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Judge-Golden C, Dotters-Katz S, Weber JM, Pieper CF, Gray BA. Parenthood and Medical Training: Challenges and Experiences of Physician Moms in the US. Teach Learn Med 2024; 36:43-52. [PMID: 36370040 PMCID: PMC10175508 DOI: 10.1080/10401334.2022.2141750] [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] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 10/12/2022] [Indexed: 05/14/2023]
Abstract
Phenomenon: Balancing the demands of medical training and parenthood is challenging. We explored perceptions of programmatic support, parental leave, breastfeeding, and self-reported biggest challenges among a large cohort of physician mothers in a variety of medical specialties and across the stage of training when they had their first child. Our goal was to inform strategies to help improve the physician parent experience. Approach: This cross-sectional, observational survey study was performed using a convenience sample from an online physician-mom support group from January to February 2018. Descriptive statistics and bivariate analyses were used to report results and examine relationships between career stage at first child and outcome variables. Responses to the open-ended question, "What is your biggest challenge as a physician mom?" were qualitatively analyzed. Findings: The survey received 896 complete responses. The most common specialties were obstetrics and gynecology (25.3%), pediatrics (19.9%), internal medicine or medicine/pediatrics (17.1%), and family medicine (10.2%). The majority of participants (63.9%) had their first child during medical training, including medical school (14.3%), residency (35.8%) or fellowship (13.6%). Medical students were less likely to perceive programmatic support than residents or fellows (44.1% vs. 63.1% vs. 62.3%, respectively), and only 19.9% of participants who became parents during medical training reported having a clear and adequate parental leave policy. Nearly 70% of participants breastfed for six months or more, with no statistical differences across career stage. Most participants (57.6%) delayed child-bearing for one or more reasons, with 32.3% delaying to complete training. The most common codes applied to responses for 'biggest challenges as a physician mom' were insufficient time, lack of work-life balance, missing out, and over-expectation. Insights: Physician mothers, particularly those who had their first child during training, continue to struggle with support from training programs, finding work-life balance, and feelings of inadequacy. Interventions such as clear and adequate leave policies, program-sponsored or onsite childcare and improved programmatic support of breastfeeding and pumping may help to ameliorate the challenges described by our participants.
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Affiliation(s)
- Colleen Judge-Golden
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Sarah Dotters-Katz
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Jeremy M. Weber
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Carl F. Pieper
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Beverly A. Gray
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
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Hagey JM, Oketch SY, Weber JM, Pieper CF, Huchko MJ. Clinical readiness for essential maternal and child health services in Kenya: A cross-sectional survey. PLOS Glob Public Health 2023; 3:e0002695. [PMID: 38100395 PMCID: PMC10723700 DOI: 10.1371/journal.pgph.0002695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/01/2023] [Indexed: 12/17/2023]
Abstract
High rates of maternal and neonatal morbidity and mortality in Kenya may be influenced by provider training and knowledge in emergency obstetric and neonatal care in addition to availability of supplies necessary for this care. While post-abortion care is a key aspect of life-saving maternal health care, no validated questionnaires have been published on provider clinical knowledge in this arena. Our aim was to determine provider knowledge of maternal-child health (MCH) emergencies (post-abortion care, pre-eclampsia, postpartum hemorrhage, neonatal resuscitation) and determine factors associated with clinical knowledge. Our secondary aim was to pilot a case-based questionnaire on post-abortion care. We conducted a cross-sectional survey of providers at health facilities in western Kenya providing maternity services. Providers estimated facility capacity through perceived availability of both general and specialized supplies. Providers reported training on the MCH topics and completed case-based questions to assess clinical knowledge. Knowledge was compared between topics using a linear mixed model. Multivariable models identified variables associated with scores by topic. 132 providers at 37 facilities were interviewed. All facilities had access to general supplies at least sometime while specialized supplies were available less frequently. While only 56.8% of providers reported training on post-abortion care, more than 80% reported training on pre-eclampsia, postpartum hemorrhage, and neonatal resuscitation. Providers' clinical knowledge across all topics was low (mean score of 63.3%), with significant differences in scores by topic area. Despite less formal training in the subject area, providers answered 71.6% (SD 16.7%) questions correctly on post-abortion care. Gaps in supply availability, training, and clinical knowledge on MCH emergencies exist. Increasing training on MCH topics may decrease pregnancy and postpartum complications. Further, validated tools to assess knowledge in post-abortion care should be created, particularly in sub-Saharan Africa where legal restrictions on abortion services exist and many abortions are performed in unsafe settings.
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Affiliation(s)
- Jill M. Hagey
- Division of Complex Family Planning, Department of Obstetrics and Gynecology, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Sandra Y. Oketch
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Jeremy M. Weber
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Carl F. Pieper
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Megan J. Huchko
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina, United States of America
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Lim SL, Knochenhauer H, Truong T, Weber JM, Havrilesky LJ, Previs RA. Outcomes and Complications for Concurrent Hernia Repair Among Women Undergoing Hysterectomy. Obstet Gynecol 2023; 142:1113-1124. [PMID: 37769312 DOI: 10.1097/aog.0000000000005371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/29/2023] [Indexed: 09/30/2023]
Abstract
OBJECTIVE To assess whether concurrent hernia repair at time of hysterectomy is associated with increased complications. METHODS In this retrospective cohort study, patients who underwent hysterectomy and hysterectomy with concurrent hernia repair were queried using the American College of Surgeons' National Surgical Quality Improvement Program participant use file (2005-2019). Propensity score matching was performed 1:1 with respect to preoperative and operative characteristics. Outcomes were operation time, length of stay (LOS), and major and minor complications. A secondary analysis of patients who underwent hysterectomy for malignancy was performed. RESULTS A total of 369,010 patients underwent hysterectomy, and 5,071 of those underwent hysterectomy with concurrent hernia repair. After propensity score matching, there were 5,071 patients in each arm. Hysterectomy with concurrent hernia repair had a longer operation time by 46 minutes (95% CI 42.6-49.6; P <.001) and longer LOS after surgery by 0.71 days (95% CI 0.59-0.84; P <.001). Hysterectomy with concurrent hernia repair was associated with a 21.9% higher risk (15.6% vs 12.8%; 95% CI 1.11-1.34, P <.001) of major complications and was associated with a 34.5% higher risk (7.4% vs 5.5%; 95% CI 1.16-1.56, P <.001) of minor complications. In subgroup analyses, there was no significant increase in risk among patients with body mass indexes (BMIs) lower than 40, those who were younger than age 40 years or older than age 60 years, and those with tobacco use, diabetes, or a minimally invasive surgical approach. For patients undergoing hysterectomy for malignancy, hysterectomy with concurrent hernia repair was associated with a 32-minute longer operation time (95% CI 25.2-38.8; P <.001) and a 0.35-day longer LOS (95% CI 0.04-0.67, P =.027), but there was no significant difference in major and minor complications. CONCLUSION Hysterectomy with concurrent hernia repair is associated with increased operation time, LOS, and risk of major and minor complications compared with hysterectomy without hernia repair. The subgroup analyses suggest that hysterectomy with concurrent hernia has a similar complication risk as hysterectomy without hernia repair in select populations, such as those with BMIs lower than 40 or with known malignancy.
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Affiliation(s)
- Stephanie L Lim
- Department of Obstetrics and Gynecology, and the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Medical Center, the Duke University School of Medicine, the Department of Biostatistics and Bioinformatics, Duke University School of Medicine, the Duke Clinical Research Institute, and the Duke Cancer Institute, Durham, North Carolina
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Ellett T, Zanolli N, Weber JM, Erkanli A, Rosette AS, Dotters-Katz SK, Davidson B. Gender and Language in Letters of Recommendation for Obstetrics and Gynecology Fellowship Applications. J Surg Educ 2023; 80:1424-1431. [PMID: 37580240 DOI: 10.1016/j.jsurg.2023.07.003] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/05/2023] [Indexed: 08/16/2023]
Abstract
OBJECTIVE To delineate the use of gender-biased language in letters of recommendation for Obstetrics and Gynecology fellowships and its impact on applicants. DESIGN Fellowship letters of recommendation from 4 Obstetrics and Gynecology specialties at a single institution in 2020 were included. PRIMARY OUTCOME frequency of agentic and communal language in letters of recommendation using Linguistics Inquiry Word Count software. SECONDARY OUTCOMES letter of recommendation length and language utilization by author gender and applicant success measured by interviews and match success. Marginal models were fit to determine if language varied by applicant and writer gender and subspecialty. Modified Poisson regression models were used to determine associations between language and interview receipt. SETTING Single academic institution (Duke University); 2020 OB/GYN fellowship application cycle. PARTICIPANTS A total of 1216 letters of recommendation submitted by 326 unique applicants for OB/GYN subspecialty fellowships at our institution. RESULTS Rates of gender-biased language were low (Agentic:1.3%; communal: 0.8%). Agentic term use did not vary by applicant or author gender (p = 0.78 and 0.16) Male authors utilized 19% fewer communal terms than females (p < 0.001). Each 0.25% increase in agentic language was associated with an 18% reduction in the probability of interview invitation at our institution (p = 0.004). Percentage of agentic or communal language was not associated with successful matching into any subspecialty. CONCLUSIONS No differences in agentic vs communal language based on applicant gender were found in this cohort, though female letter writers wrote longer letters with more communal terms. Increasing agentic terms negatively impacted interview invitation but did not affect successful matching.
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Affiliation(s)
- Tressa Ellett
- Department of Obstetrics and Gynecology, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Nicole Zanolli
- Duke University School of Medicine, Durham, North Carolina
| | - Jeremy M Weber
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Alaattin Erkanli
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | | | - Sarah K Dotters-Katz
- Duke Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Duke University Health System, Durham, North Carolina
| | - Brittany Davidson
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University Health System, Durham, North Carolina.
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Colman DE, Beltran TG, Weber JM, Erkanli A, Robinson WR, Myers ER, Gray BA. Patient and Surgery Characteristics of Inpatient Hysterectomies Among Transgender Individuals. LGBT Health 2023; 10:544-551. [PMID: 37252769 PMCID: PMC10574525 DOI: 10.1089/lgbt.2022.0388] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
Purpose: The purpose of this study is to estimate population-based rates of inpatient hysterectomy and accompanying bilateral salpingo-oophorectomy by indication and evaluate surgical patient characteristics by indication, year, patient age, and hospital location. Methods: We used 2016 and 2017 cross-sectional data from the Nationwide Inpatient Sample to estimate the hysterectomy rate for individuals aged 18-54 years with a primary indication for gender-affirming care (GAC) compared to other indications. Outcome measures were population-based rates for inpatient hysterectomy and bilateral salpingo-oophorectomy by indication. Results: The population-based rate of inpatient hysterectomy for GAC per 100,000 was 0.05 (95% confidence interval [CI] = 0.02-0.09) in 2016 and 0.09 (95% CI = 0.03-0.15) in 2017. For comparison, the rates per 100,000 for fibroids were 85.76 in 2016 and 73.25 in 2017. Rates of bilateral salpingo-oophorectomy in the setting of hysterectomy were higher in the GAC group (86.4%) than in comparison groups (22.7%-44.1% for all other benign indications, 77.4% for cancer) across all age ranges. A higher rate of hysterectomies performed for GAC was done laparoscopically or robotically (63.6%) than other indications, and none was done vaginally, as opposed to comparison groups (0.7%-9.8%). Conclusion: The population-based rate for GAC was higher in 2017 compared to 2016 and low compared to other hysterectomy indications. Rates of concomitant bilateral salpingo-oophorectomy were more prevalent for GAC than for other indications at similar ages. The patients in the GAC group tended to be younger, insured, and most procedures occurred in the Northeast (45.5%) and West (36.4%).
