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Pitt A, Mitchell C, Colwell B, Appelqvist I, Ashby F, Lloyd C, Gilbody S, Lawson R. M9 Lung Health of OPiate Users (LHOp): A pilot study to assess the respiratory health of opiate misusers attending a community substance misuse clinic. Thorax 2015. [DOI: 10.1136/thoraxjnl-2015-207770.436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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52
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Reynolds HM, Williams S, Zhang A, Chakravorty R, Rawlinson D, Ong CS, Esteva M, Mitchell C, Parameswaran B, Finnegan M, Liney G, Haworth A. Development of a registration framework to validate MRI with histology for prostate focal therapy. Med Phys 2015; 42:7078-89. [DOI: 10.1118/1.4935343] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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53
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Mitchell C, Bailey N, Bulbeck H, Hopkins K, Price S, Stewart W, Hilton D, Nicoll J, Kurian K. PO81A LACK OF CONSENT TO DONATE BRAIN TUMOUR TISSUE FOR RESEARCH HAMPERS PROGRESS. Neuro Oncol 2015. [DOI: 10.1093/neuonc/nov284.70] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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54
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Rooney J, Zou Y, Cowling B, Mitchell C, Bönnemann C. Late-onset mild myopathy with protein aggregates in two transgenic mouse models of FHL1. Neuromuscul Disord 2015. [DOI: 10.1016/j.nmd.2015.06.334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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55
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Smith K, Mitchell C, Trotter Z. 358 Point-of-Care Ultrasound for Ankle Injuries in the Pediatric Emergency Department. Ann Emerg Med 2015. [DOI: 10.1016/j.annemergmed.2015.07.394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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56
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Mitchell C, Platt S. PP70 Evaluation of user-perceived impact of edinburgh access practice keep well interventions on the health and wellbeing of gypsy/traveller and homeless service users: a mixed methods approach. Br J Soc Med 2015. [DOI: 10.1136/jech-2015-206256.166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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57
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Lucas C, Wilkinson J, Mitchell C, Kenna D, Turton J, Mustafa N, Williams C. 55 Is whole genome sequencing necessary to exclude cross infection with Mycobacterium abscessus ST26 in paediatric cystic fibrosis patients? J Cyst Fibros 2015. [DOI: 10.1016/s1569-1993(15)30232-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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58
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Osorio D, Filatov A, Hagiwara M, Mitchell C, Wisoff J, Golfinos J, Roland JT, Allen J, Karajannis M. TR-13 * EFFECTS OF EVEROLIMUS ON MENINGIOMA GROWTH IN PATIENTS WITH NEUROFIBROMATOSIS TYPE 2. Neuro Oncol 2015. [DOI: 10.1093/neuonc/nov061.158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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59
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Poudel A, Gray LC, Mitchell C, Nissen LM, Hubbard RE. 52 * GERIATRICIAN CONSULTATIONS ON APPROPRIATE PRESCRIBING FOR FRAIL OLDER PEOPLE IN RESIDENTIAL AGED CARE FACILITIES. Age Ageing 2015. [DOI: 10.1093/ageing/afv035.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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60
