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Loftus M, Brown RS, El-Farra NS, Owen EJ, Reau N, Wadei HM, Bernstein D. Improving the Management of Hepatorenal Syndrome-Acute Kidney Injury Using an Updated Guidance and a New Treatment Paradigm. Gastroenterol Hepatol (N Y) 2023; 19:527-536. [PMID: 37771795 PMCID: PMC10524408] [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: 09/30/2023]
Abstract
Cirrhosis, or advanced scarring of the liver, represents the end stage of chronic liver disease and is associated with high morbidity and mortality. Hepatorenal syndrome-acute kidney injury (HRS -AKI), a condition causing functional and progressive kidney failure, is a complication of cirrhosis that contributes to its high mortality rate. In the United States, the standard-of-care treatments for HRS -AKI have historically been suboptimal. Recently, terlipressin became the first drug approved for HRS -AKI in the United States, and the American Association for the Study of Liver Diseases updated its guidance document on HRS diagnosis and management. Clinical practice guidelines and guidance documents have a variable effect on physician behavior owing to a lack of awareness, familiarity, and education. The imple mentation of standardized order sets can improve guidance adherence and the quality of care delivered by encouraging data-driven treatment administration, especially for new therapies. This review seeks to facilitate improvements in the management of HRS -AKI by discussing early HRS -AKI interventions, which will streamline diagnosis and treatment in a practical way for clinical use, and how to incorporate new treatments into patient care to improve survival in this subset of patients. Finally, these recommendations are integrated into a sample order set developed by members of the Chronic Liver Disease Foundation and experts in the management of HRS-AKI.
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Affiliation(s)
- Michelle Loftus
- North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Robert S. Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York
| | - Neveen S. El-Farra
- UCLA Health, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Emily J. Owen
- Critical Care, Surgical Burn Trauma Intensive Care Unit, Department of Pharmacy, Barnes–Jewish Hospital, St. Louis, Missouri
| | - Nancy Reau
- Rush University Medical Center, Chicago, Illinois
| | - Hani M. Wadei
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida
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Kugelmas M, Loftus M, Owen EJ, Wadei H, Saab S. Expert perspectives for the pharmacist on facilitating and improving the use of albumin in cirrhosis. Am J Health Syst Pharm 2023; 80:806-817. [PMID: 37013893 PMCID: PMC10287532 DOI: 10.1093/ajhp/zxad070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Indexed: 04/05/2023] Open
Abstract
PURPOSE Albumin, the most abundant and arguably most important protein in the human body, plays a unique role in decompensated cirrhosis because its structure and function are quantitatively and qualitatively affected. A literature review was performed to provide insights into albumin use. The manuscript was developed using a multidisciplinary approach; 2 hepatologists, a nephrologist, a hospitalist, and a pharmacist, who are all members of or work closely with the Chronic Liver Disease Foundation, collaborated to write this expert perspective review. SUMMARY Cirrhosis represents the potential end in the spectrum of all chronic liver diseases. Decompensated cirrhosis, defined by the overt manifestation of liver failure (eg, ascites, hepatic encephalopathy, variceal bleeding), is the inflection point associated with increased mortality. Human serum albumin (HSA) infusion serves an important role in the treatment of advanced liver disease. The benefits of HSA administration in patients with cirrhosis are widely accepted, and its use has been advocated by several professional societies. However, inappropriate HSA use can lead to significant adverse patient events. This paper discusses the rationale for the administration of HSA in the treatment of complications of cirrhosis, analyzes the data on the use of HSA in cirrhosis, and streamlines practical recommendations set forth in published guidance. CONCLUSION Use of HSA in clinical practice needs to be improved. The objective of this paper is to empower pharmacists to facilitate and improve the use of HSA in patients with cirrhosis at their practice sites.
