1
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Siddique A, Parekh KR, Huddleston SJ, Shults A, Locke JE, Keshavamurthy S, Schwartz G, Hartwig MG, Whitson BA. A call to action in thoracic transplant surgical training. J Heart Lung Transplant 2023; 42:1627-1631. [PMID: 37268052 DOI: 10.1016/j.healun.2023.05.017] [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: 12/12/2022] [Revised: 05/19/2023] [Accepted: 05/30/2023] [Indexed: 06/04/2023] Open
Abstract
Thoracic organ recovery and implantation is increasing in complexity. Simultaneously the logistic burden and associated cost is rising. An electronic survey distributed to the surgical directors of thoracic transplant programs in the United States indicated dissatisfaction amongst 72% of respondents with current procurement training and 85% of respondents favored a process for certification in thoracic organ transplantation. These responses highlight concerns for the current paradigm of training in thoracic transplantation. We discuss the implications of advancements in organ retrieval and implant for surgical training and propose that the thoracic transplant community might address the need through formalized training in procurement and certification in thoracic transplantation.
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Affiliation(s)
- A Siddique
- University of Nebraska Medical Center, Department of Surgery, Division of Cardiothoracic Surgery, Omaha, Nebraska.
| | - K R Parekh
- University of Iowa Hospitals and Clinics, Department of Cardiothoracic Surgery, Carver College of Medicine, Iowa City, Iowa
| | - S J Huddleston
- University of Minnesota, Department of Surgery, Division of Cardiothoracic Surgery
| | - A Shults
- American Society of Thoracic Surgeons, Arlington, Virginia
| | - J E Locke
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, Alabama
| | - S Keshavamurthy
- University of Kentucky College of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Lexington, Kentucky
| | - G Schwartz
- Baylor University Medical Center, Department of Thoracic Surgery, Dallas, Texas
| | - M G Hartwig
- Duke University Health System, Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Durham, North Carolina
| | - B A Whitson
- The Ohio State University Wexner Medical Center, Department of Surgery, Division of Cardiac Surgery, Columbus, Ohio
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2
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Shelton BA, Reed RD, MacLennan PA, McWilliams D, Mustian MN, Sawinski D, Kumar V, Ong S, Locke JE. Increasing Obesity Prevalence in the United States End-Stage Renal Disease Population. J Health Sci Educ 2018; 2:151. [PMID: 37538870 PMCID: PMC10398833] [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] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Background Among ESRD patients, obesity may improve dialysis-survival but decreases likelihood of transplantation, and as such, obesity prevalence may directly affect growth of the dialysis population. Objective The objective of this study was to assess BMI trends in the ESRD population as compared to the general population. Materials and Methods Incident adult ESRD patients were identified from the United States Renal Data System from 01/01/1995-12/31/2010 (n=1,458,350). Data from the Behavioral Risk Factor Surveillance System (n=4,303,471) represented the US population. Trends in BMI, obesity classes I (BMI of 30-34.9), II (BMI of 35-39.9), and III (BMI ≥ 40), were examined by year of dialysis initiation. Trends in BMI slope were compared between the ESRD and US populations using linear regression. Results Mean BMI of ESRD patients in 1995 was 25.2 as compared to 29.4 in 2010, a 16.7% increase, while the US population's mean BMI increased from 25.3 to 27.2, a 7.5% increase. BMI increase among the ESRD population was significantly more rapid than among the US population (β: 0.16, 95% CI: 0.14-0.18, p<0.001). Conclusions and Recommendations Mean BMI among the ESRD population is increasing more rapidly than the US population. Given decreased access to kidney transplantation among ESRD patients with obesity, future research should be directed at controlling healthcare expenditures by identifying strategies to address the obesity epidemic among the US ESRD population.
