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Ayoub M, Faris C, Chumbe JT, Daglilar E, Anwar N, Naravadi V. Safety of DOACs in patients with Child-Pugh Class C cirrhosis and trial fibrillation. JGH Open 2024; 8:e13074. [PMID: 38699468 PMCID: PMC11063728 DOI: 10.1002/jgh3.13074] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 03/20/2024] [Accepted: 04/12/2024] [Indexed: 05/05/2024]
Abstract
Background Anticoagulation (AC) is used for stroke prevention in atrial fibrillation (AF). Direct Oral Anticoagulants (DOACs) are safe in patients with AF without cirrhosis, they are hardly studied in patients with advanced cirrhosis. Our study evaluates the safety and outcomes of DOACs in patients with Child-Pugh class C cirrhosis (CPC). Methods We queried TriNetX Database. Patients with CPC and AF were divided into three cohorts: patients on DOACs, no AC, and warfarin. Three study arms were created using a 1:1 propensity score matching system (PSM). Results Totally 16 029 patients met the inclusion criteria. Of those, 20.2% (n = 3235) were on DOACs, 47.1% (n = 7552) were not on AC, and 32.7% (n = 5242) were on warfarin. First arm comparing AC versus no AC, a statistically significant benefit was identified in 3-year mortality risk (47% vs 71%, P < 0.0001) and transplant status (17% vs 5%, p < 0.0001) with AC. However, no significant difference was identified regarding intracranial hemorrhage and GI bleeding risk. Second arm comparing patients on DOACs versus no AC, we identified mortality benefit (40% vs 72%, P < 0.0001) and a higher transplant rate (9% vs 3.2%, P < 0.0001) with DOACs. Intracranial hemorrhage rates (6% vs 4%, P = 0.03) were higher in patients on DOACs. Third arm comparing patients on DOACs versus Warfarin, a statistically significant lower risk of intracranial hemorrhage (6.6% vs 8.7%, P = 0.004) and GI bleed (2% vs 2.4%, P < 0.0001) were identified in patients on DOACs. Conclusion Anticoagulation is safe in patients with CPC with AF and may provide a mortality benefit. DOACs are a safer alternative to warfarin.
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Affiliation(s)
- Mark Ayoub
- West Virginia University Charleston Division, Internal Medicine DepartmentCharleston Area Medical CenterCharlestonWest VirginiaUSA
| | - Carol Faris
- Marshall University School of MedicineSurgery DepartmentHuntingtonWest VirginiaUSA
| | - Julton Tomanguillo Chumbe
- West Virginia University Charleston Division, Internal Medicine DepartmentCharleston Area Medical CenterCharlestonWest VirginiaUSA
| | - Ebubekir Daglilar
- Department of Gastroenterology, Charleston DivisionWest Virginia University School of Medicine, Charleston Area Medical CenterCharlestonWest VirginiaUSA
| | - Nadeem Anwar
- Department of Gastroenterology, Charleston DivisionWest Virginia University School of Medicine, Charleston Area Medical CenterCharlestonWest VirginiaUSA
| | - Vishnu Naravadi
- Department of Gastroenterology, Charleston DivisionWest Virginia University School of Medicine, Charleston Area Medical CenterCharlestonWest VirginiaUSA
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Ayoub M, Faris C, Tomanguillo J, Anwar N, Chela H, Daglilar E. The Use of Pre-Endoscopic Metoclopramide Does Not Prevent the Need for Repeat Endoscopy: A U.S. Based Retrospective Cohort Study. Life (Basel) 2024; 14:526. [PMID: 38672796 PMCID: PMC11051147 DOI: 10.3390/life14040526] [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: 03/07/2024] [Revised: 04/14/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Peptic ulcer disease (PUD) can cause upper gastrointestinal bleeding (UGIB), often needing esophagogastroduodenoscopy (EGD). Second-look endoscopies verify resolution, but cost concerns prompt research on metoclopramide's efficacy compared to erythromycin. METHODS We analyzed the Diamond Network of TriNetX Research database, dividing UGIB patients with PUD undergoing EGD into three groups: metoclopramide, erythromycin, and no medication. Using 1:1 propensity score matching, we compared repeat EGD, post-EGD transfusion, and mortality within one month in two study arms. RESULTS Out of 97,040 patients, 11.5% received metoclopramide, 3.9% received erythromycin, and 84.6% received no medication. Comparing metoclopramide to no medication showed no significant difference in repeat EGD (10.1% vs. 9.7%, p = 0.34), transfusion (0.78% vs. 0.86%, p = 0.5), or mortality (1.08% vs. 1.08%, p = 0.95). However, metoclopramide had a higher repeat EGD rate compared to erythromycin (9.4% vs. 7.5%, p = 0.003), with no significant difference in transfusion or mortality. CONCLUSIONS The need to repeat EGD was not decreased with pre-EGD use of metoclopramide. If a prokinetic agent is to be used prior to EGD, erythromycin shows superior reduction in the need of repeat EGD as compared to metoclopramide.
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Affiliation(s)
- Mark Ayoub
- Department of Internal Medicine, Charleston Area Medical Center, West Virginia University, Charleston, WV 25304, USA
| | - Carol Faris
- Department of General Surgery, Marshall University, Huntington, WV 25755, USA;
| | - Julton Tomanguillo
- Department of Internal Medicine, Charleston Area Medical Center, West Virginia University, Charleston, WV 25304, USA
| | - Nadeem Anwar
- Division of Gastroenterology and Hepatology, Charleston Area Medical Center, West Virginia University, Charleston, WV 25304, USA
| | - Harleen Chela
- Division of Gastroenterology and Hepatology, Charleston Area Medical Center, West Virginia University, Charleston, WV 25304, USA
| | - Ebubekir Daglilar
- Division of Gastroenterology and Hepatology, Charleston Area Medical Center, West Virginia University, Charleston, WV 25304, USA
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Ayoub M, Tomanguillo J, Faris C, Anwar N, Chela H, Daglilar E. Use of proton pump inhibitors improves outcomes in mild acute pancreatitis: A nationwide cohort study. Medicine (Baltimore) 2024; 103:e37694. [PMID: 38579028 PMCID: PMC10994513 DOI: 10.1097/md.0000000000037694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 03/01/2024] [Indexed: 04/07/2024] Open
Abstract
Previous studies showed a potential anti-inflammatory effect of proton pump inhibitors (PPI) as well as possible inhibition of pancreatic secretion. This presents the question of their possible use in acute pancreatitis (AP). Current clinical evidence does not address the role of PPI and the present review for possible therapeutic use and safety is lacking. Therefore, our study aims to address the role of PPI in the management of AP and their association with the different outcomes of AP. We queried the Diamond Network through TriNetX-Research Network. This network included 92 healthcare organizations. Patients with mild AP with Bedside Index of Severity in Acute Pancreatitis (BISAP) score of Zero regardless of etiology were divided into 2 cohorts; 1st cohort included patients on PPI, and 2nd cohort included patients not on any PPI. Patients with BISAP score equal to or more than 1 or on PPI prior to the study date were excluded. Two well-matched cohorts were created using 1:1 propensity-scored matching model between cohorts. We compared the incidence of intensive care unit admission, mortality, and other associated complications. A total of 431,571 patients met the inclusion criteria. Of those, 32.9% (n = 142,062) were on PPI, and 67% (n = 289,509) were not on any PPI. After propensity matching, the sample included 115,630 patients on PPI vs 115,630 patients not on PPI. The PPI group had a lower rate of mortality (3.7% vs 4.4%, P < .001), a lower rate of intensive care unit admission (3.9% vs 5.5%, P < .001), a lower rate of necrotizing pancreatitis (1.1% vs 1.9%, P < .001), a lower rate of Hospital-Acquired Pneumonia (3.6% vs 4.9%, P < .001), a lower rate of respiratory failure (2.8% vs 4.2%, P < .001), and a lower rate of acute kidney injury (6.9% vs 10.1%, P < .001). There was no statistical difference in the rate of Clostridium difficile infection between the 2 cohorts (0.9% vs 0.8%, P = .5). The use of PPI in mild AP with a BISAP-score of zero is associated with reduced pancreatitis-related complications and improved mortality. Prospective studies are needed to confirm these findings.
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Affiliation(s)
- Mark Ayoub
- Internal Medicine Department, Charleston Area Medical Center, West Virginia University, Charleston, WV, USA
| | - Julton Tomanguillo
- Internal Medicine Department, Charleston Area Medical Center, West Virginia University, Charleston, WV, USA
| | - Carol Faris
- Department of General Surgery, Marshall University School of Medicine, Huntington, WV, USA
| | - Nadeem Anwar
- West Virginia University School of Medicine, Charleston Division, Gastroenterology, Charleston, WV, USA
| | - Harleen Chela
- West Virginia University School of Medicine, Charleston Division, Gastroenterology, Charleston, WV, USA
| | - Ebubekir Daglilar
- West Virginia University School of Medicine, Charleston Division, Gastroenterology, Charleston, WV, USA
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Rajamanuri M, Tomanguillo J, Ayoub M, Anwar N. Daptomycin-Induced Acute Liver Failure: A Rare Case Report. Cureus 2023; 15:e46692. [PMID: 37942364 PMCID: PMC10629966 DOI: 10.7759/cureus.46692] [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] [Accepted: 10/08/2023] [Indexed: 11/10/2023] Open
Abstract
Acute liver failure (ALF) is characterized by severe liver injury, encephalopathy, and impaired coagulation/synthetic function. Drug-induced liver injury (DILI) can rarely, in a dose-dependent manner, lead to ALF. This article presents a rare case of daptomycin-induced acute liver failure in a patient with no prior liver disease. A 73-year-old male with multiple comorbidities including heart failure, diabetes, and chronic kidney disease received daptomycin treatment for diabetic left foot osteomyelitis. Five days after starting therapy, he developed weakness, jaundice, and drowsiness, leading to ICU admission. Physical examination and labs revealed hepatomegaly, elevated liver enzymes and abnormal ultrasound findings. Autoimmune and infectious causes were ruled out. Daptomycin was discontinued, and the patient's labs showed significant improvement within three days. One week after recovery from acute liver failure, he experienced cardiogenic shock due to worsening of his underlying heart failure and was transferred to the Cardiac ICU before ultimately being discharged to inpatient hospice care. To our best knowledge, this is the first reported case of daptomycin-induced acute liver failure, presenting with massive liver enzyme elevations, synthetic dysfunction, and encephalopathy. The Naranjo scale score suggests a probable causal relationship between daptomycin and liver injury. While a few cases of daptomycin-induced liver injury have been reported, there are no previous reports of acute liver failure. The rapid development of liver failure following daptomycin administration and subsequent recovery after discontinuation is noteworthy. However, various confounding factors and the mechanism of daptomycin-induced liver failure remain unclear. Further research is needed to identify predisposing factors and better understand this rare complication. While rare, this care also raises caution to follow liver function closely while prescribing daptomycin.