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Affiliation(s)
| | - Michelle Loftus
- Division of Hospital Medicine, North Shore University Hospital, Hempstead, NY, and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Emily J Owen
- Critical Care, Surgical Burn Trauma Intensive Care Unit, Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Hani Wadei
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Sammy Saab
- Department of Internal Medicine and Surgery, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
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Nieves JW, Cosman F, McMahon D, Redko M, Hentschel I, Bartolotta R, Loftus M, Kazam JJ, Rotman J, Lane J. Teriparatide and pelvic fracture healing: a phase 2 randomized controlled trial. Osteoporos Int 2022; 33:239-250. [PMID: 34383100 PMCID: PMC8758515 DOI: 10.1007/s00198-021-06065-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/08/2021] [Indexed: 01/03/2023]
Abstract
UNLABELLED Pelvic fracture patients were randomized to blinded daily subcutaneous teriparatide (TPTD) or placebo to assess healing and functional outcomes over 3 months. With TPTD, there was no evidence of improved healing by CT or pain reduction; however, physical performance improved with TPTD but not placebo (group difference p < 0.03). INTRODUCTION To determine if teriparatide (20 μg/day; TPTD) results in improved radiologic healing, reduced pain, and improved functional outcome vs placebo over 3 months in pelvic fracture patients. METHODS This randomized, placebo-controlled study enrolled 35 patients (women and men >50 years old) within 4 weeks of pelvic fracture and evaluated the effect of blinded TPTD vs placebo over 3 months on fracture healing. Fracture healing from CT images at 0 and 3 months was assessed as cortical bridging using a 5-point scale. The numeric rating scale (NRS) for pain was administered monthly. Physical performance was assessed monthly by Continuous Summary Physical Performance Score (based on 4 m walk speed, timed repeated chair stands, and balance) and the Timed Up and Go (TUG) test. RESULTS The mean age was 82, and >80% were female. The intention to treat analysis showed no group difference in cortical bridging score, and 50% of fractures in TPTD-treated and 53% of fractures in placebo-treated patients were healed at 3 months, unchanged after adjustment for age, sacral fracture, and fracture displacement. Median pain score dropped significantly in both groups with no group differences. Both CSPPS and TUG improved in the teriparatide group, whereas there was no improvement in the placebo group (group difference p < 0.03 for CSPPS at 2 and 3 months). CONCLUSION In this small randomized, blinded study, there was no improvement in radiographic healing (CT at 3 months) or pain with TPTD vs placebo; however, there was improved physical performance in TPTD-treated subjects that was not evident in the placebo group.
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Affiliation(s)
- J W Nieves
- Hospital for Special Surgery, New York, NY, USA.
- Department of Epidemiology, Columbia University, New York, NY, USA.
| | - F Cosman
- Department of Medicine, Columbia University, New York, NY, USA
| | - D McMahon
- Hospital for Special Surgery, New York, NY, USA
| | - M Redko
- Hospital for Special Surgery, New York, NY, USA
| | - I Hentschel
- Hospital for Special Surgery, New York, NY, USA
| | - R Bartolotta
- Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - M Loftus
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - J J Kazam
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - J Rotman
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - J Lane
- Hospital for Special Surgery, New York, NY, USA
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du Plessis LM, Daniels LC, Koornhof HE, Solomon ZL, Loftus M, Babajee LC, Ronquest C, Kleingeld B, Greener CM, Burn KJ. Field-testing of the revised, draft South African Paediatric Food-Based Dietary Guidelines amongst mothers/caregivers of children aged 0–12 months in the Breede Valley sub-district, Western Cape province, South Africa. South African Journal of Clinical Nutrition 2021. [DOI: 10.1080/16070658.2020.1769335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- LM du Plessis
- Division of Human Nutrition, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | - LC Daniels
- Division of Human Nutrition, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | - HE Koornhof
- Division of Human Nutrition, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | - ZL Solomon
- Division of Human Nutrition, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | - M Loftus
- Division of Human Nutrition, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | - LC Babajee
- Division of Human Nutrition, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | - C Ronquest
- Division of Human Nutrition, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | - B Kleingeld
- Division of Human Nutrition, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | - CM Greener
- Division of Human Nutrition, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | - KJ Burn