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Affiliation(s)
- BA Shelton
- Comprehensive Transplant Institute, University of Alabama at Birmingham, USA
| | - RD Reed
- Comprehensive Transplant Institute, University of Alabama at Birmingham, USA
| | - PA MacLennan
- Comprehensive Transplant Institute, University of Alabama at Birmingham, USA
| | - D McWilliams
- Comprehensive Transplant Institute, University of Alabama at Birmingham, USA
| | - MN Mustian
- Comprehensive Transplant Institute, University of Alabama at Birmingham, USA
| | - D Sawinski
- Renal, Electrolyte and Hypertension Division, University of Pennsylvania, USA
| | - V Kumar
- Comprehensive Transplant Institute, University of Alabama at Birmingham, USA
| | - S Ong
- Comprehensive Transplant Institute, University of Alabama at Birmingham, USA
| | - JE Locke
- Comprehensive Transplant Institute, University of Alabama at Birmingham, USA
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3
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Shelton BA, Sawinski D, Locke JE. Response to: Regarding "HIV protease inhibitors and mortality following kidney transplantation". Am J Transplant 2018; 18:1571. [PMID: 29419939 DOI: 10.1111/ajt.14688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- B A Shelton
- University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - D Sawinski
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - J E Locke
- University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
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4
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Sawinski D, Shelton BA, Mehta S, Reed RD, MacLennan PA, Gustafson S, Segev DL, Locke JE. Impact of Protease Inhibitor-Based Anti-Retroviral Therapy on Outcomes for HIV+ Kidney Transplant Recipients. Am J Transplant 2017; 17:3114-3122. [PMID: 28696079 DOI: 10.1111/ajt.14419] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 06/02/2017] [Accepted: 06/28/2017] [Indexed: 01/25/2023]
Abstract
Excellent outcomes have been demonstrated among select HIV-positive kidney transplant (KT) recipients with well-controlled infection, but to date, no national study has explored outcomes among HIV+ KT recipients by antiretroviral therapy (ART) regimen. Intercontinental Marketing Services (IMS) pharmacy fills (1/1/01-10/1/12) were linked with Scientific Registry of Transplant Recipients (SRTR) data. A total of 332 recipients with pre- and posttransplantation fills were characterized by ART at the time of transplantation as protease inhibitor (PI) or non-PI-based ART (88 PI vs. 244 non-PI). Cox proportional hazards models were adjusted for recipient and donor characteristics. Comparing recipients by ART regimen, there were no significant differences in age, race, or HCV status. Recipients on PI-based regimens were significantly more likely to have an Estimated Post Transplant Survival (EPTS) score of >20% (70.9% vs. 56.3%, p = 0.02) than those on non-PI regimens. On adjusted analyses, PI-based regimens were associated with a 1.8-fold increased risk of allograft loss (adjusted hazard ratio [aHR] 1.84, 95% confidence interval [CI] 1.22-2.77, p = 0.003), with the greatest risk observed in the first posttransplantation year (aHR 4.48, 95% CI 1.75-11.48, p = 0.002), and a 1.9-fold increased risk of death as compared to non-PI regimens (aHR 1.91, 95% CI 1.02-3.59, p = 0.05). These results suggest that whenever possible, recipients should be converted to a non-PI regimen prior to kidney transplantation.
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Affiliation(s)
- D Sawinski
- University of Pennsylvania Comprehensive Transplant Center, Philadelphia, PA
| | - B A Shelton
- University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL
| | - S Mehta
- University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL
| | - R D Reed
- University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL
| | - P A MacLennan
- University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL
| | - S Gustafson
- Scientific Registry of Transplant Recipients, Minneapolis, MN
| | - D L Segev
- Johns Hopkins School of Medicine, Baltimore, MD
| | - J E Locke
- University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL
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5
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Hobeika MJ, Miller CM, Pruett TL, Gifford KA, Locke JE, Cameron AM, Englesbe MJ, Kuhr CS, Magliocca JF, McCune KR, Mekeel KL, Pelletier SJ, Singer AL, Segev DL. PROviding Better ACcess To ORgans: A comprehensive overview of organ-access initiatives from the ASTS PROACTOR Task Force. Am J Transplant 2017; 17:2546-2558. [PMID: 28742951 DOI: 10.1111/ajt.14441] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 02/09/2017] [Revised: 06/25/2017] [Accepted: 07/13/2017] [Indexed: 01/25/2023]
Abstract
The American Society of Transplant Surgeons (ASTS) PROviding better Access To Organs (PROACTOR) Task Force was created to inform ongoing ASTS organ access efforts. Task force members were charged with comprehensively cataloguing current organ access activities and organizing them according to stakeholder type. This white paper summarizes the task force findings and makes recommendations for future ASTS organ access initiatives.
