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Bach E, Krishnamurthy V, Mote S, Shukla J, Sharma AS, Kalnay E, Ghil M. Improved subseasonal prediction of South Asian monsoon rainfall using data-driven forecasts of oscillatory modes. Proc Natl Acad Sci U S A 2024; 121:e2312573121. [PMID: 38557185 PMCID: PMC11009656 DOI: 10.1073/pnas.2312573121] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 02/01/2024] [Indexed: 04/04/2024] Open
Abstract
Predicting the temporal and spatial patterns of South Asian monsoon rainfall within a season is of critical importance due to its impact on agriculture, water availability, and flooding. The monsoon intraseasonal oscillation (MISO) is a robust northward-propagating mode that determines the active and break phases of the monsoon and much of the regional distribution of rainfall. However, dynamical atmospheric forecast models predict this mode poorly. Data-driven methods for MISO prediction have shown more skill, but only predict the portion of the rainfall corresponding to MISO rather than the full rainfall signal. Here, we combine state-of-the-art ensemble precipitation forecasts from a high-resolution atmospheric model with data-driven forecasts of MISO. The ensemble members of the detailed atmospheric model are projected onto a lower-dimensional subspace corresponding to the MISO dynamics and are then weighted according to their distance from the data-driven MISO forecast in this subspace. We thereby achieve improvements in rainfall forecasts over India, as well as the broader monsoon region, at 10- to 30-d lead times, an interval that is generally considered to be a predictability gap. The temporal correlation of rainfall forecasts is improved by up to 0.28 in this time range. Our results demonstrate the potential of leveraging the predictability of intraseasonal oscillations to improve extended-range forecasts; more generally, they point toward a future of combining dynamical and data-driven forecasts for Earth system prediction.
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Affiliation(s)
- Eviatar Bach
- Department of Environmental Science and Engineering, California Institute of Technology, Pasadena, CA91125
- Department of Computing and Mathematical Sciences, California Institute of Technology, Pasadena, CA91125
| | - V. Krishnamurthy
- Center for Ocean-Land-Atmosphere Studies, George Mason University, Fairfax, VA22030
| | - Safa Mote
- Fariborz Maseeh Department of Mathematics and Statistics, Portland State University, Portland, OR97201
- Department of Atmospheric and Oceanic Sciences and Institute for Physical Science and Technology, University of Maryland, College Park, MD20742
| | - Jagadish Shukla
- Department of Atmospheric, Oceanic and Earth Sciences, George Mason University, Fairfax, VA22030
| | | | - Eugenia Kalnay
- Department of Atmospheric and Oceanic Sciences and Institute for Physical Science and Technology, University of Maryland, College Park, MD20742
| | - Michael Ghil
- Geosciences Department and Laboratoire de Météorologie Dynamique (CNRS and Institut Pierre-Simon Laplace), École Normale Supérieure and Paris Sciences et Lettres University, Paris, France75005
- Department of Atmospheric and Oceanic Sciences, University of California, Los Angeles, CA90095
- Department of Mathematics, Imperial College London, LondonSW7 2BX, United Kingdom
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Bakhai A, McCauley L, Stones L, Khalil S, Mehta J, Price N, Krishnamurthy V, Parker LHH, Hughes D. Shining a light on an additional clinical burden: work-related digital communication survey study - COVID-19 impact on NHS staff wellbeing. Humanit Soc Sci Commun 2022; 9:414. [PMID: 36439048 PMCID: PMC9676904 DOI: 10.1057/s41599-022-01427-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 10/25/2022] [Indexed: 06/16/2023]
Abstract
Work-related communication volume within the United Kingdom's National Health Service (NHS) has had little systematic research previously. The impact of communication volume on work-life balance of healthcare staff in the NHS is also not known and has not been an area of focus or governance. COVID-19 led to a shift to non-physical work, with greater reliance on digital communication for clinical decision making. We sought to elucidate the relationship between communication, work-life balance, and COVID-19. An online survey was conducted to assess the platforms used to communicate professionally, the volume of and time spent on work-related communications, how this has changed from before to during COVID-19, and the effect on work-life balance. A total of 3047 healthcare staff provided consent and evaluable data. Emails were reported as the most frequently used communication tool, and the majority of staff asked, reported increased work-related communications due to COVID-19. Staff estimated receiving 14 emails on an average day before COVID-19. During the pandemic, staff estimated getting approximately 17 emails on an average day and 29 emails on a busy day. Work communications reportedly took up increased amounts of family and home time during COVID-19. A large proportion (36%) of staff were unable to switch off from work-related communications already before COVID-19, worsening (57%) during the pandemic. Work-related digital communication is a vital component of working in the NHS. We provide the first detailed data on the types, volume, and impact of such communication on NHS staff during the COVID-19 pandemic, compared to pre-pandemic levels. We found that 82% of staff support the need for NHS guidance on work-related communications to help manage overload, protect emotional wellbeing, and increase resilience. Further work is urgently needed in this area to tackle the negative impact of communication technologies (technostress) on work-life balance to reduce staff stress, burnout, and turnover or early retirement of some staff.
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Affiliation(s)
- Ameet Bakhai
- Royal Free London NHS Foundation Trust, London, UK
| | | | - Liba Stones
- Royal Free London NHS Foundation Trust, London, UK
| | - Saria Khalil
- Royal Free London NHS Foundation Trust, London, UK
| | - Jay Mehta
- Royal Free London NHS Foundation Trust, London, UK
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Ahmed O, Krishnamurthy V, Kaba RA, Tahir H. The Management of Cardiovascular Disease Risk in Patients with Rheumatoid Arthritis. Expert Opin Pharmacother 2022; 23:947-958. [PMID: 35575484 DOI: 10.1080/14656566.2022.2076594] [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]
Abstract
INTRODUCTION Rheumatoid Arthritis (RA) is a chronic inflammatory disorder associated with an increased incidence and prevalence of cardiovascular disease (CVD), including myocardial infarction and heart failure. In addition to traditional risk factors, evidence suggests inflammation is critical to the pathophysiology of both conditions. Despite the association being well-recognised, challenges remain in managing cardiovascular risk in RA. AREAS COVERED This manuscript analyses the association between CVD and RA andexplores the limitations in evaluating cardiovascular risk in RA with available risk assessment tools. The authors review and discuss the optimal management of traditional risk factors such as hypertension and dyslipidaemia and contemporary risk factors such as inflammation and analyse the cardiovascular impact of RA medications. EXPERT OPINION Analysis points to the critical role of inflammation in the pathogenesis of RA and CVD. It is well established that conventional disease-modifying anti-rheumatic drugs (DMARDs) improve cardiovascular outcomes; however, underlying risk often remains underappreciated. The authors suggest there remains an opportunity to improve mortality and morbidity with the early recognition and identification of at-risk populations and the timely initiation of appropriate cardiovascular and anti-inflammatory medications. More research is necessary into the role that imaging may play in stratifying risk and in the longer-term cardiovascular impact of biological DMARDs.
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Affiliation(s)
- Omar Ahmed
- Senior Research Fellow in Cardiology & Cardiac Electrophysiology, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, London, UK
| | - Vinodh Krishnamurthy
- Research Practitioner, Royal Free London NHS Trust, Barnet Hospital, Wellhouse Lane, Wellhouse Lane EN5 3DJ, UK
| | - Riyaz A Kaba
- Consultant in Cardiac Electrophysiology & Devices, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, UK
| | - Hasan Tahir
- Consultant Physician & Rheumatologist, Honorary Clinical Professor, University College London, Royal Free London NHS Trust, Wellhouse Lane EN5 3DJ, UK