- Division of Human Nutrition, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
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Lukin DJ, Lawlor G, Hudesman DP, Durbin L, Axelrad JE, Passi M, Cavaliere K, Coburn E, Loftus M, Jen H, Feathers A, Rosen MH, Malter LB, Swaminath A. Escalation of Immunosuppressive Therapy for Inflammatory Bowel Disease Is Not Associated With Adverse Outcomes After Infection With Clostridium difficile. Inflamm Bowel Dis 2019; 25:775-781. [PMID: 30312400 DOI: 10.1093/ibd/izy308] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 07/12/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is common in patients with inflammatory bowel disease (IBD), often leading to diagnostic confusion and delays in IBD therapy escalation. This study sought to assess outcomes after CDI in IBD patients exposed to new or escalated immunosuppressive therapy. METHODS This multicenter retrospective cohort study included IBD patients with documented CDI at 4 academic medical centers. Data were abstracted from clinical databases at each institution. Outcomes at 30 and 90 days were compared between patients undergoing new or intensified immunosuppressive therapy and those without therapy escalation. Continuous variables were compared using t tests, and proportions using chi-square tests. Multivariable logistic regression was used to determine the association of individual variables with severe outcomes (including death, sepsis, and/or colectomy) within 90 days. Secondary outcomes included CDI recurrence, rehospitalization, worsening of IBD, and severe outcomes within 30 days. RESULTS A total of 207 adult patients with IBD and CDI were included, of whom 62 underwent escalation to biologic or corticosteroid therapy (median time to escalation, 13 days). Severe outcomes within 90 days occurred in 21 (15.6%) nonescalated and 1 (1.8%) therapy-escalated patients. Serum albumin <2.5 mg/dL, lactate >2.2 mg/dL, intensive care unit admission, hypotension, and comorbid disease were associated with severe outcomes. Likelihood of severe outcomes was decreased in patients undergoing escalation of IBD therapy after CDI (adjusted odds ratio [aOR], 0.12) and increased among patients aged >65 years (aOR, 4.55). CONCLUSIONS Therapy escalation for IBD within 90 days of CDI was not associated with worse clinical outcomes. Initiation of immunosuppression for active IBD may therefore be appropriate in carefully selected patients after treatment of CDI.
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Affiliation(s)
- Dana J Lukin
- Division of Gastroenterology and Liver Diseases, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Garrett Lawlor
- Division of Digestive and Liver Diseases, New York Presbyterian Hospital-Columbia University Medical Center, New York, New York
| | - David P Hudesman
- Division of Gastroenterology, New York University Medical Center, New York, New York
| | - Laura Durbin
- Division of Gastroenterology, Northwell Health, New York, New York
| | - Jordan E Axelrad
- Division of Digestive and Liver Diseases, New York Presbyterian Hospital-Columbia University Medical Center, New York, New York
| | - Monica Passi
- Division of Gastroenterology, Northwell Health, New York, New York
| | - Kimberly Cavaliere
- Division of Gastroenterology and Liver Diseases, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Elliot Coburn
- Division of Gastroenterology, New York University Medical Center, New York, New York
| | - Michelle Loftus
- Division of Gastroenterology, Northwell Health, New York, New York
| | - Henry Jen
- Division of Gastroenterology, Northwell Health, New York, New York
| | | | - Melissa H Rosen
- Division of Gastroenterology, New York University Medical Center, New York, New York
| | - Lisa B Malter
- Division of Gastroenterology, New York University Medical Center, New York, New York
| | - Arun Swaminath
- Division of Gastroenterology, Northwell Health, New York, New York
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Chagpar AB, Longley PB, Horowitz NR, Killelea BK, Tsangaris TN, Li F, Butler M, Stavris K, Yao X, Harigopal M, Bossuyt V, Lannin DR, Pusztai L, Loftus M, Davidoff AJ, Gross CP. Abstract P3-13-01: Impact of routine cavity shave margins on time and money: Results from the SHAVE trial. Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-p3-13-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
INTRODUCTION: Taking routine cavity shave margins (CSM) reduces positive margin and re-excision rates by 50%, but the impact of this technique on operative time and overall costs have not been well-elucidated.
METHODS: The SHAVE trial randomized 235 Stage 0-3 breast cancer patients undergoing partial mastectomy 1:1 to either have further cavity shave margins resected ("shave") or not ("no shave"). Randomization occurred intraoperatively after surgeons had completed standard partial mastectomy. Intraoperative time as well as actual direct costs incurred by the hospital were measured, for both the index case as well as any surgeries over the subsequent 90 days.
