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Laue K, Schultz M, Talbot-Montgomery E, Garrick A, Java A, Corbett C, Lammert DM, Rogers J, Davis K, Malhotra K, Philipneri M, Kimbel MA, Mustafa RA, Hardesty V. Show Me CKDintercept Initiative: A Collective Impact Approach to Improve Population Health in Missouri. Mayo Clin Proc Innov Qual Outcomes 2024; 8:82-96. [PMID: 38283097 PMCID: PMC10821387 DOI: 10.1016/j.mayocpiqo.2023.12.004] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024] Open
Abstract
Ninety percent of people with chronic kidney disease (CKD) remain undiagnosed, most people at risk do not receive guideline-concordant testing, and disparities of care and outcomes exist across all stages of the disease. To improve CKD diagnosis and management across primary care, the National Kidney Foundation launched a collective impact (CI) initiative known as Show Me CKDintercept. The initiative was implemented in Missouri, USA from January 2021 to June 2022, using a data strategy, stakeholder engagement and relationship mapping, learning in action working groups (LAWG), and a virtual leadership summit. The Reach, Effectiveness, Adoption, Implementation, and Maintenance framework was used to evaluate success. The initiative united 159 stakeholders from 81 organizations (Reach) to create an urgency for change and engage new CKD champions (Effectiveness). The adoption resulted in 53% of participants committed to advancing the roadmap (Adoption). Short-term results reported success in laying a foundation for CI across Missouri. The long-term success of the CI initiative in addressing the public health burden of kidney disease remains to be determined. The project reported the potential use of a CI initiative to build leadership consensus to drive measurable public health improvements nationwide.
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Affiliation(s)
| | | | | | | | - Anuja Java
- Division of Nephrology, Washington University School of Medicine, St. Louis, MO
| | | | | | - JoAnna Rogers
- National Kidney Foundation, NKF Serving Kansas and Western Missouri, Kansas City, MO
| | - Kathleen Davis
- National Kidney Foundation, NKF Serving Eastern Missouri, Metro East, and Arkansas, St. Louis, MO
| | - Kunal Malhotra
- Division of Nephrology, University of Missouri, Columbia, MO
| | - Marie Philipneri
- Saint Louis University School of Medicine, Internal Medicine/Nephrology, Saint Louis, MO
| | | | - Reem A. Mustafa
- Division of Nephrology and Hypertension, University of Kansas Medical Center, Kansas City, KS
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Valerie Hardesty
- Missouri Kidney Program, University of Missouri School of Medicine, Columbia, MO
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Younger K, Malhotra K, Clark HD, Kelly K. An interprofessional clinic for adults with Turner syndrome: the patient perspective. Climacteric 2022; 25:609-614. [PMID: 36183703 DOI: 10.1080/13697137.2022.2122428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES This qualitative study assessed the value of a primary care-based interprofessional clinical team for adults with Turner syndrome (TS) utilizing patient perspectives. METHODS Ten patients within one institution's interprofessional adult TS clinic participated in one of two semi-structured focus groups. Content analysis was used to classify content provided by participants into themes and sub-themes using Dedoose software. RESULTS Participants found that their quality of care and life were both improved due to the presence of the interprofessional Adults with TS Clinic. Specifically, participants reported that the clinic helped address problems with finding knowledgeable providers and care gaps, made appointments more convenient and improved interprofessional communication. Participants also reported that the clinic helped them find a sense of community and increased personal confidence. Study participants suggested improvements to the clinic by expanding the scope of practice further, simplifying processes to schedule appointments, and potentially creating interprofessional clinics for other rare diseases as well. CONCLUSION Pursuing avenues to create interprofessional clinics for adults with rare diseases has value from the patient perspective. This value can translate to improved patient outcomes through improvements in patient knowledge of their diagnosis, adherence to evidence-based care and quality of life.
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Affiliation(s)
- K Younger
- Department of Family Medicine and Community Health, University of Kansas Medical Center, Kansas City, KS, USA
| | - K Malhotra
- Department of Family Medicine and Community Health, Northwestern University, Chicago, IL, USA
| | - H D Clark
- Department of Psychology, University of Kansas, Lawrence, KS, USA
| | - K Kelly
- Department of Family Medicine and Community Health, University of Kansas Medical Center, Kansas City, KS, USA
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Qureshi AI, Huang W, Gomez FE, Malhotra K, Arora N, Chandrasekaran PN, Siddiq F, French BR, Gomez CR, Suarez JI. Early hyperchloremia and outcomes after acute ischemic stroke. J Stroke Cerebrovasc Dis 2022; 31:106523. [PMID: 35633589 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/29/2022] [Accepted: 04/17/2022] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Based on the relationship between hyperchloremia and mortality in critically ill patients, we investigated the effect of early hyperchloremia on 90-day outcomes in acute ischemic stroke patients. MATERIALS AND METHODS Acute ischemic stroke patients recruited within 5 h of symptom onset were analyzed. Hyperchloremia (defined as 110 mmol/L or greater) at either baseline, or 24, or 48 h after randomization was identified and classified as one occurrence or two or more occurrences. Logistic regression analyses were performed to determine the effects of hyperchloremia on: favorable outcomes (defined by a National Institutes of Health Stroke Scale and/or modified Rankin scale scores of 0-1) at 90-day, death or disability at 90-day, and death within 90-day after accounting for potential confounders. RESULTS Among the total of 1275 patients, one and two or more occurrence of hyperchloremia within 48 h were seen in 191 patients and 108 patients, respectively. Compared with patients without hyperchloremia, patients with two or more occurrences of hyperchloremia at significantly higher odds of lack of favorable outcomes (odds ratio 3.0, 95% confidence interval 1.8-5.1) and death or disability (odds ratio 2.6, 95% confidence interval 1.6-4.1) at 90-day after adjustment for age, National Institutes of Health Stroke Scale score strata (6-9, 10-19, ≥ 20), study intervention, initial SBP, and intra-arterial treatment. CONCLUSIONS The independent association between sustained hyperchloremia and lack of favorable outcomes at 90-day suggest that avoidance of hyperchloremia may reduce the rate of lack of favorable outcomes and death or disability in patients with acute ischemic stroke.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, One Hospital Dr. CE507, Columbia, MO, USA
| | - Wei Huang
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, One Hospital Dr. CE507, Columbia, MO, USA.
| | | | - Kunal Malhotra
- Department of Nephrology, University of Missouri, Columbia, MO, USA
| | - Niraj Arora
- Department of Neurology, University of Missouri, Columbia, MO, USA
| | | | - Farhan Siddiq
- Division of Neurosurgery, University of Missouri, Columbia, MO, USA
| | - Brandi R French
- Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Camilo R Gomez
- Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Dandachi D, Fabricius M, Saad B, Sawkin MT, Malhotra K. Antiretrovirals for People with HIV on Dialysis. AIDS Patient Care STDS 2022; 36:86-96. [PMID: 35289690 DOI: 10.1089/apc.2021.0173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In the era of widespread use of antiretroviral therapy (ART), people with HIV (PWH) have a near-normal life expectancy. However, PWH have high rates of kidney diseases and progression to end-stage renal disease at a younger age. PWH have multiple risks for developing acute and chronic kidney diseases, including traditional risk factors such as diabetes, hypertension, and HIV-related factors such as HIV-associated nephropathy and increased susceptibility to infections and exposure to nephrotoxic medications. Despite an improvement in access to kidney transplant among PWH, the number of PWH on dialysis continues to increase. The expansion of the number of antiretrovirals (ARVs) and kidney replacement modalities, the absence of pharmacokinetic data, and therapeutic drug monitoring make it very challenging for providers to dose ARVs appropriately leading to medication errors, adverse events, and higher mortality. Most of the recommendations are either based on small sample size studies or extrapolated based on physiochemical characteristics of ART. We aim to review the most available and most current literature on ART in PWH with renal insufficiency and ART dosing recommendations on dialysis to ensure that PWH are provided with the safest and most effective ART regimen.
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Affiliation(s)
- Dima Dandachi
- Division of Infectious Diseases, Department of Medicine, University of Missouri-Columbia, Missouri, USA
| | | | - Baraa Saad
- Department of Medicine, Internal Medicine Residency, University of Missouri-Columbia, Missouri, USA
| | - Mark T. Sawkin
- Division of Pharmacy Practice and Administration, School of Pharmacy, University of Missouri-Kansas City, Missouri, USA
| | - Kunal Malhotra
- Division of Nephrology, Department of Medicine, University of Missouri-Columbia, Missouri, USA
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Gomez FE, Huang W, Bains N, ISHFAQ M, French BR, Siddiq F, Malhotra K, Gomez CR, Qureshi AI. Abstract WP3: Early Sustained Hyperchloremia Independently Reduces The Rates Of Favorable Outcomes In Acute Ischemic Stroke Patients: A Post Hoc Analysis Of Alias Part 1 And 2 Trials. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.wp3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective:
To investigate the effect of early hyperchloremia on 90-day outcomes in acute ischemic stroke
Methods:
We analyzed data from Albumin in Acute Ischemic Stroke (ALIAS) Part 1 and 2 trials which recruited patients with acute ischemic stroke within 5 hours of onset. Patients with hyperchloremia (defined as 110 mmol/L or greater) at baseline, 24, or 48 hours after randomization were identified. We trichotomized patients into 3 groups; no instances, one instance, and two or more instances of measured hyperchloremia within the first 48 hours. Serum creatinine levels at baseline, 24, and 48 hours were used to identify acute kidney injury (AKI) via the Acute Kidney Injury Network (AKIN) classification. Logistic regressions were performed to determine the effects of hyperchloremia on outcomes defined by modified Rankin scales or National Institutes of Health Stroke Scale scores at 90 days and mortality at 90 days.
