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Sagi V, Kosaraju N, Moore LS, Mulders JY, Solyali M, Ma X, Regula DP, Hooper JE, Stankovic KM. Mortui vivos docent: a modern revival of temporal bone plug harvests. Front Neurosci 2023; 17:1242831. [PMID: 37886674 PMCID: PMC10598599 DOI: 10.3389/fnins.2023.1242831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/04/2023] [Indexed: 10/28/2023] Open
Abstract
Human temporal bones (HTBs) are invaluable resources for the study of otologic disorders and for evaluating novel treatment approaches. Given the high costs and technical expertise required to collect and process HTBs, there has been a decline in the number of otopathology laboratories. Our objective is to encourage ongoing study of HTBs by outlining the necessary steps to establish a pipeline for collection and processing of HTBs. In this methods manuscript, we: (1) provide the design of a temporal bone plug sawblade that can be used to collect specimens from autopsy donors; (2) establish that decalcification time can be dramatically reduced from 9 to 3 months if ethylenediaminetetraacetic acid is combined with microwave tissue processing and periodic bone trimming; (3) show that serial sections of relatively-rapidly decalcified HTBs can be successfully immunostained for key inner ear proteins; (4) demonstrate how to drill down a HTB to the otic capsule within a few hours so that subsequent decalcification time can be further reduced to only weeks. We include photographs and videos to facilitate rapid dissemination of the developed methods. Collected HTBs can be used for many purposes, including, but not limited to device testing, imaging studies, education, histopathology, and molecular studies. As new technology develops, it is imperative to continue studying HTBs to further our understanding of the cellular and molecular underpinnings of otologic disorders.
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Affiliation(s)
- Varun Sagi
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Nikitha Kosaraju
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States
- David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Lindsay S. Moore
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Jip Y. Mulders
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Mehmet Solyali
- Department of Physics, Stanford University School of Humanities and Sciences, Stanford, CA, United States
| | - Xiaojie Ma
- Department of Otolaryngology – Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, United States
| | - Donald P. Regula
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
| | - Jody E. Hooper
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
| | - Konstantina M. Stankovic
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
- Wu Tsai Neurosciences Institute, Stanford University, Stanford, CA, United States
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2
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Natarajan N, Batts S, Gombar S, Manickam R, Sagi V, Curhan SG, Stankovic KM. Associations of Tinnitus Incidence with Use of Tumor Necrosis Factor-Alpha Inhibitors among Patients with Autoimmune Conditions. J Clin Med 2023; 12:jcm12051935. [PMID: 36902722 PMCID: PMC10004033 DOI: 10.3390/jcm12051935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/20/2023] [Accepted: 02/24/2023] [Indexed: 03/05/2023] Open
Abstract
Tumor necrosis factor-alpha (TNFα) may promote neuroinflammation prompting tinnitus. This retrospective cohort study evaluated whether anti-TNFα therapy influences incident tinnitus risk among adults with autoimmune disorders and no baseline tinnitus selected from a US electronic health records database (Eversana; 1 January 2010-27 January 2022). Patients with anti-TNFα had ≥90-day history pre-index (first autoimmune disorder diagnosis) and ≥180-day follow-up post-index. Random samples (n = 25,000) of autoimmune patients without anti-TNFα were selected for comparisons. Tinnitus incidence was compared among patients with or without anti-TNFα therapy, overall and among at-risk age groups or by anti-TNFα category. High-dimensionality propensity score (hdPS) matching was used to adjust for baseline confounders. Compared with patients with no anti-TNFα, anti-TNFα was not associated with tinnitus risk overall (hdPS-matched HR [95% CI]: 1.06 [0.85, 1.33]), or between groups stratified by age (30-50 years: 1 [0.68, 1.48]; 51-70 years: 1.18 [0.89, 1.56]) or anti-TNFα category (monoclonal antibody vs. fusion protein: 0.91 [0.59, 1.41]). Anti-TNFα was not associated with tinnitus risk among those treated for ≥6 months (hdPS-matched HR [95% CI]: 0.96 [0.69, 1.32]) or ≥12 (1.03 [0.71, 1.5]), or those with RA (1.16 [0.88, 1.53]). Thus, in this US cohort study, anti-TNFα therapy was not associated with tinnitus incidence among patients with autoimmune disorders.