RESULTS: Median patient age was 61 (range; 33-94). 54 patients (23%) had invasive cancer, 45 (19%) had DCIS, and 125 (53%) had both. Median invasive tumor size was 1.1 cm (range; 0-6.5), and median DCIS size was 1.0 cm (range; 0-9.3). The "shave" and "no shave" groups were well-matched in terms of baseline characteristics, including the proportion having a sentinel node biopsy (75.6% vs. 69.8%, p=0.32) and/or axillary node dissection (9.2% vs. 7.8%, p=0.68) at the time of the initial surgery. The median number of additional CSM in the "shave" group was 4 (range; 3-6). At the initial surgery, those in the "shave" group had a longer operative time (median 76 vs. 66 minutes, p=0.005), and higher OR, pathology and total costs (see table). 48 patients required a subsequent surgery; 45 (93.8%) for margin clearance, 3 for sentinel lymph node biopsy alone (2 in the "shave" and 1 in the "no shave" group, p=1.00). There was a significantly lower re-excision rate for margins in the "shave" group (10.9% vs. 27.6%, p=0.001). Median time to re-excision was 22 days (range; 10-62). The mean cost of additional surgeries for those who required them was no different between the "shave" and "no shave" groups ($2636 vs. $3453, p=0.12); however, given the overall lower reoperation rate in the "shave" group (12.6% vs. 28.4%, p=0.003), the mean cost per patient for additional surgeries was significantly lower in the "shave" vs. "no shave" group. Taking into account all surgeries (including the index case and any additional surgeries within 90 days), there was no significant difference in cost (from a hospital perspective) between the two groups.
Mean (± SE) Costs per patient"Shave" (n=119)"No Shave" (n=116)p-valueIndex surgery: OR costs$1315 (± $69)$1138 (± $52)0.042Pathology costs$1195 (± $43)$795 (± $48)< 0.001Total costs$4758 (± $123)$4133 (± $119)< 0.001Additional surgery: OR costs$94 (± $24)$247 (± $44)0.003Pathology costs$51 (± $18)$112 (± $21)0.031Total costs$332 (± $88)$983 (± $189)0.002Total 90 day surgery costs: OR costs$1409 (± $76)$1385 (± $64)0.808Pathology costs$1247 (± $49)$909 (± $52)< 0.001Total costs$5090 (± $166)$5116 (± $214)0.925
CONCLUSIONS: Taking routine CSM is associated with increased time and cost for the index surgery, but this is offset by the cost savings of reduced re-excision rates. While the strategies of "shave" and "no shave" are similar in terms of 90 day hospital-related costs, taking CSM is associated with a lower need for reoperative surgery, thereby reducing patient angst and improving utilization of surgeon and OR time.
Citation Format: Chagpar AB, Longley PB, Horowitz NR, Killelea BK, Tsangaris TN, Li F, Butler M, Stavris K, Yao X, Harigopal M, Bossuyt V, Lannin DR, Pusztai L, Loftus M, Davidoff AJ, Gross CP. Impact of routine cavity shave margins on time and money: Results from the SHAVE trial. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-13-01.