Results:
Among the total of 1275 patients analyzed, zero, one and two or more occurrence of hyperchloremia within 48 hours were observed in 976, 191 and 108 patients respectively. Compared with patients without hyperchloremia, patients with two or more occurrences of hyperchloremia at significantly higher odds of non-favorable outcomes within 90 days after adjustment for age, NIHSS score, initial systolic blood pressure, and ALIAS treatment group (albumin or placebo) (OR 3.0, 95%, CI 1.8-5.0). Patients with two or more occurrences of hyperchloremia also presented higher odds of death within 90 days vs the non-hyperchloremia group. Patients with one occurrence of hyperchloremia were not at higher odds for non-favorable outcomes at 90 days. There was no association between occurrence of two or more occurrence of hyperchloremia and AKI (OR 0.8, 95% CI 0.3-1.9).
Conclusions:
The independent association between sustained hyperchloremia and non-favorable outcomes at 90 days suggest that avoidance of hyperchloremia may increase the rate of favorable outcomes in patients with acute ischemic stroke.
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Raina R, Davenport A, Warady B, Vasistha P, Sethi SK, Chakraborty R, Khooblall P, Agarwal N, Vij M, Schaefer F, Malhotra K, Misra M. Dialysis disequilibrium syndrome (DDS) in pediatric patients on dialysis: systematic review and clinical practice recommendations. Pediatr Nephrol 2022; 37:263-274. [PMID: 34609583 DOI: 10.1007/s00467-021-05242-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Dialysis disequilibrium syndrome (DDS) is a rare neurological complication, most commonly affecting patients undergoing new initiation of hemodialysis (HD), but can also be seen in patients receiving chronic dialysis who miss regular treatments, patients having acute kidney injury (AKI), and in those treated with continuous kidney replacement therapy (CKRT) or peritoneal dialysis (PD). Although the pathogenesis is not well understood, DDS is likely a result of multiple physiological abnormalities. In this systematic review, we provide a synopsis of the data available on DDS that allow for a clear picture of its pathogenesis, preventive measures, and focus on effective management strategies. METHODS We conducted a literature search on PubMed/Medline and Embase from January 1960 to January 2021. Studies were included if the patient developed DDS irrespective of age and gender. A summary table was used to summarize the data from individual studies and included study type, population group, age group, sample size, patient characteristics, blood and dialysate flow rate, and overall outcome. A descriptive analysis calculating the frequency of population size, symptoms, and various treatments was performed using R software version 3.1.0. RESULTS A total of 49 studies (321 samples) were identified and analyzed. Out of the included 49 studies, a total of 48 studies reported the presence of DSS among patients (1 study reported based on number of dialysis and therefore was not considered for analysis). Among these 48 studies, 74.3% (226/304) patients were reported to have DSS. The most common symptoms were nausea (25.2%), headache (24.8%), vomiting (23.9%), muscle cramps (18.1%), affected level of consciousness (8.8%), confusion (4.4%), and seizure (4.9%) among the 226 DDS patients. Furthermore, 12 studies decided to switch from HD to alternative dialysis modalities including continuous venovenous hemofiltration/hemodiafiltration (CVVH/CVVHDF) or PD which reported no DDS symptoms. CONCLUSION Early recognition and timely prevention are crucial for DDS patients. We have provided comprehensive clinical practice points for pediatric, adolescent, and young adult populations. However, it is essential to recognize that DDS was reported more frequently in the early dialysis era, as there was a lack of advanced dialysis technology and limited resources.
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Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA. .,Department of Nephrology, Akron Children's Hospital, Akron, OH, USA. .,School of Medicine Cleveland Ohio, Case Western Reserve University, Cleveland, OH, USA.
| | - Andrew Davenport
- University College London Centre for Nephrology, Division of Medicine, University College London Medical School, Royal Free Hospital, London, UK
| | - Bradley Warady
- Division of Nephrology, University of Missouri-Kansas City School of Medicine, Children's Mercy, Kansas City, MO, USA
| | - Prabhav Vasistha
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Sidharth Kumar Sethi
- Pediatric Nephrology & Pediatric Kidney Transplantation, Kidney and Urology Institute, MedantaThe Medicity Hospital, Gurgaon, India
| | - Ronith Chakraborty
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.,Department of Nephrology, Akron Children's Hospital, Akron, OH, USA
| | - Prajit Khooblall
- Department of Internal Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Nirav Agarwal
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Manan Vij
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Franz Schaefer
- Department of Pediatric Nephrology, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Kunal Malhotra
- Division of Nephrology, University of Missouri School of Medicine, Columbia, MO, USA
| | - Madhukar Misra
- Division of Nephrology, University of Missouri School of Medicine, Columbia, MO, USA
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Malhotra K, Cowan-Dickie S, Shaw C. Active marsden - development of a physical activity strategy. Physiotherapy 2021. [DOI: 10.1016/j.physio.2021.10.245] [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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Malhotra K, Malhotra J, Malhotra N, Malhotra N. P–771 I hear, I forget. I see and I remember. I do and I understand. An Insight into the need for training for add on techniques. Hum Reprod 2021. [DOI: 10.1093/humrep/deab130.770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Study question
Do embryologists need additional training or certifications before using add on techniques in the lab ?
Summary answer
Out of 173 respondents majority feel add on techniques require training and/or certifications, the mode of training varies for different add ons.
What is known already
Cochrane reviews have suggested that minimal evidence exists for the use of add on treatments in ART, the data on the prevalence of add ons in IVF is unclear but the presence of technologies in ART laboratories world over suggests a increasing trend of adoption of unproven techniques. No data exists suggesting the role of embryologists in performing the Add on techniques and how their training or lack of, can impact patient safety. The most common method of training comes from the manufacturers and there is a lack of structured trainings for add on treatments worldover.
Study design, size, duration
An internet based survey was designed keeping in mind commonly available laboratory add ons. It comprised of 9 sections and a total of 18 multiple choice questions. Answer choices ranged from a simple yes or no to more complex choices suggesting the type of training and the potential benefits of training.
Participants/materials, setting, methods
The Survey includes results from 173 embryologists from india with varying degree of experience. Add ons included in the survey were Sperm DNA Fragmentation test, IMSI, PICSI, Microfluidics, MACS, Advanced culture media, Oocyte vitrification, Assisted hatching, Time Lapse imaging, spindle view and Electronic Witnessing. The most common practice suggestions were tabulated and identified.
Main results and the role of chance
The survey reports huge need for training for different add on treatments (SDF –91.4%, IMSI - 81.2%, PICSI- 66.5%, Microfluidics- 55.9%, MACS –55.3%, MicroTese- 86.9%, using advanced culture medias{Calcium ionophore- 73.4%, Hyaluronan rich media- 52.1%, growth cytokine rich media–48.5%, Theophylline for sperm motility–50.9%},oocyte Vitrification 85.5%, Assisted Hatching 75.4%, Time-lapse and Electronic witnessing 77.3%, Polarised microscopy for spindle assessment 73.5%). The Most preferred mode of training for more invasive procedures was Hands on training, followed by On the job training and validation followed by workshops(SDF- 62.6%, IMSI- 61%,PICSI–56.1%, MACS and Microfluidics 38.8%,microTese- 50.6%,Oocyte freezing 85.5%, assisted hatching 67.8%,Time-lapse and electronic witnessing 77.3%, Spindle view 73.5% ). The most preferred mode of training for non invasive procedures was Workshops and Observerships, followed by CME’s, followed by product Leaflets(44.4%,42.1%,13.5% respectively). The most common answer for the disadvantages of not being trained was unable to use the technology to its fullest potential(88.5%), whereas the most common answer for the benefit of being trained was better outcomes with said technologies(76.6%).
Limitations, reasons for caution
This study includes responses from embryologists who have varied levels of experience, while the need for training can be established based on these results, a junior level embryologist might answer the survey differently as compared to a senior or a lab director.
Wider implications of the findings: This is a first of its kind large survey, suggesting the need for training and validation from the perspective of the embryologist. This data can be used in formulating guidelines for future trainings and can help regulators in deciding on the most preferred mode of training.
Trial registration number
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Affiliation(s)
- K Malhotra
- ART Rainbow IVF, Embryology, AGRA, India
| | - J Malhotra
- ART Rainbow IVF, Infertility, Agra, India
| | - N Malhotra
- ART Rainbow IVF, Infertility, Agra, India
| | - N Malhotra
- ART Rainbow IVF, Infertility, Agra, India
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Sheckley H, Malhotra K, Katyal N, Narula N, Govindarajan R. Clinical experience with maintenance therapeutic plasma exchange in refractory generalized myasthenia gravis. J Clin Apher 2021; 36:727-736. [PMID: 34241920 DOI: 10.1002/jca.21923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/22/2021] [Accepted: 06/29/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Despite the availability of several immunomodulatory therapies, about 20% of myasthenia gravis (MG) patients remain refractory to conventional treatments. There is limited evidence to support the use of maintenance therapeutic plasma exchange (TPE) therapy for refractory generalized MG. METHODS Retrospective chart review of 14 patients with refractory generalized MG treated for 12 months with maintenance TPE therapy. Outcome measures were myasthenia gravis composite (MGC) score, myasthenia gravis activities of daily living (MG-ADL), number of acute exacerbations, medication changes, and adverse events. Data were collected at 3 monthly intervals for 12 months before and after initiation of TPE therapy. RESULTS Clinically meaningful reductions in mean MG-ADL (>2 points) (mean MG-ADL score: 9.9 ± 0.5; 12-month pre-TPE to 5.2 ± 0.9; 12-month post-TPE) and MGC (>3 points) (mean MGC score: 25.2 ± 1.6; 12-month pre-TPE to 11.7 ± 1.4; 12-month post-TPE) were observed at 3 months following initiation of TPE and were maintained up to 12 months in all patients. After 12 months of TPE therapy, all patients had a significant reduction in daily prednisone and pyridostigmine use. Patients previously on IVIG or rituximab therapy were successfully weaned off both treatments. There was a significant reduction in acute MG exacerbations; 7.8 ± 1.1 mean exacerbations/patient (12-month pre-TPE) to 2 ± 1.1 mean exacerbations/patient (12-month post-TPE). CONCLUSION Over a period of 12 months, maintenance TPE therapy improved MG-ADL, and MGC with decreased immunosuppressant requirement, while being well-tolerated.