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Affiliation(s)
- Nirvikalpa Natarajan
- Department of Otolaryngology—Head and Neck Surgery, Stanford University School of Medicine, 801 Welch Rd, Palo Alto, CA 94304, USA
| | - Shelley Batts
- Department of Otolaryngology—Head and Neck Surgery, Stanford University School of Medicine, 801 Welch Rd, Palo Alto, CA 94304, USA
| | - Saurabh Gombar
- Atropos Health, 71 W 83rd St #3R., New York, NY 10024, USA
- Department of Pathology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Raj Manickam
- Atropos Health, 71 W 83rd St #3R., New York, NY 10024, USA
| | - Varun Sagi
- Department of Otolaryngology—Head and Neck Surgery, Stanford University School of Medicine, 801 Welch Rd, Palo Alto, CA 94304, USA
| | - Sharon G. Curhan
- Channing Division of Network Medicine, Brigham and Women’s Hospital and Harvard Medical School, 181 Longwood Avenue, Boston, MA 02115, USA
| | - Konstantina M. Stankovic
- Department of Otolaryngology—Head and Neck Surgery, Stanford University School of Medicine, 801 Welch Rd, Palo Alto, CA 94304, USA
- Department of Neurosurgery, Stanford University School of Medicine, 801 Welch Rd, Palo Alto, CA 94304, USA
- Wu Tsai Neuroscience Institute, Stanford University, 288 Campus Dr, Stanford, CA 94305, USA
- Correspondence:
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Cherukury HM, Argueta DA, Garcia N, Fouda R, Kiven S, Lei J, Sagi V, Velasco GJ, Avalos B, DiPatrizio NV, Gupta K. Cannabidiol attenuates hyperalgesia in a mouse model of sickle cell disease. Blood 2023; 141:203-208. [PMID: 36122382 PMCID: PMC9936305 DOI: 10.1182/blood.2022016382] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 08/17/2022] [Accepted: 09/04/2022] [Indexed: 01/17/2023] Open
Affiliation(s)
- Hemanth M. Cherukury
- Division of Hematology/Oncology, Department of Medicine, University of California, Irvine, Irvine, CA
| | - Donovan A. Argueta
- Division of Hematology/Oncology, Department of Medicine, University of California, Irvine, Irvine, CA
| | - Natalie Garcia
- Division of Hematology/Oncology, Department of Medicine, University of California, Irvine, Irvine, CA
| | - Raghda Fouda
- Division of Hematology/Oncology, Department of Medicine, University of California, Irvine, Irvine, CA
| | - Stacy Kiven
- Division of Hematology/Oncology, Department of Medicine, University of California, Irvine, Irvine, CA
| | - Jianxun Lei
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Varun Sagi
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | | | - Bryant Avalos
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, Riverside, CA
| | - Nicholas V. DiPatrizio
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, Riverside, CA
| | - Kalpna Gupta
- Division of Hematology/Oncology, Department of Medicine, University of California, Irvine, Irvine, CA
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
- Southern California Institute for Research and Education, VA Medical Center, Long Beach, CA
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4
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Bommakanti KK, Iyer JS, Sagi V, Brown A, Ma X, Gonzales M, Stankovic KM. Reversible contrast enhancement for visualization of human temporal bones using micro computed tomography. Front Surg 2022; 9:952348. [PMID: 36268215 PMCID: PMC9577409 DOI: 10.3389/fsurg.2022.952348] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/08/2022] [Indexed: 11/13/2022] Open
Abstract
Sensorineural hearing loss (SNHL), which typically arises from the inner ear, is the most common sensory deficit worldwide. The traditional method for studying pathophysiology underlying human SNHL involves histological processing of the inner ear from temporal bones collected during autopsy. Histopathological analysis is destructive and limits future use of a given specimen. Non-destructive strategies for the study of the inner ear are urgently needed to fully leverage the utility of each specimen because access to human temporal bones is increasingly difficult and these precious specimens are required to uncover disease mechanisms and to enable development of new devices. We highlight the potential of reversible iodine staining for micro-computed tomography imaging of the human inner ear. This approach provides reversible, high-resolution visualization of intracochlear structures and is becoming more rapid and accessible.