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Affiliation(s)
- AB Chagpar
- Yale University School of Medicine, New Haven, CT; Yale-New Haven Hospital, New Haven, CT; Thomas Jefferson University, Philadelphia, PA; Yale Center for Analytical Sciences, New Haven, CT; Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
| | - PB Longley
- Yale University School of Medicine, New Haven, CT; Yale-New Haven Hospital, New Haven, CT; Thomas Jefferson University, Philadelphia, PA; Yale Center for Analytical Sciences, New Haven, CT; Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
| | - NR Horowitz
- Yale University School of Medicine, New Haven, CT; Yale-New Haven Hospital, New Haven, CT; Thomas Jefferson University, Philadelphia, PA; Yale Center for Analytical Sciences, New Haven, CT; Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
| | - BK Killelea
- Yale University School of Medicine, New Haven, CT; Yale-New Haven Hospital, New Haven, CT; Thomas Jefferson University, Philadelphia, PA; Yale Center for Analytical Sciences, New Haven, CT; Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
| | - TN Tsangaris
- Yale University School of Medicine, New Haven, CT; Yale-New Haven Hospital, New Haven, CT; Thomas Jefferson University, Philadelphia, PA; Yale Center for Analytical Sciences, New Haven, CT; Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
| | - F Li
- Yale University School of Medicine, New Haven, CT; Yale-New Haven Hospital, New Haven, CT; Thomas Jefferson University, Philadelphia, PA; Yale Center for Analytical Sciences, New Haven, CT; Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
| | - M Butler
- Yale University School of Medicine, New Haven, CT; Yale-New Haven Hospital, New Haven, CT; Thomas Jefferson University, Philadelphia, PA; Yale Center for Analytical Sciences, New Haven, CT; Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
| | - K Stavris
- Yale University School of Medicine, New Haven, CT; Yale-New Haven Hospital, New Haven, CT; Thomas Jefferson University, Philadelphia, PA; Yale Center for Analytical Sciences, New Haven, CT; Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
| | - X Yao
- Yale University School of Medicine, New Haven, CT; Yale-New Haven Hospital, New Haven, CT; Thomas Jefferson University, Philadelphia, PA; Yale Center for Analytical Sciences, New Haven, CT; Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
| | - M Harigopal
- Yale University School of Medicine, New Haven, CT; Yale-New Haven Hospital, New Haven, CT; Thomas Jefferson University, Philadelphia, PA; Yale Center for Analytical Sciences, New Haven, CT; Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
| | - V Bossuyt
- Yale University School of Medicine, New Haven, CT; Yale-New Haven Hospital, New Haven, CT; Thomas Jefferson University, Philadelphia, PA; Yale Center for Analytical Sciences, New Haven, CT; Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
| | - DR Lannin
- Yale University School of Medicine, New Haven, CT; Yale-New Haven Hospital, New Haven, CT; Thomas Jefferson University, Philadelphia, PA; Yale Center for Analytical Sciences, New Haven, CT; Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
| | - L Pusztai
- Yale University School of Medicine, New Haven, CT; Yale-New Haven Hospital, New Haven, CT; Thomas Jefferson University, Philadelphia, PA; Yale Center for Analytical Sciences, New Haven, CT; Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
| | - M Loftus
- Yale University School of Medicine, New Haven, CT; Yale-New Haven Hospital, New Haven, CT; Thomas Jefferson University, Philadelphia, PA; Yale Center for Analytical Sciences, New Haven, CT; Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
| | - AJ Davidoff
- Yale University School of Medicine, New Haven, CT; Yale-New Haven Hospital, New Haven, CT; Thomas Jefferson University, Philadelphia, PA; Yale Center for Analytical Sciences, New Haven, CT; Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
| | - CP Gross
- Yale University School of Medicine, New Haven, CT; Yale-New Haven Hospital, New Haven, CT; Thomas Jefferson University, Philadelphia, PA; Yale Center for Analytical Sciences, New Haven, CT; Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
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Jodari M, Loftus M, Gleghorn J, Gakhar G, Pratt E, Tagawa ST, Bander NH, Giannakakou P, Kirby B, Nanus DM. Capture and analysis of prostate cancer circulating tumor cells (CTCS) using geometrically enhanced differential immunocapture (GEDI). J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.7_suppl.53] [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: 11/20/2022] Open
Abstract
