1
|
Madhavan SS, Roa Diaz S, Peralta S, Nomura M, King CD, Lin A, Bhaumik D, Shah S, Blade T, Gray W, Chamoli M, Eap B, Panda O, Diaz D, Garcia TY, Stubbs BJ, Lithgow GJ, Schilling B, Verdin E, Chaudhuri AR, Newman JC. β-hydroxybutyrate is a metabolic regulator of proteostasis in the aged and Alzheimer disease brain. bioRxiv 2023:2023.07.03.547547. [PMID: 37461525 PMCID: PMC10349929 DOI: 10.1101/2023.07.03.547547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Loss of proteostasis is a hallmark of aging and Alzheimer disease (AD). Here, we identify β-hydroxybutyrate (βHB), a ketone body, as a regulator of protein solubility in the aging brain. βHB is a small molecule metabolite which primarily provides an oxidative substrate for ATP during hypoglycemic conditions, and also regulates other cellular processes through covalent and noncovalent protein interactions. We demonstrate βHB-induced protein insolubility across in vitro, ex vivo, and in vivo mouse systems. This activity is shared by select structurally similar metabolites, is not dependent on covalent protein modification, pH, or solute load, and is observable in mouse brain in vivo after delivery of a ketone ester. Furthermore, this phenotype is selective for pathological proteins such as amyloid-β, and exogenous βHB ameliorates pathology in nematode models of amyloid-β aggregation toxicity. We have generated a comprehensive atlas of the βHB-induced protein insolublome ex vivo and in vivo using mass spectrometry proteomics, and have identified common protein domains within βHB target sequences. Finally, we show enrichment of neurodegeneration-related proteins among βHB targets and the clearance of these targets from mouse brain, likely via βHB-induced autophagy. Overall, these data indicate a new metabolically regulated mechanism of proteostasis relevant to aging and AD.
Collapse
Affiliation(s)
- S S Madhavan
- Buck Institute for Research on Aging, Novato, CA, USA
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
- Department of Geriatrics, University of California San Francisco, San Francisco, CA, USA
| | - S Roa Diaz
- Buck Institute for Research on Aging, Novato, CA, USA
- Department of Geriatrics, University of California San Francisco, San Francisco, CA, USA
| | - S Peralta
- Buck Institute for Research on Aging, Novato, CA, USA
| | - M Nomura
- Buck Institute for Research on Aging, Novato, CA, USA
| | - C D King
- Buck Institute for Research on Aging, Novato, CA, USA
| | - A Lin
- Buck Institute for Research on Aging, Novato, CA, USA
| | - D Bhaumik
- Buck Institute for Research on Aging, Novato, CA, USA
| | - S Shah
- Buck Institute for Research on Aging, Novato, CA, USA
| | - T Blade
- Buck Institute for Research on Aging, Novato, CA, USA
| | - W Gray
- Buck Institute for Research on Aging, Novato, CA, USA
| | - M Chamoli
- Buck Institute for Research on Aging, Novato, CA, USA
| | - B Eap
- Buck Institute for Research on Aging, Novato, CA, USA
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
| | - O Panda
- Buck Institute for Research on Aging, Novato, CA, USA
| | - D Diaz
- Buck Institute for Research on Aging, Novato, CA, USA
| | - T Y Garcia
- Buck Institute for Research on Aging, Novato, CA, USA
- Department of Geriatrics, University of California San Francisco, San Francisco, CA, USA
| | - B J Stubbs
- Buck Institute for Research on Aging, Novato, CA, USA
| | - G J Lithgow
- Buck Institute for Research on Aging, Novato, CA, USA
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
| | - B Schilling
- Buck Institute for Research on Aging, Novato, CA, USA
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
| | - E Verdin
- Buck Institute for Research on Aging, Novato, CA, USA
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
| | - A R Chaudhuri
- Buck Institute for Research on Aging, Novato, CA, USA
| | - J C Newman
- Buck Institute for Research on Aging, Novato, CA, USA
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
- Department of Geriatrics, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
2
|
Paddick SM, Gamassa E, Mwaluwinga N, Lewis EG, Duinmaijer A, Urasa S, Tucker L, Mukaetova-Ladinska E, Cosker G, Dekker M, Kisoli A, Cletus J, Lissu C, Dotchin C, Gray W, Walker R. Preliminary evaluation of a smartphone application (DelApp) for identification of delirium in sub-Saharan Africa. Acta Neuropsychiatr 2023:1-28. [PMID: 37345466 DOI: 10.1017/neu.2023.29] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
OBJECTIVE In sub-Saharan Africa (SSA), there are no validated screening tools for delirium in older adults, despite the known vulnerability of older people to delirium and the associated adverse outcomes. This study aimed to assess the effectiveness of a brief smartphone-based assessment of arousal and attention (DelApp) in identification of delirium amongst older adults admitted to the medical department of a tertiary referral hospital in Northern Tanzania. METHOD Consecutive admissions were screened using the DelApp during a larger study of delirium prevalence and risk factors. All participants subsequently underwent detailed clinical assessment for delirium by a research doctor. Delirium and dementia were identified against DSM-5 criteria by consensus. RESULTS Complete data for 66 individuals were collected of whom 15 (22.7%) had delirium, 24.5% had dementia without delirium and 10.6% delirium superimposed on dementia. Sensitivity and specificity of the DelApp for delirium were 0.87 and 0.62 respectively (AUROC 0.77) and 0.88 and 0.73 (AUROC 0.85) for major cognitive impairment (dementia and delirium combined). Lower DelApp score was associated with age, significant visual impairment (<6/60 acuity), illness severity, reduced arousal and DSM-5 delirium on univariable analysis, but on multivariable logistic regression only arousal remained significant. CONCLUSION In this setting, the DelApp performed well in identifying delirium and major cognitive impairment but did not differentiate delirium and dementia. Performance is likely to have been affected by confounders including uncorrected visual impairment and reduced level of arousal without delirium. Negative predictive value was nevertheless high, indicating excellent "rule out" value in this setting.
Collapse
Affiliation(s)
- S M Paddick
- Institute of Translational and Clinical Medicine, Newcastle University, Newcastle upon Tyne, UK
- Cumbria Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - E Gamassa
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - N Mwaluwinga
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - E G Lewis
- Charité - Universitätsmedizin Berlin CVK: Campus Virchow-Klinikum Institute of Tropical Medicine and International Health, Berlin, Germany
| | - A Duinmaijer
- Haydom Lutheran Hospital, Mbulu, Manyara, Tanzania
| | - S Urasa
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - L Tucker
- The London School of Hygiene & Tropical Medicine, London, UK
| | | | - G Cosker
- Cumbria Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - M Dekker
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - A Kisoli
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - J Cletus
- Hai District Hospital, Boman'gombe, Kilimanjaro, Tanzania
| | - C Lissu
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - C Dotchin
- Institute of Population Sciences, Newcastle University, Newcstle upon Tyne, UK
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - W Gray
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - R Walker
- Institute of Population Sciences, Newcastle University, Newcstle upon Tyne, UK
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| |
Collapse
|
3
|
Chia C, Shastin D, Gray W. 358 An Anatomical Study of the Sylvian Fissure Using a Large Number of MRI Data Sets. Br J Surg 2022. [DOI: 10.1093/bjs/znac039.240] [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: 11/14/2022]
Abstract
Abstract
Introduction
Accurate manoeuvring of the Sylvian fissure borders to provide an optimal operating corridor is vital for minimising retraction. The anatomy of the fissure can pose technical challenges impacting the overall success of the procedure. Yaşargil previously proposed a classification distinguishing four anatomical variants correlating with surgical difficulty. We aim to utilise the open-source Human Connectome Project MRI data set to provide a computational classification of the fissure based on morphology.
Method
MR images of 2226 hemispheres were included in this study. Morphometrical parameters were designed and refined in MATLAB simulations. Combinations of parameters were analysed using K-Means Clustering.