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Affiliation(s)
- M J Hobeika
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - C M Miller
- Liver Transplantation Program, Cleveland Clinic, Cleveland, OH, USA
| | - T L Pruett
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - K A Gifford
- American Society of Transplant Surgeons, Arlington, VA, USA
| | - J E Locke
- University of Alabama at Birmingham Comprehensive Transplant Institute, Birmingham, AL, USA
| | - A M Cameron
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - M J Englesbe
- Department of Surgery, Section of Transplantation, University of Michigan, Ann Arbor, MI, USA
| | - C S Kuhr
- Virginia Mason Medical Center, Seattle, WA, USA
| | - J F Magliocca
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - K R McCune
- Department of Surgery, Columbia University, New York, NY, USA
| | - K L Mekeel
- Division of Transplantation and Hepatobiliary Surgery, University of California San Diego, San Diego, CA, USA
| | - S J Pelletier
- Division of Transplant Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - A L Singer
- Transplant Center, Mayo Clinic, Phoenix, AZ, USA
| | - D L Segev
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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6
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Staley EM, Carruba SS, Manning M, Pham HP, Williams LA, Marques MB, Locke JE, Lorenz RG. Anti-Blood Group Antibodies in Intravenous Immunoglobulin May Complicate Interpretation of Antibody Titers in ABO-Incompatible Transplantation. Am J Transplant 2016; 16:2483-6. [PMID: 26913485 DOI: 10.1111/ajt.13760] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [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: 10/08/2015] [Revised: 02/09/2016] [Accepted: 02/14/2016] [Indexed: 01/25/2023]
Abstract
Patients receiving ABO-incompatible (ABOi) kidney transplants are treated before and after transplant with combination therapy, such as intravenous immunoglobulin (IVIG) and therapeutic plasma exchange, to prevent allograft rejection by reducing anti-A and anti-B titers. Although generally considered safe, it is well known that commercial IVIG products contain detectable anti-A and anti-B, which can be associated with hemolysis. Different preparative manufacturing techniques during the production of IVIG affect ABO antibody levels in IVIG preparations; therefore, some manufacturers now use new methods to reduce anti-A/B levels at the preproduction stage. The variations in implementing these strategies creates the potential for significant variation in antibody titers between products and, in some cases, even between lots of the same IVIG product. We report a case of persistently elevated anti-A titers in an ABOi kidney transplant recipient associated with elevated ABO antibody titers present in the preparation of IVIG used at our facility.
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Affiliation(s)
- E M Staley
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL
| | - S S Carruba
- Pharmacy Department, University of Alabama at Birmingham, Birmingham, AL
| | - M Manning
- Pharmacy Department, University of Alabama at Birmingham, Birmingham, AL
| | - H P Pham
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL
| | - L A Williams
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL
| | - M B Marques
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL
| | - J E Locke
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - R G Lorenz
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL
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7
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DuBay DA, MacLennan PA, Reed RD, Fouad M, Martin M, Meeks CB, Taylor G, Kilgore ML, Tankersley M, Gray SH, White JA, Eckhoff DE, Locke JE. The impact of proposed changes in liver allocation policy on cold ischemia times and organ transportation costs. Am J Transplant 2015; 15:541-6. [PMID: 25612501 PMCID: PMC4429785 DOI: 10.1111/ajt.12981] [Citation(s) in RCA: 27] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 08/11/2014] [Accepted: 08/12/2014] [Indexed: 01/25/2023]
Abstract
Changes to the liver allocation system have been proposed to decrease regional variation in access to liver transplant. It is unclear what impact these changes will have on cold ischemia times (CITs) and donor transportation costs. Therefore, we performed a retrospective single center study (2008-2012) measuring liver procurement CIT and transportation costs. Four groups were defined: Local-within driving distance (Local-D, n = 262), Local-flight (Local-F, n = 105), Regional-flight <3 h (Regional <3 h, n = 61) and Regional-Flight >3 h (Regional >3 h, n = 53). The median travel distance increased in each group, varying from zero miles (Local-D), 196 miles (Local-F), 384 miles (Regional <3 h), to 1647 miles (Regional >3 h). Increasing travel distances did not significantly increase CIT until the flight time was >3 h. The average CIT ranged from 5.0 to 6.0 h for Local-D, Local-F and Regional <3 h, but increased to 10 h for Regional >3 h (p < 0.0001). Transportation costs increased with greater distance traveled: Local-D $101, Local-F $1993, Regional <3 h $8324 and Regional >3 h $27 810 (p < 0.0001). With proposed redistricting, local financial modeling suggests that the average liver donor procurement transportation variable direct costs will increase from $2415 to $7547/liver donor, an increase of 313%. These findings suggest that further discussion among transplant centers and insurance providers is needed prior to policy implementation.