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Affiliation(s)
- Medha Rajamanuri
- Internal Medicine, Southern Illinois University School of Medicine, Springfield, USA
| | | | - Mark Ayoub
- Internal Medicine, Charleston Area Medical Center, Charleston, USA
| | - Nadeem Anwar
- Gastroenterology and Hepatology, Charleston Area Medical Center, Charleston, USA
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Asad F, Naz S, Ali T, Gul Y, Jamal R, Shaheen Z, Tasadaq M, Nadeem A, Anwar N, Batool N, Bano S. Effect of natural and synthetic androgen hormone on sex reversal of Nile Tilapia (Oreochromis niloticus). BRAZ J BIOL 2023; 84:e272413. [PMID: 37255178 DOI: 10.1590/1519-6984.272413] [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] [Received: 02/27/2023] [Accepted: 04/26/2023] [Indexed: 06/01/2023] Open
Abstract
The present study aimed to produce a monosex population of all male Nile tilapia (Oreochromis spp.) using 17α-methyl testosterone and common carp testes (as a source of natural androgen). Trial was conducted into two consecutive phases, the first was fry (4-5 days old)administration with negative control (without hormone) and positive control (with hormone) feed viz., MT1:60mg/kg, MT2:70mg/kg (17α-MT), carp testis CT1:70% and CT2:80% for 30 days to reverse the sex of male fish and the second phase was nursing the fingerlings for two months on control diet (32% Crude protein).Results revealed a significant growth rate (P<0.05) in the control group where final weight (4.8±0.34ab) and weight gained was recorded as 0.66±0.03ac. In proximate chemical composition of body meat, CT2 treatment showed maximum retention of crude protein, crude fat, and ash whereas dry matter showed maximum retention in MT2 and CT1 treatments. Morphological and histological examination revealed significant difference (p<0.05) in phenotypic males of Nile tilapia fed with the highest percent in MT-treated diet (MT2) of 95±0.58a while MT1, CT2 and CT1 had males of 85±6.0b, 70±5.0b and 65±6.5b, respectively. It was concluded that synthetic androgen (17αMT) was more effective for masculinization but natural androgen scan be an alternative method to produce male tilapia population in an environment-friendly manner as they are inexpensive, eco-friendly, and radially available. These results suggested that synthetic and natural androgen supplementation in the diet plays a significant role in improving growth performance and body composition.
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Affiliation(s)
- F Asad
- Government College University Faisalabad, Zoology Department, Faisalabad, Punjab, Pakistan
| | - S Naz
- Government College University Faisalabad, Zoology Department, Faisalabad, Punjab, Pakistan
| | - T Ali
- Government College University Faisalabad, Zoology Department, Faisalabad, Punjab, Pakistan
| | - Y Gul
- Government College Women University Faisalabad, Zoology Department, Faisalabad, Punjab, Pakistan
| | - R Jamal
- Government College University Faisalabad, Zoology Department, Faisalabad, Punjab, Pakistan
| | - Z Shaheen
- Government College University Faisalabad, Zoology Department, Faisalabad, Punjab, Pakistan
| | - M Tasadaq
- Government College University Faisalabad, Zoology Department, Faisalabad, Punjab, Pakistan
| | - A Nadeem
- Government College University Faisalabad, Zoology Department, Faisalabad, Punjab, Pakistan
| | - N Anwar
- Government College University Faisalabad, Zoology Department, Faisalabad, Punjab, Pakistan
| | - N Batool
- Government College University Faisalabad, Zoology Department, Faisalabad, Punjab, Pakistan
| | - S Bano
- Government College University Faisalabad, Zoology Department, Faisalabad, Punjab, Pakistan
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Zafar F, Lubert AM, Trout AT, Katz DA, Palermo JJ, Opotowsky AR, Lorts A, Chin C, Powell AW, Villa CR, Anwar N, Morales DL, Dillman JR, Alsaied T. Abdominal CT and MRI Findings of Portal Hypertension in Children and Adults with Fontan Circulation. Radiology 2022; 303:557-565. [PMID: 35289663 DOI: 10.1148/radiol.211037] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Portal hypertension in the Fontan circulation is a function of elevated systemic venous pressure and liver fibrosis. Purpose To quantify the prevalence of radiologic evidence of portal hypertension and elevated VAST score (one point each for varices, ascites, splenomegaly, and thrombocytopenia) of 2 or greater in children and adults with Fontan circulation and to determine the association with hemodynamics and adverse outcomes. Materials and Methods This was a retrospective study of individuals with Fontan circulation who underwent abdominal MRI or CT for focal liver lesion surveillance between January 2012 and December 2019. Portal hypertension was defined as the presence of at least two of the following: varices, ascites, or splenomegaly. Fontan deterioration was defined as a composite of heart failure signs or symptoms requiring diuretic escalation, placement of a ventricular assist device, heart transplant, or death. Relationships between variables and the composite end point were assessed using univariable and multivariable logistic regression. Results A total of 123 patients (age range, 9-55 years; 32 children) were evaluated (median age, 23 years; IQR, 17-30 years; 63 male patients). Median time since diagnosis of Fontan circulation was 16 years (IQR, 12-23 years). Twenty-five of the 123 patients (20%) had radiologic evidence of portal hypertension, and 34 (28%) had a VAST score of 2 or greater. Fontan deterioration occurred in 25 of the 123 patients (20%); median follow-up duration was 0.4 year (IQR, 0.1-3.1 years). Compared with patients who had Fontan circulation without deterioration, patients with Fontan deterioration were more likely to have moderate or severe ventricular systolic dysfunction (P < .01), moderate or severe atrioventricular valve regurgitation (P < .01), higher Fontan pressure (P = .01), radiologic evidence of portal hypertension (P < .01), and VAST score of 2 or greater (P < .01). Conclusion Radiologic evidence of portal hypertension at abdominal imaging in children and adults with Fontan circulation was associated with higher venous pressures and an increased risk for Fontan deterioration. These characteristics may be used to identify patients who warrant comprehensive hemodynamic evaluation. © RSNA, 2022.
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Affiliation(s)
- Faizeen Zafar
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - Adam M Lubert
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - Andrew T Trout
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - David A Katz
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - Joseph J Palermo
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - Alexander R Opotowsky
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - Angela Lorts
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - Clifford Chin
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - Adam W Powell
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - Chet R Villa
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - Nadeem Anwar
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - David L Morales
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - Jonathan R Dillman
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
| | - Tarek Alsaied
- From the Department of Pediatrics (F.Z.), Heart Institute (A.M.L., D.A.K., A.R.O., A.L., C.C., A.W.P., C.R.V., T.A.), Department of Radiology (A.T.T., J.R.D.), Division of Gastroenterology, Hepatology, and Nutrition (J.J.P.), and Division of Cardiothoracic Surgery (D.L.M.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229; Department of Radiology (A.T.T., J.R.D.) and Division of Gastroenterology (N.A.), University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio (A.T.T.); and Heart Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa (T.A.)
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Lubert AM, Opotowsky AR, Palermo JJ, Alsaied T, Szugye C, Anwar N, Tiao GM, Lorts A, Dillman JR, Trout AT. Relation of Liver Volume to Adverse Cardiovascular Events in Adolescents and Adults With Fontan Circulation. Am J Cardiol 2022; 165:88-94. [PMID: 34893302 DOI: 10.1016/j.amjcard.2021.10.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/14/2021] [Accepted: 10/19/2021] [Indexed: 11/26/2022]
Abstract
Elevated central venous pressure in those with Fontan circulation causes liver congestion and hepatomegaly. We assessed if liver volume by magnetic resonance imaging (MRI) is associated with adverse cardiovascular outcomes. Retrospective study of 122 patients with Fontan circulation who were >10 years old and had a liver MRI with magnetic resonance elastography. Liver volume (ml) was measured by manual segmentation from axial T2-weighted images and was indexed to body surface area. The composite outcome included death, heart transplant, ventricular assist device placement, or nonelective cardiovascular hospitalization. The median age at the time of MRI was 18.9 (interquartile range 15.8 to 25.9) years, and 47% of the patients were women. The mean indexed liver volume was 1,133 ± 180 ml/m2. Indexed liver volume was not significantly associated with age, years since Fontan, or with liver stiffness (r = 0.15, p = 0.10), but was positively correlated with Fontan pressure (r = 0.32, p = 0.002). Over a median follow-up of 2.1 (0.8 to 4.2) years, 32 patients (26%) experienced the composite outcome. Higher indexed liver volume was associated with a greater hazard for the composite outcome (hazard ratio per 1 SD increase = 1.74, 95% confidence interval 1.27 to 2.35, p = 0.0004) but increased liver stiffness was not significantly associated with the composite outcome (hazard ratio per 1 SD increase 1.44, 95% confidence interval 0.90 to 2.21, p = 0.11). In conclusion, greater liver volume indexed to body surface area is associated with unfavorable hemodynamics and adverse outcomes in patients with Fontan circulation. Liver volume may be a useful, simple imaging biomarker in adolescents and adults with Fontan circulation.