Results
Following segmentation and removal of outliers, 1693 fissures remain for analysis. K-Means Clustering revealed three clusters with sulcal bulk displacement measure (deviation of the fissure towards the frontal or temporal lobe) and sulcal distance (width of the fissure) (silhouette score = 0.383).
Conclusions
Analysis of a large neuroimaging cohort suggested the existence of three weakly separated anatomical variants. We propose that looking at the quantitative scores rather than class allocation would be more informative for preoperative planning.
Collapse
Affiliation(s)
- C.W.L. Chia
- School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - D. Shastin
- Department of Neurosurgery, University Hospital Wales, Cardiff, United Kingdom
- Cardiff University Brain Research Imaging Centre (CUBRIC), Cardiff University, Cardiff, United Kingdom
- BRAIN Biomedical Research Unit, Health & Care Research Wales, Cardiff, United Kingdom
| | - W. Gray
- Department of Neurosurgery, University Hospital Wales, Cardiff, United Kingdom
- Cardiff University Brain Research Imaging Centre (CUBRIC), Cardiff University, Cardiff, United Kingdom
- BRAIN Biomedical Research Unit, Health & Care Research Wales, Cardiff, United Kingdom
| |
Collapse
|
4
|
Tan TK, Merola J, Zaben M, Gray W, Leach P. 723 Neuroendoscopy versus Craniotomy in Basal Ganglia Haemorrhage: A Systematic Review and Meta-Analysis. Br J Surg 2021. [DOI: 10.1093/bjs/znab258] [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: 11/12/2022]
Abstract
Abstract
Aim
Basal ganglia haemorrhage (BGH) is the most common type of intracerebral bleed with high morbidity and mortality rate. The efficacy between craniotomy and endoscopic approach in BGH is still debatable and advancement in minimally invasive technique has made endoscopic approach the preferred option. The aim of this systematic review and meta-analysis was to evaluate the outcomes of craniotomy and endoscopic approach in BGH.
Method
Databases of PubMed, EMBASE, MEDLINE and CENTRAL were systematically searched from its inception until December 2020. All randomized clinical trials and observational studies comparing craniotomy versus endoscopic approach in BGH were included.
Results
Twelve studies enrolling 1297 patients (craniotomy:675, endoscopy:632) were included for qualitative and quantitative analysis. Endoscopic approach was associated with significantly lower postoperative mortality (OR:0.35, P < 0.00001), higher haematoma evacuation rate (MD:4.95, P = 0.0002), shorter operative time (MD:-117.03, P < 0.00001), lesser intraoperative blood loss (MD:-328.47, P < 0.00001), higher postoperative Glasgow Coma Scale (GCS) (MD:1.14, P = 0.01), higher postoperative Glasgow Outcome Scale (GOS) (MD:0.44, P = 0.05), shorter length of hospital stay (MD:-2.90, P < 0.00001), lower complication rate (OR:0.30, P = 0.0004), lower infection rate (OR:0.29, P < 0.00001) and lower modified Rankin Scale (mRS) (MD:-0.57, P = 0.004) compared to craniotomy. No significant difference was detected in reoperation, intracranial infection, re-bleeding.
Conclusions
The best available evidence suggest that endoscopic approach has better outcomes in mortality rate, operative time, haematoma evacuation rate, intraoperative blood loss, length of hospital stay, mRS, postoperative GCS and GOS compared with craniotomy in the management of BGH. However, there is a need for high quality randomised controlled trials with large sample size for definite conclusions.
Collapse
Affiliation(s)
- T K Tan
- Sir Charles Gairdner Hospital, Perth, Australia
| | - J Merola
- University Hospital of Wales, Cardiff, United Kingdom
| | - M Zaben
- University Hospital of Wales, Cardiff, United Kingdom
| | - W Gray
- University Hospital of Wales, Cardiff, United Kingdom
| | - P Leach
- University Hospital of Wales, Cardiff, United Kingdom
| |
Collapse
|
5
|
Bhatia S, Shastin D, Tax C, Parker G, Shwartz S, Hamandi K, Gray W, Jones D, Chamberland M. 875 Use of Oriented Priors Through Magnetic Tractography (MAGNET) In Deliniation Of Meyer's Loop and Correlation with Visual Field Deficit In Temporal Lobe Epilepsy (TLE) Surgery: A Pilot Study. Br J Surg 2021. [DOI: 10.1093/bjs/znab134.028] [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: 11/14/2022]
Abstract
Abstract
Introduction
Pre-operative white matter tract reconstruction of the Meyer’s loop (ML) of the optic radiation using diffusion MRI (tractography) can be used to prevent post-operative visual-field deficit. Due to its complex anatomy, precise reconstruction of the ML is challenging and often underestimated. Previous work has suggested that an innovative tractography technique using oriented priors called MAGNET better approximates reconstruction to reported histological prosections. This proof-of-context study validates the MAGNET methodology in predicting visual-field deficits in patients undergoing TLE surgery.
Method
Diffusion MRI datasets were used to reconstruct pre-operative ML using MAGNET in five patients. These were overlaid on post-operative T2-MRI series demonstrating the surgically resected area to measure overlap between resection and reconstructed ML. A correlation with post-operative visual-field defects was established.
Results
There was no evidence of visual field deficit in the cases where there was no overlap between the reconstructed ML and the resected region. In the cases with overlap with reconstructed ML and resection, there was visual deficit found. There was no correlation between proportion of resected ML and visual deficit.
Conclusions
This pilot demonstrates that MAGNET accurately reconstructs ML in pre-surgical TLE cases compared to standard tractography techniques and can be used to augment neurosurgical planning and resection.
