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Rashidi-Alavijeh J, Nuruzade N, Frey A, Huessler EM, Hörster A, Zeller AC, Schütte A, Schmidt H, Willuweit K, Lange CM. Implications of anaemia and response to anaemia treatment on outcomes in patients with cirrhosis. JHEP Rep 2023; 5:100688. [PMID: 36926273 PMCID: PMC10011825 DOI: 10.1016/j.jhepr.2023.100688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 12/29/2022] [Accepted: 01/12/2023] [Indexed: 01/30/2023] Open
Abstract
Background & Aims Anaemia is frequently observed in patients with cirrhosis and was identified as a predictor of adverse outcomes, such as increased mortality and occurrence of acute-on-chronic liver failure. To date, the possible effects of iron supplementation on these adverse outcomes are not well described. We therefore aimed to assess the role of iron supplementation in patients with cirrhosis and its capability to improve prognosis. Methods Laboratory diagnostics were performed in consecutive outpatients with cirrhosis admitted between July 2018 and December 2019 to the University Hospital Essen. Associations with transplant-free survival were assessed in regression models. Results A total of 317 outpatients with cirrhosis were included, of whom 61 received a liver transplant (n = 19) or died (n = 42). In multivariate Cox regression analysis, male sex (hazard ratio [HR] = 3.33, 95% CI [1.59, 6.99], p = 0.001), model for end-stage liver disease score (HR = 1.19, 95% CI [1.11, 1.27], p <0.001) and the increase of haemoglobin levels within 6 months (ΔHb6) (HR = 0.72, 95% CI [0.63, 0.83], p <0.001) were associated with transplant-free survival. Regarding the prediction of haemoglobin increase, intake of rifaximin (beta = 0.50, SD beta = 0.19, p = 0.007) and iron supplementation (beta = 0.79, SD beta = 0.26, p = 0.003) were significant predictors in multivariate analysis. Conclusions An increase of haemoglobin levels is associated with improvement of transplant-free survival in patients with cirrhosis. Because the prediction of haemoglobin increase significantly depends on rifaximin and iron supplementation, application of these two medications can have an important impact on the outcome of these patients. Impact and implications Anaemia is very common in patients with cirrhosis and is known to be a predictor of negative outcomes, but little is known about the effect of iron substitution in these individuals. In our cohort, increase of haemoglobin levels improved transplant-free survival of patients with cirrhosis. The increase of haemoglobin levels was mainly induced by iron supplementation and was even stronger in the case of concomitant use of iron and rifaximin. Clinical trial registration UME-ID-10042.
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Key Words
- ACLF, acute-on-chronic liver failure
- AIH, autoimmune hepatitis
- ALT, alanine aminotransferase
- AP, alkaline phosphatase
- AST, aspartate aminotransferase
- CRP, C-reactive protein
- Haemoglobin
- INR, international normalised ratio
- Iron deficiency
- Iron supplementation
- LT, liver transplantation
- Liver transplantation
- MELD, model for end-stage liver disease
- NASH, non-alcoholic steatohepatitis
- NSBBs, non-selective beta blockers
- PBC, primary biliary cholangitis
- PSC, primary sclerosing cholangitis
- Rifaximin
- SSC, secondary sclerosing cholangitis
- TIPS, transjugular intrahepatic portosystemic shunt
- aPTT, activated partial thromboplastin time
- ΔHb3, difference of haemoglobin levels after 3 months
- ΔHb6, difference of haemoglobin levels after 6 months
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Affiliation(s)
- Jassin Rashidi-Alavijeh
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Nargiz Nuruzade
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Alexandra Frey
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Eva-Maria Huessler
- Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), University of Duisburg-Essen, Duisburg, Germany
| | - Anne Hörster
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Amos Cornelius Zeller
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Andreas Schütte
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Hartmut Schmidt
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Katharina Willuweit
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Christian Markus Lange
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
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Schwarzkopf KM, Eberle L, Uschner FE, Klein S, Schierwagen R, Mücke MM, Schaefer L, Clària J, Zeuzem S, Hintermann E, Christen U, Lange CM, Trebicka J, Welsch C. Interleukin-22 in acute-on-chronic liver failure: A matter of ineffective levels, receptor dysregulation or defective signalling? J Hepatol 2020; 73:980-982. [PMID: 32698966 DOI: 10.1016/j.jhep.2020.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/12/2020] [Accepted: 05/12/2020] [Indexed: 01/16/2023]
Affiliation(s)
- Katharina Maria Schwarzkopf
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University, Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Larissa Eberle
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University, Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Frank Erhard Uschner
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University, Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Sabine Klein
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University, Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Robert Schierwagen
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University, Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Marcus Maximilian Mücke
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University, Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Liliana Schaefer
- Pharmazentrum Frankfurt/ZAFES, Goethe University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Joan Clària
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain; Hospital Clínic-IDIBAPS, Barcelona, Spain
| | - Stefan Zeuzem
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University, Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Edith Hintermann
- Pharmazentrum Frankfurt/ZAFES, Goethe University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Urs Christen
- Pharmazentrum Frankfurt/ZAFES, Goethe University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Christian Markus Lange
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Jonel Trebicka
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University, Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain.
| | - Christoph Welsch
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University, Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
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Schwarzkopf KM, Queck A, Thomas D, Angioni C, Cai C, Freygang Y, Rüschenbaum S, Geisslinger G, Zeuzem S, Welsch C, Lange CM. Omega-3 and -6 fatty acid plasma levels are not associated with liver cirrhosis-associated systemic inflammation. PLoS One 2019; 14:e0211537. [PMID: 30703151 PMCID: PMC6355116 DOI: 10.1371/journal.pone.0211537] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 01/16/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Liver cirrhosis is associated with profound immunodysfunction, i.e. a parallel presence of chronic systemic inflammation and immunosuppression, which can result in acute-on-chronic liver failure (ACLF). Omega-3 fatty acids are precursors of pro-resolving mediators and support the resolution of inflammation. OBJECTIVE The aim of this study was to determine plasma levels of omega-3 fatty acids in patients with liver cirrhosis and ACLF. METHODS Patients with liver cirrhosis with and without ACLF were enrolled in a prospective cohort study and analyzed post-hoc for the present sub-study. Clinical data and biomaterials were collected at baseline and at day 7, 28 and after 3 months of follow-up. Plasma concentrations of arachidonic acid (ARA) and docosahexaenoic acid (DHA), which represent key omega-6 and -3 fatty acids, respectively, were quantified and associated with markers of systemic inflammation and severity of liver cirrhosis. RESULTS A total of 117 patients were included in the present analyses. Of those, 26 (22.2%), 51 (43.6%) and 40 (34.2%) patients had compensated or decompensated liver cirrhosis, and ACLF. Plasma levels of ARA and DHA were similar in patients with compensated cirrhosis, decompensated cirrhosis, and ACLF. Furthermore, no significant association between plasma ARA or DHA and C-reactive protein or peripheral blood leukocytes were observed (P>0.05). CONCLUSION In our study plasma levels of key omega-3 and omega-6 fatty acid are neither associated with the severity of liver cirrhosis nor with liver-cirrhosis-associated systemic inflammation.
