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Golden MR, Soge OO, Mills M, Berzkalns A, Cannon C, Ramchandani M, Dombrowski JC, Karmarkar EN, Chow EJ, Gov JP, Swenson P, Greninger AL. Asymptomatic and Subclinical Mpox: An Association With Modified Vaccinia Ankara Vaccine. Sex Transm Dis 2024; 51:342-347. [PMID: 38301634 DOI: 10.1097/olq.0000000000001939] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
BACKGROUND How often mpox causes asymptomatic infections, particularly among persons who have received the Modified Vaccinia Ankara (MVA) vaccine, is unknown. METHODS We performed mpox polymerase chain reaction testing on rectal and pharyngeal specimens collected from symptomatic and asymptomatic patients at a sexual health clinic in Seattle, WA, between May 2022 and May 2023. Analyses evaluated the prevalence of asymptomatic or subclinical infection and, among persons with polymerase chain reaction-positive tests, the association of MVA vaccination status with the symptomatic infection. RESULTS The study population included 1663 persons tested for mpox during 2353 clinic visits. Ninety-three percent of study participants were cisgender men and 96% were men who have sex with men. A total of 198 symptomatic patients (30%) had a first mpox-positive test during 664 visits. Eighteen patients (1.1%) tested during 1689 visits had asymptomatic or subclinical mpox based on a positive rectal or pharyngeal test done in the absence of testing done because of clinical suspicion for mpox. Fourteen (78%) of 18 persons with asymptomatic/subclinical mpox and 53 (26%) of 198 persons with symptomatic mpox had received at least 1 dose of the MVA vaccine ( P < 0.0001). Controlling for calendar month, study subjects who received 1 and 2 doses of MVA vaccine were 4.4 (95% confidence interval, 1.3-15) and 11.9 (3.6-40) times more likely to have asymptomatic versus symptomatic mpox, respectively, than persons who were unvaccinated. CONCLUSIONS Asymptomatic mpox is uncommon. Modified Vaccinia Ankara vaccination is associated with an asymptomatic/subclinical infection among persons with mpox.
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Affiliation(s)
| | | | - Margaret Mills
- Laboratory Medicine and Pathology, Washington, Seattle, WA
| | | | | | | | | | - Ellora N Karmarkar
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington
| | | | - Jolene P Gov
- Laboratory Medicine and Pathology, Washington, Seattle, WA
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2
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Marra CM, Maxwell CL, Ramchandani M, Tantalo LC, Sahi SK, Dunaway SB, Litvack JR. Hearing loss in individuals at risk for neurosyphilis. Int J STD AIDS 2020; 31:1178-1185. [PMID: 32928054 DOI: 10.1177/0956462420947584] [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: 11/17/2022]
Abstract
Otosyphilis is a serious complication of syphilis.329 participants enrolled in a study of cerebrospinal fluid (CSF) abnormalities in syphilis underwent portable audiometry (250 Hz to 8000 Hz at 5-75 dB); it was repeated in 33 after otosyphilis treatment. Treponema pallidum spp pallidum (T. pallidum) DNA in blood was quantitated by polymerase chain reaction. Odds ratios (ORs) or hazard ratios (HRs) with 95% confidence intervals (CIs) were determined by logistic, ordinal or Cox regression.166 (50.5%) had normal hearing; 15 (4.6%) had low frequency (LF) loss alone, 93 (28.3%) had high frequency (HF) loss alone, and 55 (16.7%) had both. Adjusted odds of any hearing loss were higher with detectable blood T. pallidum DNA (3.00 [1.58-5.69], p = 0.001), CSF pleocytosis (2.02 [1.12-3.66], p = 0.02), and older age (2.22 per 10-year increase, [1.70-2.91], p < 0.001). HRs of normalization of LF and HF loss were lower for older individuals (0.20 [0.07-0.63, p = 0.005] and 0.22 [0.05-0.94, p = 0.04]), and HRs for normalization of HF loss were lower for those with more severe loss (0.09 [0.02-0.43], p = 0.002), and in those with CSF pleocytosis (0.32 [0.11-0.96], p = 0.04).Older age and CSF pleocytosis increase the likelihood of otosyphilis and impair hearing recovery after otosyphilis treatment.
