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Gradidge PJL, Constantinou D, Goldberg L. Sudden cardiac arrest risk in young athletes. SOUTH AFRICAN JOURNAL OF SPORTS MEDICINE 2013. [DOI: 10.17159/2078-516x/2013/v25i2a379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Underlying cardiac abnormalities are the main cause of unexpected death in athletes on field. These abnormalities have been associated with a previous history of syncope, a family history of sudden cardiac arrest (SCA), cardiac murmur, a history of over-exhaustion post exercise and ventricular tachyarrhythmia during physical activity. The timely diagnosis of susceptible athletes may assist with an appropriate management plan for these individuals, and allow for the prevention of premature death in sport. A young football player was screened for SCA risk using the fundamental components of the pre-participation examination (PPE) – essentially, a medical history, a resting and stress electrocardiogram, and an echocardiogram to support clinical findings. The case is submitted with consideration of the applicable literature to accentuate the importance of using PPE to prevent SCA in young athletes.
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Kuehl KS, Elliot DL, Goldberg L, Moe EL, Perrier E, Smith J. Economic benefit of the PHLAME wellness programme on firefighter injury. Occup Med (Lond) 2013; 63:203-9. [PMID: 23416849 DOI: 10.1093/occmed/kqs232] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Work-related injuries and illness are prevalent and costly. Firefighting is especially hazardous and many firefighters sustain work-related injuries. Workplace health promotion programmes have shown positive return on investment (ROI). Little is known about how similar programmes would impact injury and cost among firefighters. AIMS To evaluate the impact of a workplace health promotion intervention on workers' compensation (WC) claims and medical costs among Oregon fire departments participating in the PHLAME (Promoting Healthy Lifestyles: Alternative Models' Effects) health promotion programme compared with Oregon fire departments not participating in PHLAME. METHODS Data from firefighters from four large urban fire departments in Oregon were evaluated using a retrospective quasi-experimental study design. Outcomes were (i) total annual firefighter WC claims, (ii) total annual incurred medical costs prior to and after implementation of the PHLAME firefighter worksite health promotion programme (iii) and an ROI analysis. RESULTS Data were obtained from 1369 firefighters (mean age of 42 years, 91% white, 93% male). WC claims (P < 0.001) and medical costs (P < 0.01) were significantly lower among PHLAME fire departments compared with Oregon fire departments not participating in the programme. Fire departments participating in the PHLAME TEAM programme demonstrated a positive ROI of 4.61-1.00 (TEAM is used to indicate the 12-session peer-led health promotion programme). CONCLUSIONS Fire department WC claims and medical costs were reduced after implementation of the PHLAME workplace health promotion programme. This is a low cost, team-based, peer-led, wellness programme that may provide a feasible, cost-effective means to reduce firefighter injury and illness rates.
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Mendese GW, Beckford A, Krejci N, Mahalingam M, Goldberg L, Gilchrest BA. Pagetoid reticulosis in a prepubescent boy successfully treated with photodynamic therapy. Clin Exp Dermatol 2012; 37:759-61. [DOI: 10.1111/j.1365-2230.2012.04352.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Bernhard CG, Goldberg L. Über die Einwirkung der durch Kohlensäure gesteigerten Atmung auf die Ausscheidung des Methylalkohols beim Kaninchen1. ACTA ACUST UNITED AC 2012. [DOI: 10.1111/j.1748-1716.1934.tb01037.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Molina M, Ticehurst E, Goldberg L, Chojnowski D, Hornsby N, Forfia P. 360 Echo-Doppler Profile of Abnormal Right Ventricular-Pulmonary Arterial Interaction Is Associated with Beneficial Response to Sildenafil in Heart Transplant Recipients with Pulmonary Hypertension. J Heart Lung Transplant 2012. [DOI: 10.1016/j.healun.2012.01.369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Goldberg L, Israeli R, Kloog Y. FTS and 2-DG induce pancreatic cancer cell death and tumor shrinkage in mice. Cell Death Dis 2012; 3:e284. [PMID: 22419113 PMCID: PMC3317504 DOI: 10.1038/cddis.2012.24] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The Ras inhibitor S-trans-trans farnesylthiosalicylic acid (FTS)
inhibits active Ras, which controls cell proliferation, differentiation,
survival, and metabolism. FTS also inhibits HIF1α expression in
cancer cells, leading to an energy crisis. The synthetic glucose analog
2-deoxy-D-glucose (2-DG), which inhibits glycolysis, is selectively directed to
tumor cells that exhibit increased glucose consumption. The 2-DG enters tumor
cells, where it competes with glucose for glycolytic enzymes. In cancer models,
as well as in human phase 1 trials, 2-DG inhibits tumor growth without toxicity.