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Affiliation(s)
- Drew E. Colman
- Department of Combined Internal Medicine and Pediatrics, Los Angeles County+University of Southern California Medical Center, Los Angeles, California, USA
| | - Theo G. Beltran
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jeremy M. Weber
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Alaattin Erkanli
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Whitney R. Robinson
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Evan R. Myers
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Beverly A. Gray
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
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Todd JL, Weber JM, Kelly FL, Neely ML, Mulder H, Frankel CW, Nagler A, McCrae C, Newbold P, Kreindler J, Palmer SM. BAL Fluid Eosinophilia Associates With Chronic Lung Allograft Dysfunction Risk: A Multicenter Study. Chest 2023; 164:670-681. [PMID: 37003354 PMCID: PMC10548454 DOI: 10.1016/j.chest.2023.03.033] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Chronic lung allograft dysfunction (CLAD) is the leading cause of death among lung transplant recipients. Eosinophils, effector cells of type 2 immunity, are implicated in the pathobiology of many lung diseases, and prior studies suggest their presence associates with acute rejection or CLAD after lung transplantation. RESEARCH QUESTION Does histologic allograft injury or respiratory microbiology correlate with the presence of eosinophils in BAL fluid (BALF)? Does early posttransplant BALF eosinophilia associate with future CLAD development, including after adjustment for other known risk factors? STUDY DESIGN AND METHODS We analyzed BALF cell count, microbiology, and biopsy data from a multicenter cohort of 531 lung recipients with 2,592 bronchoscopies over the first posttransplant year. Generalized estimating equation models were used to examine the correlation of allograft histology or BALF microbiology with the presence of BALF eosinophils. Multivariable Cox regression was used to determine the association between ≥ 1% BALF eosinophils in the first posttransplant year and definite CLAD. Expression of eosinophil-relevant genes was quantified in CLAD and transplant control tissues. RESULTS The odds of BALF eosinophils being present was significantly higher at the time of acute rejection and nonrejection lung injury histologies and during pulmonary fungal detection. Early posttransplant ≥ 1% BALF eosinophils significantly and independently increased the risk for definite CLAD development (adjusted hazard ratio, 2.04; P = .009). Tissue expression of eotaxins, IL-13-related genes, and the epithelial-derived cytokines IL-33 and thymic stromal lymphoprotein were significantly increased in CLAD. INTERPRETATION BALF eosinophilia was an independent predictor of future CLAD risk across a multicenter lung recipient cohort. Additionally, type 2 inflammatory signals were induced in established CLAD. These data underscore the need for mechanistic and clinical studies to clarify the role of type 2 pathway-specific interventions in CLAD prevention or treatment.
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Affiliation(s)
- Jamie L Todd
- Department of Medicine, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC.
| | | | - Francine L Kelly
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Megan L Neely
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | | | | | - Andrew Nagler
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Christopher McCrae
- Translational Science & Experimental Medicine, Early Respiratory & Immunology, AstraZeneca, Gaithersburg, MD
| | | | | | - Scott M Palmer
- Department of Medicine, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC
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Clausen ES, Weber JM, Neely ML, Ramos KJ, Snyder LD. Erratum to Survival difference between high-risk and low-risk CFTR genotypes after lung transplant. J Heart Lung Transpl 2022;41(10):1511-19. https://doi.org/10.1016/j.healun.2022.04.009. J Heart Lung Transplant 2023; 42:688. [PMID: 37080657 DOI: 10.1016/j.healun.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023] Open
Affiliation(s)
- Emily S Clausen
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
| | - Jeremy M Weber
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Megan L Neely
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Kathleen J Ramos
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Laurie D Snyder
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
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Hynes JS, Weber JM, Truong T, Acharya KS, Eaton JL. Body mass index is negatively associated with a good perinatal outcome after in vitro fertilization among patients with polycystic ovary syndrome: a national study. F S Rep 2023; 4:77-84. [PMID: 36959962 PMCID: PMC10028420 DOI: 10.1016/j.xfre.2022.11.014] [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] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 11/23/2022] [Accepted: 11/29/2022] [Indexed: 12/05/2022] Open
Abstract
Objective To evaluate the association between body mass index (BMI) and good perinatal outcomes after in vitro fertilization (IVF) among women with polycystic ovary syndrome (PCOS). Design Retrospective cohort study using 2012-2015 Society for Assisted Reproductive Technology Clinic Outcomes Reporting System data. Setting Fertility clinics. Patients To identify patients most likely to have PCOS, we included women with a diagnosis of ovulation disorder and serum antimüllerian hormone >4.45 ng/mL. Exclusion criteria included age ≥ 41 years, secondary diagnosis of diminished ovarian reserve, preimplantation genetic testing, and missing BMI or primary outcome data. Interventions None. Main Outcome Measures Good perinatal outcome, defined as a singleton live birth at ≥ 37 weeks with birth weight ≥ 2,500 g and ≤ 4,000 g. Results The analysis included 9,521 fresh, autologous IVF cycles from 8,351 women. Among women with PCOS, the proportion of cycles with a good perinatal outcome was inversely associated with BMI: underweight 25.1%, normal weight 22.7%, overweight 18.9%, class I 18.4%, class II 14.9%, and class III or super obesity 12.2%. After adjusting for confounders, women in the highest BMI category had 51% reduced odds of a good perinatal outcome compared with normal weight women (adjusted odds ratio 0.49, 95% confidence interval 0.36-0.67). Conclusions Among women with PCOS undergoing fresh, autologous IVF, the odds of a good perinatal outcome decline with increasing BMI. Women with PCOS should be counseled that the odds of achieving a good perinatal outcome decrease as their weight increases.
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Affiliation(s)
- Jenna S. Hynes
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Duke Fertility Center, Durham, NC
- Reprint requests: Jenna S. Hynes, M.D., Division of Reproductive Endocrinology and Infertility, Columbia University Fertility Center, 5 Columbus Circle, PH Floor, New York, New York 10019.
| | - Jeremy M. Weber
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
| | - Tracy Truong
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
| | - Kelly S. Acharya
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Duke Fertility Center, Durham, NC
| | - Jennifer L. Eaton
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Duke Fertility Center, Durham, NC
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Todd JL, Weber JM, Kelly FL, Neely ML, Nagler A, Carmack D, Frankel CW, Brass DM, Belperio JA, Budev MM, Hartwig MG, Martinu T, Reynolds JM, Shah PD, Singer LG, Snyder LD, Weigt SS, Palmer SM. Early posttransplant reductions in club cell secretory protein associate with future risk for chronic allograft dysfunction in lung recipients: results from a multicenter study. J Heart Lung Transplant 2023; 42:741-749. [PMID: 36941179 DOI: 10.1016/j.healun.2023.02.1495] [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] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 02/15/2023] [Accepted: 02/20/2023] [Indexed: 03/19/2023] Open
Abstract
BACKGROUND Chronic lung allograft dysfunction (CLAD) increases morbidity and mortality for lung transplant recipients. Club cell secretory protein (CCSP), produced by airway club cells, is reduced in the bronchoalveolar lavage fluid (BALF) of lung recipients with CLAD. We sought to understand the relationship between BALF CCSP and early posttransplant allograft injury and determine if early posttransplant BALF CCSP reductions indicate later CLAD risk. METHODS We quantified CCSP and total protein in 1606 BALF samples collected over the first posttransplant year from 392 adult lung recipients at 5 centers. Generalized estimating equation models were used to examine the correlation of allograft histology or infection events with protein-normalized BALF CCSP. We performed multivariable Cox regression to determine the association between a time-dependent binary indicator of normalized BALF CCSP level below the median in the first posttransplant year and development of probable CLAD. RESULTS Normalized BALF CCSP concentrations were 19% to 48% lower among samples corresponding to histological allograft injury as compared with healthy samples. Patients who experienced any occurrence of a normalized BALF CCSP level below the median over the first posttransplant year had a significant increase in probable CLAD risk independent of other factors previously linked to CLAD (adjusted hazard ratio 1.95; p = 0.035). CONCLUSIONS We discovered a threshold for reduced BALF CCSP to discriminate future CLAD risk; supporting the utility of BALF CCSP as a tool for early posttransplant risk stratification. Additionally, our finding that low CCSP associates with future CLAD underscores a role for club cell injury in CLAD pathobiology.
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Affiliation(s)
- Jamie L Todd
- Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
| | - Jeremy M Weber
- Duke Clinical Research Institute, Durham, North Carolina
| | - Francine L Kelly
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Megan L Neely
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Andrew Nagler
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Dylan Carmack
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Courtney W Frankel
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - David M Brass
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - John A Belperio
- David Geffen School of Medicine, University of California, Los Angeles, California
| | | | - Matthew G Hartwig
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Tereza Martinu
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - John M Reynolds
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Pali D Shah
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lianne G Singer
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Laurie D Snyder
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - S Sam Weigt
- David Geffen School of Medicine, University of California, Los Angeles, California
| | - Scott M Palmer
- Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
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LacKamp AN, Weber JM, Mac Grory B, Caye A, Stenuf C, Barkley T, Messe S, Alhanti B, Blanco RG, Fonarow GC, Xian Y, Mangat HS. Abstract TP116: Procoagulant Reversal Of Warfarin After Intracranial Hemorrhage Is Not Associated With Improved Functional Outcome When Coagulation Is Abnormal Without Full Anticoagulation. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tp116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction:
Although the current guidelines recommend procoagulant reversal of elevated INR >= 2.0 (International Normalized Ratio) in patients with intracranial hemorrhage using warfarin, the benefit of procoagulant reversal is uncertain when patients have abnormal coagulation but are not fully anticoagulated.
Hypothesis:
For patients using warfarin (INR 1.5 to 1.9) who have intracranial hemorrhage the use of procoagulant reversal will improve functional outcome based upon dichotomized discharge mRS (modified Rankin scale) 0-3 vs 4-6.
Methods:
The Get With The Guidelines - Stroke registry was used to identify 239,681 patients with intracranial hemorrhage from hospitals using the comprehensive stroke center form between January 1, 2015 and January 4, 2022. Patients were excluded if they received thrombolytics, were using direct oral anticoagulants, if INR was not between 1.5 and 1.9, or if they were not using warfarin. To evaluate the association between procoagulant reversal and mRS at discharge, 1868 patients with non-missing mRS were analyzed for the primary outcome (mRS 0-3 vs. 4-6). Secondary outcomes that did not require mRS were analyzed among a possible 2569 patients. Propensity scores were estimated and overlap weighting was used to account for confounding. Logistic and negative binomial regression models were fit for binary and count variables, respectively.
Results:
There was an even distribution of patients into treatment and nontreatment (N=974 no reversal, N=894 reversal), and the groups were strikingly similar. Key outcomes are shown in the Table.
Conclusions:
Procoagulant reversal of warfarin for patients with acute intracranial hemorrhage and INR 1.5 - 1.9 was not associated with an improvement in functional outcome based upon mRS 0-3 vs 4-6. Patients that received a reversal agent had 25% lower odds of dying in the hospital or being discharged to hospice, but had a longer hospital stay and were less likely to be fully ambulatory at discharge.
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Affiliation(s)
- Aaron N LacKamp
- Anesthesiology and Neurology, The Univ of Kansas, Kansas City, KS
| | | | | | - Adrien Caye
- Sch of Medicine, The Univ of Kansas, Kansas City, KS
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Mosher CL, Weber JM, Adagarla BS, Neely ML, Palmer SM, MacIntyre NR. Timing of Treatment Outcomes and Risk Factors for Failure of BPAP in Patients Hospitalized for COPD Exacerbation. Respir Care 2022; 67:1517-1526. [PMID: 36195347 PMCID: PMC9994036 DOI: 10.4187/respcare.10155] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Patients hospitalized for COPD exacerbation have an increased risk of mortality, particularly among those who fail bi-level positive airway pressure (BPAP) for hypercapnic respiratory failure subsequently requiring invasive mechanical ventilation. Therefore, we sought to investigate the treatment course of BPAP and factors associated with BPAP treatment failure. METHODS We performed a retrospective cohort study using real-world evidence to investigate subjects with COPD who were treated with BPAP during a hospitalization for COPD exacerbation. Treatment outcomes were defined within 7 d from BPAP initiation as either failure, persistent, or success. Failure was defined as death or progression to invasive ventilation. Persistent was defined as receiving BPAP during hospital day 7. Success was defined as liberation from BPAP prior to hospital day 7 and not meeting criteria for failure. Unadjusted multinomial logistic regression models were used to examine the association between BPAP treatment outcomes and 17 recipient characteristics. RESULTS Among the 427 clinical encounters, 78% were successful, 10% were persistent, and 12% experienced failure. The median time to failure and success was 8 h and 16 h, respectively. Increasing age, body mass index (BMI), bicarbonate level, and creatinine level were significantly associated with either BPAP treatment failure, persistent treatment, or both. CONCLUSIONS The first 8 h following initiation of BPAP is a critical time period where patients are at high risk for life-threatening decompensation. Careful consideration should be given to increasing age, BMI, bicarbonate level, and creatinine level as these factors were associated with BPAP treatment failure or persistent treatment.
