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Diamond T, Burn TN, Nishiguchi MA, Minichino D, Chase J, Chu N, Kreiger PA, Behrens EM. Familial hemophagocytic lymphohistiocytosis hepatitis is mediated by IFN-γ in a predominantly hepatic-intrinsic manner. PLoS One 2022; 17:e0269553. [PMID: 35671274 PMCID: PMC9173616 DOI: 10.1371/journal.pone.0269553] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 05/23/2022] [Indexed: 12/03/2022] Open
Abstract
Interferon gamma (IFN-γ) is the main cytokine driving organ dysfunction in Familial Hemophagocytic Lymphohistiocytosis (FHL). Blockade of IFN-γ pathway ameliorates FHL hepatitis, both in animal models and in humans with FHL. Hepatocytes are known to express IFN-γ receptor (IFN-γ-R). However, whether IFN-γ induced hepatitis in FHL is a lymphocyte or liver intrinsic response to the cytokine has yet to be elucidated. Using a IFNgR-/- bone marrow chimeric model, this study showed that non-hematopoietic IFN-γ response is critical for development of FHL hepatitis in LCMV-infected Prf1-/- mice. Lack of hepatic IFN-γ responsiveness results in reduced hepatitis as measured by hepatomegaly, alanine aminotransferase (ALT) levels and abrogated histologic endothelial inflammation. In addition, IFN-γ non-hematopoietic response was critical in activation of lymphocytes by soluble interleukin 2 receptor (sIL-2r) and recruitment of CD8+ effector T lymphocytes (CD8+ CD44hi CD62Llo) (Teff) and inflammatory monocytes. Lastly, non-hematopoietic IFN-γ response results in increased hepatic transcription of type 1 immune response and oxidative stress response pathways, while decreasing transcription of genes involved in extracellular matrix (ECM) production. In summary, these findings demonstrate that there is a hepatic transcriptional response to IFN-γ, likely critical in the pathogenesis of FHL hepatitis and hepatic specific responses could be a therapeutic target in this disorder.
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Affiliation(s)
- Tamir Diamond
- Division of Gastroenterology Hepatology and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Thomas N. Burn
- Perlman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
| | - Mailyn A. Nishiguchi
- Perlman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
| | - Danielle Minichino
- Perlman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
| | - Julie Chase
- Division of Rheumatology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Niansheng Chu
- Division of Rheumatology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Portia A. Kreiger
- Department of Pathology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Edward M. Behrens
- Division of Rheumatology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
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2
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Nieuwhof-Leppink AJ, Hussong J, Chase J, Larsson J, Renson C, Hoebeke P, Yang S, von Gontard A. Definitions, indications and practice of urotherapy in children and adolescents: - A standardization document of the International Children's Continence Society (ICCS). J Pediatr Urol 2021; 17:172-181. [PMID: 33478902 DOI: 10.1016/j.jpurol.2020.11.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [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: 06/11/2020] [Revised: 09/09/2020] [Accepted: 11/04/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Urotherapy is an umbrella term for all non-surgical, non-pharmacological interventions for lower urinary tract disorders (LUTD) in children and adolescents. Urotherapy is a specialized practice, which has become mainstay therapy not only for daytime urinary incontinence, but also for nocturnal enuresis, functional constipation and fecal incontinence. The aim of urotherapy is to achieve the normalization of the micturition and bowel pattern and to prevent further functional disturbances by repeated training. It is well known that in the treatment of adult and childhood incontinence a team approach is best, where there are shared areas of expertise and also discipline-specific expertise available. AIM We present a consensus view from a cross-professional team of experts affiliated with the International Children's Continence Society on definitions, indications and practice of urotherapy. This is a selective, non-systematic review with practical recommendations for the implementation and research on urotherapy. METHODS The document uses the globally accepted ICCS terminology. Evidence-based literature serves as the basis, but in areas lacking in primary evidence, expert consensus is used. Before submission, a full draft was made available to all ICCS members for additional comments. RESULTS Urotherapy uses non-pharmacological, non-surgical methods and focuses on behavioral interventions, largely based on cognitive-behavioral psychotherapy (CBT). Standard urotherapy comprises components such as provision of information, instructions, life-style advice, counselling and registration of symptoms. Specific urotherapy is tailored towards specific disorders and includes alarm treatment, biofeedback training, pelvic floor training, neurostimulation and other interventions. Fig. 1. Urotherapy is a treatment that addresses all aspects of incontinence, leading to the best clinical outcome. This includes somatic, psychosocial, and behavioral problems and quality of life. Therefore urotherapy is recommended by the ICCS as the first-line treatment for most types of LUTD. The document is intended to be clinically useful in primary, secondary and tertiary care.
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Affiliation(s)
- A J Nieuwhof-Leppink
- Department Psychology and Urology, Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands.
| | - J Hussong
- Department of Child and Adolescent Psychiatry, Saarland University Hospital Homburg, Germany
| | - J Chase
- Victorian Children's Continence Clinic, Paediatric Gastroenterology Victoria, Royal Children's Hospital, Melbourne, Australia
| | - J Larsson
- Section for Paediatric Nephrology, Kristianstad Hospital CSK, Sweden
| | - C Renson
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - P Hoebeke
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - S Yang
- Department of Urolgy, Taipei Tzu Chi Hospital and Buddhist Tzu Chi Universtiy, New Taipei, Taiwan
| | - A von Gontard
- Department of Child and Adolescent Psychiatry, Saarland University Hospital Homburg, Germany
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3
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Vella LA, Giles JR, Baxter AE, Oldridge DA, Diorio C, Kuri-Cervantes L, Alanio C, Pampena MB, Wu JE, Chen Z, Huang YJ, Anderson EM, Gouma S, McNerney KO, Chase J, Burudpakdee C, Lee JH, Apostolidis SA, Huang AC, Mathew D, Kuthuru O, Goodwin EC, Weirick ME, Bolton MJ, Arevalo CP, Ramos A, Jasen CJ, Conrey PE, Sayed S, Giannini HM, D'Andrea K, Meyer NJ, Behrens EM, Bassiri H, Hensley SE, Henrickson SE, Teachey DT, Betts MR, Wherry EJ. Deep immune profiling of MIS-C demonstrates marked but transient immune activation compared to adult and pediatric COVID-19. Sci Immunol 2021; 6:6/57/eabf7570. [PMID: 33653907 PMCID: PMC8128303 DOI: 10.1126/sciimmunol.abf7570] [Citation(s) in RCA: 125] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/25/2021] [Indexed: 12/14/2022]
Abstract
Pediatric COVID-19 following SARS-CoV-2 infection is associated with fewer hospitalizations and often milder disease than in adults. A subset of children, however, present with Multisystem Inflammatory Syndrome in Children (MIS-C) that can lead to vascular complications and shock, but rarely death. The immune features of MIS-C compared to pediatric COVID-19 or adult disease remain poorly understood. We analyzed peripheral blood immune responses in hospitalized SARS-CoV-2 infected pediatric patients (pediatric COVID-19) and patients with MIS-C. MIS-C patients had patterns of T cell-biased lymphopenia and T cell activation similar to severely ill adults, and all patients with MIS-C had SARS-CoV-2 spike-specific antibodies at admission. A distinct feature of MIS-C patients was robust activation of vascular patrolling CX3CR1+ CD8+ T cells that correlated with the use of vasoactive medication. Finally, whereas pediatric COVID-19 patients with acute respiratory distress syndrome (ARDS) had sustained immune activation, MIS-C patients displayed clinical improvement over time, concomitant with decreasing immune activation. Thus, non-MIS-C versus MIS-C SARS-CoV-2 associated illnesses are characterized by divergent immune signatures that are temporally distinct from one another and implicate CD8+ T cells in the clinical presentation and trajectory of MIS-C.