We postulated that under normoxic conditions, tumor cells treated with FTS would
be more sensitive than normal cells to 2-DG. We show here that combined
treatment with FTS and 2-DG inhibited cancer cell proliferation additively, yet
induced apoptotic cell death synergistically both in vitro and in
vivo. The induced apoptosis was inferred from QVD-OPH inhibition, an
increase in cleaved caspase 3, and loss of survivin. FTS and 2-DG when combined,
but not separately, also induced an increase in fibrosis of the tumor tissue,
chronic inflammation, and tumor shrinkage. Overall, these results suggest a
possible new treatment of pancreatic tumors by the combined administration of
FTS and 2-DG, which together induce pancreatic tumor cell death and tumor
shrinkage under non-toxic conditions.
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Pereira M, Aliotta JM, Amaral A, Dooner M, Goldberg L, Quesenberry PJ. Persistence of microvesicle-induced gene expression changes in murine marrow cells using an in vitro and in vivo model. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.e21086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Goldberg L. Stem cell plasticity and microvesicles. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.e13504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Aliotta JM, Pereira M, Amaral A, Dooner M, Goldberg L, Quesenberry PJ. Microvesicle-mediated transfer of genetic phenotype from lung to marrow cells. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.e21092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Venditti EM, Elliot DL, Faith MS, Firrell LS, Giles CM, Goldberg L, Marcus MD, Schneider M, Solomon S, Thompson D, Yin Z. Rationale, design and methods of the HEALTHY study behavior intervention component. Int J Obes (Lond) 2010; 33 Suppl 4:S44-51. [PMID: 19623189 DOI: 10.1038/ijo.2009.116] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
HEALTHY was a multi-center primary prevention trial designed to reduce risk factors for type 2 diabetes in adolescents. Seven centers each recruited six middle schools that were randomized to either intervention or control. The HEALTHY intervention integrated multiple components in nutrition, physical education, behavior change and communications and promotion. The conceptual rationale as well as the design and development of the behavior intervention component are described. Pilot study data informed the development of the behavior intervention component. Principles of social learning and health-related behavior change were incorporated. One element of the behavior intervention component was a sequence of peer-led, teacher-facilitated learning activities known as FLASH (Fun Learning Activities for Student Health). Five FLASH modules were implemented over five semesters of the HEALTHY study, with the first module delivered in the second semester of the sixth grade and the last module in the second semester of the eighth grade. Each module contained sessions that were designed to be delivered on a weekly basis to foster self-awareness, knowledge, decision-making skills and peer involvement for health behavior change. FLASH behavioral practice incorporated individual and group self-monitoring challenges for eating and activity. Another element of the behavior intervention component was the family outreach strategy for extending changes in physical activity and healthy eating beyond the school day and for supporting the student's lifestyle change choices. Family outreach strategies included the delivery of newsletters and supplemental packages with materials to promote healthy behavior in the home environment during school summer and winter holiday breaks. In conclusion, the HEALTHY behavior intervention component, when integrated with total school food and physical education environmental changes enhanced by communications and promotional campaigns, is a feasible and acceptable mechanism for delivering age-appropriate social learning for healthy eating and physical activity among an ethnically diverse group of middle school students across the United States.
