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Win A, Jiang J, Fitzwater J, Caro EH, Cruickshank A, Hardy D, Perez YE, Prater M, Sagar M. A pediatric case of neuromyelitis optica and pulmonary inflammatory myofibroblastic tumor. Pediatr Pulmonol 2024; 59:189-191. [PMID: 37772630 DOI: 10.1002/ppul.26710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 09/30/2023]
Affiliation(s)
- Alyson Win
- Texas A&M Health Science Center School of Medicine, Baylor Scott and White Medical Center, Temple, Texas, USA
| | - Jesper Jiang
- Texas A&M Health Science Center School of Medicine, Baylor Scott and White Medical Center, Temple, Texas, USA
| | - John Fitzwater
- Department of Pediatric Surgery, Baylor Scott and White McClane Children's Medical Center, Temple, Texas, USA
| | - Edwin H Caro
- Department of Pediatric Pulmonology, Baylor Scott and White McClane Children's Medical Center, Temple, Texas, USA
| | - Amy Cruickshank
- Department of Pediatric Hematology/Oncology, Baylor Scott and White McClane Children's Medical Center, Temple, Texas, USA
| | - Duriel Hardy
- Department of Pediatric Neurology, Dell Children's Medical Center, Austin, Texas, USA
| | - Ydamis E Perez
- Department of Pathology, Baylor Scott and White Medical Center, Temple, Texas, USA
| | - Michele Prater
- Department of Pediatric Pulmonology, Baylor Scott and White McClane Children's Medical Center, Temple, Texas, USA
| | - Malvika Sagar
- Department of Pediatric Pulmonology, Baylor Scott and White McClane Children's Medical Center, Temple, Texas, USA
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Roby P, Smith Beltran G, Finch C, Malhotra S, Reiling K, Dayyat E, Birkemeier K, Raju M, Macmurdo C, Hernandez E, Sagar M. The Perfect Storm: A Case of Rapid-Onset Obesity With Hypoventilation, Hypothalamic, Autonomic Dysregulation, Neuroendocrine Tumor (ROHHADNET) With Heart Failure, Narcolepsy, and a Rare Location of a Pelvic Neuroendocrine Tumor. Cureus 2023; 15:e50341. [PMID: 38205461 PMCID: PMC10777333 DOI: 10.7759/cureus.50341] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2023] [Indexed: 01/12/2024] Open
Abstract
Rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD) syndrome is a rare disease of concurrent respiratory dysfunction and autonomic dysregulation with endocrine abnormalities. ROHHADNET includes ROHHAD plus coexisting neuroendocrine tumors (NETs). We describe an eight-year-old boy, who originally presented at four years of age with rapid weight gain and hyperhidrosis and who developed mild obstructive sleep apnea (OSA). His clinical course was eventually complicated by hypoxic respiratory failure requiring admission to the pediatric intensive care unit (PICU). Echocardiogram at that time demonstrated dilated cardiomyopathy left ventricular ejection fraction (LVEF) of 28% at time of admission. His respiratory failure persisted despite average volume-assured pressure support (AVAPS) around the clock leading to tracheostomy placement for cardiopulmonary support. He also demonstrated autonomic instability with multiple pituitary hormone deficiencies. Computed tomography (CT) imaging of the abdomen and pelvis demonstrated a presacral soft tissue mass consistent with a tumor of neural crest origin. Daytime somnolence and confusion progressed and a low cerebrospinal fluid hypocretin level revealed a diagnosis of narcolepsy type 1.
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Affiliation(s)
- Paul Roby
- Internal Medicine, Baylor Scott & White Health, Temple, USA
| | | | - Casey Finch
- Pediatrics, Baylor Scott & White Health, Temple, USA
| | | | | | - Ehab Dayyat
- Pediatric Neurology, Baylor Scott & White Health, Temple, USA
| | | | - Muppala Raju
- Neonatology, Baylor Scott & White Health, Temple, USA
| | | | | | - Malvika Sagar
- Pediatric Pulmonary, Baylor Scott & White Health, Temple, USA
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Zheng A, Huang N, Bean D, Rayapaneni S, Deeney J, Sagar M, Hamilton JA. Resolvin E1 heals injured cardiomyocytes: Therapeutic implications and H-FABP as a readout for cardiovascular disease & systemic inflammation. Prostaglandins Leukot Essent Fatty Acids 2023; 197:102586. [PMID: 37604082 DOI: 10.1016/j.plefa.2023.102586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 08/23/2023]
Abstract
The purpose of this study is to investigate heart-fatty acid binding protein (H-FABP) leakage from cardiomyocytes as a quantitative measure of cell membrane damage and to test healing by Resolvin E1 (RVE1) as a potential therapeutic for patients with inflammatory diseases (cardiovascular disease and comorbidities) with high morbidity and mortality. Our quantitative ELISA assays demonstrated H-FABP as a sensitive and reliable biomarker for measuring cardiomyocyte damage induced by lipopolysaccharide (LPS) and healing by RvE1, a specialized pro-resolving mediator (SPM) derived from the Omega-3 fatty acid, eicosapentaenoic acid (EPA), a dietary nutrient that balances inflammation to restore homeostasis. RvE1 reduced leakage of H-FABP by up to 86%, which supports our hypothesis that inflammation as a mechanism of injury can be targeted for therapy. H-FABP as a blood biomarker was tested in 40 patients admitted to Boston Medical Center for respiratory distress, (20 patients with and 20 patients without COVID infection). High levels of H-FABP correlated with clinically diagnosed CVD, diabetes, and end-stage renal disease (ESRD) in both patient groups. The level of H-FABP indicates not only CVD damage but is a valuable measure for patients with increased inflammation disease comorbidities.
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Affiliation(s)
- A Zheng
- Boston University, United States of America
| | - N Huang
- Boston University School of Medicine, United States of America
| | - D Bean
- Boston University School of Medicine, United States of America
| | | | - Jude Deeney
- Boston University School of Medicine, United States of America
| | - M Sagar
- Boston Medical Center, United States of America
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4
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Raju M, Sagar M, Bush A, Quaye E, Ghamande S, Malhotra S, Arroliga ME. The role of supervised school therapy in poorly controlled asthma in children. Proc AMIA Symp 2023; 36:448-452. [PMID: 37334099 PMCID: PMC10269411 DOI: 10.1080/08998280.2023.2204522] [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: 12/28/2022] [Revised: 03/31/2023] [Accepted: 04/04/2023] [Indexed: 06/20/2023] Open
Abstract
Background In children, nonadherence to inhaled corticosteroid (ICS) therapy leads to poor asthma control and complications. Methods We evaluated the benefit from initiation of ICS administration once daily at school. We retrospectively chose patients from our pediatric pulmonary clinic who had poorly controlled asthma and prescribed ICS daily. For the study period, we examined the number of corticosteroid courses, emergency room visits, hospital admissions, symptom history, and pulmonary function tests. Results Thirty-four patients who satisfied the inclusion criteria began the intervention. Preintervention, there were a mean number of 2.6 oral corticosteroid courses compared to 2 courses in the year following intervention (P = 0.8). Postintervention emergency department visits decreased from a mean of 1.4 to 1.0 (P = 0.71), and hospital admissions decreased from 1.23 to 0.57 (P = 0.04). There was also a significant increase in forced expiratory volume in 1 second (1.69 vs 1.4 L/sec, P = 0.02), a decrease in systemic steroid-free days in a year (96 vs 141 days, P = 0.03), and an increase in symptom-free days postintervention (28 vs 26 days, P = 0.325). Conclusion These findings suggest that ICS administration in schools may help reduce hospital admissions and improve lung function in patients with poorly controlled asthma.