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Affiliation(s)
- Laura A Vella
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA. .,Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Josephine R Giles
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Parker Institute for Cancer Immunotherapy at University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Amy E Baxter
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Derek A Oldridge
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.,Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Caroline Diorio
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Leticia Kuri-Cervantes
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Cécile Alanio
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Parker Institute for Cancer Immunotherapy at University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - M Betina Pampena
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Jennifer E Wu
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Parker Institute for Cancer Immunotherapy at University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Zeyu Chen
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Yinghui Jane Huang
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Elizabeth M Anderson
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Sigrid Gouma
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Kevin O McNerney
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Julie Chase
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Division of Rheumatology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Chakkapong Burudpakdee
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Jessica H Lee
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Sokratis A Apostolidis
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Division of Rheumatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Alexander C Huang
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Divij Mathew
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Oliva Kuthuru
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Eileen C Goodwin
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Madison E Weirick
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Marcus J Bolton
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Claudia P Arevalo
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Andre Ramos
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - C J Jasen
- Division of Allergy and Immunology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,19104, USA
| | - Peyton E Conrey
- Division of Allergy and Immunology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,19104, USA
| | - Samir Sayed
- Division of Allergy and Immunology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,19104, USA
| | - Heather M Giannini
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Kurt D'Andrea
- Division of Translational Medicine and Human Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | | | - Nuala J Meyer
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Edward M Behrens
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Division of Rheumatology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Hamid Bassiri
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Scott E Hensley
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Sarah E Henrickson
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Division of Allergy and Immunology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,19104, USA
| | - David T Teachey
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - Michael R Betts
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
| | - E John Wherry
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA. .,Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.,Parker Institute for Cancer Immunotherapy at University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA
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4
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Anderson EM, Diorio C, Goodwin EC, McNerney KO, Weirick ME, Gouma S, Bolton MJ, Arevalo CP, Chase J, Hicks P, Manzoni TB, Baxter AE, Andrea KP, Burudpakdee C, Lee JH, Vella LA, Henrickson SE, Harris RM, Wherry EJ, Bates P, Bassiri H, Behrens EM, Teachey DT, Hensley SE. Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) Antibody Responses in Children With Multisystem Inflammatory Syndrome in Children (MIS-C) and Mild and Severe Coronavirus Disease 2019 (COVID-19). J Pediatric Infect Dis Soc 2020; 10:669-673. [PMID: 33263756 PMCID: PMC7799010 DOI: 10.1093/jpids/piaa161] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [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: 09/15/2020] [Accepted: 12/01/2020] [Indexed: 12/24/2022]
Abstract
Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) antibody responses in children remain poorly characterized. Here, we show that pediatric patients with multisystem inflammatory syndrome in children (MIS-C) possess higher SARS-CoV-2 spike immunoglobulin G (IgG) titers compared with those with severe coronavirus disease 2019, likely reflecting a longer time since the onset of infection in MIS-C patients.
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Affiliation(s)
- Elizabeth M Anderson
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Caroline Diorio
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA,Division of Oncology, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Eileen C Goodwin
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Kevin O McNerney
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA,Division of Oncology, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Madison E Weirick
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Sigrid Gouma
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Marcus J Bolton
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Claudia P Arevalo
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Julie Chase
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA,Division of Rheumatology, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Philip Hicks
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA,School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Tomaz B Manzoni
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Amy E Baxter
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA, USA
| | - Kurt P Andrea
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA, USA
| | - Chakkapong Burudpakdee
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jessica H Lee
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Laura A Vella
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA, USA,Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sarah E Henrickson
- Division of Allergy and Immunology, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Rebecca M Harris
- Department of Pathology and Laboratory Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - E John Wherry
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul Bates
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA,Penn Center for Research on Coronavirus and Other Emerging Pathogens, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Hamid Bassiri
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA,Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Edward M Behrens
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA,Division of Rheumatology, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - David T Teachey
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA,Division of Oncology, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Scott E Hensley
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA,Correspondence:
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5
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Diorio C, Henrickson SE, Vella LA, McNerney KO, Chase J, Burudpakdee C, Lee JH, Jasen C, Balamuth F, Barrett DM, Banwell BL, Bernt KM, Blatz AM, Chiotos K, Fisher BT, Fitzgerald JC, Gerber JS, Gollomp K, Gray C, Grupp SA, Harris RM, Kilbaugh TJ, John ARO, Lambert M, Liebling EJ, Paessler ME, Petrosa W, Phillips C, Reilly AF, Romberg ND, Seif A, Sesok-Pizzini DA, Sullivan KE, Vardaro J, Behrens EM, Teachey DT, Bassiri H. Multisystem inflammatory syndrome in children and COVID-19 are distinct presentations of SARS-CoV-2. J Clin Invest 2020; 130:5967-5975. [PMID: 32730233 DOI: 10.1172/jci140970] [Citation(s) in RCA: 285] [Impact Index Per Article: 71.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 07/27/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUNDInitial reports from the severe acute respiratory coronavirus 2 (SARS-CoV-2) pandemic described children as being less susceptible to coronavirus disease 2019 (COVID-19) than adults. Subsequently, a severe and novel pediatric disorder termed multisystem inflammatory syndrome in children (MIS-C) emerged. We report on unique hematologic and immunologic parameters that distinguish between COVID-19 and MIS-C and provide insight into pathophysiology.METHODSWe prospectively enrolled hospitalized patients with evidence of SARS-CoV-2 infection and classified them as having MIS-C or COVID-19. Patients with COVID-19 were classified as having either minimal or severe disease. Cytokine profiles, viral cycle thresholds (Cts), blood smears, and soluble C5b-9 values were analyzed with clinical data.RESULTSTwenty patients were enrolled (9 severe COVID-19, 5 minimal COVID-19, and 6 MIS-C). Five cytokines (IFN-γ, IL-10, IL-6, IL-8, and TNF-α) contributed to the analysis. TNF-α and IL-10 discriminated between patients with MIS-C and severe COVID-19. The presence of burr cells on blood smears, as well as Cts, differentiated between patients with severe COVID-19 and those with MIS-C.CONCLUSIONPediatric patients with SARS-CoV-2 are at risk for critical illness with severe COVID-19 and MIS-C. Cytokine profiling and examination of peripheral blood smears may distinguish between patients with MIS-C and those with severe COVID-19.FUNDINGFinancial support for this project was provided by CHOP Frontiers Program Immune Dysregulation Team; National Institute of Allergy and Infectious Diseases; National Cancer Institute; the Leukemia and Lymphoma Society; Cookies for Kids Cancer; Alex's Lemonade Stand Foundation for Childhood Cancer; Children's Oncology Group; Stand UP 2 Cancer; Team Connor; the Kate Amato Foundations; Burroughs Wellcome Fund CAMS; the Clinical Immunology Society; the American Academy of Allergy, Asthma, and Immunology; and the Institute for Translational Medicine and Therapeutics.
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Affiliation(s)
| | - Sarah E Henrickson
- Immune Dysregulation Frontier Program.,Division of Allergy and Immunology
| | - Laura A Vella
- Immune Dysregulation Frontier Program.,Division of Infectious Diseases
| | | | - Julie Chase
- Immune Dysregulation Frontier Program.,Division of Rheumatology
| | | | | | - Cristina Jasen
- Immune Dysregulation Frontier Program.,Division of Allergy and Immunology
| | | | | | - Brenda L Banwell
- Immune Dysregulation Frontier Program.,Division of Neurology, Department of Pediatrics
| | | | | | - Kathleen Chiotos
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, and
| | - Brian T Fisher
- Immune Dysregulation Frontier Program.,Division of Infectious Diseases
| | - Julie C Fitzgerald
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, and
| | | | - Kandace Gollomp
- Immune Dysregulation Frontier Program.,Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | | | | | - Todd J Kilbaugh
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, and
| | | | - Michele Lambert
- Immune Dysregulation Frontier Program.,Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Michele E Paessler
- Immune Dysregulation Frontier Program.,Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | | | - Anne F Reilly
- Immune Dysregulation Frontier Program.,Division of Oncology
| | - Neil D Romberg
- Immune Dysregulation Frontier Program.,Division of Allergy and Immunology
| | - Alix Seif
- Immune Dysregulation Frontier Program.,Division of Oncology
| | - Deborah A Sesok-Pizzini
- Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Julie Vardaro
- Center for Healthcare Quality and Analytics (CHQA), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | | | - Hamid Bassiri
- Immune Dysregulation Frontier Program.,Division of Infectious Diseases
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6
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Vella L, Giles JR, Baxter AE, Oldridge DA, Diorio C, Kuri-Cervantes L, Alanio C, Pampena MB, Wu JE, Chen Z, Huang YJ, Anderson EM, Gouma S, McNerney KO, Chase J, Burudpakdee C, Lee JH, Apostolidis SA, Huang AC, Mathew D, Kuthuru O, Goodwin EC, Weirick ME, Bolton MJ, Arevalo CP, Ramos A, Jasen C, Giannini HM, DAndrea K, Meyer NJ, Behrens EM, Bassiri H, Hensley SE, Henrickson SE, Teachey DT, Betts MR, Wherry EJ. Deep Immune Profiling of MIS-C demonstrates marked but transient immune activation compared to adult and pediatric COVID-19. medRxiv 2020. [PMID: 32995826 DOI: 10.1101/2020.09.25.20201863] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pediatric COVID-19 following SARS-CoV-2 infection is associated with fewer hospitalizations and often milder disease than in adults. A subset of children, however, present with Multisystem Inflammatory Syndrome in Children (MIS-C) that can lead to vascular complications and shock, but rarely death. The immune features of MIS-C compared to pediatric COVID-19 or adult disease remain poorly understood. We analyzed peripheral blood immune responses in hospitalized SARS-CoV-2 infected pediatric patients (pediatric COVID-19) and patients with MIS-C. MIS-C patients had patterns of T cell-biased lymphopenia and T cell activation similar to severely ill adults, and all patients with MIS-C had SARS-CoV-2 spike-specific antibodies at admission. A distinct feature of MIS-C patients was robust activation of vascular patrolling CX3CR1+ CD8 T cells that correlated with use of vasoactive medication. Finally, whereas pediatric COVID-19 patients with acute respiratory distress syndrome (ARDS) had sustained immune activation, MIS-C patients displayed clinical improvement over time, concomitant with decreasing immune activation. Thus, non-MIS-C versus MIS-C SARS-CoV-2 associated illnesses are characterized by divergent immune signatures that are temporally distinct and implicate CD8 T cells in clinical presentation and trajectory of MIS-C.