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Affiliation(s)
- Hunter Sheckley
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Kunal Malhotra
- Division of Nephrology, Department of Internal Medicine, University of Missouri, Columbia, Missouri, USA
| | - Nakul Katyal
- Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Naureen Narula
- Department of Pulmonology and Critical Care Medicine, Staten Island University Hospital, Staten Island, New York, USA
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Nance ME, Tarim AO, Nguyen V, Malhotra K, Davis RM, Bhat AP. Risk Factors for Major Hemorrhage Following Percutaneous Image-Guided Renal Biopsy: What is the "core" of the Problem? A Retrospective Case-control Study. J Clin Imaging Sci 2020; 10:54. [PMID: 33024609 PMCID: PMC7533095 DOI: 10.25259/jcis_87_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/13/2020] [Indexed: 11/19/2022] Open
Abstract
Objectives: Percutaneous renal biopsy (PRB) plays a critical role in the work-up of renal parenchymal disease. Although it is considered a low-risk procedure, additional interventions may be required in about 7% of the cases following biopsy. The purpose of this study was to identify risk factors for major hemorrhage by microscopic analysis of the cores obtained following PRB, with an intent to enhance the sensitivity and specificity of the risk stratification process, especially in patients undergoing this procedure in an outpatient setting. Material and Methods: A retrospective review identified 17 of 179 patients (9.50%) with major hemorrhage following PRB between July 2014 and June 2019. Using propensity score matching, 26 controls (without major hemorrhage) were matched to 17 cases (with major hemorrhage). The biopsy cores obtained from the cases and controls were analyzed by a single pathologist for medullary, cortical, total (medullary + cortical) lengths, and the number of arcuate arteries (AAs). Medullary:cortical (M:C), cortical:total (C:T), and medullary:total (M:T) length ratios were then calculated. Results: A stratified version of logistic regression was used to test for an association between each of the variables identified on the cores and the probability of a major hemorrhage. The analysis revealed that there was a statistically significant association between the number of AAs per specimen with the risk of major hemorrhage (P = 0.0006). When 0, 1, or >2 AAs were identified, the frequency of major hemorrhage was 13.04%, 66.67%, and 75.00%, respectively. The odds of major hemorrhage were 6 times higher with one AA and (95% CI, 1.28–32.30) and 15 times higher with >2 AAs (95% CI, 1.41–169.57). No significant association was found between medullary length (P = 0.228), medulla:cortex (M:C) (P = 0.089), medulla:total (M:T) (P = 0.108), or cortex:total (C:T) (P = 0.112) length ratios and major hemorrhage. Conclusion: There was a strong and incremental correlation between major renal hemorrhage following PRB and the number of AAs per core specimen. Identification of AAs by the pathologist, while assessing for sample adequacy, in the US suite can help predict major hemorrhage in patients undergoing PRBs.
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Affiliation(s)
- Michael E Nance
- Departments of Radiology, University of Missouri, Columbia, Missouri, United States
| | - Andrew O Tarim
- Departments of Radiology, University of Missouri, Columbia, Missouri, United States
| | - Van Nguyen
- Departments of Pathology, University of Missouri, Columbia, Missouri, United States
| | - Kunal Malhotra
- Department of Medicine, Division of Nephrology, University of Missouri, Columbia, Missouri, United States
| | - Ryan M Davis
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri, Columbia, Missouri, United States
| | - Ambarish P Bhat
- Department of Radiology, Section of Vascular and Interventional Radiology, University of Missouri, Columbia, Missouri, United States
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Qureshi AI, Huang W, Lobanova I, Hanley DF, Hsu CY, Malhotra K, Steiner T, Suarez JI, Toyoda K, Yamamoto H. Systolic Blood Pressure Reduction and Acute Kidney Injury in Intracerebral Hemorrhage. Stroke 2020; 51:3030-3038. [PMID: 32838673 DOI: 10.1161/strokeaha.120.030272] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE We determined the rates and predictors of acute kidney injury (AKI) and renal adverse events (AEs), and effects of AKI and renal AEs on death or disability in patients with intracerebral hemorrhage. METHODS We analyzed data from a multicenter trial which randomized 1000 intracerebral hemorrhage patients with initial systolic blood pressure ≥180 mm Hg to intensive (goal 110-139 mm Hg) over standard (goal 140-179 mm Hg) systolic blood pressure reduction within 4.5 hours of symptom onset. AKI was identified by serial assessment of daily serum creatinine for 3 days post randomization. RESULTS AKI and renal AEs were observed in 149 patients (14.9%) and 65 patients (6.5%) among 1000 patients, respectively. In multivariate analysis, the higher baseline serum creatinine (≥110 μmol/L) was associated with AKI (odds ratio 2.4 [95% CI, 1.2-4.5]) and renal AEs (odds ratio 3.1 [95% CI, 1.2-8.1]). Higher area under the curve for intravenous nicardipine dose was associated with AKI (odds ratio 1.003 [95% CI, 1.001-1.005]) and renal AEs (odds ratio 1.003 [95% CI, 1.001-1.006]). There was a higher risk to death (relative risk 2.6 [95% CI, 1.6-4.2]) and death or disability (relative risk 1.5 [95% CI, 1.3-1.8]) at 90 days in patients with AKI but not in those with renal AEs. CONCLUSIONS Intracerebral hemorrhage patients with higher baseline serum creatinine and those receiving higher doses of nicardipine were at higher risk for AKI and renal AEs. Occurrence of AKI was associated higher rates of death or disability at 3 months. Registration: URL: https://clinicaltrials.gov. Unique identifier: NCT01176565.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institute, and Department of Neurology, University of Missouri-Columbia (A.I.Q., W.H., I.L.)
| | - Wei Huang
- Zeenat Qureshi Stroke Institute, and Department of Neurology, University of Missouri-Columbia (A.I.Q., W.H., I.L.)
| | - Iryna Lobanova
- Zeenat Qureshi Stroke Institute, and Department of Neurology, University of Missouri-Columbia (A.I.Q., W.H., I.L.)
| | - Daniel F Hanley
- The Neurology Department of Johns Hopkins University, Baltimore, MD (D.F.H.)
| | - Chung Y Hsu
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan (C.Y.H.)
| | - Kunal Malhotra
- Department of Nephrology, University of Missouri-Columbia. (K.M.)
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Germany (T.S.).,Department of Neurology, Heidelberg University Hospital, Germany (T.S.)
| | - Jose I Suarez
- Division of Neurosciences Critical Care, The Johns Hopkins University School of Medicine, Baltimore, MD (J.I.S.)
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan. (K.T.)
| | - Haruko Yamamoto
- Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center, Suita, Japan. (H.Y.)
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12
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Kumari P, Malhotra K, Suvirya S, Pathania S, Kumar M, Saraswat A. Bilateral nasal nodules with supraciliary madarosis. Clin Exp Dermatol 2020; 45:775-779. [PMID: 32419155 DOI: 10.1111/ced.14231] [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] [Accepted: 03/04/2020] [Indexed: 11/30/2022]
Affiliation(s)
- P Kumari
- Department of Dermatology, Venereology and Leprosy, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India
| | - K Malhotra
- Department of Pathology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - S Suvirya
- Department of Dermatology, Venereology and Leprosy, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India
| | - S Pathania
- Department of Dermatology, Venereology and Leprosy, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India
| | - M Kumar
- Department of Pathology, King George's Medical University, Lucknow, Uttar Pradesh, India
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13
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Tsivgoulis G, Goyal N, Katsanos AH, Malhotra K, Ishfaq MF, Pandhi A, Frohler MT, Spiotta AM, Anadani M, Psychogios M, Maus V, Siddiqui A, Waqas M, Schellinger PD, Groen M, Krogias C, Richter D, Saqqur M, Garcia-Bermejo P, Mokin M, Leker R, Cohen JE, Magoufis G, Psychogios K, Lioutas VA, Van Nostrand M, Sharma VK, Paciaroni M, Rentzos A, Shoirah H, Mocco J, Nickele C, Mitsias PD, Inoa V, Hoit D, Elijovich L, Arthur AS, Alexandrov AV. Intravenous thrombolysis for large vessel or distal occlusions presenting with mild stroke severity. Eur J Neurol 2020; 27:1039-1047. [PMID: 32149450 DOI: 10.1111/ene.14199] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 02/29/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE We investigated the effectiveness of intravenous thrombolysis (IVT) in acute ischaemic stroke (AIS) patients with large vessel or distal occlusions and mild neurological deficits, defined as National Institutes of Health Stroke Scale scores < 6 points. METHODS The primary efficacy outcome was 3-month functional independence (FI) [modified Rankin Scale (mRS) scores 0-2] that was compared between patients with and without IVT treatment. Other efficacy outcomes of interest included 3-month favorable functional outcome (mRS scores 0-1) and mRS score distribution at discharge and at 3 months. The safety outcomes comprised all-cause 3-month mortality, symptomatic intracranial hemorrhage (ICH), asymptomatic ICH and severe systemic bleeding. RESULTS We evaluated 336 AIS patients with large vessel or distal occlusions and mild stroke severity (mean age 63 ± 15 years, 45% women). Patients treated with IVT (n = 162) had higher FI (85.6% vs. 74.8%, P = 0.027) with lower mRS scores at hospital discharge (P = 0.034) compared with the remaining patients. No differences were detected in any of the safety outcomes including symptomatic ICH, asymptomatic ICH, severe systemic bleeding and 3-month mortality. IVT was associated with higher likelihood of 3-month FI [odds ratio (OR), 2.19; 95% confidence intervals (CI), 1.09-4.42], 3-month favorable functional outcome (OR, 1.99; 95% CI, 1.10-3.57), functional improvement at discharge [common OR (per 1-point decrease in mRS score), 2.94; 95% CI, 1.67-5.26)] and at 3 months (common OR, 1.72; 95% CI, 1.06-2.86) on multivariable logistic regression models adjusting for potential confounders, including mechanical thrombectomy. CONCLUSIONS Intravenous thrombolysis is independently associated with higher odds of improved discharge and 3-month functional outcomes in AIS patients with large vessel or distal occlusions and mild stroke severity. IVT appears not to increase the risk of systemic or symptomatic intracranial bleeding.
