies de l'Appareil Digestif, CHRU Lille, and Unité INSERM 995, Lille, France
| | - Alexandre Louvet
- Hôpital Claude Huriez, Services des Maladies de l'Appareil Digestif, CHRU Lille, and Unité INSERM 995, Lille, France
| | - Guadalupe García-Tsao
- Section of Digestive Diseases, Yale University School of Medicine/VA-CT Healthcare System, New Haven/West Haven, USA
| | - José Alberto González
- Gastroenterology Department, Hospital Universitario "Dr José E González" Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Elizabeth Verna
- Division of Digestive and Liver Diseases, Department of Medicine and Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, NY, USA
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY
| | - Juan Pablo Roblero
- Sección Gastroenterología, Hospital Clínico Universidad de Chile, Escuela de Medicina Universidad de Chile, Santiago, Chile
| | - Juan G Abraldes
- Division of Gastroenterology, Liver Unit, University of Alberta, Edmonton, Canada
| | - Marco Arrese
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Ashwani K Singal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA
| | - Ramon Bataller
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
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Marek G, Collinsworth A, Liu C, Brantly M, Clark V. Quantitative measurement of the histological features of alpha-1 antitrypsin deficiency-associated liver disease in biopsy specimens. PLoS One 2021; 16:e0256117. [PMID: 34398915 PMCID: PMC8366994 DOI: 10.1371/journal.pone.0256117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 07/31/2021] [Indexed: 11/27/2022] Open
Abstract
Background Pathological mutations in Alpha-1 Antitrypsin (AAT) protein cause retention of toxic polymers in the hepatocyte endoplasmic reticulum. The risk for cirrhosis in AAT deficiency is likely directly related to retention of these polymers within the liver. Polymers are classically identified on liver biopsy as inclusion bodies by periodic acid schiff staining after diastase treatment and immunohistochemistry. However, characterization of the polymer burden within a biopsy sample is limited to a semi-quantitative scale as described by a pathologist. Better methods to quantify polymer are needed to advance our understanding of pathogenesis of disease. Therefore, we developed a method to quantify polymer aggregation from standard histologic specimens. In addition, we sought to understand the relationship of polymer burden and other histologic findings to the presence of liver fibrosis. Methods Liver samples from a well-categorized AATD cohort were used to develop histo-morphometric tools to measure protein aggregation. Results Whole-slide morphometry reliably quantifies aggregates in AATD individuals. Despite very low levels of inclusions present (0–0.41%), accumulation of globules is not linear and is associated with higher fibrosis stages. Immunohistochemistry demonstrates that fibrosis is associated with polymer accumulation and not total AAT. A proportion of patients were found to be “heavy accumulators” with a polymer burden above the upper 25% of normal distribution. Males had significantly more liver inclusions and polymer than females. These measurements also highlight interrelated phenotypes of hepatocellular degeneration and autophagy in AATD liver disease. Conclusion Quantitative inclusion analysis measures AAT accumulation in liver biopsy specimens. Quantification of polymer may identify individuals at risk for progressive disease and candidates for therapeutic interventions. Furthermore, these methods may be useful for evaluating efficacy of drugs targeting accumulation of AAT.
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Affiliation(s)
- George Marek
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, Gainesville, Florida, United States of America
- * E-mail:
| | - Amy Collinsworth
- Advanced Pathology Solutions, Little Rock, Arkansas, United States of America
| | - Chen Liu
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Mark Brantly
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Virginia Clark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, United States of America
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Khan W, Zhang W, Clark V. Persistent Abdominal Pain as Rare Complication of Duodenal Perforation From an Inferior Vena Cava Filter. Cureus 2021; 13:e13168. [PMID: 33717717 PMCID: PMC7939541 DOI: 10.7759/cureus.13168] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Deep vein thrombosis (DVT) continues to be a significant source of morbidity for surgical patients. Inferior vena cava (IVC) filter placement is indicated for DVT in patients who have contraindications to anticoagulation or anticoagulation failure. Over the last decade, there is an exponential increase in IVC filter placement with increased complications reported. These include IVC penetration, IVC occlusion, insertion complication and filter migration. We report a rare case of symptomatic duodenal perforation by an IVC filter migration. This case illustrates that even though IVC migration and perforation is a rare complication, it should be recognized as a potential cause for gastrointestinal (GI) symptoms in these patients.
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Affiliation(s)
- Walid Khan
- Department of Internal Medicine, University of Florida, Gainesville, USA
| | - Wei Zhang
- Department of Gastroenterology and Hepatology, University of Florida, Gainesville, USA
| | - Virginia Clark
- Department of Gastroenterology and Hepatology, University of Florida, Gainesville, USA
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7
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Khodayari N, Oshins R, Holliday LS, Clark V, Xiao Q, Marek G, Mehrad B, Brantly M. Alpha-1 antitrypsin deficient individuals have circulating extracellular vesicles with profibrogenic cargo. Cell Commun Signal 2020; 18:140. [PMID: 32887613 PMCID: PMC7487708 DOI: 10.1186/s12964-020-00648-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 05/14/2020] [Accepted: 08/15/2020] [Indexed: 02/06/2023] Open
Abstract
Background Alpha-1 antitrypsin deficiency (AATD)-mediated liver disease is a toxic “gain-of-function” inflammation in the liver associated with intracellular retention of mutant alpha-1 antitrypsin. The clinical presentation of the disease includes fibrosis, cirrhosis and liver failure. However, the pathogenic mechanism of AATD-mediated liver disease is not well understood. Here, we investigated the role of plasma extracellular vesicles (EVs) in progression of AATD-mediated liver disease. Methods EVs were isolated from plasma of AATD individuals with liver disease and healthy controls. Their cytokines and miRNA content were examined by multiplex assay and small RNA sequencing. The bioactivity of EVs was assessed by qPCR, western blot analysis and immunofluorescent experiments using human hepatic stellate cells (HSCs) treated with EVs isolated from control or AATD plasma samples. Results We have found that AATD individuals have a distinct population of EVs with pathological cytokine and miRNA contents. When HSCs were cultured with AATD plasma derived-EVs, the expression of genes related to the development of fibrosis were significantly amplified compared to those treated with healthy control plasma EVs. Conclusion AATD individuals have a distinct population of EVs with abnormal cytokine and miRNA contents and the capacity to activate HSCs and mediate fibrosis. Better understanding of the components which cause liver inflammation and fibrogenesis, leading to further liver injury, has the potential to lead to the development of new treatments or preventive strategies to prevent AATD-mediated liver disease. Video abstract
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Affiliation(s)
- Nazli Khodayari
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, Gainesville, USA.
| | - Regina Oshins
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, Gainesville, USA
| | | | - Virginia Clark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, USA
| | | | - George Marek
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, Gainesville, USA
| | - Borna Mehrad
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, Gainesville, USA
| | - Mark Brantly
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, Gainesville, USA.
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Quach E, Kazis L, Zhao S, Ni P, Clark V, McDannold S, Hartmann C. Safety Climate Associated with Adverse Events in Nursing Homes: A National VA Study. Health Serv Res 2020. [DOI: 10.1111/1475-6773.13445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- E. Quach
- UMASS Boston Boston MA United States
- Center for Healthcare Organization and Implementation Research Bedford MA United States
- New England Geriatric Research Education and Clinical Center Bedford MA United States
| | - L. Kazis
- Center for Healthcare Organization and Implementation Research Bedford MA United States
- Boston University School of Public Health Boston MA United States
| | - S. Zhao
- Center for Healthcare Organization and Implementation Research Bedford MA United States
| | - P. Ni
- Boston University School of Public Health Boston MA United States
| | - V. Clark
- Center for Healthcare Organization and Implementation Research Bedford MA United States
| | - S. McDannold
- Center for Healthcare Organization and Implementation Research Bedford MA United States
| | - C. Hartmann
- Center for Healthcare Organization and Implementation Research Bedford MA United States
- UMASS Lowell Lowell MA United States
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Rahaghi F, Omert L, Clark V, Sandhaus RA. Managing the Alpha-1 patient in the ICU: Adapting broad critical care strategies in AATD. J Crit Care 2019; 54:212-219. [PMID: 31614323 DOI: 10.1016/j.jcrc.2019.08.027] [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: 01/15/2019] [Revised: 07/17/2019] [Accepted: 08/27/2019] [Indexed: 10/26/2022]
Abstract
Alpha-1 Antitrypsin Deficiency (AATD) is a progressive pulmonary disease under-recognized or misdiagnosed by clinicians. Patients with AATD can develop a variety of organ-specific complications and as a result, often require hospitalization and treatment within critical care and ICU settings. Due to the complexity of AATD there are minimal guidelines in place to address the specific and highly variable needs of these patients in the critical care setting. This review presents clinical considerations with respect to the management of patients with AATD and provides treatment recommendations for these patients in the critical care setting. In addition, we have outlined certain aspects of the care of this patient population that may be of interest to critical care practitioners. With greater disease awareness and earlier diagnosis the onset of symptoms can be delayed, which will ultimately reduce the frequency of deleterious health consequences.
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Affiliation(s)
- Franck Rahaghi
- Pulmonary and Critical Care Division, Cleveland Clinic Florida, Weston, Florida, United States.
| | - Laurel Omert
- CSL Behring, King of Prussia, PA, United States.
| | - Virginia Clark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, United States.
| | - Robert A Sandhaus
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO, United States.