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7
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Anderson EM, Diorio C, Goodwin EC, McNerney KO, Weirick ME, Gouma S, Bolton MJ, Arevalo CP, Chase J, Hicks P, Manzoni TB, Baxter AE, Andrea KP, Burudpakdee C, Lee JH, Vella LA, Henrickson SE, Harris RM, Wherry EJ, Bates P, Bassiri H, Behrens EM, Teachey DT, Hensley SE. SARS-CoV-2 antibody responses in children with MIS-C and mild and severe COVID-19. medRxiv 2020. [PMID: 32839782 PMCID: PMC7444298 DOI: 10.1101/2020.08.17.20176552] [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] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
SARS-CoV-2 antibody responses in children remain poorly characterized. Here, we show that pediatric patients with multisystem inflammatory syndrome in children (MIS-C) possess higher SARS-CoV-2 spike IgG titers compared to those with severe coronavirus disease 2019 (COVID-19), likely reflecting a longer time since onset of infection in MIS-C patients.
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Affiliation(s)
- Elizabeth M Anderson
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA.,These authors contributed equally to this work: Elizabeth M. Anderson and Caroline Diorio
| | - Caroline Diorio
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,These authors contributed equally to this work: Elizabeth M. Anderson and Caroline Diorio
| | - Eileen C Goodwin
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Kevin O McNerney
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Madison E Weirick
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Sigrid Gouma
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Marcus J Bolton
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Claudia P Arevalo
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Julie Chase
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Rheumatology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Philip Hicks
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA.,School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Tomaz B Manzoni
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Amy E Baxter
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA, USA
| | - Kurt P Andrea
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA, USA
| | - Chakkapong Burudpakdee
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jessica H Lee
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Laura A Vella
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA, USA.,Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sarah E Henrickson
- Division of Allergy and Immunology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Rebecca M Harris
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - E John Wherry
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul Bates
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA.,Penn Center for Research on Coronavirus and Other Emerging Pathogens, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Hamid Bassiri
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Edward M Behrens
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Rheumatology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - David T Teachey
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Scott E Hensley
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
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8
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Klenner JB, Van Noorden BA, Knopp JL, Holder Pearson LR, Hardy AR, Vergeer SL, Shaw GM, Chase J. Determining the effects of insulin Detemir on endogenous secretion of insulin. Annu Int Conf IEEE Eng Med Biol Soc 2020; 2019:2943-2946. [PMID: 31946507 DOI: 10.1109/embc.2019.8857643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Type 2 diabetes (T2D) is a long-term metabolic disorder. A pilot trial was designed to investigate the effects of the long acting insulin Detemir on endogenous insulin secretion, to assess use in early T2D care. Provesn metabolic system models are used to identify patient-specific insulin sensitivity and endogenous insulin secretion from clinical data. Post-cardiac surgery patients with early T2D or pre-diabetes based on HbA1c were given a bolus of insulin Detemir on one day, and none on the second day in hospital. Blood glucose, insulin, C-Peptide, and all nutrition given are recorded. Early results from N=3 patients show 0.8-1.0U/hour insulin Detemir doses have no apparent suppression of endogenous insulin secretion, but does help lower glucose levels. The results show the model captures glucose-insulin dynamics in pre-diabetic post-surgical patients, and insulin Detemir may be useful to support individuals with pre-diabetes in reducing blood glucose levels. Tests with higher doses, need to be carried out to verify these results over a greater range of patients.
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9
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Button B, Holland A, Sherburn M, Chase J, Wilson J, Burge A. Prevalence, impact and specialised treatment of urinary incontinence in women with chronic lung disease. Physiotherapy 2019; 105:114-119. [DOI: 10.1016/j.physio.2018.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 07/24/2018] [Indexed: 10/28/2022]
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10
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Bowles K, Whitehouse C, Chase J, Mikkelsen M, Jordan L, Ryvicker M, Barron-Vaya Y, Murtaugh C. PROFILES OF SEPSIS SURVIVORS ENTERING HOME HEALTHCARE: CLUES TO PRIORITIZE CARE FOR MEDICARE BENEFICIARIES. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.2863] [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: 11/13/2022] Open
Affiliation(s)
- K Bowles
- University of Pennsylvania; Visiting Nurse Service of New York
| | | | | | | | - L Jordan
- Visiting Nurse Service of New York
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11
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Whitehouse C, Bowles K, Jordan L, Chase J, Murtaugh C. PREVALENCE AND SIGNIFICANCE OF GERIATRIC SYNDROMES AFTER HOSPITALIZATION FOR SEPSIS AMONG HOME HEALTH RECIPIENTS. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.1840] [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: 11/13/2022] Open
Affiliation(s)
| | - K Bowles
- University of Pennsylvania; Visiting Nurse Service of New York
| | - L Jordan
- Visiting Nurse Service of New York
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12
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Kim K, Ehrlich A, Perng V, Chase J, Raybould H, Li X, Atwill ER, Whelan R, Sokale A, Liu Y. 069 Effects of dietary β-glucan on growth performance, diarrhea, and gut permeability of weanling pigs experimentally infected with a pathogenic Escherichia coli. J Anim Sci 2017. [DOI: 10.2527/asasann.2017.069] [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: 11/13/2022] Open
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13
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Chase J, Huang L, Russell D, Hanlon A, O’Connor M, Robinson K, Bowles K. RACIAL AND ETHNIC DISPARITIES IN ADL DISABILITY AFTER HOSPITALIZATION AMONG OLDER HOME CARE RECIPIENTS. Innov Aging 2017. [DOI: 10.1093/geroni/igx004.3853] [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: 11/13/2022] Open
Affiliation(s)
- J. Chase
- University of Missouri, Columbia, Missouri,
- University of Pennsylvania, Philadelphia, Pennsylvania,
| | - L. Huang
- University of Pennsylvania, Philadelphia, Pennsylvania,
| | - D. Russell
- Visiting Nurse Service of New York, Manhattan, New York,
| | - A. Hanlon
- University of Pennsylvania, Philadelphia, Pennsylvania,
| | - M. O’Connor
- Villanova University, Villanova, Pennsylvania
| | - K. Robinson
- University of Pennsylvania, Philadelphia, Pennsylvania,
| | - K.H. Bowles
- University of Pennsylvania, Philadelphia, Pennsylvania,
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14
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Abstract
The presence of an apparent seat belt mark (SBM) on a car crash occupant is often used as evidence for use of a seat belt at the time of the crash and, conversely, the lack of a SBM is used as an indication that no seat belt was used. This study examined whether there are clear indications of seat belt use to be found at autopsy and evaluated the sensitivity and specificity of apparent SBM and whether the use of a seat belt and seating location affects the type and severity of injuries sustained. Information on the type of injuries sustained and seatbelt use was retrieved from autopsy reports and police reports, respectively, for cases of fatal motor vehicle collisions occurring in Sydney, Australia over a 5-year period. In this study, a SBM was only found on restrained occupants. The proportion of restrained occupants with evidence of a SBM was 36% (sensitivity), whilst unrestrained occupants showed no evidence of a SBM (100% specificity). A SBM was also found to reliably reflect the seating position of the occupant. We conclude that restrained occupants can be expected to show evidence of the seat belt in just over one third of cases and that the absence of a SBM is not necessarily an indication that no seat belt was used. Spurious SBM is very unlikely to be present if the occupant was unrestrained.
