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Saragò M, Fiore D, De Rosa S, Amaddeo A, Pulitanò L, Bozzarello C, Iannello AM, Sammarco G, Indolfi C, Rizzuto A. Acute acalculous cholecystitis and cardiovascular disease, which came first? After two hundred years still the classic chicken and eggs debate: A review of literature. Ann Med Surg (Lond) 2022; 78:103668. [PMID: 35734727 PMCID: PMC9206910 DOI: 10.1016/j.amsu.2022.103668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/20/2022] [Accepted: 04/25/2022] [Indexed: 11/10/2022] Open
Abstract
The existence of a close association between disease of the biliary tract and disease of the heart is known from the mists of time. Acute acalculous cholecystitis (AAC) can be defined as an acute necro inflammatory disease of the gallbladder in the absence of cholelithiasis. AAC is a challenging diagnosis. The atypical clinical onset associated to a paucity and similarity of symptoms and to laboratory data mimicking cardiovascular disease (CVD) often results in under and misdiagnosed cases. Moreover, AAC has commonly a fulminant course compared to calculous cholecystitis and it is often associated with gangrene, perforation and empyema as well as considerable morbidity and mortality (up 50%). Early diagnosis is crucial to a prompt treatment in order to avoid complications and to increase survivability. Even today, although scientific evidence dating two hundred years has shown a close association between AAC and CVD, due to the lack of RCT, there is still a lot of confusion regarding the relationship and consequently the clinical management AAC and CVD. In addition, emergency physicians are not always familiar with transient ECG changes with AAC. The aim of this review was to provide evidence regarding epidemiology, pathophysiology, clinical presentation and treatment of the complex association between AAC and CVD. Our main findings indicate that AAC should be suspected after each general disease leading to hypoperfusion such as cardiovascular diseases or cerebrovascular diseases or major heart or aortic surgery. ECG changes in absence of significant laboratory data for IMA (Acute myocardial infarction) could be related to a misdiagnosed AAC. US – Ultrasonography-plays a key role in the early diagnosis and also in the follow up of AAC. Cholecystostomy and cholecystectomy as unique or sequential represent the two prevailing treatment options for AAC. AAC should be suspected after each general disease leading to hypoperfusion such as cardiovascular diseases or cerebrovascular diseases or major heart or aortic surgery. ECG changes in absence of significant laboratory data for IMA could be related to a misdiagnosed AAC. Cholecystectomy is an only definitive treatment for AAC. The first report on this theme after 20 years.
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Makowska K, Mikolajczyk A, Calka J, Gonkowski S. Neurochemical characterization of nerve fibers in the porcine gallbladder wall under physiological conditions and after the administration of Salmonella enteritidis lipopolysaccharides (LPS). Toxicol Res (Camb) 2018; 7:73-83. [PMID: 30090564 PMCID: PMC6062139 DOI: 10.1039/c7tx00211d] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 10/24/2017] [Indexed: 12/26/2022] Open
Abstract
Lipopolysaccharides (LPS, bacterial endotoxin) are a component of the cellular membrane of Gram-negative bacteria, which is known as an important pathological factor. In spite of many previous studies describing multidirectional negative effects of LPS on living organisms, the knowledge concerning the influence of bacterial endotoxins on the gallbladder innervation is extremely scarce. The present study, based on the immunofluorescence technique, describes the changes in the neurochemical characterization of nerves within various parts of the porcine gallbladder (neck, body and fundus) after the administration of low doses of LPS. The obtained results show that even low doses of bacterial endotoxins affect the nerve structures within the gallbladder wall and the intensity of fluctuations in immunoreactivity to particular substances clearly depends on the part of the investigated organ. The most evident changes were observed in the case of fibers exhibiting the presence of neuropeptide Y (an increase from 7.84 ± 0.17 to 14.66 ± 0.37) in the neck, substance P (an increase from 0.88 ± 0.1 to 8.4 ± 0.3) in the body and the vesicular acetylocholine transporter in the gallbladder's fundus (an increase from 4.29 ± 0.18 to 11.01 ± 0.26). The mechanisms of the observed changes still remain unclear, but probably they are connected with the pro-inflammatory and/or neurodegenerative activity of LPS.