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8
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Brayer SW, Zafar F, Lubert AM, Trout AT, Palermo JJ, Opotowsky AR, Anwar N, Dillman JR, Alsaied T. Relation of Magnetic Resonance Elastography to Fontan Circulatory Failure in a Cohort of Pediatric and Adult Patients. Pediatr Cardiol 2021; 42:1871-1878. [PMID: 34448042 DOI: 10.1007/s00246-021-02707-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/04/2021] [Indexed: 01/03/2023]
Abstract
Elevated magnetic resonance elastography (MRE)-derived liver stiffness may be associated with worse outcomes in people with Fontan circulation. We sought to evaluate the association between liver stiffness and Fontan failure or portal hypertension. Single center cross-sectional retrospective study of people with Fontan circulation who underwent MRE between 2011 and 2020. The cohort was divided into adult (age ≥ 21 years) and pediatric (< 21 years) groups. Fontan circulatory failure (FF) was defined as any of the following: death, transplantation, ventricular assist device, heart failure symptoms requiring escalation of diuretics. Radiologic portal hypertension was defined as the presence of one or more of the following: splenomegaly, ascites, or gastrointestinal varices. 128 patients were included (average age = 22.6 ± 8.7 years) and 58 (45%) were children. Median liver stiffness was 4.3 kPa (interquartile range (IQR) 3.8-5.8) for the entire cohort. Thirty patients (23%) developed FF (16 adults, 14 children). Liver stiffness was higher in adults with FF compared to those without FF (4.9 (IQR 4.0-6.0) vs. 4.2 (IQR 3.8-4.7) kPa, p = 0.04). There was no difference in liver stiffness between pediatric patients with and without FF (4.4 (IQR 4.1-5.4) vs. 4.4 (IQR 3.8-5.0), p = 0.5). Adults with radiologic portal hypertension and adults with moderate or severe atrioventricular valve regurgitation had higher liver stiffness than adults without. MRE-derived liver stiffness is associated with atrioventricular valve regurgitation, portal hypertension, and poor clinical outcomes in adults with Fontan circulation. There was no association between liver stiffness and FF in pediatric patients. This difference may be due to the progressive nature of Fontan-associated liver disease.
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Affiliation(s)
- Samuel W Brayer
- Pediatric Residency Training Program, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, USA.
| | - Faizeen Zafar
- Pediatric Residency Training Program, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, USA
| | - Adam M Lubert
- Department of Pediatrics, Cincinnati Children's Hospital Heart Institute, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joseph J Palermo
- Division of Gastroenterology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Alexander R Opotowsky
- Department of Pediatrics, Cincinnati Children's Hospital Heart Institute, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Nadeem Anwar
- Division of Gastroenterology, Department of Medicine, University of Cincinnati Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jonathan R Dillman
- Department of Radiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tarek Alsaied
- UPMC Children's Hospital of Pittsburgh Heart and Vascular Institute, Pittsburgh, PA, USA
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9
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Jose A, Shah SA, Anwar N, Jones CR, Sherman KE, Elwing JM. Pulmonary Vascular Resistance Predicts Mortality and Graft Failure in Transplantation Patients With Portopulmonary Hypertension. Liver Transpl 2021; 27:1811-1823. [PMID: 33964116 PMCID: PMC8573056 DOI: 10.1002/lt.26091] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 04/27/2021] [Accepted: 04/30/2021] [Indexed: 12/13/2022]
Abstract
Portopulmonary hypertension (POPH) is a pulmonary vascular disease associated with significant morbidity and mortality in those with liver disease, conferring a higher mortality in patients awaiting liver transplantation (LT). Although not a transplant indication, patients with POPH can experience significant clinical improvement following LT, and those maintaining a mean pulmonary artery pressure (MPAP) <35mm Hg and a pulmonary vascular resistance (PVR) <5 Woods units (WU) are granted additional listing points to expedite LT. The effect of POPH on posttransplant outcomes such as mortality and graft failure, however, is not well defined. We performed a retrospective cohort study of the US Organ Procurement and Transplantation Network database of all adult patients who underwent LT between January 1, 2006, and December 1, 2020. Using adjusted accelerated failure time models, we examined the relationship between a diagnosis of POPH and outcomes following LT and the relationship between pre-LT hemodynamics and post-LT survival (alive with a functioning graft) in patients with POPH. Compared with those undergoing transplants without exception points, patients with POPH had comparable post-LT survival rates but were significantly more likely to have graft failure. Both pre-LT MPAP and PVR predicted post-LT survival in POPH, with a pre-LT PVR of ≥1.6 WU, more than doubling the hazard for mortality (death or a nonfunctioning graft; coefficient, 2.01; standard error, 0.85; hazard ratio, 2.21; P = 0.02). POPH may confer a significantly higher risk of post-LT graft failure compared with patients with cirrhosis without POPH, and a pre-LT PVR of ≥1.6 WU may predict post-LT survival. Further investigation into the relationship between pre-LT hemodynamics, right ventricular function, and post-LT outcomes of mortality and graft failure in POPH is needed.
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Affiliation(s)
- Arun Jose
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Shimul A Shah
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Nadeem Anwar
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | - Courtney R Jones
- Department of Anesthesiology, University of Cincinnati, Cincinnati, OH, USA
| | - Kenneth E Sherman
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | - Jean M Elwing
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
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10
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Jose A, Shah SA, Anwar N, Jones CR, McCormack FX, Sherman KE, Elwing JM. Predictors of outcomes following liver transplant in hepatopulmonary syndrome: An OPTN database analysis. Respir Med 2021; 190:106683. [PMID: 34784562 DOI: 10.1016/j.rmed.2021.106683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/01/2021] [Accepted: 11/08/2021] [Indexed: 02/07/2023]
Abstract
Hepatopulmonary syndrome (HPS) is a type of pulmonary vascular disease occurring exclusively in those with underlying liver disease, associated with significant mortality in patients awaiting liver transplantation (LT). LT is curative in HPS, and these patients are granted Model for End Stage Liver Disease (MELD) exception points to expedite LT. The purpose of this study is to use multivariable competing risk Accelerated Failure Time models and propensity matching to examine the relationship between pre-LT hypoxemia and post-LT outcomes in HPS. We performed a retrospective cohort study of UNOS/OPTN database of all adult patients undergoing LT between January 1, 2006 and January 12, 2020. Pre-LT PaO2 was significantly associated with post-LT mortality in HPS, with each 1 mmHg increase in PaO2 significantly decreasing the risk of post-LT mortality (coefficient 0.039, HR = 0.95, p = 0.001). HPS patients with a pre-LT PaO2 < 54 mmHg demonstrated increased mortality following LT as compared to matched non-HPS cirrhotic patients. We conclude that HPS patients with a PaO2, 54 mmHg are at increased risk of post-LT mortality and may identify high-risk patients who would benefit from additional resources during LT, and that the effects of HPS MELD exception points to optimize post-LT outcomes should be continuously re-evaluated.
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Affiliation(s)
- Arun Jose
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA.
| | - Shimul A Shah
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Nadeem Anwar
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | - Courtney R Jones
- Department of Anesthesiology, University of Cincinnati, Cincinnati, OH, USA
| | - Francis X McCormack
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Kenneth E Sherman
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH, USA
| | - Jean M Elwing
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
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11
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Katz DA, Peck D, Lubert AM, Possner M, Zafar F, Trout AT, Palermo JJ, Anwar N, Dillman JR, Powell AW, Xanthakos SA, Opotowsky AR, Veldtman G, Alsaied T. Hepatic Steatosis in Patients With Single Ventricle and a Fontan Circulation. J Am Heart Assoc 2021; 10:e019942. [PMID: 33880928 PMCID: PMC8200742 DOI: 10.1161/jaha.120.019942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Hepatic steatosis, caused by nonalcoholic fatty liver disease, is a leading cause of chronic liver disease. The interplay between hepatic steatosis and the development of liver disease following the Fontan procedure is not well understood. This study examined the prevalence and associations of hepatic steatosis in patients with a Fontan circulation. Methods and Results This was a single‐center retrospective study of 95 patients with a Fontan circulation with liver magnetic resonance imaging performed between 2012 and 2019. The average age at magnetic resonance imaging was 21.5±8.5 years. The percent liver fat signal was determined using magnetic resonance chemical shift‐encoded proton density fat fraction imaging. Hepatic steatosis was defined as liver fat ≥5% and was present in 10.5% of the cohort. The presence of hepatic steatosis was associated with higher body mass index (29±4 versus 24±6 kg/m2, P=0.006), a higher frequency of obesity (50% versus 12%, P=0.015), lower high‐density lipoprotein cholesterol (35±9 versus 43±14 mg/dL, P=0.050), and greater subcutaneous fat thickness (2.6±0.7 versus 1.8±1.0 cm, P=0.043). There was no association between hepatic steatosis and cardiovascular imaging or hemodynamic variables from cardiac catheterization. Conclusions Risk factors for hepatic steatosis in patients with Fontan circulation include obesity and dyslipidemia, similar to what is seen in the general population. Fontan hemodynamics were not associated with hepatic steatosis.