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Affiliation(s)
- J Chase
- University College London, London, UK
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15
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Eastman AL, Chase J, Stark BJ. SURVIVAL MINDSET. JEMS 2016; 41:35-37. [PMID: 27209825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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16
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Koppen IJN, von Gontard A, Chase J, Cooper CS, Rittig CS, Bauer SB, Homsy Y, Yang SS, Benninga MA. Management of functional nonretentive fecal incontinence in children: Recommendations from the International Children's Continence Society. J Pediatr Urol 2016; 12:56-64. [PMID: 26654481 DOI: 10.1016/j.jpurol.2015.09.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [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: 06/30/2015] [Accepted: 09/30/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Fecal incontinence (FI) in children is frequently encountered in pediatric practice, and often occurs in combination with urinary incontinence. In most cases, FI is constipation-associated, but in 20% of children presenting with FI, no constipation or other underlying cause can be found - these children suffer from functional nonretentive fecal incontinence (FNRFI). OBJECTIVE To summarize the evidence-based recommendations of the International Children's Continence Society for the evaluation and management of children with FNRFI. RECOMMENDATIONS Functional nonretentive fecal incontinence is a clinical diagnosis based on medical history and physical examination. Except for determining colonic transit time, additional investigations are seldom indicated in the workup of FNRFI. Treatment should consist of education, a nonaccusatory approach, and a toileting program encompassing a daily bowel diary and a reward system. Special attention should be paid to psychosocial or behavioral problems, since these frequently occur in affected children. Functional nonretentive fecal incontinence is often difficult to treat, requiring prolonged therapies with incremental improvement on treatment and frequent relapses.
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Affiliation(s)
- I J N Koppen
- Department of Pediatric Gastroenterology, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands.
| | - A von Gontard
- Department of Child and Adolescent Psychiatry, Saarland University Hospital, Homburg, Germany
| | - J Chase
- Paediatric Gastroenterology Victoria, Royal Children's Hospital, Melbourne, Australia
| | - C S Cooper
- Division of Pediatric Urology, University of Iowa, Iowa City, United States of America
| | - C S Rittig
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - S B Bauer
- Department of Urology, Boston Children's Hospital, Boston, United States of America
| | - Y Homsy
- Children's Urology Group, All Children's Hospital/Johns Hopkins Medicine, University of South Florida, Tampa, FL, United States of America
| | - S S Yang
- Taipei Tzu Chi Hospital, Buddhist Medical Foundation, New Taipei, Taiwan; School of Medicine, Buddhist Tzu Chi University, Hualien, Taiwan
| | - M A Benninga
- Department of Pediatric Gastroenterology, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
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17
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Madden K, Ashe M, Chase J. O-090: Intensity of physical activity and daily energy expenditure in athletic older adults. Eur Geriatr Med 2015. [DOI: 10.1016/s1878-7649(15)30103-0] [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: 11/25/2022]
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18
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Simmonds J, Ninis N, Chase J, Meadows N, Rawat D, Watson T. Interferential for slow transit constipation in children with Ehlers Danlos Syndrome – Hypermobility Type: a novel service development. Physiotherapy 2015. [DOI: 10.1016/j.physio.2015.03.1348] [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: 10/23/2022]
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19
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Horvath SJ, Couto CG, Yant K, Kontur K, Bohenko L, Iazbik MC, Marín LM, Hudson D, Chase J, Frye M, Denicola DB. Effects of racing on reticulocyte concentrations in Greyhounds. Vet Clin Pathol 2014; 43:15-23. [PMID: 24405452 DOI: 10.1111/vcp.12113] [Citation(s) in RCA: 7] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Greyhounds have several hematologic variables that are outside of the respective reference intervals of other dog breeds. In addition, increases in HCT, total protein and HGB concentration, and RBC and WBC counts occur immediately after exercise; these values return to resting values within a few hour after racing. OBJECTIVE This study evaluated the effects of exercise on the concentration of reticulocytes in circulating blood in racing Greyhounds. We hypothesized that reticulocyte numbers are significantly increased immediately after a race, and return to baseline within one to 2 h postrace. METHODS Fifty actively racing Greyhounds at the Wheeling Island Racetrack and Casino were included in the study. Samples were collected by jugular venipuncture one day prior to racing at the kennel (resting), immediately after racing, and one to 2 h after the race (recovery). Reticulocyte counts were determined with an IDEXX ProCyte Dx Hematology Analyzer (IDEXX Laboratories, Inc., Westbrook, ME, USA). Due to a nonparametric distribution, the results were statistically compared using the Friedman test. RESULTS Reticulocyte concentrations were significantly different among the 3 sample collection times (P < .0001). There was a significant increase in reticulocyte concentration immediately after racing (P < .001); one to 2 h after racing, the reticulocyte numbers decreased significantly (P < .001) to counts comparable to resting samples. CONCLUSION The increase in reticulocyte concentration is probably related to splenic contraction secondary to the release of catecholamines, although premature bone marrow release could also account for these changes. Thus, it is important to consider a Greyhound's activity and degree of excitement when interpreting selected hematologic data in a clinical setting.
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Affiliation(s)
- S J Horvath
- Department of Veterinary Clinical Sciences, OSU Veterinary Medical Center, The Ohio State University College of Veterinary Medicine, Columbus, OH, USA
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20
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Jurenka RA, Schal C, Burns E, Chase J, Blomquist GJ. Structural correlation between cuticular hydrocarbons and female contact sex pheromone of German cockroachBlattella germanica (L.). J Chem Ecol 2013; 15:939-49. [PMID: 24271896 DOI: 10.1007/bf01015189] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/1988] [Accepted: 04/04/1988] [Indexed: 11/29/2022]
Abstract
The structural relationships between the cuticular hydrocarbons and the contact sex pheromone of the female German cockroach,Blattella germanica, were investigated. Cuticular hexane extracts were separated into hydrocarbon and ketone fractions by TLC or silicic acid column chromatography. The ketone fraction (which contains the major contact sex pheromone component) was analyzed by GC-MS before and after reduction to ydrocarbon. In addition to 3,11-dimethyl-2-nonacosanone, 3,11-dimethyl-2-heptacosanone was also identified. Females have the 3,11- and 3,9-dimethyl C27 and C29 alkanes, but only the 3,11- isomer of the dimethylketones. Inddition to the hydrocarbon components previously reported, a number of new components were characterized. Although the ratios of cuticular hydrocarbons differ among nymphs, adult males, and adult females, they have qualitatively identical hydrocarbon profiles, suggesting that the production of the contact sex pheromone results from the sex-specific oxidation of 3,11-imethylalkanes to pheromone components by the female.
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Affiliation(s)
- R A Jurenka
- Department of Biochemistry, University of Nevada-Reno, 89557-0014, Reno, Nevada
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21
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Leong J, Chase J, Romee R, Schneider S, Sullivan R, Fehniger T. Cytokine activation induces CD25 expression and a functional high-affinity IL-2 receptor on CD56dim human NK Cells (P4349). The Journal of Immunology 2013. [DOI: 10.4049/jimmunol.190.supp.183.10] [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] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Abstract
The heterotrimeric high affinity IL-2 receptor (IL-2Rαβγ) is expressed on CD56bright human NK cells and confers responsiveness to picomolar concentrations of IL-2. In contrast, resting CD56dim NK cells lack IL-2Rα (CD25), but constitutively express the intermediate affinity IL-2Rβγ chains. Here, we show that cytokine-activation induces rapid and prolonged expression of CD25 on CD56dim NK cells, especially the combination of IL-15 plus IL-18. This expression of CD25 correlated with STAT5 phosphorylation in response to picomolar concentrations of IL-2, indicating the presence of a signal-competent IL-2Rαβγ. Furthermore, picomolar concentrations of IL-2 acted synergistically with IL-12 to co-stimulate IFN-γ production by pre-activated CD56dim NK cells. Similarly, low dose IL-2 enhanced the cytotoxicity of pre-activated CD56dim NK cells against K562 tumor targets. Both effects were dependent on the expression of CD25. Preliminary experiments also suggest that the induction of CD25 on CD56dim NK cells enhances proliferative capacity and survival in cultures supplemented with low dose IL-2. Since CD56dim NK cells represent the major subset of human peripheral blood NK cells, these data support a rationale for immunotherapeutic strategies that include cytokine pre-activation prior to adoptive NK cell transfer, followed by low dose IL-2 therapy.