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Al-Shahi Salman R, Keerie C, Stephen J, Lewis S, Norrie J, Dennis MS, Newby DE, Wardlaw JM, Lip GY, Parry-Jones A, White PM, Baigent C, Lasserson D, Oliver C, O'Mahony F, Amoils S, Bamford J, Armitage J, Emberson J, Rinkel GJ, Lowe G, Innes K, Adamczuk K, Dinsmore L, Drever J, Milne G, Walker A, Hutchison A, Williams C, Fraser R, Anderson R, Covil K, Stewart K, Rees J, Hall P, Bullen A, Stoddart A, Moullaali TJ, Palmer J, Sakka E, Perthen J, Lyttle N, Samarasekera N, MacRaild A, Burgess S, Teasdale J, Coakley M, Taylor P, Blair G, Whiteley W, Shenkin S, Clancy U, Macleod M, Sutherland R, Moullaali T, Barugh A, Lerpiniere C, Moreton F, Fethers N, Anjum T, Krishnan M, Slade P, Storton S, Williams M, Davies C, Connor L, Gainard G, Murphy C, Barber M, Esson D, Choulerton J, Shaw L, Lucas S, Hierons S, Avis J, Stone A, Gbadamoshi L, Costa T, Pearce L, Harkness K, Richards E, Howe J, Kamara C, Lindert R, Ali A, Rehan J, Chapman S, Edwards M, Bathula R, Cohen D, Devine J, Mpelembue M, Yesupatham P, Chhabra S, Adewetan G, Ballantine R, Brooks D, Smith G, Rogers G, Marsden S, Clark S, Wilkinson A, Brown E, Stephenson L, Nyo K, Abraham A, Pai Y, Shim G, Baliga V, Nair A, Robinson M, Hawksworth C, Greig J, Alam I, Nortcliffe T, Ramiz R, Shaw R, Parry-Jones A, Lee S, Marsden T, Perez J, Birleson E, Yadava R, Sangombe M, Stafford S, Hughes T, Knibbs L, Morse B, Schwarz S, Jelley B, White S, Richard B, Lawson H, Moseley S, Tayler M, Edwards M, Triscott C, Wallace R, Hall A, Dell A, Rashed K, Board S, Buckley C, Tanate A, Pitt-Kerby T, Beesley K, Perry J, Hellyer C, Guyler P, Menon N, Tysoe S, Prabakaran R, Cooper M, Rajapakse A, Wynter I, Smith S, Weir N, Boxall C, Yates H, Smith S, Crawford P, Marigold J, Smith F, Harvey J, Evans S, Baldwin L, Hammond S, Mudd P, Bowring A, Keenan S, Thorpe K, Haque M, Taaffe J, Temple N, Peachey T, Wells K, Haines F, Butterworth-Cowin N, Horne Z, Licenik R, Boughton H, England T, Hedstrom A, Menezes B, Davies R, Johnson V, Whittingham-Jones S, Werring D, Obarey S, Watchurst C, Ashton A, Feerick S, Francia N, Banaras A, Epstein D, Marinescu M, Williams A, Robinson A, Humphries F, Anwar I, Annamalai A, Crawford S, Collins V, Shepherd L, Siddle E, Penge J, Epstein D, Qureshi S, Krishnamurthy V, Papavasileiou V, Waugh D, Veraque E, Douglas N, Khan N, Ramachandran S, Sommerville P, Rudd A, Kullane S, Bhalla A, Birns J, Ahmed R, Gibbons M, Klamerus E, Cendreda B, Muir K, Day N, Welch A, Smith W, Elliot J, Eltawil S, Mahmood A, Hatherley K, Mitchell S, Bains H, Quinn L, Teal R, Gbinigie I, Harston G, Mathieson P, Ford G, Schulz U, Kennedy J, Nagaratnam K, Bangalore K, Bhupathiraju N, Wharton C, Fotherby K, Nasar A, Stevens A, Willberry A, Evans R, Rai B, Blake C, Thavanesan K, Hann G, Changuion T, Nix S, Whiting A, Dharmasiri M, Mallon L, Keltos M, Smyth N, Eglinton C, Duffy J, Tone E, Sykes L, Porter E, Fitton C, Kirkineziadis N, Cluckie G, Kennedy K, Trippier S, Williams R, Hayter E, Rackie J, Patel B, Rita G, Blight A, Jones V, Zhang L, Choy L, Pereira A, Clarke B, Al-Hussayni S, Dixon L, Young A, Bergin A, Broughton D, Raghunathan S, Jackson B, Appleton J, Wilkes G, Buck A, Richardson C, Clarke J, Fleming L, Squires G, Law Z, Hutchinson C, Cvoro V, Couser M, McGregor A, McAuley S, Pound S, Cochrane P, Holmes C, Murphy P, Devitt N, Osborn M, Steele A, Guthrie LB, Smith E, Hewitt J, Chaston N, Myint M, Smith A, Fairlie L, Davis M, Atkinson B, Woodward S, Hogg V, Fawcett M, Finlay L, Dixit A, Cameron E, Keegan B, Kelly J, Concannon D, Dutta D, Ward D, Glass J, O'Connell S, Ngeh J, O'Kelly A, Williams E, Ragab S, Jenkinson D, Dube J, Gleave L, Leggett J, Kissoon N, Southern L, Naghotra U, Bokhari M, McClelland B, Adie K, Mate A, Harrington F, James A, Swanson E, Chant T, Naccache M, Coutts A, Courtauld G, Whurr S, Webber S, Shead E, Luder R, Bhargava M, Murali E, Cuenoud L, Pasco K, Speirs O, Chapman L, Inskip L, Kavanagh L, Srinivasan M, Motherwell N, Mukherjee I, Tonks L, Donaldson D, Button H, Wilcox R, Hurford F, Logan R, Taylor A, Arden T, Carpenter M, Datta P, Zahoor T, Jackson L, Needle A, Stanners A, Ghouri I, Exley D, Akhtar S, Brooke H, Beadle S, O'Brien E, Francis J, McGee J, Amis E, Mitchell J, Finlay S, Sinha D, Manoczki C, King S, Tarka J, Choudhary S, Premaruban J, Sutton D, Kumar P, Culmsee C, Winckley C, Davies H, Thatcher H, Vasileiadis E, Aweid B, Holden M, Mason C, Hlaing T, Madzamba G, Ingram T, Linforth M, Cullen C, Thomas N, France J, Saulat A, Bhaskaran B, Fitzell P, Horan K, Manyoni C, Garfield-Smith J, Griffin H, Atkins S, Redome J, Muddegowda G, Maguire H, Barry A, Abano N, Varquez R, Hiden J, Lyjko S, Remegoso A, Finney K, Butler A, Strecker M, MaCleod MJ, Irvine J, Nelson S, Guzmangutierrez G, Furnace J, Taylor V, Ramadan H, Storton K, Hassan S, Abdus Sami E, Bellfield R, Stewart K, Quinn O, Patterson C, Emsley H, Gregary B, Ahmed S, Patel S, Raj S, Sultan S, Wright F, Langhorne P, Graham R, Quinn T, McArthur K. Effects of oral anticoagulation for atrial fibrillation after spontaneous intracranial haemorrhage in the UK: a randomised, open-label, assessor-masked, pilot-phase, non-inferiority trial. Lancet Neurol 2021; 20:842-853. [PMID: 34487722 DOI: 10.1016/s1474-4422(21)00264-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Oral anticoagulation reduces the rate of systemic embolism for patients with atrial fibrillation by two-thirds, but its benefits for patients with previous intracranial haemorrhage are uncertain. In the Start or STop Anticoagulants Randomised Trial (SoSTART), we aimed to establish whether starting is non-inferior to avoiding oral anticoagulation for survivors of intracranial haemorrhage who have atrial fibrillation. METHODS SoSTART was a prospective, randomised, open-label, assessor-masked, parallel-group, pilot phase trial done at 67 hospitals in the UK. We recruited adults (aged ≥18 years) who had survived at least 24 h after symptomatic spontaneous intracranial haemorrhage, had atrial fibrillation, and had a CHA2DS2-VASc score of at least 2. Web-based computerised randomisation incorporating a minimisation algorithm allocated participants (1:1) to start or avoid long-term (≥1 year) full treatment dose open-label oral anticoagulation. The participants assigned to start oral anticoagulation received either a direct oral anticoagulant or vitamin K antagonist, and the group assigned to avoid oral anticoagulation received standard clinical practice (antiplatelet agent or no antithrombotic agent). The primary outcome was recurrent symptomatic spontaneous intracranial haemorrhage, and was adjudicated by an individual masked to treatment allocation. All outcomes were ascertained for at least 1 year after randomisation and assessed in the intention-to-treat population of all randomly assigned participants, using Cox proportional hazards regression adjusted for minimisation covariates. We planned a sample size of 190 participants (one-sided p=0·025, power 90%, allowing for non-adherence) based on a non-inferiority margin of 12% (or adjusted hazard ratio [HR] of 3·2). This trial is registered with ClinicalTrials.gov (NCT03153150) and is complete. FINDINGS Between March 29, 2018, and Feb 27, 2020, consent was obtained at 61 sites for 218 participants, of whom 203 were randomly assigned at a median of 115 days (IQR 49-265) after intracranial haemorrhage onset. 101 were assigned to start and 102 to avoid oral anticoagulation. Participants were followed up for median of 1·2 years (IQR 0·97-1·95; completeness 97·2%). Starting oral anticoagulation was not non-inferior to avoiding oral anticoagulation: eight (8%) of 101 in the start group versus four (4%) of 102 in the avoid group had intracranial haemorrhage recurrences (adjusted HR 2·42 [95% CI 0·72-8·09]; p=0·152). Serious adverse events occurred in 17 (17%) participants in the start group and 15 (15%) in the avoid group. 22 (22%) patients in the start group and 11 (11%) patients in the avoid group died during the study. INTERPRETATION Whether starting oral anticoagulation was non-inferior to avoiding it for people with atrial fibrillation after intracranial haemorrhage was inconclusive, although rates of recurrent intracranial haemorrhage were lower than expected. In view of weak evidence from analyses of three composite secondary outcomes, the possibility that oral anticoagulation might be superior for preventing symptomatic major vascular events should be investigated in adequately powered randomised trials. FUNDING British Heart Foundation, Medical Research Council, Chest Heart & Stroke Scotland.
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Anil AC, Desai DV, Khandeparker L, Krishnamurthy V, Mapari K, Mitbavkar S, Patil JS, Sarma VVSS, Sawant SS. Short term response of plankton community to nutrient enrichment in central eastern Arabian Sea: Elucidation through mesocosm experiments. J Environ Manage 2021; 288:112390. [PMID: 33773214 DOI: 10.1016/j.jenvman.2021.112390] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 06/12/2023]
Abstract
Oligotrophic waters (OW), generally favour longer food chain facilitated by the microbial loop. In such ecosystems, physical mixing (e.g. upwelling, and winter convection) inject nutrients and propagules from subsurface to the photic zone. Such events are expected to alter the food chain through shifts in the plankton community. Mesocosm experiments were carried out to evaluate the influence of nutrient enrichment from the deep (100-150 m) on the surface plankton community for the first time in the Arabian Sea, through custom-designed enclosures in OW of the central-eastern Arabian Sea (CEAS). Surface water was characterized by low nutrients and phytoplankton biomass (chlorophyll-a of <0.2 μg m-3) and upon nutrient enrichment yielded differing response. Higher abundance of picophytoplankton, bacteria and protists was noticed at a depth of ~100 m than at surface. The inoculation of such a population to the surface, resulted in a significant enhancement of autotrophic (picophytoplankton) and heterotrophic (bacteria and protists) populations. However, significant changes in the abundance of larger plankton was not evident till three days of incubation. Even though autotrophic picophytoplankton responded positively, a distinct increase in chlorophyll-a was not evident. This study points out that the lack of sufficient viable microphytoplankton propagules, neither at the surface nor at the depth (inoculum) are the possible reasons for the lack of their distinct positive response. These experiments suggest the dominance of microbial community response to physical mixing in the OW regions of the Arabian Sea and the importance of propagule diversity. The insights from this experiment will serve as a precursor for appropriate modifications in ocean modelling and forecasting studies and help in building global environmental management tools.
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Affiliation(s)
- A C Anil
- CSIR-National Institute of Oceanography, Dona Paula 403004, Goa, India.
