1
|
Thomas AR, Levy PT, Sperotto F, Braudis N, Valencia E, DiNardo JA, Friedman K, Kheir JN. Arch watch: current approaches and opportunities for improvement. J Perinatol 2024; 44:325-332. [PMID: 38129600 DOI: 10.1038/s41372-023-01854-7] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/03/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023]
Abstract
Coarctation of the aorta (CoA) is a ductus arteriosus (DA)-dependent form of congenital heart disease (CHD) characterized by narrowing in the region of the aortic isthmus. CoA is a challenging diagnosis to make prenatally and is the critical cardiac lesion most likely to go undetected on the pulse oximetry-based newborn critical CHD screen. When undetected CoA causes obstruction to blood flow, life-threatening cardiovascular collapse may result, with a high burden of morbidity and mortality. Hemodynamic monitoring practices during DA closure (known as an "arch watch") vary across institutions and existing tools are often insensitive to developing arch obstruction. Novel measures of tissue oxygenation and oxygen deprivation may improve sensitivity and specificity for identifying evolving hemodynamic compromise in the newborn with CoA. We explore the benefits and limitations of existing and new tools to monitor the physiological changes of the aorta as the DA closes in infants at risk of CoA.
Collapse
Affiliation(s)
- Alyssa R Thomas
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Philip T Levy
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Francesca Sperotto
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Nancy Braudis
- Department of Nursing, Boston Children's Hospital, Boston, MA, USA
| | - Eleonore Valencia
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - James A DiNardo
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Kevin Friedman
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - John N Kheir
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| |
Collapse
|
2
|
Thomas AR, Levy PT, Donofrio MT, Law B, Joynt C, Gupta R, Elshenawy S, Reed D, Pavlek LR, Shepherd J, Gowda SH, Johnson BA, Abdulhayoglu E, Valencia E, Guseh S, Ball MK, Ali N. Call to action: prioritizing delivery room care for neonates with critical congenital heart disease. J Perinatol 2024; 44:321-324. [PMID: 37980393 DOI: 10.1038/s41372-023-01828-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/01/2023] [Accepted: 11/07/2023] [Indexed: 11/20/2023]
Affiliation(s)
- Alyssa R Thomas
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Philip T Levy
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mary T Donofrio
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Brenda Law
- Division of Neonatology, Department of Pediatrics, Stollery Children's Hospital/University of Alberta, Edmonton, AB, Canada
| | - Chloe Joynt
- Division of Neonatology, Department of Pediatrics, Stollery Children's Hospital/University of Alberta, Edmonton, AB, Canada
| | - Ruby Gupta
- Division of Neonatology, Department of Pediatrics, Children's Wisconsin, Milwaukee, WI, USA
| | - Summer Elshenawy
- Division of Neonatology, Department of Pediatrics, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, USA
| | - Danielle Reed
- Division of Neonatology, Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, MO, USA
| | - Leeann R Pavlek
- Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Jennifer Shepherd
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Sharada H Gowda
- Division of Neonatology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Beth Ann Johnson
- Division of Neonatology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Elisa Abdulhayoglu
- Department of Pediatrics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eleonore Valencia
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephanie Guseh
- Division of Maternal Fetal Medicine, Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Molly K Ball
- Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Noorjahan Ali
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern, Dallas, TX, USA
| |
Collapse
|
3
|
Levy P, Thomas AR, Law BHY, Joynt C, Gupta R, Elshenawy S, Reed D, Pavlek LR, Shepherd J, Gowda S, Johnson BA, Ball M, Ali N. Multicentre study protocol comparing standard NRP to deveLoped Educational Modules for Resuscitation of Neonates in the Delivery Room with Congenital Heart Disease (LEARN-CHD). BMJ Open 2023; 13:e067391. [PMID: 37019485 PMCID: PMC10083808 DOI: 10.1136/bmjopen-2022-067391] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
INTRODUCTION Infants born with critical congenital heart defects (CCHDs) have unique transitional pathophysiology that often requires special resuscitation and management considerations in the delivery room (DR). While much is known about neonatal resuscitation of infants with CCHDs, current neonatal resuscitation guidelines such as the neonatal resuscitation programme (NRP) do not include algorithm modifications or education specific to CCHDs. The implementation of CCHD specific neonatal resuscitation education is further hampered by the large number of healthcare providers (HCPs) that need to be reached. Online learning modules (eLearning) may provide a solution but have not been designed or tested for this specific learning need. Our objective in this study is to design targeted eLearning modules for DR resuscitation of infants with specific CCHDs and compare HCP knowledge and team performance in simulated resuscitations among HCPs exposed to these modules compared with directed CCHD readings. METHODS AND ANALYSIS In a prospective multicentre trial, HCP proficient in standard NRP education curriculum are randomised to either (a) directed CCHD readings or (b) CCHD eLearning modules developed by the study team. The efficacy of these modules will be evaluated using (a) individual preknowledge/postknowledge testing and (b) team-based resuscitation simulations. ETHICS AND DISSEMINATION This study protocol is approved by nine participating sites: the Boston Children's Hospital Institutional Review Board (IRB-P00042003), University of Alberta Research Ethics Board (Pro00114424), the Children's Wisconsin IRB (1760009-1), Nationwide Children's Hospital IRB (STUDY00001518), Milwaukee Children's IRB (1760009-1) and University of Texas Southwestern IRB (STU-2021-0457) and is under review at following sites: University of Cincinnati, Children's Healthcare of Atlanta, Children's Hospital of Los Angeles and Children's Mercy-Kansas City. Study results will be disseminated to participating individuals in a lay format and presented to the scientific community at paediatric and critical care conferences and published in relevant peer-reviewed journals.