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Affiliation(s)
- Krystyna Makowska
- Departement of Clinical Physiology , Faculty of Veterinary Medicine University of Warmia and Mazury in Olsztyn , Poland .
| | - Anita Mikolajczyk
- Department of Public Health , Epidemiology and Microbiology , Faculty of Medical Sciences University of Warmia and Mazury in Olsztyn , Poland
| | - Jaroslaw Calka
- Departement of Clinical Physiology , Faculty of Veterinary Medicine University of Warmia and Mazury in Olsztyn , Poland .
| | - Slawomir Gonkowski
- Departement of Clinical Physiology , Faculty of Veterinary Medicine University of Warmia and Mazury in Olsztyn , Poland .
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The effect of lysolecithin on prostanoid and platelet-activating factor formation by human gall-bladder mucosal cells. Mediators Inflamm 2012; 4:90-4. [PMID: 18475621 PMCID: PMC2365627 DOI: 10.1155/s0962935195000147] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
It has been demonstrated that lysolecithin (lysophosphatidyl choline, LPC) produces experimental cholecystitis in cats mediated by arachidonic acid metabolites. LPC is a cytolytic agent that has been postulated as a contributing factor in the development of cholecystitis in humans. The purpose of this research was to evaluate the effect of LPC on human gall-bladder mucosal cell phospholipase A2 and cyclooxygenase activity. Gall-bladder mucosal cells were isolated from the gall-bladders of patients undergoing routine cholecystectomy. Fresh, isolated cells were maintained in tissue culture and stimulated with varying doses of LPC. Platelet-activating factor concentration was quantitated as an index of phospholipase A2 activity and prostanoids were measured as an index of cyclooxygenase activity. Also, the effect of LPC on cyclooxygenase 1 and 2 expression in microsomal protein was evaluated. LPC caused dose related increases in 6-keto-PGF1α and PAF produced by human gall-bladder mucosal cells. Exposure of human gall-bladder mucosal cells to LPC failed to elicit expression of constitutive cyclooxygenase-1, while the expression of inducible cyclooxygenase-2 was increased. The results of this study indicate that LPC induces the formation of prostanoids and PAF by human gall-bladder mucosal cells, suggesting that this substance may promote the development of gall-bladder inflammation.
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Abstract
Acute acalculous cholecystitis (ACC) can develop with or without gallstones after surgery and in critically ill or injured patients. Diabetes mellitus, malignant disease, abdominal vasculitis, congestive heart failure, cholesterol embolization, shock, and cardiac arrest also have been associated with AAC. The pathogenesis of AAC is complex and multifactorial. Ultrasound of the gallbladder is most accurate for the diagnosis of AAC in the critically ill patient. CT is probably of comparable accuracy, but carries both advantages and disadvantages. Rapid improvement may be expected when AAC is diagnosed correctly and cholecystostomy is performed timely.
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Affiliation(s)
- Philip S Barie
- Division of Critical Care and Trauma, Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY 0065, USA.
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Huffman JL, Schenker S. Acute acalculous cholecystitis: a review. Clin Gastroenterol Hepatol 2010; 8:15-22. [PMID: 19747982 DOI: 10.1016/j.cgh.2009.08.034] [Citation(s) in RCA: 212] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Revised: 08/14/2009] [Accepted: 08/19/2009] [Indexed: 02/07/2023]
Abstract
Although recognized for more than 150 years, acute acalculous cholecystitis (AAC) remains an elusive diagnosis. This is likely because of the complex clinical setting in which this entity develops, the lack of large prospective controlled trials that evaluate various diagnostic modalities, and thus dependence on a small data base for clinical decision making. AAC most often occurs in critically ill patients, especially related to trauma, surgery, shock, burns, sepsis, total parenteral nutrition, and/or prolonged fasting. Clinically, AAC is difficult to diagnose because the findings of right upper-quadrant pain, fever, leukocytosis, and abnormal liver tests are not specific. AAC is associated with a high mortality, but early diagnosis and intervention can change this. Early diagnosis is the crux of debate surrounding AAC, and it usually rests with imaging modalities. There are no specific criteria to diagnose AAC. Therefore, this review discusses the imaging methods most likely to arrive at an early and accurate diagnosis despite the complexities of the radiologic modalities. A pragmatic approach is vital. A timely diagnosis will depend on a high index of suspicion in the appropriate patient, and the combined results of clinical findings (admittedly nonspecific), plus properly interpreted imaging. Sonogram (often sequential) and hepatic iminodiacetic acid scans are the most reliable modalities for diagnosis. It is generally agreed that cholecystectomy is the definitive therapy for AAC. However, at times a diagnostic/therapeutic drainage via interventional radiology/surgery may be necessary and life-saving, and may be the only treatment needed.