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Affiliation(s)
- David A Katz
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH.,The Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Daniel Peck
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH.,The Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Adam M Lubert
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH.,The Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Mathias Possner
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH.,The Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Faizeen Zafar
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Andrew T Trout
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH.,Department of Radiology Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Radiology University of Cincinnati College of Medicine Cincinnati OH
| | - Joseph J Palermo
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH.,Department of Gastroenterology Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Nadeem Anwar
- Department of Gastroenterology University of Cincinnati Cincinnati OH
| | - Jonathan R Dillman
- Department of Radiology Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Radiology University of Cincinnati College of Medicine Cincinnati OH
| | - Adam W Powell
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH.,The Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Stavra A Xanthakos
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH.,Department of Gastroenterology Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Alexander R Opotowsky
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH.,The Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Gruschen Veldtman
- King Faisal Specialist Hospital and Research Centre Riyadh Saudi Arabia
| | - Tarek Alsaied
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH.,The Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH
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12
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Lubert AM, Alsaied T, Palermo JJ, Anwar N, Urbina EM, Brown NM, Alexander C, Almeneisi H, Wu F, Leventhal AR, Aldweib N, Mendelson M, Opotowsky AR. Fontan-Associated Dyslipidemia. J Am Heart Assoc 2021; 10:e019578. [PMID: 33787283 PMCID: PMC8174355 DOI: 10.1161/jaha.120.019578] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Hypocholesterolemia is a marker of liver disease, and patients with a Fontan circulation may have hypocholesterolemia secondary to Fontan‐associated liver disease or inflammation. We investigated circulating lipids in adults with a Fontan circulation and assessed the associations with clinical characteristics and adverse events. Methods and Results We enrolled 164 outpatients with a Fontan circulation, aged ≥18 years, in the Boston Adult Congenital Heart Disease Biobank and compared them with 81 healthy controls. The outcome was a combined outcome of nonelective cardiovascular hospitalization or death. Participants with a Fontan (median age, 30.3 [interquartile range, 22.8–34.3 years], 42% women) had lower total cholesterol (149.0±30.1 mg/dL versus 190.8±41.4 mg/dL, P<0.0001), low‐density lipoprotein cholesterol (82.5±25.4 mg/dL versus 102.0±34.7 mg/dL, P<0.0001), and high‐density lipoprotein cholesterol (42.8±12.2 mg/dL versus 64.1±16.9 mg/dL, P<0.0001) than controls. In those with a Fontan, high‐density lipoprotein cholesterol was inversely correlated with body mass index (r=−0.30, P<0.0001), high‐sensitivity C‐reactive protein (r=−0.27, P=0.0006), and alanine aminotransferase (r=−0.18, P=0.02) but not with other liver disease markers. Lower high‐density lipoprotein cholesterol was independently associated with greater hazard for the combined outcome adjusting for age, sex, body mass index, and functional class (hazard ratio [HR] per decrease of 10 mg/dL, 1.37; 95% CI, 1.04–1.81 [P=0.03]). This relationship was attenuated when log high‐sensitivity C‐reactive protein was added to the model (HR, 1.26; 95% CI, 0.95–1.67 [P=0.10]). Total cholesterol, low‐density lipoprotein cholesterol, and triglycerides were not associated with the combined outcome. Conclusions The Fontan circulation is associated with decreased cholesterol levels, and lower high‐density lipoprotein cholesterol is associated with adverse outcomes. This association may be driven by inflammation. Further studies are needed to understand the relationship between the severity of Fontan‐associated liver disease and lipid metabolism.
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Affiliation(s)
- Adam M Lubert
- Department of Pediatrics Cincinnati Children's Hospital Heart InstituteUniversity of Cincinnati College of Medicine Cincinnati OH
| | - Tarek Alsaied
- Department of Pediatrics Cincinnati Children's Hospital Heart InstituteUniversity of Cincinnati College of Medicine Cincinnati OH
| | - Joseph J Palermo
- Department of Pediatrics Division of Gastroenterology Cincinnati Children's Hospital Medical CenterUniversity of Cincinnati College of Medicine Cincinnati OH
| | - Nadeem Anwar
- Department of Medicine Digestive Disease Division University of Cincinnati College of Medicine Cincinnati OH
| | - Elaine M Urbina
- Department of Pediatrics Cincinnati Children's Hospital Heart InstituteUniversity of Cincinnati College of Medicine Cincinnati OH
| | - Nicole M Brown
- Department of Pediatrics Cincinnati Children's Hospital Heart InstituteUniversity of Cincinnati College of Medicine Cincinnati OH
| | - Craig Alexander
- Department of Pediatrics Cincinnati Children's Hospital Heart InstituteUniversity of Cincinnati College of Medicine Cincinnati OH
| | - Hassan Almeneisi
- Department of Pediatrics Cincinnati Children's Hospital Heart InstituteUniversity of Cincinnati College of Medicine Cincinnati OH
| | - Fred Wu
- Department of Cardiology Boston Children's HospitalHarvard Medical School Boston MA.,Department of Medicine Division of Cardiovascular Medicine Brigham and Women's Hospital Harvard Medical School Boston MA
| | | | - Nael Aldweib
- Department of Cardiology Boston Children's HospitalHarvard Medical School Boston MA.,Department of Medicine Division of Cardiovascular Medicine Brigham and Women's Hospital Harvard Medical School Boston MA
| | - Michael Mendelson
- Department of Cardiology Boston Children's HospitalHarvard Medical School Boston MA
| | - Alexander R Opotowsky
- Department of Pediatrics Cincinnati Children's Hospital Heart InstituteUniversity of Cincinnati College of Medicine Cincinnati OH.,Department of Cardiology Boston Children's HospitalHarvard Medical School Boston MA.,Department of Medicine Division of Cardiovascular Medicine Brigham and Women's Hospital Harvard Medical School Boston MA
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13
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Bari K, Shah SA, Kaiser TE, Cohen RM, Anwar N, Kleesattel D, Sherman KE. Safety and Efficacy of Budesonide for Liver Transplant Immune Suppression: Results of a Pilot Phase 2a Trial. Liver Transpl 2020; 26:1430-1440. [PMID: 32602616 PMCID: PMC7606621 DOI: 10.1002/lt.25837] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/04/2020] [Accepted: 06/19/2020] [Indexed: 02/06/2023]
Abstract
Despite adverse effects like hyperglycemia, new-onset diabetes after transplant (NODAT), and infectious complications, corticosteroid use remains an important part of liver transplantation (LT) immune suppression. Budesonide, a synthetic corticosteroid, undergoes extensive first-pass hepatic metabolism with only 10% systemic bioavailability, providing an opportunity for an improved toxicity-therapeutic ratio. Although effective in the treatment of autoimmune hepatitis, the effects of budesonide for LT immune suppression are unknown. We conducted a single-center phase 2a trial to study the safety and efficacy of budesonide immunosuppressive therapy. From July 2017 to November 2018, 20 patients undergoing a first LT received budesonide tapering doses (from 9 to 3 mg) for 12 weeks. Patients were compared with matched control patients who received prednisone from the same time period. Additionally, both groups received calcineurin inhibitors and mycophenolate mofetil. Outcome measures at week 24 included rates of biopsy-proven acute cellular rejection (ACR), NODAT (hemoglobin A1c >6.4%), and infectious complications. In the budesonide arm, 1 patient developed ACR at week 5 and was removed from the study. Another patient stopped the study drug at week 8 due to persistent nausea. Rates of ACR were similar between the budesonide and control groups (5% versus 5%, P = 1.00). Three patients in the control group developed NODAT versus none in the budesonide group (15% versus 0%; P = 0.23). There were 6 infections in the control group compared with none in the budesonide group (30% versus 0; P = 0.02). These pilot data suggest that budesonide has the potential to be a safe and effective alternative to prednisone for LT immune suppression while reducing steroid-induced infections and NODAT. Randomized controlled trials are required to validate these findings.
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Affiliation(s)
- Khurram Bari
- University of Cincinnati, Division of Digestive Diseases, Department of Medicine, Cincinnati, Ohio
| | - Shimul A. Shah
- University of Cincinnati, Division of Transplant Surgery, Department of Surgery, Cincinnati, Ohio
| | - Tiffany E. Kaiser
- University of Cincinnati, Division of Digestive Diseases, Department of Medicine, Cincinnati, Ohio
| | - Robert M Cohen
- University of Cincinnati, Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Cincinnati, Ohio
| | - Nadeem Anwar
- University of Cincinnati, Division of Digestive Diseases, Department of Medicine, Cincinnati, Ohio
| | - David Kleesattel
- University of Cincinnati, Department of Internal Medicine, Cincinnati, Ohio
| | - Kenneth E. Sherman
- University of Cincinnati, Division of Digestive Diseases, Department of Medicine, Cincinnati, Ohio
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14
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Possner M, Gordon-Walker T, Egbe AC, Poterucha JT, Warnes CA, Connolly HM, Ginde S, Clift P, Kogon B, Book WM, Walker N, Wagenaar LJ, Moe T, Oechslin E, Kay WA, Norris M, Dillman JR, Trout AT, Anwar N, Hoskoppal A, Broering DC, Bzeizi K, Veldtman G. Hepatocellular carcinoma and the Fontan circulation: Clinical presentation and outcomes. Int J Cardiol 2020; 322:142-148. [PMID: 32828959 DOI: 10.1016/j.ijcard.2020.08.057] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/16/2020] [Accepted: 08/17/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Fontan-associated liver disease (FALD) is universal in patients with a Fontan circulation. Hepatocellular carcinoma (HCC) is one of its severe expressions, and, though rare, frequently fatal. The purpose of this study was to describe the clinical presentation, risk factors, and outcomes of HCC in patients with a Fontan circulation. METHODS A multicenter case series of Fontan patients with a diagnosis of HCC formed the basis of this study. The case series was extended by published cases and case reports. Clinical presentation, tumor characteristics, laboratory and hemodynamic findings as well as treatment types and outcomes, were described. RESULTS Fifty-four Fontan patients (50% female) with a diagnosis of HCC were included. Mean age at HCC diagnosis was 30 ± 9.4 years and mean duration from Fontan surgery to HCC diagnosis was 21.6 ± 7.4 years. Median HCC size at the time of diagnosis was 4 cm with a range of 1 to 22 cm. The tumor was located in the right hepatic lobe in 65% of the patients. Fifty-one percent had liver cirrhosis at the time of HCC diagnosis. Fifty percent of the patients had no symptoms related to HCC and alpha-fetoprotein was normal in 26% of the cases. Twenty-six patients (48%) died during a median follow-up duration of 10.6 (range 1-50) months. CONCLUSIONS HCC in Fontan patients occurs at a young age with a 1-year survival rate of only 50%. Meticulous liver surveillance is crucial to detect small tumors in the early stage.