Collapse
Affiliation(s)
- Philip Levy
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Alyssa R Thomas
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Brenda Hiu Yan Law
- Department of Pediatrics, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Chloe Joynt
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Ruby Gupta
- Department of Pediatrics, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Summer Elshenawy
- Department of Pediatrics, Emory University School of Medicine Atlanta, Atlanta, Georgia, USA
| | - Danielle Reed
- Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, Missouri, USA
| | - Leeann R Pavlek
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Jennifer Shepherd
- Department of Pediatrics, Keck School of Medicine University of Southern California, Los Angeles, California, USA
| | - Sharada Gowda
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Beth Ann Johnson
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Molly Ball
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Noorjahan Ali
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
4
|
Levy PT, Thomas AR, Wethall A, Perez D, Steurer M, Ball MK. Rethinking Congenital Heart Disease in Preterm Neonates. Neoreviews 2022; 23:e373-e387. [PMID: 35641458 DOI: 10.1542/neo.23-6-e373] [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: 11/24/2022]
Abstract
Congenital heart disease (CHD) and prematurity are the leading causes of infant mortality in the United States. Importantly, the combination of prematurity and CHD results in a further increased risk of mortality and significant morbidity. The key factors in these adverse outcomes are not well understood, but likely include maternal-fetal environment, perinatal and neonatal elements, and challenging postnatal care. Preterm neonates with CHD are born with "double jeopardy": not only do they experience challenges related to immaturity of the lungs, brain, and other organs, but they also must undergo treatment for cardiac disease. The role of the neonatologist caring for preterm infants with CHD has changed with the evolution of the field of pediatric cardiac critical care. Increasingly, neonatologists invested in the cardiovascular care of the newborn with CHD engage at multiple stages in their course, including fetal consultation, delivery room management, preoperative care, and postoperative treatment. A more comprehensive understanding of prematurity and CHD may inform clinical practice and ultimately improve outcomes in preterm infants with CHD. In this review, we discuss the current evidence surrounding neonatal and cardiac outcomes in preterm infants with CHD; examine the prenatal, perinatal, and postnatal factors recognized to influence these outcomes; identify knowledge gaps; consider research and clinical opportunities; and highlight the ways in which a neonatologist can contribute to the care of preterm infants with CHD.
Collapse
Affiliation(s)
- Philip T Levy
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Alyssa R Thomas
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Ashley Wethall
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Danielle Perez
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Martina Steurer
- Department of Pediatrics, University of California San Francisco, San Francisco, CA.,Department of Epidemiology and Biostatistics, California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA
| | - Molly K Ball
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH.,Division of Neonatology, The Ohio State University Wexner Medical Center, Columbus, OH
| |
Collapse
|
5
|
Dijkman C, Thomas AR, Koenraadt KLM, Ermens AAM, van Geenen RCI. Synovial neutrophilic gelatinase-associated lipocalin in the diagnosis of periprosthetic joint infection after total knee arthroplasty. Arch Orthop Trauma Surg 2020; 140:941-947. [PMID: 32222802 DOI: 10.1007/s00402-020-03427-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 05/06/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is one of the most serious complications following total knee arthroplasty (TKA). However, the diagnosis remains a challenge for clinicians. In 2011, the muscoskeletal infection society (MSIS) criteria provided a consensus which has been updated in 2013, but these criteria are complex and contain tests that are time-consuming. The same is applicable to the pro-Implant guidelines. Therefore, a simpler diagnostic test is desirable. OBJECTIVES The value of neutrophil gelatinase-associated lipocalin (NGAL), leucocyte esterase (LE) levels, and the white blood cell (WBC) count in synovial fluid to diagnose PJI after TKA was evaluated. METHODS In a retrospective cohort study, we analyzed 89 synovial fluid samples from 86 patients with suspected PJI after TKA. Thirteen and 23 of those samples were classified as PJI according to the MSIS and pro-Implant criteria, respectively. Subsequently, NGAL, LE levels, and the WBC count were determined, the former one using an immunoassay. Using either the MSIS or pro-Implant criteria as the golden standard for PJI, sensitivity and specificity of those markers were determined with ROC curves, and medians were compared with Mann-Whitney U and Pearson Chi-square tests. RESULTS When applying the MSIS criteria, NGAL revealed 92% sensitivity and 83% specificity. WBC count showed similar sensitivity (92%) and specificity (84%), whereas sensitivity and specificity for LE were 39% and 88% respectively. When applying the pro-Implant criteria, sensitivity was 95% and specificity was 95% for NGAL. Sensitivity and specificity for WBC count were 100% and 97% and for LE 39% and 92% respectively. CONCLUSION NGAL and WBC count in synovial fluid has high accuracy in the diagnosis of PJI after TKA and should seriously be considered as part of PJI diagnostics. Leucocyte esterase can serve as rule-in criterion peroperatively. These conclusions are independent of which criteria set was used as golden standard.