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Affiliation(s)
- Jason L Huffman
- Department of Internal Medicine, Division of Gastroenterology and Nutrition, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.
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Abstract
Acute cholecystitis can develop without gallstones in critically ill or injured patients. However, the development of acute acalculous cholecystitis is not limited to surgical or injured patients, or even to the intensive care unit. Diabetes, malignant disease, abdominal vasculitis, congestive heart failure, cholesterol embolization, and shock or cardiac arrest have been associated with acute acalculous cholecystitis. Children may also be affected, especially after a viral illness. The pathogenesis of acute acalculous cholecystitis is a paradigm of complexity. Ischemia and reperfusion injury, or the effects of eicosanoid proinflammatory mediators, appear to be the central mechanisms, but bile stasis, opioid therapy, positive-pressure ventilation, and total parenteral nutrition have all been implicated. Ultrasound of the gallbladder is the most accurate diagnostic modality in the critically ill patient, with gallbladder wall thickness of 3.5 mm or greater and pericholecystic fluid being the two most reliable criteria. The historical treatment of choice for acute acalculous cholecystitis has been cholecystectomy, but percutaneous cholecystostomy is now the mainstay of therapy, controlling the disease in about 85% of patients. Rapid improvement can be expected when the procedure is performed properly. The mortality rates (historically about 30%) for percutaneous and open cholecystostomy appear to be similar, reflecting the severity of illness, but improved resuscitation and critical care may portend a decreased risk of death. Interval cholecystectomy is usually not indicated after acute acalculous cholecystitis in survivors; if the absence of gallstones is confirmed and the precipitating disorder has been controlled, the cholecystostomy tube can be pulled out after the patient has recovered.
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Affiliation(s)
- Philip S Barie
- Department of Surgery, NewYork-Presbyterian Hospital, Weill Medical College of Cornell University, 525 East 68th Street, P-713A, New York, NY 10021, USA.
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Parkman HP, James AN, Thomas RM, Bartula LL, Ryan JP, Myers SI. Effect of indomethacin on gallbladder inflammation and contractility during acute cholecystitis. J Surg Res 2001; 96:135-42. [PMID: 11181007 DOI: 10.1006/jsre.2001.6082] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to determine whether the prostaglandin synthase inhibitor indomethacin reverses the inflammation and abnormal gallbladder contractility that occur after common bile duct ligation (CBDL), a model of acute cholecystitis. METHODS Gallbladder muscle contractility was studied in vitro in normal, CBDL, and sham-operated guinea pigs. Animals were treated with saline or indomethacin in vivo. Acetylcholine (ACh) was used to directly contract the muscle and electric field stimulation (EFS) to activate intrinsic nerves. Hematoxylin and eosin-stained slides of muscle strips were scored for inflammation. RESULTS CBDL in saline-treated animals increased the inflammation score and decreased gallbladder muscle contractility to ACh and EFS. Indomethacin decreased the inflammation score and partly reversed the smooth muscle contractile response to ACh 6 and 24 h after CBDL, but not at 48 h. Indomethacin did not reverse the CBDL-induced decrease in nerve-evoked contractions. CONCLUSION Gallbladder inflammation and contractile dysfunction after CBDL are partly reversed with indomethacin at 6 and 24 h, but not at 48 h. This suggests that, early in the course of CBDL, the inflammation and contractile dysfunction are, in part, prostaglandin-mediated.
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Affiliation(s)
- H P Parkman
- Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania 19140, USA.