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Affiliation(s)
- Mathias Possner
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Timothy Gordon-Walker
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; The University of Edinburgh, Edinburgh, United Kingdom
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Carole A Warnes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Salil Ginde
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Paul Clift
- Department of Cardiology, New Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Brian Kogon
- Department of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Egleston, Emory University, Atlanta, GA, USA
| | - Wendy M Book
- Division of Cardiology, Department of Medicine, Emory University Department of Medicine, Atlanta, GA, USA
| | - Niki Walker
- Scottish Adult Congenital Cardiac Service, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Lodewijk J Wagenaar
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente Hospital, Enschede, the Netherlands
| | - Tabitha Moe
- Division of Cardiology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Erwin Oechslin
- Toronto Congenital Cardiac Centre for Adults, University Health Network / Peter Munk Cardiac Centre, and University of Toronto, Toronto, Ontario, Canada
| | - W Aaron Kay
- Section of Pediatric Cardiology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA; Krannert Institute of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mark Norris
- Division of Pediatric Cardiology, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Jonathan R Dillman
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Nadeem Anwar
- Division of Gastroenterology, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Arvind Hoskoppal
- Department of Pediatrics, University of Utah and Intermountain Healthcare, Salt Lake City, UT, USA
| | - Dieter C Broering
- Department of Liver Transplantation, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Khalid Bzeizi
- Adult Congenital Heart Disease, Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Gruschen Veldtman
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Adult Congenital Heart Disease, Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
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15
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Anwar N, Kaiser TE, Bari K, Schoech M, Diwan TS, Cuffy MC, Silski L, Quillin RC, Safdar K, Shah SA. Use of Hepatitis C Nucleic Acid Test-Positive Liver Allografts in Hepatitis C Virus Seronegative Recipients. Liver Transpl 2020; 26:673-680. [PMID: 32125753 DOI: 10.1002/lt.25741] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/06/2020] [Accepted: 02/25/2020] [Indexed: 02/07/2023]
Abstract
Because of underutilization of liver allografts, our center previously showed that hepatitis C virus (HCV) antibody-positive/nucleic acid test (NAT)-negative livers when transplanted into HCV nonviremic recipients were safe with a 10% risk of HCV transmission. Herein, we present our single-center prospective experience of using HCV NAT+ liver allografts transplanted into HCV NAT- recipients. An institutional review board-approved matched cohort study was conducted examining post- liver transplantation (LT) outcomes of HCV- patients who received HCV NAT+ organs (treatment group) compared with matched recipients with HCV NAT- organs (matched comparator group) between June 2018 to October 2019. The primary endpoint was success of HCV treatment and elimination of HCV infection. The secondary outcomes included the 30-day and 1-year graft and patient survival as well as perioperative complications. There were 32 recipients enrolled into each group. Because of 1 death in the index admission, 30/31 patients (97%) were given HCV treatment at a median starting time of 47 days (18-140 days) after LT. A total of 19 (63%) patients achieved sustained virological response at week 12 (SVR12). Another 6 patients achieved end-of-treatment response, while 5 remained on therapy and 1 is yet to start treatment. No HCV treatment failure has been noted. There were no differences in 30-day and 1-year graft and patient survival, length of hospital stay, biliary or vascular complications, or cytomegalovirus viremia between the 2 groups. In this interim analysis of a matched cohort study, which is the first and largest study to date, the patients who received the HCV NAT+ organs had similar outcomes regarding graft function, patient survival, and post-LT complications.
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Affiliation(s)
- Nadeem Anwar
- Digestive Disease Division, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Tiffany E Kaiser
- Digestive Disease Division, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Khurram Bari
- Digestive Disease Division, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Michael Schoech
- Digestive Disease Division, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Tayyab S Diwan
- Solid Organ Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Madison C Cuffy
- Solid Organ Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Latifa Silski
- Digestive Disease Division, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Ralph C Quillin
- Solid Organ Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kamran Safdar
- Digestive Disease Division, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Solid Organ Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
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Wenker Z, Pagano B, Wahab S, Wade G, Bari K, Safdar K, Schoech M, Anwar N, Makramalla A. 3:09 PM Abstract No. 318 Abnormal doppler findings in transjugular intrahepatic portosystemic shunt using the new GORE VIATORR controlled expansion endoprosthesis: a retrospective single-center analysis. J Vasc Interv Radiol 2020. [DOI: 10.1016/j.jvir.2019.12.373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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17
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Anwar N, Merchant M, Werel T, Tooth A, Uttleyl L, Gokal R. A Prospective, Randomized Study of the Comparative Safety and Efficacy of Intraperitoneal Imipenem versus Vancomycin and Netilmicin in the Treatment of Peritonitis on CAPD. Perit Dial Int 2020. [DOI: 10.1177/089686089501500214] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- N. Anwar
- Department of Renal Medicine, Manchester Royal Infirmary Manchester, U.K
| | - M. Merchant
- Department of Renal Medicine, Manchester Royal Infirmary Manchester, U.K
| | - T. Werel
- Department of Renal Medicine, Manchester Royal Infirmary Manchester, U.K
| | - A. Tooth
- Department of Microbiology Manchester Royal Infirmary Manchester, U.K
| | - L. Uttleyl
- Department of Renal Medicine, Manchester Royal Infirmary Manchester, U.K
| | - R. Gokal
- Department of Renal Medicine, Manchester Royal Infirmary Manchester, U.K
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18
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Alsaied T, Possner M, Lubert AM, Trout AT, Szugye C, Palermo JJ, Lorts A, Goldstein BH, Veldtman GR, Anwar N, Dillman JR. Relation of Magnetic Resonance Elastography to Fontan Failure and Portal Hypertension. Am J Cardiol 2019; 124:1454-1459. [PMID: 31474329 DOI: 10.1016/j.amjcard.2019.07.052] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 07/24/2019] [Accepted: 07/25/2019] [Indexed: 12/11/2022]
Abstract
Fontan associated liver disease is associated with morbidity and mortality in palliated single-ventricle congenital heart disease patients. Magnetic resonance elastography (MRE) provides a quantitative assessment of liver stiffness in Fontan patients. We hypothesized that MRE liver stiffness correlates with liver enzymes, hemodynamics, portal hypertension, and Fontan failure (FF). All adult Fontan patients who had MRE between 2011 and 2018 were included. Radiologic portal hypertension was defined as splenomegaly, ascites, and/or varices. FF was defined as death, transplantation, or heart failure symptoms requiring escalation of diuretics. Seventy patients with a median age of 24.7 years and a median follow-up from MRE of 3.9 years were included. The median liver stiffness was 4.3 kPa (interquartile range [IQR]: 3.8 to 5.0 kPa). There was a weak, positive correlation between liver stiffness and Fontan pathway pressure (r = 0.34, p = 0.03). There was a moderate negative correlation of liver stiffness with ventricular ejection fraction (r = -0.52, p = 0.03). Liver stiffness was weakly positively correlated with liver transaminases and gamma glutamyl transferase. Patients with portal hypertension had higher liver stiffness compared to patients without (5.2 ± 1.3 vs 4.2 ± 0.8 kPa, p = 0.03). At MRE or during follow-up, 13 patients (19%) met definition of FF and had significantly higher liver stiffness compared to patients without FF (5.1 [IQR: 4.3 to 6.3] vs 4.2 [IQR: 3.7 to 4.7] kPa, p = 0.01). Liver stiffness above 4.5 kPa differentiated FF with a sensitivity of 77% and specificity of 77%. In conclusion, elevated MRE-derived liver stiffness is associated with worse hemodynamics, liver enzymes and clinical outcomes in Fontan patients. This measure may serve as a global imaging biomarker of Fontan health.
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Affiliation(s)
- Tarek Alsaied
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine Cincinnati, Ohio.
| | - Mathias Possner
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Adam M Lubert
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Andrew T Trout
- Cincinnati Children's Hospital Medical Center, Department of Radiology, University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Cassandra Szugye
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Joseph J Palermo
- Cincinnati Children's Hospital Medical Center, Division of Gastroenterology, Department of Pediatrics, University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Angela Lorts
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Bryan H Goldstein
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Gruschen R Veldtman
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine Cincinnati, Ohio; Adult Congenital Heart Disease, Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Nadeem Anwar
- University of Cincinnati Medical Center, Division of Gastroenterology, Department of Medicine, University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Johnathan R Dillman
- Cincinnati Children's Hospital Medical Center, Department of Radiology, University of Cincinnati College of Medicine Cincinnati, Ohio
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Lee TC, Kaiser TE, Luckett K, Wima K, Winer LK, Morris MC, Kassam AF, Safdar K, Bari K, Anwar N, Quillin RC, Shah SA. Use, Safety, and Effectiveness of Viremic Hepatitis B Virus Donor Livers: A Potential Opportunity to Expand the Donor Pool. Liver Transpl 2019; 25:1581-1584. [PMID: 31273919 DOI: 10.1002/lt.25595] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/18/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Tiffany C Lee
- Cincinnati Research on Outcomes and Safety in Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Tiffany E Kaiser
- Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Keith Luckett
- Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Koffi Wima
- Cincinnati Research on Outcomes and Safety in Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Leah K Winer
- Cincinnati Research on Outcomes and Safety in Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Mackenzie C Morris
- Cincinnati Research on Outcomes and Safety in Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Al-Faraaz Kassam
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kamran Safdar
- Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Khurram Bari
- Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Nadeem Anwar
- Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - R Cutler Quillin
- Cincinnati Research on Outcomes and Safety in Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Cincinnati Research on Outcomes and Safety in Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH.,Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati, OH
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20
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Paterno F, Guarrera JV, Wima K, Diwan T, Cuffy MC, Anwar N, Woodle ES, Shah S. Clinical Implications of Donor Warm and Cold Ischemia Time in Donor After Circulatory Death Liver Transplantation. Liver Transpl 2019; 25:1342-1352. [PMID: 30912253 DOI: 10.1002/lt.25453] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 03/19/2019] [Indexed: 02/07/2023]
Abstract
The use of donation after circulatory death (DCD) liver allografts has been constrained by limitations in the duration of donor warm ischemia time (DWIT), donor agonal time (DAT), and cold ischemia time (CIT). The purpose of this study is to assess the impact of longer DWIT, DAT, and CIT on graft survival and other outcomes in DCD liver transplants. The Scientific Registry of Transplant Recipients was queried for adult liver transplants from DCD donors between 2009 and 2015. Donor, recipient, and center variables were included in the analysis. During the study period, 2107 patients underwent liver transplant with DCD allografts. In most patients, DWIT and DAT were <30 minutes. DWIT was <30 minutes in 1804 donors, between 30 and 40 minutes in 248, and >40 minutes in 37. There was no difference in graft survival, duration of posttransplant hospital length of stay, and readmission rate between DCD liver transplants from donors with DWIT <30 minutes and DWIT between 30 and 40 minutes. Similar outcomes were noted for DAT. In the multivariate analysis, DAT and DWIT were not associated with graft loss. The predictors associated with graft loss were donor age, donor sharing, CIT, recipient admission to the intensive care unit, recipient ventilator dependence, Model for End-Stage Liver Disease score, and low-volume transplant centers. Any CIT cutoff >4 hours was associated with increased risk for graft loss. Longer CIT was also associated with a longer posttransplant hospital stay, higher rate of primary nonfunction, and hyperbilirubinemia. In conclusion, slightly longer DAT and DWIT (up to 40 minutes) were not associated with graft loss, longer posttransplant hospitalization, or hospital readmissions, whereas longer CIT was associated with worse outcomes after DCD liver transplants.