Collapse
Affiliation(s)
- S Bhatia
- Cardiff University School of Medicine, Cardiff, United Kingdom
| | - D Shastin
- Cardiff University Brain Imaging Centre, Cardiff, United Kingdom
- University Hospital of Wales, Cardiff, United Kingdom
| | - C Tax
- Cardiff University Brain Imaging Centre, Cardiff, United Kingdom
| | - G Parker
- Cardiff University Brain Imaging Centre, Cardiff, United Kingdom
| | - S Shwartz
- Cardiff University Brain Imaging Centre, Cardiff, United Kingdom
- University Hospital of Wales, Cardiff, United Kingdom
| | - K Hamandi
- Cardiff University Brain Imaging Centre, Cardiff, United Kingdom
- University Hospital of Wales, Cardiff, United Kingdom
| | - W Gray
- Cardiff University Brain Imaging Centre, Cardiff, United Kingdom
- University Hospital of Wales, Cardiff, United Kingdom
| | - D Jones
- Cardiff University Brain Imaging Centre, Cardiff, United Kingdom
| | - M Chamberland
- Cardiff University Brain Imaging Centre, Cardiff, United Kingdom
| |
Collapse
|
6
|
Lewis EG, Coles S, Mohammed A, Mkodo J, Gray W, Walker R, Haule I, Dotchin C. 43FRAILTY AND NUTRITION IN OLDER TANZANIANS. Age Ageing 2019. [DOI: 10.1093/ageing/afz075.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- E G Lewis
- The institute of Health and Society, Newcastle University
- Northumbria Healthcare NHS Foundation Trust, Tyne and Wear
| | - S Coles
- The Medical School, Newcastle University, Newcastle upon Tyne
| | - A Mohammed
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - J Mkodo
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - W Gray
- The institute of Health and Society, Newcastle University
| | - R Walker
- The institute of Health and Society, Newcastle University
- Northumbria Healthcare NHS Foundation Trust, Tyne and Wear
| | - I Haule
- Hai District Hospital, Bomang’ombe, Tanzania
| | - C Dotchin
- The institute of Health and Society, Newcastle University
- Northumbria Healthcare NHS Foundation Trust, Tyne and Wear
| |
Collapse
|
7
|
Lewis EG, Wood G, Howorth K, Shah B, Mulligan L, Kissima J, Dotchin C, Gray W, Walker R, Urasa S. 12THE PREVALENCE OF FRAILTY IN OLDER COMMUNITY-DWELLING TANZANIANS BY COMPREHENSIVE GERIATRIC ASSESSMENT. Age Ageing 2018. [DOI: 10.1093/ageing/afy134.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- E G Lewis
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
- Northumbria Healthcare NHS Foundation Trust, United Kingdom
| | - G Wood
- The Medical School, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - K Howorth
- Northumbria Healthcare NHS Foundation Trust, United Kingdom
| | - B Shah
- Northumbria Healthcare NHS Foundation Trust, United Kingdom
| | - L Mulligan
- Northumbria Healthcare NHS Foundation Trust, United Kingdom
| | - J Kissima
- Hai District Hospital, Boma Ngâ-ombe, Hai, Kilimanjaro, Tanzania
| | - C Dotchin
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
- Northumbria Healthcare NHS Foundation Trust, United Kingdom
| | - W Gray
- Northumbria Healthcare NHS Foundation Trust, United Kingdom
| | - R Walker
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
- Northumbria Healthcare NHS Foundation Trust, United Kingdom
| | - S Urasa
- Kilimanjaro Christian Medical Centre, Moshi, Kilimanjaro, Tanzania
| |
Collapse
|
8
|
Putnam H, Jones R, Rogathi J, Gray W, Walker R. 40HYPERTENSIVE END ORGAN DAMAGE IN AN ELDERLY COHORT OF TANZANIANS. Age Ageing 2017. [DOI: 10.1093/ageing/afx110.40] [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
|
9
|
Lewis E, Banks J, Paddick S, Dotchin C, Gray W, Walker R, Urasa S. RISK FACTORS FOR PREVALENT DELIRIUM IN OLDER MEDICAL INPATIENTS IN TANZANIA. Innov Aging 2017. [DOI: 10.1093/geroni/igx004.4685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- E.G. Lewis
- Charite -Universitatsmedizin, Berlin, Germany,
- Education centre/Geriatrics, Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, North Shields, United Kingdom,
| | - J.E. Banks
- The Medical School Newcastle University, Newcastle upon Tyne, United Kingdom,
| | - S. Paddick
- Newcastle University, Newcastle upon Tyne, United Kingdom,
- Education centre/Geriatrics, Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, North Shields, United Kingdom,
| | - C. Dotchin
- Newcastle University, Newcastle upon Tyne, United Kingdom,
- Education centre/Geriatrics, Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, North Shields, United Kingdom,
| | - W. Gray
- Education centre/Geriatrics, Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, North Shields, United Kingdom,
| | - R. Walker
- Newcastle University, Newcastle upon Tyne, United Kingdom,
- Education centre/Geriatrics, Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, North Shields, United Kingdom,
| | - S. Urasa
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania, United Republic of
| |
Collapse
|
10
|
Gray W. Arthur Ivens Spriggs, DM, FRCP, FRCPath b. 12th September 1919, d. 12th December 2015. Cytopathology 2016; 27:146-8. [PMID: 27221748 DOI: 10.1111/cyt.12349] [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: 11/30/2022]
Affiliation(s)
- W Gray
- Oxford Radcliffe Hospital, Oxford, UK
| |
Collapse
|
11
|
Smith E, Taylor-Robinson D, Gray W, Foster H, Beresford M. AB0658 Predictors of access to care in JSLE - evidence from the UK JSLE cohort study. Ann Rheum Dis 2013. [DOI: 10.1136/annrheumdis-2012-eular.658] [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: 11/03/2022]
|
12
|
Lim D, Todd M, Kourtoglou N, Gerasimidis K, Gardner-Medwin J, Watson L, Tullus K, Pilkington C, Chesters C, Marks SD, Newland P, Jones C, Beresford MW, O'Neill P, Lee H, Tattersall R, McErlane F, Beresford M, Baildam E, Alice Chieng SE, Davidson J, Foster H, Gardner-Medwin J, Lunt M, Wedderburn LR, Thomson W, Hyrich KL, Kavirayani A, Thyagarajan MS, Ellis J, Helen Strike CNS, Ramanan AV, Coda A, Davidson J, Fowlie P, Walsh J, Carline T, Santos D, Brimlow KW, Rangaraj S, Grant C, Little J, Helen Strike CNS, Hinchcliffe A, Dick A, Ramanan A, Ekdawy D, Nagra G, Camina N, Edgerton J, Choi J, Lamb K, Hawley D, Rangaraj S, Cruikshank M, Sen E, Pain C, Leone V, Cruikshank M, Walsh J, Tattersall R, Hawley D, Dunkley L, Lee H, McMahon AM, Bale P, Armon K, Amin T, Wood M, Davies R, Southwood TR, Kearsley-Fleet L, Hyrich KL, Kearsley-Fleet L, Baildam E, Beresford M, Davies R, Foster HE, Mowbray K, Southwood TR, Thomson W, Hyrich KL, Agarwal M, Kavirayani A, Ramanan AV, Ellis J, Smith E, Gray W, Taylor-Robinson D, Foster HE, Beresford MW, Morgan T, Watson L, Beresford MW, Gohar F, Watson L, Beresford MW, Artim-Esen B, Radziszewska A, Pericleous C, Rahman A, Giles I, Ioannou Y, Jashek D, Mosley E, Rangaraj S, Moraitis E, Arnold K, Pilkington C, Russell NJ, Roderick M, Ramanan A, Roderick M, Russell N, Ramanan AV, Smith NSM, Wilson N, Gardner-Medwin J, Sen E, Chan M, Hardy E, Rapley T, Hensman P, Wraith JE, Foster H, Clarkson J, Gardner-Medwin J, Choudhery V, McVitty C, Davidson J, Hughes DH, Martin N, Warrier K, Sen E, Abinun M, Jandial S, O'Leary D, Staunton D, Lowry C, McSweeney N, Sen E, Abinun M, Friswell M, Foster H, Walsh A, Lowry C, Raja A. BSPAR ANNUAL CONFERENCE ABSTRACTS * Oral presentations * O1. The impact of modern management on outcomes of JIA compared with healthy controls. Rheumatology (Oxford) 2012. [DOI: 10.1093/rheumatology/ket116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
13
|
Lim D, Todd M, Kourtoglou N, Gerasimidis K, Gardner-Medwin J, Watson L, Tullus K, Pilkington C, Chesters C, Marks SD, Newland P, Jones C, Beresford MW, O'Neill P, Lee H, Tattersall R, McErlane F, Beresford M, Baildam E, Alice Chieng SE, Davidson J, Foster H, Gardner-Medwin J, Lunt M, Wedderburn LR, Thomson W, Hyrich KL, Kavirayani A, Thyagarajan MS, Ellis J, Helen Strike CNS, Ramanan AV, Coda A, Davidson J, Fowlie P, Walsh J, Carline T, Santos D, Brimlow KW, Rangaraj S, Grant C, Little J, Helen Strike CNS, Hinchcliffe A, Dick A, Ramanan A, Ekdawy D, Nagra G, Camina N, Edgerton J, Choi J, Lamb K, Hawley D, Rangaraj S, Cruikshank M, Sen E, Pain C, Leone V, Cruikshank M, Walsh J, Tattersall R, Hawley D, Dunkley L, Lee H, McMahon AM, Bale P, Armon K, Amin T, Wood M, Davies R, Southwood TR, Kearsley-Fleet L, Hyrich KL, Kearsley-Fleet L, Baildam E, Beresford M, Davies R, Foster HE, Mowbray K, Southwood TR, Thomson W, Hyrich KL, Agarwal M, Kavirayani A, Ramanan AV, Ellis J, Smith E, Gray W, Taylor-Robinson D, Foster HE, Beresford MW, Morgan T, Watson L, Beresford MW, Gohar F, Watson L, Beresford MW, Artim-Esen B, Radziszewska A, Pericleous C, Rahman A, Giles I, Ioannou Y, Jashek D, Mosley E, Rangaraj S, Moraitis E, Arnold K, Pilkington C, Russell NJ, Roderick M, Ramanan A, Roderick M, Russell N, Ramanan AV, Smith NSM, Wilson N, Gardner-Medwin J, Sen E, Chan M, Hardy E, Rapley T, Hensman P, Wraith JE, Foster H, Clarkson J, Gardner-Medwin J, Choudhery V, McVitty C, Davidson J, Hughes DH, Martin N, Warrier K, Sen E, Abinun M, Jandial S, O'Leary D, Staunton D, Lowry C, McSweeney N, Sen E, Abinun M, Friswell M, Foster H, Walsh A, Lowry C, Raja A. BSPAR ANNUAL CONFERENCE ABSTRACTS * Oral presentations * O1. The impact of modern management on outcomes of JIA compared with healthy controls. Rheumatology (Oxford) 2012. [DOI: 10.1093/rheumatology/kes277] [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: 11/12/2022] Open