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Parkman HP, James AN, Ryan JP. The contractile action of platelet-activating factor on gallbladder smooth muscle. Am J Physiol Gastrointest Liver Physiol 2000; 279:G67-72. [PMID: 10898747 DOI: 10.1152/ajpgi.2000.279.1.g67] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Platelet-activating factor (PAF) may be a mediator of some sequelae of cholecystitis, a disorder with gallbladder motor dysfunction. The aims of this study were to determine the effect and mechanism of PAF on gallbladder muscle. Exogenous administration of PAF-16 or PAF-18 caused dose-dependent contractions of gallbladder muscle strips in vitro with threshold doses of 1 ng/ml and 10 ng/ml, respectively. The PAF-induced contractions were not significantly reduced by TTX, atropine, or hexamethonium but were significantly inhibited with the PAF receptor antagonists ginkolide B and CV-3988. The PAF-induced contraction was reduced by indomethacin. Preventing influx of extracellular calcium with a calcium-free solution nearly abolished the PAF contractile response. Nifedipine inhibited the PAF contractile response, whereas ryanodine had no effect. Pertussis toxin reduced the PAF contractile response. In conclusion, PAF causes gallbladder contraction through specific PAF receptors on gallbladder muscle. These PAF receptors appear to be linked to a prostaglandin-mediated mechanism and to pertussis toxin-sensitive G proteins. The contractile response is largely mediated through the utilization of extracellular calcium influx through voltage-dependent calcium channels.
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Affiliation(s)
- H P Parkman
- Departments of Medicine and Physiology, Temple University School of Medicine, Philadelphia, Pennsylvania 19140, USA.
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Liolios A, Oropello JM, Benjamin E. Gastrointestinal complications in the intensive care unit. Clin Chest Med 1999; 20:329-45, viii. [PMID: 10386260 DOI: 10.1016/s0272-5231(05)70145-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Pathologic conditions affecting the abdomen are a significant cause of morbidity and mortality in the intensive care unit, but their importance is not widely recognized. This article presents several aspects of abdominal pathology that can occur in intensive care unit patients. This pathology may have a considerable impact on the prognosis and survival of the critically ill patient. The diagnostic contribution of laboratory tests and imaging is discussed. Conditions such as the abdominal compartment syndrome, acute mesenteric ischemia, gastrointestinal bleeding, diarrhea, abdominal sepsis, complications of entereal and parenteral nutrition, and ileus in critically ill patients are also reviewed.
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Affiliation(s)
- A Liolios
- Department of Surgery, Mount Sinai Medical Center, City University of New York, New York, USA
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Solomon H, Contis J, Li AP, Kaminski DL. The effect of prostanoids on hepatic bile flow in dogs with normal liver and bile duct cell hyperplasia. Prostaglandins Leukot Essent Fatty Acids 1996; 54:265-71. [PMID: 8804123 DOI: 10.1016/s0952-3278(96)90057-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Bile flow rates and composition are subject to a wide variety of neural, endocrine and paracrine influences. The effects of these multiple factors may be different in the diseased liver compared to the response produced in the normal liver. As prostanoids may have a therapeutic role in liver disease it was intended to evaluate the effects of two principal therapeutic prostanoids, prostaglandin E2 and prostacyclin, on bile flow in dogs with a normal liver and in dogs with hepatotoxin-induced liver injury. Initially, in awake animals with chronic biliary and gastric fistulas the bile flow response to prostaglandin E2 and prostacyclin was evaluated and compared to the response produced by bile salt infusion alone and to that produced by the standard choleretic hormones, secretin and glucagon. The animals were then fed alpha-naphthylisothiocyanate (ANIT) and the studies repeated. ANIT is a hepatoxin that produces bile duct cell hyperplasia which was confirmed in dogs by demonstrating that ANIT increased [3H]thymidine incorporation by isolated canine bile duct cells. In normal dogs, the prostanoids, secretin, and glucagon increased hepatic bile flow. 10 days of ANIT feeding produced a hypercholeresis. While secretin was able to stimulate the hyperplastic biliary epithelium and increase bile flow over values produced by the hyperplastic biliary epithelium alone, neither prostaglandin E2, prostacyclin, or glucagon appeared to stimulate the hyperplastic biliary epithelium. As ANIT produced evidence of cholestasis and hepatocellular damage, only secretin would seem to have a potential therapeutic role in increasing bile flow in cholestatic liver disorders associated with bile duct cell hyperplasia.