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Affiliation(s)
- Jeff Leong
- 1Oncology, Washington University School of Medicine, Saint Louis, MO
| | - Julie Chase
- 1Oncology, Washington University School of Medicine, Saint Louis, MO
| | - Rizwan Romee
- 1Oncology, Washington University School of Medicine, Saint Louis, MO
| | | | - Ryan Sullivan
- 1Oncology, Washington University School of Medicine, Saint Louis, MO
| | - Todd Fehniger
- 1Oncology, Washington University School of Medicine, Saint Louis, MO
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22
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Fisk L, Le Compte A, Shaw G, Chase J. Improving Safety of Glucose Control in Intensive Care using Virtual Patients and Simulated Clinical Trials. Journal of Healthcare Engineering 2012. [DOI: 10.1260/2040-2295.3.3.415] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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23
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Dayan N, Sivalenka R, Chase J. Skin moisturization by hydrogenated polyisobutene-Quantitative and visual evaluation. Int J Cosmet Sci 2010. [DOI: 10.1111/j.1468-2494.2009.00533_3.x] [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: 11/30/2022]
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24
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Desaive T, Ghuysen A, Lambermont B, Kolh P, Dauby PC, Starfinger C, Hann CE, Chase J, Shaw GM. Study of ventricular interaction during pulmonary embolism using clinical identification in a minimum cardiovascular system model. ACTA ACUST UNITED AC 2008; 2007:2976-9. [PMID: 18002620 DOI: 10.1109/iembs.2007.4352954] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cardiovascular disturbances are difficult to diagnose and treat because of the large range of possible underlying dysfunctions combined with regulatory reflex mechanisms that can result in conflicting clinical data. Thus, medical professionals often rely on experience and intuition to optimize hemodynamics in the critically ill. This paper combines an existing minimal cardiovascular system model with an extended integral based parameter identification method to track the evolution of induced pulmonary embolism in porcine data. The model accounts for ventricular interaction dynamics and is shown to predict an increase in the right ventricle expansion index and a decrease in septum volume consistent with known physiological response to pulmonary embolism. The full range of hemodynamic responses was captured with mean prediction errors of 4.1% in the pressures and 3.1% in the volumes for 6 sets of clinical data. Pulmonary resistance increased significantly with the onset of embolism in all cases, as expected, with the percentage increase ranging from 89.98% to 261.44% of the initial state. These results are an important first step towards model-based cardiac diagnosis in the Intensive Care Unit.
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25
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Kalet AL, Sanger J, Chase J, Keller A, Schwartz MD, Fishman ML, Garfall AL, Kitay A. Promoting professionalism through an online professional development portfolio: successes, joys, and frustrations. Acad Med 2007; 82:1065-72. [PMID: 17971693 DOI: 10.1097/acm.0b013e31815762af] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Medical educators strive to promote the development of a sound professional identity in learners, yet it is challenging to design, implement, and sustain fair and meaningful assessments of professionalism to accomplish this goal. The authors developed and implemented a program built around a Web-based Professional Development Portfolio (PDP) to assess and document professional development in medical students at New York University School of Medicine. This program requires students to regularly document their professional development through written reflections on curricular activities spanning preclinical and clinical years. Students post reflections, along with other documents that chronicle their professional growth, to their online PDP. Students meet annually with a faculty mentor to review their portfolios, assess their professional development based on predetermined criteria, and establish goals for the coming year. In this article, the authors describe the development of the PDP and share four years of experience with its implementation. We describe the experiences and attitudes of the first students to participate in this program as reported in an annual student survey. Students' experiences of and satisfaction with the PDP was varied. The PDP has been a catalyst for honest and lively debate concerning the meaning and behavioral manifestations of professionalism. A Web-based PDP promoted self-regulation on an individual level because it facilitated narrative reflection, self-assessment, and goal setting, and it structured mentorship. Therefore, the PDP may prepare students for the self-regulation of the medical profession--a privilege and obligation under the physician's social contract with society.
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Affiliation(s)
- Adina L Kalet
- Section of Primary Care Internal Medicine, Division of General Internal Medicine, New York University School of Medicine, New York, New York, USA.
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Chase J, Shaw G, Lotz T, LeCompte A, Wong J, Lin J, Lonergan T, Willacy M, Hann C. Model-Based Insulin and Nutrition Administration for Tight Glycaemic Control in Critical Care. Curr Drug Deliv 2007; 4:283-96. [DOI: 10.2174/156720107782151223] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
We report on the motivations of potential ovum donors entering an assisted reproduction program and discuss the potential ramifications of escalating payments to donors. From July 1995 to July 1998, recruitment of ovum donors was directed at healthy women between 21 and 34 years of age. Financial remuneration for services rendered was USD 2,500 from July 1995 through March 1998 and increased to USD 5,000 after that. Donors were screened and consented according to established SART guidelines. The demographic background of the women was similar for women paid USD 2,500 to those receiving USD 5,000. The financial motivation was greater in those receiving USD 5,000 (68%) than USD 2,500 (39%). Some form of expressed altruism was similarly present in both groups (USD 5,000 90%, and USD 2,500 91%). However, altruism expressed as the sole motivation occurred more in those receiving USD 2,500 (61%) compared to USD 5,000 (32%). Financial reimbursement has escalated for the services of ovum donors in order to maintain the increasing demand. While money has become a dominant factor motivating ovum donors, its seductive nature requires even greater attention to adequate informed consent. Young donors may be unable to adequately weigh the risks of ovarian hyperstimulation and oocyte retrieval against the monetary reward.
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Affiliation(s)
- S R Lindheim
- Center for Advanced Reproductive Medicine, Norwalk, Conn., USA
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Meric F, Patt YZ, Curley SA, Chase J, Roh MS, Vauthey JN, Ellis LM. Surgery after downstaging of unresectable hepatic tumors with intra-arterial chemotherapy. Ann Surg Oncol 2000; 7:490-5. [PMID: 10947016 DOI: 10.1007/s10434-000-0490-2] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.5] [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] [Indexed: 12/17/2022]
Abstract
BACKGROUND This retrospective study was performed to assess the outcome among patients who underwent hepatic resection or tumor ablation after hepatic artery infusion (HAI) therapy down-staged previously unresectable hepatocellular carcinoma (HCC) or liver metastases from colorectal cancer (CRC). METHODS Between 1983 and 1998, 25 patients with HCC and 383 patients with hepatic CRC metastases were treated with HAI therapy for unresectable liver disease. We retrospectively reviewed the records of 26 (6%) of these patients who underwent subsequent surgical exploration for tumor resection or ablation. RESULTS At a median of 9 months (range 7-12 months) after HAI treatment, four patients (16%) with HCC underwent exploratory surgery; two underwent resection with negative margins, and the other two were given radiofrequency ablation (RFA) because of underlying cirrhosis. At a median postoperative follow-up of 16 months (range 6-48 months), all four patients were alive with no evidence of disease. At a median of 14.5 months (range 8-24 months) after HAI therapy, 22 patients with hepatic CRC metastases underwent exploratory surgery; 10 underwent resection, 6 underwent resection and RFA or cryotherapy, and 2 underwent RFA only. At a median follow-up of 17 months, 15 (83%) of the 18 patients with CRC who had received surgical treatment had developed recurrent disease; the other 3 died of other causes (1 of postoperative complications) within 7 months of the surgery. One patient in whom disease recurred underwent a second resection and was disease-free at 1 year follow-up. CONCLUSIONS Hepatic resection or ablation after tumor downstaging with HAI therapy is a viable option for patients with unresectable HCC. However, given the high rate of recurrence of metastases from CRC, hepatic resection or ablation after downstaging with HAI should be used with caution.