Collapse
Affiliation(s)
- C Dijkman
- Department of Orthopaedic Surgery, Amphia Hospital, Breda, The Netherlands.
| | - A R Thomas
- Department of Orthopaedic Surgery, Amphia Hospital, Breda, The Netherlands
| | - K L M Koenraadt
- Department of Orthopaedic Surgery, Amphia Hospital, Breda, The Netherlands.,Foundation for Orthopedic Research Care and Education, Amphia Hospital, Breda, The Netherlands
| | - A A M Ermens
- Laboratory for Clinical Chemistry and Hematology, Amphia Hospital, Breda, The Netherlands
| | - R C I van Geenen
- Department of Orthopaedic Surgery, Amphia Hospital, Breda, The Netherlands.,Foundation for Orthopedic Research Care and Education, Amphia Hospital, Breda, The Netherlands
| |
Collapse
|
6
|
Abstract
Reflective practice may ameliorate the burnout, empathy loss, and depression that medical students experience during clerkships. We describe a student-led reflective writing workshop in a safe and structured small group setting. We provide twelve tips for implementing such a workshop, informed by the existing literature on reflective writing and near-peer teaching, which include developing writing prompts, guiding student facilitators, and obtaining feedback. Common topics include patient suffering, workplace dynamics, and the joys of practicing medicine. Participants develop camaraderie with peers as well as tools they can carry forward as they continue to process the challenging experiences intrinsic to clinical medicine.
Collapse
Affiliation(s)
- Andi Shahu
- Department of Medicine, Johns Hopkins Hospital, Baltimore, MD USA
| | - Alyssa R. Thomas
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Eli Neustadter
- Yale School of Medicine, 333 Cedar Street, New Haven, CT 06511 USA
| | - Anna Reisman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT USA
| |
Collapse
|
7
|
Thomas AR, Lacadie C, Vohr B, Ment LR, Scheinost D. Fine Motor Skill Mediates Visual Memory Ability with Microstructural Neuro-correlates in Cerebellar Peduncles in Prematurely Born Adolescents. Cereb Cortex 2018; 27:322-329. [PMID: 28108493 PMCID: PMC5939198 DOI: 10.1093/cercor/bhw415] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Indexed: 12/22/2022] Open
Abstract
Adolescents born preterm (PT) with no evidence of neonatal brain injury are at risk of deficits in visual memory and fine motor skills that diminish academic performance. The association between these deficits and white matter microstructure is relatively unexplored. We studied 190 PTs with no brain injury and 92 term controls at age 16 years. The Rey-Osterrieth Complex Figure Test (ROCF), the Beery visual-motor integration (VMI), and the Grooved Pegboard Test (GPT) were collected for all participants, while a subset (40 PTs and 40 terms) underwent diffusion-weighted magnetic resonance imaging. PTs performed more poorly than terms on ROCF, VMI, and GPT (all P < 0.01). Mediation analysis showed fine motor skill (GPT score) significantly mediates group difference in ROCF and VMI (all P < 0.001). PTs showed a negative correlation (P < 0.05, corrected) between fractional anisotropy (FA) in the bilateral middle cerebellar peduncles and GPT score, with higher FA correlating to lower (faster task completion) GPT scores, and between FA in the right superior cerebellar peduncle and ROCF scores. PTs also had a positive correlation (P < 0.05, corrected) between VMI and left middle cerebellar peduncle FA. Novel strategies to target fine motor skills and the cerebellum may help PTs reach their full academic potential.
Collapse
Affiliation(s)
- Alyssa R Thomas
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Cheryl Lacadie
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Betty Vohr
- Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Laura R Ment
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA.,Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Dustin Scheinost
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|
8
|
Kim RK, Thomas AR, Card ME, Malhotra D, Holleck JL. Four Cancers and a Rash: Henoch-Schönlein Purpura. Am J Med 2017; 130:1158-1160. [PMID: 28711558 DOI: 10.1016/j.amjmed.2017.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 03/15/2017] [Revised: 06/06/2017] [Accepted: 06/06/2017] [Indexed: 01/12/2023]
Affiliation(s)
- Richard K Kim
- Department of Internal Medicine, Yale-New Haven Hospital, New Haven, Conn.
| | | | | | - Divyanshu Malhotra
- Department of Internal Medicine, Yale-New Haven Hospital, New Haven, Conn; Section of Nephrology, Yale-New Haven Hospital, New Haven, Conn
| | - Jürgen L Holleck
- Department of Internal Medicine, Yale-New Haven Hospital, New Haven, Conn; Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, Conn
| |
Collapse
|
9
|
Maguire LH, Thomas AR, Goldstein AM. Tumors of the neural crest: Common themes in development and cancer. Dev Dyn 2014; 244:311-22. [PMID: 25382669 DOI: 10.1002/dvdy.24226] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 10/31/2014] [Accepted: 11/03/2014] [Indexed: 12/17/2022] Open
Abstract
The neural crest (NC) is a remarkable transient structure in the vertebrate embryo that gives rise to a highly versatile population of pluripotent cells that contribute to the formation of multiple tissues and organs throughout the body. In order to achieve their task, NC-derived cells have developed specialized mechanisms to promote (1) their transition from an epithelial to a mesenchymal phenotype, (2) their capacity for extensive migration and cell proliferation, and (3) their ability to produce diverse cell types largely depending on the microenvironment encountered during and after their migratory path. Following embryogenesis, these same features of cellular motility, invasion, and proliferation can become a liability by contributing to tumorigenesis and metastasis. Ample evidence has shown that cancer cells have cleverly co-opted many of the genetic and molecular features used by developing NC cells. This review focuses on tumors that arise from NC-derived tissues and examines mechanistic themes shared during their oncogenic and metastatic development with embryonic NC cell ontogeny.