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Affiliation(s)
- Muppala Raju
- Department of Pediatrics, Baylor Research Institute, Temple, Texas
| | - Malvika Sagar
- Division of Pediatric Pulmonology, Department of Pediatrics, Baylor Scott and White McLane Children’s Medical Center, Temple, Texas
| | - Andrew Bush
- Department of Paediatrics, Imperial College London, London, UK
| | - Eugene Quaye
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Baylor Scott & White Medical Center – Temple, Temple, Texas
| | - Shekhar Ghamande
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Baylor Scott & White Medical Center – Temple, Temple, Texas
| | - Sonal Malhotra
- Pulmonary and Sleep Medicine Services, Baylor College of Medicine, Houston, Texas
| | - Mercedes E. Arroliga
- Division of Allergy and Clinical Immunology, Department of Medicine, Baylor Scott and White Center for Diagnostic Medicine, Temple, Texas
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Vora N, Raju M, Jackson I, Mallett L, Samson S, Malhotra S, Shetty A, Beeram MR, Bush A, Sagar M. Maternal preeclampsia as a risk factor for developing bronchopulmonary dysplasia in neonates. Minerva Pediatr (Torino) 2022:S2724-5276.22.07019-7. [PMID: 36239587 DOI: 10.23736/s2724-5276.22.07019-7] [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: 06/16/2023]
Abstract
OBJECTIVE To determine the effect of preeclampsia on the development of bronchopulmonary dysplasia (BPD) in preterm infants. METHODS Retrospective cohort study of infants' ≤32 weeks' gestation admitted to a level-IV single center neonatal intensive care unit from 2014 to 2016. Infants with major congenital anomalies, death or transfer before 28 days were excluded. Infants were stratified by maternal preeclampsia status. Demographic, clinical, and laboratory data were reviewed. Logistic regression was used to examine predictors for BPD. MAIN OUTCOME MEASURE The primary outcome was BPD incidence. RESULTS 432 infants met inclusion criteria; 22% developed BPD, of which, 16% had severe BPD. Thirty-eight percent of infants were born to preeclamptic mothers, with 23% of those infants developing BPD. Infants born to preeclamptic mothers were delivered by cesarean section (88% vs. 60%; p<0.0001) more often and had lower birthweight (Median=1265g, IQR 910-1555 vs. Median=1388g, IQR 959-1752; p=0.008) compared to infants born to non-preeclamptic mothers. Higher incidence of intrauterine growth restriction was noted in pre-eclampsia group,24% vs 8%, p=0.0001). Gestational age, length of stay and days on ventilator were all associated with the development of BPD. In multivariable logistic regression, preeclampsia was not a risk factor for development of BPD (OR 1.12 [0.68, 1.83]). CONCLUSIONS Preeclampsia was not a significant risk factor for development of BPD nor the severity of BPD in infants' ≤32 weeks' gestation. IUGR infants with or without preeclampsia mothers were at higher risk for BPD.
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Affiliation(s)
- Niraj Vora
- Department of Pediatrics, Texas A&M Health Science Center, Baylor Scott & White Health, Temple, TX, USA
| | - Muppala Raju
- Department of Pediatrics, Texas A&M Health Science Center, Baylor Scott & White Health, Temple, TX, USA -
| | - Ineshia Jackson
- Department of Pediatrics, Texas A&M Health Science Center, Baylor Scott & White Health, Temple, TX, USA
| | - Lea Mallett
- Department of Pediatrics, Texas A&M Health Science Center, Baylor Scott & White Health, Temple, TX, USA
| | - Shoji Samson
- Department of Pediatrics, Texas A&M Health Science Center, Baylor Scott & White Health, Temple, TX, USA
| | - Sonal Malhotra
- Department of Pediatrics, Texas A&M Health Science Center, Baylor Scott & White Health, Temple, TX, USA
| | - Ashith Shetty
- Department of Pediatrics, Texas A&M Health Science Center, Baylor Scott & White Health, Temple, TX, USA
| | - Madhava R Beeram
- Department of Pediatrics, Texas A&M Health Science Center, Baylor Scott & White Health, Temple, TX, USA
| | - Andrew Bush
- Department of Pediatrics, Texas A&M Health Science Center, Baylor Scott & White Health, Temple, TX, USA
| | - Malvika Sagar
- Department of Pediatrics, Texas A&M Health Science Center, Baylor Scott & White Health, Temple, TX, USA
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Angirekula A, Estrada VA, Sagar M, Arroliga ME. Hypersensitivity reactions to multiple biologicals in a pediatric patient with severe persistent asthma. Proc AMIA Symp 2022; 36:66-67. [PMID: 36578600 PMCID: PMC9762826 DOI: 10.1080/08998280.2022.2116692] [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: 12/31/2022] Open
Abstract
Asthma is a common chronic pediatric disease that negatively impacts the quality of patients' lives. While most cases can be effectively managed with a regimen of inhaled corticosteroids, severe cases require prolonged or frequent courses of oral corticosteroids or the addition of biologic therapies and allergen immunotherapy. Biologics are well tolerated with few side effects; however, reactions as severe as anaphylaxis have been reported. We present a pediatric patient with severe persistent asthma who developed hypersensitivity reactions to three different biologic agents.
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Affiliation(s)
| | - Victor A. Estrada
- Division of Allergy and Clinic Immunology, Department of Medicine, Baylor Scott and White Center for Diagnostic Medicine, Temple, Texas
| | - Malvika Sagar
- Department of Pediatrics, Baylor Scott and White McLane Children’s Medical Center, Temple, Texas
| | - Mercedes E. Arroliga
- Division of Allergy and Clinic Immunology, Department of Medicine, Baylor Scott and White Center for Diagnostic Medicine, Temple, Texas,Corresponding author: Mercedes E. Arroliga, MD, Baylor Scott and White Center for Diagnostic Medicine, 1605 S. 31st St., Temple, TX76508 (e-mail: )
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7
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Reiling K, Sagar M, Finch R, Typaldos M, McHugh E, Spielberg D, Malhotra S. 859 Trial of average volume-assured pressure support (AVAPS) to treat hypoventilation in a child with rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD) and systolic heart failure. Sleep 2021. [DOI: 10.1093/sleep/zsab072.856] [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: 11/14/2022] Open
Abstract
Abstract
Introduction
ROHHAD syndrome is a rare disorder of respiratory control and autonomic nervous system regulation with endocrine abnormalities. Although children may present with obstructive sleep apnea, their blunted respond to hypoxemia and hypercapnia is a life-threating feature, often leading to cardiorespiratory arrest. There is limited literature regarding non-invasive positive pressure ventilation (NIPPV) in these children. We report a trial of AVAPS in a child with ROHHAD syndrome.
Report of case(s)
Our patient is a 6-year-old male with history of rapid weight-gain (49.9 kg in 2.5 years), type-2 diabetes, and mild OSA who presented to an outside hospital (OSH) in March 2020 with acute hypercapnic hypoxemic respiratory failure. He required bilevel PAP therapy, steroids, and bromocriptine for thermoregulatory dysfunction. His clinical presentation, along with negative PHOX2B gene mutation and absence of parenchymal lung disease on chest computerized tomography suggested a diagnosis of ROHHAD syndrome. Outpatient, he was successfully transitioned to empiric AVAPS therapy. In November 2020, he presented again to an OSH in hypercapnic hypoxemic respiratory failure with new systolic heart failure with ejection fraction of 28%. After clinical stabilization, he was transferred to our hospital on CPAP 10 cmH20 with 100% FiO2 for further management. Awake blood gas was consistent with chronic hypercapnic respiratory failure; therefore, the patient was placed initially on bilevel PAP therapy empirically until an inpatient bilevel PAP titration polysomnogram was conducted. The patient remained hypercapnic and was converted to continuous AVAPS therapy starting at a tidal volume of 8.6mL/kg based on ideal body weight. AVAPS was titrated until achieving adequate ventilation, but the patient was unable to tolerate continuous NIPPV. Because of his heart failure in the setting of expected worsening respiratory failure, the decision was made to pursue tracheostomy placement for invasive positive pressure ventilation.
Conclusion
ROHHAD syndrome is a rare disorder that begins within the first decade of life, making adherence to daytime NIPPV difficult. This case illustrates a trial of AVAPS in a child with ROHHAD syndrome prior to tracheostomy placement. It highlights the need for future research in advanced ventilatory support strategies in children.