|
14
|
Brown L, Arthur A, Lynch B, Gray W, Zumwalt N, Goodloe J, Dixon J, Thomas S. 271 Impact of Nursing Short-Staffing and Emergency Department Left Without Being Seen. Ann Emerg Med 2012. [DOI: 10.1016/j.annemergmed.2012.06.249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
15
|
Howard G, Roubin G, Hopkins LN, Moore W, Gray W, Rosenfield K, Katzen B, Chakhtoura E, Morrish W, Ferguson R, Hye R, Shawl F, Harrigan M, Voeks J, Lal B, Meschia J, Brott T. Did Carotid Stenting and Endarterectomy Outcomes Change over Time in the Carotid Revascularization Endarterectomy Versus Stenting Trial? (S09.005). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.s09.005] [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
|
16
|
|
17
|
|
18
|
Anshu, Herbert A, Cochand-Priollet B, Cross P, Desai M, Dina R, Duskova J, Evered A, Farnsworth A, Gray W, Gupta SS, Kapila K, Kardum-Skelin I, Kloboves-Prevodnik V, Kobayashi TK, Koutselini H, Olszewski W, Onal B, Pitman MB, Marinsek Z, Sauer T, Schenck U, Schmitt F, Shabalova I, Smith JHF, Tani E, Vass L, Vielh P, Wiener H. Survey of medical training in cytopathology carried out by the journal Cytopathology. Cytopathology 2010; 21:147-56. [PMID: 20482722 DOI: 10.1111/j.1365-2303.2010.00761.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
This report of the Editorial Advisory Board of Cytopathology gives the results of a survey of medical practitioners in cytopathology, which aimed to find out their views on the current situation in undergraduate and postgraduate training in their institutions and countries. The results show that training in cytopathology and histopathology are largely carried out at postgraduate level and tend to be organized nationally rather than locally. Histopathology was regarded as essential for training in cytopathology by 89.5% of respondents and was mandatory according to 83.1%. Mandatory cytopathology sections of histopathology were reported by 67.3% and specific examinations in cytopathology by 55.4%. The main deficiencies in training were due to its variability; there were insufficient numbers of pathologists interested in cytology and a consequent lack of training to a high level of competence. Pathologists without specific training in cytopathology signed out cytology reports according to 54.7% of responses, more often in centres where training was 3-6 months or less duration. Although 92.2% of respondents thought that specialist cytology should not be reported by pathologists without experience in general cytopathology, that practice was reported by 30.9%, more often in centres with small workloads. The survey report recommends that 6-12 months should be dedicated to cytopathology during histopathology training, with optional additional training for those wanting to carry out independent practice in cytopathology. Formal accreditation should be mandatory for independent practice in cytopathology. When necessary, temporary placements to centres of good practice should be available for trainees intending to practise independently in cytopathology. There should be adequate numbers of pathologists trained in cytopathology to a high level of competence; some of their time could be released by training cytotechnologists and trainee pathologists to prescreen cytology slides and assess adequacy of fine-needle aspiration samples when immediate diagnosis was not required. The survey demonstrated a clear need for European and international guidelines for training in cytopathology.
Collapse
Affiliation(s)
- Anshu
- Mahatma Gandhi Institute of Medical Sciences, Sevagram, India
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Myers C, Gray W. Scan pattern adaptations to repeated visual search. J Vis 2010. [DOI: 10.1167/8.6.107] [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: 11/24/2022] Open
|
20
|
Keoghane SR, Raslan F, Gray W, Charnock FM. A new approach to Nd: YAG sidefire laser in the uterus: In vitro studies. MINIM INVASIV THER 2009. [DOI: 10.3109/13645709509152783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
21
|
Merriman H, Martingale P, Charnock FM, Gray W. The Role of Cervical Cytology in the Detection of Adenocarcinoma and Glandular Intraepithelial Neoplasia of the Cervix –A Retrospective Study. J OBSTET GYNAECOL 2009. [DOI: 10.3109/01443619509020699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
22
|
Herbert A, Gray W, Cross P. Terminology of the BSCC, European Community and the Bethesda system: the boundary between low-grade and high-grade cytology. Cytopathology 2009; 20:3-4. [PMID: 19133066 DOI: 10.1111/j.1365-2303.2008.00637.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
23
|
Gray W, Bayer-Pietsch E, Chieco P, Cochand Priollet B, Desai M, Drijkoningen M, Griffin M, Hagmar B, Kapila K, Kloboves-Prevodnik V, Kobayashi T, Krogerus L, Majak B, Mihailovici M, Olszewski W, Schenck U, Schmitt F, Shabalova I, Shapiro N, Smith J, Tani E, Totsch M, Vass L, Wiener H, Herbert A. The future of cytopathology in Europe. Will the wider use of HPV testing have an impact on the provision of cervical screening? Cytopathology 2007; 18:278-82. [DOI: 10.1111/j.1365-2303.2007.00487.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
24
|
Scheinert D, Graziani L, Peeters P, Bosiers M, O'Sullivan G, Sultan S, Gray W, Laird J, Turco M, Dave R, Das T, Piemonte T, Khanna P, Gershony G. Results from the multi-center registry of the novel AngioSculpt scoring balloon catheter for the treatment of infra-popliteal disease. Cardiovascular Revascularization Medicine 2007. [DOI: 10.1016/j.carrev.2007.03.163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
25
|
Gray W. Cytopathology in Europe: on seeing what the neighbours do. Cytopathology 2005; 16:167. [PMID: 16048502 DOI: 10.1111/j.1365-2303.2005.00276.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
26
|
Canfell K, Gray W, Snijders P, Murray C, Tipper S, Drinkwater K, Beral V. Factors predicting successful DNA recovery from archival cervical smear samples. Cytopathology 2004; 15:276-82. [PMID: 15456416 DOI: 10.1111/j.1365-2303.2004.00164.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Polymerase chain reaction (PCR)-based DNA testing of archival cervical smear slides is a useful method of retrospectively establishing the presence of the human papillomavirus (HPV) in cervical cells. A cellular DNA recovery test is performed in parallel to HPV DNA testing to ensure that sufficient cells are present and purification of sample DNA has been successfully performed. Previous studies have not comprehensively assessed DNA recovery rates in slides older than 13 years. We undertook a study to determine the factors impacting DNA recovery in 436 UK slides dating from 11 to 33 years prior to testing. Overall, a low cellular DNA recovery success rate of 29% was obtained but a strong trend was observed with increasing recovery rates the older the slides (P < 0.001). Recovery rates increased from 22% in the most recent slides collected from 1988 to 1992, to 61% in the oldest slides, collected in 1970-72. It is likely that fixation compounds incorporating acetic acid, introduced in the UK through the 1980s, have compromised subsequent attempts at PCR amplification. These findings emphasize the importance of the original fixation method in the success of DNA recovery from archival smear samples.