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Affiliation(s)
- Krishna K. Bommakanti
- Department of Head / Neck Surgery, University of California Los Angeles, Los Angeles, CA, United States,Department of Otolaryngology – Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, United States
| | - Janani S. Iyer
- Department of Otolaryngology – Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, United States,Department of Otolaryngology, Harvard Medical School, Boston, MA, United States,Program in Speech and Hearing Bioscience and Technology, Harvard University Graduate School of Arts and Sciences, Cambridge, MA, United States
| | - Varun Sagi
- Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States,University of Minnesota Medical School, Minneapolis, MN, United States
| | - Alyssa Brown
- Department of Otolaryngology – Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, United States
| | - Xiaojie Ma
- Department of Otolaryngology – Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, United States,Department of Otolaryngology, Harvard Medical School, Boston, MA, United States
| | - Marissa Gonzales
- Department of Otolaryngology – Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, United States
| | - Konstantina M. Stankovic
- Department of Otolaryngology – Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, United States,Department of Otolaryngology, Harvard Medical School, Boston, MA, United States,Department of Otolaryngology – Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States,Correspondence: Konstantina M. Stankovic
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5
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Sagi V, Kraft E, Venteicher AS, Tyler MA. Spontaneous cerebrospinal fluid leak due to severe sinonasal granulomatosis with polyangiitis. Otolaryngology Case Reports 2022. [DOI: 10.1016/j.xocr.2022.100435] [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: 10/18/2022] Open
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Shahriar AA, Puram VV, Miller JM, Sagi V, Castañón-Gonzalez LA, Prasad S, Crichlow R. Socioeconomic Diversity of the Matriculating US Medical Student Body by Race, Ethnicity, and Sex, 2017-2019. JAMA Netw Open 2022; 5:e222621. [PMID: 35289863 PMCID: PMC8924719 DOI: 10.1001/jamanetworkopen.2022.2621] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This survey study compares the socioeconomic composition of the 2017 to 2019 matriculating medical student body with that of the US population, by self-identified race and ethnicity and by sex.
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Affiliation(s)
| | | | | | - Varun Sagi
- University of Minnesota Medical School, Minneapolis
| | | | - Shailendra Prasad
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis
| | - Renée Crichlow
- Codman Square Health Center, Boston, Massachusetts
- Department of Family Medicine, Boston University, Boston, Massachusetts
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Jeong M, Bojkovic K, Sagi V, Stankovic KM. Molecular and Clinical Significance of Fibroblast Growth Factor 2 in Development and Regeneration of the Auditory System. Front Mol Neurosci 2022; 14:757441. [PMID: 35002617 PMCID: PMC8733209 DOI: 10.3389/fnmol.2021.757441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 08/12/2021] [Accepted: 11/18/2021] [Indexed: 01/25/2023] Open
Abstract
The fibroblast growth factor 2 (FGF2) is a member of the FGF family which is involved in key biological processes including development, cellular proliferation, wound healing, and angiogenesis. Although the utility of the FGF family as therapeutic agents has attracted attention, and FGF2 has been studied in several clinical contexts, there remains an incomplete understanding of the molecular and clinical function of FGF2 in the auditory system. In this review, we highlight the role of FGF2 in inner ear development and hearing protection and present relevant clinical studies for tympanic membrane (TM) repair. We conclude by discussing the future implications of FGF2 as a potential therapeutic agent.