Collapse
Affiliation(s)
- Lillias H Maguire
- Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | |
Collapse
|
10
|
Badizadegan K, Thomas AR, Nagy N, Ndishabandi D, Miller SA, Alessandrini A, Belkind-Gerson J, Goldstein AM. Presence of intramucosal neuroglial cells in normal and aganglionic human colon. Am J Physiol Gastrointest Liver Physiol 2014; 307:G1002-12. [PMID: 25214400 PMCID: PMC7864228 DOI: 10.1152/ajpgi.00164.2014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [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: 02/08/2023]
Abstract
The enteric nervous system (ENS) is composed of neural crest-derived neurons (also known as ganglion cells) the cell bodies of which are located in the submucosal and myenteric plexuses of the intestinal wall. Intramucosal ganglion cells are known to exist but are rare and often considered ectopic. Also derived from the neural crest are enteric glial cells that populate the ganglia and the associated nerves, as well as the lamina propria of the intestinal mucosa. In Hirschsprung disease (HSCR), ganglion cells are absent from the distal gut because of a failure of neural crest-derived progenitor cells to complete their rostrocaudal migration during embryogenesis. The fate of intramucosal glial cells in human HSCR is essentially unknown. We demonstrate a network of intramucosal cells that exhibit dendritic morphology typical of neurons and glial cells. These dendritic cells are present throughout the human gut and express Tuj1, S100, glial fibrillary acidic protein, CD56, synaptophysin, and calretinin, consistent with mixed or overlapping neuroglial differentiation. The cells are present in aganglionic colon from patients with HSCR, but with an altered immunophenotype. Coexpression of Tuj1 and HNK1 in this cell population supports a neural crest origin. These findings extend and challenge the current understanding of ENS microanatomy and suggest the existence of an intramucosal population of neural crest-derived cells, present in HSCR, with overlapping immunophenotype of neurons and glia. Intramucosal neuroglial cells have not been previously recognized, and their presence in HSCR poses new questions about ENS development and the pathobiology of HSCR that merit further investigation.
Collapse
Affiliation(s)
- Kamran Badizadegan
- 1Department of Pathology and Laboratory Medicine, Nemours Children's Hospital, Orlando, Florida;
| | - Alyssa R. Thomas
- 2Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts;
| | - Nandor Nagy
- 2Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; ,3Department of Human Morphology and Developmental Biology, Faculty of Medicine, Semmelweis University, Budapest, Hungary; and
| | - Dorothy Ndishabandi
- 2Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts;
| | - Sarah A. Miller
- 2Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts;
| | - Alessandro Alessandrini
- 2Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts;
| | - Jaime Belkind-Gerson
- 4Division of Pediatric Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Allan M. Goldstein
- 2Department of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts;
| |
Collapse
|
11
|
Hotta R, Thomas AR, Pan W, Belkind-Gerson J, Goldstein AM. Transplantation of Enteric Neuronal Precursors to Restore Enteric Innervation in Hirschsprung Disease. J Am Coll Surg 2014. [DOI: 10.1016/j.jamcollsurg.2014.07.321] [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: 12/01/2022]
|
12
|
Thiagarajah JR, Yildiz H, Carlson T, Thomas AR, Steiger C, Pieretti A, Zukerberg LR, Carrier RL, Goldstein AM. Altered goblet cell differentiation and surface mucus properties in Hirschsprung disease. PLoS One 2014; 9:e99944. [PMID: 24945437 PMCID: PMC4063789 DOI: 10.1371/journal.pone.0099944] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 05/07/2014] [Indexed: 02/07/2023] Open
Abstract
Hirschsprung disease-associated enterocolitis (HAEC) leads to significant mortality and morbidity, but its pathogenesis remains unknown. Changes in the colonic epithelium related to goblet cells and the luminal mucus layer have been postulated to play a key role. Here we show that the colonic epithelium of both aganglionic and ganglionic segments are altered in patients and in mice with Hirschsprung disease (HSCR). Structurally, goblet cells were altered with increased goblet cell number and reduced intracellular mucins in the distal colon of biopsies from patients with HSCR. Endothelin receptor B (Ednrb) mutant mice showed increased goblet cell number and size and increased cell proliferation compared to wild-type mice in aganglionic segments, and reduced goblet cell size and number in ganglionic segments. Functionally, compared to littermates, Ednrb−/− mice showed increased transepithelial resistance, reduced stool water content and similar chloride secretion in the distal colon. Transcript levels of goblet cell differentiation factors SPDEF and Math1 were increased in the distal colon of Ednrb−/− mice. Both distal colon from Ednrb mice and biopsies from HSCR patients showed reduced Muc4 expression as compared to controls, but similar expression of Muc2. Particle tracking studies showed that mucus from Ednrb−/− mice provided a more significant barrier to diffusion of 200 nm nanoparticles as compared to wild-type mice. These results suggest that aganglionosis is associated with increased goblet cell proliferation and differentiation and subsequent altered surface mucus properties, prior to the development of inflammation in the distal colon epithelium. Restoration of normal goblet cell function and mucus layer properties in the colonic epithelium may represent a therapeutic strategy for prevention of HAEC.