| | - D V Desai
- CSIR-National Institute of Oceanography, Dona Paula 403004, Goa, India
| | - L Khandeparker
- CSIR-National Institute of Oceanography, Dona Paula 403004, Goa, India
| | - V Krishnamurthy
- CSIR-National Institute of Oceanography, Dona Paula 403004, Goa, India
| | - K Mapari
- CSIR-National Institute of Oceanography, Dona Paula 403004, Goa, India
| | - S Mitbavkar
- CSIR-National Institute of Oceanography, Dona Paula 403004, Goa, India
| | - J S Patil
- CSIR-National Institute of Oceanography, Dona Paula 403004, Goa, India
| | - V V S S Sarma
- CSIR-National Institute of Oceanography, 176 Regional Centre, Vishakhapatnam, India
| | - S S Sawant
- CSIR-National Institute of Oceanography, Dona Paula 403004, Goa, India
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Angus DC, Derde L, Al-Beidh F, Annane D, Arabi Y, Beane A, van Bentum-Puijk W, Berry L, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Buzgau A, Cheng AC, de Jong M, Detry M, Estcourt L, Fitzgerald M, Goossens H, Green C, Haniffa R, Higgins AM, Horvat C, Hullegie SJ, Kruger P, Lamontagne F, Lawler PR, Linstrum K, Litton E, Lorenzi E, Marshall J, McAuley D, McGlothin A, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Parker J, Rowan K, Sanil A, Santos M, Saunders C, Seymour C, Turner A, van de Veerdonk F, Venkatesh B, Zarychanski R, Berry S, Lewis RJ, McArthur C, Webb SA, Gordon AC, Al-Beidh F, Angus D, Annane D, Arabi Y, van Bentum-Puijk W, Berry S, Beane A, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Cheng A, De Jong M, Derde L, Estcourt L, Goossens H, Gordon A, Green C, Haniffa R, Lamontagne F, Lawler P, Litton E, Marshall J, McArthur C, McAuley D, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Rowan K, Seymour C, Turner A, van de Veerdonk F, Webb S, Zarychanski R, Campbell L, Forbes A, Gattas D, Heritier S, Higgins L, Kruger P, Peake S, Presneill J, Seppelt I, Trapani T, Young P, Bagshaw S, Daneman N, Ferguson N, Misak C, Santos M, Hullegie S, Pletz M, Rohde G, Rowan K, Alexander B, Basile K, Girard T, Horvat C, Huang D, Linstrum K, Vates J, Beasley R, Fowler R, McGloughlin S, Morpeth S, Paterson D, Venkatesh B, Uyeki T, Baillie K, Duffy E, Fowler R, Hills T, Orr K, Patanwala A, Tong S, Netea M, Bihari S, Carrier M, Fergusson D, Goligher E, Haidar G, Hunt B, Kumar A, Laffan M, Lawless P, Lother S, McCallum P, Middeldopr S, McQuilten Z, Neal M, Pasi J, Schutgens R, Stanworth S, Turgeon A, Weissman A, Adhikari N, Anstey M, Brant E, de Man A, Lamonagne F, Masse MH, Udy A, Arnold D, Begin P, Charlewood R, Chasse M, Coyne M, Cooper J, Daly J, Gosbell I, Harvala-Simmonds H, Hills T, MacLennan S, Menon D, McDyer J, Pridee N, Roberts D, Shankar-Hari M, Thomas H, Tinmouth A, Triulzi D, Walsh T, Wood E, Calfee C, O’Kane C, Shyamsundar M, Sinha P, Thompson T, Young I, Bihari S, Hodgson C, Laffey J, McAuley D, Orford N, Neto A, Detry M, Fitzgerald M, Lewis R, McGlothlin A, Sanil A, Saunders C, Berry L, Lorenzi E, Miller E, Singh V, Zammit C, van Bentum Puijk W, Bouwman W, Mangindaan Y, Parker L, Peters S, Rietveld I, Raymakers K, Ganpat R, Brillinger N, Markgraf R, Ainscough K, Brickell K, Anjum A, Lane JB, Richards-Belle A, Saull M, Wiley D, Bion J, Connor J, Gates S, Manax V, van der Poll T, Reynolds J, van Beurden M, Effelaar E, Schotsman J, Boyd C, Harland C, Shearer A, Wren J, Clermont G, Garrard W, Kalchthaler K, King A, Ricketts D, Malakoutis S, Marroquin O, Music E, Quinn K, Cate H, Pearson K, Collins J, Hanson J, Williams P, Jackson S, Asghar A, Dyas S, Sutu M, Murphy S, Williamson D, Mguni N, Potter A, Porter D, Goodwin J, Rook C, Harrison S, Williams H, Campbell H, Lomme K, Williamson J, Sheffield J, van’t Hoff W, McCracken P, Young M, Board J, Mart E, Knott C, Smith J, Boschert C, Affleck J, Ramanan M, D’Souza R, Pateman K, Shakih A, Cheung W, Kol M, Wong H, Shah A, Wagh A, Simpson J, Duke G, Chan P, Cartner B, Hunter S, Laver R, Shrestha T, Regli A, Pellicano A, McCullough J, Tallott M, Kumar N, Panwar R, Brinkerhoff G, Koppen C, Cazzola F, Brain M, Mineall S, Fischer R, Biradar V, Soar N, White H, Estensen K, Morrison L, Smith J, Cooper M, Health M, Shehabi Y, Al-Bassam W, Hulley A, Whitehead C, Lowrey J, Gresha R, Walsham J, Meyer J, Harward M, Venz E, Williams P, Kurenda C, Smith K, Smith M, Garcia R, Barge D, Byrne D, Byrne K, Driscoll A, Fortune L, Janin P, Yarad E, Hammond N, Bass F, Ashelford A, Waterson S, Wedd S, McNamara R, Buhr H, Coles J, Schweikert S, Wibrow B, Rauniyar R, Myers E, Fysh E, Dawda A, Mevavala B, Litton E, Ferrier J, Nair P, Buscher H, Reynolds C, Santamaria J, Barbazza L, Homes J, Smith R, Murray L, Brailsford J, Forbes L, Maguire T, Mariappa V, Smith J, Simpson S, Maiden M, Bone A, Horton M, Salerno T, Sterba M, Geng W, Depuydt P, De Waele J, De Bus L, Fierens J, Bracke S, Reeve B, Dechert W, Chassé M, Carrier FM, Boumahni D, Benettaib F, Ghamraoui A, Bellemare D, Cloutier È, Francoeur C, Lamontagne F, D’Aragon F, Carbonneau E, Leblond J, Vazquez-Grande G, Marten N, Wilson M, Albert M, Serri K, Cavayas A, Duplaix M, Williams V, Rochwerg B, Karachi T, Oczkowski S, Centofanti J, Millen T, Duan E, Tsang J, Patterson L, English S, Watpool I, Porteous R, Miezitis S, McIntyre L, Brochard L, Burns K, Sandhu G, Khalid I, Binnie A, Powell E, McMillan A, Luk T, Aref N, Andric Z, Cviljevic S, Đimoti R, Zapalac M, Mirković G, Baršić B, Kutleša M, Kotarski V, Vujaklija Brajković A, Babel J, Sever H, Dragija L, Kušan I, Vaara S, Pettilä L, Heinonen J, Kuitunen A, Karlsson S, Vahtera A, Kiiski H, Ristimäki S, Azaiz A, Charron C, Godement M, Geri G, Vieillard-Baron A, Pourcine F, Monchi M, Luis D, Mercier R, Sagnier A, Verrier N, Caplin C, Siami S, Aparicio C, Vautier S, Jeblaoui A, Fartoukh M, Courtin L, Labbe V, Leparco C, Muller G, Nay MA, Kamel T, Benzekri D, Jacquier S, Mercier E, Chartier D, Salmon C, Dequin P, Schneider F, Morel G, L’Hotellier S, Badie J, Berdaguer FD, Malfroy S, Mezher C, Bourgoin C, Megarbane B, Voicu S, Deye N, Malissin I, Sutterlin L, Guitton C, Darreau C, Landais M, Chudeau N, Robert A, Moine P, Heming N, Maxime V, Bossard I, Nicholier TB, Colin G, Zinzoni V, Maquigneau N, Finn A, Kreß G, Hoff U, Friedrich Hinrichs C, Nee J, Pletz M, Hagel S, Ankert J, Kolanos S, Bloos F, Petros S, Pasieka B, Kunz K, Appelt P, Schütze B, Kluge S, Nierhaus A, Jarczak D, Roedl K, Weismann D, Frey A, Klinikum Neukölln V, Reill L, Distler M, Maselli A, Bélteczki J, Magyar I, Fazekas Á, Kovács S, Szőke V, Szigligeti G, Leszkoven J, Collins D, Breen P, Frohlich S, Whelan R, McNicholas B, Scully M, Casey S, Kernan M, Doran P, O’Dywer M, Smyth M, Hayes L, Hoiting O, Peters M, Rengers E, Evers M, Prinssen A, Bosch Ziekenhuis J, Simons K, Rozendaal W, Polderman F, de Jager 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Davies G, Puxty K, McCue C, Cathcart S, Hickey N, Ireland J, Yusuff H, Isgro G, Brightling C, Bourne M, Craner M, Watters M, Prout R, Davies L, Pegler S, Kyeremeh L, Arbane G, Wilson K, Gomm L, Francia F, Brett S, Sousa Arias S, Elin Hall R, Budd J, Small C, Birch J, Collins E, Henning J, Bonner S, Hugill K, Cirstea E, Wilkinson D, Karlikowski M, Sutherland H, Wilhelmsen E, Woods J, North J, Sundaran D, Hollos L, Coburn S, Walsh J, Turns M, Hopkins P, Smith J, Noble H, Depante MT, Clarey E, Laha S, Verlander M, Williams A, Huckle A, Hall A, Cooke J, Gardiner-Hill C, Maloney C, Qureshi H, Flint N, Nicholson S, Southin S, Nicholson A, Borgatta B, Turner-Bone I, Reddy A, Wilding L, Chamara Warnapura L, Agno Sathianathan R, Golden D, Hart C, Jones J, Bannard-Smith J, Henry J, Birchall K, Pomeroy F, Quayle R, Makowski A, Misztal B, Ahmed I, KyereDiabour T, Naiker K, Stewart R, Mwaura E, Mew L, Wren L, Willams F, Innes R, Doble P, Hutter J, Shovelton C, Plumb B, Szakmany T, Hamlyn V, Hawkins 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Keenan S, Baker E, Cherian S, Cutler S, Roynon-Reed A, Harrington K, Raithatha A, Bauchmuller K, Ahmad N, Grecu I, Trodd D, Martin J, Wrey Brown C, Arias AM, Craven T, Hope D, Singleton J, Clark S, Rae N, Welters I, Hamilton DO, Williams K, Waugh V, Shaw D, Puthucheary Z, Martin T, Santos F, Uddin R, Somerville A, Tatham KC, Jhanji S, Black E, Dela Rosa A, Howle R, Tully R, Drummond A, Dearden J, Philbin J, Munt S, Vuylsteke A, Chan C, Victor S, Matsa R, Gellamucho M, Creagh-Brown B, Tooley J, Montague L, De Beaux F, Bullman L, Kersiake I, Demetriou C, Mitchard S, Ramos L, White K, Donnison P, Johns M, Casey R, Mattocks L, Salisbury S, Dark P, Claxton A, McLachlan D, Slevin K, Lee S, Hulme J, Joseph S, Kinney F, Senya HJ, Oborska A, Kayani A, Hadebe B, Orath Prabakaran R, Nichols L, Thomas M, Worner R, Faulkner B, Gendall E, Hayes K, Hamilton-Davies C, Chan C, Mfuko C, Abbass H, Mandadapu V, Leaver S, Forton D, Patel K, Paramasivam E, Powell M, Gould R, Wilby E, Howcroft C, Banach D, Fernández de Pinedo Artaraz Z, Cabreros L, White I, Croft M, Holland N, Pereira R, Zaki A, Johnson D, Jackson M, Garrard H, Juhaz V, Roy A, Rostron A, Woods L, Cornell S, Pillai S, Harford R, Rees T, Ivatt H, Sundara Raman A, Davey M, Lee K, Barber R, Chablani M, Brohi F, Jagannathan V, Clark M, Purvis S, Wetherill B, Dushianthan A, Cusack R, de Courcy-Golder K, Smith S, Jackson S, Attwood B, Parsons P, Page V, Zhao XB, Oza D, Rhodes J, Anderson T, Morris S, Xia Le Tai C, Thomas A, Keen A, Digby S, Cowley N, Wild L, Southern D, Reddy H, Campbell A, Watkins C, Smuts S, Touma O, Barnes N, Alexander P, Felton T, Ferguson S, Sellers K, Bradley-Potts J, Yates D, Birkinshaw I, Kell K, Marshall N, Carr-Knott L, Summers C. Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial. JAMA 2020. [PMID: 32876697 DOI: 10.1001/jama.2020.1702221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. OBJECTIVE To determine whether hydrocortisone improves outcome for patients with severe COVID-19. DESIGN, SETTING, AND PARTICIPANTS An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. INTERVENTIONS The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). MAIN OUTCOMES AND MEASURES The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). RESULTS After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. CONCLUSIONS AND RELEVANCE Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02735707.