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Abdalla SM, Dejman A, Clark V, Levy C. Use of Fenofibrate for patients with primary Sclerosing Cholangitis. Clin Res Hepatol Gastroenterol 2019; 43:e33-e36. [PMID: 30880099 DOI: 10.1016/j.clinre.2018.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 11/12/2018] [Indexed: 02/04/2023]
Affiliation(s)
- Sherine M Abdalla
- Division of Hepatology, Department of Medicine, University of Miami, Jackson Medical Towers, 1500 NW, 12th avenue, Suite 1101, Miami, FL, USA
| | - Adriana Dejman
- Division of Hepatology, Department of Medicine, University of Miami, Jackson Medical Towers, 1500 NW, 12th avenue, Suite 1101, Miami, FL, USA
| | - Virginia Clark
- Division of Hepatology, Department of Medicine, University of Miami, Jackson Medical Towers, 1500 NW, 12th avenue, Suite 1101, Miami, FL, USA
| | - Cynthia Levy
- Division of Hepatology, Department of Medicine, University of Miami, Jackson Medical Towers, 1500 NW, 12th avenue, Suite 1101, Miami, FL, USA.
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Mullins T, Sanguinetti J, Gibson B, Heinrich M, Aragon D, Spinks J, Jones A, Robert B, Lamphere M, Yu A, Clark V. Transcranial ultrasound stimulation and the effect on inhibition as assessed by a stop signal task. Brain Stimul 2019. [DOI: 10.1016/j.brs.2018.12.533] [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: 11/25/2022] Open
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12
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Gibson B, Sanguinetti J, Mullins T, Salazar S, Buchman L, Cutter C, Klein E, Aragon D, Heinrich M, Badran B, Yu A, Clark V. Excitability changes induced in the motor cortex by transcranial ultrasound stimulation. Brain Stimul 2019. [DOI: 10.1016/j.brs.2018.12.530] [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: 11/26/2022] Open
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13
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Heinrich M, Sanguinetti J, Hicks G, Gibson B, Mullins T, Aragon D, Spinks J, Lamphere M, Yu A, Clark V. Photobiomodulation for Cognitive Enhancement in Healthy Adults. Brain Stimul 2019. [DOI: 10.1016/j.brs.2018.12.658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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14
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Snow A, Clark V, Zhao S, Nash P, Allen R, Bolton R, Hartmann C. CHARACTERIZING STAFF INTERACTIONS IN A SAMPLE OF HIGH PERFORMING NURSING HOMES. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.2934] [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: 11/14/2022] Open
Affiliation(s)
- A Snow
- Tuscaloosa VA Medical Center & University of Alabama
| | - V Clark
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital
| | - S Zhao
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital
| | - P Nash
- Tuscaloosa VA Medical Center
| | | | | | - C Hartmann
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital & Boston University
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15
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Quach E, Zhao S, Kazis L, Clark V, McDannold S, Hartmann C. Long Term Care: Policy and Practice Outcomes. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.1639] [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: 11/13/2022] Open
Affiliation(s)
- E Quach
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital
| | - S Zhao
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital
| | - L Kazis
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital & Boston University
| | - V Clark
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital
| | - S McDannold
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital
| | - C Hartmann
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital & Boston University
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Mertens NA, Bryant NB, Gill HA, Jones AP, Robert B, Clark V, Pilly PK. 0091 REM Sleep Has No Effect on Consolidation of Emotionally Salient Information Seen in Animated Threat Detection Task. Sleep 2018. [DOI: 10.1093/sleep/zsy061.090] [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: 11/13/2022] Open
Affiliation(s)
- N A Mertens
- Department of Psychology, University of New Mexico, Albuquerque, NM
| | - N B Bryant
- Department of Psychology, University of New Mexico, Albuquerque, NM
| | - H A Gill
- Department of Psychology, University of New Mexico, Albuquerque, NM
| | - A P Jones
- Department of Psychology, University of New Mexico, Albuquerque, NM
| | - B Robert
- Department of Psychology, University of New Mexico, Albuquerque, NM
| | - V Clark
- Department of Psychology, University of New Mexico, Albuquerque, NM
| | - P K Pilly
- Information and Systems Sciences Laboratory, HRL Laboratory, LLC, Malibu, CA
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Gill HA, Bryant NB, Mertens NA, Jones AP, Robert B, Clark V, Pilly PK. 0179 Low-Amplitude tDCS Does Not Affect Threat Detection Performance Under Sleep Loss. Sleep 2018. [DOI: 10.1093/sleep/zsy061.178] [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: 11/13/2022] Open
Affiliation(s)
- H A Gill
- Department of Psychology, University of New Mexico”, Albuqerque, NM
| | - N B Bryant
- Department of Psychology, University of New Mexico”, Albuqerque, NM
| | - N A Mertens
- Department of Psychology, University of New Mexico”, Albuqerque, NM
| | - A P Jones
- Department of Psychology, University of New Mexico”, Albuqerque, NM
| | - B Robert
- Department of Psychology, University of New Mexico”, Albuqerque, NM
| | - V Clark
- Department of Psychology, University of New Mexico”, Albuqerque, NM
| | - P K Pilly
- Information and System Sciences Laboratory, HRL Laboratory, LLC, Malibu, CA
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Jones D, Boudes PF, Swain MG, Bowlus CL, Galambos MR, Bacon BR, Doerffel Y, Gitlin N, Gordon SC, Odin JA, Sheridan D, Wörns MA, Clark V, Corless L, Hartmann H, Jonas ME, Kremer AE, Mells GF, Buggisch P, Freilich BL, Levy C, Vierling JM, Bernstein DE, Hartleb M, Janczewska E, Rochling F, Shah H, Shiffman ML, Smith JH, Choi YJ, Steinberg A, Varga M, Chera H, Martin R, McWherter CA, Hirschfield GM. Seladelpar (MBX-8025), a selective PPAR-δ agonist, in patients with primary biliary cholangitis with an inadequate response to ursodeoxycholic acid: a double-blind, randomised, placebo-controlled, phase 2, proof-of-concept study. Lancet Gastroenterol Hepatol 2017; 2:716-726. [PMID: 28818518 DOI: 10.1016/s2468-1253(17)30246-7] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 07/05/2017] [Accepted: 07/10/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Many patients with primary biliary cholangitis have an inadequate response to first-line therapy with ursodeoxycholic acid. Seladelpar is a potent, selective agonist for the peroxisome proliferator-activated receptor-delta (PPAR-δ), which is implicated in bile acid homoeostasis. This first-in-class study evaluated the anti-cholestatic effects and safety of seladelpar in patients with an inadequate response to ursodeoxycholic acid. METHODS The study was a 12-week, double-blind, placebo-controlled, phase 2 trial of patients with alkaline phosphatase of at least 1·67 times the upper limit of normal (ULN) despite treatment with ursodeoxycholic acid. Patients, recruited at 29 sites in North America and Europe, were randomly assigned to placebo, seladelpar 50 mg/day, or seladelpar 200 mg/day while ursodeoxycholic acid was continued. Randomisation was done centrally (1:1:1) by a computerised system using an interactive voice-web response system with a block size of three. Randomisation was stratified by region (North America and Europe). The primary outcome was the percentage change from baseline in alkaline phosphatase over 12 weeks, analysed in the modified intention-to-treat (ITT) population (any randomised patient who received at least one dose of medication and had at least one post-baseline alkaline phosphatase evaluation). This study is registered with ClinicalTrials.gov (NCT02609048) and the EU Clinical Trials Registry (EudraCT2015-002698-39). FINDINGS Between Nov 4, 2015, and May 26, 2016, 70 patients were screened at 29 sites in North America and Europe. During recruitment, three patients treated with seladelpar developed fully reversible, asymptomatic grade 3 alanine aminotransferase increases (one on 50 mg, two on 200 mg), ranging from just over five to 20 times the ULN; as a result, the study was terminated after 41 patients were randomly assigned. The modified ITT population consisted of 12 patients in the placebo group, 13 in the seladelpar 50 mg group, and 10 in the seladelpar 200 mg group. Mean changes from baseline in alkaline phosphatase were -2% (SD 16) in the placebo group, -53% (14) in the seladelpar 50 mg group, and -63% (8) in the seladelpar 200 mg group. Changes in both seladelpar groups versus placebo were significant (p<0·0001 for both groups vs placebo), with no significant difference between the two seladelpar groups (p=0·1729). All five patients who received seladelpar for 12 weeks had normal alkaline phosphatase values at the end of treatment, based on a central laboratory ULN for alkaline phosphatase of 116 U/L. The most frequently reported adverse events were pruritus (16%; one patient on placebo, four on seladelpar 50 mg, and one on seladelpar 200 mg), nausea (13%; one patient on placebo, three on seladelpar 50 mg, and one on seladelpar 200 mg), diarrhoea (10%; two patients on placebo, one on seladelpar 50 mg, and one on seladelpar 200 mg), dyspepsia (8%; two patients on seladelpar 50 mg and one on seladelpar 200 mg), muscle spasms (8%; three patients on seladelpar 200 mg), myalgia (8%; one patient on placebo and two on seladelpar 200 mg), and dizziness (8%; one patient on placebo and two on seladelpar 50 mg). INTERPRETATION Seladelpar normalised alkaline phosphatase levels in patients who completed 12 weeks of treatment. However, treatment was associated with grade 3 increases in aminotransferases and the study was stopped early. The effects of seladelpar should be explored at lower doses. FUNDING CymaBay Therapeutics.