Support (if any):
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Affiliation(s)
| | | | | | | | - Erin McHugh
- Baylor College of Medicine, Texas Children’s Hospital
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Kashyap R, Sherani KM, Dutt T, Gnanapandithan K, Sagar M, Vallabhajosyula S, Vakil AP, Surani S. Current Utility of Sequential Organ Failure Assessment Score: A Literature Review and Future Directions. Open Respir Med J 2021; 15:1-6. [PMID: 34249175 PMCID: PMC8227444 DOI: 10.2174/1874306402115010001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 12/13/2020] [Accepted: 01/13/2021] [Indexed: 02/08/2023] Open
Abstract
The Sequential Organ Failure Assessment (SOFA) score is commonly used in the Intensive Care Unit (ICU) to evaluate, prognosticate and assess patients. Since its validation, the SOFA score has served in various settings, including medical, trauma, surgical, cardiac, and neurological ICUs. It has been a strong mortality predictor and literature over the years has documented the ability of the SOFA score to accurately distinguish survivors from non-survivors on admission. Over the years, multiple variations have been proposed to the SOFA score, which have led to the evolution of alternate validated scoring models replacing one or more components of the SOFA scoring system. Various SOFA based models have been used to evaluate specific clinical populations, such as patients with cardiac dysfunction, hepatic failure, renal failure, different races and public health illnesses, etc. This study is aimed to conduct a review of modifications in SOFA score in the past several years. We review the literature evaluating various modifications to the SOFA score such as modified SOFA, Modified SOFA, modified Cardiovascular SOFA, Extra-renal SOFA, Chronic Liver Failure SOFA, Mexican SOFA, quick SOFA, Lactic acid quick SOFA (LqSOFA), SOFA in hematological malignancies, SOFA with Richmond Agitation-Sedation scale and Pediatric SOFA. Various organ systems, their relevant scoring and the proposed modifications in each of these systems are presented in detail. There is a need to incorporate the most recent literature into the SOFA scoring system to make it more relevant and accurate in this rapidly evolving critical care environment. For future directions, we plan to put together most if not all updates in SOFA score and probably validate it in a large database a single institution and validate it in multisite data base.
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Affiliation(s)
- Rahul Kashyap
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Khalid M Sherani
- Department of Internal Medicine, Jamaica Hospital Medical Center, Jamaica, NY 11418, USA.,Corpus Christi Medical Center, Corpus Christi, TX 78411, USA
| | - Taru Dutt
- Department of Neurology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester MN, USA and Hennepin County Medical Center, Minneapolis, MN 55905, USA
| | - Karthik Gnanapandithan
- Department of Internal Medicine, Yale-New Haven Hospital and Yale University School of Medicine, New Haven, CT 06510, USA
| | - Malvika Sagar
- Department of Pediatrics, McLane Children's Hospital, Baylor Scott and White Health, Temple, TX 76502, USA
| | | | - Abhay P Vakil
- Department of Pediatrics, McLane Children's Hospital, Baylor Scott and White Health, Temple, TX 76502, USA.,Critical Care Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Salim Surani
- Corpus Christi Medical Center, Corpus Christi, TX 78411, USA.,Texas A&M University System Health Science Center, Bryan, TX 77807, USA
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Lucia D, Cain J, Porter A, Sagar M, Blazovic S, Finley L, Mallett L. Pediatric asthma pathway in the emergency room. Proc (Bayl Univ Med Cent) 2020; 34:40-43. [PMID: 33456142 DOI: 10.1080/08998280.2020.1801110] [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] [Indexed: 10/23/2022] Open
Abstract
Asthma is one of the leading causes of hospital admission in the pediatric population. Standardization of asthma management guidelines for patients admitted to the emergency department has been suggested to improve care delivery and patient outcomes. Utilizing a multidisciplinary asthma task force at a single academic medical center, we sought to determine if a protocol-driven approach to implementation of care for patients with asthma could improve patient outcomes by reducing wait times for administration of steroids. A prospective cohort study examined the use of a standardized asthma pathway over a 2-year period compared to historical controls. Pathway use significantly decreased time to corticosteroid administration (45 vs. 29 min [year 1] and 20 min [year 2]; P < 0.0001). By implementing this standard of care at pediatric emergency departments, time to treatment can be decreased, therefore improving the morbidity and mortality of pediatric patients with asthma nationwide.
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Affiliation(s)
- Dominic Lucia
- Department of Pediatrics, Baylor Scott & White McLane Children's Medical Center, Temple, Texas
| | - James Cain
- Department of Pediatrics, Baylor Scott & White McLane Children's Medical Center, Temple, Texas
| | - Ashlee Porter
- Department of Pediatrics, Baylor Scott & White McLane Children's Medical Center, Temple, Texas
| | - Malvika Sagar
- Department of Pediatrics, Baylor Scott & White McLane Children's Medical Center, Temple, Texas
| | - Sarah Blazovic
- Department of Pediatrics, Baylor Scott & White McLane Children's Medical Center, Temple, Texas
| | - Leland Finley
- Department of Pediatrics, Baylor Scott & White McLane Children's Medical Center, Temple, Texas
| | - Lea Mallett
- Department of Pediatrics, Baylor Scott & White McLane Children's Medical Center, Temple, Texas
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Abstract
Chronic eosinophilic pneumonia (CEP) is an eosinophilic lung disease that is typically diagnosed by a triad of clinical symptoms including pulmonary symptoms, eosinophilia and characteristic radiographic abnormalities. It requires a high index of suspicion given its overlap with other eosinophilic conditions and lack of a specific diagnostic test. The diagnosis is made after careful consideration of other secondary causes of eosinophilia, such as infectious, drugs, or toxic etiologies. CEP generally responds rapidly to treatment, which primarily consists of corticosteroid therapy, but relapses are common. Novel therapies are being explored as more information is being discovered about the pathophysiology of eosinophilic disease processes. Close follow-up is important given the difficulty in weaning patients from glucocorticoids with many patients developing sequelae of chronic glucocorticoid therapy. Therefore, exploring alternative treatments is of upmost importance.
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Affiliation(s)
- Matthew Crowe
- Department of Medicine, Division of Pulmonary and Critical Care, Baylor Scott and White Medical Center, Temple, TX, USA,
| | - Drew Robinson
- Department of Medicine, Baylor Scott and White Medical Center, Temple, TX, USA
| | - Malvika Sagar
- Department of Pediatrics, Baylor Scott and White McLane Children's Specialty Clinic Temple, Temple, TX, USA
| | - Li Chen
- Department of Pathology, Baylor Scott and White Medical Center Temple, Temple, TX, USA
| | - Shekhar Ghamande
- Department of Medicine, Division of Pulmonary and Critical Care, Baylor Scott and White Medical Center, Temple, TX, USA,
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11
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Mallett LH, Soto A, Govande J, Ogborn C, Sagar M. Role of asthma camp in improving the overall health of children with asthma. Proc (Bayl Univ Med Cent) 2019; 32:54-57. [PMID: 30956581 DOI: 10.1080/08998280.2018.1533309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 09/28/2018] [Accepted: 10/04/2018] [Indexed: 01/27/2023] Open
Abstract
This study sought to evaluate the benefit of asthma camp for patients who attended Baylor Scott & White McLane Children's Medical Center's Camp Wheeze Away in July 2016. Data were collected on children aged 8 to 15 years who were diagnosed with asthma and attended asthma camp. Information on body mass index, hospital admissions, and emergency department visits was collected 1 year before and 1 year after camp. Asthma control tests, exhaled nitric oxide tests, and pulmonary function tests were administered at the beginning and end of camp. A total of 34 children with asthma (mean age 11 [±2] years) were included in this study. Postcamp asthma-related hospitalizations and emergency department visits decreased. Mean asthma control scores improved from 20.4 (±3.2) before camp to 23.4 (±2.8) after camp (P < 0.0001). Forced expiratory volume during the first breath and forced expiratory flow at 25% to 75% of the pulmonary volume improved during the weeklong camp (P = 0.04 and 0.0007, respectively). Forced expiratory volume during the first breath further improved 6 to 12 months after camp compared to values before camp (P = 0.047). Exhaled nitric oxide levels improved from the first to last day of camp by decreasing an average of 39% (P = 0.0009). This study showed the positive effect that a short-term educational intervention in a camp setting had on asthma control scores and asthma knowledge.