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Adams T, Schutz L, Goldberg L. Platelet function abnormalities in the myeloproliferative disorders. SCANDINAVIAN JOURNAL OF HAEMATOLOGY 2009; 13:215-24. [PMID: 4533155 DOI: 10.1111/j.1600-0609.1974.tb00262.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Kielholz P, Goldberg L, Hobi V, Ladewig D, Miest P, Reggiani G. Zur quantitativen Erfassung psychischer Erlebnisveränderungen unter Delta-9-Tetrahydrocannabinol. PHARMACOPSYCHIATRY 2009. [DOI: 10.1055/s-0028-1094359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Seltzer E, Goldberg L, Krause D, Simoneau D, Boudry E. Dalbavancin safety in the phase 2/3 clinical development program. Crit Care 2008. [PMCID: PMC4088398 DOI: 10.1186/cc6248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Lindberg L, Brauer S, Wollmer P, Goldberg L, Jones AW, Olsson SG. Breath alcohol concentration determined with a new analyzer using free exhalation predicts almost precisely the arterial blood alcohol concentration. Forensic Sci Int 2006; 168:200-7. [PMID: 16978819 DOI: 10.1016/j.forsciint.2006.07.018] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2006] [Revised: 07/02/2006] [Accepted: 07/21/2006] [Indexed: 11/20/2022]
Abstract
A new breath alcohol (ethanol) analyzer has been developed, which allows free exhalation, standardizes measured exhaled alcohol concentration to fully saturated water vapor at a body temperature of 37 degrees C (43.95 mg/L) and includes a built-in self-calibration system. We evaluated the performance of this instrument by comparing standardized alcohol concentration in freely expired breath (BrAC) with arterial (ABAC) and venous (VBAC) blood alcohol concentrations in fifteen healthy volunteers who drank 0.6 g of alcohol per kg body weight. The precision (coefficient of variation, CV) of the analyzer based on in vivo duplicate measurements in all phases of the alcohol metabolism was 1.7%. The ABAC/BrAC ratio was 2251+/-46 (mean+/-S.D.) in the post-absorptive phase and the mean bias between ABAC and BrAC x 2251 was 0.0035 g/L with 95% limits of agreement of 0.033 and -0.026. The ABAC and BrAC x 2251 were highly correlated (r=0.998, p<0.001) and the regression relationship was ABAC = 0.00045 + 1.0069 x (BrAC x 2251) indicating excellent agreement and no fixed or proportional bias. In the absorption phase, ABAC exceeded BrAC x 2251 by at most 0.04+/-0.03 g/L when tests were made at 10 min post-dosing (p<0.05). The VBAC/BrAC ratio never stabilized and varied continuously between 1834 and 3259. There was a proportional bias between VBAC and BrAC x 2251 (ABAC) in the post-absorptive phase (p<0.001). The pharmacokinetic analysis of the elimination rates of alcohol and times to zero BAC confirmed that BrAC x 2251 and ABAC agreed very well with each other, but not with VBAC (p<0.001). We conclude that this new breath analyzer using free exhalation has a high precision for in vivo testing. The BrAC reflects very accurately ABAC in the post-absorption phase and substantially well in the absorption phase and thereby reflects the concentration of alcohol reaching the brain. Our findings highlight the magnitude of arterio-venous differences in alcohol concentration and support the use of breath alcohol analyzers as a stand-alone test for medical and legal purposes.