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Affiliation(s)
- David Jones
- University of Newcastle, Newcastle upon Tyne, UK
| | | | - Mark G Swain
- University of Calgary Liver Unit, Calgary, Canada
| | | | | | - Bruce R Bacon
- Saint Louis University Hospital, Saint Louis, MO, USA
| | | | - Norman Gitlin
- Atlanta Gastroenterology Associates, Atlanta, GA, USA
| | | | - Joseph A Odin
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David Sheridan
- Plymouth Hospitals NHS Trust & Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | | | | | | | - Heinz Hartmann
- Gastroenterologische Gemeinschaftspraxis, Herne, Germany
| | - Mark E Jonas
- Ohio Gastroenterology and Liver Institute, Cincinnati, OH, USA
| | - Andreas E Kremer
- Department of Medicine 1, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - George F Mells
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Peter Buggisch
- Institut für interdisziplinäre Medizin Studien GmbH an der Asklepiosklinik Saint Georg, Hamburg, Germany
| | | | - Cynthia Levy
- Division of Hepatology, University of Miami, Miami, FL, USA
| | - John M Vierling
- Advanced Liver Therapies, Baylor College of Medicine, Houston, TX, USA
| | | | - Marek Hartleb
- Department of Gastroenterology and Hepatology, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
| | | | | | - Hemant Shah
- Toronto General Hospital, University Health Network, Toronto, Canada
| | | | - John H Smith
- Digestive and Liver Disease Specialists, Norfolk, VA, USA
| | | | | | | | | | | | | | - Gideon M Hirschfield
- Center for Liver Research, Birmingham NIHR Biomedical Research Center, University of Birmingham, Birmingham, UK
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Smallridge J, Wills AK, Mahmoud O, Chong A, Clark V, Collard M, Sandy JR, Ness AR. Centre-level variation in dental treatment and oral health and individual- and area-level predictors of oral health in 5-year-old children with non-syndromic unilateral cleft lip and palate: the Cleft Care UK study. Part 3. Orthod Craniofac Res 2017; 20 Suppl 2:19-26. [DOI: 10.1111/ocr.12185] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2017] [Indexed: 11/29/2022]
Affiliation(s)
- J. Smallridge
- Cleft.NET.East; Cambridge University Hospitals NHS Foundation trust, Addenbrooke's Hospital; Cambridge UK
| | - A. K. Wills
- National Institute for Health Research (NIHR) Biomedical Research Unit in Nutrition, Diet and Lifestyle; University Hospitals Bristol NHS Foundation Trust and the University of Bristol; Bristol UK
- Bristol Dental School; University of Bristol; Bristol UK
| | - O. Mahmoud
- School of Social and Community Medicine; University of Bristol; Bristol UK
- Department of Applied Statistics; Helwan University; Cairo Egypt
| | - A. Chong
- National Institute for Health Research (NIHR) Biomedical Research Unit in Nutrition, Diet and Lifestyle; University Hospitals Bristol NHS Foundation Trust and the University of Bristol; Bristol UK
| | - V. Clark
- West Midlands Regional Centre for Cleft Lip and Palate; Birmingham Children's Hospital; Birmingham UK
| | | | - J. R. Sandy
- Bristol Dental School; University of Bristol; Bristol UK
| | - A. R. Ness
- National Institute for Health Research (NIHR) Biomedical Research Unit in Nutrition, Diet and Lifestyle; University Hospitals Bristol NHS Foundation Trust and the University of Bristol; Bristol UK
- Bristol Dental School; University of Bristol; Bristol UK
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Ratziu V, Harrison SA, Francque S, Bedossa P, Lehert P, Serfaty L, Romero-Gomez M, Boursier J, Abdelmalek M, Caldwell S, Drenth J, Anstee QM, Hum D, Hanf R, Roudot A, Megnien S, Staels B, Sanyal A, Gournay J, Nguyen-Khac E, De Ledinghen V, Larrey D, Tran A, Bourliere M, Maynard-Muet M, Asselah T, Henrion J, Nevens F, Cassiman D, Geerts A, Moreno C, Beuers U, Galle P, Spengler U, Bugianesi E, Craxi A, Angelico M, Fargion S, Voiculescu M, Gheorghe L, Preotescu L, Caballeria J, Andrade R, Crespo J, Callera J, Ala A, Aithal G, Abouda G, Luketic V, Huang M, Gordon S, Pockros P, Poordad F, Shores N, Moehlen M, Bambha K, Clark V, Satapathy S, Parekh S, Reddy R, Sheikh M, Szabo G, Vierling J, Foster T, Umpierrez G, Chang C, Box T, Gallegos-Orozco J. Elafibranor, an Agonist of the Peroxisome Proliferator-Activated Receptor-α and -δ, Induces Resolution of Nonalcoholic Steatohepatitis Without Fibrosis Worsening. Gastroenterology 2016; 150:1147-1159.e5. [PMID: 26874076 DOI: 10.1053/j.gastro.2016.01.038] [Citation(s) in RCA: 708] [Impact Index Per Article: 88.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 01/27/2016] [Accepted: 01/29/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Elafibranor is an agonist of the peroxisome proliferator-activated receptor-α and peroxisome proliferator-activated receptor-δ. Elafibranor improves insulin sensitivity, glucose homeostasis, and lipid metabolism and reduces inflammation. We assessed the safety and efficacy of elafibranor in an international, randomized, double-blind placebo-controlled trial of patients with nonalcoholic steatohepatitis (NASH). METHODS Patients with NASH without cirrhosis were randomly assigned to groups given elafibranor 80 mg (n = 93), elafibranor 120 mg (n = 91), or placebo (n = 92) each day for 52 weeks at sites in Europe and the United States. Clinical and laboratory evaluations were performed every 2 months during this 1-year period. Liver biopsies were then collected and patients were assessed 3 months later. The primary outcome was resolution of NASH without fibrosis worsening, using protocol-defined and modified definitions. Data from the groups given the different doses of elafibranor were compared with those from the placebo group using step-down logistic regression, adjusting for baseline nonalcoholic fatty liver disease activity score. RESULTS In intention-to-treat analysis, there was no significant difference between the elafibranor and placebo groups in the protocol-defined primary outcome. However, NASH resolved without fibrosis worsening in a higher proportion of patients in the 120-mg elafibranor group vs the placebo group (19% vs 12%; odds ratio = 2.31; 95% confidence interval: 1.02-5.24; P = .045), based on a post-hoc analysis for the modified definition. In post-hoc analyses of patients with nonalcoholic fatty liver disease activity score ≥4 (n = 234), elafibranor 120 mg resolved NASH in larger proportions of patients than placebo based on the protocol definition (20% vs 11%; odds ratio = 3.16; 95% confidence interval: 1.22-8.13; P = .018) and the modified definitions (19% vs 9%; odds ratio = 3.52; 95% confidence interval: 1.32-9.40; P = .013). Patients with NASH resolution after receiving elafibranor 120 mg had reduced liver fibrosis stages compared with those without NASH resolution (mean reduction of 0.65 ± 0.61 in responders for the primary outcome vs an increase of 0.10 ± 0.98 in nonresponders; P < .001). Liver enzymes, lipids, glucose profiles, and markers of systemic inflammation were significantly reduced in the elafibranor 120-mg group vs the placebo group. Elafibranor was well tolerated and did not cause weight gain or cardiac events, but did produce a mild, reversible increase in serum creatinine (effect size vs placebo: increase of 4.31 ± 1.19 μmol/L; P < .001). CONCLUSIONS A post-hoc analysis of data from trial of patients with NASH showed that elafibranor (120 mg/d for 1 year) resolved NASH without fibrosis worsening, based on a modified definition, in the intention-to-treat analysis and in patients with moderate or severe NASH. However, the predefined end point was not met in the intention to treat population. Elafibranor was well tolerated and improved patients' cardiometabolic risk profile. ClinicalTrials.gov number: NCT01694849.