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Affiliation(s)
- D. A. DuBay
- Department of Surgery-Transplantation, University of Alabama, Birmingham, AL,Corresponding author: Derek A. DuBay,
| | - P. A. MacLennan
- Department of Surgery-Transplantation, University of Alabama, Birmingham, AL
| | - R. D. Reed
- Department of Surgery-Transplantation, University of Alabama, Birmingham, AL
| | - M. Fouad
- Department of Medicine-Preventive Medicine, University of Alabama, Birmingham, AL
| | - M. Martin
- Department of Medicine-Preventive Medicine, University of Alabama, Birmingham, AL
| | - C. B. Meeks
- Alabama Organ Center, Health Services Foundation, Birmingham, AL
| | - G. Taylor
- Alabama Organ Center, Health Services Foundation, Birmingham, AL
| | - M. L. Kilgore
- School of Public Health–Health Care Organization and Policy, University of Alabama, Birmingham, AL
| | - M. Tankersley
- Transplant Services, University of Alabama at Birmingham Hospital, Birmingham, AL
| | - S. H. Gray
- Department of Surgery-Transplantation, University of Alabama, Birmingham, AL
| | - J. A. White
- Department of Surgery-Transplantation, University of Alabama, Birmingham, AL
| | - D. E. Eckhoff
- Department of Surgery-Transplantation, University of Alabama, Birmingham, AL
| | - J. E. Locke
- Department of Surgery-Transplantation, University of Alabama, Birmingham, AL
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8
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Dierberg KL, Marr KA, Subramanian A, Nace H, Desai N, Locke JE, Zhang S, Diaz J, Chamberlain C, Neofytos D. Donor-derived organ transplant transmission of coccidioidomycosis. Transpl Infect Dis 2011; 14:300-4. [PMID: 22176496 DOI: 10.1111/j.1399-3062.2011.00696.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 08/31/2011] [Accepted: 09/07/2011] [Indexed: 11/27/2022]
Abstract
Coccidioidomycosis in solid organ transplant recipients most often occurs as a result of primary infection or reactivation of latent infection. Herein, we report a series of cases of transplant-related transmission of coccidioidomycosis from a single donor from a non-endemic region whose organs were transplanted to 5 different recipients. In all, 3 of the 5 recipients developed evidence of Coccidioides infection, 2 of whom had disseminated disease. The degree of T-cell immunosuppression and timing of antifungal therapy initiation likely contributed to development of disease and disease severity in these recipients. This case series highlights the importance of having a high index of suspicion for Coccidioides infection in solid organ transplant recipients, even if the donor does not have known exposure, given the difficulties of obtaining a detailed and accurate travel history from next-of-kin.
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Affiliation(s)
- K L Dierberg
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA
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9
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Lonze BE, Dagher NN, Simpkins CE, Locke JE, Singer AL, Segev DL, Zachary AA, Montgomery RA. Eculizumab, bortezomib and kidney paired donation facilitate transplantation of a highly sensitized patient without vascular access. Am J Transplant 2010; 10:2154-60. [PMID: 20636451 DOI: 10.1111/j.1600-6143.2010.03191.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
A 43-year-old patient with end-stage renal disease, a hypercoagulable condition and 100% panel reactive antibody was transferred to our institution with loss of hemodialysis access and thrombosis of the superior and inferior vena cava, bilateral iliac and femoral veins. A transhepatic catheter was placed but became infected. Access through a stented subclavian into a dilated azygos vein was established. Desensitization with two cycles of bortezomib was undertaken after anti-CD20 and IVIg were given. A flow-positive, cytotoxic-negative cross-match live-donor kidney at the end of an eight-way multi-institution domino chain became available, with a favorable genotype for this patient with impending total loss of a dialysis option. The patient received three pretransplant plasmapheresis treatments. Intraoperatively, the superior mesenteric vein was the only identifiable patent target for venous drainage. Eculizumab was administered postoperatively in the setting of antibody-mediated rejection and an inability to perform additional plasmapheresis. Creatinine remains normal at 6 months posttransplant and flow cross-match is negative. In this report, we describe the combined use of new agents (bortezomib and eculizumab) and modalities (nontraditional vascular access, splanchnic drainage of graft and domino paired donation) in a patient who would have died without transplantation.
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Affiliation(s)
- B E Lonze
- Division of Transplant Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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10
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Affiliation(s)
| | - R A Montgomery
- Division of Transplantation, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD
| | - J E Locke
- Division of Transplantation, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD
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11
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Melancon JK, Kucirka LM, Boulware LE, Powe NR, Locke JE, Montgomery RA, Segev DL. Impact of Medicare coverage on disparities in access to simultaneous pancreas and kidney transplantation. Am J Transplant 2009; 9:2785-91. [PMID: 19845587 PMCID: PMC3644052 DOI: 10.1111/j.1600-6143.2009.02845.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In the setting of disparities in access to simultaneous pancreas and kidney transplantation (SPKT), Medicare coverage for this procedure was initiated July 1999. The impact of this change has not yet been studied. A national cohort of 22 190 type 1 diabetic candidates aged 18-55 for kidney transplantation (KT) alone or SPKT was analyzed. Before Medicare coverage, 57% of Caucasian, 36% of African American and 38% of Hispanic type 1 diabetics were registered for SPKT versus KT alone. After Medicare coverage, these proportions increased to 68%, 45% and 43%, respectively. The overall increase in SPKT registration rate was 27% (95% CI 1.16-1.38). As expected, the increase was more substantial in patients with Medicare primary insurance than those with private insurance (Relative Rate 1.18, 95% CI 1.09-1.28). However, racial disparities were unaffected by this policy change (African American vs. Caucasian: 0.97, 95% CI 0.87-1.09; Hispanic vs. Caucasian: 0.94, 95% CI 0.78-1.05). Even after Medicare coverage, African Americans and Hispanics had almost 30% lower SPKT registration rates than their Caucasian counterparts (95% CI 0.66-0.79 and 0.59-0.80, respectively). Medicare coverage for SPKT succeeded in increasing access for patients with Medicare, but did not affect the substantial racial disparities in access to this procedure.