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Jung Y, Cho M, O'Connor A, Chang C, Koozehchian M, Goodenough C, Barringer N, Ayadi F, Walker D, Simbo S, Galvan E, Dalton R, Levers K, Garcia E, Mitchell C, Rasmussen C, Greenwood M, Murano P, Earnest C, Kreider R. Effects of Pre‐Workout Supplement on Strength, Anaerobic Power, and Body Composition. FASEB J 2015. [DOI: 10.1096/fasebj.29.1_supplement.lb238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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61
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Graff H, Mitchell C. Healthy places. Obesity prevention thru the local built environment. Appetite 2015. [DOI: 10.1016/j.appet.2014.12.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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62
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Galvan E, Jung Y, Cho M, O'Connor A, Chang C, Koozehchian M, Goodenough C, Barringer N, Ayadi F, Walker D, Simbo S, Dalton R, Levers K, Garcia E, Mitchell C, Rasmussen C, Greenwood M, Murano P, Earnest C, Kreider R. Acute Hemodynamic, Hematologic and Dose Effects of Ingesting Two Creatine Nitrate Based Dietary Supplements. FASEB J 2015. [DOI: 10.1096/fasebj.29.1_supplement.lb250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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63
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Jung Y, Cho M, O'Connor A, Chang C, Koozehchian M, Goodenough C, Barringer N, Ayadi F, Walker D, Simbo S, Galvan E, Dalton R, Levers K, Garcia E, Mitchell C, Rasmussen C, Greenwood M, Murano P, Earnest C, Kreider R. Effects of 8 Weeks Ingestion of a Pre‐Workout Supplement With and Without Synephrine on Cognitive Function, and Perceptions of Readiness to Perform. FASEB J 2015. [DOI: 10.1096/fasebj.29.1_supplement.lb239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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64
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Salmena L, Shaw P, Fans I, Rosen B, Risch H, Mitchell C, Sun P, Narod SA, Kotsopoulos J. Prognostic value of INPP4B protein immunohistochemistry in ovarian cancer. EUR J GYNAECOL ONCOL 2015; 36:260-267. [PMID: 26189250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
PURPOSE OF INVESTIGATION Ovarian cancer is associated with poor prognosis and altered protein expression patterns may be useful for identifying patients likely to have poor disease outcomes. The impact of altered INPP4B protein expression on prognosis is unclear. The aim of this study was to evaluate the implication of INPP4B expression changes in a large series of ovarian cancer tissue samples. MATERIALS AND METHODS Tissue microarrays were constructed from 599 epithelial ovarian tumors and stained with antibodies for INPP4B, p53, and PTEN. Proportional hazard models were used to estimate survival hazard ratios (HRs) associated with altered protein expression. RESULTS Seventy-nine percent of the ovarian cancers demonstrated loss of INPP4B, whereas 53% showed aberrant p53 expression (i.e., complete loss of p53 or over-expression of p53) and 8% showed loss of PTEN. INPP4B was frequently lost in serous and endometrioid cancer subtypes, aberrant p53 expression was most common among serous subtype, and loss of PTEN was most common among endometrioid tumors (p for all three proteins across histologic subtypes ≤ 0.0001). INPP4B loss or aberrant p53 expression were both associated with increased mortality (HR = 1.84; 95% CI 1.27 - 2.68 and HR = 3.10; 95% CI 2.33 - 4.11, respectively); however, in multivariate models, only the relationship with p53 achieved statistical significance (HR = 1.20; 95% CI 0.82 - 1.76 for INPP4B and HR = 1.73; 95% CI 1.28 - 2.34 for p53). Conclusion: The INPP4B protein is frequently lost in serous and endometrioid subtypes of ovarian cancer. A possible prognostic role of INPP4B for endometrioid ovarian tumors requires further evaluation.