Collapse
Affiliation(s)
- Jay R. Thiagarajah
- Department of Gastroenterology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts, United States of America
| | - Hasan Yildiz
- Department of Chemical Engineering, Northeastern University, Boston, Massachusetts, United States of America
| | - Taylor Carlson
- Department of Chemical Engineering, Northeastern University, Boston, Massachusetts, United States of America
| | - Alyssa R. Thomas
- Department of Pediatric Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Casey Steiger
- Department of Pediatric Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Alberto Pieretti
- Department of Pediatric Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Lawrence R. Zukerberg
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Rebecca L. Carrier
- Department of Chemical Engineering, Northeastern University, Boston, Massachusetts, United States of America
| | - Allan M. Goldstein
- Department of Pediatric Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- * E-mail:
| |
Collapse
|
13
|
Abstract
BACKGROUND The authors examined the association of patterns of soft drink consumption and primary tooth extractions in Queensland children aged 12 years or less. METHODS Data were gathered through the Child Health Surveys conducted by Queensland Health in 2003 and 2008. The analysis allowed for various demographic characteristics using logistic regression analysis. RESULTS The data in both surveys showed an increased risk of tooth extraction in children who had a greater frequency and amount of soft drink consumption, and those that consumed soft drink between meals. In 2008, the percentage of children that had soft drink daily or several times a week had decreased, with an increase in those that never had soft drink. CONCLUSIONS To reduce the risk of primary tooth extraction due to decay, this paper recommends the continuing moderation of soft drink consumption frequency and the consumption of soft drinks with, rather than between, meals.
Collapse
Affiliation(s)
- P J Slater
- Office of the Chief Dental Officer, Queensland Health, Brisbane, Queensland.
| | | | | | | |
Collapse
|
14
|
Thomas AR, Marcus M, Zhang RH, Blanck HM, Tolbert PE, Hertzberg V, Henderson AK, Rubin C. Breast-feeding among women exposed to polybrominated biphenyls in Michigan. Environ Health Perspect 2001; 109:1133-7. [PMID: 11712998 PMCID: PMC1240474 DOI: 10.1289/ehp.01109133] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
In the early 1970s, the largest industrial accident in the United States resulted in widespread contamination of the food supply in Michigan with polybrominated biphenyls (PBBs). The chemical similarity of PBBs to compounds implicated as endocrine disruptors has raised the question of whether PBBs could affect the reproductive system. In the present analysis we examine the relation between serum measurements of PBBs and the frequency and duration of lactation. Persons who lived on or received food from farms exposed to PBBs were enrolled in a registry by the Michigan Department of Public Health. Female members of the cohort were invited to participate in a telephone survey of reproductive outcomes. The three outcomes of interest in the present analysis were a) the decision to breast-feed (yes/no); b) the duration, in months, of breast-feeding as the main source of nutrition; and c) the total duration, in months, of breast-feeding. None of the three outcomes was significantly associated with serum PBB levels, even after controlling for maternal age, previous history of breast-feeding, body mass index, maternal education, household income, history of smoking in the year before pregnancy, consumption of alcohol during the first trimester of pregnancy, history of thyroid disorder, gestational age of the infant in weeks, time to pregnancy, and year of birth.
Collapse
Affiliation(s)
- A R Thomas
- Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | | | | | | | | | | | | |
Collapse
|
15
|
Thomas AR, Naudé RJ, Oelofsen W, Naganuma T, Muramoto K. Purification and partial characterisation of alpha(2)-antiplasmin and plasmin(ogen) from ostrich plasma. Comp Biochem Physiol B Biochem Mol Biol 2001; 129:809-20. [PMID: 11435135 DOI: 10.1016/s1096-4959(01)00396-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This study reports the isolation and partial characterisation of the ostrich serpin, alpha(2)AP, and its target enzyme, ostrich plasmin, in its active and inactive proenzyme, namely plasminogen, forms. Ostrich alpha(2)AP was purified using L-lysine-Sepharose chromatography, ammonium sulfate fractionation, and Super Q-650S and ostrich LBSI-Sepharose chromatographies. It revealed a M(r) of 84 K (thousand) and had one and two N-terminal amino acids in common with 11 of those of human and bovine alpha(2)AP, respectively. It showed the largest inhibitory effect on ostrich plasmin, followed by bovine trypsin and plasmin, respectively, and much less plasmin inhibition than bovine aprotinin, but much more so than human alpha(2)AP, DFP and EACA. Ostrich plasminogen was highly purified after L-lysine-Sepharose chromatography and showed a M(r) of 92 K, a total of 775 amino acids and its N-terminal sequence showed approximately 53% identity with those of human, rabbit, cat, and ox plasminogens. Ostrich plasmin, obtained by the urokinase-activation of ostrich plasminogen, revealed a M(r) of 78 K, a total of 638 amino acids, an N-terminal sequence showing two to four residues identical to five of those of human, cat, dog, rabbit, and ox plasmins, and pH and temperature optima of 8.0 and 40 degrees C, respectively.