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Affiliation(s)
- Lea H Mallett
- Department of Pediatrics, Texas A&M Health Science Center, Baylor Scott & White McLane Children's Medical CenterTempleTexas
| | - Angela Soto
- Department of Pediatrics, Texas A&M Health Science Center, Baylor Scott & White McLane Children's Medical CenterTempleTexas
| | - Janhavi Govande
- Department of Pediatrics, Texas A&M Health Science Center, Baylor Scott & White McLane Children's Medical CenterTempleTexas
| | - Char Ogborn
- Department of Pediatrics, Texas A&M Health Science Center, Baylor Scott & White McLane Children's Medical CenterTempleTexas
| | - Malvika Sagar
- Department of Pediatrics, Texas A&M Health Science Center, Baylor Scott & White McLane Children's Medical CenterTempleTexas
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Sagar M, Nibedita K, Manohar N, Kumar KR, Suchismita S, Pradnyesh A, Reddy AB, Sadiku ER, Gupta UN, Lachit P, Jayaramudu J. A potential utilization of end-of-life tyres as recycled carbon black in EPDM rubber. Waste Manag 2018; 74:110-122. [PMID: 29331488 DOI: 10.1016/j.wasman.2018.01.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 12/13/2017] [Accepted: 01/01/2018] [Indexed: 06/07/2023]
Abstract
End-of-life (EOL) tyres and their decomposition present severe environmental concern due to their resistance to moisture, oxygen, natural degradation, etc. Pyrolysis is considered to be the most effective and sustainable process for recycling, due to its eco-friendly process. The current work studied the effect of recycled carbon black (rCB), obtained from the pyrolysis of EOL tyres, on the properties of ethylene propylene diene rubber (EPDM). The rCB was characterized by scanning electron microscopy (SEM), thermogravimetric analysis (TGA) and chemical methods. rCB was incorporated solely, into a conventional EPDM formulation and also in combination with N550 carbon black. The physico-mechanical properties of the EPDM vulcanizates, before and after aging, were succinctly studied by SEM, TGA, Differential Scanning Calorimetry (DSC), tensile tests and cross-link density. The average particle size of rCB was observed to be 8 µm and the ash content was observed to be higher when compared to the conventional N550 carbon black, which was evident, by the TGA and SEM-EDX analyses. The reinforcing effect and the cross-link density of the rCB-filled vulcanizates were found to be marginally inferior in comparison to the conventional carbon black (N550). The morphology of the tensile- and tear-fractured surfaces were studied by SEM and it was observed that the breaking mechanism follows the rubber chain detachment from the surface mode.
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Affiliation(s)
- M Sagar
- Department of Environmental Science, Institute of Science, University of Mumbai, Mumbai 400032, India
| | - K Nibedita
- Indian Rubber Manufacturers Research Association (IRMRA), Plot No. 254/1B, Road No. 16V, Wagle Industrial Estate, Thane (West) 400604, India
| | - N Manohar
- Indian Rubber Manufacturers Research Association (IRMRA), Plot No. 254/1B, Road No. 16V, Wagle Industrial Estate, Thane (West) 400604, India
| | - K Raj Kumar
- Indian Rubber Manufacturers Research Association (IRMRA), Plot No. 254/1B, Road No. 16V, Wagle Industrial Estate, Thane (West) 400604, India
| | - S Suchismita
- Indian Rubber Manufacturers Research Association (IRMRA), Plot No. 254/1B, Road No. 16V, Wagle Industrial Estate, Thane (West) 400604, India
| | - A Pradnyesh
- Department of Environmental Science, Institute of Science, University of Mumbai, Mumbai 400032, India
| | - A Babul Reddy
- Institute of Nano Engineering Research (INER) and Department of Chemical, Metallurgical and Materials Engineering, Tshwane University of Technology, Polymer Division, Pretoria, South Africa
| | - E Rotimi Sadiku
- Institute of Nano Engineering Research (INER) and Department of Chemical, Metallurgical and Materials Engineering, Tshwane University of Technology, Polymer Division, Pretoria, South Africa
| | - U N Gupta
- Polymer, Petroleum and Coal Chemistry Group, Materials Sciences and Technology Division, CSIR-North East Institute of Science and Technology, Jorhat - 785 006, Assam, India
| | - P Lachit
- Polymer, Petroleum and Coal Chemistry Group, Materials Sciences and Technology Division, CSIR-North East Institute of Science and Technology, Jorhat - 785 006, Assam, India
| | - J Jayaramudu
- Indian Rubber Manufacturers Research Association (IRMRA), Plot No. 254/1B, Road No. 16V, Wagle Industrial Estate, Thane (West) 400604, India; Polymer, Petroleum and Coal Chemistry Group, Materials Sciences and Technology Division, CSIR-North East Institute of Science and Technology, Jorhat - 785 006, Assam, India.
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13
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Sagar M, Marshall AS, Clary CW, Qureshi AM. Paediatric case of ductal origin of right pulmonary artery presenting with exertional dyspnoea and mimicking asthma and primary ciliary dyskinesia. BMJ Case Rep 2017; 2017:bcr-2016-218885. [PMID: 29018009 DOI: 10.1136/bcr-2016-218885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Ductal origin of pulmonary artery is a rare anomaly that is frequently misdiagnosed. Patients may present with exertional dyspnoea, recurrent respiratory infections and pulmonary hypertension. The presence of pulmonary hypertension can adversely affect clinical outcome in these patients; hence, early identification and intervention is the key to improve survival. A case of a 3-year-old child presenting with exertional dyspnoea is presented in this report. Chest radiograph revealed right-sided pulmonary hypoplasia and mediastinal shift to the right. Pulmonary artery agenesis was suspected when CT of the chest demonstrated right-sided pulmonary artery agenesis. Cardiac catheterisation revealed the correct diagnosis of ductal origin of right pulmonary artery. The most striking feature of this case is that the clinical presentation is mild compared with the findings on imaging.
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Affiliation(s)
- Malvika Sagar
- Department of Pediatrics, Mc Lane Children's Hospital. Baylor Scott and White Health, Temple, Texas, USA
| | - Anderson S Marshall
- Department of Internal Medicine/Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Cody W Clary
- Department of Pediatrics, Baylor College of Medicine, San Antonio, Texas, USA
| | - Athar M Qureshi
- Department of Cardiology, Texas Children's Hospital, Houston, Texas, USA
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14
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Cantey JB, Huffman LW, Subramanian A, Marshall AS, Ballard AR, Lefevre C, Sagar M, Pruszynski JE, Mallett LH. Antibiotic Exposure and Risk for Death or Bronchopulmonary Dysplasia in Very Low Birth Weight Infants. J Pediatr 2017; 181:289-293.e1. [PMID: 27908652 DOI: 10.1016/j.jpeds.2016.11.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [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: 07/27/2016] [Revised: 10/03/2016] [Accepted: 11/01/2016] [Indexed: 12/23/2022]
Abstract
We assessed the association between antibiotic exposure in the first 2 weeks of life and development of bronchopulmonary dysplasia in a cohort of very low birth weight infants. After controlling for the severity of illness, each additional day of antibiotic therapy was associated with both an increased risk for and severity of bronchopulmonary dysplasia.
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Affiliation(s)
- Joseph B Cantey
- Department of Pediatrics, Texas A&M Health Science Center, Baylor Scott & White Health, Temple, TX.