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Affiliation(s)
- Christina M Marra
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
| | - Clare L Maxwell
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
| | - Meena Ramchandani
- Department of Medicine (Infectious Diseases), University of Washington School of Medicine, Seattle, WA, USA.,Public Health - Seattle & King County HIV/STD Program, Seattle, WA, USA
| | - Lauren C Tantalo
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
| | - Sharon K Sahi
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, USA
| | - Shelia B Dunaway
- Department of Medicine (Infectious Diseases), University of Washington School of Medicine, Seattle, WA, USA
| | - Jamie R Litvack
- Department of Medical Education and Clinical Sciences, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
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3
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Turpati M, Duvvur N, Ramchandani M, Ketavarapu V, Mitnala S. 51P Role of biliary extracellular vesicles in diagnosing various pancreatobiliary malignancies. Ann Oncol 2020. [DOI: 10.1016/j.annonc.2020.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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4
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Beima-Sofie K, Begnel ER, Golden MR, Moore A, Ramchandani M, Dombrowski JC. "It's Me as a Person, Not Me the Disease": Patient Perceptions of an HIV Care Model Designed to Engage Persons with Complex Needs. AIDS Patient Care STDS 2020; 34:267-274. [PMID: 32484744 DOI: 10.1089/apc.2019.0310] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 12/15/2022] Open
Abstract
Ending the HIV epidemic will require dedicated efforts to engage the highest need persons living with HIV (PLWH) in treatment. We assessed patient perceptions of a clinic in Seattle, Washington, that is designed for PLWH who do not engage in conventional HIV care. The Max Clinic provides walk-in access to care, incentives for blood draws and achieving viral suppression, and intensive case management. We conducted semistructured individual interviews with 25 patients purposively recruited to obtain diverse viewpoints. Interviews were audio-recorded and transcribed. Analysis used a constant comparative approach to identify major themes related to the components of the program. For many participants, engagement in the Max Clinic was the first time they had success with HIV treatment. Relationships with clinic staff and the ability to receive care on a walk-in basis had the strongest influences on engagement. Participants felt that Max Clinic staff attended to their social circumstances in ways that were distinct from prior care experiences. Walk-in visits removed perceived stigma associated with failure to keep appointments and provided immediate attention to acute concerns. Financial incentives initially motivated participants to attend clinic and take medications, but were less important for supporting ongoing engagement in care. Food incentives motivated patients to seek care and helped them focus on health issues. In summary, patients identified walk-in access to care, monetary and food incentives, and relationships with clinic staff, particularly case managers, as the key elements of an HIV clinic model for high-need PLWH.
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Affiliation(s)
- Kristin Beima-Sofie
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Emily R. Begnel
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Matthew R. Golden
- Department of Medicine, University of Washington, Seattle, Washington, USA
- HIV/STD Program, Public Health–Seattle & King County, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Allison Moore
- HIV/STD Program, Public Health–Seattle & King County, Seattle, Washington, USA
| | - Meena Ramchandani
- Department of Medicine, University of Washington, Seattle, Washington, USA
- HIV/STD Program, Public Health–Seattle & King County, Seattle, Washington, USA
| | - Julia C. Dombrowski
- Department of Medicine, University of Washington, Seattle, Washington, USA
- HIV/STD Program, Public Health–Seattle & King County, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
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5
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Dombrowski JC, Galagan SR, Ramchandani M, Dhanireddy S, Harrington RD, Moore A, Hara K, Eastment M, Golden MR. HIV Care for Patients With Complex Needs: A Controlled Evaluation of a Walk-In, Incentivized Care Model. Open Forum Infect Dis 2019; 6:ofz294. [PMID: 31341930 PMCID: PMC6641789 DOI: 10.1093/ofid/ofz294] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 06/21/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND New approaches are needed to provide care to persons with HIV who do not engage in conventionally organized HIV clinics. The Max Clinic in Seattle, Washington, is a walk-in, incentivized HIV care model located in a public health STD clinic that provides care in collaboration with a comprehensive HIV primary care clinic (the Madison Clinic). METHODS We compared outcomes in the first 50 patients enrolled in Max Clinic and 100 randomly selected matched Madison Clinic control patients; patients in both groups were virally unsuppressed (viral load [VL] >200 copies/mL) at baseline. The primary outcome was any VL indicating viral suppression (≥1 VL <200 copies/mL) during the 12 months postbaseline. Secondary outcomes were continuous viral suppression (≥2 consecutive suppressed VLs ≥60 days apart) and engagement in care (≥2 medical visits ≥60 days apart). We compared outcomes in the 12 months pre- and postbaseline and used generalized estimating equations to compare changes in Max vs control patients, adjusting for unstable housing, substance use, and psychiatric disorders. RESULTS Viral suppression improved in both groups pre-to-post (20% to 82% Max patients; P < .001; and 51% to 65% controls; P = .04), with a larger improvement in Max patients (adjusted relative risk ratio [aRRR], 3.2; 95% confidence interval [CI], 1.8-5.9). Continuous viral suppression and engagement in care increased in both groups but did not differ significantly (continuous viral suppression: aRRR, 1.5; 95% CI, 0.5-5.2; engagement: aRRR, 1.3; 95% CI, 0.9-1.9). CONCLUSIONS The Max Clinic improved viral suppression among patients with complex medical and social needs.