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Affiliation(s)
- J. K. Melancon
- Department of Surgery, Georgetown University, Washington, DC,Corresponding author: Joseph Keith Melancon,
| | - L. M. Kucirka
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - L. E. Boulware
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - N. R. Powe
- Department of Medicine, University of California, San Francisco, CA
| | - J. E. Locke
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - R. A. Montgomery
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - D. L. Segev
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
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12
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Locke JE, Zachary AA, Warren DS, Segev DL, Houp JA, Montgomery RA, Leffell MS. Proinflammatory events are associated with significant increases in breadth and strength of HLA-specific antibody. Am J Transplant 2009; 9:2136-9. [PMID: 19663896 DOI: 10.1111/j.1600-6143.2009.02764.x] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Identification of factors responsible for an increase in the breadth or strength of HLA-specific antibody (HSA) is critical to the continued successful management and transplantation of sensitized patients. A retrospective review of our HLA registry identified 107 patients with known HSA and sufficient information in their electronic patient record to determine the presence or absence of a proinflammatory event. The patients were stratified according to transplant status [sensitized and on the transplant waitlist (n = 65); immunosuppressed recipients of a positive crossmatch (+XM) transplant (n = 42)]. Eighty-three percent of waitlist candidates and 55% of sensitized kidney transplant recipients with a documented proinflammatory event had an associated increase in HSA. Interestingly, among patients with a culture-proven infection, 97% of the waitlist patients and 54.8% of +XM recipients had an associated rise in HSA. Overall, proinflammatory events were associated with a greater increase among waitlist patients than +XM recipients, 5.3-fold [IRR 5.25, (95% CI 4.03-6.85), p < 0.001] versus 2.5-fold [IRR 2.54, (95% CI 1.64-3.95), p < 0.001] increase in HSA. Therefore, sensitized patients known to have an infection or undergoing surgery should be monitored for expansion of HSA.
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Affiliation(s)
- J E Locke
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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13
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Singh AK, Moros EG, Novak P, Straube W, Zeug A, Locke JE, Myerson RJ. MicroPET-compatible, small animal hyperthermia ultrasound system (SAHUS) for sustainable, collimated and controlled hyperthermia of subcutaneously implanted tumours. Int J Hyperthermia 2009; 20:32-44. [PMID: 14612312 DOI: 10.1080/02656730310001609326] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
An external ultrasound system was developed for the heating of subcutaneously implanted tumours in small animals. This small animal hyperthermia ultrasound system (SAHUS) was designed to be compatible with a microPET (small animal positron emission tomography) scanner to facilitate studies of hyperthermia effects on tumour hypoxia. Collimation and localization of energy deposition, a specific goal for the new device to avoid regional and/or systemic heating of small animals, was demonstrated using thermoradiography following high-power short-time heating of a layered gel phantom. The in vivo heating capabilities of the SAHUS were tested using PC3 cell line tumours (2000-2700 mm(3)) grown in the lateral proximal thighs of Nu-/Nu- nuBR nude mice. Intratumour temperatures were recorded during heating trials with deep and superficial interstitial thermocouples. The experimental data showed that the SAHUS could produce hyperthermia in 8 +/- 2 mm diameter tumours in small animals to a target temperature of 41.5 degrees C and maintain it within a narrow temperature range (+/- 0.3 degrees C) for up to 4 h without raising the core temperature of the animals. PET imaging studies, data to be published separately, were conducted before and during SAHUS-induced hyperthermia. Both devices performed as expected and there was no significant decrease in image quality. In this paper, the new SAHUS is described and data from phantom and in vivo experiments presented.