Collapse
Affiliation(s)
- K Canfell
- Polartechnics, Sydney, NSW 2011, Australia.
| | | | | | | | | | | | | |
Collapse
|
27
|
Sullivan P, Taylor R, Ord R, Wolf J, Gray W, VanEcho D, Kwok Y, Suntharalingam M. Long-term survival and functional quality of life assessments in patients with locally advanced unresectable squamous cell carcinomas of the head and neck treated with concurrent chemoradiation. Int J Radiat Oncol Biol Phys 2004. [DOI: 10.1016/j.ijrobp.2004.07.434] [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: 10/26/2022]
|
28
|
Williams SM, Gray W, Gleeson FV. Macroscopic assessment of pulmonary fine needle aspiration biopsies: correlation with cytological diagnostic yield. Br J Radiol 2002; 75:28-30. [PMID: 11806955 DOI: 10.1259/bjr.75.889.750028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Fine needle aspiration biopsy (FNAB) is widely used in the diagnosis of pulmonary neoplasia. Previous studies have advocated the use of immediate cytological review at the time of biopsy to reduce the number of needle passes performed, whilst stating that in the absence of this, simple macroscopic assessment of sample quality was used. This latter practice is widespread, but there is no data regarding its accuracy or the level of intra-observer consistency. We assessed the degree of correlation between a macroscopic grading of the FNAB sample at the time of lung biopsy by the radiologist performing the procedure and subsequent diagnostic yield. 45 consecutive patients in whom pulmonary neoplastic disease was strongly suspected were included. Macroscopic sample appearances were graded on a five-point scale from 1 (blood with no particulate material) to 5 (solid tissue pieces). The positivity rate increased stepwise along with macroscopic grading from 50% for samples graded 1 to 100% for samples graded 5. Grouping the predominately haemorrhagic samples (graded 1-2) together and comparing them with the particulate samples (graded 3-5) demonstrates a statistically significant difference in diagnostic yield (p<0.001). This small study shows that a simple macroscopic grading of pulmonary FNAB samples can provide a good indication of likely cytological diagnostic yield and that radiologists can develop a degree of consistency in their assessment. In the absence of direct cytological input, this may provide a basis for decisions on the number of passes performed.
Collapse
Affiliation(s)
- S M Williams
- Department of Radiology, Churchill Hospital, Old Road, Headington, Oxford OX3 7LJ, UK
| | | | | |
Collapse
|
29
|
Abstract
STUDY OBJECTIVES Pleural fluid cytology and non-image-guided Abrams or Cope biopsies have sensitivities of approximately 30% for detecting malignant mesothelioma, and thoracoscopic biopsy has a sensitivity of approximately 90%. The difference between these two probably relates to obtaining adequate tissue. The use of immunohistochemical stains allows a firm diagnosis to be made from relatively small samples. This study explores whether percutaneous image-guided cutting needle biopsy (CNB) combined with immunohistochemistry is accurate in diagnosing pleural thickening due to mesothelioma. DESIGN Retrospective review of image-guided CNB of pleural thickening performed on consecutive patients over 7 years by a single radiologist. SETTING Teaching hospital chest radiology department. PATIENTS Twenty-one adult patients with a final diagnosis of malignant mesothelioma were identified from 53 consecutive patients who underwent percutaneous image-guided CNB. All 21 patients had pleural thickening identified on contrast-enhanced CT, and all had a final histologic diagnosis of mesothelioma confirmed by postmortem examination or thoracoscopy. INTERVENTIONS Fourteen-gauge and 18-gauge cutting needles were used. Biopsy guidance was by ultrasound in 6 patients and by CT in 15 patients. MEASUREMENTS AND RESULTS A correct histologic diagnosis of malignant mesothelioma was made by CNB in 18 patients (86% sensitivity and 100% specificity). Complications included one chest wall hematoma and a small hemoptysis. Four patients with a pleural thickness of < or = 5 mm underwent biopsy, and all specimens were diagnostic for mesothelioma. CONCLUSIONS Image-guided percutaneous CNB of pleural thickening is a safe procedure, with 86% sensitivity for detecting malignant mesothelioma. Pleural thickening of < or = 5 mm may be successfully sampled.
Collapse
Affiliation(s)
- R F Adams
- Oxford Center for Respiratory Medicine, Churchill Hospital, Oxford, UK
| | | | | | | |
Collapse
|
30
|
Abstract
CLINICAL SUPERVISION has been adopted as a professional function in many of the specialties of nursing, for example, mental health nursing ( Mahood et al 1998 ), palliative care nursing ( Jones 1997 ), and practice nursing ( Cooke et al 1997 ). However, while many definitions and descriptions of its structure and functions are offered in the literature, there appears to be little overall consensus. The relationships between management supervision and clinical supervision are rarely discussed, and when they are, the emphasis is on the importance of clinical supervision operating independently from management control ( UKCC 1996 ).
Collapse
Affiliation(s)
- W Gray
- Critical Care High Dependency Unit (Neurosurgery), Hull Royal Infirmary, Hull
| |
Collapse
|
31
|
Gladman B, Kavelaars JJ, Holman M, Nicholson PD, Burns JA, Hergenrother CW, Petit JM, Marsden BG, Jacobson R, Gray W, Grav T. Discovery of 12 satellites of Saturn exhibiting orbital clustering. Nature 2001; 412:163-6. [PMID: 11449267 DOI: 10.1038/35084032] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The giant planets in the Solar System each have two groups of satellites. The regular satellites move along nearly circular orbits in the planet's orbital plane, revolving about it in the same sense as the planet spins. In contrast, the so-called irregular satellites are generally smaller in size and are characterized by large orbits with significant eccentricity, inclination or both. The differences in their characteristics suggest that the regular and irregular satellites formed by different mechanisms: the regular satellites are believed to have formed in an accretion disk around the planet, like a miniature Solar System, whereas the irregulars are generally thought to be captured planetesimals. Here we report the discovery of 12 irregular satellites of Saturn, along with the determinations of their orbits. These orbits, along with the orbits of irregular satellites of Jupiter and Uranus, fall into groups on the basis of their orbital inclinations. We interpret this result as indicating that most of the irregular moons are collisional remnants of larger satellites that were fragmented after capture, rather than being captured independently.
Collapse
Affiliation(s)
- B Gladman
- Observatoire de la Côte d'Azur, B.P. 4229, 06304 Nice Cedex 4, France.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Purdy JC, Harris D, Austin GL, Seed AW, Gray W. A case study of orographic rainfall processes incorporating multiscaling characterization techniques. ACTA ACUST UNITED AC 2001. [DOI: 10.1029/2000jd900622] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
33
|
Abstract
The aim of this study was to determine whether or not the use of medical pre-treatment of the endometrium improves the outcome of transcervical resection of the endometrium with regards to long-term operative outcome, histological findings and patient satisfaction. A prospective randomized trial comparing three endometrial pre-treatment agents (danazol, medroxyprogesterone acetate or nafarelin) with no pre-treatment was conducted. The main outcome measures were: (i) thickness of the endometrium and myometrium resected; (ii) histological stage of the endometrium at the time of operation; (iii) the presence or absence of menses and (iv) patient satisfaction 1 year post-operatively. Of the three pre-treatments studied, danazol produced a lower median endometrial thickness than the control, showed the greatest ability to induce atrophy of the endometrial glands and stroma (not statistically significant) and produced the highest rate of amenorrhoea (not different to the control). Danazol and nafarelin produced significantly lower median endometrial thickness than no pre-treatment. There were, however, no significant differences in the rates of amenorrhoea in any of the pre-treatment groups compared with that in the control group. No improvement in clinical outcome or patient satisfaction is conferred by the use of medical pre-treatments if transcervical resection of the endometrium is performed in the proliferative phase of the menstrual cycle.