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Affiliation(s)
- Julia C Dombrowski
- Department of Medicine, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Public Health – Seattle & King County HIV/STD Program, Seattle, Washington
| | - Sean R Galagan
- Department of Global Health, University of Washington, Seattle, Washington
| | - Meena Ramchandani
- Department of Medicine, University of Washington, Seattle, Washington
- Public Health – Seattle & King County HIV/STD Program, Seattle, Washington
| | | | | | - Allison Moore
- Public Health – Seattle & King County HIV/STD Program, Seattle, Washington
| | - Katie Hara
- Social Work, Harborview Medical Center, Seattle, Washington
| | - Mckenna Eastment
- Department of Medicine, University of Washington, Seattle, Washington
| | - Matthew R Golden
- Department of Medicine, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Public Health – Seattle & King County HIV/STD Program, Seattle, Washington
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6
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Cannon C, Beieler A, Ramchandani M, Kerani R, Dhanireddy S. 325. Neurosyphilis Management in the Post-Procaine Penicillin Era. Open Forum Infect Dis 2018. [PMCID: PMC6254174 DOI: 10.1093/ofid/ofy210.336] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Neurosyphilis (NS) is an infection of the central nervous system caused by Treponema pallidum. Intramuscular (IM) penicillin (PCN) G procaine is a treatment option for those who cannot receive or decline intravenous (IV) therapy. Since August 24, 2016, it has been unavailable from the manufacturer, necessitating the use of IV PCN for NS. Our institutions organized a multidisciplinary, coordinated care system to expedite outpatient treatment of NS upon diagnosis. We report successful management of NS at an urban safety-net hospital in the post-procaine PCN era. Methods We identified patients with suspected NS from the King County Public Health STD and Harborview Infectious Disease clinics from October 2016 to February 2018. Demographics, clinical symptoms, diagnostics, treatment, and outcomes were collected by chart review. Successful NS treatment was defined as resolution of cerebrospinal fluid (CSF) pleocytosis or elevated protein, improvement in neurologic symptoms or appropriate decrease in serum rapid plasma reagin (RPR) or CSF Venereal Disease Research Laboratory (VDRL) titers. aRepresents more than one payer per patient. Results We identified 43 cases of suspected NS. The most common symptoms were blurred vision, headache, and tinnitus. All had a lumbar puncture (LP). Median days from LP to treatment initiation was 6—many starting on day of diagnosis. Fourteen patients (33%) required admission for treatment. Two patients declined therapy. IV PCN G was used in 93% of cases; one received IM ceftriaxone. Treatment was successful in 32 of 41 (78%) cases, with 23 of these (72%) managed as outpatients. Three cases were treatment failures for incomplete therapy adherence or equivocal response and uncertain diagnosis. Conclusion Without available IM procaine PCN, neurosyphilis is challenging to manage in vulnerable populations or those wishing to avoid inpatient admission. Employing a multidisciplinary, coordinated care approach can lead to successful treatment of NS using IV PCN in the outpatient setting. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Chase Cannon
- Allergy and Infectious Diseases, University of Washington, Seattle, Washington
| | | | - Meena Ramchandani
- King County Public Health STD Clinic / University of Washington, Seattle, Washington
| | - Roxanne Kerani
- King County Public Health/University of Washington, Seattle, Washington
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7
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Dombrowski JC, Ramchandani M, Dhanireddy S, Harrington RD, Moore A, Golden MR. The Max Clinic: Medical Care Designed to Engage the Hardest-to-Reach Persons Living with HIV in Seattle and King County, Washington. AIDS Patient Care STDS 2018; 32:149-156. [PMID: 29630852 DOI: 10.1089/apc.2017.0313] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [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: 11/13/2022] Open
Abstract
The Max Clinic in Seattle, Washington is designed to engage patients who have extensive barriers to HIV care. In this article, we describe the clinic's evolution and outcomes of patients enrolled in the first 2 years. The clinic is a high-intensity, low-threshold, incentivized care model that includes walk-in access to primary care in a Sexually Transmitted Disease Clinic. Patients who have failed to engage in care and achieve viral suppression with lower intensity support are referred by clinicians, case managers, and the health department Data to Care program. The clinic offers food vouchers, cash incentives, no-cost bus passes, and cell phones, as well as intensive case management with cross-agency coordinated care. The primary evaluation outcome was the percentage of patients who achieved viral suppression (HIV RNA <200 copies/mL) at least once after enrollment. Secondary outcomes were continuous viral suppression (≥2 suppressed results in a row ≥60 days apart) and engagement in care (≥2 completed medical visits ≥60 days apart). During January 2015-December 2016, 263 patients were referred; 170 (65%) were eligible, and 95 (56% of eligible) were enrolled. Most patients used illicit drugs or hazardous levels of alcohol (86%) and had diagnosed psychiatric illness (72%) and unstable housing (65%). During the year after enrollment, 90 (95%) patients engaged in care. As of the end of 2016, 76 (80%) had achieved viral suppression, and 54% had continuous viral suppression. The Max Clinic successfully treated HIV in high-need patients and, to date, has been sustainable through a combination of federal, state, and local funding.