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Affiliation(s)
- A K Singh
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, MO 63108, USA
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14
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Locke JE, Magro CM, Singer AL, Segev DL, Haas M, Hillel AT, King KE, Kraus E, Lees LM, Melancon JK, Stewart ZA, Warren DS, Zachary AA, Montgomery RA. The use of antibody to complement protein C5 for salvage treatment of severe antibody-mediated rejection. Am J Transplant 2009; 9:231-5. [PMID: 18976298 DOI: 10.1111/j.1600-6143.2008.02451.x] [Citation(s) in RCA: 267] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Desensitized patients are at high risk of developing acute antibody-mediated rejection (AMR). In most cases, the rejection episodes are mild and respond to a short course of plasmapheresis (PP) / low-dose IVIg treatment. However, a subset of patients experience severe AMR associated with sudden onset oliguria. We previously described the utility of emergent splenectomy in rescuing allografts in patients with this type of severe AMR. However, not all patients are good candidates for splenectomy. Here we present a single case in which eculizumab, a complement protein C5 antibody that inhibits the formation of the membrane attack complex (MAC), was used combined with PP/IVIg to salvage a kidney undergoing severe AMR. We show a marked decrease in C5b-C9 (MAC) complex deposition in the kidney after the administration of eculizumab.
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Affiliation(s)
- J E Locke
- Deparmtent of Surgery, John Hopkins Medical Institutions, John Hopkins University, Baltimore, MD, USA
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Segev DL, Kucirka LM, Nguyen GC, Cameron AM, Locke JE, Simpkins CE, Thuluvath PJ, Montgomery RA, Maley WR. Effect modification in liver allografts with prolonged cold ischemic time. Am J Transplant 2008; 8:658-66. [PMID: 18294162 DOI: 10.1111/j.1600-6143.2007.02108.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Although prolonged cold ischemia time (PCIT) is generally associated with worse outcomes following liver transplantation, evidence suggests that some recipients and some donors might be more sensitive to PCIT than others. The purpose of this study was to identify factors that predict a higher risk of graft loss after a transplant with PCIT when compared with a similar transplant with average CIT (ACIT). 14 637 recipients reported to United Network for Organ Sharing (UNOS) in the model for end-stage liver disease (MELD) era were studied by interaction term analysis in proportional hazards models. Recipient diabetes, obesity and donor African American (AA) ethnicity were found to significantly amplify the adverse effects of PCIT. Graft loss was 1.85-fold higher in diabetic or obese PCIT recipients compared with diabetic or obese ACIT recipients, (vs. 1.17 for the same comparison in non-diabetic non-obese recipients). Similarly, graft loss was 1.80-fold higher in AA PCIT donors compared with AA ACIT donors, (vs. 1.31 for the same comparison in non-AA donors). Other factors may also exist, but current clinical practices might already mitigate the risks from those factors. As such, we recommend expanding clinical practice to include our findings, but not abandoning current judgment based on factors already perceived to amplify the adverse effects of PCIT.
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Affiliation(s)
- D L Segev
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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16
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Locke JE, Segev DL, Warren DS, Dominici F, Simpkins CE, Montgomery RA. Outcomes of kidneys from donors after cardiac death: implications for allocation and preservation. Am J Transplant 2007; 7:1797-807. [PMID: 17524076 DOI: 10.1111/j.1600-6143.2007.01852.x] [Citation(s) in RCA: 210] [Impact Index Per Article: 12.4] [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: 01/25/2023]
Abstract
Although donation after cardiac death (DCD) kidneys have a high incidence of delayed graft function (DGF) and have been considered marginal, no tool for stratifying risk of graft loss nor a specific policy governing their allocation exist. We compared outcomes of 2562 DCD, 62,800 standard criteria donor (SCD) and 12,812 expanded criteria donor (ECD) transplants reported between 1993 and 2005, and evaluated factors associated with risk of graft loss and DGF in DCD kidneys. Donor age was the only criterion used in the definition of ECD kidneys that independently predicted graft loss among DCD kidneys. Kidneys from DCD donors <50 had similar long-term graft survival to those from SCD (RR 1.1, p = NS). While DGF was higher among DCD compared to SCD and ECD, limiting cold ischemia (CIT) to <12 h decreased the rate of DGF 15% among DCD <50 kidneys. These findings suggest that DCD <50 kidneys function like SCD kidneys and should not be viewed as marginal or ECD, and further, limiting CIT <12 h markedly reduces DGF.