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Affiliation(s)
- Christopher L Mosher
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina; and Duke Clinical Research Institute, Durham, North Carolina.
| | - Jeremy M Weber
- Duke University School of Medicine, Department of Biostatistics and Bioinformatics, Durham, North Carolina
| | | | - Megan L Neely
- Duke Clinical Research Institute, Durham, North Carolina; and Duke University School of Medicine, Department of Biostatistics and Bioinformatics, Durham, North Carolina
| | - Scott M Palmer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina; and Duke Clinical Research Institute, Durham, North Carolina
| | - Neil R MacIntyre
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
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Fashakin V, Weber JM, Truong T, Craig A, Wheeler SM, James AH. Sickle cell disease and the incidence and etiology of preterm birth. Am J Obstet Gynecol MFM 2022; 4:100723. [PMID: 35995364 DOI: 10.1016/j.ajogmf.2022.100723] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 04/26/2022] [Revised: 07/29/2022] [Accepted: 08/15/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Medically indicated delivery can be defined as delivery owing to intervention for maternal or fetal well-being-most commonly because of preeclampsia or nonreassuring fetal status. Among the general population of the United States, approximately two-thirds of preterm deliveries are because of spontaneous labor and/or premature rupture of membranes, whereas the remaining one-third are medically indicated. Despite the increased risk of preterm birth among women with sickle cell disease, the specific etiologies have not been described in the medical literature. Without an understanding of the etiologies of preterm birth in women with sickle cell disease, it is difficult to develop preventative strategies. OBJECTIVE This study aimed to estimate the incidence and etiologies of preterm births (spontaneous vs medically indicated) in women with sickle cell disease. STUDY DESIGN This was a retrospective, institutional review board-exempt cohort study of deliveries at >20 weeks' gestation in women with sickle cell disease at Duke University Hospital (2013-2020). We screened pregnancy-linked hospitalizations with International Classification of Diseases-9/10 codes for sickle cell disease (n=373). We excluded cases of pregnancy with <20 weeks' gestation, multiple gestation, or unproven sickle cell disease. We limited inclusion to deliveries within Duke (n=66). We compared the proportion of preterm birth cases between the sickle cell disease cohort and the overall Duke population (n=18,365), and the proportion of spontaneous vs medically indicated preterm births between the sickle cell disease cohort and a racially matched US population. RESULTS Of the 66 pregnancies, 65 occurred in patients who self-described as Black (98.5%). There were 60.6% (n=40) term and 39.4% (n=26) preterm births vs 85.9% term (n=15,771) and 14.1% preterm (n=2594) births in the Duke population as a whole. The sickle cell disease cohort was nearly 3 times more likely to deliver preterm than the Duke cohort (risk ratio, 2.79; 95% confidence interval, 2.06-3.77; P<.001). Among the 26 preterm births in the sickle cell disease cohort, 30.8% (n=8) were spontaneous and 69.2% (n=18) were medically indicated. In the US Black population comparison cohort, 65.4% (n=392,984) of preterm births were spontaneous and 34.6% (n=207,614) were medically indicated. The sickle cell disease cohort had 2 times the risk of medically indicated preterm birth compared with the US population cohort (risk ratio, 2.00; 95% confidence interval, 1.55-2.59; P<.001). CONCLUSION Maternal sickle cell disease confers nearly triple the risk of preterm birth, which is twice as likely to be medically indicated.
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Affiliation(s)
- Victoria Fashakin
- Departments of Obstetrics and Gynecology (Drs Fashakin, Craig, Wheeler, and James) and
| | - Jeremy M Weber
- Biostatistics and Bioinformatics (Mr Weber and Ms Truong). Duke University, Durham, NC
| | - Tracy Truong
- Biostatistics and Bioinformatics (Mr Weber and Ms Truong). Duke University, Durham, NC
| | - Amanda Craig
- Departments of Obstetrics and Gynecology (Drs Fashakin, Craig, Wheeler, and James) and
| | - Sarahn M Wheeler
- Departments of Obstetrics and Gynecology (Drs Fashakin, Craig, Wheeler, and James) and
| | - Andra H James
- Departments of Obstetrics and Gynecology (Drs Fashakin, Craig, Wheeler, and James) and.
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13
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Gatta LA, Weber JM, Gilner JB, Lee PS, Grotegut CA, Herbert KA, Bashir M, Pieper CF, Ronald J, Pabon-Ramos W, Habib AS, Strickland KC, Secord AA, James AH. Transfusion Requirements with Hybrid Management of Placenta Accreta Spectrum Incorporating Targeted Embolization and a Selective Use of Delayed Hysterectomy. Am J Perinatol 2022; 29:1503-1513. [PMID: 35973741 PMCID: PMC10035416 DOI: 10.1055/s-0042-1754321] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE This study compares the number of units of red blood cells (RBCs) transfused in patients with placenta accreta spectrum (PAS) treated with or without a multidisciplinary algorithm that includes placental uterine arterial embolization (P-UAE) and selective use of either immediate or delayed hysterectomy. STUDY DESIGN This is a retrospective study of deliveries conducted at a tertiary care hospital from 2001 to 2018 with pathology-confirmed PAS. Those with previable pregnancies or microinvasive histology were excluded. To improve the equity of comparison, analyses were made separately among scheduled and unscheduled cases, therefore patients were assigned to one of four cohorts as follows: (1) scheduled/per-algorithm, (2) scheduled/off-algorithm, (3) unscheduled/per-algorithm, or (4) unscheduled/off-algorithm. Primary outcomes included RBCs transfused and estimated blood loss (EBL). Secondary outcomes included perioperative complications and disposition. RESULTS Overall, 95 patients were identified, with 87 patients meeting inclusion criteria: 36 treated per-algorithm (30 scheduled and 6 unscheduled) and 51 off-algorithm patients (24 scheduled and 27 unscheduled). Among scheduled deliveries, 9 (30.0%) patients treated per-algorithm received RBCs compared with 20 (83.3%) patients treated off-algorithm (p < 0.01), with a median (interquartile range [IQR]) of 3.0 (2.0, 4.0) and 6.0 (2.5, 7.5) units transfused (p = 0.13), respectively. Among unscheduled deliveries, 5 (83.3%) per-algorithm patients were transfused RBCs compared with 25 (92.6%) off-algorithm patients (p = 0.47) with a median (IQR) of 4.0 (2.0, 6.0) and 8.0 (3.0, 10.0) units transfused (p = 0.47), respectively. Perioperative complications were similar between cohorts. CONCLUSION A multidisciplinary algorithm including P-UAE and selective use of delayed hysterectomy is associated with a lower rate of blood transfusion in scheduled but not unscheduled cases. KEY POINTS · An algorithm with delayed hysterectomy had less transfusion in scheduled, but not unscheduled, cases.. · Over time, more cases were managed per algorithm; among scheduled cases, the transfusion rate and volume transfused decreased.. · There were similar transfusion outcomes among off-algorithm cases, regardless if delivery was scheduled..
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Affiliation(s)
- Luke A. Gatta
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, North Carolina
| | - Jeremy M. Weber
- Department of Biostatistics and Bioinformatics, Duke University Hospital, Durham, North Carolina
| | - Jennifer B. Gilner
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, North Carolina
| | - Paula S. Lee
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Gynecologic Oncology, Duke University Hospital, Durham, North Carolina
| | - Chad A. Grotegut
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, North Carolina
| | | | - Mustafa Bashir
- Department of Radiology and Medicine, Duke University Hospital, Durham, North Carolina
| | - Carl F. Pieper
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, North Carolina
| | - James Ronald
- Department of Radiology and Medicine, Duke University Hospital, Durham, North Carolina
| | - Waleska Pabon-Ramos
- Department of Radiology and Medicine, Duke University Hospital, Durham, North Carolina
| | - Ashraf S. Habib
- Department of Anesthesiology, Duke University Hospital, Durham, North Carolina
| | - Kyle C. Strickland
- Department of Pathology, Duke University Hospital, Durham, North Carolina
| | - Angeles Alvarez Secord
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Gynecologic Oncology, Duke University Hospital, Durham, North Carolina
| | - Andra H. James
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, North Carolina
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Smith MM, Weber JM, Truong T, Swamy GK, Wheeler SM. Racial and ethnic representation in 17-hydroxyprogesterone caproate preterm birth prevention studies: a systematic review. J Perinat Med 2022; 50:970-976. [PMID: 36027908 DOI: 10.1515/jpm-2021-0425] [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: 08/24/2021] [Accepted: 03/27/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The US preterm birth rate varies dramatically by race and ethnicity yet the racial and ethnic representation within studies evaluating 17-hydroxprogesterone caproate (17-P) for preterm birth prevention is unknown. The objectives of our study were to 1) examine the racial and ethnic representation of participants in 17-P preterm birth prevention studies, 2) evaluate adherence to the NIH race and ethnicity reporting guidelines and 3) compare racial and ethnic representation in research studies to national preterm birth incidence. METHODS We systematically reviewed US studies published between January 2000 and December 2019. Study participant's race and ethnicity were reported using descriptive statistics then compared to US 2017//2018 preterm birth data using Pearson's chi-square. RESULTS Eighteen studies met the inclusion criteria, 17 studies reported race, 11 studies reported ethnicity, and yet none of the studies followed the NIH criteria. Compared to 2017/2018 US preterm births, the proportion of black/African American study participants was significantly higher whereas the proportions of all other race categories were lower. CONCLUSIONS More detailed reporting of race and ethnicity is needed in 17-P literature. Black women appear to be well represented while other racial and ethnic groups may be understudied.
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Affiliation(s)
| | - Jeremy M Weber
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Tracy Truong
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Geeta K Swamy
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Sarahn M Wheeler
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
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15
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Acharya KS, Harris BS, Weber JM, Truong T, Pieper C, Eaton JL. Impact of increasing antimüllerian hormone level on in vitro fertilization fresh transfer and live birth rate. F S Rep 2022; 3:223-230. [PMID: 36212572 PMCID: PMC9532892 DOI: 10.1016/j.xfre.2022.06.005] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 06/22/2022] [Accepted: 06/27/2022] [Indexed: 11/30/2022] Open
Abstract
Objective The objective of our study was to assess the association between AMH and live birth among women with elevated AMH undergoing first fresh IVF. Serum antimüllerian hormone (AMH) correlates with oocyte yield during in vitro fertilization (IVF). However, there are limited data regarding IVF outcomes in women with elevated AMH levels. Design Retrospective cohort study using the Society for Assisted Reproductive Technology Clinical Outcomes Reporting System database from 2012-2014. Setting Fertility clinics reporting to Society for Assisted Reproductive Technology. Patients First, fresh, autologous IVF cycles with elevated AMH levels (≥5.0 ng/mL). Subanalyses were performed to examine patients with or without polycystic ovary syndrome (PCOS). Interventions None. Main Outcome Measures Odds of live birth. Results Our cohort included 10,615 patients with elevated an AMH level, including 2,707 patients with PCOS only. The adjusted odds of live birth per initiated cycle were significantly lower per each unit increase in the AMH level (odds ratio, 0.97; 95% confidence interval, 0.96-0.98). Increasing AMH level was associated with increased cancellation of fresh transfer (odds ratio, 1.12; 95% confidence interval, 1.10-1.15) up to an AMH level of 12 ng/mL. The decrease in the live birth rate appears to be caused by the increasing incidence of cancellation of fresh transfer because the live birth rate per completed transfer was maintained. Similar trends were observed in the PCOS and non-PCOS subanalyses. Conclusions Among patients with AMH levels of ≥5 ng/mL undergoing fresh, autologous IVF, each unit increase in AMH level is associated with a 3% decrease in odds of live birth because of the increased incidence of fresh embryo transfer cancellation.