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Affiliation(s)
- Minjin Jeong
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, United States
| | - Katarina Bojkovic
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, United States
| | - Varun Sagi
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States.,University of Minnesota Medical School, Minneapolis, MN, United States
| | - Konstantina M Stankovic
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, United States
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8
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Moon IS, Grant AR, Sagi V, Rehm HL, Stankovic KM. TMPRSS3 Gene Variants With Implications for Auditory Treatment and Counseling. Front Genet 2021; 12:780874. [PMID: 34868270 PMCID: PMC8641783 DOI: 10.3389/fgene.2021.780874] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 09/21/2021] [Accepted: 10/18/2021] [Indexed: 11/24/2022] Open
Abstract
Objective: To identify and report novel variants in the TMPRSS3 gene and their clinical manifestations related to hearing loss as well as intervention outcomes. This information will be helpful for genetic counseling and treatment planning for these patients. Methods: Literature review of previously reported TMPRSS3 variants was conducted. Reported variants and associated clinical information was compiled. Additionally, cohort data from 18 patients, and their families, with a positive result for TMPRSS3-associated hearing loss were analyzed. Genetic testing included sequencing and copy number variation (CNV) analysis of TMPRSS3 and the Laboratory for Molecular Medicine’s OtoGenome-v1, -v2, or -v3 panels. Clinical data regarding patient hearing rehabilitation was interpreted along with their genetic testing results and in the context of previously reported cochlear implant outcomes in individuals with TMPRSS3 variants. Results: There have been 87 previously reported TMPRSS3 variants associated with non-syndromic hearing loss in more than 20 ancestral groups worldwide. Here we report occurrences of known variants as well as one novel variant: deletion of Exons 1–5 and 13 identified from our cohort of 18 patients. The hearing impairment in many of these families was consistent with that of previously reported patients with TMPRSS3 variants (i.e., typical down-sloping audiogram). Four patients from our cohort underwent cochlear implantation. Conclusion: Bi-allelic variants of TMPRSS3 are associated with down-sloping hearing loss regardless of ancestry. The outcome following cochlear implantation in patients with variants of TMPRSS3 is excellent. Therefore, cochlear implantation is strongly recommended for hearing rehabilitation in these patients.
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Affiliation(s)
- In Seok Moon
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, United States.,Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea
| | - Andrew R Grant
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, United States.,New York Medical College, Valhalla, NY, United States
| | - Varun Sagi
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States.,University of Minnesota Medical School, Minneapolis, MN, United States
| | - Heidi L Rehm
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, United States.,Center for Genomic Medicine and Departments of Pathology and Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Konstantina M Stankovic
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, United States.,Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, United States
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9
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Sagi V, Mittal A, Tran H, Gupta K. Pain in sickle cell disease: current and potential translational therapies. Transl Res 2021; 234:141-158. [PMID: 33711512 PMCID: PMC8217144 DOI: 10.1016/j.trsl.2021.03.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/02/2021] [Accepted: 03/06/2021] [Indexed: 12/26/2022]
Abstract
Pain is a major comorbidity of sickle cell disease (SCD). Patients with SCD may suffer from both acute and chronic pain. Acute pain is caused by recurrent and unpredictable episodes of vaso-occlusive crises (VOC), whereas the exact etiology of chronic pain is still unknown. Opioids are the mainstay for pain treatment, but the opioid epidemic has significantly altered access to prescription opioids and has brought concerns over their long-term use into the forefront, which have negatively impacted the treatment of sickle pain. Opioids remain potent analgesics but growing opioid-phobia has led to the realization of an unmet need to develop nonopioid therapies that can provide relief for severe sickle pain. This realization has contributed to the approval of 3 different drugs by the Food and Drug Administration (FDA) for the treatment of SCD, particularly to reduce VOC and/or have an impact on the pathobiology of SCD. In this review, we outline the challenges and need for validation of side-effects of opioids and provide an update on the development of mechanism-based translational therapies, specifically targeting pain in SCD.
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Affiliation(s)
- Varun Sagi
- School of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Aditya Mittal
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Huy Tran
- School of Medicine, Kansas City University, Joplin, Missouri
| | - Kalpna Gupta
- Hematology/Oncology, Department of Medicine, University of California, Irvine and Southern California Institute for Research and Education, VA Medical Center, Long Beach, California.