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Affiliation(s)
- J E Locke
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Locke JE, Zachary AA, Haas M, Melancon JK, Warren DS, Simpkins CE, Segev DL, Montgomery RA. The utility of splenectomy as rescue treatment for severe acute antibody mediated rejection. Am J Transplant 2007; 7:842-6. [PMID: 17391127 DOI: 10.1111/j.1600-6143.2006.01709.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.2] [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: 01/25/2023]
Abstract
Antibody-mediated rejection (AMR) after desensitization for a positive crossmatch (+XM) live donor renal transplant can be severe and result in sudden onset oliguria and loss of the allograft. Attempts to rescue these kidneys using plasmapheresis (PP) and IVIg may be ineffective due to the magnitude of antibody burden that must be controlled to prevent renal thrombosis or cortical necrosis. We review our experience using splenectomy combined with PP/IVIg as rescue therapy for patients experiencing an acute deterioration in renal function and a rise in donor-specific antibody within the first posttransplant week after desensitization for a +XM. Five patients underwent immediate splenectomy followed by PP/IVIg and had return of allograft function within 48 h of the procedure. Emergent splenectomy followed by PP/IVIg may be an effective treatment for reversing severe AMR.
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Affiliation(s)
- J E Locke
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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18
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Simpkins CE, Montgomery RA, Hawxby AM, Locke JE, Gentry SE, Warren DS, Segev DL. Cold ischemia time and allograft outcomes in live donor renal transplantation: is live donor organ transport feasible? Am J Transplant 2007; 7:99-107. [PMID: 17227561 DOI: 10.1111/j.1600-6143.2006.01597.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
One of the greatest obstacles to the implementation of regional or national kidney paired donation programs (KPD) is the need for the donor to travel to their matched recipient's hospital. While transport of the kidney is an attractive alternative, there is concern that prolonged cold ischemia time (CIT) would diminish the benefits of live donor transplantation (LDTx). To examine the impact of increased CIT in LDTx, 1-year serum creatinine (SCr), delayed graft function (DGF), acute rejection (AR) and allograft survival (AS) were analyzed in 38 467 patients by 2 h CIT groups (0-2, 2-4, 4-6 and 6-8 h) using data from the United Network for Organ Sharing/Organ Procurement and Transplantation Network (UNOS/OPTN). Adjusted probabilities of DGF and AR were estimated in multivariate logistic regression models and AS was examined in multivariate Cox proportional hazards models. Although some increase in DGF was observed between the 0-2 h (4.7%) and 4-6 h (8.3%) groups, prolonged CIT did not result in inferior SCr, increased AR or compromised AS in any group with >2 h CIT compared with the 0-2 h group. Comparable long-term outcomes for these grafts suggests that transport of live donor organs may be a feasible alternative to donor travel in KPD regions where CIT can be limited to 8 h.
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Affiliation(s)
- C E Simpkins
- Johns Hopkins University, School of Medicine, Department of Surgery, Baltimore, Maryland, USA
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Novák P, Moros EG, Parry JJ, Rogers BE, Myerson RJ, Zeug A, Locke JE, Rossin R, Straube WL, Singh AK. Experience with a small animal hyperthermia ultrasound system (SAHUS): report on 83 tumours. Phys Med Biol 2005; 50:5127-39. [PMID: 16237245 DOI: 10.1088/0031-9155/50/21/012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
An external local ultrasound (US) system was developed to induce controlled hyperthermia of subcutaneously implanted tumours in small animals (e.g., mice and rats). It was designed to be compatible with a small animal positron emission tomography scanner (microPET) to facilitate studies of hyperthermia-induced tumour re-oxygenation using a PET radiopharmaceutical, but it is applicable for any small animal study requiring controlled heating. The system consists of an acrylic applicator bed with up to four independent 5 MHz planar disc US transducers of 1 cm in diameter, a four-channel radiofrequency (RF) generator, a multiple thermocouple thermometry unit, and a personal computer with custom monitoring and controlling software. Although the system presented here was developed to target tumours of up to 1 cm in diameter, the applicator design allows for different piezoelectric transducers to be exchanged and operated within the 3.5-6.5 MHz band to target different tumour sizes. Temperature feedback control software was developed on the basis of a proportional-integral-derivative (PID) approach when the measured temperatures were within a selectable temperature band about the target temperature. Outside this band, an on/off control action was applied. Perfused tissue-mimicking phantom experiments were performed to determine optimum controller gain constants, which were later employed successfully in animal experiments. The performance of the SAHUS (small animal hyperthermia ultrasound system) was tested using several tumour types grown in thighs of female nude (nu/nu) mice. To date, the system has successfully treated 83 tumours to target temperatures in the range of 41-43 degrees C for periods of 65 min on average.