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Affiliation(s)
- Vlad Ratziu
- Université Pierre et Marie Curie, Hôpital Pitié Salpêtrière, Paris, France; Institute of Cardiometabolism and Nutrition, INSERM, UMRS 938, Paris, France.
| | - Stephen A Harrison
- Department of Medicine, Gastroenterology and Hepatology Service, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Sven Francque
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Pierre Bedossa
- Department of Pathology, Hôpital Beaujon, University Paris-Denis Diderot, Paris, France
| | - Philippe Lehert
- Department of Psychiatry, the University of Melbourne, Melbourne, Australia; Faculty of Economics, University of Louvain UCL, Belgique, Belgium
| | - Lawrence Serfaty
- Université Pierre et Marie Curie, Hôpital Saint-Antoine, Paris, France
| | - Manuel Romero-Gomez
- Unit for the Clinical Management of Digestive Diseases and CIBERehd, Hospital Universitario de Valme, Sevilla
| | - Jérôme Boursier
- Hepatology Department, University Hospital and LUNAM University, Angers, France
| | | | - Steve Caldwell
- Gastroenterology and Hepatology Division, University of Virginia, Charlottesville, Virginia
| | - Joost Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Quentin M Anstee
- Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | | | | | | | | | - Bart Staels
- University of Lille, INSERM UMR1011, Institut Pasteur de Lille, European Genomic Institute for Diabetes, Lille, France
| | - Arun Sanyal
- Virginia Commonwealth University, Richmond, Virginia
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Humphrey V, Falzon D, Clark V. Marfan syndrome presenting with postpartum aortic dissection following dural puncture headache and epidural blood patch. Int J Obstet Anesth 2015; 24:197-8. [DOI: 10.1016/j.ijoa.2015.01.009] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 01/23/2015] [Accepted: 01/31/2015] [Indexed: 11/26/2022]
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Breitburg DL, Hondorp D, Audemard C, Carnegie RB, Burrell RB, Trice M, Clark V. Landscape-level variation in disease susceptibility related to shallow-water hypoxia. PLoS One 2015; 10:e0116223. [PMID: 25671595 PMCID: PMC4324988 DOI: 10.1371/journal.pone.0116223] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 12/03/2014] [Indexed: 11/19/2022] Open
Abstract
Diel-cycling hypoxia is widespread in shallow portions of estuaries and lagoons, especially in systems with high nutrient loads resulting from human activities. Far less is known about the effects of this form of hypoxia than deeper-water seasonal or persistent low dissolved oxygen. We examined field patterns of diel-cycling hypoxia and used field and laboratory experiments to test its effects on acquisition and progression of Perkinsus marinus infections in the eastern oyster, Crassostrea virginica, as well as on oyster growth and filtration. P. marinus infections cause the disease known as Dermo, have been responsible for declines in oyster populations, and have limited success of oyster restoration efforts. The severity of diel-cycling hypoxia varied among shallow monitored sites in Chesapeake Bay, and average daily minimum dissolved oxygen was positively correlated with average daily minimum pH. In both field and laboratory experiments, diel-cycling hypoxia increased acquisition and progression of infections, with stronger results found for younger (1-year-old) than older (2-3-year-old) oysters, and more pronounced effects on both infections and growth found in the field than in the laboratory. Filtration by oysters was reduced during brief periods of exposure to severe hypoxia. This should have reduced exposure to waterborne P. marinus, and contributed to the negative relationship found between hypoxia frequency and oyster growth. Negative effects of hypoxia on the host immune response is, therefore, the likely mechanism leading to elevated infections in oysters exposed to hypoxia relative to control treatments. Because there is considerable spatial variation in the frequency and severity of hypoxia, diel-cycling hypoxia may contribute to landscape-level spatial variation in disease dynamics within and among estuarine systems.
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Affiliation(s)
- Denise L. Breitburg
- Smithsonian Environmental Research Center, PO Box 28, Edgewater, MD, 21037, United States of America
| | - Darryl Hondorp
- Smithsonian Environmental Research Center, PO Box 28, Edgewater, MD, 21037, United States of America
- USGS Great Lakes Science Center, 1451 Green Road, Ann Arbor, MI, 48105, United States of America
| | - Corinne Audemard
- Virginia Institute of Marine Science, College of William and Mary, PO Box 1346, Gloucester Point, VA, 23062, United States of America
| | - Ryan B. Carnegie
- Virginia Institute of Marine Science, College of William and Mary, PO Box 1346, Gloucester Point, VA, 23062, United States of America
| | - Rebecca B. Burrell
- Smithsonian Environmental Research Center, PO Box 28, Edgewater, MD, 21037, United States of America
| | - Mark Trice
- Maryland Department of Natural Resources, 580 Taylor Avenue, Annapolis, MD, 21401, United States of America
| | - Virginia Clark
- Smithsonian Environmental Research Center, PO Box 28, Edgewater, MD, 21037, United States of America
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Perron L, Senikas V, Burnett M, Davis V, Bernardin J, Clark V, Davis V, Fisher W, Pellizzari R, Polomeno V, Rutherford M, Sabourin J, Shapiro J, Akhtar S, Camire B, Christilaw J, Corey J, Nelson E, Pierce M, Robertson D, Simmonds A. Female genital cutting. J Obstet Gynaecol Can 2014; 35:1028-1045. [PMID: 24246404 DOI: 10.1016/s1701-2163(15)30792-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [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: 11/29/2022]
Abstract
OBJECTIVE To strengthen the national framework for care of adolescents and women affected by female genital cutting (FGC) in Canada by providing health care professionals with: (1) information intended to strengthen their knowledge and understanding of the practice; (2) directions with regard to the legal issues related to the practice; (3) clinical guidelines for the management of obstetric and gynaecological care, including FGC related complications; and (4) guidance on the provision of culturally competent care to adolescents and women with FGC. EVIDENCE Published literature was retrieved through searches of PubMed, CINAHL, and The Cochrane Library in September 2010 using appropriate controlled vocabulary (e.g., Circumcision, Female) and keywords (e.g., female genital mutilation, clitoridectomy, infibulation). We also searched Social Science Abstracts, Sociological Abstracts, Gender Studies Database, and ProQuest Dissertations and Theses in 2010 and 2011. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to December 2011. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Summary Statements 1. Female genital cutting is internationally recognized as a harmful practice and a violation of girls' and women's rights to life, physical integrity, and health. (II-3) 2. The immediate and long-term health risks and complications of female genital cutting can be serious and life threatening. (II-3) 3. Female genital cutting continues to be practised in many countries, particularly in sub-Saharan Africa, Egypt, and Sudan. (II-3) 4. Global migration patterns have brought female genital cutting to Europe, Australia, New Zealand, and North America, including Canada. (II-3) 5. Performing or assisting in female genital cutting is a criminal offense in Canada. (III) 6. Reporting to appropriate child welfare protection services is mandatory when a child has recently been subjected to female genital cutting or is at risk of being subjected to the procedure. (III) 7. There is concern that female genital cutting continues to be perpetuated in receiving countries, mainly through the act of re-infibulation. (III) 8. There is a perception that the care of women with female genital cutting is not optimal in receiving countries. (III) 9. Female genital cutting is not considered an indication for Caesarean section. (III) Recommendations 1. Health care professionals must be careful not to stigmatize women who have undergone female genital cutting. (III-A) 2. Requests for re-infibulation should be declined. (III-B) 3. Health care professionals should strengthen their understanding and knowledge of female genital cutting and develop greater skills for the management of its complications and the provision of culturally competent care to adolescents and women who have undergone genital cutting. (III-A) 4. Health care professionals should use their knowledge and influence to educate and counsel families against having female genital cutting performed on their daughters and other family members. (III-A) 5. Health care professionals should advocate for the availability of and access to appropriate support and counselling services. (III-A) 6. Health care professionals should lend their voices to community-based initiatives seeking to promote the elimination of female genital cutting. (III-A) 7. Health care professionals should use interactions with patients as opportunities to educate women and their families about female genital cutting and other aspects of women's health and reproductive rights. (III-A) 8. Research into female genital cutting should be undertaken to explore women's perceptions and experiences of accessing sexual and reproductive health care in Canada. (III-A) The perspectives, knowledge, and clinical practice of health care professionals with respect to female genital cutting should also be studied. (III-A). 9. Information and guidance on female genital cutting should be integrated into the curricula for nursing students, medical students, residents, midwifery students, and students of other health care professions. (III-A) 10. Key practices in providing optimal care to women with female genital cutting include: a. determining how the woman refers to the practice of female genital cutting and using this terminology throughout care; (III-C) b. determining the female genital cutting status of the woman and clearly documenting this information in her medical file; (III-C) c. ensuring the availability of a well-trained, trusted, and neutral interpreter who can ensure confidentiality and who will not exert undue influence on the patient-physician interaction when providing care to a woman who faces language challenges; (III-C) d. ensuring the proper documentation of the woman's medical history in her file to minimize the need for repeated medical histories and/or examinations and to facilitate the sharing of information; (III-C) e. providing the woman with appropriate and well-timed information, including information about her reproductive system and her sexual and reproductive health; (III-C) f. ensuring the woman's privacy and confidentiality by limiting attendants in the room to those who are part of the health care team; (III-C) g. providing woman-centred care focused on ensuring that the woman's views and wishes are solicited and respected, including a discussion of why some requests cannot be granted for legal or ethical reasons; (III-C) h. helping the woman to understand and navigate the health system, including access to preventative care practices; (III-C) i. using prenatal visits to prepare the woman and her family for delivery; (III-C) j. when referring, ensuring that the services and/or practitioners who will be receiving the referral can provide culturally competent and sensitive care, paying special attention to concerns related to confidentiality and privacy. (III-C).