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Affiliation(s)
- Derek C Angus
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Lennie Derde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Intensive Care Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Farah Al-Beidh
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Djillali Annane
- Intensive Care Unit, Raymond Poincaré Hospital (AP-HP), Paris, France
- Simone Veil School of Medicine, University of Versailles, Versailles, France
- University Paris Saclay, Garches, France
| | - Yaseen Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abigail Beane
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Wilma van Bentum-Puijk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Zahra Bhimani
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Marc Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Charlotte Bradbury
- Bristol Royal Informatory, Bristol, United Kingdom
- University of Bristol, Bristol, United Kingdom
| | - Frank Brunkhorst
- Center for Clinical Studies and Center for Sepsis Control and Care (CSCC), Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Meredith Buxton
- Global Coalition for Adaptive Research, San Francisco, California
| | - Adrian Buzgau
- Helix, Monash University, Melbourne, Victoria, Australia
| | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Menno de Jong
- Department of Medical Microbiology, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | | | - Lise Estcourt
- NHS Blood and Transplant, Bristol, United Kingdom
- Transfusion Medicine, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | | | - Herman Goossens
- Department of Microbiology, Antwerp University Hospital, Antwerp, Belgium
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Christopher Horvat
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Sebastiaan J Hullegie
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter Kruger
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | | | - Patrick R Lawler
- Cardiac Intensive Care Unit, Peter Munk Cardiac Centre, University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kelsey Linstrum
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Edward Litton
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | | | - John Marshall
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Daniel McAuley
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | | | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Bryan McVerry
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stephanie Montgomery
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Paul Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Srinivas Murthy
- University of British Columbia School of Medicine, Vancouver, Canada
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Anesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Jane Parker
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kathryn Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | | | - Marlene Santos
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Christopher Seymour
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Anne Turner
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Frank van de Veerdonk
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Balasubramanian Venkatesh
- Southside Clinical Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- The George Institute for Global Health, Sydney, Australia
| | - Ryan Zarychanski
- Department of Medicine, Critical Care and Hematology/Medical Oncology, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Roger J Lewis
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Department of Emergency Medicine, David Geffen School of Medicine at University of California, Los Angeles
| | - Colin McArthur
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Steven A Webb
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
- St John of God Hospital, Subiaco, Western Australia, Australia
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
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Angus DC, Derde L, Al-Beidh F, Annane D, Arabi Y, Beane A, van Bentum-Puijk W, Berry L, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Buzgau A, Cheng AC, de Jong M, Detry M, Estcourt L, Fitzgerald M, Goossens H, Green C, Haniffa R, Higgins AM, Horvat C, Hullegie SJ, Kruger P, Lamontagne F, Lawler PR, Linstrum K, Litton E, Lorenzi E, Marshall J, McAuley D, McGlothin A, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Parker J, Rowan K, Sanil A, Santos M, Saunders C, Seymour C, Turner A, van de Veerdonk F, Venkatesh B, Zarychanski R, Berry S, Lewis RJ, McArthur C, Webb SA, Gordon AC, Al-Beidh F, Angus D, Annane D, Arabi Y, van Bentum-Puijk W, Berry S, Beane A, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Cheng A, De Jong M, Derde L, Estcourt L, Goossens H, Gordon A, Green C, Haniffa R, Lamontagne F, Lawler P, Litton E, Marshall J, McArthur C, McAuley D, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Rowan K, Seymour C, Turner A, van de Veerdonk F, Webb S, Zarychanski R, Campbell L, Forbes A, Gattas D, Heritier S, Higgins L, Kruger P, Peake S, Presneill J, Seppelt I, Trapani T, Young P, Bagshaw S, Daneman N, Ferguson N, Misak C, Santos M, Hullegie S, Pletz M, Rohde G, Rowan K, Alexander B, Basile K, Girard T, Horvat C, Huang D, Linstrum K, Vates J, Beasley R, Fowler R, McGloughlin S, Morpeth S, Paterson D, Venkatesh B, Uyeki T, Baillie K, Duffy E, Fowler R, Hills T, Orr K, Patanwala A, Tong S, Netea M, Bihari S, Carrier M, Fergusson D, Goligher E, Haidar G, Hunt B, Kumar A, Laffan M, Lawless P, Lother S, McCallum P, Middeldopr S, McQuilten Z, Neal M, Pasi J, Schutgens R, Stanworth S, Turgeon A, Weissman A, Adhikari N, Anstey M, Brant E, de Man A, Lamonagne F, Masse MH, Udy A, Arnold D, Begin P, Charlewood R, Chasse M, Coyne M, Cooper J, Daly J, Gosbell I, Harvala-Simmonds H, Hills T, MacLennan S, Menon D, McDyer J, Pridee N, Roberts D, Shankar-Hari M, Thomas H, Tinmouth A, Triulzi D, Walsh T, Wood E, Calfee C, O’Kane C, Shyamsundar M, Sinha P, Thompson T, Young I, Bihari S, Hodgson C, Laffey J, McAuley D, Orford N, Neto A, Detry M, Fitzgerald M, Lewis R, McGlothlin A, Sanil A, Saunders C, Berry L, Lorenzi E, Miller E, Singh V, Zammit C, van Bentum Puijk W, Bouwman W, Mangindaan Y, Parker L, Peters S, Rietveld I, Raymakers K, Ganpat R, Brillinger N, Markgraf R, Ainscough K, Brickell K, Anjum A, Lane JB, Richards-Belle A, Saull M, Wiley D, Bion J, Connor J, Gates S, Manax V, van der Poll T, Reynolds J, van Beurden M, Effelaar E, Schotsman J, Boyd C, Harland C, Shearer A, Wren J, Clermont G, Garrard W, Kalchthaler K, King A, Ricketts D, Malakoutis S, Marroquin O, Music E, Quinn K, Cate H, Pearson K, Collins J, Hanson J, Williams P, Jackson S, Asghar A, Dyas S, Sutu M, Murphy S, Williamson D, Mguni N, Potter A, Porter D, Goodwin J, Rook C, Harrison S, Williams H, Campbell H, Lomme K, Williamson J, Sheffield J, van’t Hoff W, McCracken P, Young M, Board J, Mart E, Knott C, Smith J, Boschert C, Affleck J, Ramanan M, D’Souza R, Pateman K, Shakih A, Cheung W, Kol M, Wong H, Shah A, Wagh A, Simpson J, Duke G, Chan P, Cartner B, Hunter S, Laver R, Shrestha T, Regli A, Pellicano A, McCullough J, Tallott M, Kumar N, Panwar R, Brinkerhoff G, Koppen C, Cazzola F, Brain M, Mineall S, Fischer R, Biradar V, Soar N, White H, Estensen K, Morrison L, Smith J, Cooper M, Health M, Shehabi Y, Al-Bassam W, Hulley A, Whitehead C, Lowrey J, Gresha R, Walsham J, Meyer J, Harward M, Venz E, Williams P, Kurenda C, Smith K, Smith M, Garcia R, Barge D, Byrne D, Byrne K, Driscoll A, Fortune L, Janin P, Yarad E, Hammond N, Bass F, Ashelford A, Waterson S, Wedd S, McNamara R, Buhr H, Coles J, Schweikert S, Wibrow B, Rauniyar R, Myers E, Fysh E, Dawda A, Mevavala B, Litton E, Ferrier J, Nair P, Buscher H, Reynolds C, Santamaria J, Barbazza L, Homes J, Smith R, Murray L, Brailsford J, Forbes L, Maguire T, Mariappa V, Smith J, Simpson S, Maiden M, Bone A, Horton M, Salerno T, Sterba M, Geng W, Depuydt P, De Waele J, De Bus L, Fierens J, Bracke S, Reeve B, Dechert W, Chassé M, Carrier FM, Boumahni D, Benettaib F, Ghamraoui A, Bellemare D, Cloutier È, Francoeur C, Lamontagne F, D’Aragon F, Carbonneau E, Leblond J, Vazquez-Grande G, Marten N, Wilson M, Albert M, Serri K, Cavayas A, Duplaix M, Williams V, Rochwerg B, Karachi T, Oczkowski S, Centofanti J, Millen T, Duan E, Tsang J, Patterson L, English S, Watpool I, Porteous R, Miezitis S, McIntyre L, Brochard L, Burns K, Sandhu G, Khalid I, Binnie A, Powell E, McMillan A, Luk T, Aref N, Andric Z, Cviljevic S, Đimoti R, Zapalac M, Mirković G, Baršić B, Kutleša M, Kotarski V, Vujaklija Brajković A, Babel J, Sever H, Dragija L, Kušan I, Vaara S, Pettilä L, Heinonen J, Kuitunen A, Karlsson S, Vahtera A, Kiiski H, Ristimäki S, Azaiz A, Charron C, Godement M, Geri G, Vieillard-Baron A, Pourcine F, Monchi M, Luis D, Mercier R, Sagnier A, Verrier N, Caplin C, Siami S, Aparicio C, Vautier S, Jeblaoui A, Fartoukh M, Courtin L, Labbe V, Leparco C, Muller G, Nay MA, Kamel T, Benzekri D, Jacquier S, Mercier E, Chartier D, Salmon C, Dequin P, Schneider F, Morel G, L’Hotellier S, Badie J, Berdaguer FD, Malfroy S, Mezher C, Bourgoin C, Megarbane B, Voicu S, Deye N, Malissin I, Sutterlin L, Guitton C, Darreau C, Landais M, Chudeau N, Robert A, Moine P, Heming N, Maxime V, Bossard I, Nicholier TB, Colin G, Zinzoni V, Maquigneau N, Finn A, Kreß G, Hoff U, Friedrich Hinrichs C, Nee J, Pletz M, Hagel S, Ankert J, Kolanos S, Bloos F, Petros S, Pasieka B, Kunz K, Appelt P, Schütze B, Kluge S, Nierhaus A, Jarczak D, Roedl K, Weismann D, Frey A, Klinikum Neukölln V, Reill L, Distler M, Maselli A, Bélteczki J, Magyar I, Fazekas Á, Kovács S, Szőke V, Szigligeti G, Leszkoven J, Collins D, Breen P, Frohlich S, Whelan R, McNicholas B, Scully M, Casey S, Kernan M, Doran P, O’Dywer M, Smyth M, Hayes L, Hoiting O, Peters M, Rengers E, Evers M, Prinssen A, Bosch Ziekenhuis J, Simons K, Rozendaal W, Polderman F, de Jager P, Moviat M, Paling A, Salet A, Rademaker E, Peters AL, de Jonge E, Wigbers J, Guilder E, Butler M, Cowdrey KA, Newby L, Chen Y, Simmonds C, McConnochie R, Ritzema Carter J, Henderson S, Van Der Heyden K, Mehrtens J, Williams T, Kazemi A, Song R, Lai V, Girijadevi D, Everitt R, Russell R, Hacking D, Buehner U, Williams E, Browne T, Grimwade K, Goodson J, Keet O, Callender O, Martynoga R, Trask K, Butler A, Schischka L, Young C, Lesona E, Olatunji S, Robertson Y, José N, Amaro dos Santos Catorze T, de Lima Pereira TNA, Neves Pessoa LM, Castro Ferreira RM, Pereira Sousa Bastos JM, Aysel Florescu S, Stanciu D, Zaharia MF, Kosa AG, Codreanu D, Marabi Y, Al Qasim E, Moneer Hagazy M, Al Swaidan L, Arishi H, Muñoz-Bermúdez R, Marin-Corral J, Salazar Degracia A, Parrilla Gómez F, Mateo López MI, Rodriguez Fernandez J, Cárcel Fernández S, Carmona Flores R, León López R, de la Fuente Martos C, Allan A, Polgarova P, Farahi N, McWilliam S, Hawcutt D, Rad L, O’Malley L, Whitbread J, Kelsall O, Wild L, Thrush J, Wood H, Austin K, Donnelly A, Kelly M, O’Kane S, McClintock D, Warnock M, Johnston P, Gallagher LJ, Mc Goldrick C, Mc Master M, Strzelecka A, Jha R, Kalogirou M, Ellis C, Krishnamurthy V, Deelchand V, Silversides J, McGuigan P, Ward K, O’Neill A, Finn S, Phillips B, Mullan D, Oritz-Ruiz de Gordoa L, Thomas M, Sweet K, Grimmer L, Johnson R, Pinnell J, Robinson M, Gledhill L, Wood T, Morgan M, Cole J, Hill H, Davies M, Antcliffe D, Templeton M, Rojo R, Coghlan P, Smee J, Mackay E, Cort J, Whileman A, Spencer T, Spittle N, Kasipandian V, Patel A, Allibone S, Genetu RM, Ramali M, Ghosh A, Bamford P, London E, Cawley K, Faulkner M, Jeffrey H, Smith T, Brewer C, Gregory J, Limb J, Cowton A, O’Brien J, Nikitas N, Wells C, Lankester L, Pulletz M, Williams P, Birch J, Wiseman S, Horton S, Alegria A, Turki S, Elsefi T, Crisp N, Allen L, McCullagh I, Robinson P, Hays C, Babio-Galan M, Stevenson H, Khare D, Pinder M, Selvamoni S, Gopinath A, Pugh R, Menzies D, Mackay C, Allan E, Davies G, Puxty K, McCue C, Cathcart S, Hickey N, Ireland J, Yusuff H, Isgro G, Brightling C, Bourne M, Craner M, Watters M, Prout R, Davies L, Pegler S, Kyeremeh L, Arbane G, Wilson K, Gomm L, Francia F, Brett S, Sousa Arias S, Elin Hall R, Budd J, Small C, Birch J, Collins E, Henning J, Bonner S, Hugill K, Cirstea E, Wilkinson D, Karlikowski M, Sutherland H, Wilhelmsen E, Woods J, North J, Sundaran D, Hollos L, Coburn S, Walsh J, Turns M, Hopkins P, Smith J, Noble H, Depante MT, Clarey E, Laha S, Verlander M, Williams A, Huckle A, Hall A, Cooke J, Gardiner-Hill C, Maloney C, Qureshi H, Flint N, Nicholson S, Southin S, Nicholson A, Borgatta B, Turner-Bone I, Reddy A, Wilding L, Chamara Warnapura L, Agno Sathianathan R, Golden D, Hart C, Jones J, Bannard-Smith J, Henry J, Birchall K, Pomeroy F, Quayle R, Makowski A, Misztal B, Ahmed I, KyereDiabour T, Naiker K, Stewart R, Mwaura E, Mew L, Wren L, Willams