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Affiliation(s)
- F Meric
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston 77030, USA
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Kohn M, Flood H, Chase J, McMahon PM. Prevalence and health consequences of stalking--Louisiana, 1998-1999. MMWR Morb Mortal Wkly Rep 2000; 49:653-5. [PMID: 10943251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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Abstract
PURPOSE Measurement of anterior leg compartment pressures in eight patients (16 limbs) who were positioned in the lithotomy position for prolonged periods of time while undergoing colorectal intra-abdominal surgery. METHODS Anterior leg compartment pressures were measured in eight patients (16 limbs) by using a slit catheter, whereas subjects were positioned in the lithotomy position for prolonged periods of time while undergoing colorectal intra-abdominal surgery. RESULTS Compartment pressures had minor elevations after initial lithotomy positioning, and gradually increased over time. Levels elevated to 30 mmHg at an average of five (range, 3.5 to 6) hours. The maximum recorded leg compartment pressure was 70 mmHg. The addition of Trendelenburg positioning was noted to consistently increase compartment pressures. All pressures returned to less than 10 mmHg shortly after removing the limb from the stirrups and placing the limb supine. No patients developed clinical evidence of compartment syndrome. CONCLUSIONS Leg anterior compartment pressures rise when limbs are placed in the lithotomy position for prolonged periods of time. The rise in pressure is increased with the addition of Trendelenburg positioning. Anterior compartment pressures reached a threshold of 30 mmHg at an average of five hours. The results of this study suggest that lithotomy positioning of the lower extremities has the potential to initiate leg compartment syndrome when the period of positioning approaches five hours. Removing the limbs from the stirrups and placing them in the supine position allows the pressure in the compartments to return to normal.
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Affiliation(s)
- J Chase
- Department of Orthopedic Surgery and Rehabilitation, Loyola University Medical Center, Loyola University Stritch School of Medicine, Maywood, Illinois 60153, USA
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Macejak DG, Lin H, Webb S, Chase J, Jensen K, Jarvis TC, Leiden JM, Couture L. Adenovirus-mediated expression of a ribozyme to c-myb mRNA inhibits smooth muscle cell proliferation and neointima formation in vivo. J Virol 1999; 73:7745-51. [PMID: 10438864 PMCID: PMC104301 DOI: 10.1128/jvi.73.9.7745-7751.1999] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Smooth muscle cell (SMC) proliferation is an important component of restenosis in response to injury after balloon angioplasty. Inhibition of proliferation in vivo can limit neointima hyperplasia in animal models of restenosis. Ribozymes against c-myb mRNA have been shown to be effective inhibitors of SMC proliferation in vitro. The effectiveness of adenovirus as a gene therapy vector in animal models of restenosis is well documented. In order to test the utility of ribozymes to inhibit SMC proliferation by a gene therapy approach, recombinant adenovirus expressing ribozymes against c-myb mRNA was generated and tested both in vitro and in vivo. This adenovirus ribozyme vector is shown to inhibit SMC proliferation in culture and neointima formation in a rat carotid artery balloon injury model of restenosis.
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Affiliation(s)
- D G Macejak
- Ribozyme Pharmaceuticals, Inc., Boulder, Colorado 80301, USA.
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Abstract
OBJECTIVE To determine the effects of cervical flexion and traction on foraminal volume and isthmus area at the C5-C6 foraminal space in cadavers. DESIGN This study evaluated the foraminal space at C5-C6 in cadaver specimens during flexion and traction of the cervical spine. SETTING An orthopedic biomechanics laboratory and department of radiology of a university medical center. PATIENTS OR OTHER PARTICIPANTS Nine cadaver cervical spines, C1 through T3, were used in the study. Superficial tissues were dissected, preserving the ligaments. INTERVENTIONS Proximal and distal portions of the cadaver spines were potted using bone cement. Spines were mounted and imaged with computed tomography in neutral position, 15 degrees of flexion, and maximum flexion with and without 25lbs of axial traction. MAIN OUTCOME MEASURES The areas and volumes of the foramen were measured and calculated. RESULTS Flexion alone significantly increased the foraminal volume and isthmus area at C5-C6. Traction resulted in little additional change. CONCLUSIONS For cervical spines with mild to moderate degenerative changes at C5-C6, cervical flexion with or without traction produces significant increases in foraminal volume and area at the foraminal isthmus.
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Affiliation(s)
- S C Humphreys
- Chattanooga Orthopaedic Group, Foundation for Research, TN 37404, USA
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Klein JD, Chase J. Value-based formulas for purchasing. Pursuing value in Medicaid managed care: access to care and enrollee information management. Manag Care Q 1997; 5:42-50. [PMID: 10164649] [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] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Medicaid and other publicly funded health coverage programs face special challenges in managed care purchasing. This article discusses two of those challenges based on the state of Minnesota's experience: how to develop, evaluate, and communicate access to care; and how to manage the transfer of enrollee eligibility and health status information.
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Affiliation(s)
- J D Klein
- Health Strategies Group, Inc., St. Paul, MN, USA
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Patt YZ, Hoque A, Lozano R, Pozdur R, Chase J, Carrasco H, Chuang V, Delpassand ES, Ellis L, Curley S, Roh M, Jones DV. Phase II trial of hepatic arterial infusion of fluorouracil and recombinant human interferon alfa-2b for liver metastases of colorectal cancer refractory to systemic fluorouracil and leucovorin. J Clin Oncol 1997; 15:1432-8. [PMID: 9193336 DOI: 10.1200/jco.1997.15.4.1432] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [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: 02/04/2023] Open
Abstract
PURPOSE To determine the toxicity, response rate, and survival in patients treated with hepatic arterial infusion (HAI) of fluorouracil (5-FU) plus recombinant human interferon alfa-2b (rIFN-alpha 2b) (Intron-A; Schering-Plough, Inc, Kenilworth, NJ) for colorectal carcinoma (CRC) liver metastases refractory to systemic 5-FU plus leucovorin (LCV). PATIENTS AND METHODS Forty-eight patients were given a 6-hour HAI of rIFN-alpha 2b 5 MU/m2 followed by an 18-hour HAI of 5-FU, 1,500 mg/m2 daily for 5 days. Twenty-nine patients were treated through percutaneously placed catheters and 19 through implantable infusion pumps (Shiley Infusaid Inc, Noorwood, MA). Treatment cycles were repeated every 28 to 35 days. RESULTS There were three (6.6%) complete remissions (CRs) and 12 (26.6%) partial remissions (PRs), for a CR plus PR rate of 33.3% among 45 assessable patients (95% confidence interval [CI], 20% to 49%). The median response duration was 7 months, while median survival duration was 15 months. Grade 3 to 4 treatment-related toxic effects included mucositis (40%), neutropenia (42%), and thrombocytopenia (12%). No hepatobiliary toxicity was encountered in any of the patients. Treatment was discontinued because of progressive liver disease in 23 patients and extrahepatic progression in 16, while six patients continue treatment through an infusaid pump. CONCLUSION HAI of 5-FU plus rIFN-alpha 2b is well tolerated, devoid of hepatobiliary toxicity, and can produce a response rate of 33.3% among patients refractory to bolus intravenous (IV) 5-FU plus LCV. The lack of hepatobiliary toxicity may permit salvage HAI with floxuridine (FUDR) in patients whose liver tumors fail to respond to HAI of 5-FU plus rIFN-alpha 2b. Because diarrhea was not a common side effect of HAI of 5-FU plus rIFN-alpha 2b, it would be of interest to investigate whether alternating HAI of 5-FU and rIFN-alpha 2b with systemic irinotecan (CPT-11) will decrease the incidence of both hepatic and extrahepatic disease progression.
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Affiliation(s)
- Y Z Patt
- Department of Gastrointestinal Oncology and Digestive Diseases, University of Texas M.D. Anderson Cancer Center, Houston 77030-4095, USA
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Abstract
The decisions which health care professionals make are the basis of treatment and care given. In order to evaluate effective care it seems logical to suggests that an awareness of the decisions which health care professionals make and how they make them is needed. This study examines the processes nurses use when making decisions about the health care needs of acutely ill patients. In stage one, 104 qualified nurses were interviewed to identify how they decide health care needs. In stage two, a 'think aloud' technique was used with patient simulations to obtain verbal protocols from a further 55 qualified nurses to identify the information strategies they used when making these decisions. The results suggest that nurses base their health care decisions mainly on their assessment of qualitative patient states or conditions. Initial indications are that the processes used differ from those characterized in the diagnostic reasoning model, with the context in which decisions are made being an important influence together with nurses' experience. It is suggested that, in order to develop effective predictive models and clinical guidelines which aid decision making, more research into the nature of health care professionals' decision making is carried out.