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Ramaswamy S, Paul A, Clark V. Two stuck epidural catheters. Anaesthesia 2013; 68:1283-4. [PMID: 24219267 DOI: 10.1111/anae.12424] [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: 11/28/2022]
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Adachi K, Sasaki H, Nagahisa S, Yoshida K, Hattori N, Nishiyama Y, Kawase T, Hasegawa M, Abe M, Hirose Y, Alentorn A, Marie Y, Poggioli S, Alshehhi H, Boisselier B, Carpentier C, Mokhtari K, Capelle L, Figarella-Branger D, Hoang-Xuan K, Sanson M, Delattre JY, Idbaih A, Yust-Katz S, Anderson M, Olar A, Eterovic A, Ezzeddine N, Chen K, Zhao H, Fuller G, Aldape K, de Groot J, Andor N, Harness J, Lopez SG, Fung TL, Mewes HW, Petritsch C, Arivazhagan A, Somasundaram K, Thennarasu K, Pandey P, Anandh B, Santosh V, Chandramouli B, Hegde A, Kondaiah P, Rao M, Bell R, Kang R, Hong C, Song J, Costello J, Bell R, Nagarajan R, Zhang B, Diaz A, Wang T, Song J, Costello J, Bie L, Li Y, Li Y, Liu H, Luyo WFC, Carnero MH, Iruegas MEP, Morell AR, Figueiras MC, Lopez RL, Valverde CF, Chan AKY, Pang JCS, Chung NYF, Li KKW, Poon WS, Chan DTM, Wang Y, Ng HAK, Chaumeil M, Larson P, Yoshihara H, Vigneron D, Nelson S, Pieper R, Phillips J, Ronen S, Clark V, Omay ZE, Serin A, Gunel J, Omay B, Grady C, Youngblood M, Bilguvar K, Baehring J, Piepmeier J, Gutin P, Vortmeyer A, Brennan C, Pamir MN, Kilic T, Krischek B, Simon M, Yasuno K, Gunel M, Cohen AL, Sato M, Aldape KD, Mason C, Diefes K, Heathcock L, Abegglen L, Shrieve D, Couldwell W, Schiffman JD, Colman H, D'Alessandris QG, Cenci T, Martini M, Ricci-Vitiani L, De Maria R, Larocca LM, Pallini R, de Groot J, Theeler B, Aldape K, Lang F, Rao G, Gilbert M, Sulman E, Luthra R, Eterovic K, Chen K, Routbort M, Verhaak R, Mills G, Mendelsohn J, Meric-Bernstam F, Yung A, MacArthur K, Hahn S, Kao G, Lustig R, Alonso-Basanta M, Chandrasekaran S, Wileyto EP, Reyes E, Dorsey J, Fujii K, Kurozumi K, Ichikawa T, Onishi M, Ishida J, Shimazu Y, Kaur B, Chiocca EA, Date I, Geisenberger C, Mock A, Warta R, Schwager C, Hartmann C, von Deimling A, Abdollahi A, Herold-Mende C, Gevaert O, Achrol A, Gholamin S, Mitra S, Westbroek E, Loya J, Mitchell L, Chang S, Steinberg G, Plevritis S, Cheshier S, Gevaert O, Mitchell L, Achrol A, Xu J, Steinberg G, Cheshier S, Napel S, Zaharchuk G, Plevritis S, Gevaert O, Achrol A, Chang S, Harsh G, Steinberg G, Cheshier S, Plevritis S, Gutman D, Holder C, Colen R, Dunn W, Jain R, Cooper L, Hwang S, Flanders A, Brat D, Hayes J, Droop A, Thygesen H, Boissinot M, Westhead D, Short S, Lawler S, Bady P, Kurscheid S, Delorenzi M, Hegi ME, Crosby C, Faulkner C, Smye-Rumsby T, Kurian K, Williams M, Hopkins K, Faulkner C, Palmer A, Williams H, Wragg C, Haynes HR, Williams M, Hopkins K, Kurian KM, Haynes HR, Crosby C, Williams H, White P, Hopkins K, Williams M, Kurian KM, Ishida J, Kurozumi K, Ichikawa T, Onishi M, Fujii K, Shimazu Y, Oka T, Date I, Jalbert L, Elkhaled A, Phillips J, Chang S, Nelson S, Jensen R, Salzman K, Schabel M, Gillespie D, Mumert M, Johnson B, Mazor T, Hong C, Barnes M, Yamamoto S, Ueda H, Tatsuno K, Aihara K, Jalbert L, Nelson S, Bollen A, Hirst M, Marra M, Mukasa A, Saito N, Aburatani H, Berger M, Chang S, Taylor B, Costello J, Popov S, Mackay A, Ingram W, Burford A, Jury A, Vinci M, Jones C, Jones DTW, Hovestadt V, Picelli S, Wang W, Northcott PA, Kool M, Reifenberger G, Pietsch T, Sultan M, Lehrach H, Yaspo ML, Borkhardt A, Landgraf P, Eils R, Korshunov A, Zapatka M, Radlwimmer B, Pfister SM, Lichter P, Joy A, Smirnov I, Reiser M, Shapiro W, Mills G, Kim S, Feuerstein B, Jungk C, Mock A, Geisenberger C, Warta R, Friauf S, Unterberg A, Herold-Mende C, Juratli TA, McElroy J, Meng W, Huebner A, Geiger KD, Krex D, Schackert G, Chakravarti A, Lautenschlaeger T, Kim BY, Jiang W, Beiko J, Prabhu S, DeMonte F, Lang F, Gilbert M, Aldape K, Sawaya R, Cahill D, McCutcheon I, Lau C, Wang L, Terashima K, Yamaguchi S, Burstein M, Sun J, Suzuki T, Nishikawa R, Nakamura H, Natsume A, Terasaka S, Ng HK, Muzny D, Gibbs R, Wheeler D, Lautenschlaeger T, Juratli TA, McElroy J, Meng W, Huebner A, Geiger KD, Krex D, Schackert G, Chakravarti A, Zhang XQ, Sun S, Lam KF, Kiang KMY, Pu JKS, Ho ASW, Leung GKK, Loebel F, Curry WT, Barker FG, Lelic N, Chi AS, Cahill DP, Lu D, Yin J, Teo C, McDonald K, Madhankumar A, Weston C, Slagle-Webb B, Sheehan J, Patel A, Glantz M, Connor J, Maire C, Francis J, Zhang CZ, Jung J, Manzo V, Adalsteinsson V, Homer H, Blumenstiel B, Pedamallu CS, Nickerson E, Ligon A, Love C, Meyerson M, Ligon K, Mazor T, Johnson B, Hong C, Barnes M, Jalbert LE, Nelson SJ, Bollen AW, Smirnov IV, Song JS, Olshen AB, Berger MS, Chang SM, Taylor BS, Costello JF, Mehta S, Armstrong B, Peng S, Bapat A, Berens M, Melendez B, Mollejo M, Mur P, Hernandez-Iglesias T, Fiano C, Ruiz J, Rey JA, Mock A, Stadler V, Schulte A, Lamszus K, Schichor C, Westphal M, Tonn JC, Unterberg A, Herold-Mende C, Morozova O, Katzman S, Grifford M, Salama S, Haussler D, Nagarajan R, Zhang B, Johnson B, Bell R, Olshen A, Fouse S, Diaz A, Smirnov I, Kang R, Wang T, Costello J, Nakamizo S, Sasayama T, Tanaka H, Tanaka K, Mizukawa K, Yoshida M, Kohmura E, Northcott P, Hovestadt V, Jones D, Kool M, Korshunov A, Lichter P, Pfister S, Otani R, Mukasa A, Takayanagi S, Saito K, Tanaka S, Shin M, Saito N, Ozawa T, Riester M, Cheng YK, Huse J, Helmy K, Charles N, Squatrito M, Michor F, Holland E, Perrech M, Dreher L, Rohn G, Goldbrunner R, Timmer M, Pollo B, Palumbo V, Calatozzolo C, Patane M, Nunziata R, Farinotti M, Silvani A, Lodrini S, Finocchiaro G, Lopez E, Rioscovian A, Ruiz R, Siordia G, de Leon AP, Rostomily C, Rostomily R, Silbergeld D, Kolstoe D, Chamberlain M, Silber J, Roth P, Keller A, Hoheisel J, Codo P, Bauer A, Backes C, Leidinger P, Meese E, Thiel E, Korfel A, Weller M, Saito K, Mukasa A, Nagae G, Nagane M, Aihara K, Takayanagi S, Tanaka S, Aburatani H, Saito N, Salama S, Sanborn JZ, Grifford M, Brennan C, Mikkelsen T, Jhanwar S, Chin L, Haussler D, Sasayama T, Tanaka K, Nakamizo S, Nishihara M, Tanaka H, Mizukawa K, Kohmura E, Schliesser M, Grimm C, Weiss E, Claus R, Weichenhan D, Weiler M, Hielscher T, Sahm F, Wiestler B, Klein AC, Blaes J, Weller M, Plass C, Wick W, Stragliotto G, Rahbar A, Soderberg-Naucler C, Sulman E, Won M, Ezhilarasan R, Sun P, Blumenthal D, Vogelbaum M, Colman H, Jenkins R, Chakravarti A, Jeraj R, Brown P, Jaeckle K, Schiff D, Dignam J, Atkins J, Brachman D, Werner-Wasik M, Gilbert M, Mehta M, Aldape K, Terashima K, Shen J, Luan J, Yu A, Suzuki T, Nishikawa R, Matsutani M, Liang Y, Man TK, Lau C, Trister A, Tokita M, Mikheeva S, Mikheev A, Friend S, Rostomily R, van den Bent M, Erdem L, Gorlia T, Taphoorn M, Kros J, Wesseling P, Dubbink H, Ibdaih A, Sanson M, French P, van Thuijl H, Mazor T, Johnson B, Fouse S, Heimans J, Wesseling P, Ylstra B, Reijneveld J, Taylor B, Berger M, Chang S, Costello J, Prabowo A, van Thuijl H, Scheinin I, van Essen H, Spliet W, Ferrier C, van Rijen P, Veersema T, Thom M, Meeteren ASV, Reijneveld J, Ylstra B, Wesseling P, Aronica E, Kim H, Zheng S, Mikkelsen T, Brat DJ, Virk S, Amini S, Sougnez C, Chin L, Barnholtz-Sloan J, Verhaak RGW, Watts C, Sottoriva A, Spiteri I, Piccirillo S, Touloumis A, Collins P, Marioni J, Curtis C, Tavare S, Weiss E, Grimm C, Schliesser M, Hielscher T, Claus R, Sahm F, Wiestler B, Klein AC, Blaes J, Tews B, Weiler M, Weichenhan D, Hartmann C, Weller M, Plass C, Wick W, Yeung TPC, Al-Khazraji B, Morrison L, Hoffman L, Jackson D, Lee TY, Yartsev S, Bauman G, Zheng S, Fu J, Vegesna R, Mao Y, Heathcock LE, Torres-Garcia W, Ezhilarasan R, Wang S, McKenna A, Chin L, Brennan CW, Yung WKA, Weinstein JN, Aldape KD, Sulman EP, Chen K, Koul D, Verhaak RGW. OMICS AND PROGNSTIC MARKERS. Neuro Oncol 2013; 15:iii136-iii155. [PMCID: PMC3823898 DOI: 10.1093/neuonc/not183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023] Open