Collapse
Affiliation(s)
- V S Rai
- Department of Obstetrics and Gynaecology, and Department of Cellular Pathology, John Radcliffe Hospital, Headington, Oxford, UK.
| | | | | |
Collapse
|
34
|
Yfantis HG, Drachenberg CB, Gray W, Papadimitriou JC. Angiectatic nasal polyps that clinically simulate a malignant process: report of 2 cases and review of the literature. Arch Pathol Lab Med 2000; 124:406-10. [PMID: 10705395 DOI: 10.5858/2000-124-0406-anptcs] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Approximately 5% of inflammatory or allergic sinonasal polyps develop extensive vascular proliferation and ectasia with deposition of pseudoamyloid. These so-called angiectatic nasal polyps (ANPs) can grow rapidly and exhibit an aggressive clinical behavior that could simulate malignancy preoperatively. OBJECTIVE To systematically address the differential histologic diagnosis of ANPs. METHODS We evaluated by light microscopy, immunohistochemistry, and electron microscopy biopsy and resection specimens from 2 large ANPs (8 and 10 cm in diameter) that presented in 2 adult men with life-threatening epistaxis and facial deformity, respectively. RESULTS The tumors were firm, lobulated, and covered by smooth, partially ulcerated mucosa. Histologically, clusters of dilated, thin-walled blood vessels embedded in pools of Congo red-negative eosinophilic material, associated with patchy necrosis and atypical stromal spindle cells, were seen. Electron microscopy and immunohistochemistry (CD34, factor VIII) confirmed the endothelial nature of the cells lining the spaces, whereas the atypical stromal cells were classified as myofibroblasts. CONCLUSIONS These 2 cases represent extreme examples of ANPs that clinically simulate a malignant process. Awareness of the histological features of ANPs should prevent confusion of such lesions with other vascular or spindle cell lesions of the nasopharynx that would require different treatment and carry a different prognosis.
Collapse
Affiliation(s)
- H G Yfantis
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | | |
Collapse
|
35
|
Abstract
Xanthoma disseminatum (XD) is a rare mucocutaneous xanthomatosis classified as a benign form of non-Langerhans' cell histiocytosis. The case history is presented of a 61 year old woman with XD who developed dyspnoea and spirometric features of airflow obstruction. Bronchoscopy and computed tomography confirmed involvement of the large and medium sized bronchi and she subsequently died from acute respiratory failure. The post-mortem findings and the importance of respiratory tract disease in this unusual condition are discussed.
Collapse
Affiliation(s)
- C W Davies
- Osler Chest Unit, Churchill Hospital, Oxford Radcliffe Trust, Oxford OX3 7LJ, UK
| | | | | | | | | | | |
Collapse
|
36
|
Davies CW, Juniper MC, Gray W, Gleeson FV, Chapel HM, Davies RJ. Lymphoid interstitial pneumonitis associated with common variable hypogammaglobulinaemia treated with cyclosporin A. Thorax 2000; 55:88-90. [PMID: 10607809 PMCID: PMC1745598 DOI: 10.1136/thorax.55.1.88] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.8] [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: 11/04/2022]
Abstract
Lymphoid interstitial pneumonitis (LIP) is a rare clinicopathological entity that may be associated with common variable immune deficiency (CVID) and may lead to respiratory failure and death. Some patients may respond to prolonged corticosteroid treatment. We hypothesised that, in view of the predominant T cell nature of LIP, cyclosporin A would be a more appropriate choice of immunosuppressive agent and report the first case of its successful use in a woman with LIP associated with CVID.
Collapse
Affiliation(s)
- C W Davies
- Osler Chest Unit, Churchill Hospital, Oxford Radcliffe Trust, Oxford OX3 7LJ, UK
| | | | | | | | | | | |
Collapse
|
37
|
Abstract
Two cases of disappearing or spontaneous regression of pulmonary metastases on CT are presented. In both cases, cytological proof was obtained by radiologically guided fine needle aspiration. The lesions subsequently regressed on follow-up CT studies without recognized systemic treatment.
Collapse
Affiliation(s)
- S J Wadsworth
- Radiology Department, Churchill Hospital, Oxford, UK
| | | | | | | |
Collapse
|
38
|
Abstract
Ecdysis behavior in the tobacco hornworm Manduca sexta (Lepidoptera: Sphingidae) is triggered through reciprocal peptide signaling between the central nervous system and the epitracheal endocrine system. Recent evidence indicates that eclosion hormone may initiate endocrine events leading to ecdysis through its action on epitracheal glands to cause the release of ecdysis-triggering hormone (ETH). Here, we report that direct exposure of epitracheal glands to eclosion hormone in vitro leads to secretion of ETH. The threshold concentration of eclosion hormone needed to evoke release of ETH is approximately 3 pmol l-1. Eclosion hormone also induces elevation of cyclic GMP, but not cAMP, concentration in epitracheal glands at concentrations similar to those causing release of ETH. Both cGMP and 8-Br-cGMP mimic the secretory action of eclosion hormone. The sensitivity of the secretory response to eclosion hormone occurs during a narrow window of development, beginning approximately 8 h prior to pupal ecdysis. However, eclosion hormone can cause elevation of cGMP levels in epitracheal glands long before they acquire competence to release ETH, showing that the initial portion of the signal transduction cascade is in place early in development, but that the absence of a downstream step in the cascade prevents secretion. Measurements of cGMP levels in epitracheal glands during the ecdysis sequence show a sudden elevation some 30 min after the onset of pre-ecdysis, well after ETH secretion has been initiated. ETH secretion can therefore be viewed as a two-step process, beginning at pre-ecdysis when cGMP levels are relatively low, followed by a massive release resulting from a logarithmic elevation of cGMP levels.
Collapse
Affiliation(s)
- T G Kingan
- Department of Entomology, University of California, Riverside, CA 92521, USA.
| | | | | | | |
Collapse
|
39
|
Conley B, Jacobs M, Suntharalingam M, Zacharski D, Ord RA, Gray W, Aisner J. A pilot trial of paclitaxel, carboplatin, and concurrent radiotherapy for unresectable squamous cell carcinoma of the head and neck. Semin Oncol 1997; 24:S2-78-S2-80. [PMID: 9045343] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Combined chemoradiotherapy is superior to radiotherapy alone for stage III and IV squamous cell carcinoma of the head and neck, and concurrent use of both offers the advantage of synergistic interactions. Our prior trial demonstrated the ease and convenience of administering carboplatin during radiotherapy. Since paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) has activity in squamous cell carcinoma of the head and neck and can act synergistically with both radiotherapy and platinum drugs, we initially added paclitaxel at 45 mg/m2/wk to carboplatin given at 100 mg/m2 during radiotherapy given at conventional fractions. The initial dose of paclitaxel was subsequently reduced to 40 mg/m2/wk. Thirteen of 18 patients entered so far have sufficient follow-up data; 12 are assessable for toxicity and 11 are assessable for response. One died early of progressive disease, two achieved a complete response, six achieved a partial response, and two had stable disease. Toxicities have so far been manageable for the 76 weekly doses administered. Chemotherapy dose reduction was needed in 10 patients. For the planned 100 doses of chemotherapy, 53 (53%) were administered as planned, 23 (23%) were reduced, and 24 (24%) were withheld due to neutropenia or mucositis. There were no toxic deaths, and no patient stopped therapy for toxicity. Paclitaxel/carboplatin can be administered during radiotherapy for squamous cell carcinoma of the head and neck with acceptable toxicities, and further accrual is needed to evaluate the effect of this combination.