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Affiliation(s)
- Flavio Paterno
- Division of Liver Transplant and Hepatobiliary Surgery, Department of Surgery, Rutgers New Jersey Medical School and University Hospital, Newark, NJ
| | - James V Guarrera
- Division of Liver Transplant and Hepatobiliary Surgery, Department of Surgery, Rutgers New Jersey Medical School and University Hospital, Newark, NJ
| | - Koffi Wima
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Tayyab Diwan
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Madison C Cuffy
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Nadeem Anwar
- Division of Hepatology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - E Steve Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Shimul Shah
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
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21
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Anwar N, Shah M, Saleem S, Rahman H. Plant mediated synthesis of silver nanoparticles and their biological applications. B CHEM SOC ETHIOPIA 2018. [DOI: 10.4314/bcse.v32i3.6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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22
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Anwar N, Sherman KE. Transplanting organs from hepatitis B positive donors: Is it safe? Is it ethical? J Viral Hepat 2018; 25:1110-1115. [PMID: 29968277 DOI: 10.1111/jvh.12962] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 06/04/2018] [Indexed: 01/10/2023]
Abstract
Liver transplant centres throughout the USA face a huge shortage of liver organs for their wait-listed patients. Various types of innovations are being considered for expansion of this donor pool. Organs that were previously deemed to be high risk are now being considered for transplantation. For the last 25 years, hepatitis B core antibody (anti-HBc+) organs have been used for liver transplantation. While the initial transplantations did reveal a high incidence of de novo hepatitis (DNH) in the recipients, the medical knowledge and experience have evolved and this risk has been markedly decreased. In this paper, medical literature evaluating the safety of such organ transplants has been reviewed. There is strong evidence to suggest that using anti-HBc+ organs with appropriate prophylaxis after transplant is a safe practice with good patient and graft survivals. In the second half of the paper, we discuss whether it is ethical to use anti-HBc+ organs. We argue that the use of such organs is in compliance with the principles of medical ethics and that society at large benefits from the use of these organs. Hence, we recommend that the use of such organs is both safe and ethical and this practice should be continued in the future.
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Affiliation(s)
- Nadeem Anwar
- University of Cincinnati College of Medicine, Cincinnati, Ohio
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23
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Egbe AC, Poterucha JT, Warnes CA, Connolly HM, Baskar S, Ginde S, Clift P, Kogon B, Book WM, Walker N, Wagenaar L, Moe T, Oechslin E, Kay WA, Norris M, Gordon-Walker T, Dillman JR, Trout A, Anwar N, Hoskoppal A, Veldtman GR. Hepatocellular Carcinoma After Fontan Operation. Circulation 2018; 138:746-748. [DOI: 10.1161/circulationaha.117.032717] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | - Shankar Baskar
- Cincinnati Children’s Hospital, OH (S.B., J.R.D., A.T., N.A., G.R.V.)
| | - Salil Ginde
- Medical College of Wisconsin, Milwaukee (S.G., M.N.)
| | - Paul Clift
- New Queen Elizabeth Hospital, Birmingham, United Kingdom (P.C.)
| | - Brian Kogon
- Emory Adult Congenital Heart Center, Atlanta, GA (B.K., W.M.B.)
| | - Wendy M. Book
- Emory Adult Congenital Heart Center, Atlanta, GA (B.K., W.M.B.)
| | - Niki Walker
- Golden Jubilee National Hospital, Glasgow, United Kingdom (N.W.)
| | | | | | | | - W. Aaron Kay
- Indiana University School of Medicine, Indianapolis (W.A.K.)
| | - Mark Norris
- Medical College of Wisconsin, Milwaukee (S.G., M.N.)
| | | | | | - Andrew Trout
- Cincinnati Children’s Hospital, OH (S.B., J.R.D., A.T., N.A., G.R.V.)
| | - Nadeem Anwar
- Cincinnati Children’s Hospital, OH (S.B., J.R.D., A.T., N.A., G.R.V.)
| | - Arvind Hoskoppal
- University of Utah and Intermountain Healthcare, Salt Lake City (A.H.)
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Borhany M, Anwar N, Tariq H, Fatima N, Arshad A, Naseer I, Shamsi T. Acute blood transfusion reactions in a tertiary care hospital in Pakistan - an initiative towards haemovigilance. Transfus Med 2018; 29:275-278. [PMID: 29845667 DOI: 10.1111/tme.12541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 01/29/2018] [Accepted: 05/09/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE In this study, we report acute blood transfusion reactions at our hospital, compare our analysis with the reported data and identify areas for improvement. BACKGROUND Haemovigilance programmes have been implemented in many countries, and adverse events associated with blood transfusion are published in their annual reports. Pakistan has no current established programme. MATERIAL AND METHODS A cross-sectional study was conducted, and all adverse reactions reported to the blood bank from January 2014 to March 2016 were included. An adverse response in the patient, related to administration of blood (within 24 h), was considered an immediate transfusion reaction. RESULTS During the study period, 20 956 blood components were issued. A total of 32 (0·15%) adverse reactions were documented. Allergic reactions were the most common adverse event observed in 15 (46·8%) of the cases. Febrile non-haemolytic transfusion reaction (FNHTR) was the second most common reaction seen in nine (28%) followed by bacterial contamination in four (12·5%) and acute haemolytic reaction in two (6·2%) of the cases. CONCLUSION The low incidence indicates underreporting and the need for a formal haemovigilance system. International benchmarking between different medical systems is helpful to identify areas in the transfusion process that have to be changed to improve transfusion safety.
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Affiliation(s)
- M Borhany
- Department of Blood Bank and Transfusion Medicine, National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, Pakistan
| | - N Anwar
- Department of Blood Bank and Transfusion Medicine, National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, Pakistan
| | - H Tariq
- Department of Blood Bank and Transfusion Medicine, National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, Pakistan
| | - N Fatima
- Department of Blood Bank and Transfusion Medicine, National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, Pakistan
| | - A Arshad
- Department of Blood Bank and Transfusion Medicine, National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, Pakistan
| | - I Naseer
- Department of Blood Bank and Transfusion Medicine, National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, Pakistan
| | - T Shamsi
- Department of Blood Bank and Transfusion Medicine, National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, Pakistan
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25
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Bari K, Luckett K, Kaiser T, Diwan T, Cuffy M, Schoech MR, Safdar K, Blackard JT, Apewokin S, Paterno F, Sherman KE, Zucker SD, Anwar N, Shah SA. Hepatitis C transmission from seropositive, nonviremic donors to non-hepatitis C liver transplant recipients. Hepatology 2018; 67:1673-1682. [PMID: 29205441 DOI: 10.1002/hep.29704] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 11/09/2017] [Accepted: 11/28/2017] [Indexed: 12/11/2022]
Abstract
UNLABELLED Breakthroughs in hepatitis C virus (HCV) treatment and rising rates of intravenous drug use have led to an increase in the number of organ donors who are HCV antibody-positive but serum nucleic acid test (NAT)-negative. The risk of HCV transmission from the liver grafts of these donors to recipients is unknown. To estimate the incidence of HCV transmission, we prospectively followed 26 consecutive HCV antibody-negative (n = 25) or NAT-negative (n = 1) transplant recipients who received a liver graft from donors who were HCV antibody-positive but serum NAT-negative between March 2016 and March 2017. HCV transmission was considered to have occurred if recipients exhibited a positive HCV PCR test by 3 months following transplantation. Drug overdose was listed as the cause of death in 15 (60%) of the donors. One recipient died 18 days after transplantation from primary graft nonfunction and was excluded. Of the remaining 25 recipients, HCV transmission occurred in 4 (16%), at a median follow-up of 11 months, all from donors who died of drug overdose. Three of these patients were treated with direct-acting antiviral therapy, with two achieving a sustained virologic response and one an end-of-treatment response. One patient with HCV transmission died after a complicated postoperative course and did not receive antiviral therapy. CONCLUSION In this prospective cohort of non-HCV liver recipients receiving grafts from HCV antibody-positive/NAT-negative donors, the incidence of HCV transmission was 16%, with the highest risk conferred by donors who died of drug overdose; given the availability of safe and highly effective antiviral therapies, use of such organs could be considered to expand the donor pool. (Hepatology 2018;67:1673-1682).
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Affiliation(s)
- Khurram Bari
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH
| | - Keith Luckett
- Division of Infectious Diseases, Department of Medicine, University of Cincinnati, Cincinnati, OH
| | - Tiffany Kaiser
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH
| | - Tayyab Diwan
- Division of Transplant Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Madison Cuffy
- Division of Transplant Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Michael R Schoech
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH
| | - Kamran Safdar
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH
| | - Jason T Blackard
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH
| | - Senu Apewokin
- Division of Infectious Diseases, Department of Medicine, University of Cincinnati, Cincinnati, OH
| | - Flavio Paterno
- Division of Transplant Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Kenneth E Sherman
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH
| | - Stephen D Zucker
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH.,Division of Gastroenterology, Hepatology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Nadeem Anwar
- Division of Digestive Diseases, University of Cincinnati, Cincinnati, OH
| | - Shimul A Shah
- Division of Transplant Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH
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Anwar N, Khurram S, Nadeem M, Shamsi T. Additional cytogenetic abnormalities in chronic myeloid leukemia and outcome - Experience from Pakistan. Ann Oncol 2017. [DOI: 10.1093/annonc/mdx664.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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27
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Anwar N, Arshad A, Faraz S, Ahmed S, Fatima N, Shamsi T. Next Generation Sequencing: The Dawn of New Era of Diagnosis in Myelodysplastic Syndromes from Pakistan. Leuk Res 2017. [DOI: 10.1016/s0145-2126(17)30282-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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28
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Anwar N, Arshad A, Nadeem M, Sharif S, Shan S, Khurram S, Fatima N, Shamsi T. Clinicohematological and Cytogenetic Profile of Myelodysplastic Syndromes in Pakistan – Compare and Contrast. Leuk Res 2017. [DOI: 10.1016/s0145-2126(17)30281-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Khurram S, Borhany M, Anwar N, Naseer I, Boota S, Mirza I, Nadeem M, Shamsi T. Frequency and reasons of donor deferral prior to blood donation process: a single centre experience. Transfus Med 2016; 27:10-15. [PMID: 27730692 DOI: 10.1111/tme.12368] [Citation(s) in RCA: 7] [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] [Received: 07/03/2015] [Revised: 07/31/2016] [Accepted: 09/18/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aim of the study was to determine the frequency and reasons for donor deferral prior to the blood donation process in our population. BACKGROUND Transfusion is an irreversible event that carries potential risks as well as benefits to the recipient. Therefore, donor selection prior to blood donation is one of the most important steps in ensuring the safety of blood and blood products. METHODS A cross-sectional study was carried out at the blood bank department in our hospital from January 2012 to December 2014. All the blood donors who visited our department in the study period were included in this study. RESULTS A total of 25 901 potential donations were recorded during the study period, comprising 24 309 (93·8%) replacement and 1592 (6·2%) voluntary donations. Females accounted for only 222 (0·9%) of potential donations. Deferral occurred in 3156 (12·2%) of attempts; 280 (1·1%) were permanently deferred, while 2876 (11·1%) were temporarily deferred. The most common reason for permanent deferral was a history of hepatitis B infection (n = 147, 4·7% of all deferrals). Major reasons for temporary donor deferral were low levels of haemoglobin (n = 971, 30·76%), low levels of platelets (n = 611, 19·35%) and previous history of jaundice (n = 192, 6·1%). CONCLUSIONS This study reported a fairly similar pattern of donor deferrals as in other regional studies. Low haemoglobin levels and a history of hepatitis B infection were the most common factors for temporary and permanent donor deferrals, respectively.