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Affiliation(s)
- D Lamond
- European Institute of Health & Medical Sciences, University of Surrey, Guildford, UK
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Bender G, Chase J, Mize D, Hill R. Retooling for the PACS age. Adm Radiol J 1996; 15:28-32. [PMID: 10162798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
- G Bender
- Madigan Army Medical Center, Tacoma, WA 98431, USA
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Abstract
This paper presents an outline of the scope for the application of decision theory to health care. Firstly, the main approaches to and assumptions of decision theory are discussed. Secondly, health care decision making is reviewed. It is noted that decision theory can be applied to either the health care professional or to the lay person. Applications of decision theory to clinical practice, to the management of care and to resourcing are considered. Thirdly, some areas which would repay further research are identified. These include social processes in individual and group decision making, the temporal distribution of outcomes and the development of techniques capable of dealing with the complex and dynamic features of decisions. On the basis of the foregoing, some conclusions are drawn.
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Affiliation(s)
- J Chase
- Department of Psychology, University of Surrey, Guildford, UK
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Abstract
A small-scale study was undertaken to test the relative predictive power of the Health Belief Model and Subjective Expected Utility Theory for the uptake of a behaviour (pelvic floor exercises) to reduce post-partum urinary incontinence in primigravida females. A structured questionnaire was used to gather data relevant to both models from a sample antenatal and postnatal primigravida women. Questions examined the perceived probability of becoming incontinent, the perceived (dis)utility of incontinence, the perceived probability of pelvic floor exercises preventing future urinary incontinence, the costs and benefits of performing pelvic floor exercises and sources of information and knowledge about incontinence. Multiple regression analysis focused on whether or not respondents intended to perform pelvic floor exercises and the factors influencing their decisions. Aggregated data were analysed to compare the Health Belief Model and Subjective Expected Utility Theory directly.
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Affiliation(s)
- M Dolman
- European Institute of Health & Medical Sciences, University of Surrey, Guildford, UK
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Price TB, Perseghin G, Duleba A, Chen W, Chase J, Rothman DL, Shulman RG, Shulman GI. NMR studies of muscle glycogen synthesis in insulin-resistant offspring of parents with non-insulin-dependent diabetes mellitus immediately after glycogen-depleting exercise. Proc Natl Acad Sci U S A 1996; 93:5329-34. [PMID: 8643574 PMCID: PMC39245 DOI: 10.1073/pnas.93.11.5329] [Citation(s) in RCA: 57] [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] [Indexed: 02/01/2023] Open
Abstract
To examine the impact of insulin resistance on the insulin-dependent and insulin-independent portions of muscle glycogen synthesis during recovery from exercise, we studied eight young, lean, normoglycemic insulin-resistant (IR) offspring of individuals with non-insulin-dependent diabetes mellitus and eight age-weight matched control (CON) subjects after plantar flexion exercise that lowered muscle glycogen to approximately 25% of resting concentration. After approximately 20 min of exercise, intramuscular glucose 6-phosphate and glycogen were simultaneously monitored with 31P and 13C NMR spectroscopies. The postexercise rate of glycogen resynthesis was nonlinear. Glycogen synthesis rates during the initial insulin independent portion (0-1 hr of recovery) were similar in the two groups (IR, 15.5 +/- 1.3 mM/hr and CON, 15.8 +/- 1.7 mM/hr); however, over the next 4 hr, insulin-dependent glycogen synthesis was significantly reduced in the IR group [IR, 0.1 +/- 0.5 mM/hr and CON, 2.9 +/- 0.2 mM/hr; (P < or = 0.001)]. After exercise there was an initial rise in glucose 6-phosphate concentrations that returned to baseline after the first hour of recovery in both groups. In summary, we found that following muscle glycogen-depleting exercise, IR offspring of parents with non-insulin-dependent diabetes mellitus had (i) normal rates of muscle glycogen synthesis during the insulin-independent phase of recovery from exercise and (ii) severely diminished rates of muscle glycogen synthesis during the subsequent recovery period (2-5 hr), which has previously been shown to be insulin-dependent in normal CON subjects. These data provide evidence that exercise and insulin stimulate muscle glycogen synthesis in humans by different mechanisms and that in the IR subjects the early response to stimulation by exercise is normal.
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Affiliation(s)
- T B Price
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
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Jones D, Chase J, Roh M, Hohn D, Curley S, Smith R, Hoque A, Patt Y. A phase I evaluation of chronotropic delivery of floxuridine by hepatic arterial infusion in patients with metastatic colorectal cancer. Oncol Rep 1996. [DOI: 10.3892/or.3.2.391] [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: 11/05/2022] Open
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Jones D, Chase J, Roh M, Hohn D, Curley S, Smith R, Hoque A, Patt Y. A phase I evaluation of chronotropic delivery of floxuridine by hepatic arterial infusion in patients with metastatic colorectal cancer. Oncol Rep 1996; 3:391-395. [PMID: 21594380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Abstract
Hepatic arterial infusion (HAI) of floxuridine is often used for metastatic colorectal cancer, though this is associated with dose-limiting hepatobiliary toxicity. A phase I trial was initiated to determine if circadian-patterned HAI floxuridine would reduce toxicity. Twenty-one patients were enrolled, and they received a continuous 14-day HAI of floxuridine, with 90-95% of the drug delivered over the same six-hour period daily. The therapy was tolerable, but there was no reduction in hepatobiliary toxicity. The response rate of 33% (1 complete and 6 partial responses) was similar to that of regimens that do not utilize circadian timing. HAI floxuridine chronotherapy for metastatic colorectal cancer cannot be recommended.
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Affiliation(s)
- D Jones
- UNIV TEXAS,MD ANDERSON CANCER CTR,DEPT GASTROINTESTINAL ONCOL & DIGEST DIS,DIV MED,HOUSTON,TX 77030. UNIV TEXAS,MD ANDERSON CANCER CTR,DIV PHARM,HOUSTON,TX 77030. UNIV TEXAS,MD ANDERSON CANCER CTR,DEPT SURG ONCOL,DIV SURG & ANESTHESIOL,HOUSTON,TX 77030
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Abstract
Simulation tasks, together with think aloud techniques are often used to research the cognitive processes individuals go through when making a decision or solving a problem. They have been utilised to a certain degree within nursing. A study was carried out to try and identify the sources of information nurses in acute medical and surgical wards used to make assessment judgements. A sample of 114 nurses were interviewed, and their responses analysed using content analysis. Four main sources of information were identified, with verbal interaction being the source of information most frequently mentioned by the subjects. The content of material presented in simulations is normally tested using techniques such as expert panels. However, this paper suggests that of equal importance may be the form of presentation or source of that information. It is suggested that in order to increase the validity of information obtained from simulation tasks, the form of presentation of information to the subject should also be considered.
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Affiliation(s)
- D Lamond
- European Institute of Health and Medical Sciences, University of Surrey, UK
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Abstract
This paper presents an analysis of the cognitive component of nursing assessment, complimenting the growth in knowledge of other important aspects of assessment. The purpose of the paper is to provide a framework for understanding how nurses structure assessment problems and the types of judgements they make. The thrust of the analysis is based on a comparison between nursing assessment and medical diagnosis, since the cognitive component and judgements formed in medical diagnosis have been more fully articulated. The results suggest that there may be similarities between the cognitive strategies used in nursing assessment and those used in medical diagnosis, particularly in relation to the gathering and organization of information. But the purpose of the information search appears to be different. In medical diagnosis the aim is to establish an explanation for the patient's presenting problem. In nursing assessment, on the other hand, the aim appears to be to provide an accurate picture of the patient's current condition or situation. The assessments formulated fit the definition of a judgement and, in common with medical diagnoses, include some form of prediction. Unlike the medical diagnoses, however, which usually remain stable throughout treatment, the assessments need to change as the patient's condition changes. The cognitive component of assessment has significant implications for nurse education and clinical practice. Further understanding of how nurses structure assessment problems and formulate judgements is therefore needed. The findings may also help to clarify the meaning of nursing diagnosis.