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Affiliation(s)
- G Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,Second Department of Neurology, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - N Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - A H Katsanos
- Second Department of Neurology, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - K Malhotra
- Charleston Division, Department of Neurology, West Virginia University, Charleston, WV, USA
| | - M F Ishfaq
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - A Pandhi
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - M T Frohler
- Cerebrovascular Program, Vanderbilt University, Nashville, TN, USA
| | - A M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - M Anadani
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - M Psychogios
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - V Maus
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - A Siddiqui
- Departments of Neurosurgery and Radiology, University at Buffalo, Buffalo, NY, USA
| | - M Waqas
- Departments of Neurosurgery and Radiology, University at Buffalo, Buffalo, NY, USA
| | - P D Schellinger
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Clinic RUB, Minden, Germany
| | - M Groen
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Clinic RUB, Minden, Germany
| | - C Krogias
- Department of Neurology, St Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - D Richter
- Department of Neurology, St Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - M Saqqur
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Neurology, Hamad General Hospital, Doha, Qatar
| | - P Garcia-Bermejo
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - M Mokin
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - J E Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - G Magoufis
- Acute Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | - K Psychogios
- Acute Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | - V A Lioutas
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - M Van Nostrand
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - V K Sharma
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, National University Hospital, Singapore, Singapore
| | - M Paciaroni
- Stroke Unit, Divisione di Medicina Cardiovascolare, Università di Perugia, Perugia, Italy
| | - A Rentzos
- Department of Interventional and Diagnostic Neuroradiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - H Shoirah
- Department of Neurosurgery, Mount Sinai Medical Center, New York, NY, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Medical Center, New York, NY, USA
| | - C Nickele
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - P D Mitsias
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA.,Department of Neurology, School of Medicine, University of Crete, Herakleion, Greece
| | - V Inoa
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - D Hoit
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - L Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - A S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - A V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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14
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Malhotra K, Sivaraman A, Regunath H. Coronavirus Disease 2019 Pandemic as Catalyst for Telemedicine Adoption: A Single-Center Experience. Telemed Rep 2020; 1:16-21. [PMID: 35722249 PMCID: PMC8812292 DOI: 10.1089/tmr.2020.0003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/19/2020] [Indexed: 05/12/2023]
Abstract
Background: Telemedicine use has increased due to stay-at-home orders during the novel coronavirus 2019 pandemic. We explored ambulatory provider's perception on telemedicine. Methods: An anonymized survey was e-mailed to physicians and midlevel providers of our university hospital ambulatory clinics to assess current use, preferences for future use, and satisfaction with televisits. Results: Of all providers, 249 responded (response rate 24%, 121 [48.6%] men, 177 [71.1%] attending physicians, 43 [17.2%] trainees, and 29 [11.6%] midlevel providers). Most respondents (120, 48.2%) belonged to subspecialties in medicine. At the time of the survey, 168 (67.5%) were using telemedicine for less than half of all visits and had video capabilities, of whom 224 (90%) considered it to be effective for return visits and 37 (15%) perceived it to be effective for new patients, 217 (87.1%) wanted to continue with telemedicine practice, and 113 (45.4%) preferred to use telemedicine for more than a quarter of their future patients even after the pandemic. Most (194 [77.9%]) were satisfied with telemedicine and we found no differences among specialties. Those with audio-only visits reported least effectiveness for new patient evaluation (p < 0.001) and overall provider satisfaction (p = 0.02) when compared with others. Those who saw more than a quarter of their patients through televisits desired to increase their future televisits to >50% including new patients (p < 0.001). Conclusions: There is widespread interest in telemedicine in all specialties. Acceptance is high for return visits, but low for new patient visits. Improvement in technology to have both audio and video capability consistently may foster further interest toward increasing telemedicine in the future.
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Affiliation(s)
- Kunal Malhotra
- Department of Medicine, University of Missouri System, Columbia, Missouri, USA
- Address correspondence to: Kunal Malhotra, MD, Department of Medicine, Division of Nephrology, University of Missouri System, 1, Hospital Dr CE 425, Columbia, MO 65211, USA
| | | | - Hariharan Regunath
- Department of Medicine, Division of Pulmonary & Critical Care & Infectious Disease, University of Missouri System, Columbia, Missouri, USA
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15
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Abstract
Infective endocarditis (IE)-related glomerulonephritis (GN) typically resolves with the treatment of IE. A 59-year-old woman with a baseline creatinine of 0.7 mg/dL presented with rash on her legs, night sweats and weight loss for 3 weeks. Further evaluation revealed IE. Her blood cultures grew gamma-haemolytic streptococcus, which subsequently cleared on appropriate antibiotic therapy. Her creatinine, however, progressively worsened requiring haemodialysis. Kidney biopsy showed immune complex-mediated necrotising and crescentic GN. She was started on plasmapheresis (PE) and high-dose steroids with rapid taper, with subsequent improvement in her creatinine to 0.8 mg/dL. She subsequently had aortic valve replacement and ventricular septal defect closure. She did not improve as expected with antibiotic therapy but turned around dramatically with steroids and PE. Our case supports the possible beneficial role of PE and steroids in IE-related crescentic GN that worsens despite appropriate antibiotic therapy, although the risks of immunosuppression and aggravating endocarditis need to be considered.
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Affiliation(s)
- Kunal Malhotra
- Division of Nephrology, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Preethi Yerram
- Division of Nephrology, University of Missouri School of Medicine, Columbia, Missouri, USA
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16
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Abstract
Aims Cone beam CT allows cross-sectional imaging of the tibiofibular syndesmosis while the patient bears weight. This may facilitate more accurate and reliable investigation of injuries to, and reconstruction of, the syndesmosis but normal ranges of measurements are required first. The purpose of this study was to establish: 1) the normal reference measurements of the syndesmosis; 2) if side-to-side variations exist in syndesmotic anatomy; 3) if age affects syndesmotic anatomy; and 4) if the syndesmotic anatomy differs between male and female patients in weight-bearing cone beam CT views. Patients and Methods A retrospective analysis was undertaken of 50 male and 50 female patients (200 feet) aged 18 years or more, who underwent bilateral, simultaneous imaging of their lower legs while standing in an upright, weight-bearing position in a pedCAT machine between June 2013 and July 2017. At the time of imaging, the mean age of male patients was 47.1 years (18 to 72) and the mean age of female patients was 57.8 years (18 to 83). We employed a previously described technique to obtain six lengths and one angle, as well as calculating three further measurements, to provide information on the relationship between the fibula and tibia with respect to translation and rotation. Results The upper limit of lateral translation in un-injured patients was 5.27 mm, so values higher than this may be indicative of syndesmotic injury. Anteroposterior translation lay within the ranges 0.31 mm to 2.59 mm, and -1.48 mm to 3.44 mm, respectively. There was no difference between right and left legs. Increasing age was associated with a reduction in lateral translation. The fibulae of men were significantly more laterally translated but data were inconsistent for rotation and anteroposterior translation. Conclusion We have established normal ranges for measurements in cross-sectional syndesmotic anatomy during weight-bearing and also established that no differences exist between right and left legs in patients without syndesmotic injury. Age and gender do, however, affect the anatomy of the syndesmosis, which should be taken into account at time of assessment. Cite this article: Bone Joint J 2019;101-B:348–352.
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Affiliation(s)
- S. Patel
- Royal National Orthopaedic Hospital, Stanmore, UK
| | - K. Malhotra
- Royal National Orthopaedic Hospital, Stanmore, UK
| | - N. P. Cullen
- Royal National Orthopaedic Hospital, Stanmore, UK
| | - D. Singh
- Royal National Orthopaedic Hospital, Stanmore, UK
| | | | - M. J. Welck
- Royal National Orthopaedic Hospital, Stanmore, UK
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17
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An S, Malhotra K, Dilley C, Han-Burgess E, Valdez JN, Robertson J, Clark C, Westover MB, Sun J. Predicting drug-resistant epilepsy - A machine learning approach based on administrative claims data. Epilepsy Behav 2018; 89:118-125. [PMID: 30412924 PMCID: PMC6461470 DOI: 10.1016/j.yebeh.2018.10.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [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: 07/24/2018] [Revised: 10/04/2018] [Accepted: 10/08/2018] [Indexed: 11/28/2022]
Abstract
Patients with drug-resistant epilepsy (DRE) are at high risk of morbidity and mortality, yet their referral to specialist care is frequently delayed. The ability to identify patients at high risk of DRE at the time of treatment initiation, and to subsequently steer their treatment pathway toward more personalized interventions, has high clinical utility. Here, we aim to demonstrate the feasibility of developing algorithms for predicting DRE using machine learning methods. Longitudinal, intersected data sourced from US pharmacy, medical, and adjudicated hospital claims from 1,376,756 patients from 2006 to 2015 were analyzed; 292,892 met inclusion criteria for epilepsy, and 38,382 were classified as having DRE using a proxy measure for drug resistance. Patients were characterized using 1270 features reflecting demographics, comorbidities, medications, procedures, epilepsy status, and payer status. Data from 175,735 randomly selected patients were used to train three algorithms and from the remainder to assess the trained models' predictive power. A model with only age and sex was used as a benchmark. The best model, random forest, achieved an area under the receiver operating characteristic curve (95% confidence interval [CI]) of 0.764 (0.759, 0.770), compared with 0.657 (0.651, 0.663) for the benchmark model. Moreover, predicted probabilities for DRE were well-calibrated with the observed frequencies in the data. The model predicted drug resistance approximately 2 years before patients in the test dataset had failed two antiepileptic drugs (AEDs). Machine learning models constructed using claims data predicted which patients are likely to fail ≥3 AEDs and are at risk of developing DRE at the time of the first AED prescription. The use of such models can ensure that patients with predicted DRE receive specialist care with potentially more aggressive therapeutic interventions from diagnosis, to help reduce the serious sequelae of DRE.
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Affiliation(s)
- Sungtae An
- Georgia Institute of Technology, College of Computing, Atlanta, GA, USA
| | - Kunal Malhotra
- Georgia Institute of Technology, College of Computing, Atlanta, GA, USA
| | | | | | - Jeffrey N Valdez
- Georgia Institute of Technology, College of Computing, Atlanta, GA, USA
| | | | | | - M Brandon Westover
- Massachusetts General Hospital, Department of Neurology, Boston, MA, USA
| | - Jimeng Sun
- Georgia Institute of Technology, College of Computing, Atlanta, GA, USA.