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Hornung C, Goldberg L, Jessup M, Mundt C, Yang D, Farberow B. 80 DISEASE MANAGEMENT WITH TELEPHONIC HOME MONITORING FOR CONGESTIVE HEART FAILURE. J Investig Med 2006. [DOI: 10.2310/6650.2005.x0015.158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Hornung C, Goldberg L, Jessup M, Mundt C, Yang D, Farberow B. Disease Management with Telephonic Home Monitoring for Congestive Heart Failure. J Investig Med 2006. [DOI: 10.1177/108155890605402s159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Grigorov V, Roodt A, Jorgova J, Goldberg L. A two-year, single-group experience with rotational atherectomy. CARDIOVASCULAR JOURNAL OF SOUTH AFRICA : OFFICIAL JOURNAL FOR SOUTHERN AFRICA CARDIAC SOCIETY [AND] SOUTH AFRICAN SOCIETY OF CARDIAC PRACTITIONERS 2005; 16:148-51. [PMID: 16049587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Rotational atherectomy was introduced with a view to approaching percutaneously, cases that were suboptimal or unsuitable for conventional percutaneous transluminal coronary angioplasty (PTCA). In this article we present our findings for a period of two years starting in April 2001, when 60 procedures were performed on 54 patients. We found the procedure to be successful in B2 and C type lesions. It is our opinion that the lower burr-to-artery ratio used in our cases was significantly beneficial in decreasing immediate complications related to the procedure. Complimentary PTCA and stenting improved the angiographic end result. Using this strategy, we have achieved very acceptable clinical results.
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Ceusters W, Smith B, Goldberg L. A terminological and ontological analysis of the NCI Thesaurus. Methods Inf Med 2005; 44:498-507. [PMID: 16342916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
OBJECTIVE The National Cancer Institute Thesaurus is described by its authors as "a biomedical vocabulary that provides consistent, unambiguous codes and definitions for concepts used in cancer research" and which "exhibits ontology-like properties in its construction and use". We performed a qualitative analysis of the Thesaurus in order to assess its conformity with principles of good practice in terminology and ontology design. MATERIALS AND METHODS We used both the on-line browsable version of the Thesaurus and its OWL-representation (version 04.08b, released on August 2, 2004), measuring each in light of the requirements put forward in relevant ISO terminology standards and in light of ontological principles advanced in the recent literature. RESULTS We found many mistakes and inconsistencies with respect to the term-formation principles used, the underlying knowledge representation system, and missing or inappropriately assigned verbal and formal definitions. CONCLUSION Version 04.08b of the NCI Thesaurus suffers from the same broad range of problems that have been observed in other biomedical terminologies. For its further development, we recommend the use of a more principled approach that allows the Thesaurus to be tested not just for internal consistency but also for its degree of correspondence to that part of reality which it is designed to represent.
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Kuehl KS, Elliot DL, Goldberg L, Moe E. 280 THE PHLAME STUDY: SHORT-TERM ECONOMIC IMPACT OF HEALTH PROMOTION. J Investig Med 2005. [DOI: 10.2310/6650.2005.00005.279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Moe EL, Elliot DL, Goldberg L, DeFrancesco CA, Durham MB, Hix-Small H. 378 CURRICULUM FOR PREVENTING DISORDERED EATING AND BODY-SHAPING DRUG USE. J Investig Med 2005. [DOI: 10.2310/6650.2005.00005.377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Goldberg L, Hagies P, Grigorov V. Transoesophageal atrial pacing stress echocardiography in coronary artery disease: role, principles and methodology. CARDIOVASCULAR JOURNAL OF SOUTH AFRICA : OFFICIAL JOURNAL FOR SOUTHERN AFRICA CARDIAC SOCIETY [AND] SOUTH AFRICAN SOCIETY OF CARDIAC PRACTITIONERS 2004; 15:81-7. [PMID: 15148543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
This article reviews the physiology and methodology of transoesophageal atrial pacing stress echocardiography (TAPSE) and clarifies its place among the other stress modalities. TAPSE correlates well with myocardial perfusion stress scintigraphy and coronary angiography and is a simple and safe diagnostic option for patients with suspected or known CAD, including those with recent myocardial infarction. Furthermore, the results of TAPSE have prognostic significance in patients with uncomplicated MI. Although, it is a highly feasible and safe technique, the cardiologist should be directly involved in the procedure and the personnel must be well trained in a large number of tests, as for any other stress echocardiographic modalities.