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Affiliation(s)
- H Solomon
- Department of Surgery, St Louis University School of Medicine, MO 63110, USA
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Nag MK, Deshpande YG, Li A, Beck D, Kaminski DL. Lysophosphatidylcholine-stimulated protein and glycoprotein production by human gallbladder mucosal cells. Dig Dis Sci 1995; 40:1990-6. [PMID: 7555454 DOI: 10.1007/bf02208668] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
It has been demonstrated in experimental cholecystitis in cats produced by lysophosphatidylcholine that the development of inflammation is associated with the exsorption of a large amount of protein into the gallbladder lumen. It was subsequently demonstrated that in feline experimental cholecystitis the protein produced was albumin and that its production was decreased by vesicular transport inhibitors, suggesting an active secretory process. In the present study, the effect of lysophosphatidylcholine on protein production by fresh, isolated human gallbladder mucosal cells was evaluated. Isolated gallbladder mucosal cells were incubated with [14C]leucine for 24 hr in tissue culture medium. The cells readily incorporated the radioactive label into cellular protein, a process inhibited by cycloheximide. Exposure of the cells to lysophosphatidylcholine for 1 hr in buffer solution resulted in loss of intracellular protein into the buffer solution. Exposure of the cells for 1 hr prior to lysophosphatidylcholine administration to vesicular transport inhibitors, colchicine, and cytochalasin B and to 4 degrees C culture conditions failed to alter the lysophosphatidylcholine-produced passage of the 14C label extracellularly. SDS-PAGE evaluation of the protein produced demonstrated that human gallbladder mucosal cells continuously produced a 66-kDa protein that was not increased by increasing concentration of lysophosphatidylcholine and a 14-kDa protein that increased with increasing concentrations of lysophosphatidylcholine. Employing Western blotting with specific antibodies, the 66-kDa protein was demonstrated to not be albumin but a 66-kDa glycoprotein, and the 14-kDa protein was demonstrated to contain phospholipase A2. Human gallbladder mucosal cells produced a protein and glycoprotein in response to lysophosphatidylcholine by a mechanism not related to vesicular transport.
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Affiliation(s)
- M K Nag
- Department of Surgery, St. Louis University Health Sciences Center, Missouri 63110-0250, USA
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Stratton MD, Chandel B, Deshpande Y, Kaminski DL, Li AP, Vernava AM, Longo WE. The effect of Clostridium difficile toxin on colonocyte prostanoid activity. PROSTAGLANDINS 1994; 48:367-75. [PMID: 7892508 DOI: 10.1016/0090-6980(94)90003-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Antibiotic-associated colitis is caused by Clostridium difficile toxin. However, the pathophysiology of this entity is poorly understood. The aim of this study was to determine the effects of C. difficile toxin on colonocyte cyclooxygenase and phospholipase A2 (PLA2) activity. A transformed colonocyte cell line (Caco-2) was grown to confluency on 6 well plates. The cells were stimulated with graded concentrations of C. difficile toxin. In separate experiments, the cells were pretreated for one hour prior to stimulation with the cyclooxygenase inhibitor, indomethacin, or the glucocorticoid, dexamethasone. The culture media was collected one hour following C. difficile stimulation. Prostaglandin E2 (PGE2), 6-keto prostaglandin F1 alpha (6KPGF), thromboxane B2 (TxB2) and leukotriene B4 (LTB4) levels were determined in the media by an ELISA. Platelet activating factor (PAF) concentration was determined by a RIA. C. difficile toxin stimulated PGE2 and 6KPGF levels in a dose dependent fashion but failed to stimulate TxB2, LTB4 or PAF. Prostanoid production was inhibited by indomethacin dose dependently but was not inhibited by dexamethasone. The presence of indomethacin resulted in production of PAF. Our results show that the effects of C. difficile toxin on colonocytes are mediated by cyclooxygenase activity. The increase in PAF formation associated with indomethacin administration suggests that the prostanoids modulate PLA2 activity and inhibit PAF formation.
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Affiliation(s)
- M D Stratton
- Department of Surgery, St. Louis University Medical Center, MO 63110-0250
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