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Affiliation(s)
- Julia C. Dombrowski
- Department of Medicine, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Public Health–Seattle & King County HIV/STD Program, Seattle, Washington
| | - Meena Ramchandani
- Department of Medicine, University of Washington, Seattle, Washington
- Public Health–Seattle & King County HIV/STD Program, Seattle, Washington
| | | | | | - Allison Moore
- Public Health–Seattle & King County HIV/STD Program, Seattle, Washington
| | - Matthew R. Golden
- Department of Medicine, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Public Health–Seattle & King County HIV/STD Program, Seattle, Washington
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8
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Ramchandani M, Selke S, Magaret A, Barnum G, Huang MLW, Corey L, Wald A. Prospective cohort study showing persistent HSV-2 shedding in women with genital herpes 2 years after acquisition. Sex Transm Infect 2017; 94:568-570. [PMID: 29175899 DOI: 10.1136/sextrans-2017-053244] [Citation(s) in RCA: 7] [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] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 11/08/2017] [Accepted: 11/11/2017] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Herpes simplex virus type 2 (HSV-2) is a prevalent infection with great variability in clinical and virological manifestations among individuals. This prospective cohort study aims to evaluate the natural history of HSV-2 reactivation in the genital area in the same group of women over time. METHODS Eighteen immunocompetent HSV-2 seropositive women were evaluated for viral shedding for 70 consecutive days within a median of 8 months (range 1-24 months) of HSV-2 acquisition and again approximately 2.5 years later from the original study. Participants obtained daily swabs of genital secretions for HSV PCR and recorded genital symptoms. RESULTS The viral shedding rate was 29% during the initial study and 19% in the follow-up study (32% reduction, P=0.019). Subclinical shedding rate also decreased from 24% to 13% (37% reduction, P=0.032), as did the rate of days with genital lesions from 22% to 15% (33% reduction, P=0.24). The mean copy number during viral shedding remained unchanged over time at 4.8 log10 c/mL (SD=2.0 and 1.6 during each study, respectively, P=0.33). Women with high viral shedding rates in the past were likely to continue to have high shedding rates (r=0.63, P=0.005). CONCLUSIONS Despite some reduction, high viral shedding rates persist in women with genital HSV-2 greater than 2 years after acquisition.
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Affiliation(s)
- Meena Ramchandani
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Stacy Selke
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA
| | - Amalia Magaret
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA.,Department of Biostatistics, University of Washington, Seattle, Washington, USA.,The Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Gail Barnum
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA
| | - Meei-Li Wu Huang
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA
| | - Lawrence Corey
- Department of Medicine, University of Washington, Seattle, Washington, USA.,Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA.,The Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Anna Wald
- Department of Medicine, University of Washington, Seattle, Washington, USA.,Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA.,The Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Department of Epidemiology, University of Washington, Seattle, Washington, USA
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9
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Bajema KL, Dalesandro MF, Fredricks DN, Ramchandani M. Disseminated coccidioidomycosis presenting with intramedullary spinal cord abscesses: Management challenges. Med Mycol Case Rep 2016; 15:1-4. [PMID: 28053850 PMCID: PMC5198726 DOI: 10.1016/j.mmcr.2016.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [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: 11/14/2016] [Revised: 11/29/2016] [Accepted: 12/01/2016] [Indexed: 01/05/2023] Open
Abstract
Coccidioides species are endemic to the southwestern United States and typically cause a mild or asymptomatic primary infection. In some instances, infection can disseminate and involve the central nervous system with meningitis being the most common manifestation. Non-osseous spinal cord involvement is exceedingly rare. We report a case of disseminated coccidioidomycosis in an otherwise healthy 20 year old man with diffuse leptomeningeal enhancement, cerebrospinal fluid findings suggestive of meningitis, and intramedullary spinal cord abscesses. Response to treatment occurred with prolonged systemic liposomal amphotericin B and voriconazole. An extended course of steroids was needed to blunt inflammation.
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Affiliation(s)
- Kristina L Bajema
- Department of Medicine, Divison of Allergy and Infectious Diseases, University of Washington, 1959 NE Pacific Street Box 356423, Seattle, WA 98195, USA
| | | | - David N Fredricks
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Meena Ramchandani
- Department of Medicine, Divison of Allergy and Infectious Diseases, Harborview Medical Center, Seattle, WA, USA
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10
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Ramchandani M, Russell R, Jing L, Magaret A, Selke S, Huang ML, Strachan E, Wald A, Koelle DM. 1154Host and Pathogen Genetics Modulate HSV-1 Severity. Open Forum Infect Dis 2014. [PMCID: PMC5781709 DOI: 10.1093/ofid/ofu052.862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | | | - Amalia Magaret
- Department of Laboratory Medicine, University of Washington, Seattle, WA
| | - Stacy Selke
- Laboratory Medicine, University of Washington, Seattle, WA
| | | | | | - Anna Wald
- Department of Medicine, University of Washington, Seattle, WA
| | - David M. Koelle
- Medicine, University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA
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11
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Ramchandani M, Bedeir K. Vascular connector devices increase the availability of minimally invasive cardiac surgery to ischemic heart patients. HSR Proc Intensive Care Cardiovasc Anesth 2011; 3:239-43. [PMID: 23440008 PMCID: PMC3563438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The revival of off-pump cardiac surgery and the exploration of less invasive techniques for coronary artery bypass grafting, have lead to an increasing technical difficulty, as compared to conventional surgery using cardiopulmonary bypass. The moving target vessel in off-pump coronary artery bypass surgery, as well as the increasingly limited space in minimally invasive cardiac surgery were not convenient to many surgeons, a fact that lead many surgeons to deprive their patients the potential benefits of these techniques. Since the 1950's, surgeons have attempted to make the anastomotic procedure less cumbersome and less time consuming. Many creative ideas and devices were made, but for many different reasons, they eventually faded away. Since then, hand-sewn anastomoses have been the standard of care in coronary artery bypass grafting. Today, with the obvious need for a facilitated and fast coronary anastomosis, interest in these anastomotic devices has been re-awakened. The exact geometry, physiology and dynamics of the perfect anastomosis have thus been studied, in an attempt to provide an understanding of reasons behind anastomosis and graft failure after coronary artery bypass surgery, and eventually design the best performing device. These devices would allow for a faster, more accurate and a more reproducible coronary anastomosis using minimally invasive techniques. Also, due to a short learning curve, the standardization of percutaneous devices would allow much more surgeons to more widely adopt less invasive techniques. In summary, we see anastomotic devices as a solution to the technical challenges surgeons encounter with minimally invasive coronary artery bypass grafting.