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MESH Headings
- Adenocarcinoma, Clear Cell/metabolism
- Adenocarcinoma, Clear Cell/mortality
- Adenocarcinoma, Clear Cell/pathology
- Adult
- Aged
- Biomarkers, Tumor/metabolism
- Carcinoma, Endometrioid/metabolism
- Carcinoma, Endometrioid/mortality
- Carcinoma, Endometrioid/pathology
- Carcinoma, Ovarian Epithelial
- Female
- Humans
- Immunohistochemistry
- Middle Aged
- Neoplasm Staging
- Neoplasms, Cystic, Mucinous, and Serous/metabolism
- Neoplasms, Cystic, Mucinous, and Serous/mortality
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Neoplasms, Glandular and Epithelial/metabolism
- Neoplasms, Glandular and Epithelial/mortality
- Neoplasms, Glandular and Epithelial/pathology
- Ovarian Neoplasms/metabolism
- Ovarian Neoplasms/mortality
- Ovarian Neoplasms/pathology
- PTEN Phosphohydrolase/metabolism
- Phosphoric Monoester Hydrolases/metabolism
- Prognosis
- Proportional Hazards Models
- Tumor Suppressor Protein p53/metabolism
- Young Adult
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Irtan S, Jitlal M, Bate J, Powis M, Vujanic G, Kelsey A, Walker J, Mitchell C, Machin D, Pritchard-Jones K. Risk factors for local recurrence in Wilms tumour and the potential influence of biopsy - the United Kingdom experience. Eur J Cancer 2014; 51:225-32. [PMID: 25465191 DOI: 10.1016/j.ejca.2014.10.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 10/01/2014] [Accepted: 10/27/2014] [Indexed: 10/24/2022]
Abstract
RATIONALE The UKW3 trial compared biopsy/pre-operative chemotherapy versus immediate nephrectomy and afforded the opportunity to examine the influence of percutaneous retroperitoneal biopsy and other factors on local and distant relapse of Wilms tumour (WT). METHODS Patients with unilateral WT (stages I-IV) excluding metachronous relapse or early progressive disease were eligible. Metastatic and 'inoperable' tumours were biopsied electively. 'Local' was defined as relapse within the abdomen, except for liver metastases considered as 'distant' relapse, together with other haematogenous routes. Uni- and multivariable analyses estimated the risk factors for relapse. RESULTS Overall, 285/635 (44.9%) patients had a biopsy. With a median follow-up of 10.1 years, 35 (5.5%) patients experienced a 'local', 15 a combined (2.4%) and 60 (9.4%) a 'distant' relapse. On univariate analysis, biopsy, anaplasia and tumour size were associated with an increased risk of local relapse. On multivariable analysis, anaplasia and tumour size remained significant for local relapse whereas the elevated risk of biopsy (hazards ratio (HR) = 1.80: 95% confidence interval (CI) 0.97-3.32, p = 0.060) was marginal. Age, anaplasia, tumour size, lymph nodes metastases and stage, but not biopsy, were individually associated with increased risk of distant relapse but only age and anaplasia remained significant following multivariable analysis. CONCLUSIONS The UKW3 trial provides some reassurance that biopsy should not automatically lead to 'upstaging' of WT. Further assessment of this controversial area is required. Comparison of local relapse rates in a multinational trial in which the United Kingdom (UK) continued the practice of routinely biopsying all patients in contrast to the standard European approach will afford this opportunity and is planned.
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66
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Karajannis M, Osorio D, Filatov A, Hagiwara M, Mitchell C, Wisoff J, Golfinos J, Roland T, Allen J. AT-30 * EFFECTS OF EVEROLIMUS ON MENINGIOMA GROWTH IN PATIENTS WITH NEUROFIBROMATOSIS TYPE 2. Neuro Oncol 2014. [DOI: 10.1093/neuonc/nou237.30] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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67
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Lewin J, Khamly KK, Young RJ, Mitchell C, Hicks RJ, Toner GC, Ngan SYK, Chander S, Powell GJ, Herschtal A, Te Marvelde L, Desai J, Choong PFM, Stacker SA, Achen MG, Ferris N, Fox S, Slavin J, Thomas DM. A phase Ib/II translational study of sunitinib with neoadjuvant radiotherapy in soft-tissue sarcoma. Br J Cancer 2014; 111:2254-61. [PMID: 25321190 PMCID: PMC4264446 DOI: 10.1038/bjc.2014.537] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Revised: 08/29/2014] [Accepted: 09/17/2014] [Indexed: 12/16/2022] Open
Abstract
Background: Preoperative radiotherapy (RT) is commonly used to treat localised soft-tissue sarcomas (STS). Hypoxia is an important determinant of radioresistance. Whether antiangiogenic therapy can ‘normalise' tumour vasculature, thereby improving oxygenation, remains unknown. Methods: Two cohorts were prospectively enrolled. Cohort A evaluated the implications of hypoxia in STS, using the hypoxic tracer 18F-azomycin arabinoside (FAZA-PET). In cohort B, sunitinib was added to preoperative RT in a dose-finding phase 1b/2 design. Results: In cohort A, 13 out of 23 tumours were hypoxic (FAZA-PET), correlating with metabolic activity (r2=0.85; P<0.001). Two-year progression-free (PFS) and overall (OS) survival were 61% (95% CI: 0.44–0.84) and 87% (95% CI: 0.74–1.00), respectively. Hypoxia was associated with radioresistance (P=0.012), higher local recurrence (Hazard ratio (HR): 10.2; P=0.02), PFS (HR: 8.4; P=0.02), and OS (HR: 41.4; P<0.04). In Cohort B, seven patients received sunitinib at dose level (DL): 0 (50 mg per day for 2 weeks before RT; 25 mg per day during RT) and two patients received DL: −1 (37.5 mg per day for entire period). Dose-limiting toxicities were observed in 4 out of 7 patients at DL 0 and 2 out of 2 patients at DL −1, resulting in premature study closure. Although there was no difference in PFS or OS, patients receiving sunitinib had higher local failure (HR: 8.1; P=0.004). Conclusion: In STS, hypoxia is associated with adverse outcomes. The combination of sunitinib with preoperative RT resulted in unacceptable toxicities, and higher local relapse rates.