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18
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Abstract
Chronic kidney disease and dialysis brings with it a plethora of complications, including malnutrition. Strict dietary restrictions in hemodialysis (HD) patients further complicate the picture as it increases the risk of deficiency of micronutrients, specifically water-soluble vitamins. Today, there is a lack of concrete guidelines concerning recommendations on vitamin supplementation in HD patients. This lack of data is partly due to our incomplete understanding of handling of vitamins in a uremic state. There is a dire need for more data on the impact of dialysis and uremic state on water-soluble vitamins to facilitate appropriate preventative supplementation. We present a case of scurvy in a HD patient that will contribute toward the understanding of vitamin status in HD. We hope it will aid in screening HD patients for vitamin C deficiency and individualizing supplementation of vitamin C.
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Affiliation(s)
- Sarju Panchal
- University of Missouri-School of Medicine, Class of 2019, One Hospital Drive, Columbia, Missouri 65212, USA
| | - Christine Schneider
- Division of Nephrology, Department of Medicine, University of Missouri, CE425, 1 Hospital Drive, Columbia, Missouri 65212, USA
| | - Kunal Malhotra
- Division of Nephrology, Department of Medicine, University of Missouri, CE425, 1 Hospital Drive, Columbia, Missouri 65212, USA
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19
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Dumor K, Malhotra K. When Love Hurts, It Leaves No Options! An Unusual Case of Pasteurella Peritoneal Dialysis Peritonitis Causing Severe Intra-abdominal Adhesions Preventing a Future Peritoneal Dialysis Option. Adv Perit Dial 2018; 34:50-52. [PMID: 30480538] [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: 06/09/2023]
Abstract
A 67-year-old white man with a history of end-stage renal disease receiving peritoneal dialysis (PD) presented with acute onset of vomiting, chills, and abdominal pain. He was diagnosed with PD-associated peritonitis secondary to Pasteurella. After failure of 3 weeks of antibiotic treatment, catheter loss occurred. On follow-up, the patient was found to have extensive intra-abdominal adhesions precluding placement of a new PD catheter.
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Affiliation(s)
- Korshie Dumor
- From: University of Missouri, Division of Nephrology, Columbia, Missouri, U.S.A
| | - Kunal Malhotra
- From: University of Missouri, Division of Nephrology, Columbia, Missouri, U.S.A
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20
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Malhotra K, Goyal N, Chang JJ, Broce M, Pandhi A, Kerro A, Shahripour RB, Alexandrov AV, Tsivgoulis G. Differential leukocyte counts on admission predict outcomes in patients with acute ischaemic stroke treated with intravenous thrombolysis. Eur J Neurol 2018; 25:1417-1424. [PMID: 29953701 DOI: 10.1111/ene.13741] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 06/20/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE To determine the association of differential leukocyte counts on admission with efficacy and safety outcomes in patients with acute ischaemic stroke (AIS) treated with intravenous thrombolysis (IVT). METHODS Consecutive patients with AIS receiving IVT were evaluated at two stroke centers. Differential leukocyte counts and neutrophil:lymphocyte ratio (NLR) were determined during the initial 12 h of admission. Efficacy outcomes were favorable functional outcome (FFO) (modified Rankin Scale scores of 0-1) and functional independence (FI) (modified Rankin Scale scores of 0-2) at 3 months, whereas safety outcomes were symptomatic intracranial hemorrhage and 3-month mortality. RESULTS Among 657 IVT-treated patients with AIS, the mean age was 64 ± 14 years, 50% were female and median National Institutes of Health Stroke Scale score was 7 points (interquartile range, 4-13). Lower neutrophil and leukocyte counts and NLR counts were observed in patients with 3-month FFO and FI, whereas higher counts were observed in patients who died at 3 months. The best discriminative factors for 3-month FFO and FI were NLR < 2.2 (sensitivity 51.4%, specificity 63.1%) and leukocyte count <8100/μL (sensitivity 57.5%, specificity 55.1%), respectively. After adjustment for potential confounders, NLR < 2.2 was associated with higher odds of FFO [odds ratio (OR), 1.56; 95% confidence interval (CI), 1.08-2.24; P = 0.018], whereas leukocyte count <8100/μL demonstrated higher odds of 3-month FI (OR, 1.69; 95% CI, 1.11-2.57; P = 0.014) and lower odds of 3-month mortality (OR, 0.31; 95% CI, 0.16-0.60; P = 0.001). Combined neutrophil (<6800/μL) and leukocyte (<8100/μL) counts demonstrated a strong interaction for 3-month FI (OR, 1.73; 95% CI, 1.13-2.67; P interaction = 0.012). CONCLUSIONS Differential leukocyte counts on admission were independently associated with clinical outcomes in patients with AIS treated with IVT. These inflammatory biomarkers are potential targets for adjunctive neuroprotection in this stroke subgroup.
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Affiliation(s)
- K Malhotra
- Department of Neurology, Charleston Area Medical Center, West Virginia University, Charleston, WV
| | - N Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - J J Chang
- Medstar Washington Hospital Medical Center, Washington, DC
| | - M Broce
- Department of Health Services & Outcomes Research, Charleston Area Medical Center, Charleston, WV, USA
| | - A Pandhi
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - A Kerro
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - R B Shahripour
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - A V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - G Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN.,Second Department of Neurology, School of Medicine, Attikon University Hospital, National & Kapodistrian University of Athens, Athens, Greece
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21
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Abstract
Aims Gastrocnemius tightness predisposes to musculoskeletal pathology and may require surgical treatment. However, it is not clear what proportion of patients with foot and ankle pathology have clinically significant gastrocnemius tightness. The aim of this study was to compare the prevalence and degree of gastrocnemius tightness in a control group of patients with a group of patients with foot and ankle pathology. Patients and Methods This prospective, case-matched, observational study compared gastrocnemius tightness, as assessed by the lunge test, in a control group and a group with foot and ankle pathology. Gastrocnemius tightness was calculated as the difference in dorsiflexion of the ankle with the knee extended and flexed. Results A total of 291 controls were paired with 97 patients with foot and ankle pathology (FAP). The mean gastrocnemius tightness was 6.0° (sd 3.5) in controls and 8.0° (sd 5.7) in the FAP group (p < 0.001). Subgroup analysis showed a mean gastrocnemius tightness of 10.3° (sd 6.0) in patients with forefoot pathology versus 6.9° (sd 5.3) in patients with other pathology (p = 0.008). A total of 12 patients (37.5%) with forefoot pathology had gastrocnemius tightness of > two standard deviations of the control group (> 13°). Conclusion Gastrocnemius tightness of > 13° may be considered abnormal. Most patients with foot and ankle pathology do not have abnormal degrees of gastrocnemius tightness compared with controls, but it is present in over a third of patients with forefoot pathology. Cite this article: Bone Joint J 2018;100-B:945–52.
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Affiliation(s)
- K. Malhotra
- Foot and Ankle Unit, Royal National Orthopaedic
Hospital, Stanmore, UK
| | - O. Chan
- Foot and Ankle Unit, Royal National Orthopaedic
Hospital, Stanmore, UK
| | - S. Cullen
- University College London Medical School, London, UK
| | - M. Welck
- Foot and Ankle Unit, Royal National Orthopaedic
Hospital, Stanmore, UK
| | - A. J. Goldberg
- Foot and Ankle Unit, Royal National Orthopaedic
Hospital, Stanmore, UK
| | - N. Cullen
- Foot and Ankle Unit, Royal National Orthopaedic
Hospital, Stanmore, UK
| | - D. Singh
- Foot and Ankle Unit, Royal National Orthopaedic
Hospital, Stanmore, UK
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22
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Ithman M, Malhotra K, Bordoloi M, Singh G. Treatment-Refractory Mania with Psychosis in a Post-Transplant Patient on Tacrolimus: A Case Report. Clin Med Res 2018; 16:47-49. [PMID: 29776917 PMCID: PMC6108512 DOI: 10.3121/cmr.2018.1409] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 04/13/2018] [Accepted: 05/01/2018] [Indexed: 11/18/2022]
Abstract
Bipolar affective disorder type I imparts significant morbidity and disease burden in the population. It is characterized by occurrence of one or more manic episodes which may be preceded or followed by a depressive or hypomanic phase. About half of these manic episodes are characterized by the presence of psychotic features. The condition is further complicated when the patient has multiple comorbid conditions. We report here the case of a Caucasian woman, aged 66 years, previously diagnosed with Bipolar disorder who developed treatment refractory mania with psychotic feature after being on the immunosuppressive agent, tacrolimus, after kidney transplantation.
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Affiliation(s)
- Muaid Ithman
- Department of Psychiatry, University of Missouri-Columbia, Columbia, Missouri
| | - Kunal Malhotra
- Department of Nephrology, University of Missouri-Columbia, Columbia, Missouri
| | - Meelie Bordoloi
- Department of Psychiatry, University of Missouri-Columbia, Columbia, Missouri
| | - Garima Singh
- Department of Psychiatry, University of Missouri-Columbia, Columbia, Missouri
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Malhotra K, Khanna R. Continuous Ambulatory Peritoneal Dialysis and Automated Peritoneal Dialysis: What, Who, Why, and How? Review and Case Study. Adv Perit Dial 2017; 33:59-64. [PMID: 29668434] [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: 06/08/2023]
Abstract
Peritoneal dialysis (PD) is an umbrella term that encompasses a variety of techniques such as continuous ambulatory PD, automated PD, tidal PD, and intermittent PD, among others. The various techniques exist to tailor the PD prescription to meet the goals of individual patients. Various clinical and nonclinical factors can change over time, requiring a change to the PD prescription. This article uses a practical case study to highlight the intricacies of the calculations behind PD prescription to achieve clearance goals. The objective is to demonstrate that all modalities of PD should be considered in the spectrum of clinical tools for achieving adequate dialysis.