F, Innes R, Doble P, Hutter J, Shovelton C, Plumb B, Szakmany T, Hamlyn V, Hawkins N, Lewis S, Dell A, Gopal S, Ganguly S, Smallwood A, Harris N, Metherell S, Lazaro JM, Newman T, Fletcher S, Nortje J, Fottrell-Gould D, Randell G, Zaman M, Elmahi E, Jones A, Hall K, Mills G, Ryalls K, Bowler H, Sall J, Bourne R, Borrill Z, Duncan T, Lamb T, Shaw J, Fox C, Moreno Cuesta J, Xavier K, Purohit D, Elhassan M, Bakthavatsalam D, Rowland M, Hutton P, Bashyal A, Davidson N, Hird C, Chhablani M, Phalod G, Kirkby A, Archer S, Netherton K, Reschreiter H, Camsooksai J, Patch S, Jenkins S, Pogson D, Rose S, Daly Z, Brimfield L, Claridge H, Parekh D, Bergin C, Bates M, Dasgin J, McGhee C, Sim M, Hay SK, Henderson S, Phull MK, Zaidi A, Pogreban T, Rosaroso LP, Harvey D, Lowe B, Meredith M, Ryan L, Hormis A, Walker R, Collier D, Kimpton S, Oakley S, Rooney K, Rodden N, Hughes E, Thomson N, McGlynn D, Walden A, Jacques N, Coles H, Tilney E, Vowell E, Schuster-Bruce M, Pitts S, Miln R, Purandare L, Vamplew L, Spivey M, Bean S, Burt K, Moore L, Day C, Gibson C, Gordon E, Zitter L, Keenan S, Baker E, Cherian S, Cutler S, Roynon-Reed A, Harrington K, Raithatha A, Bauchmuller K, Ahmad N, Grecu I, Trodd D, Martin J, Wrey Brown C, Arias AM, Craven T, Hope D, Singleton J, Clark S, Rae N, Welters I, Hamilton DO, Williams K, Waugh V, Shaw D, Puthucheary Z, Martin T, Santos F, Uddin R, Somerville A, Tatham KC, Jhanji S, Black E, Dela Rosa A, Howle R, Tully R, Drummond A, Dearden J, Philbin J, Munt S, Vuylsteke A, Chan C, Victor S, Matsa R, Gellamucho M, Creagh-Brown B, Tooley J, Montague L, De Beaux F, Bullman L, Kersiake I, Demetriou C, Mitchard S, Ramos L, White K, Donnison P, Johns M, Casey R, Mattocks L, Salisbury S, Dark P, Claxton A, McLachlan D, Slevin K, Lee S, Hulme J, Joseph S, Kinney F, Senya HJ, Oborska A, Kayani A, Hadebe B, Orath Prabakaran R, Nichols L, Thomas M, Worner R, Faulkner B, Gendall E, Hayes K, Hamilton-Davies C, Chan C, Mfuko C, Abbass H, Mandadapu V, Leaver S, Forton D, Patel K, Paramasivam E, Powell M, Gould R, Wilby E, Howcroft C, Banach D, Fernández de Pinedo Artaraz Z, Cabreros L, White I, Croft M, Holland N, Pereira R, Zaki A, Johnson D, Jackson M, Garrard H, Juhaz V, Roy A, Rostron A, Woods L, Cornell S, Pillai S, Harford R, Rees T, Ivatt H, Sundara Raman A, Davey M, Lee K, Barber R, Chablani M, Brohi F, Jagannathan V, Clark M, Purvis S, Wetherill B, Dushianthan A, Cusack R, de Courcy-Golder K, Smith S, Jackson S, Attwood B, Parsons P, Page V, Zhao XB, Oza D, Rhodes J, Anderson T, Morris S, Xia Le Tai C, Thomas A, Keen A, Digby S, Cowley N, Wild L, Southern D, Reddy H, Campbell A, Watkins C, Smuts S, Touma O, Barnes N, Alexander P, Felton T, Ferguson S, Sellers K, Bradley-Potts J, Yates D, Birkinshaw I, Kell K, Marshall N, Carr-Knott L, Summers C. Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial. JAMA 2020; 324:1317-1329. [PMID: 32876697 PMCID: PMC7489418 DOI: 10.1001/jama.2020.17022] [Citation(s) in RCA: 542] [Impact Index Per Article: 135.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
IMPORTANCE Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. OBJECTIVE To determine whether hydrocortisone improves outcome for patients with severe COVID-19. DESIGN, SETTING, AND PARTICIPANTS An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. INTERVENTIONS The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). MAIN OUTCOMES AND MEASURES The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). RESULTS After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. CONCLUSIONS AND RELEVANCE Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02735707.
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Affiliation(s)
- Derek C Angus
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Lennie Derde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Intensive Care Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Farah Al-Beidh
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Djillali Annane
- Intensive Care Unit, Raymond Poincaré Hospital (AP-HP), Paris, France
- Simone Veil School of Medicine, University of Versailles, Versailles, France
- University Paris Saclay, Garches, France
| | - Yaseen Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abigail Beane
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Wilma van Bentum-Puijk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Zahra Bhimani
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Marc Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Charlotte Bradbury
- Bristol Royal Informatory, Bristol, United Kingdom
- University of Bristol, Bristol, United Kingdom
| | - Frank Brunkhorst
- Center for Clinical Studies and Center for Sepsis Control and Care (CSCC), Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Meredith Buxton
- Global Coalition for Adaptive Research, San Francisco, California
| | - Adrian Buzgau
- Helix, Monash University, Melbourne, Victoria, Australia
| | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Menno de Jong
- Department of Medical Microbiology, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | | | - Lise Estcourt
- NHS Blood and Transplant, Bristol, United Kingdom
- Transfusion Medicine, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | | | - Herman Goossens
- Department of Microbiology, Antwerp University Hospital, Antwerp, Belgium
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Christopher Horvat
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Sebastiaan J Hullegie
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter Kruger
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | | | - Patrick R Lawler
- Cardiac Intensive Care Unit, Peter Munk Cardiac Centre, University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kelsey Linstrum
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Edward Litton
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | | | - John Marshall
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Daniel McAuley
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | | | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Bryan McVerry
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stephanie Montgomery
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Paul Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Srinivas Murthy
- University of British Columbia School of Medicine, Vancouver, Canada
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Anesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Jane Parker
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kathryn Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | | | - Marlene Santos
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Christopher Seymour
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Anne Turner
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Frank van de Veerdonk
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Balasubramanian Venkatesh
- Southside Clinical Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- The George Institute for Global Health, Sydney, Australia
| | - Ryan Zarychanski
- Department of Medicine, Critical Care and Hematology/Medical Oncology, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Roger J Lewis
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Department of Emergency Medicine, David Geffen School of Medicine at University of California, Los Angeles
| | - Colin McArthur
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Steven A Webb
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
- St John of God Hospital, Subiaco, Western Australia, Australia
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
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8
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U M S, Karunakar P, Krishnamurthy V. Homology modeling, virtual screening and dynamics study of proteins involved in Pebrine - Serine protease inhibitor 106 and spore wall protein 26. J Biomol Struct Dyn 2019; 38:5148-5158. [DOI: 10.1080/07391102.2019.1696704] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Shravan U M
- Department of Biotechnology, PES Institute of Technology, Bangalore, Karnataka, India
| | | | - V. Krishnamurthy
- Department of Biotechnology, PES University, Bangalore, Karnataka, India
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9
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Abstract
The past developments in the predictability of weather and climate are discussed from the point of view of nonlinear dynamical systems. The problems ahead for long-range predictability extending into the climate time scale are also presented. The sensitive dependence of chaos on initial conditions and the imperfections in the models limit reliable predictability of the instantaneous state of the weather to less than 10 days in present-day operational forecasts. The existence of slowly varying components such as the sea surface temperature, soil moisture, snow cover, and sea ice may provide basis for predicting certain aspects of climate at long range. The regularly varying nonlinear oscillations, such as the Madden-Julian Oscillation, monsoon intraseasonal oscillations, and El Niño-Southern Oscillation, are also possible sources of extended-range predictability at the climate time scale. A prediction model based on phase space reconstruction has demonstrated that monsoon intraseasonal oscillation can be better predicted at long leads.
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Affiliation(s)
- V. Krishnamurthy
- Center for Ocean‐Land‐Atmosphere StudiesGeorge Mason UniversityFairfaxVAUSA
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10
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Nocera J, Crosson B, Krishnamurthy L, McGregor K, Krishnamurthy V. THE RELATIONSHIP BETWEEN CORTICAL PERFUSION, THE BOLD SIGNAL, AND CARDIOVASCULAR FITNESS IN AGING. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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11
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Vgontzas AN, Fernandez-Mendoza J, Baker JH, Krishnamurthy V, Gaines J, Calhoun S, Basta M, Bixler EO. 0373 Trazodone vs. Cognitive Behavioral Therapy in Insomnia with Short Sleep Duration: Effects on Total Sleep Time and Cortisol Levels. Sleep 2018. [DOI: 10.1093/sleep/zsy061.372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | | | - J H Baker
- Sleep Research & Treatment Center, Hershey, PA
| | | | - J Gaines
- Sleep Research & Treatment Center, Hershey, PA
| | - S Calhoun
- Sleep Research & Treatment Center, Hershey, PA
| | - M Basta
- Sleep Research & Treatment Center, Hershey, PA
| | - E O Bixler
- Sleep Research & Treatment Center, Hershey, PA
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12
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Polavarapu K, Nalini A, MK S, Narayan Rao S, Preethish-Kumar V, Sekar D, Sundar V, Vengalil S, Nashi S, Krishnamurthy V. A next generation sequencing based mutational analysis in Duchenne and Becker muscular dystrophy. J Neurol Sci 2017. [DOI: 10.1016/j.jns.2017.08.2333] [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: 10/18/2022]
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13
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Krishnamurthy V, Coffey A, Yadav S, Singh J, Kong L, Vgontzas AN, Bixler EO, Meyer RE. 1130 FACTORS PREDICTING SLEEP DISTURBANCES IN OPIOID-DEPENDENT SUBJECTS ON BUPRENORPHINE. Sleep 2017. [DOI: 10.1093/sleepj/zsx050.1129] [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: 11/14/2022] Open
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14
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Novelli PM, Shields J, Krishnamurthy V, Cho K. Two Unusual but Treatable Causes of Refractory Ascites After Liver Transplantation. Cardiovasc Intervent Radiol 2015; 38:1663-9. [PMID: 26017456 DOI: 10.1007/s00270-015-1120-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 04/21/2015] [Indexed: 10/23/2022]
Abstract
Refractory ascites (RA) is thought to complicate the postoperative course of 5-7% (Nishida et al. in Am J Transplant. 6: 140-149, 2006; Gotthardt et al. in Ann Transplant. 18: 378-383, 2013) of liver transplant recipients. RA after liver transplantation is often a frustrating diagnostic dilemma with few good management options unless an obvious mechanical factor is identified. Supportive therapies often fail until a treatable precipitating cause is identified and removed. We describe two patients who developed RA following liver transplantation for primary sclerosing cholangitis, and hepatitis C and alcoholic liver disease, respectively. The cause for RA was hyperkinetic portal hypertension secondary to splenomegaly in the first case and a pancreatic AVM in the 2nd case. After failure of other interventions, surgical splenectomy resulted in immediate and durable resolution of the previously intractable ascites.