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Affiliation(s)
| | - Alexander Queck
- Department of Internal Medicine 1, Goethe-University Hospital Frankfurt, Frankfurt, Germany
| | - Dominique Thomas
- Institute of Clinical Pharmacology, Goethe-University Frankfurt, Frankfurt, Germany
| | - Carlo Angioni
- Institute of Clinical Pharmacology, Goethe-University Frankfurt, Frankfurt, Germany
| | - Chengcong Cai
- Department of Internal Medicine 1, Goethe-University Hospital Frankfurt, Frankfurt, Germany
| | - Ylva Freygang
- Department of Internal Medicine 1, Goethe-University Hospital Frankfurt, Frankfurt, Germany
| | - Sabrina Rüschenbaum
- Department of Internal Medicine 1, Goethe-University Hospital Frankfurt, Frankfurt, Germany
| | - Gerd Geisslinger
- Institute of Clinical Pharmacology, Goethe-University Frankfurt, Frankfurt, Germany
- Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Project group Translational Medicine & Pharmacology TMP, Frankfurt, Germany
| | - Stefan Zeuzem
- Department of Internal Medicine 1, Goethe-University Hospital Frankfurt, Frankfurt, Germany
| | - Christoph Welsch
- Department of Internal Medicine 1, Goethe-University Hospital Frankfurt, Frankfurt, Germany
| | - Christian Markus Lange
- Department of Internal Medicine 1, Goethe-University Hospital Frankfurt, Frankfurt, Germany
- * E-mail:
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Cai C, Koch B, Akhras S, Hildt E, Zeuzem S, Lange CM. Macrophage-derived extracellular vesicles mediate a long-lasting innate immune response against hepatitis C virus. Z Gastroenterol 2016. [DOI: 10.1055/s-0036-1597522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- C Cai
- Goethe-Universitätsklinikum Frankfurt, Medizinische Klinik 1, Frankfurt am Main, Germany
| | - B Koch
- Goethe-Universitätsklinikum Frankfurt, Medizinische Klinik 3, Frankfurt am Main, Germany
| | - S Akhras
- Paul-Ehrlich-Institut, Abteilung für Virologie, Langen, Germany
| | - E Hildt
- Paul-Ehrlich-Institut, Abteilung für Virologie, Langen, Germany
| | - S Zeuzem
- Goethe-Universitätsklinikum Frankfurt, Medizinische Klinik 1, Frankfurt am Main, Germany
| | - CM Lange
- Goethe-Universitätsklinikum Frankfurt, Medizinische Klinik 1, Frankfurt am Main, Germany
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Dietz J, Lutz T, Knecht G, Gute P, Berkowski C, Lange CM, Khaykin P, Stephan C, Brodt HR, Herrmann E, Zeuzem S, Sarrazin C. Evolution and function of the HCV NS3 protease in patients with acute hepatitis C and HIV coinfection. Virology 2015; 485:213-22. [PMID: 26295281 DOI: 10.1016/j.virol.2015.06.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 06/12/2015] [Accepted: 06/26/2015] [Indexed: 01/03/2023]
Abstract
Little is known about the importance of the hepatitis C virus (HCV) NS3 protease in acute hepatitis C. In this prospective study, 82 consecutive patients with acute hepatitis C and human immunodeficiency virus (HIV) coinfection were enrolled. Individuals were infected with highly related HCV strains and the baseline NS3 quasispecies diversity and complexity was higher compared to a chronic hepatitis C control group (P<0.0001). Both parameters were comparable in patients with spontaneous clearance (n=6) versus treatment-induced SVR (n=5) or development of chronic hepatitis C (n=9). Longitudinal NS3 quasispecies kinetics showed a trend to a decreasing diversity and complexity (P<0.05) within 4 weeks in patients with spontaneous clearance compared to the other groups. The innate immune signalling protein CARDIF was cleaved to a similar extent independent of the outcome. Together with a more pronounced viral load decline (P<0.05), an early decreasing NS3 quasispecies evolution indicates spontaneous clearance of acute hepatitis C.
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Affiliation(s)
- Julia Dietz
- Department of Internal Medicine 1, J.W. Goethe University Hospital, Frankfurt, Germany
| | | | | | | | - Caterina Berkowski
- Department of Internal Medicine 1, J.W. Goethe University Hospital, Frankfurt, Germany
| | | | - Pavel Khaykin
- Department of Internal Medicine 2, J.W. Goethe University Hospital, Frankfurt, Germany
| | - Christoph Stephan
- Department of Internal Medicine 2, J.W. Goethe University Hospital, Frankfurt, Germany
| | - Hans-Reinhard Brodt
- Department of Internal Medicine 2, J.W. Goethe University Hospital, Frankfurt, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modeling, J.W. Goethe University, Frankfurt, Germany
| | - Stefan Zeuzem
- Department of Internal Medicine 1, J.W. Goethe University Hospital, Frankfurt, Germany
| | - Christoph Sarrazin
- Department of Internal Medicine 1, J.W. Goethe University Hospital, Frankfurt, Germany.
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Susser S, Schelhorn SE, Lange CM, Welsch C, Vermehren J, Perner D, Füller C, Lengauer T, Zeuzem S, Sarrazin C. Ultratiefe Pyrosequenz-Analyse (UDPS) von neu beschriebenen seltenen Resistenzvarianten der Hepatitis C Virus NS3 Protease bei Patienten, die mit Telaprevir oder Boceprevir behandelt wurden. Z Gastroenterol 2012. [DOI: 10.1055/s-0032-1323987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Vermehren J, Susser S, Lange CM, Forestier N, Karey U, Hughes E, Ralston R, Tong X, Zeuzem S, Sarrazin C. Mutations selected in the hepatitis C virus NS3 protease domain during sequential treatment with boceprevir with and without pegylated interferon alfa-2b. J Viral Hepat 2012; 19:120-7. [PMID: 22239501 DOI: 10.1111/j.1365-2893.2011.01449.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Treatment with hepatitis C virus (HCV)-NS3-protease inhibitors lead to the selection of resistant variants. Viral kinetics and resistance profiles in patients who are re-treated with the same protease inhibitor are unknown. Viral kinetics and NS3-resistance mutations obtained by clonal sequencing of the NS3-protease were analyzed in nine HCV-genotype-1-infected nonresponder patients who were sequentially treated with boceprevir (400 mg t.i.d.) for 1 week, peginterferon-alfa-2b for 2 weeks and combination of the two for 2 weeks in varying order. In addition to predominant wild-type isolates, previously described boceprevir-resistant mutations (V36, T54, R155, A156, V170) were observed. Furthermore, two resistant mutations (Q41, F43) were detected for the first time in vivo. In three patients, mutations selected after initial treatment with boceprevir were re-selected during subsequent boceprevir exposure. However, mutational patterns after the first and second exposure to boceprevir were different in five patients. In one patient, a viral variant (V55A) known to reduce susceptibility to boceprevir was the predominant variant observed at baseline and throughout treatment and was associated with a shallow viral decline. Different resistance mutations were selected during treatment with boceprevir ± peginterferon. Sequential short-term dosing of boceprevir was not associated with accumulation of resistant variants but pre-existing variants may impair virologic response.