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Affiliation(s)
- Kunal Malhotra
- Division of Nephrology, University of Missouri-Columbia, Columbia, Missouri, U.S.A
| | - Ramesh Khanna
- Division of Nephrology, University of Missouri-Columbia, Columbia, Missouri, U.S.A
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Salandy A, Malhotra K, Goldberg AJ, Cullen N, Singh D. Can a urine dipstick test be used to assess smoking status in patients undergoing planned orthopaedic surgery? a prospective cohort study. Bone Joint J 2016; 98-B:1418-1424. [PMID: 27694599 DOI: 10.1302/0301-620x.98b10.bjj-2016-0303.r1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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: 04/21/2016] [Accepted: 06/13/2016] [Indexed: 11/05/2022]
Abstract
AIMS Smoking is associated with post-operative complications but smokers often under-report the amount they smoke. Our objective was to determine whether a urine dipstick test could be used as a substitute for quantitative cotinine assays to determine smoking status in patients. PATIENTS AND METHODS Between September 2013 and July 2014 we conducted a prospective cohort study in which 127 consecutive patients undergoing a planned foot and ankle arthrodesis or osteotomy were included. Patients self-reported their smoking status and were classified as: 'never smoked' (61 patients), 'ex-smoker' (46 patients), or 'current smoker' (20 patients). Urine samples were analysed with cotinine assays and cotinine dipstick tests. RESULTS There was a high degree of concordance between dipstick and assay results (Kappa coefficient = 0.842, p < 0.001). Compared with the quantitative assay, the dipstick had a sensitivity of 88.9% and a specificity of 97.3%. Patients claiming to have stopped smoking just before surgery had the highest rate of disagreement between reported smoking status and urine testing. CONCLUSION Urine cotinine dipstick testing is cheap, fast, reliable, and easy to use. It may be used in place of a quantitative assay as a screening tool for detecting patients who may be smoking. A positive test may be used as a trigger for further assessment and counselling. Cite this article: Bone Joint J 2016;98-B:1418-24.
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Affiliation(s)
- A Salandy
- Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK
| | - K Malhotra
- Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK
| | - A J Goldberg
- Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK
| | - N Cullen
- Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK
| | - D Singh
- Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, HA7 4LP, UK
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Li J, Hoeppner C, Gan S, Blair A, Min K, Sims A, Tietz A, Vinas M, Rehage T, Malhotra K, Halait H, Brophy V. An extended KRAS mutation test for the detection of 28 common mutations in FFPET and plasma specimens. Ann Oncol 2016. [DOI: 10.1093/annonc/mdw363.42] [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: 11/12/2022] Open
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Yu HM, Malhotra K, Butler JS, Patel A, Sewell MD, Li YZ, Molloy S. The relationship between spinopelvic measurements and patient-reported outcome scores in patients with multiple myeloma of the spine. Bone Joint J 2016; 98-B:1234-9. [DOI: 10.1302/0301-620x.98b9.37786] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Accepted: 05/06/2016] [Indexed: 11/05/2022]
Abstract
Aims Patients with multiple myeloma (MM) develop deposits in the spine which may lead to vertebral compression fractures (VCFs). Our aim was to establish which spinopelvic parameters are associated with the greatest disability in patients with spinal myeloma and VCFs. Patients and Methods We performed a retrospective cross-sectional review of 148 consecutive patients (87 male, 61 female) with spinal myeloma and analysed correlations between spinopelvic parameters and patient-reported outcome scores. The mean age of the patients was 65.5 years (37 to 91) and the mean number of vertebrae involved was 3.7 (1 to 15). Results The thoracolumbar region was most commonly affected (109 patients, 73.6%), and was the site of most posterior vertebral wall defects (47 patients, 31.8%). Poorer Oswestry Disability Index scores correlated with an increased sagittal vertical axis (p = 0.006), an increased number of VCFs (p = 0.035) and sternal involvement (p = 0.012). Poorer EuroQol visual analogue scale scores correlated with posterior vertebral wall defects in the thoracolumbar region (p = 0.012). The sagittal vertical axis increased with the number of fractures and kyphosis in the thoracolumbar (p = 0.009) and lumbar (p < 0.001) regions. Conclusions In MM, patients with VCFs have poorer clinical scores at presentation in the presence of sagittal imbalance. Outcome is particularly affected by multiple fractures in the thoracolumbar and lumbar regions and by failure to prevent kyphosis. Patients with MM should be screened for spinal lesions early. Cite this article: Bone Joint J 2016;98-B:1234–9.
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Affiliation(s)
- H. M. Yu
- The Second Affiliated Hospital of Fujian
Medical University, Quanzhou City, Fujian Province, China
| | - K. Malhotra
- Royal National Orthopaedic Hospital, Spinal
Deformity Unit, Department of Spinal Surgery, Brockley
Hill, Stanmore, HA7 4LP, UK
| | - J. S. Butler
- Royal National Orthopaedic Hospital, Spinal
Deformity Unit, Department of Spinal Surgery, Brockley
Hill, Stanmore, HA7 4LP, UK
| | - A. Patel
- Royal National Orthopaedic Hospital, Spinal
Deformity Unit, Department of Spinal Surgery, Brockley
Hill, Stanmore, HA7 4LP, UK
| | - M. D. Sewell
- Royal National Orthopaedic Hospital, Spinal
Deformity Unit, Department of Spinal Surgery, Brockley
Hill, Stanmore, HA7 4LP, UK
| | - Y. Z. Li
- The Second Affiliated Hospital of Fujian
Medical University, Quanzhou City, Fujian Province, China
| | - S. Molloy
- Royal National Orthopaedic Hospital, Spinal
Deformity Unit, Department of Spinal Surgery, Brockley
Hill, Stanmore, HA7 4LP, UK
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Malhotra K, Navathe SB, Chau DH, Hadjipanayis C, Sun J. Constraint based temporal event sequence mining for Glioblastoma survival prediction. J Biomed Inform 2016; 61:267-75. [PMID: 27064059 DOI: 10.1016/j.jbi.2016.03.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 03/05/2016] [Accepted: 03/25/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE A significant challenge in treating rare forms of cancer such as Glioblastoma (GBM) is to find optimal personalized treatment plans for patients. The goals of our study is to predict which patients survive longer than the median survival time for GBM based on clinical and genomic factors, and to assess the predictive power of treatment patterns. METHOD We developed a predictive model based on the clinical and genomic data from approximately 300 newly diagnosed GBM patients for a period of 2years. We proposed sequential mining algorithms with novel clinical constraints, namely, 'exact-order' and 'temporal overlap' constraints, to extract treatment patterns as features used in predictive modeling. With diverse features from clinical, genomic information and treatment patterns, we applied both logistic regression model and Cox regression to model patient survival outcome. RESULTS The most predictive features influencing the survival period of GBM patients included mRNA expression levels of certain genes, some clinical characteristics such as age, Karnofsky performance score, and therapeutic agents prescribed in treatment patterns. Our models achieved c-statistic of 0.85 for logistic regression and 0.84 for Cox regression. CONCLUSIONS We demonstrated the importance of diverse sources of features in predicting GBM patient survival outcome. The predictive model presented in this study is a preliminary step in a long-term plan of developing personalized treatment plans for GBM patients that can later be extended to other types of cancers.
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Affiliation(s)
- Kunal Malhotra
- College of Computing, Georgia Institute of Technology, Atlanta, GA, USA
| | | | - Duen Horng Chau
- College of Computing, Georgia Institute of Technology, Atlanta, GA, USA
| | - Costas Hadjipanayis
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA; Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Jimeng Sun
- College of Computing, Georgia Institute of Technology, Atlanta, GA, USA.
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Malhotra K, Kulshreshtha D, Shukla S, Husain N. ENL developing 10 years after leprosy treatment masquerading as atypical-mycobacterial infection. QJM 2015; 108:905-6. [PMID: 25660606 DOI: 10.1093/qjmed/hcv042] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- K Malhotra
- From the Department of Pathology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India and
| | - D Kulshreshtha
- Department of Neurology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - S Shukla
- From the Department of Pathology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India and
| | - N Husain
- From the Department of Pathology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India and
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Hackett C, Ramanathan R, Malhotra K, Quigley M, Kelly K, Tian M, Protetch J, Wong C, Wright D, Tayal A. Safety of venous thromboembolism prophylaxis with fondaparinux in ischemic stroke. Thromb Res 2015; 135:249-54. [DOI: 10.1016/j.thromres.2014.11.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 09/11/2014] [Accepted: 11/04/2014] [Indexed: 11/27/2022]
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Fisher JO, Wright G, Herman AN, Malhotra K, Serrano EL, Foster GD, Whitaker RC. "Snacks are not food". Low-income, urban mothers' perceptions of feeding snacks to their preschool-aged children. Appetite 2014; 84:61-7. [PMID: 25240637 DOI: 10.1016/j.appet.2014.09.007] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 09/12/2014] [Accepted: 09/13/2014] [Indexed: 11/19/2022]
Abstract
Snacking has become more frequent among US preschool-aged children in recent decades and represents a significant proportion of daily energy intake. Social influences on snacking among children, however, are not well understood. This qualitative research described low-income, urban mothers' perceptions of feeding snacks to their preschool-aged children using data from 7 focus groups with 32 participants. Focus group transcripts were analyzed using a constant comparative method to identify themes. Mothers described snacks as involving less preparation, balance, and sustenance than meals (Theme 1). Mothers also made reference to some snacks as not being "real food" (Theme 2). At the same time, snacks had significant hedonic value as reflected in mothers' enjoyment of those foods (Theme 3), the effectiveness of snacks to manage children's behavior (Theme 4), and the variety of restrictions that mothers placed on children's access to snacks, such as locking cabinets, offering small servings, and reducing the number of snacks in sight (Theme 5). Two overarching themes highlighted distinctions mothers made in feeding children snacks vs. meals as well as the powerful hedonic appeal of snacks for both mother and child. These observations suggest that low-income, urban mothers of preschool-aged children may perceive snacks as serving a more important role in managing children's behavior than in providing nutrition. Child feeding interventions should address non-food related ways of managing children's behavior as well as encouraging caregivers to see snacks as structured opportunities for nutrition and connecting with their children.