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12
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Santosh D, Lakhtakia S, Gupta R, Reddy DN, Rao GV, Tandan M, Ramchandani M, Guda NM. Clinical trial: a randomized trial comparing fluoroscopy guided percutaneous technique vs. endoscopic ultrasound guided technique of coeliac plexus block for treatment of pain in chronic pancreatitis. Aliment Pharmacol Ther 2009; 29:979-84. [PMID: 19222416 DOI: 10.1111/j.1365-2036.2009.03963.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Coeliac plexus block (CPB) is a management option for pain control in chronic pancreatitis. CPB is conventionally performed by percutaneous technique with fluoroscopic guidance (PCFG). Endoscopic ultrasound (EUS) is increasingly used for CPB as it offers a better visualization of the plexus. There are limited data comparing the two modalities. AIM To compare the pain relief in chronic pancreatitis among patients undergoing CPB either by PCFG technique or by EUS guided technique. METHODS Chronic pancreatitis patients with abdominal pain requiring daily analgesics for more than 4 weeks were included. Fifty six consecutive patients (41 males, 15 females) participated in the study. EUSG-CPB was performed in 27 and PCFG-CPB in 29 patients. In both the groups, 10 mL of Bupivacaine (0.25%) and 3 mL of Triamcinolone (40 mg) were given on both sides of the coeliac artery through separate punctures. RESULTS Pre and post procedure pain scores were obtained using a 0-10 visual analogue scale. Improvement in pain scores was seen in 70% of subjects undergoing EUS-CPB and 30% in Percutaneous- block group (P = 0.044). CONCLUSIONS EUS-guided coeliac block appears to be better than PCFG-CPB for controlling abdominal pain in patients with chronic pancreatitis.
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Affiliation(s)
- D Santosh
- Department of Anesthesiology, Asian Institute of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India.
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13
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Bater MC, Ramchandani PL, Ramchandani M, Flood TR. An orbital apex fracture resulting in multiple cranial neuropathies. Br J Oral Maxillofac Surg 2008; 46:163-4. [PMID: 17507123 DOI: 10.1016/j.bjoms.2007.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2007] [Indexed: 11/26/2022]
Abstract
Fractures of the orbital apex are rare after trauma, but can be devastating if associated with indirect traumatic optic neuropathy and a permanent visual defect. Computed tomography plays an important role in the diagnosis and classification of these fractures, but optimal treatment is controversial. We describe an isolated fracture of the orbital apex in a 15-year-old boy resulting in indirect traumatic optic neuropathy and palsies of cranial nerves III, IV and VI after a blunt injury to the face.
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Affiliation(s)
- M C Bater
- Maxillofacial Unit, St Richards Hospital, Spitalfield Lane, Chichester, West Sussex PO19 6SE, United Kingdom.
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14
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Affiliation(s)
- M Ramchandani
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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15
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Lagally ET, Scherer JR, Blazej RG, Toriello NM, Diep BA, Ramchandani M, Sensabaugh GF, Riley LW, Mathies RA. Integrated portable genetic analysis microsystem for pathogen/infectious disease detection. Anal Chem 2005; 76:3162-70. [PMID: 15167797 DOI: 10.1021/ac035310p] [Citation(s) in RCA: 235] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
An integrated portable genetic analysis microsystem including PCR amplification and capillary electrophoretic (CE) analysis coupled with a compact instrument for electrical control and laser-excited fluorescence detection has been developed. The microdevice contains microfabricated heaters, temperature sensors, and membrane valves to provide controlled sample positioning and immobilization in 200-nL PCR chambers. The instrument incorporates a solid-state laser and confocal fluorescence detection optics, electronics for sensing and powering the PCR reactor, and high-voltage power supplies for conducting CE separations. The fluorescein-labeled PCR products are amplified and electrophoretically analyzed in a gel-filled microchannel in <10 min. We demonstrate the utility of this instrument by performing pathogen detection and genotyping directly from whole Escherichia coli and Staphylococcus aureus cells. The E. coli detection assay consists of a triplex PCR amplification targeting genes that encode 16S ribosomal RNA, the fliC flagellar antigen, and the sltI shigatoxin. Serial dilution demonstrates a limit of detection of 2-3 bacterial cells. The S. aureus assay uses a femA marker to identify cells as S. aureus and a mecA marker to probe for methicillin resistance. This integrated portable genomic analysis microsystem demonstrates the feasibility of performing rapid high-quality detection of pathogens and their antimicrobial drug resistance.