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Affiliation(s)
- Kelly S. Acharya
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Benjamin S. Harris
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Jeremy M. Weber
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Tracy Truong
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Carl Pieper
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Jennifer L. Eaton
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
- Women & Infants Fertility Center, Providence, Rhode Island
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16
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Gatta LA, Rochat E, Weber JM, Valencia S, Erkanli A, Dotters-Katz SK, Permar S, Hughes BL. Clinical factors associated with cytomegalovirus shedding among seropositive pregnant women. Am J Obstet Gynecol MFM 2022; 4:100560. [PMID: 34990874 PMCID: PMC9942897 DOI: 10.1016/j.ajogmf.2021.100560] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/17/2021] [Accepted: 12/29/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Both neighborhood disadvantage and close contact with children have been associated with seroprevalence of cytomegalovirus in pregnancy. However, it is unknown which individual factors influence whether seropositive women are likely to have ongoing viral shedding. OBJECTIVE This study aimed to define the frequency of and risk factors for ongoing maternal cytomegalovirus shedding across gestation among seropositive pregnant women. STUDY DESIGN This was a prospective cohort study of women who were cytomegalovirus seropositive at a single tertiary care hospital between September 1, 2018, and September 1, 2020. The participants were eligible if positive for cytomegalovirus immunoglobulin G during the first trimester of pregnancy. Urine samples were planned to be collected from each trimester. DNA was isolated in urine samples to detect and quantitate cytomegalovirus immediate-early 1 gene. Participants were classified as "ever shedder" if cytomegalovirus was detected in any urine sample and "never shedder" if cytomegalovirus was never detected. Patient demographics and characteristics were compared between groups. Stochastic search variable selection (with a posterior probability of inclusion of >0.5) was used to identify predictors of cytomegalovirus shedding at any time point. Forward selection modeling was used as a sensitivity check for independent risks. RESULTS A total of 240 participants who were cytomegalovirus immunoglobulin G seropositive were enrolled, with 567 urine samples analyzed across gestation. Fifty-eight participants (24.2%) were "never shedders", and 182 participants (75.8%) were "ever shedders." The characteristics and demographics were similar between cohorts. With stochastic search variable selection, nulliparity was the only variable selected (odds ratio, 1.82; 95% credible interval, 1.00-4.09; Bayes factor, 2.22). Furthermore, nulliparity was selected with standard logistic regression, with an odds ratio and 95% confidence interval of 1.89 (1.00-3.58). Sociodemographic characteristics, such as age, race, education level, occupation, children at home, children in daycare, housing type, insurance type, income, and concurrent infections, were not associated with shedding. The only positive neonatal sample (0.42%) was detected from a participant who had cytomegalovirus detected in all 3 time points. CONCLUSION Approximately 75% of women who were positive for cytomegalovirus immunoglobulin G shed virus at some point during gestation. Nulliparity was the only variable selected that was associated with shedding.
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Affiliation(s)
- Luke A Gatta
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, NC (Drs Gatta, Dotters-Katz, and Hughes); Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, NC (Drs Gatta, Dotters-Katz, and Hughes).
| | - Eric Rochat
- Duke Human Vaccine Institute, Duke University Hospital, Durham, NC (Mr Rochat and Drs Valencia and Permar)
| | - Jeremy M Weber
- Department of Biostatistics and Bioinformatics, Duke University Hospital, Durham, NC (Mr Weber and Dr Erkanli)
| | - Sarah Valencia
- Duke Human Vaccine Institute, Duke University Hospital, Durham, NC (Mr Rochat and Drs Valencia and Permar)
| | - Alaattin Erkanli
- Department of Biostatistics and Bioinformatics, Duke University Hospital, Durham, NC (Mr Weber and Dr Erkanli)
| | - Sarah K Dotters-Katz
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, NC (Drs Gatta, Dotters-Katz, and Hughes); Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, NC (Drs Gatta, Dotters-Katz, and Hughes)
| | - Sallie Permar
- Duke Human Vaccine Institute, Duke University Hospital, Durham, NC (Mr Rochat and Drs Valencia and Permar); Department of Pediatrics, Weill Cornell Medical Center, New York, NY (Dr Permar)
| | - Brenna L Hughes
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, NC (Drs Gatta, Dotters-Katz, and Hughes); Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, NC (Drs Gatta, Dotters-Katz, and Hughes)
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17
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Goins EC, Weber JM, Truong T, Moss HA, Previs RA, Davidson BA, Havrilesky LJ. Malnutrition as a risk factor for post-operative morbidity in gynecologic cancer: Analysis using a national surgical outcomes database. Gynecol Oncol 2022; 165:309-316. [PMID: 35241292 DOI: 10.1016/j.ygyno.2022.01.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/18/2022] [Accepted: 01/26/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To assess, using a national surgical outcomes database, the association of various malnutrition definitions with post-operative morbidity in three gynecologic malignancies. METHODS Patients undergoing resection of ovarian, uterine, or cervical cancer between 2005 and 2019 were identified using the National Surgical Quality Improvement Program (NSQIP) database. Patients were classified based on specific, pre-defined malnutrition criteria: severe malnutrition (Body Mass Index (BMI) <18.5 + 10% weight loss), European Society for Clinical Nutrition and Metabolism ((ESPEN1); BMI 18.5-22 + 10% weight loss), ESPEN2 (BMI < 18.5), American Cancer Society ((ACS); normal/overweight BMI + 10% weight loss), mild malnutrition (BMI 18.5-22), or albumin (<3.5 g/dL). Outcomes included 30-day major complications, readmission, reoperation. Modified Poisson regression estimated associations between definitions and outcomes. RESULTS Of 76,290 total patients undergoing surgery, those meeting malnutrition definitions were: severe-98 (0.1%), ESPEN1-148 (0.2%), ESPEN2-877 (1.1%), ACS-1028 (1.3%), mild-2853 (3.7%), and albumin (11.1%). Complication rates were: unplanned readmission-5.5%, reoperation-1.7%, major complications-13.5%. For ovarian cancer, ESPEN2 malnutrition was associated with higher readmissions (risk ratio 1.69; 95% confidence interval 1.29-2.20), reoperations (2.53; 1.70-3.77), and complications (1.36; 1.20-1.54). For uterine cancer, ACS malnutrition was associated with readmissions (2.74; 2.09-3.59), reoperations (3.61; 2.29-5.71) and complications (3.92; 3.40-4.53). For cervical cancer, albumin<3.5 g/dL was associated with readmissions (1.48; 1.01-2.19), reoperations (2.25; 1.17-4.34), and complications (2.59; 2.11-3.17). Albumin<3.5 was associated with adverse outcomes in ovarian and uterine cancer. CONCLUSIONS Preoperative risk assessments might be tailored using cancer-specific malnutrition criteria. Major complications, readmissions, and reoperations are all associated with the ESPEN2 definition for ovarian cancer, the ACS definition for uterine cancer, and with albumin<3.5 for all cancers.
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Affiliation(s)
- Emily C Goins
- School of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Jeremy M Weber
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Tracy Truong
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Haley A Moss
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Health System, Durham, North Carolina, United States of America
| | - Rebecca A Previs
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Health System, Durham, North Carolina, United States of America
| | - Brittany A Davidson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Health System, Durham, North Carolina, United States of America
| | - Laura J Havrilesky
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Health System, Durham, North Carolina, United States of America
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18
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Harris BS, Acharya KS, Weber JM, Truong T, Eaton JL. Can high antimüllerian hormone mitigate some of the age-related decline in live birth rates? The association between antimüllerian hormone and live birth among women over 40 undergoing in vitro fertilization. F S Rep 2021; 2:440-447. [PMID: 34934985 PMCID: PMC8655414 DOI: 10.1016/j.xfre.2021.08.009] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 08/24/2021] [Accepted: 08/28/2021] [Indexed: 11/17/2022] Open
Abstract
Objective To examine the association between serum antimüllerian hormone (AMH) and live birth among women aged ≥41 years undergoing in vitro fertilization (IVF). Design Retrospective cohort study using the 2012-2014 Society for Assisted Reproductive Technology Clinic Outcome Reporting System database. Setting Fertility clinics reporting to the Society for Assisted Reproductive Technology. Patients The analysis included 7,819 patients aged ≥41 years who underwent a first fresh, autologous IVF cycle during the study period. Cycles with preimplantation genetic testing were excluded. Interventions None. Main outcome measures Live birth rate. Results The empirical distribution of AMH was examined, and extreme values were observed. Therefore, the natural logarithm transformation of AMH (log-AMH) was used in all analyses. Before adjustment for covariates, a one-unit increase in log-AMH was associated with doubling of the odds of live birth up to a log-AMH of -0.34 (equivalently, AMH, 0.71 ng/mL; odds ratio [OR], 2.02; 95% confidence interval [CI], 1.66-2.46). Above an AMH level of 0.71 ng/mL, the odds of live birth increased by only 40% with each unit increase in log-AMH (OR, 1.40; 95% CI, 1.22-1.61). After adjusting for covariates, the odds of live birth increased by 91% with each unit increase in log-AMH up to -0.34 (AMH, 0.71 ng/mL; OR, 1.91; 95% CI, 1.56-2.34). Above an AMH level of 0.71 ng/mL, the odds of live birth increased by only 32% with each unit increase in log-AMH (OR, 1.32; 95% CI, 1.15-1.53). Conclusions Among women aged ≥41 years undergoing fresh, autologous IVF, the odds of live birth significantly increase with increasing serum AMH level. As the AMH level increases above 0.71 ng/mL, the association maintains statistical significance, but the effect size is diminished.
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Affiliation(s)
- Benjamin S Harris
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Kelly S Acharya
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Jeremy M Weber
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Tracy Truong
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Jennifer L Eaton
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
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19
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Tsai S, Sun M, Asbury ML, Weber JM, Truong T, Deans E. Correction to: Novel Spaced Repetition Flashcard System for the In-training Examination for Obstetrics and Gynecology. Med Sci Educ 2021; 31:1559. [PMID: 34459835 PMCID: PMC8368837 DOI: 10.1007/s40670-021-01344-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
[This corrects the article DOI: 10.1007/s40670-021-01320-z.].
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Affiliation(s)
- Shelun Tsai
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC USA
| | - Michael Sun
- Department of Psychiatry, Duke University Medical Center, Durham, NC USA
| | - Melinda L. Asbury
- Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, NC USA
- Department of Psychiatry, Duke University Medical Center, Durham, NC USA
| | - Jeremy M. Weber
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC USA
| | - Tracy Truong
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC USA
| | - Elizabeth Deans
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC USA
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Tsai S, Sun M, Asbury ML, Weber JM, Truong T, Deans E. Novel Spaced Repetition Flashcard System for the In-training Examination for Obstetrics and Gynecology. Med Sci Educ 2021; 31:1393-1399. [PMID: 34457982 PMCID: PMC8368326 DOI: 10.1007/s40670-021-01320-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/11/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Electronic flashcards allow repeated information exposure over time along with active recall. It is increasingly used for self-study by medical students but remains poorly implemented for graduate medical education. The primary goal of this study was to determine whether a flashcard system enhances preparation for the in-training examination in obstetrics and gynecology (ob-gyn) conducted by the Council on Resident Education in Obstetrics and Gynecology (CREOG). METHODS Ob-gyn residents at Duke University were included in this study. A total of 883 electronic flashcards were created and distributed. CREOG scores and flashcard usage statistics, generated internally by interacting with the electronic flashcard system, were collected after the 2019 exam. The primary outcome was study aid usage and satisfaction. The secondary outcome was the impact of flashcard usage on CREOG exam scores. RESULTS Of the 32 residents, 31 (97%) participated in this study. Eighteen (58%) residents used the study's flashcards with a median of 276 flashcards studied over a median of 3.7 h. All of the flashcard users found the study aid helpful, and all would recommend them to another ob-gyn resident. Using the flashcards to study for the 2019 CREOG exam appeared to correlate with improvement in scores from 2018 to 2019, but did not achieve statistical significance after adjusting for post-graduate year (beta coefficient = 10.5; 95% confidence interval = - 0.60,21.7; p = 0.06). DISCUSSION This flashcard resource was well received by ob-gyn residents for in-training examination preparation, though it was not significantly correlated with improvement in CREOG scores after adjusting for post-graduate year.
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Affiliation(s)
- Shelun Tsai
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC USA
| | - Michael Sun
- Department of Psychiatry, Duke University Medical Center, Durham, NC USA
| | - Melinda L. Asbury
- Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, NC USA
- Department of Psychiatry, Duke University Medical Center, Durham, NC USA
| | - Jeremy M. Weber
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC USA
| | - Tracy Truong
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC USA
| | - Elizabeth Deans
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC USA
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Gatta LA, Lee PS, Gilner JB, Weber JM, Adkins L, Salinaro JR, Habib AS, Pabon-Ramos W, Strickland KC, Ronald J, Erkanli A, Mehdiratta JE, Grotegut CA, Secord AA. Placental uterine artery embolization followed by delayed hysterectomy for placenta percreta: A case series. Gynecol Oncol Rep 2021; 37:100833. [PMID: 34368412 PMCID: PMC8326725 DOI: 10.1016/j.gore.2021.100833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 07/07/2021] [Accepted: 07/11/2021] [Indexed: 11/20/2022] Open
Abstract
Approximately 23% of women intending delayed hysterectomy for placenta accreta spectrum will have an unscheduled surgery. Targeted embolization for placenta accreta spectrum appears to be a safe and feasible adjunct to surgical management. Placental regression may contribute to discrepancy between intraoperative and pathology diagnoses in delayed hysterectomy. A multidisciplinary approach to placenta accreta spectrum is associated with a lower blood loss.