| | - Landon W Huffman
- Department of Pediatrics, Texas A&M Health Science Center, Baylor Scott & White Health, Temple, TX
| | | | | | - A Rebecca Ballard
- Department of Pediatrics, Texas A&M Health Science Center, Baylor Scott & White Health, Temple, TX
| | - Cassandra Lefevre
- Department of Pediatrics, Texas A&M Health Science Center, Baylor Scott & White Health, Temple, TX
| | - Malvika Sagar
- Department of Pediatrics, Texas A&M Health Science Center, Baylor Scott & White Health, Temple, TX
| | | | - Lea H Mallett
- Department of Pediatrics, Texas A&M Health Science Center, Baylor Scott & White Health, Temple, TX
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15
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Lennox JL, Landovitz RJ, Ribaudo HJ, Ofotokun I, Na LH, Godfrey C, Kuritzkes DR, Sagar M, Brown TT, Cohn SE, McComsey GA, Aweeka F, Fichtenbaum CJ, Presti RM, Koletar SL, Haas DW, Patterson KB, Benson CA, Baugh BP, Leavitt RY, Rooney JF, Seekins D, Currier JS. Summaries for patients. Nonnucleoside reverse transcriptase inhibitor-sparing antiretroviral regimens for treatment-naive volunteers infected with HIV-1. Ann Intern Med 2014; 161:I-22. [PMID: 25285557 DOI: 10.7326/p14-9035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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16
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Verma SK, Rastogi K, Bhushan R, Sagar M. Molar distalisation by pendulum appliance. Case Reports 2013; 2013:bcr-2012-008461. [DOI: 10.1136/bcr-2012-008461] [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: 11/03/2022] Open
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17
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Sagar M, Crabtree S, Hollister E, Runge J, Shang Y, Heinle J, McKenzie E, Mallory G, Luna R, Schecter M. The Lung Microbiome and Development of Bronchiolitis Obliterans Syndrome after Pediatric Lung Transplantation. J Heart Lung Transplant 2013. [DOI: 10.1016/j.healun.2013.01.345] [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: 11/26/2022] Open
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18
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Luna R, Sagar M, Crabtree S, Hollister E, Runge J, Shang Y, Heinle J, McKenzie E, Mallory G, Schecter M. Characterization of the Lung Microbiome in Pediatric Lung Transplant Recipients. J Heart Lung Transplant 2013. [DOI: 10.1016/j.healun.2013.01.770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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19
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Etemad B, Redd A, Serwadda D, Lutalo T, Reynolds S, Gray R, Quinn T, Sagar M. Envelopes found early after acquisition compared to those in the chronically infected partner do not have enhanced alpha4 beta7 binding or utilization. Retrovirology 2012. [PMCID: PMC3441852 DOI: 10.1186/1742-4690-9-s2-p149] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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20
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Abstract
Nonaccidental trauma (NAT) is common and presents with varied symptoms. Pleural effusion as a complication of physical abuse has not been described in the past. We report the case of a 10-week-old infant who presented with multiple nonspecific complaints that included respiratory distress, refusal to feed, constipation, and lethargy. Sepsis was the working diagnosis on admission, but a massive pleural effusion and rib fractures seen on chest imaging ultimately led to the diagnosis of nonaccidental trauma. This interesting case highlights the importance of maintaining a high index of suspicion for abuse irrespective of atypical presenting signs.
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Affiliation(s)
- Malvika Sagar
- Department of Pediatrics, Crozer-Chester Medical Center, Upland, PA 19013, USA
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21
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Wilder-Smith C, Röhss K, Bokelund Singh S, Sagar M, Nagy P. The effects of dose and timing of esomeprazole administration on 24-h, daytime and night-time acid inhibition in healthy volunteers. Aliment Pharmacol Ther 2010; 32:1249-56. [PMID: 20955444 DOI: 10.1111/j.1365-2036.2010.04469.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Symptoms of gastro-oesophageal reflux disease (GERD) may persist despite daily treatment with a proton pump inhibitor (PPI). AIM To compare the pharmacodynamic effect of various esomeprazole dosage and timing regimens in healthy volunteers. METHODS The effect of different esomeprazole dosage regimens [20 mg once daily (od) before breakfast or dinner; 20 mg twice daily (b.d.); 40 mg od before breakfast, dinner or at bedtime; and 40 mg b.d.] on 24-h, daytime and night-time acid inhibition was evaluated in a randomized, seven-way crossover study in healthy volunteers. Each regimen was taken for 5 days. RESULTS Over the 24-h period (day 5), esomeprazole 20 mg b.d. was associated with superior acid inhibition vs. all 20 mg and 40 mg od regimens (P < 0.05), but was less effective than esomeprazole 40 mg b.d. (P < 0.05). Dosing with esomeprazole 20 mg or 40 mg od before breakfast gave improved 24-h and daytime acid inhibition vs. the corresponding administration before dinner or at bedtime (all P < 0.05). Night-time acid inhibition was improved when esomeprazole 40 mg od was administered before dinner or at bedtime vs. before-breakfast dosing (P < 0.05). CONCLUSION Varying the dose and timing of esomeprazole administration may provide acid inhibition appropriate for the symptom pattern of individual patients with GERD.
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Affiliation(s)
- C Wilder-Smith
- Brain-Gut Research Group, Gastroenterology Group Practice, Berne, Switzerland.
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22
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Haluska P, Carboni JM, TenEyck C, Attar RM, Hou X, Yu C, Sagar M, Wong TW, Gottardis MM, Erlichman C. HER receptor signaling confers resistance to the insulin-like growth factor-I receptor inhibitor, BMS-536924. Mol Cancer Ther 2008; 7:2589-98. [PMID: 18765823 DOI: 10.1158/1535-7163.mct-08-0493] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
We have reported previously the activity of the insulin-like growth factor-I (IGF-IR)/insulin receptor (InsR) inhibitor, BMS-554417, in breast and ovarian cancer cell lines. Further studies indicated treatment of OV202 ovarian cancer cells with BMS-554417 increased phosphorylation of HER-2. In addition, treatment with the pan-HER inhibitor, BMS-599626, resulted in increased phosphorylation of IGF-IR, suggesting a reciprocal cross-talk mechanism. In a panel of five ovarian cancer cell lines, simultaneous treatment with the IGF-IR/InsR inhibitor, BMS-536924 and BMS-599626, resulted in a synergistic antiproliferative effect. Furthermore, combination therapy decreased AKT and extracellular signal-regulated kinase activation and increased biochemical and nuclear morphologic changes consistent with apoptosis compared with either agent alone. In response to treatment with BMS-536924, increased expression and activation of various members of the HER family of receptors were seen in all five ovarian cancer cell lines, suggesting that inhibition of IGF-IR/InsR results in adaptive up-regulation of the HER pathway. Using MCF-7 breast cancer cell variants that overexpressed HER-1 or HER-2, we then tested the hypothesis that HER receptor expression is sufficient to confer resistance to IGF-IR-targeted therapy. In the presence of activating ligands epidermal growth factor or heregulin, respectively, MCF-7 cells expressing HER-1 or HER-2 were resistant to BMS-536924 as determined in a proliferation and clonogenic assay. These data suggested that simultaneous treatment with inhibitors of the IGF-I and HER family of receptors may be an effective strategy for clinical investigations of IGF-IR inhibitors in breast and ovarian cancer and that targeting HER-1 and HER-2 may overcome clinical resistance to IGF-IR inhibitors.
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Affiliation(s)
- Paul Haluska
- Department of Oncology, Mayo Clinic, 200 First Street, South West, Rochester, MN 55905, USA.
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23
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Haluska P, Carboni JM, Yu C, Ten Eyck C, Attar RM, Asmann YW, Sagar M, Wong TW, Gottardis MM, Erlichman CE. HER receptor signaling confers resistance to IGF-1R targeted therapy. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.14510] [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: 11/20/2022] Open
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24
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Abstract
BACKGROUND The reciprocal antagonism of T-helper-1 (Th-1) and Th-2 type immune responses suggests that helminth parasitic infection may ameliorate disease where a Th-1 type response dominates. The Mongolian gerbil has been useful in the investigation of the pathogenesis of gastric cancer, since long-term infection of gerbils with Helicobacter pylori induces adenocarcinoma. In this study the kinetics of worm expulsion and associated immune responses in gerbils infected with Trichinella spiralis were investigated in an attempt to establish an animal model of parasitic infection that could be helpful when investigating the effect of a Th-2 type response on Th-1-based intestinal disorders. METHODS Gerbils were infected with various doses of infective T. spiralis larvae and were euthanized on different days after infection to investigate the intestinal worm recovery, goblet cell population, eosinophil response and serum IgG1 responses. RESULTS The number of worms recovered from the intestine was dependent on the number of larvae used for the infection. Almost all worms were expelled spontaneously by day 26 post-infection, when the gerbils had been infected with 375 or 750 larvae. The number of intestinal goblet cells, eosinophils and the serum IgG1 level significantly increased following infection compared with the control. CONCLUSION This is the first comprehensive report on the time-course of T. spiralis infection in gerbils. The data indicate that the T. spiralis-infected gerbil could be used as a model of the Th-2-based response to investigate the effect of a parasite-induced Th-2 response on various Th-1-mediated intestinal disorders such as H. pylori-induced gastritis and gastric carcinoma.