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Limaye AR, Clark V, Soldevila-Pico C, Morelli G, Suman A, Firpi R, Nelson DR, Cabrera R. Neutrophil-lymphocyte ratio predicts overall and recurrence-free survival after liver transplantation for hepatocellular carcinoma. Hepatol Res 2013; 43. [PMID: 23193965 PMCID: PMC3622781 DOI: 10.1111/hepr.12019] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM The goal of this study is to evaluate whether an elevated neutrophil-lymphocyte ratio (NLR) at the time of diagnosis predicts survival of patients with hepatocellular carcinoma (HCC) after liver transplantation (LT). We hypothesize that the NLR is predictive of overall survival (OS) and recurrence-free survival (RFS) in patients with HCC who undergo LT. METHODS This is a retrospective analysis of adult patients undergoing LT for HCC between 2000 and 2008 at our institution. We define an elevated NLR as a ratio of 5 or greater. RESULTS We included 160 patients who underwent LT for HCC in the time period, of whom 28 had an elevated NLR. Seventeen subjects experienced recurrent HCC during the study period. The cumulative survival among subjects with an elevated NLR was significantly lower than among subjects with a normal NLR. On univariate analysis, several factors (including an elevated NLR) predicted decreased OS and RFS. However, after multivariate analysis, only three factors (including elevated NLR) remained significant as predictors of OS. Additionally, multivariate analysis revealed that an elevated NLR was the only significant independent predictor of RFS. CONCLUSION Preoperative NLR is a powerful independent predictor of OS and RFS in patients undergoing LT for HCC. Measurement of NLR could serve as a useful and easily obtained adjunct to the Model for End-Stage Liver Disease score and Milan criteria when evaluating this patient population and determining which patients will gain the most survival benefit from transplantation.
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Affiliation(s)
- Alpna R. Limaye
- Section of Hepatobiliary Diseases; Department of Gastroenterology; Hepatology and Nutrition; University of Florida; Gainesville; Florida; USA
| | - Virginia Clark
- Section of Hepatobiliary Diseases; Department of Gastroenterology; Hepatology and Nutrition; University of Florida; Gainesville; Florida; USA
| | - Consuelo Soldevila-Pico
- Section of Hepatobiliary Diseases; Department of Gastroenterology; Hepatology and Nutrition; University of Florida; Gainesville; Florida; USA
| | - Giuseppe Morelli
- Section of Hepatobiliary Diseases; Department of Gastroenterology; Hepatology and Nutrition; University of Florida; Gainesville; Florida; USA
| | - Amitabh Suman
- Section of Hepatobiliary Diseases; Department of Gastroenterology; Hepatology and Nutrition; University of Florida; Gainesville; Florida; USA
| | - Roberto Firpi
- Section of Hepatobiliary Diseases; Department of Gastroenterology; Hepatology and Nutrition; University of Florida; Gainesville; Florida; USA
| | - David R. Nelson
- Section of Hepatobiliary Diseases; Department of Gastroenterology; Hepatology and Nutrition; University of Florida; Gainesville; Florida; USA
| | - Roniel Cabrera
- Section of Hepatobiliary Diseases; Department of Gastroenterology; Hepatology and Nutrition; University of Florida; Gainesville; Florida; USA
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Dhanasekaran R, Hemming AW, Zendejas I, George T, Nelson DR, Soldevila-Pico C, Firpi RJ, Morelli G, Clark V, Cabrera R. Treatment outcomes and prognostic factors of intrahepatic cholangiocarcinoma. Oncol Rep 2013; 29:1259-67. [PMID: 23426976 PMCID: PMC3621732 DOI: 10.3892/or.2013.2290] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 01/16/2013] [Indexed: 12/25/2022] Open
Abstract
The aim of the present study was to determine the treatment outcome and prognostic factors for survival in patients with peripheral intrahepatic cholangiocarcinoma (ICC). A retrospective chart review was performed for patients diagnosed with ICC between 2000 and 2009 at a single institution. We identified a total of 105 patients with ICC. Among them, 63.8% were older than 60 years of age, 50.5% were male and 88.6% were Caucasian. By preoperative imaging approximately half of the patients (50.5%) were surgical candidates and underwent resection. The other half of the patients (49.5%) were unresectable. The unresectable group received chemoradiotherapy (53%) and transarterial chemoembolization (7.7%) as palliative treatments while 23.0% of the patients (12/52) received best supportive care alone. The median survival rates were 16.1 months (13.1‑19.2) for the entire cohort, 27.6 months (17.7-37.6) for curative resection, 12.9 months (6.5-19.2) for palliative chemoradiotherapy and 4.9 months (0.4-9.6) for best supportive care (p<0.001). Independent predictors on multivariate analysis were advanced stage at diagnosis and treatment received. In those patients who underwent resection, advanced AJCC stage and presence of microvascular invasion were also independent predictors of poor survival. We concluded that surgery offers the most beneficial curative option and outcome, emphasizing the importance of resectability as a major prognostic factor. The present study also revealed that use of chemoradiotherapy in the adjuvant setting failed to improve survival but its palliative use in those patients with unresectable ICC offered a modest survival advantage over best supportive care. The overriding factors influencing outcome were stage and the presence of microvascular invasion on pathology.
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Cabrera R, Limaye AR, Horne P, Mills R, Soldevila-Pico C, Clark V, Morelli G, Firpi R, Nelson DR. The anti-viral effect of sorafenib in hepatitis C-related hepatocellular carcinoma. Aliment Pharmacol Ther 2013; 37:91-7. [PMID: 23094860 PMCID: PMC3682667 DOI: 10.1111/apt.12098] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 07/11/2012] [Accepted: 10/01/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Sorafenib is currently the only approved systemic therapy shown to have efficacy in the treatment of advanced hepatocellular carcinoma (HCC). Recent studies suggest that hepatitis C (HCV)-related HCC patients derive more clinical benefit from sorafenib than other subgroups, but the mechanism for this effect is unknown. In vitro data suggest that sorafenib may exert anti-viral properties, and thus our aim in this study was to evaluate potential anti-viral activity of sorafenib in patients with HCV-related HCC. AIM To evaluate potential anti-viral activity of sorafenib in patients with HCV-related HCC. METHODS We prospectively enrolled patients with HCV-related HCC treated with sorafenib for up to 6 months. Baseline clinical, viral and oncologic data were collected. Patients' HCV viral loads were obtained at various time points, and compared with their baseline viral levels. No patients received any known anti-viral therapy during this time. RESULTS Thirty-three patients were identified with baseline and subsequent HCV levels available for analysis. Six patients completed 6 months of full dose sorafenib, and comparisons of their HCV viral loads showed no significant change at week 24 (difference of means = 0.3500, CI: -0.1799-0.8799, P = 0.150), or the interim time points. Similarly, the HCV viral loads of all patients who received sorafenib and the viral loads of those patients who had tumour response to sorafenib showed no significant changes at any time point. CONCLUSION Despite preclinical data and previous subgroup analyses suggesting that sorafenib has an anti-viral effect against HCV, this study suggests that sorafenib lacks significant anti-viral activity in HCV patients with HCC.
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Affiliation(s)
- R Cabrera
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, USA.