Collapse
Affiliation(s)
- B Conley
- Department of Medicine, University of Maryland School of Medicine, USA
| | | | | | | | | | | | | |
Collapse
|
40
|
Affiliation(s)
- W Gray
- University Department of Clinical Neurosciences, Wessex Neurological Centre, Southampton, UK.
| | | | | | | | | |
Collapse
|
41
|
Herrington CS, Evans MF, Charnock FM, Gray W, O'D McGee J. HPV testing in patients with low grade cervical cytological abnormalities: a follow up study. J Clin Pathol 1996; 49:493-6. [PMID: 8763265 PMCID: PMC500541 DOI: 10.1136/jcp.49.6.493] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
AIM To assess the diagnostic performance of human papillomavirus (HPV) analysis in predicting cervical intraepithelial neoplasia (CIN) grades 2 and 3 in patients with persistent low grade cervical cytological abnormalities. METHODS Cervical smears from 167 women referred for colposcopy with persistent borderline, wart virus or mildly dyskaryotic changes on cervical screening were analysed by Papanicolaou staining, non-isotopic in situ hybridisation and generic and type specific polymerase chain reaction (PCR) amplification of HPV sequences. Follow up was by cytological and, where appropriate, histological analysis. RESULTS CIN grade 2 or 3 was identified in 46 patients after a median follow up of 27 months. HPV positivity by both techniques was associated with high grade CIN and with age less than 30 years (median age 33 years). Non-isotopic in situ hybridisation was more predictive but less sensitive than either generic or type specific PCR, but prediction was greater using either molecular technique in women over 30 years of age. CONCLUSIONS Although the degree of prediction found is of only limited clinical value, the strong association of HPV positivity with both high grade CIN and patient age suggests that further studies of HPV testing in this patient group are warranted.
Collapse
Affiliation(s)
- C S Herrington
- Nuffield Department of Pathology and Bacteriology, University of Oxford
| | | | | | | | | |
Collapse
|
42
|
Herrington CS, Evans MF, Gray W, McGee JO. Morphological correlation of human papillomavirus infection of matched cervical smears and biopsies from patients with persistent mild cervical cytological abnormalities. Hum Pathol 1995; 26:951-5. [PMID: 7672795 DOI: 10.1016/0046-8177(95)90083-7] [Citation(s) in RCA: 4] [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: 01/26/2023]
Abstract
Human papillomavirus (HPV) analysis of cytological material has been advocated for determining those patients with low-grade cervical cytological abnormalities who have current high-grade squamous intraepithelial lesions (SILs). In this study, we analyzed concurrent cervical smears and biopsies from 167 patients with Papanicolaou (Pap) smears showing persistent atypical squamous cells of uncertain significance (ASCUS) or low grade SILs (1) to compare the detection of HPV by nonisotopic in situ hybridization (NISH) on matched smears and biopsies; (2) to analyze the type and distribution of NISH signal within lesions; and (3) to define further the ability of NISH techniques to distinguish between patients with low- and high-grade SIL. Whether present in cervical smears or biopsies, high-risk HPV types (16, 18, 31, 33, and related types) were significantly associated with high-grade SILs (P < .001) but were found in 15% of low-grade SILs. Ninety percent of high grade lesions were directly infected by these HPV types, and good concordance (92.2%) was found between NISH analysis of matched cervical smears and biopsies, indicating accurate colposcopic targetting of biopsies and excision specimens. Punctate signal morphology, which correlates with viral integration, was associated with high-grade SILs but was also observed in two low-grade SILs. Although the presence of high-risk HPV types in low-grade SILs limits the predictive ability of HPV testing by this means in this group of patients, those patients with high-risk HPV infection of low-grade SILs may be a greater risk of progression to high-grade SIL or invasive carcinoma. If this were the case, HPV testing would be of potential value in the management of patients with low-grade cytological abnormalities.
Collapse
Affiliation(s)
- C S Herrington
- University of Oxford, Nuffield Department of Pathology and Bacteriology, England, UK
| | | | | | | |
Collapse
|
43
|
Abstract
Cytomegalovirus (CMV) colitis may cause symptoms and signs identical to those of idiopathic inflammatory bowel disease. Although difficult to diagnose with certainty, the histological finding of cytomegalovirus inclusions in tissue from a case of suspected inflammatory bowel disease is strongly suggestive. CMV colitis is an entity almost entirely confined to cases of severe immunosuppression. The case of a 79 year old widower who was admitted to hospital with symptoms suggestive of inflammatory bowel disease is presented. Despite medical treatment his condition worsened and he developed toxic dilatation of the colon requiring colectomy. Histological examination showed a mild superficial pancolitis, with focal severe inflammation, deep fissuring ulceration, and pseudopolyposis. Abundant CMV inclusions were seen in cells associated with the ulcerating inflammatory tissue. A diagnosis of indeterminate colitis with CMV was made. The patient's condition worsened after surgery and he died a few days later despite intensive treatment, including antiviral chemotherapy directed against CMV. After death HIV serology was found to be positive. Regardless of the age and perceived lifestyle of the patient, a diagnosis of CMV colitis in someone not known to be immunosuppressed raises the possibility of HIV infection.
Collapse
|
44
|
Leidich SD, Kostova Z, Latek RR, Costello LC, Drapp DA, Gray W, Fassler JS, Orlean P. Temperature-sensitive yeast GPI anchoring mutants gpi2 and gpi3 are defective in the synthesis of N-acetylglucosaminyl phosphatidylinositol. Cloning of the GPI2 gene. J Biol Chem 1995; 270:13029-35. [PMID: 7768896 DOI: 10.1074/jbc.270.22.13029] [Citation(s) in RCA: 102] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
To identify genes required for the synthesis of glycosyl phosphatidylinositol (GPI) membrane anchors in yeast, we devised a way to isolate GPI anchoring mutants in which colonies are screened for defects in [3H]-inositol incorporation into protein. The gpi1 mutant, identified in this way, is temperature sensitive for growth and defective in vitro in the synthesis of GlcNAc-phosphatidylinositol, the first intermediate in GPI biosynthesis (Leidich, S. D., Drapp, D. A., and Orlean, P. (1994) J. Biol. Chem. 269, 10193-10196). We report the isolation of two more conditionally lethal mutants, gpi2 and gpi3, which, like gpi1, have a temperature-sensitive defect in the incorporation of [3H]inositol into protein and which lack in vitro GlcNAc-phosphatidylinositol synthetic activity. Haploid Saccharomyces cerevisiae strains containing any pairwise combination of the gpi1, gpi2, and gpi3 mutations are inviable. The GPI2 gene, cloned by complementation of the gpi2 mutant's temperature sensitivity, encodes a hydrophobic 269-amino acid protein that resembles no other gene product known to participate in GPI assembly. Gene disruption experiments show that GPI2 is required for vegetative growth. Overexpression of the GPI2 gene causes partial suppression of the gpi1 mutant's temperature sensitivity, a result that suggests that the Gpi1 and Gpi2 proteins interact with one another in vivo. The gpi3 mutant is defective in the SPT14 gene, which encodes a yeast protein similar to the product of the mammalian PIG-A gene, which complements a GlcNAc-phosphatidylinositol synthesis-defective human cell line. In yeast, at least three gene products are required for the first step in GPI synthesis, as is the case in mammalian cells, and utilization of several different proteins at this stage is therefore likely to be a general characteristic of the GPI synthetic pathway.