53 Background: EpCAM-based immunocapture of prostate cancer (PC) CTCs yields relatively low purity and specificity. We developed a geometrically enhanced differential immunocapture (GEDI) microfluidic device that incorporates flow dynamics and utilizes a mAb to prostate-specific membrane antigen (PSMA) to optimize isolation and analysis of CTCs from PC patients. Methods: GEDI microfluidic silicon chips, fabricated using standard photolithography techniques, were functionalized by chemical cross-linking ending with a neutravidin terminated surface to which anti-PSMA biotinylated-mAb J591 was bound. C4-2 (PSMA+) and PC-3 (PSMA-) cells were used for chip optimization. 1 mL of peripheral blood from PC patients was flowed (1mL/hour) over functionalized chips. Captured cells were washed with PBS × 30 min, fixed with 3.7% formaldehyde, immunofluorescently stained for DAPI, androgen receptor (AR), tubulin and EpCAM and analyzed by high resolution point-scanning confocal microscopy. PSMA+, DAPI+, and CD45- cells were manually scored. RNA was extracted from unfixed captured CTCs using lysis buffer flowed thru the chip. Results: ∼80% capture efficiency was achieved from 26 PSMA positive C4-2 cells spiked into 1 mL blood flowed through the GEDI chip. RNA extracted from 50 C4-2 cells in 1 mL blood flowed thru the chip detected a known AR point mutation by RT-PCR and Sanger sequencing. Immunofluorescence staining of PSMA+ cells captured on the chip detected changes in AR subcellular localization and microtubule structure following treatment with DHT or paclitaxel, respectively. 10 patients with metastatic PC were analyzed by CellSearch (range 0-201 cells/7.5 mL) and GEDI chip (range 35->1200 cells/mL) yielding a 7->350 fold enrichment using GEDI. Captured PC cells isolated from PC patient incubated in 50 nm paclitaxel (ex vivo) overnight demonstrated microtubule bundling, indicative of drug-target engagement. Conclusions: PSMA based GEDI microfluidic CTC capture is highly specific and sensitive in capturing PSMA positive PC CTCs; and allows detailed CTC analysis including protein expression and subcellular localization, mutational analysis and drug sensitivity assessment. [Table: see text]
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Affiliation(s)
- M. Jodari
- Weill Cornell Medical College, New York, NY; Cornell University, Ithaca, NY
| | - M. Loftus
- Weill Cornell Medical College, New York, NY; Cornell University, Ithaca, NY
| | - J. Gleghorn
- Weill Cornell Medical College, New York, NY; Cornell University, Ithaca, NY
| | - G. Gakhar
- Weill Cornell Medical College, New York, NY; Cornell University, Ithaca, NY
| | - E. Pratt
- Weill Cornell Medical College, New York, NY; Cornell University, Ithaca, NY
| | - S. T. Tagawa
- Weill Cornell Medical College, New York, NY; Cornell University, Ithaca, NY
| | - N. H. Bander
- Weill Cornell Medical College, New York, NY; Cornell University, Ithaca, NY
| | - P. Giannakakou
- Weill Cornell Medical College, New York, NY; Cornell University, Ithaca, NY
| | - B. Kirby
- Weill Cornell Medical College, New York, NY; Cornell University, Ithaca, NY
| | - D. M. Nanus
- Weill Cornell Medical College, New York, NY; Cornell University, Ithaca, NY
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McElhinny A, Ranger-Moore J, Loftin I, Wang L, Loftus M, Tubbs R, Grogan T, Roche P. PP44 Development of a quantitative scoring algorithm for a Dual-Hapten, Dual-Color ISH assay (DDISH) to determine HER2 gene status. EJC Suppl 2009. [DOI: 10.1016/s1359-6349(09)72188-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Tubbs R, Loftin I, Wang L, Miller R, Sugarman M, Loftus M, Pettay J, Ranger-Moore J, McElhinny A, Roche P. PP45 Analytical performance of a novel dual color dual hapten brightfield genotypic assay for determination of HER2 status in breast carcinoma (DDISH). EJC Suppl 2009. [DOI: 10.1016/s1359-6349(09)72216-5] [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: 10/20/2022] Open
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10
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Willey B, Gnanasuntharam P, Rostas A, Porter V, Kreiswirth N, Louie L, Le V, Boyd E, Loftus M, McGeer A, Svoboda T, Wong H, Gelosia A, Low D, Borgundvaag B. P269 Molecular diversity of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) in Toronto. Int J Antimicrob Agents 2009. [DOI: 10.1016/s0924-8579(09)70488-1] [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: 10/20/2022]
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Tubbs RR, Nitta H, Gaire F, Dietel M, Loftus M, Pettay J, Grogan TM. Concomitant delineation of HER2 gene amplification and protein expression status using a two-color bright field immunogenotypic assay (SISHPro HER2). J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.22006] [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: 11/20/2022] Open