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Affiliation(s)
- E T Lagally
- Chemistry Department, University of California, Berkeley, California 94720, USA
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Ramchandani M, Manges AR, DebRoy C, Smith SP, Johnson JR, Riley LW. Possible Animal Origin of Human-Associated, Multidrug-Resistant, Uropathogenic Escherichia coli. Clin Infect Dis 2005; 40:251-7. [PMID: 15655743 DOI: 10.1086/426819] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2004] [Accepted: 09/08/2004] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The multistate occurrence of cases of urinary tract infection (UTI) caused by trimethoprim-sulfamethoxazole (TMP-SMZ)-resistant Escherichia coli strains belonging to a single clonal group (designated as clonal group A [CgA]) in the United States has raised an intriguing hypothesis that these infections may have been spread by contaminated food products. The present study attempted to determine if CgA strains could be traced to food animals. METHODS A total of 495 animal and environmental E. coli isolates, which belonged to serogroups O11, O17, O73, and O77 and were collected between 1965 and 2002 by the Gastroenteric Disease Center at Pennsylvania State University (University Park, PA), were further subtyped by antimicrobial drug susceptibility, enterobacterial repetitive intergenic consensus (ERIC2) PCR, random amplified polymorphic DNA analysis, pulsed-field gel electrophoresis (PFGE), and virulence profile pattern. RESULTS Of 495 isolates, 128 (26%) had an ERIC2 PCR electrophoretic pattern indistinguishable from that of the human prototype CgA strain, and 14 CgA isolates were resistant to TMP-SMZ. Cluster analysis of PFGE patterns showed that 1 of these 14 isolates, obtained from a cow in 1988, was 94% similar to a CgA uropathogenic human-associated E. coli strain. The pattern for this isolate was included among a cluster of PFGE patterns for 5 human-associated UTI isolates that were >80% similar to each other. CONCLUSIONS These observations suggest that drug-resistant, uropathogenic human-associated E. coli strains potentially have an animal origin. The possibility that human drug-resistant UTI could be a foodborne illness has serious public health implications.
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Affiliation(s)
- Meena Ramchandani
- Division of Infectious Diseases, School of Public Health, University of California, Berkeley, CA 94720, USA
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Abstract
AIM To assess, against a checklist of specific areas of required information and using standard published criteria, to what extent leaflets given before cataract surgery provided patients with enough information to give adequately informed consent. METHOD Twelve ophthalmology departments in the West Midlands region were asked to submit the cataract information leaflets given to their patients at the preoperative assessment for analysis. Using criteria published by the General Medical Council, British Medical Association, and Medical Defence Union the leaflets were assessed for their contribution to informed consent for patients considering cataract surgery. Leaflets were scored according to the information they provided on: diagnosis, prognosis, treatment options, costs to the patient, details about the procedure, its purpose, likely benefits, how to prepare for it, what to expect during and after the operation, and the common as well as serious complications that may occur. The readability of the information was also assessed. RESULTS All the units' leaflets provided information on diagnosis, the lifestyle changes required postoperatively, and cost involved to the patient. Only five units had leaflets that mentioned the risks involved in cataract surgery. The other areas of information were covered by 50-75% of the leaflets. Fifty per cent of the leaflets included a diagram. The average SMOG readability score was high. CONCLUSION Although present cataract information leaflets make some contribution to the process of informed consent, most do not address important areas outlined by the General Medical Council. Many of the areas of information that are required for informed consent could easily be covered, and should be borne in mind when designing patient information leaflets. Resources are available on the internet including toolkits, guides, and means of assessment for the production of patient information leaflets.
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Affiliation(s)
- H Brown
- The Birmingham and Midland Eye Centre, Birmingham, UK.
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Abstract
PURPOSE To report the problems and outcomes of penetrating keratoplasty (PKP) in patients with corneal oedema due to congenital glaucoma. METHOD Case note review of nine such consecutive patients treated with PKP. A Kaplan - Meir survival curve was plotted for the series. RESULTS Nine patients, ranging in age from 27 to 71 years at the time of their surgery were followed up for a mean of 28 months. All had undergone previous surgery for glaucoma. Preoperatively all patients had controlled intraocular pressures, and four were on ocular hypotensives. Two patients developed corneal graft failure at 15 and 41 months postoperative. Raised pressure was the cause in both. Final visual acuity improved in five patients, was the same in three, and deteriorated in only one. Complications included raised intraocular pressure, cataract, retinal detachment, and endophthalmitis secondary to an infected Molteno implant. CONCLUSION Despite multiple impediments to good postoperative vision including previous surgery and pre-existing glaucomatous damage, a successful outcome was achieved by careful patient selection, and an awareness of, and meticulous attention to postoperative complications.
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Affiliation(s)
- M Ramchandani
- Birmingham and Midland Eye Centre, City Hospitals NHS Trust, Birmingham, UK
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Loo A, Fitt AW, Ramchandani M, Kirkby GR. Pars plana vitrectomy with silicone oil in the management of combined rhegmatogenous retinal and choroidal detachment. Eye (Lond) 2001; 15:612-5. [PMID: 11702972 DOI: 10.1038/eye.2001.195] [Citation(s) in RCA: 16] [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] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
PURPOSE Rhegmatogenous retinal detachment combined with spontaneous pre-operative choroidal detachment (RDCD) represents a rare but specific entity, which has in the past been associated with a poor prognosis. This study was designed to determine the efficacy of pars plana vitrectomy with silicone oil injection in the management of this very difficult vitreoretinal problem. METHODS A retrospective analysis was carried out of 13 eyes of 13 consecutive patients who underwent vitrectomy and silicone oil exchange. RESULTS In a total of 10 eyes (77%) the first procedure produced anatomical success. Two eyes required a further procedure to achieve retinal reattachment, producing a final anatomical success rate of 92%. CONCLUSION Pars plana vitrectomy with silicone oil exchange is an effective technique for managing RDCD.