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Affiliation(s)
- J Vermehren
- Medizinische Klinik 1, Klinikum der J W Goethe-Universität, Frankfurt am Main, Germany
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Farnik H, Lange CM, Hofmann WP, Berger A, Allwinn R, Welker MW, Trojan J, Sarrazin C, Herrmann E, Zeuzem S, Kronenberger B. Nucleos(t)ide analogue treatment reduces apoptotic activity in patients with chronic hepatitis B. J Clin Virol 2011; 52:204-9. [PMID: 21903459 DOI: 10.1016/j.jcv.2011.08.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 06/23/2011] [Accepted: 08/08/2011] [Indexed: 01/05/2023]
Abstract
BACKGROUND Reduction of necroinflammatory activity is a major goal of antiviral therapy of patients with chronic hepatitis B. Serum ALT does not detect all forms of cell death. OBJECTIVES To analyze dynamics of novel serum cell death markers for apoptosis and necrosis in association with virologic response to nucleos(t)ide (Nuc) analogue treatment. STUDY DESIGN Quantification of the M30-apoptosis neoepitope and the cytokeratin-18 (M65-necrosis) serum levels before and during treatment of patients with chronic hepatitis B with Nuc (n = 26). RESULTS Before treatment, M30-apoptotic activity was significantly correlated with M65-necrosis and fibrosis but not with serum ALT. During therapy with Nucs, cell death parameters M30-apoptosis, M65-necrosis, and ALT declined in association with virologic response. The most frequent cell death pattern was simultaneous decline of ALT and M30-apoptosis which occurred more frequently in patients with HBs-Antigen decline than in patients with HBs-Antigen increase during treatment (87.5% vs. 40.0%; p = 0.024). ALT decline in association with increase of M30 apoptosis was frequent in patients with HBs-Antigen increase during treatment (36.3%) but was not observed in patients with HBs-Antigen decline during treatment. CONCLUSION Decline of cell death parameters in association with decline of HBV-DNA and HBs-Antigen indicates a reduction in overall cell death activity during Nuc treatment supporting the concept that response to Nuc therapy reduces necroinflammatory activity and progression of liver disease.
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Affiliation(s)
- Harald Farnik
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität Frankfurt, Theodor-Stern-Kai 7, Haus 11, 60590 Frankfurt, Germany
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Welker MW, Hofmann WP, Lange CM, Herrmann E, Sarrazin C, Zeuzem S, Kronenberger B. CD81 expression for discrimination between sustained virologic response and relapse in patients with chronic hepatitis C. Scand J Gastroenterol 2011; 46:973-80. [PMID: 21615225 DOI: 10.3109/00365521.2011.579155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIM The hepatitis C virus (HCV) receptor CD81 is overexpressed on peripheral blood mononuclear cells (PBMC) in patients chronically infected with HCV compared with healthy controls, and expression declines during antiviral therapy. The aim of this study was to prospectively investigate CD81 expression on PBMC for early discrimination between sustained virologic response (SVR) and relapse (REL) to pegylated interferon alfa-2b and ribavirin treatment. METHODS Sixty-one patients with chronic HCV infection (genotype, GT, 1 and low baseline viremia <600,000 IU/ml, n = 30; GT 2 or 3, n = 31) were investigated. CD81 expression on CD4(+), CD8(+), CD19(+), and CD56(+) cells was measured at baseline, therapy week (TW) 4 and 12 during antiviral therapy by fluorescence-activated cell sorting (FACS) analysis. RESULTS Baseline levels of CD81 on CD4(+), CD8(+), and CD56(+) cells were similar between patients who achieved a SVR (n = 42) and those who relapsed (n = 19). On CD19(+) cells, baseline CD81 expression was higher in patients with SVR than in patients with virologic relapse (REL) (p < 0.006). A cutoff value of 720 relative fluorescence units (RFU) discriminated correctly between SVR and REL with a sensitivity and specificity of 73.7% and 66.7%, respectively. SVR patients showed a significant decline of CD81 expression on CD4(+), CD8(+), CD19(+), and CD56(+) cells (p < 0.01 for all) while in REL patients a significant decline of CD81 expression was observed on CD8(+) and CD56(+) cells, only (p = 0.050 and p = 0.038, respectively). CONCLUSIONS The current study confirms significant down-regulation of CD81 expression on different lymphocyte subpopulations during pegylated interferon alfa-based antiviral therapy in patients with chronic hepatitis C. Baseline CD81 expression on CD19(+) cells was found to discriminate between SVR and REL.
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Affiliation(s)
- Martin-Walter Welker
- Klinikum der Johann Wolfgang Goethe-Universität, Medizinische Klinik 1, Frankfurt am Main, Germany
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Lange CM, Bojunga J, Ramos-Lopez E, von Wagner M, Hassler A, Vermehren J, Herrmann E, Badenhoop K, Zeuzem S, Sarrazin C. Vitamin D deficiency and a CYP27B1-1260 promoter polymorphism are associated with chronic hepatitis C and poor response to interferon-alfa based therapy. J Hepatol 2011. [PMID: 21145801 DOI: 10.1016/j.jhep.2010.08.03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS Vitamin D is an important immune modulator and preliminary data indicated an association between vitamin D deficiency and sustained virologic response (SVR) rates in hepatitis C virus (HCV) genotype 1 patients. We, therefore, performed a comprehensive analysis on the impact of vitamin D serum levels and of genetic polymorphisms with functional relevance within the vitamin D cascade on chronic hepatitis C and its treatment. METHODS Vitamin D serum levels, genetic polymorphisms within the vitamin D receptor and 1α-hydroxylase were determined in a cohort of 468 HCV genotype 1, 2, and 3 infected patients who were treated with interferon-alfa based regimens. RESULTS Chronic hepatitis C was associated with a high incidence of severe vitamin D deficiency compared to controls (25(OH)D(3)<10 ng/ml in 25% versus 12%, p<0.00001). 25(OH)D(3) deficiency correlated with SVR in HCV genotype 2 and 3 patients (50% and 81% SVR for patients with and without severe vitamin D deficiency, respectively, p<0.0001). In addition, the CYP27B1-1260 promoter polymorphism rs10877012 had substantial impact on 1,25-dihydroxyvitamin D serum levels (72, 61, and 60 pmol/ml for rs10877012 AA, AC, and CC, respectively, p=0.04) and on SVR rates in HCV genotype 1, 2, and 3 infected patients (77% and 65% versus 42% for rs10877012 AA, AC, and CC, respectively, p=0.02). CONCLUSIONS Chronic hepatitis C virus infection is associated with vitamin D deficiency. Reduced 25-hydroxyvitamin D levels and CYP27B1-1260 promoter polymorphism leading to reduced 1,25-dihydroxyvitamin D levels are associated with failure to achieve SVR in HCV genotype 1, 2, and 3 infected patients.