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Affiliation(s)
- M Sagar
- Intestinal Disease Research Programme, McMaster University, Hamilton, Ontario, Canada
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25
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Abstract
To investigate the etiology and differential features of cavitary lung disease in patients with acquired immune deficiency syndrome (AIDS), chest computed tomography (CT) records from a 2-year period were reviewed to identify all human immunodeficiency virus (HIV)-positive patients with cavitary lung disease. Medical records were reviewed for the documentation of specific causes of lung cavitation and the CD4 count at the time of imaging. Of 25 HIV-positive patients with cavitary lung disease, 20 had specific diagnoses. Infection was the etiology in all the cases. Polymicrobial infection was found in 17 patients (85%) and unimicrobial in 3 (15%). Seventeen patients (85%) had bacterial organisms, 10 of whom had other pathogens as well. Mycobacteria were isolated in 8 patients (40%), fungi in 3 (15%), cytomegalovirus (CMV) in 3 (15%), and Pneumocystis carinii pneumonia (PCP) in 1 (5%). Mediastinal or hilar lymphadenopathy and additional noncavitary ill-defined nodular opacities were found more frequently in patients with mycobacterial pathogens. Mean CD4 count in patients with cavitary disease because of bacterial pathogens alone was significantly higher than in patients with nonbacterial pathogens (alone or combined with bacterial pathogens) (203 vs. 42, p < 0.05). Four patients expired during the diagnostic hospital admission; 2 of them had pulmonary cavitary disease associated with Nocardia asteroides. Cavitary lung disease in patients with AIDS undergoing chest CT should be assumed infectious and is generally polymicrobial.
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Affiliation(s)
- G Aviram
- Department of Radiology, Jackson Memorial Hospital, University of Miami School of Medicine, Miami, Florida
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26
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Sagar M, Bertilsson L, Stridsberg M, Kjellin A, Mârdh S, Seensalu R. Omeprazole and CYP2C19 polymorphism: effects of long-term treatment on gastrin, pepsinogen I, and chromogranin A in patients with acid related disorders. Aliment Pharmacol Ther 2000; 14:1495-502. [PMID: 11069321 DOI: 10.1046/j.1365-2036.2000.00835.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The polymorphic enzyme CYP2C19 is of importance for the metabolism and effects of omeprazole during short-term treatment. AIM To investigate the relationship between CYP2C19 genotype and the effects of long-term omeprazole treatment. MATERIAL AND METHODS A total of 180 patients with acid related disorders were genotyped for wild type and mutated CYP2C19 alleles by allele-specific PCR amplification. Gastrin and chromogranin A were assessed by radioimmunoassays, and pepsinogen I and H. pylori serology were assessed by ELISA methods. RESULTS In 108 of the patients, who received a single dose of 20 mg omeprazole, there was no difference in gastrin and chromogranin A concentrations between the three CYP2C19 genotypes. In 72 patients on long-term treatment (> 1 year) with 20 mg omeprazole daily, serum gastrin as well as plasma chromogranin A concentrations (mean +/- s.e.) were both about threefold higher in the wild type/mutated (52.1 +/- 7.6 pM and 7.3 +/- 1.3 nM (n=19), respectively) compared to wild type/wild type (14. 7 +/- 0.9 pM and 2.5 +/- 0.1 nM (n=52), respectively; both comparisons P=0.0001). In a single mutated/mutated patient on long-term treatment, both gastrin and chromogranin A were high (88 pM and 13.7 nM, respectively). Serum pepsinogen I concentration was significantly lower in wild type/mutated (n=19) patients on long-term treatment, compared with the corresponding wild type/wild type (n=49) group (147 +/- 19 microg/L vs. 193 +/- 12 microg/L, P=0. 04). CONCLUSION Patients with one (and probably also with two) mutated CYP2C19 allele(s) on long-term treatment with omeprazole had significantly affected serum gastrin and pepsinogen I and plasma chromogranin A concentrations compared with patients with two normal alleles. This indicates that changes in gastric mucosal morphology during omeprazole treatment might be dependent upon the degree of the individual's capacity to metabolize omeprazole.
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Affiliation(s)
- M Sagar
- Center of Gastroenterology, Departments of Surgery and Medicine, Clinical Research Center, Sweden
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27
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Affiliation(s)
- A P Limaye
- Department of Laboratory Medicine, University of Washington, Seattle, USA.
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28
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Abstract
BACKGROUND & AIMS Omeprazole is metabolized by cytochrome P450 (CYP2C19). The activity of this enzyme is polymorphic, with incidences of poor metabolizers (PMs), heterozygous extensive metabolizers (EMs), and homozygous EMs in white populations of 3%, 30%, and 67%, respectively. The importance of the CYP2C19 polymorphism for the effects of omeprazole on intragastric pH and plasma gastrin concentrations has been investigated. METHODS Twenty-five white patients were genotyped for CYP2C19 by allele-specific polymerase chain reaction amplification, and their Helicobacter pylori status was assessed by serology and with immunoblot analysis. Intragastric pH was monitored over 24 hours, and meal-stimulated plasma gastrin concentration was measured over 4 hours (AUC 4h) before (day 0) and during (day 8) treatment with 20 mg omeprazole once daily. RESULTS Eleven patients were homozygous for the wild-type allele (wt/wt), 12 were heterozygous EMs (wt/mut), and 2 were PMs (mut/mut). Median (95% confidence interval) 24-hour intragastric pH in the heterozygous EM group was 5.5 (range, 5.1-5. 9) compared with 3.1 (range, 2.7-3.6) in homozygous EMs (P < 0.0001) at day 8. The percentage of time with intragastric pH > 4 at day 8 was significantly higher in the wt/mut than wt/wt group (72.4% vs. 37.1%; P < 0.0001). H. pylori status had less influence than CYP2C19 on intragastric acidity. Omeprazole treatment increased meal-stimulated plasma gastrin concentrations from day 0 to day 8 in the homozygous EMs and heterozygous EMs by 16% (NS) and 157% (P = 0. 002), respectively. In heterozygous EMs, the gastrin increase was more pronounced in the H. pylori-positive group (226%) than H. pylori-negative group (80%; P = 0.02). CONCLUSIONS The effects of omeprazole on intragastric pH and plasma gastrin are dependent on the CYP2C19 polymorphism in patients with acid-related disorders.
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Affiliation(s)
- M Sagar
- Center of Gastroenterology, Departments of Surgery and Medicine, Clinical Research Center, Huddinge University Hospital, Stockholm, Sweden
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29
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Fernández-Salas E, Sagar M, Cheng C, Yuspa SH, Weinberg WC. p53 and tumor necrosis factor alpha regulate the expression of a mitochondrial chloride channel protein. J Biol Chem 1999; 274:36488-97. [PMID: 10593946 DOI: 10.1074/jbc.274.51.36488] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A novel chloride intracellular channel (CLIC) gene, clone mc3s5/mtCLIC, has been identified from differential display analysis of differentiating mouse keratinocytes from p53+/+ and p53-/- mice. The 4.2-kilobase pair cDNA contains an open reading frame of 762 base pairs encoding a 253-amino acid protein with two putative transmembrane domains. mc3s5/mtCLIC protein shares extensive homology with a family of intracellular organelle chloride channels but is the first shown to be differentially regulated. mc3s5/mtCLIC mRNA is expressed to the greatest extent in vivo in heart, lung, liver, kidney, and skin, with reduced levels in some organs from p53-/- mice. mc3s5/mtCLIC mRNA and protein are higher in p53+/+ compared with p53-/- basal keratinocytes in culture, and both increase in differentiating keratinocytes independent of genotype. Overexpression of p53 in keratinocytes induces mc3s5/mtCLIC mRNA and protein. Exogenous human recombinant tumor necrosis factor alpha also up-regulates mc3s5/mtCLIC mRNA and protein in keratinocytes. Subcellular fractionation of keratinocytes indicates that both the green fluorescent protein-mc3s5 fusion protein and the endogenous mc3s5/mtCLIC are localized to the cytoplasm and mitochondria. Similarly, mc3s5/mtCLIC was localized to mitochondria and cytoplasmic fractions of rat liver homogenates. Furthermore, mc3s5/mtCLIC colocalized with cytochrome oxidase in keratinocyte mitochondria by immunofluorescence and was also detected in the cytoplasmic compartment. Sucrose gradient-purified mitochondria from rat liver confirmed this mitochondrial localization. This represents the first report of localization of a CLIC type chloride channel in mitochondria and the first indication that expression of an organellular chloride channel can be regulated by p53 and tumor necrosis factor alpha.
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Affiliation(s)
- E Fernández-Salas
- Laboratory of Cellular Carcinogenesis and Tumor Promotion, NCI, National Institutes of Health, Bethesda, Maryland 20892, USA.