We describe outcomes of patients with suspected placenta percreta treated with placental uterine artery embolization (P-UAE) followed by delayed hysterectomy. This is a prospective case series of subjects from 2005 to 2018 with suspected placenta percreta who underwent P-UAE at the time of cesarean delivery followed by delayed hysterectomy. Both scheduled and unscheduled surgical cases were included. Maternal characteristics, surgical approaches, intra- and postoperative outcomes were abstracted from medical records. In total, twenty-two subjects were included. Median (interquartile range, IQR) delivery gestational age was 34.6 (31.9, 35.7) weeks, occurring as scheduled in 17 (77.3%) subjects and unscheduled in 5 (22.7%). Delayed hysterectomy was performed as scheduled in 17 (77.3%) subjects at a median (IQR) 40.5 (38.0, 44.0) days after delivery, and 5 (22.7%) subjects had a hysterectomy prior to scheduled date, median (IQR) 27.0 (17.0, 35.0) days after delivery. Indications for the 5 unscheduled hysterectomies included bleeding (n = 3) and suspected endometritis (n = 2). Three subjects (13.6%) received a blood transfusion (1, 3, 3 units) during delivery, and 7 (31.8%) were transfused during delayed hysterectomy (median [IQR] 2 [1,3] units). Three (13.6%) subjects had bladder resection at the time of hysterectomy; 1 (4.5%) had an unintentional cystotomy and 1 (4.5%) had a ureteral injury. P-UAE followed by delayed hysterectomy appears to be a safe and feasible, although appropriate patient selection and close surveillance are imperative, as 22.7% of patients underwent unscheduled hysterectomy.
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Affiliation(s)
- Luke A. Gatta
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, NC, USA
- Corresponding author at: 2608 Erwin Road, Suite 220, Durham, NC 27705, USA.
| | - Paula S. Lee
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University Hospital, Durham, NC, USA
| | - Jennifer B. Gilner
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, NC, USA
| | - Jeremy M. Weber
- Department of Biostatistics & Bioinformatics, Duke University Hospital, Durham, NC, USA
| | - LaMani Adkins
- Department of Obstetrics & Gynecology, Duke University Hospital, Durham, NC, USA
| | - Julia R. Salinaro
- Department of Obstetrics & Gynecology, Duke University Hospital, Durham, NC, USA
| | - Ashraf S. Habib
- Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Waleska Pabon-Ramos
- Department of Radiology and Medicine, Duke University Hospital, Durham, NC, USA
| | | | - James Ronald
- Department of Radiology and Medicine, Duke University Hospital, Durham, NC, USA
| | - Alaattin Erkanli
- Department of Biostatistics & Bioinformatics, Duke University Hospital, Durham, NC, USA
| | | | - Chad A. Grotegut
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, NC, USA
| | - Angeles Alvarez Secord
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University Hospital, Durham, NC, USA
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Peipert BJ, Spinosa D, Howell EP, Weber JM, Truong T, Harris BS. Innovations in infertility: a comprehensive analysis of the ClinicalTrials.gov database. Fertil Steril 2021; 116:1381-1390. [PMID: 34256949 DOI: 10.1016/j.fertnstert.2021.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 02/16/2021] [Revised: 05/14/2021] [Accepted: 06/03/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To characterize the interventional clinical trials in infertility and to assess whether trial location or industry sponsorship was associated with trial noncompletion. DESIGN Retrospective review of trials registered with ClinicalTrials.gov. SETTING None. PATIENT(S) None. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Descriptive statistics characterizing the attributes of the clinical trials including intervention type, topic, population, completion status, size, location, sponsor, and results. The effects of the sponsor and trial location on trial noncompletion were assessed via logistic regression. RESULT(S) In total, 505 trials initiated between 2010 and 2020 were included in our analysis. Drug interventions were the most commonly studied (45%); ovarian stimulation trials accounted for 27% of the studies. Live birth was tracked as an outcome by 20% of the studies; 3% of the trials included mental health outcomes. Few trials (15%) enrolled male participants. Only 11% of the trials reported results, and 4% of the trials reported the race or ethnicity of the participants. Most trials (82%) were conducted outside the United States. Overall, 18% of the trials were not completed, most often because of lack of accrual (47%). United States trials had over twice the odds of noncompletion in univariate analysis (odds ratio = 2.48, 95% confidence interval = [1.47, 4.17]); however, this relationship lost significance after adjusting for potential confounders (odds ratio = 0.95, 95% confidence interval = [0.42, 2.14]). Trial sponsorship was not associated with trial noncompletion. CONCLUSION(S) Infertility trials predominantly investigated drug interventions, particularly ovarian stimulation. Live birth was an infrequent outcome despite its relevance to patients. Clinical trials should aim to address the unmet needs in fertility care and be inclusive of underserved populations affected by infertility.
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Affiliation(s)
- Benjamin J Peipert
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Daniel Spinosa
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Elizabeth P Howell
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Jeremy M Weber
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Tracy Truong
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Benjamin S Harris
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina.
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Gatta LA, Rochat E, Weber JM, Permar S, Valencia S, Erkanli A, Dotters-Katz S, Hughes BL. 578 Urine cytomegalovirus shedding among seropositive pregnant women. Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2020.12.599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Mosher CL, Weber JM, Frankel CW, Neely ML, Palmer SM. Risk factors for mortality in lung transplant recipients aged ≥65 years: A retrospective cohort study of 5,815 patients in the scientific registry of transplant recipients. J Heart Lung Transplant 2021; 40:42-55. [PMID: 33208278 PMCID: PMC7770611 DOI: 10.1016/j.healun.2020.10.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/19/2020] [Accepted: 10/27/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Lung transplantation is increasingly performed in recipients aged ≥65 years. However, the risk factors for mortality specific to this population have not been well studied. In lung transplant recipients aged ≥65 years, we sought to determine post-transplant survival and clinical factors associated with post-transplant mortality. METHODS We investigated 5,815 adult lung transplants recipients aged ≥65 years in the Scientific Registry of Transplant Recipients. Mortality was defined as a composite of recipient death or retransplantation. The Kaplan-Meier method was used to estimate the median time to mortality. Univariable and multivariable Cox proportional hazards regression models were used to examine the association between time to mortality and 23 donor, recipient, or center characteristics. RESULTS Median survival in lung transplant recipients aged ≥65 years was 4.41 years (95% CI: 4.21-4.60 years) and significantly worsened by increasing age strata. In the multivariable model, increasing recipient age strata, creatinine level, bilirubin level, hospitalization at the time of transplantation, single lung transplant operation, steroid use at the time of transplantation, donor diabetes, and cytomegalovirus mismatch were independently associated with increased mortality. CONCLUSIONS Among the 8 risk factors we identified, 5 factors are readily available, which can be used to optimize post-transplant survival by informing risk during candidate selection of patients aged ≥65 years. Furthermore, bilateral lung transplantation may confer improved survival in comparison with single lung transplantation. Our results support that after careful consideration of risk factors, lung transplantation can provide life-extending benefits in individuals aged ≥65 years.
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Affiliation(s)
- Christopher L Mosher
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
| | - Jeremy M Weber
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Courtney W Frankel
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
| | - Megan L Neely
- Duke Clinical Research Institute, Durham, North Carolina; Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Scott M Palmer
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
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Tsai S, Chung EH, Truong T, Weber JM, Farrell AS, Wu J, Ohamadike O, Eaton JL. RACIAL AND ETHNIC DISPARITIES AMONG DONOR OOCYTE BANKS IN THE UNITED STATES. Fertil Steril 2020. [DOI: 10.1016/j.fertnstert.2020.08.755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Shaia KL, Acharya KS, Harris BS, Weber JM, Truong T, Muasher SJ. Total follicle stimulating hormone dose is negatively correlated with live births in a donor/recipient model with fresh transfer: an analysis of 8,627 cycles from the Society for Assisted Reproductive Technology Registry. Fertil Steril 2020; 114:545-551. [PMID: 32563543 DOI: 10.1016/j.fertnstert.2020.04.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 03/12/2020] [Revised: 04/07/2020] [Accepted: 04/13/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Oocyte donation has optimized our understanding of ovarian stimulation. Increasing the follicle-stimulating hormone (FSH) dose has been shown to adversely affect live birth rates in autologous cycles. Our objective is to assess whether this relationship holds true within the donor/recipient population. DESIGN Retrospective cohort study. SETTING Not applicable. PATIENTS Data from 2014-2016 included 8,627 fresh donor cycles. INTERVENTIONS None. MAIN OUTCOME MEASURES Live birth, clinical pregnancy, and miscarriage rates. RESULTS The mean donor age ± standard deviation (SD) was 25.8 ± 2.8 years. Donors underwent a median of 16 days (interquartile range [IQR] 12, 19) of stimulation with a median (IQR) total FSH dose and daily dose of 2,350.0 (1,800.0, 3,025.0) and 153.8 (113.2, 205.0) IU, respectively. The live birth rate was 56.7% per transfer. For every 500-unit increase in FSH dose, there was a 3% reduction in the odds of a live birth (odds ratio [OR] 0.97; 95% confidence interval 0.95, 0.99), and a 3% reduction in the odds of a clinical pregnancy (OR 0.97; 95% confidence interval 0.95, 0.99). Days of stimulation and average daily dose were not significantly associated with live birth or clinical pregnancy. No significant association was found between miscarriage rates and total FSH dose, days of stimulation, or average daily dose. CONCLUSION This is a novel report of a negative association of total FSH dosage on fresh IVF live births, performed in the donor population to control for oocyte source and endometrial receptivity.
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Affiliation(s)
- Kathryn L Shaia
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Kelly S Acharya
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Benjamin S Harris
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Jeremy M Weber
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Tracy Truong
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Suheil J Muasher
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina.
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Hynes JS, Weber JM, Truong T, Acharya KS, Eaton JL. Does body mass index influence the odds of a good perinatal outcome following fresh autologous in vitro fertilization cycles among patients with polycystic ovary syndrome? A national study. Fertil Steril 2019. [DOI: 10.1016/j.fertnstert.2019.07.861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Harris BS, Hopkins MK, Villers MS, Weber JM, Pieper C, Grotegut CA, Swamy GK, Hughes BL, Heine RP. Efficacy of Non-Beta-lactam Antibiotics for Prevention of Cesarean Delivery Surgical Site Infections. AJP Rep 2019; 9:e167-e171. [PMID: 31044099 PMCID: PMC6491367 DOI: 10.1055/s-0039-1685503] [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] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 03/08/2019] [Indexed: 11/03/2022] Open
Abstract
Objective To examine the association between perioperative Beta ( β ))-lactam versus non- β -lactam antibiotics and cesarean delivery surgical site infection (SSI). Study Design Retrospective cohort of women undergoing cesarean delivery from January 1 to December 31, 2014. All women undergoing cesarean after 34 weeks with a postpartum visit were included. Prevalence of SSI was compared between women receiving β -lactam versus non- β -lactam antibiotics. Bivariate analyses were performed using Pearson's Chi-square, Fisher's exact, or Wilcoxon's rank-sum tests. Logistic regression models were fit controlling for possible confounders. Results Of the 929 women included, 826 (89%) received β -lactam prophylaxis and 103 (11%) received a non- β -lactam. Among the 893 women who reported a non-type I (low risk) allergy, 819 (92%) received β -lactam prophylaxis. SSI occurred in 7% of women who received β -lactam antibiotics versus 15% of women who received a non- β -lactam ( p = 0.004). β -Lactam prophylaxis was associated with lower odds of SSI compared with non- β -lactam antibiotics (odds ratio [OR] = 0.43; 95% confidence interval [CI] = 0.22-0.83; p = 0.01) after controlling for chorioamnionitis in labor, postlabor cesarean, endometritis, tobacco use, and body mass index (BMI). Conclusion β -Lactam perioperative prophylaxis is associated with lower odds of a cesarean delivery surgical site infection compared with non- β -lactam antibiotics.