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Affiliation(s)
- Christian Markus Lange
- Klinikum der J.W. Goethe-Universität Frankfurt am Main, Medizinische Klinik 1, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
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Lange CM, Bojunga J, Ramos-Lopez E, von Wagner M, Hassler A, Vermehren J, Herrmann E, Badenhoop K, Zeuzem S, Sarrazin C. Vitamin D deficiency and a CYP27B1-1260 promoter polymorphism are associated with chronic hepatitis C and poor response to interferon-alfa based therapy. J Hepatol 2011; 54:887-93. [PMID: 21145801 DOI: 10.1016/j.jhep.2010.08.036] [Citation(s) in RCA: 187] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Revised: 07/28/2010] [Accepted: 08/17/2010] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Vitamin D is an important immune modulator and preliminary data indicated an association between vitamin D deficiency and sustained virologic response (SVR) rates in hepatitis C virus (HCV) genotype 1 patients. We, therefore, performed a comprehensive analysis on the impact of vitamin D serum levels and of genetic polymorphisms with functional relevance within the vitamin D cascade on chronic hepatitis C and its treatment. METHODS Vitamin D serum levels, genetic polymorphisms within the vitamin D receptor and 1α-hydroxylase were determined in a cohort of 468 HCV genotype 1, 2, and 3 infected patients who were treated with interferon-alfa based regimens. RESULTS Chronic hepatitis C was associated with a high incidence of severe vitamin D deficiency compared to controls (25(OH)D(3)<10 ng/ml in 25% versus 12%, p<0.00001). 25(OH)D(3) deficiency correlated with SVR in HCV genotype 2 and 3 patients (50% and 81% SVR for patients with and without severe vitamin D deficiency, respectively, p<0.0001). In addition, the CYP27B1-1260 promoter polymorphism rs10877012 had substantial impact on 1,25-dihydroxyvitamin D serum levels (72, 61, and 60 pmol/ml for rs10877012 AA, AC, and CC, respectively, p=0.04) and on SVR rates in HCV genotype 1, 2, and 3 infected patients (77% and 65% versus 42% for rs10877012 AA, AC, and CC, respectively, p=0.02). CONCLUSIONS Chronic hepatitis C virus infection is associated with vitamin D deficiency. Reduced 25-hydroxyvitamin D levels and CYP27B1-1260 promoter polymorphism leading to reduced 1,25-dihydroxyvitamin D levels are associated with failure to achieve SVR in HCV genotype 1, 2, and 3 infected patients.
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Affiliation(s)
- Christian Markus Lange
- Klinikum der J.W. Goethe-Universität Frankfurt am Main, Medizinische Klinik 1, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
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Abstract
Hepatitis C virus (HCV) nonstructural protein 3-4A (NS3-4A) is a complex composed of NS3 and its cofactor NS4A. It harbours serine protease as well as NTPase/RNA helicase activities and is essential for viral polyprotein processing, RNA replication and virion formation. Specific inhibitors of the NS3-4A protease significantly improve sustained virological response rates in patients with chronic hepatitis C when combined with pegylated interferon-α and ribavirin. The NS3-4A protease can also target selected cellular proteins, thereby blocking innate immune pathways and modulating growth factor signalling. Hence, NS3-4A is not only an essential component of the viral replication complex and prime target for antiviral intervention but also a key player in the persistence and pathogenesis of HCV. This review provides a concise update on the biochemical and structural aspects of NS3-4A, its role in the pathogenesis of chronic hepatitis C and the clinical development of NS3-4A protease inhibitors.
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Affiliation(s)
- K Morikawa
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
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Sarrazin C, Susser S, Doehring A, Lange CM, Müller T, Schlecker C, Herrmann E, Lötsch J, Berg T. Importance of IL28B gene polymorphisms in hepatitis C virus genotype 2 and 3 infected patients. J Hepatol 2011; 54:415-21. [PMID: 21112657 DOI: 10.1016/j.jhep.2010.07.041] [Citation(s) in RCA: 186] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Revised: 06/09/2010] [Accepted: 07/05/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Genetic variation in the interleukin 28B (IL28B) gene has been associated with the response to interferon-alfa/ribavirin therapy in hepatitis C virus (HCV) genotype 1-infected patients. The importance of three IL28B single nucleotide polymorphisms (rs8099917, rs12980275 and rs12979860) for HCV genotype 2/3-infected patients is unknown. METHODS In patients with chronic hepatitis C genotype 2/3 (n=267), IL28B host genotypes (rs8099917, rs12980275 and rs12979860) were analyzed for associations with sustained virologic response (SVR) to antiviral therapy with (pegylated) interferon-alfa and ribavirin and with respect to epidemiological, biochemical, and virological parameters. For comparison, hepatitis C genotype 1 patients (n=378) and healthy controls (n=200) were included. RESULTS The rs12979860 CC genotype, lower age, and genotype 2 were significantly associated with SVR in HCV genotype 2/3-infected patients (p=0.01, p=0.03 and p=0.03, respectively). No association was observed for rs8099917 and rs12980275. In addition, an SVR in patients with rapid virologic response (RVR) was associated with the rs12979860 CC genotype (p=0.05), while for non-RVR no association was found. Furthermore, a significant association with a higher baseline viral load was observed for all three IL28B genotypes in genotype 1/2/3-infected patients. Finally, increasing frequencies of the rs12979860 CC genotypes were observed in genotype 1- (33.9%), genotype 3- (38.9%), and genotype 2-infected (51.9%) patients in comparison with healthy controls (49.0%) (p<0.01). CONCLUSIONS In genotype 2/3-infected patients, rs12979860 was significantly associated with SVR. The frequency of the rs12979860 CC genotype is lower in HCV genotype 1 vs. genotype 2/3 patients. All major IL28B genotypes are associated with HCV-RNA concentration.
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Affiliation(s)
- Christoph Sarrazin
- Medizinische Klinik 1, J. W. Goethe-University Hospital, Frankfurt am Main, Germany.
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Lange CM, Sarrazin C, Zeuzem S. New Antiviral Therapies in the Management of Hepatitis C Virus Infection. Gut Liver 2011. [DOI: 10.1159/000322447] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Lange CM, Roomp K, Dragan A, Nattermann J, Michalk M, Spengler U, Weich V, Lengauer T, Zeuzem S, Berg T, Sarrazin C. HLA class I allele associations with HCV genetic variants in patients with chronic HCV genotypes 1a or 1b infection. J Hepatol 2010; 53:1022-8. [PMID: 20800922 DOI: 10.1016/j.jhep.2010.06.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Revised: 06/02/2010] [Accepted: 06/03/2010] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS The adaptive immune response against hepatitis C virus (HCV) is significantly shaped by the host's composition of HLA-alleles with the consequence that the HLA phenotype is a critical determinant of viral evolution during adaptive immune pressure. In the present study, we aimed to identify associations of HLA class I alleles with HCV subtypes 1a and 1b genetic variants. METHODS The association between HCV genetic variants and specific HLA-alleles was investigated in a cohort of 159 patients with chronic HCV genotypes 1a- and 1b-infection who were treated with pegylated interferon-alfa 2b and ribavirin in a prospective controlled trial for 48 weeks by direct sequencing of the genes encoding the HCV proteins E2, NS3, and NS5B and by HLA class I-genotyping of patients. HCV genetic variants were associated with specific HLA-alleles and the binding strength of accordant amino acid sequences to the corresponding HLA-allele was assessed by using the SYFPEITHI-algorithm. RESULTS Overall, associations between HLA class I alleles and HCV sequence variation were rare. Five unknown HLA class I-associated viral genetic variations were identified, which in part affected the binding of predicted HCV CD8+ T cell epitopes to the respective HLA-allele. In addition, different patterns of HLA class I-allele/HCV sequence associations between the two subtypes were observed. CONCLUSIONS We identified several unknown HLA class I-restricted HCV variants which in part impair binding to predicted HCV CD8+ T cell epitopes with remarkable differences between HCV subtypes 1a and 1b quasispecies.