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30
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Abstract
To evaluate the etiology and differential features of intrathoracic lymphadenopathy (LAD) in HIV patients, chest computed tomography (CT) records from an 18-month period were reviewed to identify all HIV-positive patients with intrathoracic LAD (nodal size > or = 1 cm). Medical records were reviewed for the documentation of specific diseases causing LAD and the CD4 count at the time of imaging. Of 45 HIV-positive patients with LAD, 40 had specific diagnoses including 22 (55%) infections and 17 (43%) tumors; one patient had both (3%). Mycobacterial disease accounted for 78% of infections; five cases were secondary to bacterial pneumonia and sepsis. Of tumors, lymphoma (7 cases, 39%) was most common, followed by lung cancer, germ cell tumors, and Kaposi's sarcoma. Mean CD4 cell count in patients with tumors was much higher than in patients with infections (314 vs. 62, p < .01). Patients with tumors were somewhat more likely than patients with infections to demonstrate axillary adenopathy (29 vs. 5%, p = .068). Cavitary disease was only observed in patients with infections (27%, p < .03). CT and clinical findings may help direct the differential diagnosis of LAD in AIDS, and promote expedient definitive diagnosis and therapy.
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Affiliation(s)
- J E Fishman
- Department of Radiology, University of Miami School of Medicine, Jackson Memorial Hospital, Florida, USA.
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31
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Sagar M, Janczewska I, Ljungdahl A, Bertilsson L, Seensalu R. Effect of CYP2C19 polymorphism on serum levels of vitamin B12 in patients on long-term omeprazole treatment. Aliment Pharmacol Ther 1999; 13:453-8. [PMID: 10215728 DOI: 10.1046/j.1365-2036.1999.00490.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
BACKGROUND The S-mephenytoin hydroxylase is a polymorphic cytochrome P450 (CYP) enzyme, identified as CYP2C19, which catalyses the metabolism of omeprazole and some other drugs. AIM To determine whether long-term treatment with omeprazole affects serum vitamin B12 levels, and if so to what extent it depends on CYP2C19 activity. METHODS Serum vitamin B12 levels (pmol/L) were assessed in 179 patients. Genotyping for wild-type (wt) and mutated (mut) CYP2C19 alleles was performed by allele-specific PCR amplification. RESULTS One-hundred and eleven of the patients received one dose of 20 mg omeprazole. No difference in B12 levels were found between heterozygous (wt/mut) (n = 23) and homozygous (wt/wt) (n = 85) patients (mean +/- s.d., 350 +/- 82 vs. 315 +/- 87 pmol/L, respectively). Three patients were mut/mut, with serum vitamin B12 levels of 303 +/- 50 pmol/L. In the 68 patients on long-term (>1 year) therapy with 20 mg omeprazole daily, serum vitamin B12 levels were lower in the heterozygous (wt/mut) (n = 19) compared to homozygous wt/wt (n = 49) (246 +/- 71 vs. 305 +/- 98 pmol/L, P = 0. 01, respectively). In one patient (mut/mut) who was studied both after a single dose and after long-term (15 months) treatment with omeprazole, serum vitamin B12 decreased from 360 to 178 pmol/L. In the wt/mut, but not in the wt/wt group, serum vitamin B12 levels were significantly lower in patients on long-term therapy compared with those receiving one dose (246 +/- 71 vs. 350 +/- 82 pmol/L, P < 0.0001, respectively). CONCLUSIONS CYP2C19 polymorphism significantly affected serum vitamin B12 levels in patients on long-term therapy with omeprazole. In the future, genotyping of CYP2C19 may be useful for patients in need of long-term treatment with omeprazole or other proton pump inhibitors.
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Affiliation(s)
- M Sagar
- Center of Gastroenterology, Departments of Surgery and Medicine, Clinical Research Center, Stockholm, Sweden
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32
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Affiliation(s)
- M Sagar
- Department of Medicine, Johns Hopkins Hospital, Baltimore, MD 21205, USA
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33
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Janczewska I, Sagar M, Sjöstedt S, Hammarlund B, Iwarzon M, Seensalu R. Comparison of the effect of lansoprazole and omeprazole on intragastric acidity and gastroesophageal reflux in patients with gastroesophageal reflux disease. Scand J Gastroenterol 1998; 33:1239-43. [PMID: 9930385 DOI: 10.1080/00365529850172304] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Lansoprazole (LAN) and omeprazole (OME) heal esophagitis effectively and to similar extents, but LAN has a faster effect on the relief of symptoms of gastroesophageal reflux. However, no strict comparison of the two proton pump inhibitors' effect on acid reflux and gastric acidity has been published. The aim of this study was to compare the effects of LAN and OME on gastroesophageal reflux with simultaneous measurements of gastric acidity in patients with established gastroesophageal reflux disease (GERD) and esophagitis. METHODS Fourteen patients with endoscopically verified erosive esophagitis and with a pretreatment esophageal 24-h pH measurement showing acid reflux to the esophagus participated in the study. This was a double-blind, randomized study with crossover design. Before (day 0) and on the last day (day 5) of each treatment period with encapsulated 30 mg LAN or 20 mg OME daily, 24-h intraesophageal and intragastric acidity were measured with antimony electrodes connected to an ambulatory pH recording system. RESULTS Ten of 14 patients completed the study. There were no differences in intragastric or intraesophageal acidity or the number of reflux episodes on day 0 between the two treatments. Both LAN and OME treatments increased the median and nocturnal intragastric pH and decreased the 24-h area under the time curve for intragastric acidity significantly and to about the same extent (79% and 69% acid inhibition by LAN and OME, respectively) (NS). However, the percentage of time with pH below 4 in the esophagus was significantly less during LAN treatment (1.92% +/- 2.29; mean +/- standard deviation) than during OME treatment (4.76% +/- 2.88%) on day 5 (P = 0.002). There were also significantly fewer reflux episodes >5 min during treatment with LAN (1.00 +/- 1.33) than with OME (2.90 +/- 2.42) at the end of the treatment period (P = 0.031). CONCLUSIONS In this study lansoprazole and omeprazole had a comparable effect on gastric acidity in patients with established GERD with esophagitis. However, 30 mg lansoprazole daily reduced the acidity in the oesophagus and the number of refluxes more effectively than 20 mg omeprazole daily. This might indicate that proton pump inhibitors affect the esophageal clearance and/or influence the lower esophageal sphincter differently.
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Affiliation(s)
- I Janczewska
- Dept. of Gastroenterology and Hepatology, Huddinge University Hospital, Sweden
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Sagar M, Seensalu R, Tybring G, Dahl ML, Bertilsson L. CYP2C19 genotype and phenotype determined with omeprazole in patients with acid-related disorders with and without Helicobacter pylori infection. Scand J Gastroenterol 1998; 33:1034-8. [PMID: 9829356 DOI: 10.1080/003655298750026714] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Omeprazole is to a major extent metabolized by cytochrome P450 isozyme CYP2C19. The aims of this study were to compare the phenotype of CYP2C19 determined by omeprazole with the genotype and to determine the effect of Helicobacter pylori infection on the metabolism of omeprazole. METHODS One-hundred and forty-three Caucasian patients with acid-related disorders assessed with a combination of gastrointestinal symptoms and upper endoscopic findings were given 20 mg omeprazole orally. Three hours after intake, omeprazole and 5-hydroxyomeprazole plasma concentrations were determined with high-performance liquid chromatography, and the phenotype for metabolic capacity was expressed as metabolic ratio (MR). Genotyping of defect alleles (CYP2C19*2 and *3) was performed by polymerase chain reaction amplification. One hundred eleven patients were tested after the first dose of omeprazole and 32 patients after repetitive administration (median time, 30 days). H. pylori serology was determined with enzyme-linked immunosorbent assay at the time of phenotyping. RESULTS Genotypically, 2.8% had two mutated alleles and were poor metabolizers (PM), and 22.4% were heterozygous extensive metabolizers (EM). Among the 111 patients who received the first omeprazole dose, 4 patients had MR >5--that is, belonged to the PM phenotype. Two of these had PM genotype (both CYP2C19*2/*2), and two had an EM genotype (CYP2C19*11*1 and *1/*3), indicating that they have still unidentified mutations. In the heterozygous EM group the mean MR was higher in patients who had been on continued omeprazole treatment than in those given the first dose (5.7 versus 2.5, P = 0.02). There were no significant differences in MR and omeprazole concentrations between H. pylori-negative (43%) and -positive (57%) patients. CONCLUSION In all but two patients with probable unidentified mutations there was agreement between the CYP2C19 phenotype determined by omeprazole and the genotype. The metabolism of omeprazole in patients with acid-related disorders is genetically determined and without relation to H. pylori infection.