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Dunn S, Guilbert É, Burnett M, Aggarwal A, Bernardin J, Clark V, Davis V, Dempster J, Fisher W, MacKinnon K, Pellizzari R, Polomeno V, Rutherford M, Sabourin J, Senikas V, Wagner MS. Emergency contraception. Int J Gynaecol Obstet 2012; 120:102-7. [DOI: 10.1016/j.ijgo.2012.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
Despite years of clinical use and extensive research efforts, the mechanism of action of ribavirin (RBV) is not well understood. Although it has only a mild, transient antiviral effect on HCV replication when administered as monotherapy, when combined with interferon, RBV improves sustained virological response (SVR) rates by approximately 25-30%. Proposed mechanisms of action for RBV against HCV include (1) a direct effect against the HCV RNA dependent RNA polymerase; (2) induction of misincorporation of nucleotides leading to lethal mutagenesis; (3) depletion of intracellular pools via inhibition of inosine monophosphate dehydrogenase; (4) alteration in the cytokine balance between a Th2 profile (anti-inflammatory) to a Th1 profile (pro-inflammatory); and (5) potentiating the effect of interferon via up-regulation of genes involved in interferon signalling. Given the lack of a clear understanding of RBV mechanism of action, it has been challenging to confidently position this drug with new direct antiviral agents (DAA). However, early clinical studies provide strong evidence for a benefit of RBV in combination with DAAs for both IFN containing and sparing regimens. The addition of RBV reduces viral breakthroughs and/or relapses, at least when drugs with low to moderate genetic barriers to resistance are paired together. This is particularly true in patients harbouring HCV subtype 1a. Ongoing studies are now addressing the utility of RBV in nucleoside containing DAA regimens, which offer both potent antiviral activity as well as a high genetic barrier to resistance. It is remarkable that the age-old question of the role of RBV in the future of HCV therapy remains as real today as it was two decades ago.
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Affiliation(s)
- Virginia Clark
- University of Florida, College of Medicine; Gainesville; FL; USA
| | - David R. Nelson
- University of Florida, College of Medicine; Gainesville; FL; USA
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Cabrera R, Pannu DS, Caridi J, Firpi RJ, Soldevila-Pico C, Morelli G, Clark V, Suman A, George TJ, Nelson DR. The combination of sorafenib with transarterial chemoembolisation for hepatocellular carcinoma. Aliment Pharmacol Ther 2011; 34:205-13. [PMID: 21605146 PMCID: PMC3807574 DOI: 10.1111/j.1365-2036.2011.04697.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [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] [Indexed: 12/11/2022]
Abstract
BACKGROUND Standard of practice involves using transarterial therapy for multifocal hepatocellular carcinoma (HCC) alone and sorafenib only for more advanced HCC, but the sorafenib and transarterial therapy combination may provide greater efficacy. AIM To evaluate the safety and efficacy of concurrent sorafenib and transarterial therapy in HCC. METHODS Consecutive cases of HCC were treated with sorafenib and transarterial therapy, receiving sorafenib 2 to 4weeks before transarterial therapy. Baseline clinical parameters, adverse events (AEs) and survival were collected. RESULTS A total of 47 patients received sorafenib and transarterial therapy. The majority of the patients were male (70%) with HCV (60%), median age of 60years, good performance status (0-1), stable cirrhosis (Child: A 72%; B 28%), unresectable tumour (stage: B 81%; C 19%) and median AFP of 24ng/mL. Median follow-up was 12months and median time on sorafenib was 6months. LC Bead TACE was used with a median frequency of 3. The majority of the patients (89%) experienced AEs. The most common AEs were fatigue (51%), hand-foot skin reaction (51%) and diarrhoea (43%). Grade 3 and 4 AEs included fatigue (13%) and hand-foot skin reaction (26%). Most patients required a dose reduction (66%). The main AE related to transarterial therapy was post-TACE syndrome (23%). The disease control rate was 68% at 6months. Overall median survival rate was 18.5months (95% CI 16.1-20.9months). CONCLUSION Concurrent sorafenib and transarterial therapy is overall safe with no unexpected side effects and encouraging efficacy that warrants further study.
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Affiliation(s)
- R Cabrera
- Division of Gastroenterology, Hepatology and Nutrition, Section of Hepatobiliary Diseases, Department of Medicine, University of Florida, Gainesville, FL 32610-0214, USA.
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Cabrera R, Pannu DS, Caridi J, Firpi R, Soldevila-Pico C, Morelli G, Clark V, George TJ, Nelson D. Combination of transarterial therapy with sorafenib for hepatocellular carcinoma. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.e14598] [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: 11/20/2022] Open
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Clark V, Burnet N, Jefferies S, Harris F, Jena R. Does the Use of Chemo-radiation Therapy Alter Primary Relapse Patterns for Patients with Glioblastoma? Clin Oncol (R Coll Radiol) 2011. [DOI: 10.1016/j.clon.2011.01.374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Peacock L, Clark V. Cell Salvage in obstetrics: a review of data from the 2007 Scottish Confidential Audit of Severe Maternal Morbidity. Int J Obstet Anesth 2011; 20:196-8. [PMID: 21414771 DOI: 10.1016/j.ijoa.2010.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2010] [Accepted: 12/14/2010] [Indexed: 10/18/2022]
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Singal AK, Stanca CM, Clark V, Dixon L, Levy C, Odin JA, Fiel MI, Friedman SL, Bach N. Natural history of small duct primary sclerosing cholangitis: a case series with review of the literature. Hepatol Int 2011; 5:808-13. [PMID: 21484124 DOI: 10.1007/s12072-011-9260-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2010] [Accepted: 02/04/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Information about the natural history of small duct primary sclerosing cholangitis (SDPSC) remains scant despite literature suggesting that it constitutes 6-16% of all cases of primary sclerosing cholangitis (PSC). We combined clinical data on SDPSC cases from two tertiary care institutions with liver transplantation programs with the aim of studying the natural history of SDPSC. METHODS Medical records of 25 individuals with SDPSC were reviewed. Diagnosis of SDPSC was based on liver biopsy findings consistent with PSC, a normal cholangiogram, and elimination of known causes of secondary sclerosing cholangitis. Demographic information, symptoms, past medical history, laboratory values, and histologic data were evaluated. Our primary outcome measure was liver transplantation or death. Secondary outcome measures included evidence of end-stage liver disease, development of cholangiocarcinoma, and/or the development of classic PSC on a repeat cholangiogram. RESULTS Data on 25 individuals (13 males, 12 females; mean age 40 ± 15 years) diagnosed with SDPSC were analyzed. Upon presentation, 11 patients had symptoms including abdominal pain, fatigue, and pruritus. Inflammatory bowel disease was present in 14 patients (56%) at diagnosis. On initial liver biopsy, 60% had early-stage disease (I or II) and none had cirrhosis. On follow-up (1-168 months, median 17 months), malignancy or progression to classic large duct PSC was not noted. Two (8%) patients had evidence of varices and one of the two also developed ascites; one of these patients underwent liver transplantation and the other one died due to sepsis. CONCLUSIONS SDPSC, a mild disease at presentation typically runs a benign course and likely is not an early stage of classic PSC. Further studies with a control group of classic PSC and longer follow-up are needed to study the natural history of SDPSC.
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Affiliation(s)
- A K Singal
- Department of Gastroenterology, University of Texas Medical Branch, Galveston, TX, USA
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Levy C, Peter JA, Nelson DR, Keach J, Petz J, Cabrera R, Clark V, Firpi RJ, Morelli G, Soldevila-Pico C, Lindor K. Pilot study: fenofibrate for patients with primary biliary cirrhosis and an incomplete response to ursodeoxycholic acid. Aliment Pharmacol Ther 2011; 33:235-42. [PMID: 21083674 DOI: 10.1111/j.1365-2036.2010.04512.x] [Citation(s) in RCA: 108] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Newer therapies are needed for patients with primary biliary cirrhosis and incomplete response to ursodeoxycholic acid (UDCA). Fenofibrate is a fibric acid postulated to regulate immune response and cell proliferation. AIM To evaluate the efficacy and safety of fenofibrate in patients with primary biliary cirrhosis and incomplete response to UDCA. METHODS We undertook a pilot study involving 20 patients with primary biliary cirrhosis and serum alkaline phosphatase (ALP) ≥ 2× ULN. Nonparametric statistical tests and Spearman correlation test were used as appropriate. RESULTS Twenty patients received fenofibrate (160 mg/day) in addition to UDCA for 48 weeks. Median serum ALP decreased significantly at 48 weeks compared with baseline values [351 (214-779) U/L at baseline vs. 177 (60-384) U/L at 48 weeks, P < 0.05]. A rebound in ALP occurred upon drug discontinuation. Serum aspartate aminotransferase and Immunoglobulin M also decreased significantly, while bilirubin and albumin remained unchanged. Median IL-1 decreased from 28.9 (2.7-10 000) to 11.3 (2.5-277.7) pg/mL (P = 0.049), and median IL-6 from 4.6 (3.2-5205) to 3.5 (3.2-73.4) pg/mL (P = 0.027). Heartburn was the most frequent adverse event, leading to discontinuation of two study subjects. CONCLUSIONS Combination therapy of fenofibrate and UDCA induced significant biochemical improvement in patients with primary biliary cirrhosis and incomplete response to UDCA. Further studies are warranted.
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Affiliation(s)
- C Levy
- Department of Medicine, University of Florida, Gainesville, USA.