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Affiliation(s)
- R A Crow
- Department of Nursing and Midwifery, University of Surrey, Guildford, England
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Hammond C, Chase J, Hogbin B. Nurse practitioners. A unique service? Nurs Times 1995; 91:28-29. [PMID: 7644365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
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Patt YZ, Charnsangavej C, Yoffe B, Smith R, Lawrence D, Chuang V, Carrasco H, Roh M, Chase J, Fischer H. Hepatic arterial infusion of floxuridine, leucovorin, doxorubicin, and cisplatin for hepatocellular carcinoma: effects of hepatitis B and C viral infection on drug toxicity and patient survival. J Clin Oncol 1994; 12:1204-11. [PMID: 8201383 DOI: 10.1200/jco.1994.12.6.1204] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.1] [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: 01/29/2023] Open
Abstract
PURPOSE To conduct a pilot trial of hepatic arterial infusion (HAI) of floxuridine (FUDR), leucovorin, Adriamycin (doxorubicin; Adria Laboratories, Columbus, OH), and cisplatin (FLAP) in nonresectable hepatocellular cancer (HCC) confined to the liver and assess the effects of hepatitis B (HBV) and hepatitis C (HCV) viral markers on toxicity, response to treatment, and patient survival. PATIENTS AND METHODS Of 31 HCC patients, 13 were HBV- and HCV-nonreactive, and 18 had evidence of either current or prior HBV and/or HCV infection. Treatment was delivered through percutaneous hepatic arterial catheters, and Infusaid pumps (Shiley Infusaid, Norwood, MA) were placed in responding patients. Cisplatin (100 mg/m2) and Adriamycin (30 to 35 mg/m2) were administered on day 1, followed by a continuous 24-hour HAI of an admixture of floxuridine (60 mg/m2) and leucovorin (15 mg/m2) daily for 4 days. Treatment was repeated every 5 weeks. RESULTS Twelve (41%) of 29 assessable patients had a partial response (PR), with a median time to disease progression of 13 months. Six (50%) of 12 HBV-negative (HBV-)/HCV-negative (HCV-) and six of 17 (35%) HBV-positive (HCV+) and/or HCV-positive (HCV+) patients achieved a PR. Eight patients have been maintained in remission for a median duration greater than 15.5 months. The median survival duration of all 31 patients was 15 months, 7.5 months among HBV+ and/or HCV+ patients, and significantly longer among hepatitis-non-reactive patients (P = .007). (A median has not yet been reached.) Granulocylopenia (< 0.1 x 10(3)/microL), thrombocytopenia (< 25 x 10(3)/microL), and hospitalizations for infectious complications were significantly more common among HBV-HCV-reactive than -nonreactive patients: 56%, 50%, and 67% versus 15%, 15%, and 8%, respectively (P < .05 for all). CONCLUSION HAI of FLAP has induced long-term PR and has palliated extensive nonresectable HCC. Positive hepatitis serology appeared to increase bone marrow susceptibility to myelotoxic drugs. Conceivably, one or both viruses may have a direct inhibitory effect on bone marrow progenitors and thereby contribute to the observed myelotoxicity.
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Affiliation(s)
- Y Z Patt
- Department of Gastrointestinal Medical Oncology and Digestive Diseases, University of Texas M.D. Anderson Cancer Center, Houston 77030
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Curley SA, Byrd DR, Newman RA, Ellis HJ, Chase J, Carrasco CH, Cleary K, Bodden W, Hohn DC. Reduction of systemic drug exposure after hepatic arterial infusion of doxorubicin with complete hepatic venous isolation and extracorporeal chemofiltration. Surgery 1993. [PMID: 8367814 DOI: 10.5555/uri:pii:003960609390297q] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
BACKGROUND Hepatic arterial infusion of doxorubicin has produced tumor response in hepatic malignancies; however, the limited success of these treatments is related in part to dose-limiting systemic toxicities. The purpose of this study was to determine whether a novel venous isolation-chemofiltration system could limit systemic exposure to doxorubicin after hepatic arterial infusion. METHODS Doxorubicin (1 or 3 mg/kg) was infused in the hepatic arteries of domestic pigs after complete hepatic venous isolation was achieved with a dual-balloon vena cava catheter. The hepatic vein effluent was pumped through an extracorporeal carbon chemofiltration circuit. Doxorubicin levels were measured in prefilter (hepatic vein), postfilter, and systemic serum at intervals up to 1 hour after drug infusion. RESULTS Complete hepatic venous isolation with extracorporeal chemofiltration significantly reduced (> 90%) the postfilter and systemic levels of doxorubicin compared with prefilter levels (p < 0.01). At the time animals were killed 7 days after infusion of doxorubicin (3 mg/kg), tissue levels of doxorubicin in the liver showed a 16-fold increase compared with levels in the heart (p < 0.01). CONCLUSIONS For chemotherapeutic drugs like doxorubicin with a low first-pass extraction by the liver, the novel system described herein achieved significant reduction in systemic drug exposure. This system will allow dose intensification of doxorubicin administered by hepatic arterial infusion to treat hepatic malignancies.
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Affiliation(s)
- S A Curley
- Department of General Surgery, University of Texas M. D. Anderson Cancer Center, Houston 77030
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48
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Chase J, Touhara K, Prestwich GD, Schal C, Blomquist GJ. Biosynthesis and endocrine control of the production of the German cockroach sex pheromone 3,11-dimethylnonacosan-2-one. Proc Natl Acad Sci U S A 1992; 89:6050-4. [PMID: 1631090 PMCID: PMC49435 DOI: 10.1073/pnas.89.13.6050] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.6] [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: 12/28/2022] Open
Abstract
The biosynthesis and endocrine regulation of sex pheromone production in the female German cockroach (Blattella germanica) were determined. Radio-TLC and radio-GLC were used to demonstrate the metabolism of 3,11-dimethylnonacosane, a major cuticular lipid component, to the corresponding alkan-2-ol and methyl ketone. [11,12-3H2]-3,11-Dimethylnonacosan-2-ol was efficiently metabolized to the methyl ketone, and radio-GLC showed that the methyl ketone product from both experiments was coeluted with a methyl ketone standard. A comparison of the metabolism of the labeled dimethylalkane and dimethylalkan-2-ol by age and sex showed that both males and females from day 1 through day 9 after adult emergence readily metabolized the alcohol to the corresponding methyl ketone, whereas only females of 5-9 days postemergence efficiently converted the labeled dimethylalkane to the corresponding methyl ketone. Application of the juvenile hormone analog hydroprene induced significant increases in the conversion of the labeled hydrocarbon to the methyl ketone in starved adult females as well as in females fed a protein-free diet, conditions under which endogenous juvenile hormone biosynthesis is nearly undetectable. These data show that the methyl ketone sex pheromone is formed by the hydroxylation and oxidation of the 3,11-dimethylalkane at the 2 position, show that the age- and sex-specific step in this process is the conversion of 3,11-dimethylnonacosane to 3,11-dimethylnonacosan-2-ol, and provide evidence that juvenile hormone regulates sex pheromone production in the German cockroach.
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Affiliation(s)
- J Chase
- Department of Biochemistry, University of Nevada, Reno 89557-0014
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49
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Check JH, Nowroozi K, Chase J, Nazari A, Braithwaite C. Comparison of pregnancy rates following in vitro fertilization-embryo transfer between the donors and the recipients in a donor oocyte program. J Assist Reprod Genet 1992; 9:248-50. [PMID: 1525455 DOI: 10.1007/bf01203822] [Citation(s) in RCA: 36] [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: 12/27/2022] Open
Abstract
Our in vitro fertilization (IVF) program provides a unique opportunity to evaluate influences of hormonal milieu on pregnancy outcome, by using a shared pool of oocytes obtained by donors (in exchange for financial assistance). The study presented herein evaluated 38 retrieval cycles (28 oocyte donors/22 recipients). No difference in mean number of embryos transferred was seen (2.7 in the donors vs 2.8 in the recipients). However, a statistically significant difference was seen in the pregnancy rates per retrieval (10.5% donors vs 29% recipients) and per transfer (4/35, 11.1%, vs 11/34, 32.3%). Abortion rates were similar (25% donor, 27.2% recipients). These data suggest that other reports of higher pregnancy rates from donor oocyte programs may not be due exclusively to better-quality oocytes. Possibly a negative effect of hyperstimulation or adverse endometrial environment of the donor (possible chronic endometritis) may explain these data.
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Affiliation(s)
- J H Check
- UMDNJ, Robert Wood Johnson Medical School, Camden
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50
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McConnell M, Walker B, Middleton P, Chase J, Owens J, Hyatt D, Gutierrez H, Williams M, Hambright D, Barry M. Restriction endonuclease and genetic mapping studies indicate that the vegetative genome of the temperate, Salmonella-specific bacteriophage, epsilon 15, is circularly-permuted. Arch Virol 1992; 123:215-21. [PMID: 1312823 DOI: 10.1007/bf01317151] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Data from physical and genetic mapping studies show that the vegetative genome of the temperate, Group E 1 Salmonella bacteriophage, epsilon 15, is circularly-permuted. Preliminary evidence suggests that the circular permutation of the epsilon 15 genome is non-random.
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Affiliation(s)
- M McConnell
- Department of Biology, Loma Nazarene College, San Diego, California
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