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68
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Hermann H, Trachsel M, Mitchell C, Biller-Andorno N. Medical decision-making capacity: knowledge, attitudes, and assessment practices of physicians in Switzerland. Swiss Med Wkly 2014; 144:w14039. [DOI: 10.4414/smw.2014.14039] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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69
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Boardman A, Clements H, Kellett D, Mitchell C, Board R. The assessment of deaths after radiotherapy is an essential part of service evaluation—results of a 30 day mortality audit of patient deaths after palliative radiotherapy. Clin Oncol (R Coll Radiol) 2014; 26:807. [PMID: 25262844 DOI: 10.1016/j.clon.2014.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 08/28/2014] [Accepted: 09/09/2014] [Indexed: 11/17/2022]
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70
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Poudel A, Peel N, Nissen L, Mitchell C, Gray L, Hubbard R. Potentially Inappropriate Prescribing in Older People Discharged to Residential Aged Care Facilities. Res Social Adm Pharm 2014. [DOI: 10.1016/j.sapharm.2014.07.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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71
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Ziaj S, Mitchell C, Roufosse C, Dubrey SW. Occult microscopic polyangiitis presenting as pyrexia of unknown origin. Br J Hosp Med (Lond) 2014; 75:172-3. [PMID: 24621636 DOI: 10.12968/hmed.2014.75.3.172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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72
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Mitchell C, Parikh O. Delays in Treatment of Muscle-invasive Bladder Carcinoma. Clin Oncol (R Coll Radiol) 2014. [DOI: 10.1016/j.clon.2013.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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73
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Chai SY, Smith R, Fitter JT, Mitchell C, Pan X, Ilicic M, Maiti K, Zakar T, Madsen G. Increased progesterone receptor A expression in labouring human myometrium is associated with decreased promoter occupancy by the histone demethylase JARID1A. Mol Hum Reprod 2014; 20:442-53. [PMID: 24442343 DOI: 10.1093/molehr/gau005] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Progesterone regulates female reproductive function predominantly through two nuclear progesterone receptors (PRs), PR-A and PR-B. During human parturition myometrial PR expression is altered to favour PR-A, which activates pro-labour genes. We have previously identified histone H3 lysine 4 trimethylation (H3K4me3) as an activator of myometrial PR-A expression at labour. To further elucidate the mechanisms regulating PR isoform expression in the human uterus at labour, we have (i) determined the methylation profile of the cytosine-guanine dinucleotides (CpG) island in the promoter region of the PR gene and (ii) identified the histone-modifying enzymes that target the H3K4me3 mark at the PR promoters in term and preterm human myometrial tissues obtained before and after labour onset. Bisulphite sequencing showed that despite overall low levels of PR CpG island methylation, there was a significant decrease in methylated CpGs with labour in both preterm (P < 0.05) and term (P < 0.01) groups downstream of the PR-B transcription start site. This methylation change was not associated with altered PR-B expression, but may contribute to the increase in PR-A expression with labour. Chromatin immunoprecipitation revealed that the histone methyltransferase, SET and MYND domain-containing protein 3 (SMYD3), bound to the PR gene at significantly higher levels at the PR-A promoter compared with the PR-B promoter (P < 0.010), with no labour-associated changes observed. The H3K4 demethylase, Jumonji AT-rich interactive domain 1A (JARID1A), also bound to the PR-A, but not to the PR-B promoter prior to term labour, and decreased significantly at the onset of labour (P = 0.014), providing a mechanism for the previously reported increase in H3K4me3 level and PR-A expression with labour. Our studies suggest that epigenetic changes mediated by JARID1A, SMYD3 and DNA methylation may be responsible, at least in part, for the functional progesterone withdrawal that precipitates human labour.