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Affiliation(s)
- Benjamin S Harris
- Department of Obstetrics and Gynecology, Duke University Health System, Durham, North Carolina
| | - Maeve K Hopkins
- Department of Obstetrics and Gynecology, Duke University Health System, Durham, North Carolina
| | - Margaret S Villers
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Health System, Durham, North Carolina
| | - Jeremy M Weber
- Department of Biostatistics and Bioinformatics, Duke University Health System, Durham, North Carolina
| | - Carl Pieper
- Department of Biostatistics and Bioinformatics, Duke University Health System, Durham, North Carolina
| | - Chad A Grotegut
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Health System, Durham, North Carolina
| | - Geeta K Swamy
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Health System, Durham, North Carolina
| | - Brenna L Hughes
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Health System, Durham, North Carolina
| | - R Phillips Heine
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Health System, Durham, North Carolina
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Strosberg JR, Weber JM, Choi J, Campos TL, Valone TL, Han G, Schell MJ, Kvols LK. A phase II clinical trial of sunitinib following hepatic transarterial embolization for metastatic neuroendocrine tumors. Ann Oncol 2012; 23:2335-2341. [PMID: 22317769 PMCID: PMC4559904 DOI: 10.1093/annonc/mdr614] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Revised: 12/12/2011] [Accepted: 12/13/2011] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The liver is the predominant site of metastases among patients with advanced neuroendocrine tumors (NETs). Prior retrospective studies have reported high response rates in patients treated with transarterial embolization (TAE). NETs are highly vascular and are known to express vascular endothelial growth factor (VEGF) and vascular endothelial growth factor receptor (VEGFR). We hypothesized that administration of sunitinib, a VEGFR inhibitor, following TAE would extend progression-free survival (PFS). PATIENTS AND METHODS Patients with metastatic NETs to the liver underwent a series of selective TAEs followed by sunitinib (until disease progression or maximum of 12 months). Radiographic response (by RECIST), survival, and safety parameters were monitored. RESULTS Thirty-nine patients were enrolled. The overall response rate was 72% [95% confidence interval (CI), 0.58-0.86]. Median PFS was 15.2 months. Rates of overall survival (OS) at 1 and 4 years were 95% (95% CI, 0.88-1.00) and 59% (95% CI, 0.38-0.80), respectively. A significant 34% rise in serum VEGF was observed following the initial TAE (P = 0.03). CONCLUSIONS Hepatic TAE is a highly active treatment option for patients with metastatic NETs to the liver. Embolization stimulates release of VEGF into the circulation. Sunitinib, an oral VEGFR inhibitor, can be safely administered following embolization. The high rates of PFS and OS associated with this sequence of therapies are encouraging.
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Affiliation(s)
| | - J M Weber
- Departments of Gastrointestinal Oncology
| | - J Choi
- Departments of Interventional Radiology
| | - T L Campos
- Departments of Gastrointestinal Oncology
| | - T L Valone
- Departments of Gastrointestinal Oncology
| | - G Han
- Departments of Biostatistics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - M J Schell
- Departments of Biostatistics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - L K Kvols
- Departments of Gastrointestinal Oncology
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De Weck AL, Sanz ML, Gamboa PM, Jermann JM, Kowalski M, Medrala W, Sainte-Laudy J, Schneider MS, Weber JM, Wolanczyk-Medrala A. Nonsteroidal anti-inflammatory drug hypersensitivity syndrome: a multicenter study. II. Basophil activation by nonsteroidal anti-inflammatory drugs and its impact on pathogenesis. J Investig Allergol Clin Immunol 2010; 20:39-57. [PMID: 20232773] [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: 05/28/2023] Open
Abstract
BACKGROUND Patients who are clinically hypersensitive to nonsteroidal anti-inflammatory drugs (NSAIDs) sometimes present basophil activation in vitro, and in 50% of cases a parallel response to release of sulfidoleukotrienes (cellular allergen stimulation test) is observed. These phenomena occur not only in clinically hypersensitive patients, but also in some healthy controls who tolerate NSAIDs. MATERIAL AND METHODS We studied 16 clinically hypersensitive patients, 22 controls tolerating NSAIDs, and 29 healthy blood donors (clinical NSAID status unknown) using 2 different basophil isolation techniques (buffy coat or plasma leukocytes). RESULTS In a population of 13 aspirin-tolerant healthy controls and 29 healthy blood donors, basophil activation with aspirin, diclofenac, and naproxen was analyzed at 4 different concentrations. The results in the 2 groups were quite similar in qualitative terms. Choosing a cutoff of 5% and a stimulation index >2, the proportion of positive results increased with the concentration. There were more positive results at all concentrations using the plasma leukocyte technique. CONCLUSIONS The most important finding of this study is that basophil activation by NSAIDs occurs not only in clinically hypersensitive patients but also, to a very variable extent and on an individual basis, in apparently normal healthy individuals who tolerate NSAIDs. The phenomenon is clearly dose-related, and hypersensitive patients seem to react to lower NSAID concentrations.
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Affiliation(s)
- A L De Weck
- Department of Allergology and Clinical Immunology, University of Navarra, Pamplona, Spain
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De Weck AL, Sanz ML, Gamboa PM, Aberer W, Blanca M, Correia S, Erdman S, Jermann JM, Kanny G, Kowalski M, Mayorga L, Medrala W, Merk A, Sturm GJ, Sainte-Laudy J, Schneider MS, Sczczeklik A, Weber JM, Wedi A. Nonsteroidal anti-inflammatory drug hypersensitivity syndrome. A multicenter study. I. Clinical findings and in vitro diagnosis. J Investig Allergol Clin Immunol 2009; 19:355-369. [PMID: 19862935] [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: 05/28/2023] Open
Abstract
BACKGROUND We present the results obtained from the largest series of in vitro diagnostic tests ever reported in patients with clinically validated hypersensitivity to acetylsalicylic acid (ASA)/nonsteroidal anti-inflammatory drugs (NSAID) compared with various categories of controls tolerating ASA/NSAIDs. This multicenter study, which was performed within the framework of the European Network for Drug Allergy (ENDA) group, showed that the basophil activation test (BAT), particularly when used with the 3 NSAIDs aspirin (ASA), diclofenac (DIC), and naproxen (NAP), allows us to confirm the diagnosis of NSAID hypersensitivity syndrome. The results of the cellular allergen stimulation test (CAST) frequently correlate with those of the BAT, although not always. An unexpected finding was that basophil activation by NSAIDs is not an all-or-nothing phenomenon restricted to clinically hypersensitive patients, but that it also occurs in a dose-related manner in some NSAID-tolerant control individuals.Therefore, NSAID hypersensitivity appears as a shift in the normal pharmacological response to NSAIDs. These findings allow us to formulate a new rational hypothesis about the mechanism of NSAID hypersensitivity syndrome, a mechanism that most authors continue to describe as "unknown." METHODS We enrolled 152 patients with a history of hypersensitivity to NSAIDs and 136 control participants in 11 different centers between spring 2003 and spring 2006. Flowcytometric BAT was performed. RESULTS The most noteworthy results of our study were that 57% of 140 patients presented very clear-cut positive BAT results to multiple NSAIDs, and 16% were entirely negative. In about 27% of cases, positive results were obtained with 1 or 2 concentrations of a single NSAID. There is clearly a correlation between the results of BAT and CAST. CONCLUSIONS BAT seems particularly indicated in patients with a clinical history of NSAID intolerance, and in whom a provocation test is not advisable for ethical, clinical, or other reasons. Clear-cut positive results can be considered as confirming a history of NSAID hypersensitivity, although negative results may not exclude it.
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Affiliation(s)
- A L De Weck
- Department of Allergology and Clinical Immunology, Clinica Universidad de Navarra, Collaborative center of Pamplona, Spain
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De Week AL, Sanz ML, Gamboa PM, Aberer W, Sturm G, Bilo MB, Montroni M, Blanca M, Torres MJ, Mayorga L, Campi P, Manfredi M, Drouet M, Sainte-Laudy J, Romano A, Merk H, Weber JM, Jermann TM. Diagnosis of immediate-type beta-lactam allergy in vitro by flow-cytometric basophil activation test and sulfidoleukotriene production: a multicenter study. J Investig Allergol Clin Immunol 2009; 19:91-109. [PMID: 19476013] [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: 05/27/2023] Open
Abstract
INTRODUCTION This multicenter study aimed to evaluate the diagnostic value of 2 cellular tests based on basophil reactivity--the basophil activation test (BAT, Flow-CAST) and the sulfidoleukotriene release assay (CAST-ELISA)--in immediate-type beta-lactam allergy, particularly in patients with a clinical history of allergy and a negative skin test result. MATERIAL AND METHODS In a multicenter study encompassing 10 European centers, 181 patients with a history of immediate-type beta-lactam allergy, and 81 controls, we evaluated the diagnostic efficiency of specific IgE determinations and of 2 cellular tests based on basophil reactivity, the BAT and the sulfidoleukotriene release assay. RESULTS With Flow-CAST, sensitivity varied for individual beta-lactam allergens from 16% for penicilloyl-polylysine to 33% for amoxicillin, reaching 50% when all 5 allergens were considered. In beta-lactam-allergic patients with negative skin test results (22.8%), Flow-CAST showed positive results for at least 1 of the 5 allergens in 37%. Specificity varied from 89% to 97%, depending on the allergens used. In CAST-ELISA, the overall sensitivity in skin test-positive patients was 41.7%; in patients with negative skin test results it was 27.9%. Both tests were not absolutely correlated, so that when all the results were considered together, sensitivity increased to 64.3% and specificity varied for both tests combined from 73% to 92%. In contrast, specific IgE determinations in the same population yielded a lower sensitivity (28.3%). CONCLUSIONS A diagnostic algorithm including skin tests and specific IgE, followed by cellular tests in negative patients and controlled challenge enabled us to confirm beta-lactam allergy in 92% of cases. This procedure would also allow us to avoid two-thirds of the required controlled challenges.
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Affiliation(s)
- A L De Week
- Department of Allergology and Clinical Immunology, University of Navarra, Collaborative Center of GA2LEN, Pamplona, Spain
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Ballmer-Weber BK, Weber JM, Vieths S, Wüthrich B. Predictive value of the sulfidoleukotriene release assay in oral allergy syndrome to celery, hazelnut, and carrot. J Investig Allergol Clin Immunol 2008; 18:93-99. [PMID: 18447137] [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: 05/26/2023] Open
Abstract
BACKGROUND Patients sensitized to birch pollen frequently suffer from a food allergy to plant foods such as celery, carrots, or hazelnut. One of the main manifestations of birch pollen-related food allergy is the oral allergy syndrome. Skin tests and allergen-specific immunoglobulin (Ig) E determinations are poor predictors of such reactions when assessed by double-blind placebo-controlled food challenge (DBPCFC). OBJECTIVE To investigate whether a cellular test based on leukotriene release from basophils, the cellular antigen stimulation test in combination with enzyme-linked immunosorbent assay (CAST-ELISA), is predictive of pollen-related food allergy. METHODS Birch pollen-sensitized patients with positive DBPCFC to celery (n=21), hazelnut (n=15), and carrot (n=7) underwent skin tests along with determination of specific IgE and CAST-ELISA for the respective allergens. The results were compared with those of 24 birch pollen-sensitized patients with negative open food challenge to celery, hazelnut, and carrot. RESULTS While skin prick tests had a sensitivity of 85%, 80%, and 29% for commercial extracts of celery, hazelnut, and carrot, respectively, prick testing with self-prepared extracts yielded sensitivities of 100%, 80%, and 100%, respectively. For specific IgE determinations, sensitivities were 71%, 73%, and 57%, respectively, and the respective specificities were 67%, 73%, and 60%. For CAST-ELISA with various sources and doses of allergens, the sensitivity varied from 71% to 95% for celery, 73% to 80% for hazelnut, and 43% to 86% for carrot. The respective specificities were 67% to 92%, 75% to 88%, and 77% to 91%. Analysis of the predictive value of CAST-ELISA with receiver operating characteristic curves showed that the results of the tests were more predictive of pollen-related food allergy than quantitative allergen-specific IgE determinations. CONCLUSIONS CAST-ELISA is more specific than routine diagnostic tests for the diagnosis of pollen-related food allergy to celery, hazelnut, and carrot.
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Affiliation(s)
- B K Ballmer-Weber
- Allergy Unit, Department of Dermatology, University of Zurich, Switzerland.