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Nitta H, Hauss-Wegrzyniak B, Lehrkamp M, Gaire F, Kurosumi M, Dietel M, Loftus M, Pettay J, Tubbs RR, Grogan TM. Development of automated brightfield HER2 and chromosome 17 centromere (CEN17) double in situ hybridization application for breast carcinomas and its performance comparison to manual HER2 fluorescence in situ hybridization (FISH). J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.11080] [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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Loftus M. Special report E-learning. But what's it like? US News World Rep 2001; 131:56-7. [PMID: 11682875] [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: 02/22/2023]
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Loftus M, Knight RT, Amaral DG. An analysis of atrophy in the medial mammillary nucleus following hippocampal and fornix lesions in humans and nonhuman primates. Exp Neurol 2000; 163:180-90. [PMID: 10785457 DOI: 10.1006/exnr.2000.7361] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Lesions of the hippocampal formation or transections of the fornix are followed by shrinkage of the medial mammillary nucleus (MMN). We determined whether the shrinkage of this nucleus was due to loss and/or shrinkage of neurons in addition to the loss of neuropil. We examined the MMN in a patient (KB) with an infarct that led to marked atrophy of the left hippocampus and subiculum, leaving the right MMN intact. Unbiased, stereological measurement techniques were used to compare the total cell number and individual neuronal cross-sectional areas in both left and right MMN in this patient and in two control human brains. We also analyzed the MMN in four macaque monkeys that underwent experimental unilateral transections of the fornix. The volume of the MMN on the lesioned side in KB was 55% of the unlesioned side (2.8 mm(3) vs 5.1 mm(3)); the MMN in the monkey cases were reduced to 47-58% of the volume of the nonlesioned side. Neurons in the deafferented MMN of KB and of the monkey subjects were decreased in cross-sectional area (16-20%, P < 0.0001). There was a trend toward decreased cell numbers (11-15%) on the lesioned side in all cases. We have estimated that the loss in cell number and shrinkage of remaining cells contribute negligibly to the 45% reduction in MMN volume. Therefore, the loss of neuropil (dendrites and afferent and efferent axons) appears to be the major contributor to the change in MMN volume.
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Affiliation(s)
- M Loftus
- Department of Psychiatry, University of California at Davis, Davis, California 95616, USA
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Tzeng E, Billiar TR, Robbins PD, Loftus M, Stuehr DJ. Expression of human inducible nitric oxide synthase in a tetrahydrobiopterin (H4B)-deficient cell line: H4B promotes assembly of enzyme subunits into an active dimer. Proc Natl Acad Sci U S A 1995; 92:11771-5. [PMID: 8524846 PMCID: PMC40484 DOI: 10.1073/pnas.92.25.11771] [Citation(s) in RCA: 141] [Impact Index Per Article: 4.9] [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: 01/31/2023] Open
Abstract
Murine inducible nitric oxide (NO) synthase (iNOS) is catalytically active only in dimeric form. Assembly of its purified subunits into a dimer requires H4B. To understand the structure-activity relationships of human iNOS, we constitutively expressed recombinant human iNOS in NIH 3T3 cells by using a retroviral vector. These cells are deficient in de novo H4B biosynthesis and the role of H4B in the expression and assembly of active iNOS in an intact cell system could be studied. In the absence of added H4B, NO synthesis by the cells was minimal, whereas cells grown with supplemental H4B or the H4B precursor sepiapterin generated NO (74.1 and 63.3 nmol of nitrite per 10(6) cells per 24 h, respectively). NO synthesis correlated with an increase in intracellular H4B but no increase in iNOS protein. Instead, an increased percentage of dimeric iNOS was observed, rising from 20% in cytosols from unsupplemented cells to 66% in H4B-supplemented cell cytosols. In all cases, only dimeric iNOS displayed catalytic activity. Cytosols prepared from H4B-deficient cells exhibited little iNOS activity but acquired activity during a 60- to 120-min incubation with H4B, reaching final activities of 60-72 pmol of citrulline per mg of protein per min. Reconstitution of cytosolic NO synthesis activity was associated with conversion of monomers into dimeric iNOS during the incubation. Thus, human iNOS subunits dimerize to form an active enzyme, and H4B plays a critical role in promoting dimerization in intact cells. This reveals a post-translational mechanism by which intracellular H4B can regulate iNOS expression.