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Affiliation(s)
- P M Novelli
- Department of Radiology, University of Michigan Medical Center, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA.
| | - J Shields
- Department of Radiology, University of Michigan Medical Center, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - V Krishnamurthy
- Department of Radiology, University of Michigan Medical Center, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - K Cho
- Department of Radiology, University of Michigan Medical Center, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
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15
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Handa R, Chaturvedi V, Danda D, Krishnamurthy V. Pneumococcal Vaccination in Rheumatic Diseases. J Assoc Physicians India 2015; 63:40-42. [PMID: 26562966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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16
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Bivard A, Levi C, Krishnamurthy V, Hislop-Jambrich J, Salazar P, Jackson B, Davis S, Parsons M. Defining acute ischemic stroke tissue pathophysiology with whole brain CT perfusion. J Neuroradiol 2014; 41:307-15. [PMID: 24433950 DOI: 10.1016/j.neurad.2013.11.006] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 11/25/2013] [Accepted: 11/27/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND This study aimed to identify and validate whole brain perfusion computed tomography (CTP) thresholds for ischemic core and salvageable penumbra in acute stroke patients and develop a probability based model to increase the accuracy of tissue pathophysiology measurements. METHODS One hundred and eighty-three patients underwent multimodal stroke CT using a 320-slice scanner within 6hours of acute stroke onset, followed by 24hour MRI that included diffusion weighted imaging (DWI) and dynamic susceptibility weighted perfusion imaging (PWI). Coregistered acute CTP and 24hour DWI was used to identify the optimum single perfusion parameter thresholds to define penumbra (in patients without reperfusion), and ischemic core (in patients with reperfusion), using a pixel based receiver operator curve analysis. Then, these results were used to develop a sigma curve fitted probability based model incorporating multiple perfusion parameter thresholds. RESULTS For single perfusion thresholds, a time to peak (TTP) of +5seconds best defined the penumbra (area under the curve, AUC 0.79 CI 0.74-0.83) while a cerebral blood flow (CBF) of < 50% best defined the acute ischemic core (AUC 0.73, CI 0.69-0.77). The probability model was more accurate at detecting the ischemic core (AUC 0.80 SD 0.75-0.83) and penumbra (0.85 SD 0.83-0.87) and was significantly closer in volume to the corresponding reference DWI (P=0.031). CONCLUSIONS Whole brain CTP can accurately identify penumbra and ischemic core using similar thresholds to previously validated 16 or 64 slice CTP. Additionally, a novel probability based model was closer to defining the ischemic core and penumbra than single thresholds.
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Affiliation(s)
- A Bivard
- Melbourne Brain Centre, Flory Neuroscience Institute, University of Melbourne, Melbourne, Australia.
| | - C Levi
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia.
| | - V Krishnamurthy
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia.
| | | | - P Salazar
- Vital Images, Minneapolis, United States
| | - B Jackson
- Vital Images, Minneapolis, United States
| | - S Davis
- Melbourne Brain Centre, Flory Neuroscience Institute, University of Melbourne, Melbourne, Australia
| | - M Parsons
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, Australia.
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17
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Rangarajan D, Ramakrishnan S, Patro KC, Devaraj S, Krishnamurthy V, Kothari Y, Satyaki N. Native valve Escherichia coli endocarditis following urosepsis. Indian J Nephrol 2013; 23:232-4. [PMID: 23814428 PMCID: PMC3692155 DOI: 10.4103/0971-4065.111866] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Gram-negative organisms are a rare cause of infective endocarditis. Escherichia coli, the most common cause of urinary tract infection and gram-negative septicemia involves endocardium rarely. In this case report, we describe infection of native mitral valve by E. coli following septicemia of urinary tract origin in a diabetic male; subsequently, he required prosthetic tissue valve replacement indicated by persistent sepsis and congestive cardiac failure.
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Affiliation(s)
- D Rangarajan
- Department of Nephrology, NU Trust, Bangalore, India
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18
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Yamuna AJ, Karunakar P, Girija CR, Vaidya VP, Krishnamurthy V. Ethyl 3-amino-5-bromo-1-benzo-furan-2-carboxyl-ate. Acta Crystallogr Sect E Struct Rep Online 2013; 69:o775. [PMID: 23723919 PMCID: PMC3648299 DOI: 10.1107/s1600536813010209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 04/14/2013] [Indexed: 11/30/2022]
Abstract
The title compound, C11H10BrNO3, is close to planar with the benzofuran unit and the ester group subtending a dihedral angle of 5.25 (2)°. The molecular structure features an intramolecular N—H⋯O interaction. In the crystal, N—H⋯O hydrogen bonds involving carboxyl O-atom acceptors generate a chain extending along [201].
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Affiliation(s)
- A J Yamuna
- Department of Chemistry, Kuvempu University, Jnana Sahyadri, Shankaraghatta 577 451, India
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19
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Karunakar P, Krishnamurthy V, Girija CR, Krishna V, Vaidya VP, Yamuna AJ. Ethyl 5-bromo-3-eth-oxy-carbonyl-amino-1-benzofuran-2-carboxyl-ate. Acta Crystallogr Sect E Struct Rep Online 2013; 69:o342. [PMID: 23476536 PMCID: PMC3588419 DOI: 10.1107/s1600536813002997] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 01/29/2013] [Indexed: 12/02/2022]
Abstract
In the title compound, C14H14BrNO5, the ester group is disordered [occupancy ratio 0.52 (2):0.48 (2)]. The major component is nearly coplanar with the benzofuran plane, subtending a dihedral angle of 7.84 (2)°, while the amide group is twisted out of the benzofuran plane making a dihedral angle of 39.69 (2)°. An intramolecular N—H⋯O hydrogen bond occurs. In the crystal, pairs of weak C—H⋯O hydrogen bonds link the molecules into inversion dimers, which are further linked via strong N—H⋯O hydrogen bonds, generating a zigzag chain extending along [100].
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Affiliation(s)
- Prashantha Karunakar
- Department of Biotechnology, PES Institute of Technology, BSK III Stg, Bangalore 560 085, India
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20
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Brownlee W, Anderson N, Krishnamurthy V. Stroke Complicating Infective Endocarditis Treated with Thrombolysis: A Case Report and Review of the Literature (P01.120). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.p01.120] [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: 11/15/2022] Open
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21
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Krishnamurthy V, Zaytsev L, Freier Randall K, Chinnock R. 390 Infant Heart Transplantation: 10 Years and beyond. J Heart Lung Transplant 2012. [DOI: 10.1016/j.healun.2012.01.400] [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: 10/28/2022] Open
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22
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Abstract
39 Background: Ductal carcinoma in situ (DCIS) is a heterogeneous and potentially curable disease with a long natural history. DCIS represents 21% of breast cancers diagnosed in 2010. The risk of dying after a diagnosis of DCIS is low, emphasizing the importance of treatment-related morbidity, yet the risk of recurrence remains substantial. Optimum individualized therapy remains elusive. We previously identified p53 overexpression as a biomarker for ipsilateral tumor recurrence (IBTR). The purpose of the current study was to investigate its prognostic validity in an expanded patient cohort with long-term follow-up. Methods: We studied 186 consecutive pure DCIS patients from our Breast Cancer Registry and identified 142 cases with sufficient histopathologic material to perform evaluable immunostaining for p53. Median follow-up was 11 years. Statistical analysis was performed with SAS software. Results: Median patient age was 66 (range 35-91) years and 47/153 (31%) presented with palpable disease. Median tumor size was 10 (range 2-165) mm. Predominant histologic subtype included 34 (24%) comedo, 43 (30%) solid, 50 (35%) cribiform and 15 (11%) micropapillary/papillary cases. Necrosis was present in 74/142 (52%) of tumors. Overexpression of p53 was identified in 33/142 (23%) and was associated with necrosis, but not with any other patient, tumor or treatment variables. Fifteen patients (11%) were diagnosed with an IBTR at a median of 56 (range 11-154) months after their initial diagnosis; 3 recurrences were DCIS, while 12 were invasive cancer. p53 overexpression, present in 10/15 (68%) of cases with recurrence versus 23/127 (18%) of non-recurrent tumors, p < 0.001, and no adjuvant tamoxifen, p = 0.003, were associated with IBTR. No other patient, tumor or treatment factors studied were predictive of IBTR. The type of IBTR did not correlate with the p53 status of the index tumor. Conclusions: These data suggest that p53 may be a biomarker for elevated risk of IBTR after a diagnosis of DCIS and support the value of adjuvant tamoxifen for DCIS patients. Further investigation to validate these findings and to identify clinically useful individualized risk stratification for DCIS patients is warranted.
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Affiliation(s)
- T. J. Hieken
- NorthShore University HealthSystem Skokie Hospital, Rush University Medical Center and Rush Medical College, Chicago, IL; Rush University Medical Center, Chicago, IL; University of Illinois at Chicago, Edward Hospital, Naperville, IL; NorthShore Unviersity HealthSystem Skokie Hospital, Skokie, IL
| | - V. Krishnamurthy
- NorthShore University HealthSystem Skokie Hospital, Rush University Medical Center and Rush Medical College, Chicago, IL; Rush University Medical Center, Chicago, IL; University of Illinois at Chicago, Edward Hospital, Naperville, IL; NorthShore Unviersity HealthSystem Skokie Hospital, Skokie, IL
| | - M. Farolan
- NorthShore University HealthSystem Skokie Hospital, Rush University Medical Center and Rush Medical College, Chicago, IL; Rush University Medical Center, Chicago, IL; University of Illinois at Chicago, Edward Hospital, Naperville, IL; NorthShore Unviersity HealthSystem Skokie Hospital, Skokie, IL
| | - J. M. Velasco
- NorthShore University HealthSystem Skokie Hospital, Rush University Medical Center and Rush Medical College, Chicago, IL; Rush University Medical Center, Chicago, IL; University of Illinois at Chicago, Edward Hospital, Naperville, IL; NorthShore Unviersity HealthSystem Skokie Hospital, Skokie, IL
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Achuthavarier D, Krishnamurthy V. Relation between intraseasonal and interannual variability of the South Asian monsoon in the National Centers for Environmental Predictions forecast systems. ACTA ACUST UNITED AC 2010. [DOI: 10.1029/2009jd012865] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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24
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Siksik M, Krishnamurthy V. An asymmetric approach to modeling ion channels using finite element analysis. Annu Int Conf IEEE Eng Med Biol Soc 2009; 2009:3873-6. [PMID: 19963603 DOI: 10.1109/iembs.2009.5332636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Biological ion channels are water filled pores in the cell membrane. They regulate the flow of ions in and out of the cell. Modeling the dynamics of these channels and relating their structure to functionality is crucial in understanding the mechanisms by which they conduct. This paper proposes a novel Finite Element Method (FEM) based simulation framework for modeling of ion channels that does not assume channel symmetry. This is the first framework that allows the use of multiple dielectric constants inside such channels without assuming geometrical symmetry thus providing a more realistic model of the channel. Due to the run-time complexity of the problem, lookup tables must be constructed in memory to store pre-calculated electric potential information. The large number of elements involved in FEM and channel resolution requirements can potentially result in very large lookup tables leading to a performance "bottleneck". This paper answers the following question: Does the accuracy introduced by using an asymmetric model outweigh the inaccuracy caused by having to reduce the size and resolution of electric-field look-up tables? This paper compares the memory footprint of an ion channel simulator that assumes a symmetric channel model versus an asymmetric model. We show that currently available personal computers are sufficient for attaining reasonable levels of accuracy for both. Our results show diminishing returns in accuracy with tables sized greater than 8.5 GB for the asymmetric model.