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Mok M, Heidemann B, Dundas K, Gillespie I, Clark V. Bloodless trilogy? Anesthesia, obstetrics and interventional radiology for cesarean delivery. Int J Obstet Anesth 2010; 19:456; author reply 456-7. [DOI: 10.1016/j.ijoa.2010.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Accepted: 05/23/2010] [Indexed: 10/19/2022]
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Gaidos J, Clark V, Valentine JF. Treatment of chronic hepatitis C in patients with Crohn's disease. Gastroenterol Hepatol (N Y) 2010; 6:527-528. [PMID: 20978558 PMCID: PMC2950671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Savage L, Williams T, Hiles S, Clark V. Gender Variances in Chest Pain Presentation: An Audit of 15805 Patients. Heart Lung Circ 2010. [DOI: 10.1016/j.hlc.2010.06.596] [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: 11/26/2022]
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Deasy J, Clark V, Chen Y, Apte A, Michalski J, Cui J. Development and Validation of an Automated IMRT Treatment Planning Algorithm. Int J Radiat Oncol Biol Phys 2009. [DOI: 10.1016/j.ijrobp.2009.07.1507] [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: 10/20/2022]
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Clark V, Waters J. Blood transfusions: more is not necessarily better. Int J Obstet Anesth 2009; 18:299-301. [DOI: 10.1016/j.ijoa.2009.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Revised: 04/12/2009] [Accepted: 04/22/2009] [Indexed: 11/26/2022]
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Firpi RJ, Clark V, Soldevila-Pico C, Morelli G, Cabrera R, Levy C, Machicao VI, Chaoru C, Nelson DR. The natural history of hepatitis C cirrhosis after liver transplantation. Liver Transpl 2009; 15:1063-71. [PMID: 19718647 DOI: 10.1002/lt.21784] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Hepatitis C after liver transplantation leads to graft cirrhosis in up to 30% of patients within 5 years, but limited data exist regarding the clinical course of cirrhosis after transplantation. The aims of this study were to report the natural history of hepatitis C cirrhosis after liver transplantation and to identify risk factors for decompensation and survival. Hepatitis C patients underwent protocol liver biopsies yearly after liver transplantation. After cirrhosis was identified by biopsy, the outcomes of interest were the development of decompensation, death, or retransplantation for hepatitis C. Kaplan-Meier and Cox regression analysis was used to determine survival and risk factors for decompensation and mortality. Out of 502 liver transplants performed for hepatitis C, 88 patients (18%) had cirrhosis within 3.7 years. Seventy-one patients were compensated at diagnosis. The cumulative probability of decompensation 1 year after cirrhosis was 30%. A Model for End-Stage Liver disease score >or= 16 was predictive of decompensation and poor survival, whereas successful interferon treatment was found to reduce this risk (relative risk = 0.05). Once decompensation occurred, 1-year survival was 46%. In conclusion, the results confirm an accelerated natural history of hepatitis C cirrhosis after liver transplantation and demonstrate poor survival after decompensation. The Model for End-Stage Liver Disease can stratify risk for decompensation and survival, whereas successful antiviral therapy may be protective.
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Affiliation(s)
- Roberto J Firpi
- Section of Hepatobiliary Diseases, Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, FL 32610-0214, USA.
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Abstract
The current standard of care for treatment of hepatitis C is pegylated interferon and ribavirin. Despite the large number of new oral agents under development, interferon will likely remain the backbone of future therapy. Interferon has unique antiviral and immunomodulatory properties, which have been critical in limiting resistance to protease inhibitors and improving efficacy. Hence, optimizing pharmacokinetics and promoting adherence to interferon dosing regimens will become even more critical as new regimens enter the clinical arena. This review highlights novel interferons under development that may offer therapeutic advantages over the formulations currently available.
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Affiliation(s)
- Virginia Clark
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Florida, Gainesville, FL 32610, USA
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Brar S, Tang S, Drummond N, Palacios-Derflingher L, Clark V, John M, Ross S. Perinatal Care for South Asian Immigrant Women and Women Born in Canada: Telephone Survey of Users. Journal of Obstetrics and Gynaecology Canada 2009; 31:708-716. [DOI: 10.1016/s1701-2163(16)34274-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Lieberman R, Snyder C, Clark V, Lynch H, Holt J. Detecting BRCA2 protein truncation in breast tissue biopsies to identify hereditary cancer. Cancer Res 2009. [DOI: 10.1158/0008-5472.sabcs-501] [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: 11/16/2022]
Abstract
Abstract
Abstract #501
Background: Mutations in the BRCA2 gene are dominantly inherited but cause cancers when the wildtype allele has LOH (loss of heterozygosity) within the cancer. It is important to identify breast cancer patients with BRCA mutations so they can be appropriately treated and affected family members can implement cancer prevention strategies. Because most disease-associated BRCA2 mutations are truncating mutations, a test for truncated BRCA2 proteins should identify most BRCA2 hereditary cancers. Methods: We have developed a tissue truncation test to identify truncated BRCA2 proteins in breast cancer tissue biopsies by direct immunohistochemistry, without amplification or genetic manipulations. N-terminal and C-terminal antibodies are used to visualize protein truncation by demonstrating that the beginning of the protein is present but the end (terminus) is absent. Results: A quantitative C-terminal immunostaining score or a C/N terminal truncation ratio correctly classified 20/21 breast cancers from BRCA2 mutation carriers and 57/58 sporadic breast cancers. This represents a sensitivity of 95% and specificity of 98%. Figure 1 shows a loss of C-terminal staining (except for a lymphocyte) in the upper panel but strong N-terminal staining in the lower panel sections of the same hereditary breast cancer.
 
 Due to the presence of C-terminal BRCA2 protein and atypical clinical features of the misclassifed cancer in a BRCA2 mutation carrier,we performed PCR and sequence analyses on this cancer. The results showed continued presence of the BRCA2 wildtype allele in the cancer, indicating that this represents a sporadic cancer which occurred in a mutation carrier. Conclusions: This immunohistochemistry based test (which takes only 4 hours) appears to identify BRCA2 hereditary cancer with high accuracy. The test also appears to diagnose the biochemical loss of BRCA2 protein in cancers (BRCA2 mutant genotype) which will usually but not always agree with the presence of a germline BRCA2 mutation found by susceptibility testing by DNA sequencing of blood samples. This rapid but accurate tissue test can diagnose hereditary BRCA2 breast cancer at time of biopsy, allowing medical oncologists to implement targeted therapies and surgeons to perform timely prophylactic surgery without the usual 4 week wait for DNA sequencing results.
Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 501.
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Affiliation(s)
- R Lieberman
- 1 Pathology, University of Colorado Health Sciences, Aurora, CO
- 2 Preventive Medicine, Creighton University, Omaha, NE
| | - C Snyder
- 1 Pathology, University of Colorado Health Sciences, Aurora, CO
- 2 Preventive Medicine, Creighton University, Omaha, NE
| | - V Clark
- 1 Pathology, University of Colorado Health Sciences, Aurora, CO
- 2 Preventive Medicine, Creighton University, Omaha, NE
| | - H Lynch
- 1 Pathology, University of Colorado Health Sciences, Aurora, CO
- 2 Preventive Medicine, Creighton University, Omaha, NE
| | - J Holt
- 1 Pathology, University of Colorado Health Sciences, Aurora, CO
- 2 Preventive Medicine, Creighton University, Omaha, NE
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Abstract
Background Concerns about the safety and supply of donor blood mean that clinicians are increasingly looking for alternatives to allogenic blood transfusion. One such alternative is cell salvage. Theoretical concerns about the safety of giving salvaged blood to obstetric patients have so far limited its use in maternity patients, but its use in obstetrics is now growing. Aims To determine how many Scottish maternity units use cell salvage and what barriers anaesthetists see to its use in obstetrics. Methods A survey was posted to one consultant anaesthetist at each of Scotland's 18 consultant led maternity units. Results Two out of 18 maternity units in Scotland use cell salvage. Perceived barriers to use include lack of machine, insufficient cases and lack of familiarity with the technology. Only 4/15 anaesthetists saw safety concerns as a barrier to using the technology. Conclusion It would appear that practical issues such as staff training and maintaining familiarity with the technology are greater barriers to the use of cell salvage during obstetric procedures than concerns over safety or financial costs. Although cell salvage would appear to be safe, its use in obstetrics must be accompanied by ongoing audit and detailed data should be collected for each case.
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Affiliation(s)
- M Harkness
- Transfusion Research Nurse/Midwife, Better Blood Transfusion Programme, Scottish National Blood Transfusion Service, Ellen's Glen Road, Edinburgh, EH17 7QT
| | - V Clark
- Consultant Anaesthetist, Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh, Little France, Edinburgh, EH16 4SA
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Mok M, Heidemann B, Dundas K, Gillespie I, Clark V. Interventional radiology in women with suspected placenta accreta undergoing caesarean section. Int J Obstet Anesth 2008; 17:255-61. [DOI: 10.1016/j.ijoa.2007.11.010] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2007] [Accepted: 11/01/2007] [Indexed: 11/25/2022]
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Clark V, Chen Y, Fergus S, Deasy J. TU-EE-A2-04: Increasing the Efficiency and Radiobiological Relevance of IMRT Treatment Planning: Replacing Dose-Volume Thresholds with Generalized Equivalent Uniform Dose Or Mean-Tail-Dose Metrics. Med Phys 2008. [DOI: 10.1118/1.2962614] [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: 11/07/2022] Open
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Clark V. Obstetric Anesthesia. Br J Anaesth 2008. [DOI: 10.1093/bja/aen118] [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: 11/13/2022] Open
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