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Affiliation(s)
- E Tzeng
- Department of Surgery, University of Pittsburgh, PA 15261, USA
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Abu-Soud HM, Loftus M, Stuehr DJ. Subunit dissociation and unfolding of macrophage NO synthase: relationship between enzyme structure, prosthetic group binding, and catalytic function. Biochemistry 1995; 34:11167-75. [PMID: 7545434 DOI: 10.1021/bi00035a023] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.6] [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: 01/25/2023]
Abstract
Macrophage NO synthase is a homodimer of 130 kDa subunits. Each subunit contains an oxygenase domain that binds iron protoporphyrin IX (heme) and tetrahydrobiopterin (H4biopterin) and a reductase domain that binds FAD, FMN, and calmodulin (CaM) [Ghosh & Stuehr (1995) Biochemistry 34, 801-807]. We have studied the dissociation and unfolding reactions of dimeric iNOS in urea to learn how enzyme structure relates to catalysis and prosthetic group binding. The iNOS dimer dissociated between 0 and 2.5 M urea, and the subunits partially unfolded at 2.5 M urea and above. Dimer dissociation was accompanied by loss of NO synthesis activity and release of bound H4biopterin from the protein. However, the dissociated subunits maintained their cytochrome c and ferricyanide reductase activities and retained near stoichiometric quantities of bound heme. The subunit unfolding transition was accompanied by loss of reductase activities and partial loss of bound heme but retention of bound flavins and CaM. The heme iron in the dissociated subunits remained coordinated through axial cysteine thiolate ligation. Kinetic analysis of dimer dissociation showed that loss of NO synthesis correlated with a loss of heme Soret absorbance at 398 nm and an appearance of absorbance bands at 377 and 460 nm, which were attributed to DTT coordination to the sixth position of the heme iron to form a mixed bisthiolate complex. Subunits could reassociate into a dimer when incubated with L-arginine and H4biopterin. Dimer formation correlated with proportional recoveries of NO synthesis and heme Soret absorbance at 398 nm. Thus, dimeric iNOS undergoes separate dissociation and unfolding transitions in urea, and each transition is accompanied by a loss of a specific catalytic function.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- H M Abu-Soud
- Department of Immunology, Cleveland Clinic, Ohio 44195, USA
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Bate AS, Sidebottom D, Cooper RG, Loftus M, Chattopadhyay C, Grennan DM. DNA variants of alpha-1-antitrypsin in rheumatoid arthritis with and without pulmonary complications. Dis Markers 1990; 8:317-21. [PMID: 1983194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Restriction fragment length polymorphisms (RFLPs) of alpha-1-antitrypsin were studied in 99 subjects with rheumatoid arthritis alone, 21 subjects with rheumatoid arthritis and pulmonary fibrosis, 26 subjects with rheumatoid arthritis and bronchiectasis, and 86 controls. No associations with either rheumatoid arthritis itself or with the associated pulmonary disorders were noted in this U.K. Caucasoid population.
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Affiliation(s)
- A S Bate
- Rheumatic Diseases Centre, Hope Hospital, Salford, Manchester, U.K
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Clements DB, Copeland LG, Loftus M. Critical times for families with a chronically ill child. Pediatr Nurs 1990; 16:157-61, 224. [PMID: 2359641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Parents identified difficult times in caring for their chronically ill children. A model describing these critical times was developed through an analysis of parent interviews. Predicting these critical times enables the health care team to optimize and maximize the effectiveness of their interventions.
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Abstract
This paper presents an account of setting up and running an "Action Group" in an out-patient setting. The ideas and aims underlying "Action Groups" are presented through a contrast with Social Skills Training. The paper illustrates the way in which this "therapeutic philosophy" informs the details which are attended to in defining such a group's boundaries, procedure and purpose. A typical group session is described, and the paper seeks to illustrate how the therapeutic potency of such work is intimately related to the clarity of the group's boundaries and structure.
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Affiliation(s)
- M Loftus
- Department of Psychology, St. Crispin Hospital, Northampton, U.K
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