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25
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Krishnamurthy V, Hammond-Tooke G, Fulton J, Oliver J, du Plessis L, Wright R. PO06-MO-13 Diffusion weighted imaging in transient global amnesia. J Neurol Sci 2009. [DOI: 10.1016/s0022-510x(09)70704-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: 11/29/2022]
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26
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27
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Krishnamurthy V. Chikungunya arthritis. Indian Journal of Rheumatology 2008. [DOI: 10.1016/s0973-3698(10)60124-0] [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: 10/19/2022] Open
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Affiliation(s)
- Renguang Wu
- Center for Ocean-Land-Atmosphere Studies; Calverton Maryland USA
| | - Ben P. Kirtman
- Center for Ocean-Land-Atmosphere Studies; Calverton Maryland USA
- Department of Climate Dynamics; George Mason University; Fairfax Virginia USA
| | - V. Krishnamurthy
- Center for Ocean-Land-Atmosphere Studies; Calverton Maryland USA
- Department of Climate Dynamics; George Mason University; Fairfax Virginia USA
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29
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Ravichandran B, Krishnamurthy V, Ravibabu K, Raghavan S, Rajan BK, Rajmohan HR. Assessing dust exposure in an integrated iron and steel manufacturing plant in South India. Work 2008; 30:195-200. [PMID: 18413935] [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: 05/26/2023] Open
Abstract
A study to monitor and estimate respirable particulate matter (RPM), toxic trace metal concentrations in the work environment was carried out in different sections of an integrated steel manufacturing industry. The average RPM concentration observed varied according to the section blast furnace was 2.41 mg/m;{3}; energy optimization furnace, 1.87 mg/m;{3}; sintering plant, 0.98 mg/m;{3}; continuous casting machine, 1.93 mg/m;{3}. The average trace metal concentration estimated from the RPM samples like iron, manganese, lead and chromium did not exceed ACGIH prescribed levels.
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Affiliation(s)
- B Ravichandran
- Regional Occupational Health Centre, Bangalore Medical College Campus, Bangalore, India.
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30
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Krishnamurthy V, Eschrich K, Boney A, Sullivan J, McDonald M, Kishnani PS, Koeberl DD. Three successful pregnancies through dietary management of fructose-1,6-bisphosphatase deficiency. J Inherit Metab Dis 2007; 30:819. [PMID: 17705024 DOI: 10.1007/s10545-007-0606-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [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: 03/02/2007] [Revised: 07/05/2007] [Accepted: 07/09/2007] [Indexed: 10/22/2022]
Abstract
Fructose-1,6-bisphosphatase (FBPase) deficiency (OMIM 229700) has been characterized as the cause of life-threatening hypoglycaemia and lactic acidaemia following prolonged fasting. The patient, an adult African-American woman, presented during the second trimester of her first pregnancy with recurrent episodes of lactic acidaemia and hypoglycaemia. She had recently been admitted to a nearby intensive care unit after presentation with profound hypoglycaemia and lactic acidosis, and was found to be pregnant. The history was remarkable for approximately 30 hospitalizations for hypoglycaemia and acidosis. She had previously undergone liver biopsy at another centre and was diagnosed with a 'glycogen storage disease', although no enzyme testing had been done for confirmation. Based on clinical symptoms, a diagnosis of FBPase deficiency was accomplished through gene sequencing, which revealed homozygosity for a panethnic, common mutation, 960/961insG in exon 7. The availability of mutation testing facilitated the confirmation of FBPase deficiency in this patient, obviating liver biopsy for enzyme activity confirmation. The patient underwent three successful pregnancies by strict compliance with dietary management, including nocturnal uncooked cornstarch to manage hypoglycaemia. The pregnancies were complicated by mild gestational diabetes, increased cornstarch requirements, and hypoglycaemia at the time of discharge from the hospital. The three infants had normal birth weights and experienced no complications during the neonatal period. The patient subsequently developed sensorineural hearing loss and early-onset cognitive impairment, despite compliance with the monitoring and treatment of hypoglycaemia. The experience with multiple pregnancies in this FBPase-deficient patient provides insight into the management of hypoglycaemia in inherited disorders of gluconeogenesis.
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Affiliation(s)
- V Krishnamurthy
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC 27710, USA
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31
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Krishnamurthy V. Correspondence. Indian Journal of Rheumatology 2007. [DOI: 10.1016/s0973-3698(10)60045-3] [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] Open
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32
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Krishnamurthy V, Jones J, Nichols J, Naramor T, Freier M. 21. J Heart Lung Transplant 2006. [DOI: 10.1016/j.healun.2005.11.022] [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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33
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Wemmer C, Krishnamurthy V, Shrestha S, Hayek LA, Thant M, Nanjappa K. Assessment of body condition in Asian elephants (Elephas maximus). Zoo Biol 2006. [DOI: 10.1002/zoo.20099] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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34
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Ravichandran B, Ravibabu K, Raghavan S, Krishnamurthy V, Rajan BK, Rajmohan HR. Environmental and Biological Monitoring in a Lead Acid Battery Manufacturing Unit in India. J Occup Health 2005; 47:350-3. [PMID: 16096364 DOI: 10.1539/joh.47.350] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
An environmental and biological monitoring of a lead acid battery manufacturing unit was carried out to measure the respirable particulate matter, lead content in working atmosphere and blood lead levels of workers employed in different sections. The results showed high mean air lead concentration in buffing (1444.45 microg/m(3)), plate cutting (430.14 microg/m(3)) and pasting (277.48 microg/m(3)) sections. The mean blood lead levels of employees in these sections were also higher than the values prescribed by ACGIH.
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Affiliation(s)
- B Ravichandran
- Regional Occupational Health Centre, Bangalore Medical College Campus, India.
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35
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36
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Franco LM, Krishnamurthy V, Bali D, Weinstein DA, Arn P, Clary B, Boney A, Sullivan J, Frush DP, Chen YT, Kishnani PS. Hepatocellular carcinoma in glycogen storage disease type Ia: a case series. J Inherit Metab Dis 2005; 28:153-62. [PMID: 15877204 DOI: 10.1007/s10545-005-7500-2] [Citation(s) in RCA: 136] [Impact Index Per Article: 7.2] [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: 05/26/2004] [Accepted: 12/03/2004] [Indexed: 12/19/2022]
Abstract
We present a series of 8 patients (6 males, 2 females) with hepatocellular carcinoma (HCC) and glycogen storage disease type Ia (GSD Ia). In this group, the age at which treatment was initiated ranged from birth to 39 years (mean 9.9 years). All patients but one were noncompliant with treatment. Hepatic masses were first detected at an age range of 13-45 years (mean 28.1 years). Age at diagnosis of HCC ranged from 19 to 49 years (mean 36.9 years). Duration between the diagnosis of liver adenomas and the diagnosis of HCC ranged from 0 to 28 years (mean 8.8 years, SD = 11.5). Two patients had positive hepatitis serologies (one hepatitis B, one hepatitis C). Alpha-fetoprotein (AFP) was normal in 6 of the 8 patients. Carcinoembryonic antigen (CEA) was normal in the 5 patients in which it was measured. Current guidelines recommend abdominal ultrasonography with AFP and CEA levels every 3 months once patients develop hepatic lesions. Abdominal CT or MRI is advised when the lesions are large or poorly defined or are growing larger. We question the reliability of AFP and CEA as markers for HCC in GSD Ia. Aggressive interventional management of masses with rapid growth or poorly defined margins may be necessary to prevent the development of HCC in this patient population.
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Affiliation(s)
- L M Franco
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina 27710, USA
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37
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Rasmussen L, Sukumar R, Krishnamurthy V. Behavioural and chemical confirmation of the preovulatory pheromone, (Z)-7-dodecenyl acetate, in wild Asian elephants: its relationship to musth. BEHAVIOUR 2005. [DOI: 10.1163/1568539053778300] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Mammalian breeding strategies vary depending on particular social contexts and sensory systems emphasized in various species. Among sexually dimorphic non-territorial Asian elephants, Elephas maximus, a multiplex olfactory chemical signaling system has been implicated in ensuring effective reproduction. This study explores how, using chemosensory mechanisms, widely roaming, wild male elephants locate periovulatory females in matriarchal-led female family units and precisely assess their ovulatory status. In this species, the dual obstacles of separately living sexes and infrequent oestrus are overcome by lengthy female cycles. During an extended preovulatory period captive females release increasing concentrations of the urinary pheromone (Z)-7-dodecenyl acetate, timed to reach a maximum just before ovulation. The current field studies combined chemical identification and quantification of female urinary (Z)-7-dodecenyl acetate with behavioural observations, monitoring the frequencies of chemosensory responses and premating behaviours by various categories of males. The results suggest the temporal extension of the preovulatory period effectively provides a synchrony between sexes for successful reproduction. Male elephants undergo a two-decade-long maturation process that involves physical, sexual, social, and physiological maturation. Males older than 30 years are generally large, sexually active, socially adept and capable of sustaining long periods of musth, during which they release secretions distinctive of adult musth. These older adult males in musth demonstrated significantly more chemosensory responses and premating behaviours than their younger or nonmusth counterparts; they apparently are more skilled at detecting the precise ovulatory status of females. Male–male interactions are affected by size, age, and musth; the winners gain greater access to females, as indicated by the high incidence of mate guarding. The Asian elephant shares some breeding tactics common to other mammals including some primates (e.g. orangutans) and whales, while the musth parameter adds a unique feature. Fusion–fission events are influenced by elephant reproductive strategies, as roving males join female groups while tracking preovulatory pheromone concentrations.
Mammalian breeding strategies vary depending on particular social contexts and sensory systems emphasized in various species. Among sexually dimorphic non-territorial Asian elephants,
Elephas maximus
, a multiplex olfactory chemical signaling system has been implicated in ensuring effective reproduction. This study explores how, using chemosensory mechanisms, widely roaming, wild male elephants locate periovulatory females in matriarchal-led female family units and precisely assess their ovulatory status. In this species, the dual obstacles of separately living sexes and infrequent oestrus are overcome by lengthy female cycles. During an extended preovulatory period captive females release increasing concentrations of the urinary pheromone (
Z
)-7-dodecenyl acetate, timed to reach a maximum just before ovulation. The current field studies combined chemical identification and quantification of female urinary (
Z
)-7-dodecenyl acetate with behavioural observations, monitoring the frequencies of chemosensory responses and premating behaviours by various categories of males. The results suggest the temporal extension of the preovulatory period effectively provides a synchrony between sexes for successful reproduction. Male elephants undergo a two-decade-long maturation process that involves physical, sexual, social, and physiological maturation. Males older than 30 years are generally large, sexually active, socially adept and capable of sustaining long periods of musth, during which they release secretions distinctive of adult musth. These older adult males in musth demonstrated significantly more chemosensory responses and premating behaviours than their younger or nonmusth counterparts; they apparently are more skilled at detecting the precise ovulatory status of females. Male–male interactions are affected by size, age, and musth; the winners gain greater access to females, as indicated by the high incidence of mate guarding. The Asian elephant shares some breeding tactics common to other mammals including some primates (e.g. orangutans) and whales, while the musth parameter adds a unique feature. Fusion–fission events are influenced by elephant reproductive strategies, as roving males join female groups while tracking preovulatory pheromone concentrations.