Collapse
Affiliation(s)
- A R Thomas
- Department of Biochemistry and Microbiology, University of Port Elizabeth, P.O. Box 1600, 6000, Port Elizabeth, South Africa
| | | | | | | | | |
Collapse
|
16
|
Seraj MJ, Thomas AR, Chin JL, Theodorescu D. Molecular determination of perivesical and lymph node metastasis after radical cystectomy for urothelial carcinoma of the bladder. Clin Cancer Res 2001; 7:1516-22. [PMID: 11410485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
PURPOSE Current methods used to determine the pathological stage of the primary tumor and associated lymphatics after radical cystectomy are tedious, costly, and may lack the sensitivity afforded by molecular approaches such as reverse transcription-PCR (RT-PCR) for markers specific for urothelial tissue such as the uroplakin II (UPII) gene. Thus, we sought to evaluate an objective and sensitive molecular approach for the assessment of perivesical extension and lymph node status after radical cystectomy, based on the detection of UPII expression using RT-PCR and compare this assay to standard clinical and pathological examination. EXPERIMENTAL DESIGN From November 1999 to September 2000, 27 patients with clinical T(a)-T(3)N(0)M(0) urothelial bladder cancer underwent radical cystectomy, 19 (70%) of which also had pelvic lymphadenectomy. At the completion of cystectomy, systematic biopsies of the external surface of the bladder specimen as well as from the largest palpable lymph node found at lymphadenectomy were obtained for molecular analysis. RT-PCR analysis for UPII mRNA was carried out on these biopsy specimens, and results were compared with data obtained from conventional pathological examination. RESULTS Pathologically organ-confined tumors had a 42% (5 of 12) incidence of positive signals in the perivesical tissues and 17% (1 of 7) in the lymph nodes. Corresponding percentages for pT(3a)N(0) and pT(3b)-T(4)N(0) lesions were 67% (4 of 6)/25% (1 of 4) and 67% (4 of 6)/33% (2 of 6), respectively. Overall, pathologically node-negative cancers had a perivesical positivity rate of 54% (13 of 24) and a lymph node positivity rate of 25% (4 of 16). All patients with pathologically positive nodes had positive UPII signals in the lymph node sample. CONCLUSIONS This molecular assay aimed at assessing perivesical extension and lymph node status after radical cystectomy appears to identify patients that may harbor residual disease not appreciated by conventional histology. Larger studies with 5-7-year follow-up will be required to determine the prognostic significance of such molecular information.
Collapse
Affiliation(s)
- M J Seraj
- Department of Urology, University of Virginia Health Sciences Center, Charlottesville, Virginia 22908, USA
| | | | | | | |
Collapse
|
17
|
Thomas AR, Hedberg K, Fleming DW. Comparison of physician based reporting of tobacco attributable deaths and computer derived estimates of smoking attributable deaths, Oregon, 1989 to 1996. Tob Control 2001; 10:161-4. [PMID: 11387537 PMCID: PMC1747540 DOI: 10.1136/tc.10.2.161] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Tobacco use prevention programmes need accurate information about smoking related mortality. Beginning in 1989, Oregon began asking physicians to report on death certificates whether tobacco use contributed to the death. OBJECTIVE To determine the long term comparability of this method of estimating tobacco attributable mortality to estimates of smoking attributable mortality derived from a computer model. DESIGN For the period 1989 to 1996, we compared mortality resulting from tobacco use reported by Oregon physicians to estimates of smoking attributable deaths (SADs) derived by "Smoking attributable mortality, morbidity and economic costs" software version 3.0 (SAMMEC 3.0), a widely used software program that estimates SADs on the basis of smoking prevalence and relative risks of specific diseases among current and former smokers. MAIN OUTCOME MEASURES Numbers of deaths, age, sex, and category of disease. RESULTS Of 212, 448 Oregon deaths during 1989-1996, SAMMEC 3.0 estimated that 42, 778 (20.1%) were attributable to cigarette smoking. For the same 27 diagnoses, physicians reported that tobacco contributed to 42, 839 (20.2%) deaths-a cumulative difference of only 61 deaths over the eight year period. The age and sex distributions of tobacco and smoking attributable deaths reported by the two systems were also similar. By category of disease, the ratio of SAMMEC 3.0 estimates to physician reported deaths was 1.11 for neoplasms, 0.88 for heart disease, and 1.04 for respiratory disease. CONCLUSIONS Physician reporting provides comparable estimates of smoking attributable mortality and can be a valuable source of data for communicating the risks of tobacco use to the public.
Collapse
Affiliation(s)
- A R Thomas
- Division of Applied Public Health Training, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
| | | | | |
Collapse
|
18
|
Johnson JT, Granberry MC, Thomas AR, Smith ES. Anticoagulation management in mechanical heart valve patients who undergo dental procedures. J Ark Med Soc 2000; 97:128-31. [PMID: 12876814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Affiliation(s)
- J T Johnson
- College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, USA
| | | | | | | |
Collapse
|
19
|
Hines JF, Thomas AR, Call R, Satin AJ, Armstrong AY, Haffner WH. Development and use of military-unique standardized gynecology patients in military undergraduate medical education. Mil Med 1999; 164:280-2. [PMID: 10226455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
Performance-based testing using standardized patients is becoming increasingly popular as a means to assess the clinical competence of medical students. Medical students entering postgraduate training in military treatment facilities have the additional responsibility of military readiness. The increasing number of women in the active armed forces and the diverse missions encountered by the military today necessitate inclusion of military-unique standardized gynecologic patients and scenarios into curricula. We developed a military-unique standardized gynecology patient and scenario and an objective structured clinical examination to evaluate medical students' skills in data gathering and synthesis, development of differential diagnoses, problem solving, and working through military-unique issues of the patient scenario. Integration of an objective structured clinical examination of military-unique gynecology standardized patient scenarios into the obstetrics and gynecology curriculum at the Uniformed Services University of the Health Sciences can lead to successful assessment of student clinical skills and provide a means of ongoing military readiness training.