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Affiliation(s)
- S Khurram
- Department of Blood Bank, National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, Pakistan
| | - M Borhany
- Department of Blood Bank, National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, Pakistan
| | - N Anwar
- Department of Blood Bank, National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, Pakistan
| | - I Naseer
- Department of Blood Bank, National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, Pakistan
| | - S Boota
- Department of Blood Bank, National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, Pakistan
| | - I Mirza
- Department of Blood Bank, National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, Pakistan
| | - M Nadeem
- Department of Blood Bank, National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, Pakistan
| | - T Shamsi
- Department of Blood Bank, National Institute of Blood Disease and Bone Marrow Transplantation, Karachi, Pakistan
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Anwar N, Zaman N, Nimmi N, Chowdhury TA, Khan MH. Factors Associated with Periodontal Disease in Pregnant Diabetic Women. Mymensingh Med J 2016; 25:289-295. [PMID: 27277362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
There have been an association between systemic diseases and hormonal changes particularly diabetes which has been cited as a risk factor in the progression of periodontitis in pregnant women. The incidence and severity of periodontal diseases are increasing at a higher rate and a common condition in pregnant diabetic women among Bangladeshi population. This cross sectional study included 200 pregnant women who were selected from gynecological department and examined at the dental unit. The clinical parameters used were the Silness and Loe plaque index (PI), gingival scores and periodontal status and any relationship to socio demographic variables (age, occupation, level of education and urban or rural residence) and clinical variables (gestation period, previous pregnancy, type of diabetes and periodontal maintenance) were evaluated. The results showed that these clinical parameters increased concomitantly with an increase in the stage of pregnancy and in women with multiple pregnancies. Increased age, lower level of education, unemployment and patients residing in rural areas were associated with significantly higher gingival scores and periodontal measures. Women with increased age and multiple pregnancies usually have less interest to frequent periodontal maintenance showing a significant statistical relation between an increased age and changes in gingival and periodontal status; however no significant association was found between increased age and plaque index. It is concluded that gingival inflammatory symptoms are aggravated during pregnancy in diabetic women and are related to different clinical and demographic variables.
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Affiliation(s)
- N Anwar
- Dr Nabila Anwar, Post Graduate Student, Department of Orthodontics, Faculty of Dentistry, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
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Abdel-Hameed EA, Rouster SD, Ji H, Ulm A, Hetta HF, Anwar N, Sherman KE, Shata MTM. Evaluating the Role of Cellular Immune Responses in the Emergence of HCV NS3 Resistance Mutations During Protease Inhibitor Therapy. Viral Immunol 2016; 29:252-8. [PMID: 26885675 DOI: 10.1089/vim.2015.0093] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The efficacy of protease inhibitor drugs in hepatitis C virus (HCV) treatment is limited by the selection and expansion of drug-resistant mutations. HCV replication is error-prone and genetic variability within the dominant epitopes ensures its persistence. The aims of this study are to evaluate the role of cellular immune response in the emergence of HCV protease resistance mutations and its effects on treatment outcome. Ten chronically HCV-infected subjects were treated with boceprevir (BOC)-based triple therapy. HCV-RNA was tested for BOC resistance-associated viral variants. HCV protease resistance mutations were investigated pretreatment and 24 weeks post-treatment. Synthetic peptides representing the wild-type and the potential nonstructural (NS)3 variants were used to evaluate T cell responses and human leukocyte antigen binding. Sustained viral response was achieved in 70% of patients, two patients were treatment nonresponders (NRs) and one was classified as a relapse. Pretreatment, the proportion of drug-resistant variants within individuals was higher in sustained viral responders (SVRs) than in NR patients. However, resistance-associated variants increased in NRs after BOC combined triple therapy. In contrast to NR patients, significant stronger cell-mediated immune responses were observed at the baseline among those who achieved sustained viral response for all T cell epitopes tested. Despite the increase in cell-mediated immune responses at week 24 in NRs, they failed to control the virus replication, leading to development of overt drug-resistant variants. Our data suggest that strong NS3-specific T cell immune responses at the baseline may predict a positive outcome of directly acting antiviral-based therapy, and the presence of pre-existent resistance mutations does not play a significant role in the outcome of anti-HCV combined therapy.
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Affiliation(s)
| | - Susan D Rouster
- 1 Department of Internal Medicine, University of Cincinnati , Cincinnati, Ohio
| | - Hong Ji
- 2 Division of Asthma Research, Pyrosequencing Core for Genetic and Epigenetic Studies, Cincinnati Children's Hospital Medical Center , Cincinnati, Ohio
| | - Ashley Ulm
- 2 Division of Asthma Research, Pyrosequencing Core for Genetic and Epigenetic Studies, Cincinnati Children's Hospital Medical Center , Cincinnati, Ohio
| | - Helal F Hetta
- 3 Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University , Assiut, Egypt
| | - Nadeem Anwar
- 1 Department of Internal Medicine, University of Cincinnati , Cincinnati, Ohio
| | - Kenneth E Sherman
- 1 Department of Internal Medicine, University of Cincinnati , Cincinnati, Ohio
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Singhal A, Wilson GC, Wima K, Quillin RC, Cuffy M, Anwar N, Kaiser TE, Paterno F, Diwan TS, Woodle ES, Abbott DE, Shah SA. Impact of recipient morbid obesity on outcomes after liver transplantation. Transpl Int 2015; 28:148-55. [PMID: 25363625 DOI: 10.1111/tri.12483] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 09/25/2014] [Accepted: 10/24/2014] [Indexed: 12/28/2022]
Abstract
The aim of this study was to analyze the impact of morbid obesity in recipients on peritransplant resource utilization and survival outcomes. Using a linkage between the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases, we identified 12 445 patients who underwent liver transplantation (LT) between 2007 and 2011 and divided them into two cohorts based on recipient body mass index (BMI; <40 vs. ≥40 kg/m²). Recipients with BMI ≥40 comprised 3.3% (n = 416) of all LTs in the studied population. There were no significant differences in donor characteristics between two groups. Recipients with BMI ≥40 were significant for being female, diabetic, and with NASH cirrhosis. Patients with a BMI ≥40 had a higher median MELD score, limited physical capacity, and were more likely to be hospitalized at LT. BMI ≥40 recipients had higher post-LT length of stay and were less often discharged to home. With a median follow-up of 2 years, patient and graft survival were equivalent between the two groups. In conclusion, morbidly obese LT recipients appear sicker at time of LT with an increase in resource utilization but have similar short-term outcomes.
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Affiliation(s)
- Ashish Singhal
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
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Anwar N, Bibi A, Grech P, Wilson S. 38: Diagnostic rate of physician performed cutting needle pleural biopsy. Lung Cancer 2015. [DOI: 10.1016/s0169-5002(15)50038-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Anwar N, Sherman KE. HCV treatment of special populations: HIV coinfected, liver transplant, and renal failure. Clin Liver Dis (Hoboken) 2014; 4:80-83. [PMID: 30992927 PMCID: PMC6448740 DOI: 10.1002/cld.397] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 06/07/2014] [Accepted: 06/14/2014] [Indexed: 02/07/2023] Open
Affiliation(s)
- Nadeem Anwar
- University of Cincinnati College of MedicineDepartment of Internal Medicine, Division of Digestive DiseasesCincinnatiOH
| | - Kenneth E. Sherman
- University of Cincinnati College of MedicineDepartment of Internal Medicine, Division of Digestive DiseasesCincinnatiOH
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Leyakath Ali Khan S, Anwar N, Nuttal E, Clarke S, Zaman F. 136 Lung cancer from symptoms to referral across the Lancashire and South Cumbria Network. Lung Cancer 2014. [DOI: 10.1016/s0169-5002(14)70137-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Satia I, Bashagha S, Anwar N, Green RM, Wilson S. Not your typical pneumonia. Clin Med (Lond) 2013. [DOI: 10.7861/clinmedicine.13-3-318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Satia I, Bashagha S, Anwar N, Green RM, Wilson S. Not your typical pneumonia. Clin Med (Lond) 2013; 13:206-10. [PMID: 23681877 PMCID: PMC4952645 DOI: 10.7861/clinmedicine.13-2-206] [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: 11/27/2022]
Affiliation(s)
- Imran Satia
- Department of Respiratory Medicine, Royal Blackburn Hospital, UK.