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Affiliation(s)
- P Novák
- Department of Radiation Oncology, Washington University School of Medicine, 4511 Forest Park Ave., Suite 200, St Louis, MO 63108, USA
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Locke JE, Bradbury CM, Wei SJ, Shah S, Rene LM, Clemens RA, Roti Roti J, Horikoshi N, Gius D. Indomethacin lowers the threshold thermal exposure for hyperthermic radiosensitization and heat-shock inhibition of ionizing radiation-induced activation of NF-kappaB. Int J Radiat Biol 2002; 78:493-502. [PMID: 12065054 DOI: 10.1080/095530002317577312] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
PURPOSE It is well established that salicylate and several other non-steroidal anti-inflammatory agents (NSAID), including indomethacin, can activate the heat-shock response, albeit at high concentrations. This is significant since heat shock significantly alters the cellular cytotoxic response to ionizing radiation (IR). It was previously shown that heat shock, as well as NSAIDs, inhibits IR-induced activation of NF-kappaB and that NF-kappaB protects against IR-induced cytotoxicity. Hence, it is hypothesized that pretreatment with indomethacin before heating will lower the temperature and heating times required to inhibit the activation of NF-kappaB and induce significant hyperthermic radiosensitization. MATERIALS AND METHODS Experiments were performed in HeLa cell lines and the DNA-binding activity was determined by EMSA. Cellular radiosensitivity was determined by clonogenic assay. RESULTS HeLa cells pretreated with indomethacin showed a decrease in the temperature-time combination necessary to inhibit IR-induction of NF-kappaB DNA binding. In addition, clonogenic cell survival assays using identical conditions showed an indomethacin dose-dependent enhancement of hyperthermic radiosensitization. Thus, similar concentrations of indomethacin both lowered the threshold thermal exposure to inhibit activation of NF-kappaB DNA-binding and increased the sensitivity of tumour cells to hyperthermic radiosensitization-induced cytotoxicity. In HeLa cells treated with N-alpha-tosylphenylalanyl-chloromethyl ketone (TPCK), a serine protease inhibitor that blocks activation of NF-kappaB, an increase in radiosensitivity was observed. Interestingly, no additional cell killing was observed when heat shock was added to cells treated with TPCK before IR, suggesting a possible common cytotoxic pathway. CONCLUSIONS The results demonstrate that indomethacin lowers the temperature-time conbination necessary to induce several physiological processes associated with the heat-shock response. Furthermore, NSAID may be potential adjuvants in improving the clinical effectiveness of hyperthermia in radiation therapy.
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Affiliation(s)
- J E Locke
- Section of Cancer Biology, Radiation Oncology Center, Institute of Radiology, Washington University School of Medicine, Saint Louis, MO, USA
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Bradbury CM, Locke JE, Wei SJ, Rene LM, Karimpour S, Hunt C, Spitz DR, Gius D. Increased activator protein 1 activity as well as resistance to heat-induced radiosensitization, hydrogen peroxide, and cisplatin are inhibited by indomethacin in oxidative stress-resistant cells. Cancer Res 2001; 61:3486-92. [PMID: 11309312] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
It has been established that tumor cells develop resistance to a variety of therapeutic agents after multiple exposures to these agents/drugs. Many of these therapeutic agents also appear to increase the activity of transcription factors, such as activator protein 1 (AP-1), believed to be involved in cellular responses to oxidative stress. Therefore, we hypothesized that cellular resistance to cancer therapeutic agents may involve the increased activity of transcription factors that govern resistance to oxidative stress, such as AP-1. To investigate this hypothesis, a previously characterized cisplatin, hyperthermia, and oxidative stress-resistant Chinese hamster fibroblast cell line, OC-14, was compared to the parental HA-1 cell line. Electrophoretic mobility shift and Western blot assays performed on extracts isolated from OC-14 cells demonstrated a 10-fold increase in constitutive AP-1 DNA-binding activity as well as increased constitutive c-Fos and c-Jun immunoreactive protein relative to HA-1 cells. Treatment of OC-14 cells with indomethacin inhibited constitutive increases in AP-1 DNA-binding activity and c-Fos/c-Jun-immunoreactive protein levels. Clonogenic survival assays demonstrated that pretreatment with indomethacin, at concentrations that inhibited AP-1 activity, significantly reduced the resistance of OC-14 cells to heat-induced radiosensitization, hydrogen peroxide, and cisplatin. These results demonstrate a relationship between increases in AP-1 DNA-binding activity and increased cellular resistance to cancer therapeutic agents and oxidative stress that is inhibited by indomethacin. These results support the hypothesis that inhibition of AP-1 activity with nonsteroidal anti-inflammatory drugs, such as indomethacin, may represent a useful adjuvant to cancer therapy.
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Affiliation(s)
- C M Bradbury
- Section of Cancer Biology, Radiation Oncology Center, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri 63108, USA
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Affiliation(s)
| | - J. E. Locke
- The Rohm and Haas Company; Bristol Pennsylvania
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