Collapse
Affiliation(s)
- J F Hines
- Department of Obstetrics and Gynecology, Brooke Army Medical Center, San Antonio, TX, USA
| | | | | | | | | | | |
Collapse
|
20
|
Steingart KR, Thomas AR, Dykewicz CA, Redd SC. Transmission of measles virus in healthcare settings during a communitywide outbreak. Infect Control Hosp Epidemiol 1999; 20:115-9. [PMID: 10064215 DOI: 10.1086/501595] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To describe the epidemiology of measles in medical settings and to evaluate the implementation and effectiveness of the 1989 Advisory Committee on Immunization Practices (ACIP) guidelines for measles immunization in healthcare workers (HCWs). DESIGN Confirmed cases of measles reported in Clark County, Washington, from March 14 to June 2, 1996, were analyzed for characteristics of cases occurring in medical settings. A questionnaire was used to assess employee immunization (95% response rate). SETTING AND PARTICIPANTS Reported measles cases and HCWs at community hospitals, primary-care medical facilities, a health-maintenance organization, and a multispecialty group practice. RESULTS Of 31 cases of measles, 8 (26%) occurred in HCWs, and 5 (16%) occurred in patients or visitors to medical facilities. Cases of measles occurred in HCWs who were not required to have proof of measles immunity as defined by the 1989 ACIP guidelines. The relative risk of measles in HCWs compared to Clark County adults was 18.6 (95% confidence interval, 7.4-45.8; P<.001). A survey of medical facilities revealed that 47% had an employee measles immunization policy; only 21% met ACIP recommendations and enforced their policies. CONCLUSIONS HCWs were at higher risk of measles than the adult population. Transmission of measles in medical settings was related to both deficiencies in, and lack of implementation of, the ACIP guidelines.
Collapse
Affiliation(s)
- K R Steingart
- Southwest Washington Health District, Vancouver 98663, USA
| | | | | | | |
Collapse
|
21
|
Zedek IJ, Hines JF, Thomas AR, Satin AJ, Armstrong AY, Haffner WH. Development and use of military-unique standardized gynecology patients for military residents in obstetrics and gynecology training programs. Mil Med 1998; 163:767-9. [PMID: 9819538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
Abstract
Focused military curricula and readiness training are often inadequate for military resident physicians. We developed a standardized gynecologic military-unique patient scenario and examination to assess obstetrics and gynecology residents' clinical and operational problem-solving abilities. Integration of military-unique gynecologic standardized patients, clinical scenarios, and objective structured clinical examinations into obstetrics and gynecology curricula is a novel approach for realistic medical readiness training for resident physicians. This tool can become a cornerstone in the ongoing development of needed military-unique curricula.
Collapse
Affiliation(s)
- I J Zedek
- Department of Obstetrics, Brooke Army Medical Center, San Antonio, TX, USA
| | | | | | | | | | | |
Collapse
|
22
|
Abstract
Severe ULD presents a challenge in ventilator management because of the marked asymmetry in the mechanics of the two lungs. The asymmetry may result from significant decreases or increases in the compliance of the involved lung. Traditional ventilator support may fail to produce adequate gas exchange in these situations and has the potential to cause further deterioration. Fortunately, conventional techniques can be safely and effectively applied in the majority of cases without having to resort to less familiar and potentially hazardous forms of support. In those circumstances when conventional ventilation is unsuccessful in restoring adequate gas exchange, lateral positioning and ILV have proved effective at improving and maintaining gas exchange. Controlled trials to guide clinical decision making are lacking. In patients who have processes associated with decreased compliance in the involved lung, lateral positioning may be a simple method of improving gas exchange but is associated with many practical limitations. ILV in these patients is frequently successful when differential PEEP is applied with the higher pressure to the involved lung. In patients in whom the pathology results in distribution of ventilation favoring the involved lung, particularly BPF, ILV can be used to supply adequate support while minimizing flow through the fistula and allowing it to close. The application of these techniques should be undertaken with an understanding of the pathophysiology of the underlying process; the reported experience with these techniques, including indications and successfully applied methods; and the potential problems encountered with their use. Fortunately, these modalities are infrequently required, but they provide a critical means of support when conventional techniques fail.
Collapse
Affiliation(s)
- A R Thomas
- Department of Medicine, University of Arizona/Maricopa Medical Center, Phoenix, Arizona, USA
| | | |
Collapse
|
23
|
Abstract
The incidence of coccidiodomycosis in the southwestern United States has sharply increased over the last decade as a result of environmental and demographic changes. It is important to review the epidemiology, diagnostic indicators, and therapeutic options for both immunocompetent and immunocompromised patients who have a particularly high risk of infection.
Collapse
Affiliation(s)
- A Vaz
- Department of Medicine, Maricopa Medical Center, Phoenix, USA
| | | | | | | |
Collapse
|
24
|
Thomas AR, Chan LN, Bauman JL, Olopade CO. Prolongation of the QT interval related to cisapride-diltiazem interaction. Pharmacotherapy 1998; 18:381-5. [PMID: 9545159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cisapride, a cytochrome P450 3A4 (CYP3A4) substrate, is widely prescribed for the treatment of gastrointestinal motility disorders. Prolongation of QT interval, torsades de pointes, and sudden cardiac death have been reported after concomitant administration with erythromycin or azole antifungal agents, but not with other CYP3A4 inhibitors. A possible drug interaction occurred in a 45-year-old woman who was taking cisapride for gastroesophageal reflux disorder and diltiazem, an agent that has inhibitory effect on CYP3A4, for hypertension. The patient was in near syncope and had QT-interval prolongation. After discontinuing cisapride, the QT interval returned to normal and symptoms did not recur. We suggest that caution be taken when cisapride is prescribed with any potent inhibitor of CYP3A4, including diltiazem.