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Affiliation(s)
- J O Fisher
- Center for Obesity Research and Education, Temple University, 3223 N. Broad Street, Philadelphia, PA 19140, USA.
| | - G Wright
- Center for Obesity Research and Education, Temple University, 3223 N. Broad Street, Philadelphia, PA 19140, USA
| | - A N Herman
- Center for Obesity Research and Education, Temple University, 3223 N. Broad Street, Philadelphia, PA 19140, USA
| | - K Malhotra
- Center for Obesity Research and Education, Temple University, 3223 N. Broad Street, Philadelphia, PA 19140, USA
| | - E L Serrano
- Virginia Polytechnic Institute and State University, 201 Wallace Annex, Blacksburg, VA 24061, USA
| | - G D Foster
- Center for Obesity Research and Education, Temple University, 3223 N. Broad Street, Philadelphia, PA 19140, USA
| | - R C Whitaker
- Center for Obesity Research and Education, Temple University, 3223 N. Broad Street, Philadelphia, PA 19140, USA
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Abstract
Elevated serum uric acid levels are a frequent finding in persons with obesity, hypertension, cardiovascular and kidney disease as well as in those with the cardiorenal metabolic syndrome (CRS). The increased consumption of a fructose-rich Western diet has contributed to the increasing incidence of the CRS, obesity and diabetes especially in industrialized populations. There is also increasing evidence that supports a causal role of high dietary fructose driving elevations in uric acid in association with the CRS. Animal and epidemiological studies support the notion that elevated serum uric acid levels play an important role in promoting insulin resistance and hypertension and suggest potential pathophysiological mechanisms that contribute to the development of the CRS and associated cardiovascular disease and chronic kidney disease. To this point, elevated serum levels of uric acid appear to contribute to impaired nitric oxide production/endothelial dysfunction, increased vascular stiffness, inappropriate activation of the renin-angiotensin-aldosterone system, enhanced oxidative stress, and maladaptive immune and inflammatory responses. These abnormalities, in turn, promote vascular, cardiac and renal fibrosis as well as associated functional abnormalities. Small clinical trials have suggested that uric acid-lowering therapies may be beneficial in such patients; however, a consensus on the treatment of asymptomatic hyperuricemia is lacking. Larger randomized controlled trials need to be performed in order to critically evaluate the beneficial effect of lowering serum uric acid in patients with the CRS and those with diabetes and/or hypertension.
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Deodhar A, Mease P, Reveille J, Curtis J, Karunaratne P, Malhotra K, Pangan A. THU0065 Prevalence of Axial Spondyloarthritis among Undiagnosed Chronic Back Pain Patients in the United States: Table 1. Ann Rheum Dis 2014. [DOI: 10.1136/annrheumdis-2014-eular.1135] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Malhotra K, Schramke C, Ku A. E-057 Risk factors influencing duration of Cerebral Angiography: A single centre study. J Neurointerv Surg 2013. [DOI: 10.1136/neurintsurg-2013-010870.115] [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: 11/04/2022]
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Dhawan V, Ariyamuthu V, Malhotra K, Dalal P, Bichu P, Dorairajan S. Isolated pleural effusion as a presentation of high cardiac output heart failure in a hemodialysis patient. Hemodial Int 2013; 16 Suppl 1:S54-7. [PMID: 23036038 DOI: 10.1111/j.1542-4758.2012.00746.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Congestive heart failure is a well-recognized complication of hemodialysis arteriovenous fistula. Symptoms of dyspnea are usually associated with signs of congestive heart failure including pulmonary edema, pleural effusions, lower extremity edema, and liver enlargement, to name a few. We present a case of a gentleman with end-stage renal disease on chronic hemodialysis, which developed acute bilateral transudative pleural effusions in the absence of other signs of systemic venous congestion, associated with pulmonary venous congestion. We also discuss the pathogenesis and role of hemodialysis in management of this patient.
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Affiliation(s)
- Vibhu Dhawan
- Division of Nephrology, Department of Internal Medicine, University of Missouri, Columbia, Missouri 65212, USA.
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Malhotra K, Dhawan V, Dalal P, Ariyamuthu V, Bichu P, Botdorf J, Khanna R. Decompensated high-output congestive heart failure in a patient with AVF and the role of right heart catheterization: a case study. Hemodial Int 2013; 16 Suppl 1:S58-61. [PMID: 23036039 DOI: 10.1111/j.1542-4758.2012.00749.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A 70-year-old Caucasian male presented 8 months postcadaveric renal transplant with slowly progressive shortness of breath, abdominal distention, and cough for a duration of a few days. Thorough evaluation found him to have severe pulmonary hypertension (PH) on echocardiogram with decompensated high-output congestive heart failure. A right heart catheterization was done, which confirmed elevated right-sided pressures and high cardiac output. The mean pulmonary artery pressure, on a Swan-Ganz catheter, improved from 37 to 30 mmHg on partial manual occlusion of his still functioning hemodialysis arteriovenous fistula. Subsequently, the patient underwent ligation of the fistula and this led to gradual improvement in his symptoms. Follow-up right heart catheterization and echocardiogram showed marked improvement and normalization of right heart pressures. We recommend that patients with arteriovenous fistula should undergo close monitoring for development of early signs and symptoms of congestive heart failure and screening for PH by echocardiography post-kidney transplant. Right heart catheterization should be considered if screening is positive. Risk and benefit of fistula closure should be weighed in face of reduced survival from PH in dialysis patients and closure should be considered in post-transplant patients.
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Affiliation(s)
- Kunal Malhotra
- Division of Nephrology, Department of Internal Medicine, University of Missouri, Columbia, Missouri 65212, USA.
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37
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Camille B, Christophe B, Yvon B, Henri VC, Pierre M, Dominique T, Bataille S, Chondolu S, An T, Khan S, Rayamajhi S, Kim GH, Roh YW, Lee CH, Kang CM, Bansal R, Singh KN, Saxena S, Malhotra K, Van Laecke S, Nagler E, Van Biesen W, Jadoul M, Vanholder R, Cucchiari D, Cucchiari D, Angelini C, Mirani M, Arosio P, Graziani G, Badalamenti S, Girfoglio D, Allen D, Kirkham A, Johri N, Wheeler DC, Choong S, Moochhala S, Unwin R, Fabris A, Lupo A, Fantin F, Ferraro PM, Caletti C, Comellato G, Messa M, Gambaro G, Tanaka H, Tatsumoto N, Tsuneyoshi S, Daijo Y, Bacallao Mendez RA, Bacallao R, Crombet T, Davalos JM, Llerena B, Leyva C, Manalich R, Beltrami P, Ruggera L, Iannetti A, Iafrate M, Guttilla A, Zattoni F, Arancio M, Zattoni F, Beltrami P, Ruggera L, Guttilla A, Iannetti A, Zattoni F, Gigli F, Zattoni F. Electrolyte disorders / Nephrolithiasis. Nephrol Dial Transplant 2012. [DOI: 10.1093/ndt/gfs222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Dalal P, Bichu P, Dhawan V, Ariyamuthu V, Malhotra K, Misra M, Khanna R. Post-transplant Lymphoproliferative Disorder--a case of late-onset T-cell lymphoma after failed renal transplant. Adv Perit Dial 2012; 28:94-96. [PMID: 23311222] [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: 06/01/2023]
Abstract
Post-transplant lymphoproliferative disease (PTLD) is a rare but life-threatening complication after solid organ transplantation. The risk of PTLD varies with recipient age, serostatus of the donor and the recipient for Epstein-Barr virus, type of organ transplanted, and intensity of immunosuppression. The risk of PTLD is highest in the early post-transplant period, but the cumulative risk increases with time. We report a case of PTLD occurring 17 years after renal transplantation in a 59-year-old woman.
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Affiliation(s)
- Pranav Dalal
- Division of Nephrology, University of Missouri, Columbia, Missouri 65212, USA.
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Haygood T, Malhotra K, Ng C, Chasen B, McEnery K, Chasen M. Migration of central lines from the superior vena cava to the azygous vein. Clin Radiol 2012; 67:49-54. [DOI: 10.1016/j.crad.2011.05.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Revised: 05/10/2011] [Accepted: 05/31/2011] [Indexed: 10/15/2022]
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Abstract
Functional colonic obstruction is a colonic motility disorder with a number of causes. One cause is myenteric ganglionitis, which may result from paraneoplastic processes. We present the case of a previously healthy 53-year-old man who presented with a week's history of functional colonic obstruction. A transverse loop colostomy failed to resolve his symptoms and he subsequently underwent an extended right hemicolectomy. Histology demonstrated lymphocytic myenteric ganglionitis that was felt to be of paraneoplastic origin. The patient later developed bilateral ptosis and was diagnosed with ocular myasthenia gravis. Further investigation revealed the presence of a thymoma that was resected, resulting in an improvement to his symptoms. We present this case and a review of the literature to illustrate the importance of seeking out a paraneoplastic cause for functional colonic obstruction in adults as early resection of the tumour may help alleviate symptoms and avoid bowel surgery.
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Rao RN, Krishnani N, Malhotra K, Suresh B, Mehrotra R. Dilemmas in cytodiagnosis of subcutaneous swellings: mimics and look-alikes of cysticercosis. J Clin Pathol 2010; 63:926-9. [DOI: 10.1136/jcp.2010.076976] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Malhotra K, Schwartz T, Hameed U. Presence of suicidality as a prognostic indicator. J Postgrad Med 2004; 50:185-7; discussion 187-8. [PMID: 15377802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND Suicidal symptoms in depression are often thought to predict a higher severity of illness and a worse prognosis. AIMS To determine if suicidal ideation at the time of treatment for major depression can predict response to antidepressant medication in primary care. SETTINGS AND DESIGN A retrospective analysis of subjects receiving anti-depressant drugs in a primary care setting METHODS AND MATERIAL Nine depressed patients (14%) who acknowledged suicidality on the PHQ-9 depression scale were followed up for and compared to a group of 54 (86%) depressed patients (controls) who did not have suicidal thoughts for four months. All were given treatment with antidepressants and followed with a disease management protocol where the PHQ-9 was used as a systematic outcome measure. STATISTICAL ANALYSIS Descriptive measures and t-tests were utilized to show statistical significance. RESULTS There were no statistical differences in remission from depressive symptoms based on the PHQ-9 scale after antidepressant treatment, between patients with suicidal thoughts (56%) and those without (44%). CONCLUSION The presence of suicidality as a depressive symptom did not predict poorer clinical outcome when treating depression in the primary care setting in the patients studied.