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Affiliation(s)
- A Loo
- Vitreoretinal Surgery Unit, Birmingham & Midland Eye Centre, UK
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Abstract
PURPOSE To report a case of labial basal cell adenocarcinoma in a patient with uveitis on treatment with cyclosporin A. METHOD Case report. A 73-year-old woman with panuveitis and retinal vasculitis presented with a lump on her lip after 52 months of treatment with cyclosporin A. RESULT Excision biopsy showed a labial adenocarcinoma. CONCLUSION Malignancy can occur after long-term cyclosporin A treatment for uveitis.
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Affiliation(s)
- M Ramchandani
- Birmingham and Midland Eye Centre, Birmingham, United Kingdom
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Manuchehri K, Loo A, Ramchandani M, Kirkby GR. Acute suprachoroidal haemorrhage in a patient treated with streptokinase for myocardial infarction. Eye (Lond) 1999; 13 ( Pt 5):685-6. [PMID: 10696335 DOI: 10.1038/eye.1999.192] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Abstract
Poly(lactides-co-glycolides) [PLGA] are widely investigated biodegradable polymers and are extensively used in several biomaterials applications as well as drug delivery systems. These polymers degrade by bulk hydrolysis of ester bonds and break down into their constituent monomers, lactic and glycolic acids which are excreted from the body. The purpose of this investigation was to develop and characterize a biodegradable, implantable delivery system containing ciprofloxacin hydrochloride (HCl) for the localized treatment of osteomyelitis and to study the extent of drug penetration from the site of implantation into the bone. Osteomyelitis is an inflammatory bone disease caused by pyogenic bacteria and involves the medullary cavity, cortex and periosteum. The advantages of localized biodegradable therapy include high, local antibiotic concentration at the site of infection, as well as, obviation of the need for removal of the implant after treatment. PLGA 50:50 implants were compressed from microcapsules prepared by nonsolvent-induced phase-separation using two solvent-nonsolvent systems, viz., methylene chloride-hexane (non-polar) and acetone-phosphate buffer (polar). In vitro dissolution studies were performed to study the effect of manufacturing procedure, drug loading and pH on the release of ciprofloxacin HCl. The extent of penetration of the drug from the site of implantation was studied using a rabbit model. The results of in vitro studies illustrated that drug release from implants made by the nonpolar method was more rapid as compared to implants made by the polar method. The release of ciprofloxacin HCl. The extent of the penetration of the drug from the site of implantation was studied using a rabbit model. The results of in vitro studies illustrated that drug release from implants made by the nonpolar method was more rapid as compared to implants made by the polar method. The release of ciprofloxacin HCl from the implants was biphasic at < or = 20% w/w drug loading, and monophasic at drug loading levels > or = 35% w/w. In vivo studies indicated that PLGA 50:50 implants were almost completely resorbed within five to six weeks. Sustained drug levels, greater than the minimum inhibitory concentration (MIC) of ciprofloxacin, up to 70 mm from the site of implantation, were detected for a period of six weeks.
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Affiliation(s)
- M Ramchandani
- Integra LifeSciences Corporation, Plainsboro, NJ 08536, USA
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Reiter LA, Koch K, Piscopio AD, Showell HJ, Alpert R, Biggers MS, Chambers RJ, Conklyn MJ, Cooper K, Cortina SR, Dibrino JN, Dominy BW, Farrell CA, Hingorani GP, Martinelli GJ, Ramchandani M, Wright KF. trans-3-Benzyl-4-hydroxy-7-chromanylbenzoic acid derivatives as antagonists of the leukotriene B4 (LTB4) receptor. Bioorg Med Chem Lett 1998; 8:1781-6. [PMID: 9873433 DOI: 10.1016/s0960-894x(98)00275-3] [Citation(s) in RCA: 10] [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] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The SAR of a series of 2-(7-chromanyl)benzoic acids has been investigated with the aim of identifying potent and selective LTB4 receptor antagonists that maintain potency in complex biological fluids. We found optimal activity in derivatives with electron-withdrawing groups in the benzoic acid ring and with an unsubstituted C-3 benzyl group on the chromanol nucleus. While compounds containing a 3-(4-phenyl)benzyl chromanol substituent were potent LTB4 receptor antagonists, the increased lipophilicity imparted by the additional phenyl substituent led to decreased potency in the presence of plasma proteins. From among the potent compounds identified, CP-195543, the 5'-trifluoromethyl 3-benzyl chromanol, was selected for development.