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Affiliation(s)
- M Sagar
- Dept. of Surgery, Clinical Research Center, Karolinska Institute, Huddinge Hospital, Sweden
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Sjöstedt S, Sagar M, Lindberg G, Wikström B, Nord CE, Seensalu R. Prolonged and profound acid inhibition is crucial in Helicobacter pylori treatment with a proton pump inhibitor combined with amoxicillin. Scand J Gastroenterol 1998; 33:39-43. [PMID: 9489906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND The aim was to investigate whether intragastric pH, meal-stimulated gastrin release, or demographic factors predict the outcome of Helicobacter pylori treatment. METHODS Thirty-six patients with H. pylori infection were investigated with 24-h intragastric pH registration and meal-stimulated gastrin release before and during treatment with 20 mg omeprazole twice daily and 750 mg amoxicillin twice daily for 14 days. The influence of age, sex, smoking, ethnic origin, pH, and gastrin on treatment outcome were analysed with logistic regression. RESULTS Eradication of H. pylori was achieved in 18 of 34 (53%) patients. The univariate analysis showed that age, ethnic origin, more than 84.2% of the time with pH above 4, and continuous periods longer than 156 min with intragastric pH above 6 were significantly associated with successful treatment of H. pylori. In the multivariate analysis only the two pH variables were found to be independent factors for predicting treatment outcome. CONCLUSION The outcome of H. pylori treatment with omeprazole and amoxicillin may depend on several factors, such as age, ethnic origin, and a pronounced acid suppression. However, the only factor of independent importance in this study was prolonged and profound acid inhibition.
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Affiliation(s)
- S Sjöstedt
- Dept. of Surgical and Medical Gastroenterology and Hepatology, Huddinge University Hospital, Karolinska Institute, Sweden
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Abstract
We previously demonstrated that after transduction with the v-Ha-ras oncogene and grafting onto nude mouse hosts, primary epidermal keratinocytes with a null mutation in the p53 gene form tumors with increased growth rates and predisposition to malignant conversion relative to p53 wild-type keratinocytes (Weinberg WC, et al., Cancer Res 54:5584-5592, 1994). To further explore the cooperation between p53 loss of function and activation of the ras oncogene, cell lines were established from the normal epidermises of newborn and adult p53-null mice, and parallel subclones were reconstituted with the p53val135 temperature-sensitive mutant. Reconstituted lines C, G, N, and V demonstrated functional p53 transcriptional activator activity at the wild-type-permissive temperature of 32 degrees C, compared with the hygromycin-selected control line X and parental p53-null lines NHK4 and AK1b. Hygromycin-selected subclones, but not the parental lines, made normal skin in vivo; all cell lines made carcinomas after introduction of v-Ha-ras, independent of p53 status. These cell lines were compared in vitro at 32 degrees C to maximize the amount of p53val135 in the wild-type conformation. Expression of v-Ha-ras did not consistently alter p53-mediated transcriptional activity, suggesting tat ras acts downstream or independently of p53. No correlation was observed between p53-mediated transcriptional activity and in vitro growth rates, colony formation after exposure to ultraviolet light, or suppression by normal neighboring keratinocytes. However, keratinocyte cell lines devoid of p53 and expressing v-Ha-ras formed colonies in soft agar; this was blocked at 32 degrees C in all cell lines reconstituted with p53val135. These keratinocyte lines provide a model for exploring the role of p53 and the interaction of p53 and ras in keratinocyte transformation.
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Affiliation(s)
- C G Azzoli
- Laboratory of Cellular Carcinogenesis and Tumor Promotion, National Cancer Institute, Bethesda, MD 20892-4255, USA
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Goldschmidt-Clermont PJ, Schulman SP, Bray PF, Chandra NC, Grigoryev D, Dise KR, Sagar M, Fox RJ, Coleman LD, Richardson C, Dorsey FC, du Mee C, Kitt MM, Ouyang P, Baughman KL, Gerstenblith G. Refining the treatment of women with unstable angina--a randomized, double-blind, comparative safety and efficacy evaluation of Integrelin versus aspirin in the management of unstable angina. Clin Cardiol 1996; 19:869-74. [PMID: 8914780 DOI: 10.1002/clc.4960191106] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Although women typically develop coronary artery disease several years after men, once they have symptomatic disease their thromboembolic complications are worse than in men. The mechanism mediating this gender difference in outcome after thromboembolic events is unknown. We previously studied platelet functions in siblings from patients with premature coronary artery disease. We observed that platelets from women are responsive than their male counterparts. In particular, platelets from women stimulated ex vivo with various agonists bind more fibrinogen molecules than platelets from men. HYPOTHESIS We hypothesized that in patients with acute coronary events, the control of platelet activity might require stronger antagonists in women than in men. METHODS To test this hypothesis, we investigated retrospectively the results of a trial on Integrelin in unstable angina. RESULTS We report that platelet aggregation and Holter-detected ischemic episodes are significantly reduced in women with unstable angina treated with the specific GPIIb-IIIa inhibitor, Integrelin, compared with the standard platelet inhibitor aspirin. In contrast, both platelet aggregation and Holter-detected ischemic events are well controlled in men with unstable angina treated with standard therapy including aspirin. CONCLUSION Integrelin does provide protection in men, but, in contrast with women, not beyond what can be achieved with aspirin. Our data are consistent with the concept that the platelets from women require stronger and more specific inhibitors to limit their activity, and that platelets may play a more important role in women with acute coronary syndromes than in men. Most important, specific GPIIb-IIIa inhibitors may represent a therapeutic option which provides as much suppression of ischemic events in women as they do in men with coronary artery disease.
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Chang M, Tybring G, Dahl ML, Götharson E, Sagar M, Seensalu R, Bertilsson L. Interphenotype differences in disposition and effect on gastrin levels of omeprazole--suitability of omeprazole as a probe for CYP2C19. Br J Clin Pharmacol 1995; 39:511-8. [PMID: 7669487 PMCID: PMC1365058 DOI: 10.1111/j.1365-2125.1995.tb04488.x] [Citation(s) in RCA: 136] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
1. Fourteen healthy Swedish Caucasian subjects were given 20 mg of omeprazole orally each morning for 8 days. The subjects included five poor metabolisers (PM) of S-mephenytoin, four heterozygous extensive metabolisers (hetEM) and five subjects with a very rapid metabolism (rapidEM). 2. After the first dose, the relative mean areas under the plasma concentration vs time curve (AUC) of omeprazole in rapidEM, hetEM and PM were 1:3.7:20 (all different, P < 0.001). A similar relation was seen in the AUC(0,10 h) of the sulphone metabolite (1:3:12). Concentrations of hydroxyomeprazole were higher in EM than in PM confirming that the hydroxy, but not the sulphone metabolite, is formed by the S-mephenytoin hydroxylase (CYP2C19). After 8 days of treatment, the differences between groups were similar. 3. After both the first and the eighth doses, the omeprazole/hydroxyomeprazole plasma concentration ratio, determined 3 h after drug intake, correlated with the mephenytoin S/R ratio (rs = 0.94; P < 0.001; n = 14) suggesting that omeprazole might be used to phenotype for CYP2C19. 4. After the first dose of omeprazole, there was no difference in the AUC(0,10 h) of plasma gastrin between the three groups. From the first to the eighth dose, the AUC(0,10) of gastrin increased significantly in both hetEM and PM, while there was no change in the rapidEM. After the eighth dose, the AUC(0,10) of gastrin correlated significantly with the AUC of omeprazole in plasma (rs = 0.79; P < 0.01; n = 13).
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Affiliation(s)
- M Chang
- Department of Clinical Pharmacology, Karolinska Institute, Huddinge University Hospital, Sweden
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Sagar M. Computing. Program for practice. Nurs Times 1993; 89:42-4. [PMID: 8456008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Sagar M. Education and training of nurses in a child health program. Can J Public Health 1967; 58:464-6. [PMID: 6065347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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