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Fischer C, Reperant LA, Weber JM, Hegglin D, Deplazes P. Echinococcus multlocularis infections of rural, residential and urban foxes (Vulpes vulpes) in the canton of Geneva, Switzerland. Parasite 2006; 12:339-46. [PMID: 16402566 DOI: 10.1051/parasite/2005124339] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [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: 11/14/2022] Open
Abstract
We examined 267 red foxes (Vulpes vulpes) from the canton of Geneva, Switzerland, for intestinal infections with Echinococcus multilocularis. This region is situated in the core area of the endemic range of this zoonotic cestode in Central Europe. Several factors were taken into account and urbanisation level appeared to be the most explicative to describe observed differences. The prevalence decreased significantly from rural and residential areas (prevalence of 52%, CI 43-62%, and 49%, CI 38-59 %, respectively) to the urban area (prevalence of 31%, CI 19-42%). A few juvenile foxes harboured very high burdens up to more than 120,000 worms and were significantly more heavily infected than adults. The intensity of infection decreased from rural and residential areas to the city, suggesting a lower contamination of the urban environment.
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Affiliation(s)
- C Fischer
- Université de Lausanne, Département d'ecologie et evolution, Bâtiment de biologie, 1015 Lausanne, Switzerland
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Löffler D, Weber JM, Kappes MM. Photodetachment spectroscopy of PtBr42−: Probing the Coulomb barrier of a doubly charged anion. J Chem Phys 2005; 123:224308. [PMID: 16375477 DOI: 10.1063/1.2135769] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
We probe the repulsive Coulomb barrier of the doubly charged anion PtBr(4) (2-) by photodetachment spectroscopy. The results are discussed in terms of models for the photoemission process, the excitation spectrum of PtBr(4) (2-), and calculations of the energy-dependent tunneling probability for various model potentials.
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Affiliation(s)
- D Löffler
- Institut für Physikalische Chemie, Universität Karlsruhe, D-76128 Karlsruhe, Germany
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Shin JW, Hammer NI, Johnson MA, Schneider H, Glöss A, Weber JM. An Infrared Investigation of the (CO2)n- Clusters: Core Ion Switching from Both the Ion and Solvent Perspectives. J Phys Chem A 2005; 109:3146-52. [PMID: 16833642 DOI: 10.1021/jp050092k] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The (CO2)n- clusters are thought to accommodate the excess electron by forming a localized molecular anion, or "core ion", solvated by the remaining, largely neutral CO2 molecules. Earlier studies interpreted discontinuities in the (CO2)n- photoelectron spectra to indicate that both the CO2- and C2O4- species were present in a size-dependent fashion. Here we use vibrational predissociation spectroscopy to unambiguously establish the molecular structures of the core ions in the 2 < or = n < or = 17 size range. Spectra are reported in the 2300-3800 cm(-1) region, which allows us to independently monitor the contribution of each ion through its characteristic overtone and combination bands. These signature bands are observed to be essentially intact in the larger clusters, establishing that the CO2- and C2O4- molecular ions are indeed the only electron accommodation modes at play. The size dependence of the core ion suggested in earlier analyses of the photoelectron spectra is largely confirmed, although both species are present over a range of clusters near the expected critical cluster sizes, as opposed to the prompt changes inferred earlier. Perturbations in the bands associated with the nominally neutral CO2 "solvent" molecules are correlated with the changes in the molecular structure of the core ion. These observations are discussed in the context of a diabatic model for electron delocalization over the CO2 dimer. In this picture, the driving force leading to the transient formation of the monomer ion is traced to the solvent asymmetry inherent in an incomplete coordination shell.
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Affiliation(s)
- J-W Shin
- Sterling Chemistry Laboratory, Yale University, P. O. Box 208107, New Haven, Connecticut 06520
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Calvi LM, Shin HI, Knight MC, Weber JM, Young MF, Giovannetti A, Schipani E. Constitutively active PTH/PTHrP receptor in odontoblasts alters odontoblast and ameloblast function and maturation. Mech Dev 2005; 121:397-408. [PMID: 15110049 DOI: 10.1016/j.mod.2004.02.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2003] [Revised: 01/28/2004] [Accepted: 02/02/2004] [Indexed: 11/15/2022]
Abstract
Parathyroid hormone (PTH)-related protein (PTH-rP) is an important autocrine/paracrine attenuator of programmed cell differentiation whose expression is restricted to the epithelial layer in tooth development. The PTH/PTHrP receptor (PPR) mRNA in contrast is detected in the dental papilla, suggesting that PTHrP and the PPR may modulate epithelial-mesenchymal interactions. To explore the possible interactions, we studied the previously described transgenic mice in which a constitutively active PPR is targeted to osteoblastic cells. These transgenic mice have a vivid postnatal bone and tooth phenotype, with normal tooth eruption but abnormal, widened crowns. Transgene mRNA expression was first detected at birth in the dental papilla and, at 1 week postnatally, in odontoblasts. There was no transgene expression in ameloblasts or in other epithelial structures. Prenatally, transgenic molars and incisors revealed no remarkable change. By the age of 1 week, the dental papilla was widened, with disorganization of the odontoblastic layer and decreased dentin matrix. In addition, the number of cusps was abnormally increased, the ameloblastic layer disorganized, and enamel matrix decreased. Odontoblastic and, surprisingly, ameloblastic cytodifferentiation was impaired, as shown by in situ hybridization and electron microscopy. Interestingly, ameloblastic expression of Sonic Hedgehog, a major determinant of ameloblastic cytodifferentiation, was dramatically altered in the transgenic molars. These data suggest that odontoblastic activation of the PPR may play an important role in terminal odontoblastic and, indirectly, ameloblastic cytodifferentiation, and describe a useful model to study how this novel action of the PPR may modulate mesenchymal/epithelial interactions at later stages of tooth morphogenesis and development.
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Affiliation(s)
- L M Calvi
- Endocrine Unit, Department of Medicine, University of Rochester School of Medicine, Rochester, NY, USA
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Calvi LM, Adams GB, Weibrecht KW, Weber JM, Olson DP, Knight MC, Martin RP, Schipani E, Divieti P, Bringhurst FR, Milner LA, Kronenberg HM, Scadden DT. Osteoblastic cells regulate the haematopoietic stem cell niche. Nature 2003; 425:841-6. [PMID: 14574413 DOI: 10.1038/nature02040] [Citation(s) in RCA: 2441] [Impact Index Per Article: 116.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2003] [Accepted: 08/26/2003] [Indexed: 12/14/2022]
Abstract
Stem cell fate is influenced by specialized microenvironments that remain poorly defined in mammals. To explore the possibility that haematopoietic stem cells derive regulatory information from bone, accounting for the localization of haematopoiesis in bone marrow, we assessed mice that were genetically altered to produce osteoblast-specific, activated PTH/PTHrP receptors (PPRs). Here we show that PPR-stimulated osteoblastic cells that are increased in number produce high levels of the Notch ligand jagged 1 and support an increase in the number of haematopoietic stem cells with evidence of Notch1 activation in vivo. Furthermore, ligand-dependent activation of PPR with parathyroid hormone (PTH) increased the number of osteoblasts in stromal cultures, and augmented ex vivo primitive haematopoietic cell growth that was abrogated by gamma-secretase inhibition of Notch activation. An increase in the number of stem cells was observed in wild-type animals after PTH injection, and survival after bone marrow transplantation was markedly improved. Therefore, osteoblastic cells are a regulatory component of the haematopoietic stem cell niche in vivo that influences stem cell function through Notch activation. Niche constituent cells or signalling pathways provide pharmacological targets with therapeutic potential for stem-cell-based therapies.
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Affiliation(s)
- L M Calvi
- Endocrine Unit, Department of Medicine, Center for Human Genetics and Molecular Pediatric Disease, University of Rochester School of Medicine, Rochester, New York 14642, USA
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Bigliardi PL, Izakovic J, Weber JM, Bircher AJ. Anaphylaxis to the carbohydrate carboxymethylcellulose in parenteral corticosteroid preparations. Dermatology 2003; 207:100-3. [PMID: 12835567 DOI: 10.1159/000070958] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [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: 11/19/2022] Open
Abstract
BACKGROUND Carboxymethylcellulose is a carbohydrate widely used as additive in tablets, cosmetics, some injectable hormone formulations, food (as E466) and as active principle in hydrocolloid dressings. Anaphylaxis to carboxymethylcellulose in parenteral corticosteroid preparations has previously been reported. Typically, skin tests were positive in such cases, occasionally specific IgE or histamine release have been demonstrated. CASE REPORT We report on 3 patients who suffered from anaphylactic symptoms after local injection of corticosteroid preparations. Intracutaneous skin tests with carboxymethylcellulose were positive; in 2, sulfidoleukotriene release could be measured in the cellular antigen stimulation test (CAST). Specific IgE could not be identified. Oral provocation tests with typical doses of carboxymethylcellulose as found in food and tablets were negative. CONCLUSION In patients with anaphylaxis to parenteral administration of carboxymethylcellulose, small amounts are tolerated by the oral route. Skin tests and CAST are useful diagnostic tools.
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Affiliation(s)
- P L Bigliardi
- Department of Dermatology, Kantonsspital Schaffhausen, Schaffhausen, Switzerland
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Boschelli DH, Ye F, Wang YD, Dutia M, Johnson SL, Wu B, Miller K, Powell DW, Yaczko D, Young M, Tischler M, Arndt K, Discafani C, Etienne C, Gibbons J, Grod J, Lucas J, Weber JM, Boschelli F. Optimization of 4-phenylamino-3-quinolinecarbonitriles as potent inhibitors of Src kinase activity. J Med Chem 2001; 44:3965-77. [PMID: 11689083 DOI: 10.1021/jm0102250] [Citation(s) in RCA: 170] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Subsequent to the discovery of 4-[(2,4-dichlorophenyl)amino]-6,7-dimethoxy-3-quinolinecarbonitrile (1a) as an inhibitor of Src kinase activity (IC(50) = 30 nM), several additional analogues were prepared. Optimization of the C-4 anilino group of 1a led to 1c, which contains a 2,4-dichloro-5-methoxy-substituted aniline. Replacement of the methoxy group at C-7 of 1c with a 3-(morpholin-4-yl)propoxy group provided 2c, resulting in increased inhibition of both Src kinase activity and Src-mediated cell proliferation. Analogues of 2c with other trisubstituted anilines at C-4 were also potent Src inhibitors, and the propoxy group of 2c was preferred over ethoxy, butoxy, or pentoxy. Replacement of the morpholine group of 2c with a 4-methylpiperazine group provided 31a, which had an IC(50) of 1.2 nM in the Src enzymatic assay, an IC(50) of 100 nM for the inhibition of Src-dependent cell proliferation and was selective for Src over non-Src family kinases. Compound 31a, which had higher 1 and 4 h plasma levels than 2c, effectively inhibited tumor growth in xenograft models.
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Affiliation(s)
- D H Boschelli
- Chemical Sciences, Wyeth-Ayerst Research, 401 North Middletown Road, Pearl River, New York 10965, USA.
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Abstract
High-altitude acclimation alters lipid metabolism during exercise, but it is unknown whether this involves changes in rates of lipolysis or reesterification, which form the triacylglycerol/fatty acid (TAG/FA) cycle. We combined indirect calorimetry with [2-(3)H]glycerol and [1-(14)C]palmitate infusions to simultaneously measure total lipid oxidation, lipolysis, and rate of appearance (R(a)) of nonesterified fatty acids (NEFA) in high-altitude-acclimated (HA) rats exercising at 60% maximal O(2) uptake (VO(2 max)). During exercise, relative total lipid oxidation (%VO(2)) equaled sea-level control (SL) values; however, acclimation greatly stimulated lipolysis (+75%) but had no effect on R(a) NEFA. As a result, TAG/FA cycling increased (+119%), due solely to an increase in recycling (+144%) within adipocytes. There was no change in either group in these variables with the transition from rest to exercise. We conclude that, in HA, 1) acclimation is a potent stimulator of lipolysis; 2) rats do not modify TAG/FA cycling with the transition to exercise; and 3) in normoxia, HA and SL derive the same fraction of their total energy from lipids and carbohydrates.
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Affiliation(s)
- G B McClelland
- Department of Zoology, University of British Columbia, Vancouver, British Columbia V6T 1Z4, Canada.