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Kobashigawa J, Miller L, Russell S, Ewald G, Zucker M, Goldberg L, Eisen H, Tolzman D, Fitzsimmons W. A randomized, prospective, multi-center comparison of tacrolimus, mycophenolate mofetil (MMF) and steroids vs. cyclosporine (modified usp), mmf and steroids vs tacrolimus, sirolimus and steroids in de novo cardiac transplant recipients - 6 month report. J Heart Lung Transplant 2004. [DOI: 10.1016/j.healun.2003.11.192] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Bilbao R, Reay DP, Hughes T, Biermann V, Volpers C, Goldberg L, Bergelson J, Kochanek S, Clemens PR. Fetal muscle gene transfer is not enhanced by an RGD capsid modification to high-capacity adenoviral vectors. Gene Ther 2003; 10:1821-9. [PMID: 12960972 DOI: 10.1038/sj.gt.3302084] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
High levels of alpha(v) integrin expression by fetal muscle suggested that vector re-targeting to integrins could enhance adenoviral vector-mediated transduction, thereby increasing safety and efficacy of muscle gene transfer in utero. High-capacity adenoviral (HC-Ad) vectors modified by an Arg-Gly-Asp (RGD) peptide motif in the HI loop of the adenoviral fiber (RGD-HC-Ad) have demonstrated efficient gene transfer through binding to alpha(v) integrins. To test integrin targeting of HC-Ad vectors for fetal muscle gene transfer, we compared unmodified and RGD-modified HC-Ad vectors. In vivo, unmodified HC-Ad vector transduced fetal mouse muscle with four-fold higher efficiency compared to RGD-HC-Ad vector. Confirming that the difference was due to muscle cell autonomous factors and not mechanical barriers, transduction of primary myogenic cells isolated from murine fetal muscle in vitro demonstrated a three-fold better transduction by HC-Ad vector than by RGD-HC-Ad vector. We hypothesized that the high expression level of coxsackievirus and adenovirus receptor (CAR), demonstrated in fetal muscle cells both in vitro and in vivo, was the crucial variable influencing the relative transduction efficiencies of HC-Ad and RGD-HC-Ad vectors. To explore this further, we studied transduction by HC-Ad and RGD-HC-Ad vectors in paired cell lines that expressed alpha(v) integrins and differed only by the presence or absence of CAR expression. The results increase our understanding of factors that will be important for retargeting HC-Ad vectors to enhance gene transfer to fetal muscle.
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Goldberg L, Hagios P, Grigorov V, Mekel J. "Low pressure" left ventricular tamponade in a patient with rheumatic mitral stenosis and HIV-related acute pericarditis. CARDIOVASCULAR JOURNAL OF SOUTH AFRICA : OFFICIAL JOURNAL FOR SOUTHERN AFRICA CARDIAC SOCIETY [AND] SOUTH AFRICAN SOCIETY OF CARDIAC PRACTITIONERS 2003; 14:91-4. [PMID: 12748746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
A case report of isolated left ventricular tamponade in a patient with rheumatic mitral stenosis and effusive pericarditis is presented. The haemodynamics and management of this under-diagnosed pathology is discussed.
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Goldberg L, Hagios P. Chronic idiopathic effusive pericarditis in a patient with 'cor pulmonale'. CARDIOVASCULAR JOURNAL OF SOUTH AFRICA : OFFICIAL JOURNAL FOR SOUTHERN AFRICA CARDIAC SOCIETY [AND] SOUTH AFRICAN SOCIETY OF CARDIAC PRACTITIONERS 2003; 14:30-4. [PMID: 12621541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Chronic idiopathic pericarditis is a diagnosis of exclusion that is estimated to occur in 3.5% of primary pericardial disease. It is possible that many of these cases are secondary to unrecognised viral infections. The natural history is variable and treatment should be individualised, although chronic colchicines administration may hold promise as a newer therapeutic modality in symptomatic recurrent pericarditis. This case presentation illustrates the diagnostic and therapeutic difficulties that may arise in such patients.
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