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Affiliation(s)
- Christian Markus Lange
- Klinikum der J.W. Goethe-Universität Frankfurt am Main, Medizinische Klinik 1, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
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Abstract
BACKGROUND Novel, directly acting anti-viral agents, also named 'specifically targeted anti-viral therapy for hepatitis C' (STAT-C) compounds, are currently under development. AIM To review the potential of STAT-C agents which are currently under clinical development, with a focus on agents that target HCV proteins. METHODS Studies evaluating STAT-C compounds were identified by systematic literature search using PubMed as well as databases of abstracts presented in English at recent liver and gastroenterology congresses. RESULTS Numerous directly-acting anti-viral agents are currently under clinical phase I-III evaluation. Final results of phase II clinical trials evaluating the most advanced compounds telaprevir and boceprevir indicate that the addition of these NS3/4A protease inhibitors to pegylated interferon-alfa and ribavirin strongly improves the chance to achieve a SVR in treatment-naive HCV genotype 1 patient as well as in prior nonresponders and relapsers to standard therapy. Monotherapy with directly acting anti-virals is not suitable. NS5B polymerase inhibitors in general have a lower anti-viral efficacy than protease inhibitors. CONCLUSIONS STAT-C compounds in addition to pegylated interferon-alfa and ribavirin can improve SVR rates at least in HCV genotype 1 patients. Future research needs to evaluate whether a SVR can be achieved by combination therapies of STAT-C compounds in interferon-free regimens.
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Affiliation(s)
- C M Lange
- Department of Medicine, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
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Lange CM, Hofmann WP, Kriener S, Jacobi V, Welsch C, Just-Nuebling G, Zeuzem S. Primary actinomycosis of the liver mimicking malignancy. Z Gastroenterol 2009; 47:1062-4. [PMID: 19809957 DOI: 10.1055/s-0028-1109752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
A 71-year old women presented with fever, a significant loss of body weight and abdominal pain in the upper right quadrant since approximately six months. Abdominal ultrasonography and magnetic resonance imaging (MRI) showed an irregularly shaped, inhomogeneous and hypointense lesion of the right liver lobe (6 x 8 cm in segment 7 and 8) with multiple satellite lesions. Irregular shape, hypovascular presentation during gadolinium enhancement, hypointensity in T 1-weighted images and dilation of peripheral bile ducts were suggestive for cholangiocarcinoma or metastasis. However, histological investigations revealed a rare case of primary actinomycosis of the liver which was successfully treated with antibiotics.
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Affiliation(s)
- C M Lange
- Medizinische Klinik 1, J.-W.-Goethe-Universitätsklinikum, Frankfurt am Main.
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Loutelier-Bourhis C, Legros H, Bonnet JJ, Costentin J, Lange CM. Gas chromatography/mass spectrometric identification of dopaminergic metabolites in striata of rats treated with L-DOPA. Rapid Commun Mass Spectrom 2004; 18:571-576. [PMID: 14978802 DOI: 10.1002/rcm.1369] [Citation(s) in RCA: 8] [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] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The ex vivo identification of dopaminergic metabolites present in rat striata after (L-DOPA + benserazide) treatment is reported. The different metabolites have been identified as the trimethylsilyl derivatives in the striatal extracts by gas chromatography/mass spectrometry.
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Affiliation(s)
- C Loutelier-Bourhis
- Spectrométrie de masse Bio-Organique, UMR 6014 CNRS, Université de Rouen, 76821 Mont-saint-Aignan cedex, France.
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Carraze B, Delafoy J, Bertin J, Beziau JF, Lange CM. Mass spectral fingerprints of detergents in gasolines using electrospray ionization. Rapid Commun Mass Spectrom 2004; 18:451-457. [PMID: 14966852 DOI: 10.1002/rcm.1355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Mass spectral fingerprints of detergents in Austrian, Hungarian, Uruguayan, and Chilean gasolines have been obtained using electrospray ionization mass spectrometry. Polymers or copolymers were observed based on ether motifs (inter-peak spacings of 44, 58 and 72 u) in all samples. Austrian gasoline was found to also contain polymers based on isobutene-amine.
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Affiliation(s)
- B Carraze
- PSA Peugeot Citroën, DMOV/MXP/TAC, Centre de Vélizy, 78943 Velizy Villacoublay, France
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Abstract
Sequences in the transcribed region of the c-fos gene have been suggested to control c-fos induction following exposure of cells to mitogens or stimuli that increase intracellular calcium concentrations. Using a mutational analysis we show that putative regulatory elements present in the first intron of the human c-fos gene and the fos-intragenic-regulatory-element (FIRE) are not required for c-fos regulation by growth factor and calcium signalling pathways in AtT20 and PC12 cells. Removal of the c-fos first intron and the FIRE did not increase the basal level of c-fos mRNA and only moderately reduced the magnitude of calcium-induced transcription mediated by either the entire c-fos promoter or the cAMP response element (CRE). Intragenic mutations did not affect serum response element (SRE)-dependent gene expression induced by calcium signals but caused a superinduction of c-fos expression in nerve growth factor-stimulated PC12 cells. These results indicate that c-fos promoter elements, rather than intragenic sequences, are the principal targets of transcription-regulating signalling pathways. This suggests that CRE- and SRE-bound activators of transcription initiation may also enhance, in a signal-dependent manner, c-fos transcript elongation beyond promoter-proximal pause sites.
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Affiliation(s)
- C M Lange
- MRC Laboratory of Molecular Biology, Hills Road, Cambridge, UK
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Maxson PM, Berge KH, Hall-Flavin DK, Zietlow SP, Schroeder DR, Lange CM. Detectable blood alcohol after a motor vehicle crash and screening for alcohol abuse/dependence. Mayo Clin Proc 2000; 75:231-4. [PMID: 10725947 DOI: 10.4065/75.3.231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine the percentage of patients hospitalized after an alcohol-related motor vehicle crash (MVC) who underwent a screening evaluation for alcohol abuse/dependence and had a diagnosis of alcohol abuse/dependence. PATIENTS AND METHODS Medical and emergency trauma records were reviewed retrospectively for 1994 through 1996 to identify patients who were hospitalized as a result of being involved in an MVC with any detected blood alcohol at the time of admission to a large midwestern Level I trauma center. The primary outcome measure was the performance of alcohol abuse/dependence screening by a psychiatrist or a chemical dependency counselor. A univariate analysis was performed to identify factors associated with the performance of alcohol abuse/dependence screening. The Fisher exact test and the 2-sample rank sum test were used in the analyses. RESULTS Of the 294 study patients, 78 (26.5%) underwent a screening evaluation for alcohol abuse/dependence by a psychiatrist or a chemical dependency counselor during hospitalization, and 69 (88%) of the 78 patients screened had a diagnosis of alcohol abuse/dependence. Factors associated with the performance of alcohol abuse/dependence evaluation included a known prior history of alcohol abuse, suspicion of alcohol consumption documented by emergency department personnel, higher blood alcohol level at admission, and longer length of hospitalization (all P < .001). CONCLUSION While the high rate of alcohol abuse/dependence may be explained partially by distinguishing factors in those screened, these findings suggest that routine alcohol abuse/dependence screening of persons presenting with a detectable blood alcohol level following an MVC may identify patients who would benefit from a chemical dependency intervention.