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Affiliation(s)
- L A Reiter
- Pfizer Inc, Central Research Division, Groton, CT 06340, USA
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Chambers RJ, Koch K, Biggers MS, Ramchandani M. Synthetic approaches to 2-(4-hydroxy-7-chromanyl)benzoic acids as antagonists of leukotriene B4. Bioorg Med Chem Lett 1998; 8:1787-90. [PMID: 9873434 DOI: 10.1016/s0960-894x(98)00276-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Structural modification of 1 led to a series of 2-(4-hydroxy-7-chromanyl)benzoic acid LTB4 antagonists exemplified by 2 and 3. The use of an organostannane biaryl coupling, a non steroselective reduction and a chromatographic resolution limited the utility of this synthetic route. To address these issues, a new synthetic route was developed utilizing a palladium catalyzed coupling of aryl oxazolines in tandem with a stereospecific enone reduction as key synthetic steps. Resolution was achieved by fractional crystallization of a (S)-(-)-alpha-methylbenzylamine salt.
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Affiliation(s)
- R J Chambers
- Central Research Division, Pfizer Inc, Groton, CT 06340, USA
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Ramchandani M, Nahhas G. Orbital pseudotumour in the differential diagnosis of eyelid swelling. J Accid Emerg Med 1998; 15:62. [PMID: 9475229 PMCID: PMC1343014 DOI: 10.1136/emj.15.1.62] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- M Ramchandani
- Birmingham and Midland Eye Centre, City Hospitals NHS Trust, UK
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Ueyama K, Jones JW, Ramchandani M, Beall AC, Thornby JI. Clinical variables influencing the appearance of right bundle branch block after cardiac surgery. Cardiovasc Surg 1997; 5:574-8. [PMID: 9423941 DOI: 10.1016/s0967-2109(97)00071-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Right bundle branch block following coronary surgery is a common occurrence. Among 759 coronary surgery cases, 104 patients (13.7%) had a new right bundle branch block. Of these right bundle branch blocks, 62 were transient, and 42 (40.4%) were permanent. The large number of bypasses (3.20 versus 2.75, P = 0.0001) and stenosis of the right coronary artery (81.7% versus 66.5%, P = 0.003) was strongly associated with a new right bundle branch block. In the analysis of the permanent right bundle branch block, blood cardioplegia prevented the block from becoming permanent (35.7% versus 75.8%, P = 0.0001). Therefore, it is concluded that perioperative right bundle branch block occurs predominantly in patients who have a critical stenosis in an artery which supplies the conduction system and in those undergoing more extensive procedures. In addition, blood cardioplegia affects the conduction system less severely than does crystalloid cardioplegia.
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Affiliation(s)
- K Ueyama
- Baylor College of Medicine, Department of Surgery, Veterans Affairs Medical Center, Houston, Texas, USA
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Abstract
BACKGROUND Origin of the left circumflex coronary artery from the right sinus of Valsalva is the most common anatomic variation of the coronary artery circulation. However, there are few reports about the operative approach to this anomalous vessel. METHODS Forty patients having this anomaly were identified from 10,216 adult cardiac catheterization procedures. Forty percent of the anomalous circumflex coronary arteries (ACCAs) had critical atherosclerotic lesions. Eighty cases needed bypass grafting. RESULTS For diagnosis of ACCA, the aortic root sign was positive in 94.9% of the diagnosed patients and the nonperfused myocardium sign was found in 92.5%. Eighty percent of ACCAs were larger than 2 mm in radiographic diameter before their passage into the atrioventricular groove. However, after emerging from the atrioventricular groove, 70% measured less than 1.5 mm. Consequently, a technique was developed to bypass the proximal ACCA and was used in 2 cases. Six other patients with more distal disease and larger vessels underwent conventional bypass grafting. CONCLUSIONS The aortic root sign and nonperfused myocardium are useful in diagnosing ACCA. The ACCA is usually too small for use of the conventional graft technique. Therefore, a technique was developed to graft more proximally and was applied successfully in 2 cases.
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Affiliation(s)
- K Ueyama
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
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Abstract
Isolated right ventricular aneurysms are rare. Postinfarction right ventricular aneurysm associated with a ventricular septal defect is a very unusual complication. We present such a case that was successfully treated surgically.
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Affiliation(s)
- C Nahas
- Cora and Webb Mading Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
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Koch K, Hanson DC, Newborg MF, Cooper K, Fouda HG, Biehl ML, Shepard RM, Donovan CB, Biggers MS, Ramchandani M. CP-123,369: a potent, orally active immunosuppressive agent. Inflamm Res 1995; 44 Suppl 2:S183-4. [PMID: 8548388 DOI: 10.1007/bf01778322] [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] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
- K Koch
- Central Research Division, Pfizer Inc., Groton, CT 06340, USA
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Koch K, Newborg MF, Hanson DC, Cooper K, Shepard RM, Biehl ML, Biggers MS, Ramchandani M, Schulte G, Snyder JR. The C-32 triacetyl-L-rhamnose derivative of ascomycin: a potent, orally active macrolactone immunosuppressant. J Med Chem 1995; 38:1255-8. [PMID: 7537331 DOI: 10.1021/jm00008a001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- K Koch
- Central Research Division, Pfizer Inc., Groton, Connecticut 06340, USA
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Zoretic PA, Ramchandani M, Caspar ML. Aspects of Manganese (III) - Promoted Oxidative Free Radical Cyclizations to Functionalized Bicyclic Systems. SYNTHETIC COMMUN 1991. [DOI: 10.1080/00397919108019776] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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