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74
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Watson LPE, Raymond-Barker P, Moran C, Schoenmakers N, Mitchell C, Bluck L, Chatterjee VK, Savage DB, Murgatroyd PR. An approach to quantifying abnormalities in energy expenditure and lean mass in metabolic disease. Eur J Clin Nutr 2013; 68:234-40. [PMID: 24281313 PMCID: PMC3916834 DOI: 10.1038/ejcn.2013.237] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 09/25/2013] [Accepted: 09/27/2013] [Indexed: 01/09/2023]
Abstract
Background/objectives: The objective of this study was to develop approaches to expressing resting energy expenditure (REE) and lean body mass (LM) phenotypes of metabolic disorders in terms of Z-scores relative to their predicted healthy values. Subjects/methods: Body composition and REE were measured in 135 healthy participants. Prediction equations for LM and REE were obtained from linear regression and the range of normality by the standard deviation of residuals. Application is demonstrated in patients from three metabolic disorder groups (lipodystrophy, n=7; thyrotoxicosis, n=16; and resistance to thyroid hormone (RTH), n=46) in which altered REE and/or LM were characterised by departure from the predicted healthy values, expressed as a Z-score. Results: REE (kJ/min)=−0.010 × age (years)+0.016 × FM (kg)+0.054 × fat-free mass (kg)+1.736 (R2=0.732, RSD=0.36 kJ/min). LM (kg)=5.30 × bone mineral content (kg)+10.66 × height2 (m)+6.40 (male). LM (kg)=0.20 × fat (kg)+14.08 × height2 (m)−2.93 (female). (male R2=0.55, RSD=3.90 kg; female R2=0.59, RSD=3.85 kg). We found average Z-scores for REE and LM of 1.77 kJ/min and −0.17 kg in the RTH group, 5.82 kJ/min and −1.23 kg in the thyrotoxic group and 2.97 kJ/min and 4.20 kg in the LD group. Conclusion: This approach enables comparison of data from individuals with metabolic disorders with those of healthy individuals, describing their departure from the healthy mean by a Z-score.
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75
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Poudel A, Hubbard RE, Nissen L, Mitchell C. Frailty: a key indicator to minimize inappropriate medication in older people. QJM 2013; 106:969-75. [PMID: 23824943 DOI: 10.1093/qjmed/hct146] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Older populations are more likely to have multiple co-morbid diseases that require multiple treatments, which make them a large consumer of medications. As a person grows older, their ability to tolerate medications becomes less due to age-related changes in pharmacokinetics and pharmacodynamics often heading along a path that leads to frailty. Frail older persons often have multiple co-morbidities with signs of impairment in activities of daily living. Prescribing drugs for these vulnerable individuals is difficult and is a potentially unsafe activity. Inappropriate prescribing in older population can be detected using explicit (criterion-based) or implicit (judgment-based) criteria. Unfortunately, most current therapeutic guidelines are applicable only to healthy older adults and cannot be generalized to frail patients. These discrepancies should be addressed either by developing new criteria or by refining the existing tools for frail older people. The first and foremost step is to identify the frail patient in clinical practice by applying clinically validated tools. Once the frail patient has been identified, there is a need for specific measures or criteria to assess appropriateness of therapy that consider such factors as quality of life, functional status and remaining life expectancy and thus modified goals of care.
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