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Affiliation(s)
- K Malhotra
- Department of Psychiatry, SUNY Upstate Medical University, Syracuse, NY 13210, USA
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Abstract
Treatment-resistant depression may be due to factors such as co-morbid psychiatric or medical illnesses, chronic psychosocial stresses, and medication nonadherence. Alternative treatment strategies such as optimization, switching to a different antidepressant, augmentation or combination with another antidepressant are strategies useful in such patients. The first strategy in treating resistant depression is to optimize monotherapy. A switch should be made to another agent if there is no response to treatment after an adequate duration. Augmentation and combination strategies are useful if there is sub-optimal response to the initial antidepressant. With several antidepressants (selective serotonin reuptake inhibitors, tricyclic antidepressants, monoamine oxidase inhibitors and the newer antidepresssants) and various antidepressant augmentation and combination strategies available to clinicians, the outcome of treating patients with depression should improve.
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Affiliation(s)
- A O Alao
- Department of Psychiatry, SUNY Upstate Medical University, 750, East Adams Street, Syracuse, NY 13210, USA.
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Affiliation(s)
- U Jurt
- Division of Cardiology and Internal Medicine, Toronto General Hospital, Toronto, Ontario, Canada
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Martin KJ, González E, Lindberg JS, Taccetta C, Amdahl M, Malhotra K, Llach F. Paricalcitol dosing according to body weight or severity of hyperparathyroidism: a double-blind, multicenter, randomized study. Am J Kidney Dis 2001; 38:S57-63. [PMID: 11689389 DOI: 10.1053/ajkd.2001.28112] [Citation(s) in RCA: 36] [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: 11/11/2022]
Abstract
Vitamin D therapy for patients with end-stage renal disease (ESRD) on hemodialysis therapy has relied on patient dry weight to determine the initial dose of medication. Obtaining a patient's dry weight can be difficult, and no correlation has been established between a patient's body weight and severity of secondary hyperparathyroidism. We conducted a double-blind, double-dummy, randomized, 12-week, multicenter trial to compare the incidence of hypercalcemia (single occurrence) between two dosing regimens: one regimen based on baseline intact parathyroid hormone (iPTH; PTH/80) level, and the other regimen based on patient body weight (0.04 microgram/kg). One hundred twenty-five adult patients with ESRD on maintenance hemodialysis therapy were enrolled at multiple sites. Before treatment, all patients were required to have PTH levels of 300 pg/mL or greater, calcium levels of 8.0 mg/dL or greater and 10.5 mg/dL or less, and a calcium x phosphorus (Ca x P) product of 70 or less. Patients were randomized to one of two regimens: the nonrandomized treatment was also administered as a placebo dummy. No incidence of hypercalcemia occurred in either treatment group during the study. Patients treated according to the formula iPTH/80 required fewer dose adjustments and achieved the first of four consecutive reductions from baseline PTH level of 30% or greater more rapidly than patients treated based on body weight (P = 0.0306). Incidences of elevated Ca x P product levels were similar between treatment groups. Treatment with paricalcitol injection based on degree of secondary hyperparathyroidism incurred no greater risk for hypercalcemia and achieved meaningful therapeutic results with fewer dose adjustments than dosing based on patient body weight.
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Affiliation(s)
- K J Martin
- Division of Nephrology, Louis University, St Louis, MO, USA.
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Malhotra KT, Malhotra K, Lubin BH, Kuypers FA. Identification and molecular characterization of acyl-CoA synthetase in human erythrocytes and erythroid precursors. Biochem J 1999; 344 Pt 1:135-43. [PMID: 10548543 PMCID: PMC1220623] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
Full-length cDNA species encoding two forms of acyl-CoA synthetase from a K-562 human erythroleukaemic cell line were cloned, sequenced and expressed. The first form, named long-chain acyl-CoA synthetase 5 (LACS5), was found to be a novel, unreported, human acyl-CoA synthetase with high similarity to rat brain ACS2 (91% identical). The second form (66% identical with LACS5) was 97% identical with human liver LACS1. The LACS5 gene encodes a highly expressed 2.9 kb mRNA transcript in human haemopoietic stem cells from cord blood, bone marrow, reticulocytes and fetal blood cells derived from fetal liver. An additional 6.3 kb transcript is also found in these erythrocyte precursors; 2.9 and 9.6 kb transcripts of LACS5 are found in human brain, but transcripts are virtually absent from human heart, kidney, liver, lung, pancreas, spleen and skeletal muscle. The 78 kDa expressed LACS5 protein used the long-chain fatty acids palmitic acid, oleic acid and arachidonic acid as substrates. Antibodies directed against LACS5 cross-reacted with erythrocyte membranes. We conclude that early erythrocyte precursors express at least two different forms of acyl-CoA synthetase and that LACS5 is present in mature erythrocyte plasma membranes.
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Affiliation(s)
- K T Malhotra
- Children's Hospital, Oakland Research Institute, 5700 Martin Luther King Jr. Way, Oakland, CA 94609, USA
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Malhotra K, Luehrsen KR, Costello LL, Raich TJ, Sim K, Foltz L, Davidson S, Xu H, Chen A, Yamanishi DT, Lindemann GW, Cain CA, Madlansacay MR, Hashima SM, Pham TL, Mahoney W, Schueler PA. Identification of differentially expressed mRNAs in human fetal liver across gestation. Nucleic Acids Res 1999; 27:839-47. [PMID: 9889281 PMCID: PMC148255 DOI: 10.1093/nar/27.3.839] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Differential gene expression, with its precise start and stop times, is believed to be critical for the programmed development of new cells and tissues. Within the developing fetus, one tissue of particular interest is fetal liver. This organ undergoes rapid changes in the pathway toward liver development in utero since it is also the major site of hematopoiesis, until bone marrow hematopoiesis predominates. Believing that patterns would emerge from the bi-weekly large-scale inspection of expressed genes in the fetal liver, we employed differential display reverse transcription-polymerase chain reaction (DDRT-PCR) as ourprimary inspection tool. Using DDRT-PCR, we isolated cDNAs differentially expressed throughout fetal liver development and in adult liver. We displayed approximately 25 000 cDNAs from 10 and 24 week fetal liver and adult liver. From this initial screen, we determined that approximately 0.1-1% of the mRNA population undergoes expression changes. We extracted, purified and sequenced 25 differentially displayed cDNA bands. Fourteen cDNAs had similarities to known genes, while 11 cDNAs were not similar to any characterized gene. The differentially expressed cDNAs from known genes present in fetal liver include alpha-fetoprotein, stem cell factor, erythroid alpha-spectrin, 2,3-bisphosphoglycerate mutase, insulin-like growth factor-2, porphobilinogen deaminase and Mac30. The differentially expressed cDNAs present in adult liver but not in 10 week fetal liver were nicotinamide deaminase, human fibrinogen-related protein and alpha-acid glycoprotein. The majority of differentially expressed genes found during this effort appear to be turned on during organogenesis, however, some genes were found that are apparently turned off completely.
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Affiliation(s)
- K Malhotra
- Roche Diagnostics, Chief Technology Office, 2929 7th Street, Suite 100, Berkeley, CA 94710, USA
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Malhotra K, Foltz L, Mahoney WC, Schueler PA. Interaction and effect of annealing temperature on primers used in differential display RT-PCR. Nucleic Acids Res 1998; 26:854-6. [PMID: 9443980 PMCID: PMC147309 DOI: 10.1093/nar/26.3.854] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Differential display of mRNA is a simple, sensitive and powerful method to identify differentially expressed gene fragments. The main drawback of differential display is the lack of reproducibility and the inability to read and compare complex gels. This issue results from employing unoptimized primer combinations and non-specific amplification, most likely due to unavoidable low annealing temperatures. In order to display most of the expressed transcripts (80-120 bands/lane), 26 different 5' primers were used in conjunction with nine different 3' poly (dT) primers. These primer combinations, used with the optimized annealing temperature for each set of primers, produced highly reproducible bands. BSA has a direct effect on the number of bands resolved. Variations in ramping time (9-40 s) had little or no effect on the resolution and reproducibility of differential display.
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Affiliation(s)
- K Malhotra
- Boehringer Mannheim Group, Corange Technology Office, 4300 Hacienda Drive, Pleasanton, CA 94588-2722, USA
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Abstract
Animal-type photolyases have very limited sequence homology to microbial-type photolyases. We wanted to find out whether the two types of enzymes have different or similar biochemical and photochemical properties. In particular, the chromophore/cofactor composition of animal photolyases is of special interest since the presence and nature of a second chromophore in these enzymes are not known in contrast to the microbial photolyases which contain FAD cofactor, and folate or deazaflavin as second chromophores. We overproduced the Drosophila melanogaster photolyase in Escherichia coli using the cloned gene. The enzyme contains FAD and folate and thus belongs in the folate class of enzymes but with an action spectrum peak at 420 nm.
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Affiliation(s)
- S T Kim
- Department of Biochemistry and Biophysics, University of North Carolina School of Medicine, Chapel Hill 27599, USA
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Abstract
The (6-4) photoproduct DNA photolyase was detected in two vertebrate animals Crotalus atrox (rattlesnake) and Xenopus laevis (South African clawed toad). The enzyme was extensively purified from X. laevis and characterized. The highly purified enzyme is fluorescent with an excitation maximum at 420-440 nm and emission maximum at 460-480 nm. The photorepair action spectrum matches the fluorescence excitation spectrum with a 430 nm maximum.
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Affiliation(s)
- S T Kim
- Department of Biochemistry & Biophysics, University of North Carolina at Chapel Hill 27599-7260, USA
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