Collapse
Affiliation(s)
- A R Thomas
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, 60612, USA
| | | | | | | |
Collapse
|
25
|
Singh VR, Smith DK, Lawerence J, Kelly PC, Thomas AR, Spitz B, Sarosi GA. Coccidioidomycosis in patients infected with human immunodeficiency virus: review of 91 cases at a single institution. Clin Infect Dis 1996; 23:563-8. [PMID: 8879781 DOI: 10.1093/clinids/23.3.563] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
We retrospectively evaluated the clinical manifestations, diagnosis, treatment, and outcome of coccidioidomycosis in 91 patients infected with human immunodeficiency virus (HIV) at a single institution. Coccidioidomycosis was the AIDS-defining illness in 37 patients. Fever and chills, weight loss, and night sweats were the most frequent symptoms. The lung was the most frequently involved organ (80%), followed by the meninges (15%). A diffuse reticulonodular infiltrate was seen in 59 patients (65%), and 13 (14%) had focal pulmonary disease; for 15 patients (16%), the chest radiograph was normal. Coccidioidal serologies were positive for 60 patients (68%), while for 23% with proven coccidioidomycosis such tests were negative Most patients were treated with systemic amphotericin B and then an oral azole. The mortality for the whole group was 60%. Patients with diffuse pulmonary disease had the highest mortality (68%), with a median duration of survival of 54 days (P < .05; 95% confidence interval, 147-175 days). The presence of diffuse pulmonary disease and a CD4 lymphocyte count of < 50/microL were independent predictors of death. In our experience, coccidioidomycosis is an important opportunistic infection that causes substantial morbidity and mortality among HIV-infected patients living in an area of endemicity.
Collapse
Affiliation(s)
- V R Singh
- Maricopa Medical Center, Department of Internal Medicine, Phoenix, Arizona 85008, USA
| | | | | | | | | | | | | |
Collapse
|
26
|
Abstract
Deficiencies of mitochondrial enzymes cause a number of severe neurologic syndromes in pediatric patients. Isolated myopathy secondary to enzymatic deficiency only rarely has been recognized and reported in adults. Three normal-appearing patients with unexplained dyspnea on exertion, tachycardia, and fatigue were studied with progressive incremental and constant load exercise testing with hemodynamic and gas exchange measurements. Subsequently, muscle biopsies were performed and enzymatic profiles determined. Exercise testing suggested altered cellular energy metabolism. Oxygen transport and gas exchange at rest and with exercise were normal. During exercise, ventilation increased excessively for the work performed, but it was appropriate for carbon dioxide production. Cardiac outputs increased significantly (196 to 305%), heart rates reached maximum levels, and lactic acid levels increased (385 to 833%) during exercise at 25 W. Muscle morphology was normal, but mitochondrial enzyme assays demonstrated one or more deficiencies in all three patients. Mitochondrial enzymatic deficiency can be a cause of unexplained exercise symptomatology and limitation in adults. Our experience would suggest the incidence of the disorder may be greater than that previously recognized or expected. Symptoms of exercise limitation associated with dyspnea, tachycardia, or muscle fatigue should alert the clinician to a possible abnormality in cellular energy metabolism.
Collapse
Affiliation(s)
- R G Hooper
- St. Luke's Charles A Barrow Heart Lung Center, Phoenix, AZ
| | | | | |
Collapse
|
27
|
Abstract
Interactions between migratory granule neurons and the developing molecular layer of the mouse cerebellum were examined using an in situ binding assay. Single cell suspensions of postnatal granule neurons specifically adhere to unfixed frozen cerebellar tissue sections. We investigated the influence of postnatal age of granule neurons and of tissue on this interaction. Granule neurons from P10 (the time of peak migratory activity) bind preferentially to the molecular layer. Premigratory granule neurons, P5, do not bind age-matched cerebellar tissue. Postmigratory granule neurons, P14 and older, adhere to the molecular and internal granular layers of age-matched and older cerebellar tissue but not to younger tissue. These binding patterns are most simply explained as a single receptor-ligand system in which both elements exhibit independent developmental regulation. Although granule neurons lose the ability to bind with increasing age, the molecular layer ligand retains its capacity for this interaction into adulthood, long after normal migration has ceased.
Collapse
Affiliation(s)
- L M Bolin
- Department of Pathology, Stanford University, CA 94305
| | | | | | | |
Collapse
|
28
|
Abstract
An asymptomatic 18-year-old man presented for treatment of alcohol and substance abuse. He related a history of a recent motor vehicle accident with chest trauma and remote history of colonic interposition for esophageal atresia. Radiographic investigation yielded an interesting set of roentgenograms.
Collapse
|
29
|
|
30
|
Levine M, Thomas AR. Simple Medium for Maintenance of Meningococci. J Bacteriol 1947; 53:33-5. [PMID: 16561246 PMCID: PMC518269 DOI: 10.1128/jb.53.1.33-35.1947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- M Levine
- Clinical Laboratory Service, Brooke General Hospital, Fort Sam Houston, Texas
| | | |
Collapse
|
31
|
Affiliation(s)
- A R Thomas
- Brooke General and Convalescent Hospital, Fort Sam Houston, Texas
| | | |
Collapse
|