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Mariano EA, Bathini VG, Barnard G, Anwar N, Bozorgzadeh A, Saidi R, Jabbour N, D'Antonio A, Barry C, Switzer BA. Single-institution experience with sorafenib for hepatocellular carcinoma (HCC) in the post-liver transplant setting (Ltx). J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.4_suppl.237] [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: 11/20/2022] Open
Abstract
237 Background: Sorafenib plays a role in the treatment of advanced HCC; however its role after Ltx has not yet been defined in the adjuvant setting. Patients at high risk for HCC recurrence, or those with recurrence after Ltx may benefit from this therapy. Methods: We present our institution’s experience of the use of sorafenib in the post Ltx setting in 11 patients. High risk for HCC recurrence (9 patients) was defined as vascular invasion, lymphovascular invasion, liver capsule invasion, or >3 tumors present in the liver explant. 2 patients had recurrent HCC post Ltx. The starting dose of sorafenib varied, but was most commonly 200mg po BID. Patients were seen monthly while on sorafenib, and 4-phase liver CTs or MRIs were performed every 3 months. Results: Median age at Ltx was 55 (range 48-77). Median time between Ltx and start of sorafenib was 150 days (range 30-543). Reasons for sorafenib use were high risk of recurrence 8/11 (72.7%), recurrence 2/11 (18.2%), rising AFP 1/11 (9%). Median duration of therapy was 152 days (range 21-295). Only 1/9 (11%) of patients could not complete 6 months of adjuvant therapy due to toxicity. 2 patients have yet to comple 6 months of adjuvant sorafenib. All 9 patients receiving therapy for high risk of recurrence are alive with longest survival of 40 months. Both patients with recurrent disease have died. Toxicity:36% (4 patients) had Grade 2 or 3 hand foot syndrome, 18% (2 patients) had grade 1 diarrhea and hypertension, 9% (1 patient) had grade 3 elevation in liver function tests, 9% (1 patient) had grade 3 parasthesias. Other side effects include grade 2 nausea (1 patient); grade 2 muscle weakness (1 patient), grade 1 lightheadedness (1 patient), grade 1 hair loss (1 patient), and grade 1 LFT elevation (1 patient). Zero patients reported no toxicity. Conclusions: Sorafenib in the post Ltx setting was well tolerated with manageable toxicities. The majority of patients at high risk for recurrent HCC were able to complete 6 months of adjuvant therapy. Further studies investigating this therapy in post transplant patients are warranted.
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Affiliation(s)
| | | | - Graham Barnard
- University of Massachusetts Medical Center, Worcester, MA
| | - Nadeem Anwar
- University of Massachusetts Medical Center, Worcester, MA
| | | | - Reza Saidi
- University of Massachusetts Medical Center, Worcester, MA
| | | | | | - Curtis Barry
- University of Massachusetts Medical Center, Worcester, MA
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Badar F, Anwar N. SP3-28 Is vaccination against the human papillomavirus for prevention of the cervix uteri cancer indicated in Pakistan where there is no Pap smear cervical cancer screening program-a public health perspective? Br J Soc Med 2011. [DOI: 10.1136/jech.2011.142976o.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Anwar N, Yadavilli R, Ibrahim K. Swyer-James-McLeod's syndrome and pneumothorax on same side: delay in chest drain removal despite full expansion. BMJ Case Rep 2011; 2011:2011/feb21_2/bcr0820103207. [PMID: 22707546 DOI: 10.1136/bcr.08.2010.3207] [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: 11/04/2022] Open
Abstract
Swyer-James-McLeod's syndrome (SJMS) occurs as a result of childhood recurrent respiratory infections. As this condition presents with few symptoms, if any, it may pass unnoticed until adulthood. The authors are presenting a case of a 17-year-old male admitted with spontaneous pneumothorax. Even though his lung expanded, his chest x-rays still mimicked a pneumothorax. Chest CT pulmonary angiogram was needed to confirm the diagnosis of unilateral SJMS. Diagnostic difficulty arose because both conditions were on the same side.
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Affiliation(s)
- Nadeem Anwar
- Department of Respiratory Medicine, Royal Bolton Hospital, Bolton, UK.
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Affiliation(s)
- Nadeem Anwar
- Department of Psychiatry, Pialla Unit, Nepean Hospital, Penrith, New South Wales, Australia
| | - Vlasios Brakoulias
- Department of Psychiatry, Nepean Hospital, University of Sydney, Penrith, New South Wales, Australia
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Majeed U, Jamshed A, Hameed S, Shah MA, Anwar N, Ahmed Q, Mohsin F. Invasive carcinoma of uterine cervix in young females under 20 years. J OBSTET GYNAECOL 2009; 29:269-70. [DOI: 10.1080/01443610902734978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Siddiqui N, Siddique MK, Muazzam IA, Faiz R, Anwar N, Badar F. Breast cancer in very young Pakistani women at a cancer hospital in Lahore. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.11596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Eckardt AJ, Swales C, Bhattacharya K, Wassef WY, Phelan NP, Zubair S, Martins N, Patel S, Moquin B, Anwar N, Leung K, Levey JM. Open access colonoscopy in the training setting: which factors affect patient satisfaction and pain? Endoscopy 2008; 40:98-105. [PMID: 18253904 DOI: 10.1055/s-2007-995469] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND STUDY AIM Patient satisfaction with colonoscopy is important for quality assurance; it may be affected by various factors, including patient characteristics, physician training level, and procedural or organizational features. We aimed to analyze how these factors influenced patient satisfaction and pain in an outpatient training setting. METHODS Consecutive patients for open access colonoscopy (OAC) were enrolled in a prospective, single-blinded, controlled study. Primary and secondary outcomes were satisfaction and pain scores with and without trainee participation. A multivariate analysis was designed to achieve an 80 % power with an alpha value of 0.05. RESULTS 368 patients were enrolled. Satisfaction with the procedure was high (mean score 1.36; 1 = best to 5 = worst). In the multivariate analysis only waiting time in the endoscopy suite was significantly associated with lower satisfaction scores ( P = 0.024). Satisfaction was unaffected by patient factors (gender, American Society of Anesthesiologists' [ASA] score, anxiety, etc). Higher pain scores were associated with higher anxiety levels ( P = 0.02), female gender ( P = 0.02), longer procedure ( P< 0.001), and lower sedation levels ( P = 0.001); trainee involvement (49 % of procedures) did not adversely affect satisfaction or pain scores. CONCLUSIONS Patient satisfaction with OAC using sedation appears to depend primarily on organizational factors (waiting time beforehand). In contrast, pain is associated with patient characteristics (female gender, anxiety) and procedural factors (lower sedation, longer procedure). Trainee participation did not affect satisfaction or pain scores, a finding which may help to reassure patients undergoing OAC with trainee participation.
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Affiliation(s)
- A J Eckardt
- Division of Gastroenterology and Hepatology, UMass Memorial Medical Center, Worcester, Massachusetts, United States.
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Anwar N, Siddiqui M. Opinions on suicide: a web-based discussion group in a programme on biomedical ethics in Pakistan. Indian J Med Ethics 2007; 4:181-183. [PMID: 18630240 DOI: 10.20529/ijme.2007.071] [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: 05/26/2023]
Affiliation(s)
- N Anwar
- Shaukat Khanum Memorial Cancer Hospital and Research Centre, 7A Block R3, JoharTown, Lahore, Punjab 54000, Pakistan.
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Kostelka M, Walther T, Rastan A, Fabricius A, Daehnert I, Bellinghausen W, Anwar N, Janousek J, Mohr FW. Congenital cardiac surgery in newborns – current outcome. Thorac Cardiovasc Surg 2007. [DOI: 10.1055/s-2007-967327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Ender J, Häntschel D, Kuntze T, Birnbaum U, Anwar N, Mohr FW. Implementation of a recovery room for patients undergoing cardiac surgery. Thorac Cardiovasc Surg 2007. [DOI: 10.1055/s-2007-967606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Anwar N, Goodman M, Hulme P, Elsmore P, Greenhalgh M, McKeown B. Amelogenin as a target for real time PCR quantitation of forensic templates. ACTA ACUST UNITED AC 2006. [DOI: 10.1016/j.ics.2005.12.069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Welch MG, Keune JD, Welch-Horan TB, Anwar N, Anwar M, Ludwig RJ, Ruggiero DA. Secretin: hypothalamic distribution and hypothesized neuroregulatory role in autism. Cell Mol Neurobiol 2004; 24:219-41. [PMID: 15176437 DOI: 10.1023/b:cemn.0000018618.59015.a2] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [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: 11/12/2022]
Abstract
1. This study aims (1) to determine whether secretin is synthesized centrally, specifically by the HPA axis and (2) to discuss, on the basis of the findings in this and previous studies, secretin's possible neuroregulatory role in autism. 2. An immunocytochemical technique with single-cell resolution was performed in 12 age/weight-matched male rats pretreated with stereotaxic microinjection of colchicine (0.6 microg/kg) or vehicle into the lateral ventricle. Following 2-day survival, rats were anesthetized and perfused for immunocytochemistry. Brain segments were blocked and alternate frozen 30-microm sections incubated in rabbit antibodies against secretin, vasoactive intestinal peptide, glucagon, or pituitary-adenylate-cyclase-activating peptide. Adjacent sections were processed for Nissl stain. Preadsorption studies were performed with members of the secretin peptide family to demonstrate primary antibody specificity. 3. Specificity of secretin immunoreactivity (ir) was verified by clear-cut preadsorption control data and relatively high concentrations and distinct topographic localization of secretin ir to paraventricular/supraoptic and intercalated hypothalamic nuclei. Secretin levels were upregulated by colchicine, an exemplar of homeostatic stressors, as compared with low constitutive expression in untreated rats. 4. This study provides the first direct immunocytochemical demonstration of secretinergic immunoreactivity in the forebrain and offers evidence that the hypothalamus, like the gut, is capable of synthesizing secretin. Secretin's dual expression by gut and brain secretin cells, as well as its overlapping central distribution with other stress-adaptation neurohormones, especially oxytocin, indicates that it is stress-sensitive. A neuroregulatory relationship between the peripheral and central stress response systems is suggested, as is a dual role for secretin in conditioning both of those stress-adaptation systems. Colchicine-induced upregulation of secretin indicates that secretin may be synthesized on demand in response to stress, a possible mechanism of action that may underlie secretin's role in autism.
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Affiliation(s)
- M G Welch
- Laboratory of Childhood Regulatory Disorders, Columbia University College of Physicians and Surgeons, Division of Neuroscience, NYSPI, 1051 Riverside Drive, New York, New York 10032, USA.
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