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AmirthaLakshmi S, Pushparaj V, Krishnamurthy V, Biswas J, Krishnakumar S, Shanmugam MP. Tetraspanin protein KAI1 expression in retinoblastoma. Br J Ophthalmol 2004; 88:593-5. [PMID: 15031195 PMCID: PMC1772078 DOI: 10.1136/bjo.2003.030585] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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39
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Hanna R, McDonald MT, Sullivan JA, Mackey JF, Krishnamurthy V, Kishnani PS. Diagnostic and treatment challenges of neuronopathic Gaucher disease: two cases with an intermediate phenotype. J Inherit Metab Dis 2004; 27:687-90. [PMID: 15669686 DOI: 10.1023/b:boli.0000043027.80328.75] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Gaucher disease (GD) is a lysosomal storage disorder with a broad, overlapping clinical spectrum. The presented two case reports highlight the clinical evaluation required in neuronopathic GD to assist with medical management and genetic counselling.
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Affiliation(s)
- R Hanna
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
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40
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Abstract
Male Asian elephants in musth--an annual period of heightened sexual activity and intensified aggression--broadcast odoriferous, behaviourally influential messages from secretions of the temporal gland. From our observations in the wild, together with instantaneous chemical sampling and captive-elephant playback experiments, we have discovered that young, socially immature males in musth signal their naivety by releasing honey-like odours to avoid conflict with adult males, whereas older musth males broadcast malodorous combinations to deter young males, facilitating the smooth functioning of male society. As elephant--human conflicts can upset this equilibrium, chemically modulating male behaviour may be one way to help the conservation of wild elephants.
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Affiliation(s)
- L E L Rasmussen
- Department of Biochemistry and Molecular Biology, OGI School of Science and Engineering, Oregon Health and Science University, Beaverton, Oregon 97006-8921, USA.
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Bist P, Sistla S, Krishnamurthy V, Acharya A, Chandrakala B, Rao DN. S-adenosyl-L-methionine is required for DNA cleavage by type III restriction enzymes. J Mol Biol 2001; 310:93-109. [PMID: 11419939 DOI: 10.1006/jmbi.2001.4744] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The requirement of S-adenosyl-L-methionine (AdoMet) in the cleavage reaction carried out by type III restriction-modification enzymes has been investigated. We show that DNA restriction by EcoPI restriction enzyme does not take place in the absence of exogenously added AdoMet. Interestingly, the closely related EcoP15I enzyme has endogenously bound AdoMet and therefore does not require the addition of the cofactor for DNA cleavage. By employing a variety of AdoMet analogs, which differ structurally from AdoMet, this study demonstrates that the carboxyl group and any substitution at the epsilon carbon of methionine is absolutely essential for DNA cleavage. Such analogs could bring about the necessary conformational change(s) in the enzyme, which make the enzyme proficient in DNA cleavage. Our studies, which include native polyacrylamide gel electrophoresis, molecular size exclusion chromatography, UV, fluorescence and circular dichroism spectroscopy, clearly demonstrate that the holoenzyme and apoenzyme forms of EcoP15I restriction enzyme have different conformations. Furthermore, the Res and Mod subunits of the EcoP15I restriction enzyme can be separated by gel filtration chromatography in the presence of 2 M NaCl. Reconstitution experiments, which involve mixing of the isolated subunits, result in an apoenzyme form, which is restriction proficient in the presence of AdoMet. However, mixing the Res subunit with Mod subunit deficient in AdoMet binding does not result in a functional restriction enzyme. These observations are consistent with the fact that AdoMet is required for DNA cleavage. In vivo complementation of the defective mod allele with a wild-type mod allele showed that an active restriction enzyme could be formed. Furthermore, we show that while the purified c2-134 mutant restriction enzyme is unable to cleave DNA, the c2-440 mutant enzyme is able to cleave DNA albeit poorly. Taken together, these results suggest that AdoMet binding causes conformational changes in the restriction enzyme and is necessary to bring about DNA cleavage.
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Affiliation(s)
- P Bist
- Department of Biochemistry, Indian Institute of Science, Bangalore, 560 012, India
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Abstract
The phenomenon of restriction and modification (R-M) was first observed in the course of studies on bacteriophages in the early 1950s. It was only in the 1960s that work of Arber and colleagues provided a molecular explanation for the host specificity. DNA restriction and modification enzymes are responsible for the host-specific barriers to interstrain and interspecies transfer of genetic information that have been observed in a variety of bacterial cell types. R-M systems comprise an endonuclease and a methyltransferase activity. They serve to protect bacterial cells against bacteriophage infection, because incoming foreign DNA is specifically cleaved by the restriction enzyme if it contains the recognition sequence of the endonuclease. The DNA is protected from cleavage by a specific methylation within the recognition sequence, which is introduced by the methyltransferase. Classic R-M systems are now divided into three types on the basis of enzyme complexity, cofactor requirements, and position of DNA cleavage, although new systems are being discovered that do not fit readily into this classification. This review concentrates on multisubunit, multifunctional ATP-dependent restriction enzymes. A growing number of these enzymes are being subjected to biochemical and genetic studies that, when combined with ongoing structural analyses, promise to provide detailed models for mechanisms of DNA recognition and catalysis. It is now clear that DNA cleavage by these enzymes involves highly unusual modes of interaction between the enzymes and their substrates. These unique features of mechanism pose exciting questions and in addition have led to the suggestion that these enzymes may have biological functions beyond that of restriction and modification. The purpose of this review is to describe the exciting developments in our understanding of how the ATP-dependent restriction enzymes recognize specific DNA sequences and cleave or modify DNA.
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Affiliation(s)
- D N Rao
- Department of Biochemistry, Indian Institute of Science, Bangalore, India
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Abstract
A rule-based programming paradigm is described as a formal basis for biological, chemical and physical computations. In this paradigm, the computations are interpreted as the outcome arising out of interaction of elements in an object space. The interactions can create new elements (or same elements with modified attributes) or annihilate old elements according to specific rules. Since the interaction rules are inherently parallel, any number of actions can be performed cooperatively or competitively among the subsets of elements, so that the elements evolve toward an equilibrium or unstable or chaotic state. Such an evolution may retain certain invariant properties of the attributes of the elements. The object space resembles Gibbsian ensemble that corresponds to a distribution of points in the space of positions and momenta (called phase space). It permits the introduction of probabilities in rule applications. As each element of the ensemble changes over time, its phase point is carried into a new phase point. The evolution of this probability cloud in phase space corresponds to a distributed probabilistic computation. Thus, this paradigm can handle tor deterministic exact computation when the initial conditions are exactly specified and the trajectory of evolution is deterministic. Also, it can handle probabilistic mode of computation if we want to derive macroscopic or bulk properties of matter. We also explain how to support this rule-based paradigm using relational-database like query processing and transactions.
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Affiliation(s)
- V Krishnamurthy
- Computer Sciences Laboratory, Research School of Information Sciences and Engineering, Australian National University, Canberra
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Abstract
EcoP1I and EcoP15I are members of type III restriction-modification enzymes. EcoPI and EcoP15I DNA methyltransferases transfer a methyl group from S-adenosyl-L-methionine (AdoMet) to the N6 position of the second adenine residues in their recognition sequences, 5'-AGACC-3' and 5'-CAGCAG-3' respectively. We have altered various residues in two highly conserved sequences, FxGxG (motif I) and DPPY (motif IV) in these proteins by site-directed mutagenesis. Using a mixture of in vivo and in vitro assays, our results on the mutational analysis of these methyltransferases demonstrate the universal role of motif I in AdoMet binding and a role for motif IV in catalysis. All six cysteine residues in EcoP15I DNA methyltransferase have been substituted with serine and the role of cysteine residues in EcoP15I DNA methyltransferase catalysed reaction assessed. The Res subunits of type III restriction enzymes share a distant sequence similarity with and contain the motifs characteristic of the DEAD box proteins. We have carried out site-directed mutagenesis of the conserved residues in two of the helicase motifs of the EcoP1I restriction enzyme in order to investigate the role of motifs in DNA cleavage by this enzyme. Our findings indicate that certain conserved residues in these motifs are involved in ATP hydrolysis while the other residues are involved in coupling restriction of DNA to ATP hydrolysis. Taken collectively, these results form the basis for a detailed structure-function analysis of EcoP1I and EcoP15I restriction enzymes.
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Affiliation(s)
- S Saha
- Department of Biochemistry, Indian Institute of Science, Bangalore
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Lowenwirt I, Dadic P, Krishnamurthy V. Essential thrombocythemia and epidural analgesia in the parturient. Does thromboelastography help? Reg Anesth 1996; 21:525-8. [PMID: 8956388] [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] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVES It is often considered that essential thrombocythemia contraindicates placement of an epidural catheter because of the danger of epidural hematoma. Thromboelastography offers a possible means of determining the appropriateness of epidural analgesia in a patient with this disorder. METHODS A pregnant woman with essential thrombocythemia and a history of spontaneous abortions was evaluated by thromboelastography at 38 weeks of gestation to determine the safety of using epidural analgesia for labor pain management. On the basis of the thermoelastography findings, the patient was given epidural analgesia with bupivacaine and fentanyl during her labor. RESULTS The patient experienced good pain relief, delivered a healthy infant vaginally, and suffered no complications. CONCLUSIONS Thromboelastography may be a useful diagnostic test in determining the suitability of regional techniques for labor analgesia in parturients with essential thrombocythemia. However, success in one patient does not prove the general safety of this approach.
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Affiliation(s)
- I Lowenwirt
- Department of Anesthesiology, New York Hospital Medical Center of Queens, NY 11355-5095, USA
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Abstract
The DNA-binding properties of the EcoP15I DNA methyltransferase (M.EcoP15I; MTase) were studied using electrophoretic mobility shift assays. We show by molecular size-exclusion chromatography and dimethyl suberimidate cross-linking that M.EcoP15I is a dimer in solution. While M.EcoP15I binds approx. threefold more tightly to its recognition sequence, 5'-CAGCAG-3', than to non-specific sequences in the presence of AdoMet or its analogs, the discrimination between specific and non-specific sequences significantly increases in presence of ATP. These results suggest for the first time a role for ATP in DNA recognition by type-III restriction-modification enzymes. Furthermore, we show that although c2 EcoPI mutant MTases are defective in AdoMet binding, they are still able to bind DNA in a sequence-specific manner.
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Affiliation(s)
- I Ahmad
- Department of Biochemistry, Indian Institute of Science, Bangalore
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Krishnamurthy V, Rao DN. Interaction of EcoP1 modification methylase with S-adenosyl-L-methionine: a UV-crosslinking study. Biochem Mol Biol Int 1994; 32:623-32. [PMID: 8038713] [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] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
EcoP1 modification methylase was radioactively labeled when incubated with S-adenosyl-L-[methyl-3H]methionine in the presence of ultraviolet light. Crosslinking of the enzyme as detected by electrophoresis on sodium dodecyl sulfate-polyacrylamide gel followed by fluorography and autoradiography, was shown to be specific by a number of criteria. More importantly, EcoP1 modification methylase was also radioactively labeled with S-adenosyl-L-[carboxyl-14C]methionine demonstrating that labeling involved binding of the entire AdoMet molecule rather than methylation of the protein. Further, c2 EcoP1 mutant DNA modification methylases which show negligible or very little methylation activity, correspondingly formed a weak or no adduct upon crosslinking. These results suggest that photolabeling of EcoP1 DNA modification methylase occurs at the AdoMet binding site.
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Affiliation(s)
- V Krishnamurthy
- Department of Biochemistry, Indian Institute of Science, Bangalore
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