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Affiliation(s)
- P M Maxson
- Department of Anesthesiology, Mayo Clinic Rochester, MN 55905, USA
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Bonner JA, Garces YI, Sawyer TE, Gould PM, Foote RL, Deschamps C, Lange CM, Li H. Frequency of noncontiguous lymph node involvement in patients with resectable nonsmall cell lung carcinoma. Cancer 1999; 86:1159-64. [PMID: 10506699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
BACKGROUND This study was undertaken to investigate the patterns of lymph node spread and the frequency of involvement of noncontiguous lymph node stations in patients with nonsmall cell lung carcinoma who had complete surgical resection. METHODS All patients who had surgical resection as their sole treatment for nonsmall cell lung carcinoma during the years 1987-1990 were reviewed. All patients were treated similarly. Generally, complete mediastinal lymph node dissection was performed after resection of the primary lesion and N1 lymph nodes. Patients were assessed for patterns of involvement of N1 and N2 lymph node stations. The frequency of noncontiguous involvement of lymph nodes (involvement of N2 lymph nodes without involvement of N1 lymph nodes) was determined. Patient and tumor characteristics were assessed to ascertain whether certain factors were likely to predict this noncontiguous pattern of lymph node spread. RESULTS During the 4-year period of study, 336 patients with nonsmall cell lung carcinoma were managed with surgical resection alone. Of the 336, 100 had no involvement of lymph nodes, 108 had involvement of N1 lymph nodes only, 76 had involvement of N1 and N2 lymph nodes, and 52 had involvement of N2 lymph nodes only. Therefore, 52 of all 336 patients (15%) and 52 of 236 patients with lymph node involvement (22%) had noncontiguous lymph node spread. A review of the initial patient and tumor characteristics revealed that patients with a suggestion of enlarged mediastinal lymph nodes on preoperative computed tomography scans of the chest (compared with negative findings) and patients with T1 and T2 lesions (compared with T3 and T4) were more likely to have noncontiguous lymph node spread; the odds ratios (with 95% confidence intervals) were 2.18 (1.01-4.71) and 2.82 (1.36-5.84), respectively. CONCLUSIONS Noncontiguous involvement of thoracic lymph nodes occurred in approximately 15% of patients who had complete surgical resection of nonsmall cell lung carcinoma. This factor suggests that lack of involvement of N1 lymph nodes does not rule out mediastinal involvement and provides important information for complete surgical staging.
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Affiliation(s)
- J A Bonner
- Division of Radiation Oncology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
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Abstract
BACKGROUND Although irradiation and chemotherapy are unproved adjuvant treatments for completely resected N1 non-small cell lung carcinoma, previous studies may have been diluted by the inclusion of low-risk patients. Risk factors in this situation, however, are not yet well defined. METHODS One hundred seven consecutive patients with complete resection of N1 disease who received no other therapy were studied to identify factors independently predicting the risk of freedom from local recurrence (FFLR), freedom from distant metastasis (FFDM), and overall survival (OS). RESULTS Twelve factors were assessed for a potential prognostic relationship with FFLR, FFDM, and OS. Regression analyses revealed that the factors independently associated with an improved outcome were positive bronchoscopic findings (FFLR, p = 0.005), a greater number of dissected N1 nodes (FFDM, p = 0.02), and a lesser T stage (OS, p = 0.01). Classification and regression tree analyses were then used to separate the patients into risk groups. CONCLUSIONS Although these results require corroboration in further studies, they may aid the design of trials examining therapies used to decrease rates of local recurrence or distant metastasis.
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Affiliation(s)
- T E Sawyer
- Division of Radiation Oncology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Sawyer TE, Bonner JA, Gould PM, Deschamps C, Lange CM, Li H. Patients with stage I non-small cell lung carcinoma at postoperative risk for local recurrence, distant metastasis, and death: implications related to the design of clinical trials. Int J Radiat Oncol Biol Phys 1999; 45:315-21. [PMID: 10487551 DOI: 10.1016/s0360-3016(99)00189-3] [Citation(s) in RCA: 31] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE Patients with pathologically staged American Joint Committee on Cancer stage I (T1 N0 or T2 N0) non-small cell lung cancer have a favorable prognosis after complete surgical resection compared with patients with more advanced stages. Benefits of adjuvant therapy in this setting are unproved. However, there may be subgroups of patients with stage I disease at high enough risk for local recurrence to prompt consideration of adjuvant or neoadjuvant radiation therapy. Likewise, there may be subgroups of patients at high enough risk for distant metastasis to justify the evaluation of chemotherapy. METHODS AND MATERIALS From 1987 through 1990, 370 patients undergoing gross total resection of non-small cell lung cancer had stage I disease and received no chemotherapy or radiation therapy as part of their primary treatment. These patients were the subject of a retrospective review to separate patients into high-, intermediate-, and low-risk groups with respect to freedom from local recurrence (FFLR), freedom from distant metastasis (FFDM), and overall survival by using a regression tree analysis. RESULTS The 5-year rates of FFLR, FFDM, and survival were 85%, 83%, and 66%, respectively. Regression analyses revealed that the factors independently predicting for a poorer FFLR rate included fewer than 15 lymph nodes dissected and pathologically evaluated (p = 0.002) and the presence of a T2 tumor (p = 0.04). Factors independently predicting for a poorer FFDM rate included a maximal dimension greater than 5 cm (p = 0.02) and nonsquamous histology (p = 0.03). Factors independently predicting for a poorer survival rate included fewer than 15 lymph nodes dissected and pathologically evaluated p = 0.001) and a maximal dimension greater than 3 cm (p = 0.003). Regression tree analyses were used to separate patients into risk groups. CONCLUSION Incorporating the aforementioned factors into regression tree analyses, three risk groups were identified with respect to FFLR. Two each were identified for FFDM and for survival. For each of these three end-points, the differences in outcomes for each risk group were found to be both statistically and clinically significant. These risk groups may be useful in the future design of phase III trials evaluating the use of adjuvant chemotherapy and radiation therapy in the stage I setting.
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Affiliation(s)
- T E Sawyer
- Division of Radiation Oncology, Mayo Clinic and Mayo Foundation, Rochester, MN, USA
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Gould PM, Bonner JA, Sawyer TE, Deschamps C, Lange CM, Li H. Patterns of failure and overall survival in patients with completely resected T3 N0 M0 non-small cell lung cancer. Int J Radiat Oncol Biol Phys 1999; 45:91-5. [PMID: 10477011 DOI: 10.1016/s0360-3016(99)00148-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Previous studies of patients with surgically resected non-small cell lung cancer and chest wall invasion have shown conflicting results with respect to prognosis. Whether high-risk subsets of the T3 N0 M0 population exist with respect to patterns of failure and overall survival has been difficult to ascertain, owing to small numbers of patients in most series. METHODS AND MATERIALS A retrospective review was performed to determine patterns of failure and overall survival for patients with completely resected T3 N0 M0 non-small cell lung cancer. From 1979 to 1993, 92 evaluable patients underwent complete resection for T3 N0 M0 non-small cell lung cancer. The following potential prognostic factors were recorded from the history: tumor size, location, grade, histology, patient age, use of adjuvant radiation therapy (18 of 92 patients), and type of surgical procedure (chest wall or extrapleural resection). RESULTS The actuarial 2- and 4-year overall survival rates for the entire cohort were 48% and 35%, respectively. The actuarial local control at 4 years was 94%. Neither the type of surgical procedure performed nor the addition of thoracic radiation therapy impacted local control or overall survival. CONCLUSION Patients with completely resected T3 N0 M0 non-small cell lung cancer have similar local control and overall survival irrespective of primary location, type of surgery performed, or use of adjuvant radiation therapy. Additionally, the tumor recurrence rate and overall survival found in this study support the placement of this group of patients in Stage IIB of the 1997 AJCC lung staging classification.