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42
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Abstract
Over 100 serotypes of adenoviruses have been implicated in a variety of human and domesticated animal pathologies and some serotypes are widely used as gene transfer vectors. Aside from the limited use of vaccines for specific serotypes, little effort has been expended in the development of antivirals. The objective here was to study the effect of cystatins from human saliva (CS) and tears (CT), two points of viral entry, on adenain, the adenovirus type 2 encoded proteinase, which is absolutely required for infectivity. Two molecular weight species (13 and 14.5 kDa) were purified from both fluids at a yield of 5 mg/l. In vitro adenain activity was inhibited to 50% at a molar ratio of 5 CS:1 adenain and 3 CT:1 adenain. By comparison, papain was inhibited to 50% at a molar ratio of 2 CS:1 papain and 1.5 CT:1 papain. Adenain differed from papain in response to CS and chicken egg white (CEW) cystatin in being stimulated at low concentrations, and in being inhibited only at very high concentrations of cystatins. The presence of cleavage consensus sites specific to adenain in the human cystatins could drive the adenain-cystatin interaction predominantly in the substrate pathway direction. However, we found that the cystatins could only be digested after denaturation and by highly active fresh enzyme preparations. Our experiments designed to test the nature of the interaction between adenain and cystatins suggest a docking model for the adenain-human cystatin interaction, similar to that proposed for papain and CEW. At equilibrium the dissociation constant, K(d), between adenain and CT was 1.2 nM. The kinetic parameters determined here suggest a simple reversible mechanism for the inhibition of adenain by human cystatins. We conclude that the cystatins present in tears and saliva are unlikely to play a significant role in inhibiting adenovirus infections.
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Affiliation(s)
- A Ruzindana-Umunyana
- Departement de Microbiologie et d'Infectiologie, Faculte de Medecine, Universite de Sherbrooke, Quebec, J1H 5N4, Sherbrooke, Canada
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Abstract
BACKGROUND Historically, group A beta-hemolytic streptococci (GAS) burn wound infection has been a major source of morbidity and mortality in burn patients and has prompted the prophylactic administration of antibiotics to children with burns. Wound monitoring, surveillance cultures, and early excision of deep wounds may have changed this. Our objective in this project was to determine the efficacy of routine antibiotic prophylaxis in the era of early excision and closure of deep burn wounds. METHODS Two cohorts of burned children were compared: all children admitted during calendar years 1992 through 1994 (group 1) and during calendar years 1995 through 1997 (group 2). All group 1 children received routine GAS antibiotic prophylaxis. Only those group 2 children with documented positive admission or surveillance cultures for GAS were treated. RESULTS There were 511 children in group 1 and 406 children in group 2. They were well matched for age (4.7 +/- 0.21 years vs. 5.3 +/- 0.26 years, p = 0.06) and burn size (11.0% +/- 0.7% vs. 12.4% +/- 0.8%, p = 0.18). GAS species were recovered at admission or during hospitalization from 11 (2.6%) of group 1 children and 18 (4.4%) of group 2 children (p = 0.05), indicating a marginally higher rate of carriage in group 2. Nevertheless, in group 1 there were three (0.6%) who developed GAS wound infection and in group 2 there were four (0.98%, p = 0.71). The incidence of GAS infection in those patients with positive admission cultures was three (27%) of group 1 and four (22%) of group 2. No child developed fulminant GAS infection. CONCLUSION Routine antibiotic prophylaxis of burn wounds in children in not effective in further reducing a low baseline incidence of GAS wound infection if admission screening by culture is used to identify those children who carry the organism and early excision of deep burns is practiced.
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Affiliation(s)
- R L Sheridan
- Shriners Burns Hospital, Massachusetts General Hospital, Boston 02114, USA.
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Boschelli DH, Wang YD, Ye F, Wu B, Zhang N, Dutia M, Powell DW, Wissner A, Arndt K, Weber JM, Boschelli F. Synthesis and Src kinase inhibitory activity of a series of 4-phenylamino-3-quinolinecarbonitriles. J Med Chem 2001; 44:822-33. [PMID: 11262092 DOI: 10.1021/jm000420z] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.0] [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: 11/30/2022]
Abstract
Screening of a directed compound library in a yeast-based assay identified 4-[(2,4-dichlorophenyl)amino]-6,7-dimethoxy-3-quinolinecarbonitrile (2a) as a Src inhibitor. An enzymatic assay established that 2a was an ATP-competitive inhibitor of the kinase activity of Src. We present here SAR data for 2a which shows that the aniline group at C-4, the carbonitrile group at C-3, and the alkoxy groups at C-6 and C-7 of the quinoline are crucial for optimal activity. Increasing the size of the C-2 substituent of the aniline at C-4 of 2a from chloro to bromo to iodo resulted in a corresponding increase in Src inhibition. Furthermore, replacement of the 7-methoxy group of 2a with various 3-heteroalkylaminopropoxy groups provided increased inhibition of both Src enzymatic and cellular activity. Compound 25, which contains a 3-morpholinopropoxy group, had an IC(50) of 3.8 nM in the Src enzymatic assay and an IC(50) of 940 nM for the inhibition of Src-dependent cell proliferation.
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Affiliation(s)
- D H Boschelli
- Chemical Sciences and Oncology, Wyeth-Ayerst Research, 401 North Middletown Road, Pearl River, New York 10965, USA.
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Wang YD, Miller K, Boschelli DH, Ye F, Wu B, Floyd MB, Powell DW, Wissner A, Weber JM, Boschelli F. Inhibitors of src tyrosine kinase: the preparation and structure-activity relationship of 4-anilino-3-cyanoquinolines and 4-anilinoquinazolines. Bioorg Med Chem Lett 2000; 10:2477-80. [PMID: 11078204 DOI: 10.1016/s0960-894x(00)00493-5] [Citation(s) in RCA: 53] [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] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Src is a nonreceptor tyrosine kinase involved in signaling pathways that control proliferation, migration, and angiogenesis. Increased Src expression and activity are associated with an increase in tumor malignancy and poor prognosis. Several quinolines and quinazolines were identified as potent and selective inhibitors of Src kinase activity.
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Affiliation(s)
- Y D Wang
- Chemical Sciences and Oncology, Wyeth-Ayerst Research, Pearl River, NY 10965, USA.
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Abstract
Many people harbor herpes simplex virus, often with a known history of "cold sores". During the relatively immunosuppressed state associated with a serious burn, recrudescence of such infections can occur. We report four adults and two children who developed severe herpetic ulceration, over the face and neck in five patients and in a partial thickness wound in one patient. Herpetic infection was diagnosed by culture and direct immunofluorescence testing and treatment was immediately instituted with systemic and topical Acylovir(R) (Zovirax, Glaxo Wellcome). Ulceration healed under treatment and did not leave visible scarring in any of the patients. Although these infections are rapidly progressive, they respond to prompt treatment with antiviral chemotherapy. Rapidly progressive vesicles and ulceration appearing on the face or in the wounds of burn patients should prompt immediate evaluation for herpetic infection.
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Affiliation(s)
- R L Sheridan
- Department of Surgery, Division of Burns and Trauma, Massachusetts General Hospital, Boston, MA, USA.
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Abstract
The authors' previous experiments have shown that dawn simulation at low light intensities can phase advance the circadian rhythm of melatonin in humans. The aim of this study was to compare the effect of repeated dawn signals on the phase position of circadian rhythms in healthy participants kept under controlled light conditions. Nine men participated in two 9-day laboratory sessions under an LD cycle 17.5:6.5 h, < 30:0 lux, receiving 6 consecutive daily dawn (average illuminance 155 lux) or control light (0.1 lux) signals from 0600 to 0730 h (crossover, random-order design). Two modified constant routine protocols before and after the light stimuli measured salivary melatonin (dim light melatonin onset DLMOn and offset DLMOff) and rectal temperature rhythms (midrange crossing time [MRCT]). Compared with initial values, participants significantly phase delayed after 6 days under control light conditions (at least -42 min DLMOn, -54 min DLMOff, -41 min MRCT) in spite of constant bedtimes. This delay was not observed with dawn signals (+10 min DLMOn, +2 min DLMOff, 0 min MRCT). Given that the endogenous circadian period of the human circadian pacemaker is slightly longer than 24 h, the findings suggest that a naturalistic dawn signal is sufficient to forestall this natural delay drift. Zeitgeber transduction and circadian system response are hypothesized to be tuned to the time-rate-of-change of naturalistic twilight signals.
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Affiliation(s)
- K V Danilenko
- Institute of Physiology, Siberian Branch of the Russian Academy of Medical Sciences, Novosibirsk
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Abstract
A specially designed apparatus that can simulate the waveform of the dawn or dusk signal at any latitude and any day of the year has been shown to phase shift the circadian pacemaker in rodents and primates at a fraction of the illuminance previously used. Until recently, it was considered that rather high illuminances or rather long exposure episodes to room light were necessary to phase shift human circadian rhythms. This experiment shows that, under controlled conditions of a modified constant routine protocol, a single dawn signal is sufficient to phase advance the timing of the onset of secretion of the pineal hormone melatonin. The significant phase advance of salivary melatonin of 20 minutes, which is enhanced to 34 minutes after three consecutive dawn signals, is small, but appears to be of sufficient magnitude to entrain the human circadian pacemaker, which has an endogenous period of about 24.2h.
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Affiliation(s)
- K V Danilenko
- Chronobiology and Sleep Laboratory, Psychiatric University Clinic, Basel, Switzerland
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Oualikene W, Lamoureux L, Weber JM, Massie B. Protease-deleted adenovirus vectors and complementing cell lines: potential applications of single-round replication mutants for vaccination and gene therapy. Hum Gene Ther 2000; 11:1341-53. [PMID: 10890743 DOI: 10.1089/10430340050032438] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [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: 11/12/2022] Open
Abstract
A new kind of versatile adenoviral vector (AdV) has been constructed, one that is completely replication disabled in the absence of Ad-E1 proteins but is capable of a single round of replication when Ad-E1 is present. This was made possible by deletion of the Ad protease gene (PS), which is essential for many steps of the Ad life cycle. The PS-deleted virus can be propagated in 293-derived cell lines engineered to express PS. In these new complementing cells, the PS gene was expressed from a tetracycline-inducible promoter in a dicistronic vector coexpressing the green fluorescent protein (GFP). When induced, the best 293-PS stable clones produced the PS in amounts greater than the level reached after Ad infection. Biological activity was first demonstrated by the ability of 293-PS cells to support the replication of Ad2ts1, a mutant expressing a functionally defective PS. While overexpression of the Ad PS slightly affected cell growth, moderate expression at levels sufficient to fully complement Ad2ts1 was well tolerated in 293 cells. Two PS-deleted mutants, deleted or not deleted for E1/E3, were then generated and characterized. Despite their complete loss of infectivity after a single round of replication in permissive cells, the PS-deleted mutants produced as much viral protein as wildtype Ad. These new vectors should thus be both safer and more efficient for applications in which enhancement of transgene expression is desirable, as in the case of vaccination, in situ therapy for tumors, protein production, or the large-scale production of other viral vectors such as adeno-associated virus (AAV).
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Affiliation(s)
- W Oualikene
- Institut de Recherche en Biotechnologie, Conseil National de Recherche Canada, Montréal, QC
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Abstract
Adenoviruses encode a cysteine protease, adenain, required for uncoating and virion maturation. Adenain activity is regulated by an 11-amino-acid peptide cofactor thiol-bonded distal to the active site. Structural and experimental data suggest that the peptide might stabilize adenain in an optimal conformation for enzyme activity by bridging two noncontiguous regions of the molecule. The sequence requirements for this mechanism were examined both in vitro and ex vivo by means of mutant peptides and databank analysis. The results of in vitro experiments suggested that activation is not an all or nothing mechanism. With the exception of the smallest peptide, the mutant peptides bound to adenain, activated it, and competed with the wild-type peptide, but all of this occurred with reduced efficiency. When added to the medium of infected cells, most of the peptides inhibited infectious virus production to varying degrees in a dose-dependent manner and in accordance with their in vitro activity on adenain. We interpret this inhibition to be due to unscheduled adenain activation. Examination of the activation peptide sequences from 19 adenovirus serotypes revealed a limited number of conserved sequence features. These features were in agreement with the experimental data. We conclude that binding and activation of adenain by pVIc may be reversible and this reversibility may be an integral aspect of the in vivo regulation of enzyme activity in the course of virus assembly. The peptide cofactor binding domain is therefore a potential target for the development of anti-adenoviral agents.
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Affiliation(s)
- A Ruzindana-Umunyana
- Departement de Microbiologie et d'Infectiologie, Universite de Sherbrooke, Sherbrooke, Quebec, J1H 5N4, Canada
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