Collapse
Affiliation(s)
- S D Leidich
- Department of Biochemistry, University of Illinois at Urbana-Champaign 61801, USA
| | | | | | | | | | | | | | | |
Collapse
|
45
|
Aisner J, Hiponia D, Conley B, Jacobs M, Gray W, Belani CP. Combined modalities in the treatment of head and neck cancers. Semin Oncol 1995; 22:28-34. [PMID: 7541154] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The higher the T and N stages at diagnosis of head and neck cancer, the lower the proportion of patients who achieve complete, durable local control and the lower the survival. These cancers and their treatments often produce considerable anatomic distortion, affecting function, nutritional status, and appearance. New treatment approaches for locally and regionally advanced head and neck cancers are thus needed to improve survival, quality of life, or both. Combined-modality approaches show promise. Induction chemotherapy and subsequent radiotherapy produce results equivalent to aggressive surgery but allow for better organ function and speech. Induction chemotherapy and radiotherapy are superior to radiotherapy alone. Concurrent chemotherapy and radiotherapy may produce additive or synergistic interactions but increase toxicities. Some studies suggest that concurrent chemotherapy and radiotherapy significantly improves survival over radiotherapy alone in regionally advanced disease. Drug selection criteria have included enhancement of radiation cytotoxicity, effect on cellular kinetics, and, possibly, single-agent antitumor activity. The platinum compounds are of interest, especially in combination with other chemotherapy agents, like 5-fluorouracil and paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ). Concurrent carboplatin and radiotherapy produced a 77-week duration of survival in responders in a University of Maryland Cancer Center study. A study of concurrent carboplatin/bleomycin/radiotherapy had to be halted because of severe bleomycin-induced mucositis. The results in this small group suggest that attenuating mucositis would be desirable. In a subsequent trial, paclitaxel, which shows considerable activity against head and neck cancers, was substituted for bleomycin. Data from the seven patients accrued thus far are too immature to define response. The study continues to accrue patients.
Collapse
Affiliation(s)
- J Aisner
- University of Maryland Cancer Center, Baltimore, USA
| | | | | | | | | | | |
Collapse
|
46
|
Herrington CS, Evans MF, Hallam NF, Charnock FM, Gray W, McGee JD. Human papillomavirus status in the prediction of high-grade cervical intraepithelial neoplasia in patients with persistent low-grade cervical cytological abnormalities. Br J Cancer 1995; 71:206-9. [PMID: 7819041 PMCID: PMC2033453 DOI: 10.1038/bjc.1995.42] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
The role of human papillomavirus (HPV) detection in the management of patients with persistent low-grade (mild dyskaryosis or less) cervical cytological abnormalities is unclear. We have analysed cytological material from 167 such patients both cytologically and by non-isotopic in situ hybridisation (NISH) for HPV 16, 18, 31 and 33 and consensus primer polymerase chain reaction (PCR) amplification followed by both generic and specific typing for these HPV types. Cervical intraepithelial neoplasia (CIN) 2 or 3 was present in 40 of 167 patients (23.9%), and the positive predictive values (PPVs) for the presence of CIN 2 or 3, of moderate or severe dyskaryosis at repeat cytology and an HPV-positive NISH and generic PCR signal were 100%, 66% and 42% respectively. The corresponding sensitivities were 48%, 68% and 87%. Addition of cytology to molecular analysis improved both PPV and sensitivity, the best combination being NISH and cytopathology (PPV 71%, sensitivity 87%). These data demonstrate that the presence of CIN 2 or 3 in patients with mild cytological abnormalities can be predicted by molecular detection of HPV in some cases, particularly when combined with cytological analysis. However, the magnitude of this prediction is dependent on the population of patients studied, and the clinical role of this approach therefore remains to be defined.
Collapse
Affiliation(s)
- C S Herrington
- University of Oxford, Nuffield Department of Pathology and Bacteriology, UK
| | | | | | | | | | | |
Collapse
|
47
|
Aisner J, Jacobs M, Sinabaldi V, Gray W, Eisenberger M. Chemoradiotherapy for the treatment of regionally advanced head and neck cancers. Semin Oncol 1994; 21:35-44. [PMID: 7992065] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Despite the use of aggressive surgery and radiotherapy, patients with locoregionally advanced squamous cell carcinoma of the head and neck continue to suffer poor local control and poor survival. Chemotherapy produces excellent regressions of locoregional disease when given as part of initial induction therapy. The use of chemoradiotherapy for regionally advanced disease offers the possibility of organ preservation and retention of organ function for many of these patients. Randomized studies have suggested that chemoradiotherapy also offers better local control and survival than radiotherapy alone. Many chemotherapy regimens used in modern chemoradiotherapy include cisplatin. Because of its ease of outpatient administration, lesser degree of nausea and vomiting, reduced nephrotoxicity, improved nutritional status during therapy, and predictable myelotoxicity, carboplatin has important advantages over cisplatin. Carboplatin possesses well-defined single-agent activity against head and neck cancers, and produces excellent responses in combination with 5-fluorouracil in previously untreated patients. Sequential studies at the University of Maryland Cancer Center showed that weekly carboplatin could be safely and easily combined with standard doses and fractions of radiotherapy. With this regimen, 57% of the patients achieved a complete response and 21% achieved a partial response. Although the addition of bleomycin to this regimen proved somewhat toxic, concurrent carboplatin and radiotherapy allows for the further testing of new agents in developing a combination chemotherapy/concurrent radiotherapy program. Such regimens may improve local control and survival, and may be developed further for organ preservation studies.
Collapse
Affiliation(s)
- J Aisner
- University of Maryland Cancer Center, Baltimore
| | | | | | | | | |
Collapse
|
48
|
|
49
|
Abstract
A 29-year-old man presented with nodular skin lesions localized to areas of navy-blue pigmentation within a tattoo. Light microscopy demonstrated well-defined epithelioid granulomata in close relation to blue and black pigment. Although the patient was asymptomatic, a chest X-ray showed bilateral pulmonary shadowing, and histology of a transbronchial biopsy specimen showed features compatible with a diagnosis of sarcoidosis. X-ray energy dispersive spectroscopy identified copper and titanium in the tattoo pigment. These elements were not found in tissue from the lung biopsy. The cutaneous eruption resolved with oral steroid therapy. Our observations suggest that the granulomatous reaction in the tattoo was a manifestation of sarcoidosis, rather than a specific reaction to pigment.
Collapse
Affiliation(s)
- P Collins
- Department of Dermatology, Ninewells Hospital and Medical School, Dundee, Scotland, U.K
| | | | | | | |
Collapse
|
50
|
Mills I, Fallon JT, Wrenn D, Sasken H, Gray W, Bier J, Levine D, Berman S, Gilson M, Gewirtz H. Adaptive responses of coronary circulation and myocardium to chronic reduction in perfusion pressure and flow. Am J Physiol 1994; 266:H447-57. [PMID: 8141345 DOI: 10.1152/ajpheart.1994.266.2.h447] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
We tested the hypothesis that chronic reduction in perfusion pressure and flow in the coronary circulation induces a state of myocardial "hibernation" characterized not only by a steady-state reduction in myocardial O2 consumption (MVO2) but also by evidence of persistent dilator reserve of the distal vasculature. Biochemical and morphological changes in the coronary vasculature were also assessed. Experiments were conducted in swine with an extraluminal coronary stenosis placed 4-32 wk before study. Stenosis reduced lumen diameter by approximately 80% at the time of final experimentation. Baseline, regional myocardial blood flow distal to the stenosis in both endocardial and epicardial layers was reduced vs. that of the normal zone. Vasodilator reserve persisted in both endocardial and epicardial layers of the stenosis zone. Flow increased in each layer in response to adenosine plus phenylephrine and failed to decline despite a marked reduction in perfusion pressure in response to adenosine alone. Regional MVO2 at baseline was reduced vs. historical controls without coronary stenosis. Protein synthesis rate in coronary vessels of the stenosis zone was reduced vs. that of the normal zone. Morphological responses of stenosis zone vessel walls were heterogeneous. Smaller microvessels exhibited mild hypertrophy of their walls, whereas walls of larger microvessels tended to atrophy. Thus chronic reduction in perfusion pressure and flow induces a state of myocardial hibernation characterized by a steady-state reduction in MVO2 in association with persistent dilator capacity. Biochemical and morphological changes occur in microvessel walls and may contribute to observed physiological responses.
Collapse
Affiliation(s)
- I Mills
- Department of Medicine, Rhode Island Hospital
| | | | | | | | | | | | | | | | | | | |
Collapse
|