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Affiliation(s)
- P M Gould
- Division of Radiation Oncology, Mayo Clinic and Mayo Foundation, Rochester, MN, USA
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Maxson PM, Schultz KL, Berge KH, Lange CM, Schroeder DR, Rummans TA. Probable alcohol abuse or dependence: a risk factor for intensive-care readmission in patients undergoing elective vascular and thoracic surgical procedures. Mayo Perioperative Outcomes Group. Mayo Clin Proc 1999; 74:448-53. [PMID: 10319073] [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: 02/12/2023]
Abstract
OBJECTIVE To determine whether alcohol abuse or dependence is a risk factor for perioperative complications, increased duration of hospital stay, and increased utilization of nursing resources in patients undergoing thoracic and vascular surgical procedures. MATERIAL AND METHODS We conducted a prospective study of all adult patients who underwent an elective vascular or thoracic surgical procedure and who received postoperative care in an intensive-care setting. Patients were screened for alcohol abuse or dependence, and actual versus expected durations of stay were evaluated. The patients' medical records were reviewed for preoperative comorbidities and perioperative complications. Fisher's exact test and the rank sum test were used in the analyses. RESULTS Of 321 study subjects, 290 were classified as nonalcoholic and 31 as probable alcoholic patients. Patients in the probable alcohol abuse group had a significantly increased rate of alcohol withdrawal (12.9% versus 1.7%; P = 0.006) in comparison with patients in the nonalcoholic group. Patients in the probable alcohol abuse group were readmitted to an intensive-care unit more frequently (19.4% versus 7.9%; P = 0.047) and required sedation more often (32.3% versus 13.5%; P = 0.014) than those in the nonalcoholic group. No significant differences were found between the two study groups in intensive-care unit and hospital durations of stay or in utilization of nursing resources. A dismissal diagnosis of alcoholism was recorded for only one of four patients who had a documented withdrawal episode among those categorized in the probable alcoholic group and for three of five patients with alcohol withdrawal symptoms categorized in the nonalcoholic group. CONCLUSION Except for the occurrence of alcohol withdrawal syndrome, study patients classified in the probable alcohol abuse group did not have more medical or surgical perioperative complications than patients in the nonalcoholic group. They did have significantly more intensive-care setting readmissions. Patients with documented alcohol withdrawal episodes frequently were dismissed without a diagnosis of substance abuse or dependence.
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Affiliation(s)
- P M Maxson
- Department of Anesthesiology, Mayo Clinic Rochester, MN 55905, USA
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Sawyer TE, Bonner JA, Gould PM, Garces YI, Foote RL, Lange CM, Li H. Predictors of subclinical nodal involvement in clinical stages I and II non-small cell lung cancer: implications in the inoperable and three-dimensional dose-escalation settings. Int J Radiat Oncol Biol Phys 1999; 43:965-70. [PMID: 10192341 DOI: 10.1016/s0360-3016(98)00508-2] [Citation(s) in RCA: 32] [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: 10/17/2022]
Abstract
PURPOSE When mediastinal lymph nodes are clinically uninvolved in the setting of inoperable non-small cell lung cancer, whether conventional radiation techniques or three-dimensional dose-escalation techniques are used, the benefit of elective nodal irradiation is unclear. Inclusion of the clinically negative mediastinum in the radiation portals increases the risk of lung toxicity and limits the ability to escalate dose. This analysis represents an attempt to use clinical characteristics to estimate the risk of subclinical nodal involvement, which may help determine which patients are most likely to benefit from elective nodal irradiation. METHODS From 1987 to 1990, 346 patients undergoing complete resection of non-small cell lung cancer underwent a preoperative computed tomographic scan revealing no clinical evidence of N2/N3 involvement. Multivariate regression and regression tree analyses attempted to define which patients were at highest risk for subclinical mediastinal involvement (N2) and which patients were at highest risk for subclinical N1 and/or N2 involvement (N1/N2). Immunohistochemical data suggest that the conventional histopathologic techniques used during this study somewhat underestimate the true degree of lymph node involvement; therefore, a third end point was also evaluated: N1 involvement and/or N2 involvement and/or local-regional recurrence (N1/N2/LRR). RESULTS Regression analyses revealed that the following factors were independently associated with a high risk of more advanced disease: positive preoperative bronchoscopy (N2, p = 0.02; N1/N2, p < 0.0001; N1/N2/LRR, p < 0.001) and tumor grade 3/4 (N1/N2/LRR, p < 0.01). A regression tree analysis was then used to separate patients into risk groups with respect to N1/N2/LRR. CONCLUSION In inoperable non-small cell lung cancer, the patients for whom mediastinal radiation therapy may most likely be indicated are those with a positive preoperative bronchoscopy, especially with large (> 3 cm) primary tumors.
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Affiliation(s)
- T E Sawyer
- Division of Radiation Oncology, Mayo Clinic and Mayo Foundation, Rochester, MN, USA
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Gould PM, Bonner JA, Sawyer TE, Deschamps C, Lange CM, Li H. Bronchial carcinoid tumors: importance of prognostic factors that influence patterns of recurrence and overall survival. Radiology 1998; 208:181-5. [PMID: 9646811 DOI: 10.1148/radiology.208.1.9646811] [Citation(s) in RCA: 35] [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: 11/11/2022]
Abstract
PURPOSE To analyze bronchial carcinoid characteristics that might influence patterns of disease recurrence and overall survival in patients with these tumors. MATERIALS AND METHODS In a retrospective review, the actuarial rates of local relapse, regional relapse, and overall survival were determined in patients who had undergone resection of bronchial carcinoid tumors. The evaluable files for 87 patients (50 male, 37 female; age range, 15-82 years) who underwent resection of bronchial carcinoid cancer at the authors' institution between 1980 and 1993 were reviewed for pathologic findings, extent of disease, and recurrence patterns after surgery. RESULTS The actuarial 4-year overall survival, local control, and regional control rates in the entire cohort of patients were 89%, 92%, and 94%, respectively. Univariate analyses revealed that an atypical histologic pattern was the only tumor-related factor that substantially affected local and regional control. Atypical histologic pattern and tumor size were among the multiple factors that independently affected overall survival. CONCLUSION Atypical histologic findings in patients who had undergone complete resection of bronchial carcinoid tumors were associated with increased local-regional disease recurrence and decreased survival compared with recurrence and survival in patients with typical histologic findings.
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Affiliation(s)
- P M Gould
- Division of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
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Sawyer TE, Bonner JA, Gould PM, Foote RL, Deschamps C, Trastek VF, Pairolero PC, Allen MS, Lange CM, Li H. Effectiveness of postoperative irradiation in stage IIIA non-small cell lung cancer according to regression tree analyses of recurrence risks. Ann Thorac Surg 1997; 64:1402-7; discussion 1407-8. [PMID: 9386711 DOI: 10.1016/s0003-4975(97)00908-9] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND In the setting of grossly resected stage IIIA (N2 involvement) non-small cell lung carcinoma, the role of adjuvant postoperative thoracic radiation therapy (TRT) remains controversial. This study was initiated to subcategorize these patients into high-, intermediate-, and low-risk groups with respect to local recurrence and survival rates, and to determine whether there were certain subgroups of patients who were particularly likely or unlikely to benefit from postoperative TRT. METHODS Two hundred twenty-four patients were studied. A regression tree analysis was used to separate patients who had undergone operation alone into groups that had a high, intermediate, or low risk of local recurrence and death. The effect of adjuvant postoperative TRT then was examined in each of these groups. RESULTS The use of adjuvant postoperative TRT (compared with operation alone) was associated with an improvement in freedom from local recurrence and survival for patients who had an intermediate or high risk of local recurrence and death. However, the greatest level of improvement in freedom from local recurrence (p < 0.0001) and survival (p = 0.0002) associated with the use of adjuvant postoperative TRT was in the high-risk group. Similarly, but of lesser magnitude, the intermediate-risk group had improved freedom from local recurrence and survival rates with the use of adjuvant post-operative TRT (p = 0.002 and p = 0.01, respectively). For the low-risk group, the freedom from local recurrence and survival rates were not statistically different between the patients who received adjuvant postoperative TRT and those who underwent observation. CONCLUSIONS Patients with non-small cell lung carcinoma involving ipsilateral mediastinal lymph nodes (stage IIIA) who undergo gross resection and who are at either high or intermediate risk for local recurrence and death are likely to benefit from adjuvant postoperative irradiation. The role of radiation therapy in low-risk patients is unclear. Prospective confirmation of these observations is warranted.
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Affiliation(s)
- T E Sawyer
- Division of Radiation Oncology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Sawyer TE, Bonner JA, Gould PM, Foote RL, Deschamps C, Trastek VF, Pairolero PC, Allen MS, Shaw EG, Marks RS, Frytak S, Lange CM, Li H. The impact of surgical adjuvant thoracic radiation therapy for patients with nonsmall cell lung carcinoma with ipsilateral mediastinal lymph node involvement. Cancer 1997; 80:1399-408. [PMID: 9338463 DOI: 10.1002/(sici)1097-0142(19971015)80:8<1399::aid-cncr6>3.0.co;2-a] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.7] [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: 02/05/2023]
Abstract
BACKGROUND Previous nonsmall cell lung carcinoma studies have shown that patients with ipsilateral mediastinal (N2) lymph node involvement who underwent surgical resection have a greater local recurrence rate than those with less lymph node involvement (N0, N1). Therefore, it was hypothesized that complete surgical clearance of subclinical lymph node disease is difficult in N2 patients and that adjuvant postoperative thoracic radiotherapy (TRT) may be beneficial. METHODS A retrospective review was performed to determine the local recurrence and survival rates for patients with N2 disease undergoing complete surgical resection with or without adjuvant TRT. Between 1987 and 1993 at the Mayo Clinic, 224 patients underwent complete resection of N2 nonsmall cell lung carcinoma. More than one mediastinal lymph node station was sampled in 98% of patients; 39% then received adjuvant TRT (median dose, 50.4 grays). RESULTS The median follow-up time was 3.5 years for the patients who were alive at the time of the analysis. The surgery alone versus surgery plus TRT groups were well balanced with respect to gender, age, histology, tumor grade, number of mediastinal lymph node stations dissected or involved, and involved N1 lymph node number. There were slightly more patients with right lower lobe lesions (compared with other lobes), patients with multiple lobe involvement, and patients with only one N2 lymph node involved in the surgery alone group. After treatment with surgery alone, the actuarial 4-year local recurrence rate was 60%, compared with 17% for treatment with adjuvant TRT (P < 0.0001). The actuarial 4-year survival rate was 22% for treatment with surgery alone, compared with 43% for treatment with adjuvant TRT (P = 0.005). On multivariate analysis, the addition of TRT (P = 0.0001), absence of superior mediastinal lymph node involvement (P = 0.005), and fewer N1 lymph nodes involved (P = 0.02) were independently associated with improved survival rate. CONCLUSIONS This study, which to the authors' knowledge is the largest evaluating adjuvant TRT in N2 nonsmall cell lung carcinoma, suggests that adjuvant TRT may improve local control and survival.
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Affiliation(s)
- T E Sawyer
- Division of Radiation Oncology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Lange CM. Adapting media for independent study. AJNR Am J Neuroradiol 1985; 24:546. [PMID: 60743 PMCID: PMC8367707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A retrospective review of cranial CT scans obtained over a 4 year period in patients with acquired immunodeficiency syndrome (AIDS) and documented central nervous system (CNS) pathology is presented. The spectrum of diseases and the value of CT in detecting new, recurrent, and superimposed disease processes were determined. Fifty-one AIDS patients with confirmed CNS pathology were identified. Six of them had two coexistent diseases. Opportunistic infections predominated, especially Toxoplasma encephalitis and cryptococcal meningitis, while tumor was seen infrequently. Initial CT was positive in 76% of cases. In contrast to meningeal processes, where it was not very effective, CT was very sensitive in detecting most parenchymal disease processes. Characteristic although not pathognomonic CT patterns were found for certain diseases. Improvement or resolution of CT abnormalities in patients on medical therapy for Toxoplasma encephalitis correlated well with clinical improvement. Recurrence of CT abnormalities correlated well with medical noncompliance. The optimal contrast enhancement technique for detecting CNS pathology and for monitoring the effectiveness of medical therapy was also evaluated by a prospective study in which both immediate (IDD) and 1 hr delayed (DDD) double-dose contrast CT scans were compared. The examination found to be diagnostically superior in 30 of the 41 IDD/DDD studies was the delayed scan. It is recommended that CT be used routinely and with the 1 hr DDD scan to evaluate and follow AIDS patients with neurologic symptoms and/or signs.
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Lange CM. Education and influence as power sources for nursing. Mich Nurse 1984; 57:8-10. [PMID: 6564346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
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Lange CM. Creation of self-learning centers. Top Clin Nurs 1982; 4:20-8. [PMID: 6922658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Lange CM. Instructional technology for the '90's. Mich Nurse 1982; 55:7-9. [PMID: 7035841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Lange CM. Future directions. Nurs Outlook 1977; 25:753. [PMID: 73168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Lange CM. Excellence in mediated instruction. Nurs Outlook 1977; 25:689. [PMID: 73167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Lange CM. Copyright law and instructional material. Nurs Outlook 1977; 25:558. [PMID: 70778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Lange CM. Satellite transmission. Nurs Outlook 1977; 25:493. [PMID: 329227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Lange CM. Using media in evaluation. Nurs Outlook 1977; 25:241. [PMID: 66669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Lange CM. Availability and cost of media. Nurs Outlook 1977; 25:164. [PMID: 65768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Lange CM. Matching media to learning styles. Nurs Outlook 1977; 25:18. [PMID: 64970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Lange CM. Determining cognitive styles. Nurs Outlook 1976; 24:734. [PMID: 1049847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Lange CM. Media and learning styles. Nurs Outlook 1976; 24:672. [PMID: 1049425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Lange CM. Developing low-cost teaching materials. Nurs Outlook 1976; 24:614. [PMID: 1049044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Lange CM. Modifying media for individual instruction. Nurs Outlook 1976; 24:477. [PMID: 59919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Lange CM. Faculty rewards. Nurs Outlook 1976; 24:415. [PMID: 1047274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Lange CM. Securing funding. Nurs Outlook 1976; 24:351. [PMID: 58411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Lange CM. Stimulating faculty involvement. Nurs Outlook 1976; 24:290. [PMID: 1046174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Lange CM. Designing teaching strategies. Nurs Outlook 1976; 24:224. [PMID: 1046167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Lange CM. Using the overhead projector. Nurs Outlook 1976; 24:145. [PMID: 56744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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