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10
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Shahriar AA, Sagi V, Castañón-Gonzalez LA, Kottke TE, Vazquez-Benitez G, Crichlow R. Comparison of Medical School Financing Plans Among Matriculating US Medical Students From 2017 to 2019. JAMA Netw Open 2021; 4:e2117704. [PMID: 34283231 PMCID: PMC8293019 DOI: 10.1001/jamanetworkopen.2021.17704] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This survey study explores US students’ financing plans for medical school overall and by several demographic factors, focusing on race/ethnicity and household income.
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Affiliation(s)
| | - Varun Sagi
- University of Minnesota Medical School, Minneapolis
| | | | | | | | - Renée Crichlow
- Codman Square Health Center, Boston, Massachusetts
- Department of Family Medicine, Boston University, Boston, Massachusetts
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11
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Gupta M, Sagi V, Mittal A, Yekula A, Hawkins D, Shimizu J, Duddleston PJ, Thomas K, Goetsch SJ, Alksne JF, Hodgens DW, Ott K, Shimizu KT, Duma C, Ben-Haim S. Results of three or more Gamma Knife radiosurgery procedures for recurrent trigeminal neuralgia. J Neurosurg 2021; 135:1789-1798. [PMID: 34852325 DOI: 10.3171/2020.10.jns202323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 10/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Gamma Knife radiosurgery (GKRS) is an established surgical option for the treatment of trigeminal neuralgia (TN), particularly for high-risk surgical candidates and those with recurrent pain. However, outcomes after three or more GKRS treatments have rarely been reported. Herein, the authors reviewed outcomes among patients who had undergone three or more GKRS procedures for recurrent TN. METHODS The authors conducted a multicenter retrospective analysis of patients who had undergone at least three GKRS treatments for TN between July 1997 and April 2019 at two different institutions. Clinical characteristics, radiosurgical dosimetry and technique, pain outcomes, and complications were reviewed. Pain outcomes were scored on the Barrow Neurological Institute (BNI) scale, including time to pain relief (BNI score ≤ III) and recurrence (BNI score > III). RESULTS A total of 30 patients were identified, including 16 women and 14 men. Median pain duration prior to the first GKRS treatment was 10 years. Three patients (10%) had multiple sclerosis. Time to pain relief was longer after the third treatment (p = 0.0003), whereas time to pain recurrence was similar across each of the successive treatments (p = 0.842). Complete or partial pain relief was achieved in 93.1% of patients after the third treatment. The maximum pain relief achieved after the third treatment was significantly better among patients with no prior percutaneous procedures (p = 0.0111) and patients with shorter durations of pain before initiation of GKRS therapy (p = 0.0449). New or progressive facial sensory dysfunction occurred in 29% of patients after the third GKRS treatment and was reported as bothersome in 14%. One patient developed facial twitching, while another experienced persistent lacrimation. No statistically significant predictors of adverse effects following the third treatment were found. Over a median of 39 months of follow-up, 77% of patients maintained complete or partial pain relief. Three patients underwent a fourth GKRS treatment, including one who ultimately received five treatments; all of them reported sustained pain relief at the extended follow-up. CONCLUSIONS The authors describe the largest series to date of patients undergoing three or more GKRS treatments for refractory TN. A third treatment may produce outcomes similar to those of the first two treatments in terms of long-term pain relief, recurrence, and adverse effects.
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Affiliation(s)
- Mihir Gupta
- 1Department of Neurosurgery, University of California San Diego, La Jolla, California
| | - Varun Sagi
- 2School of Medicine, University of Minnesota Twin Cities, Minneapolis, Minnesota
| | - Aditya Mittal
- 3School of Medicine, University of Pittsburgh, Pennsylvania
| | - Anudeep Yekula
- 4Department of Neurosurgery, Massachusetts General Hospital, Boston
| | - Devan Hawkins
- 5Department of Public Health, School of Arts and Sciences, Massachusetts College of Pharmacy and Health Sciences, Boston, Massachusetts
| | | | | | | | | | - John F Alksne
- 1Department of Neurosurgery, University of California San Diego, La Jolla, California.,9San Diego Gamma Knife Center, San Diego, California
| | | | - Kenneth Ott
- 9San Diego Gamma Knife Center, San Diego, California
| | | | | | - Sharona Ben-Haim
- 1Department of Neurosurgery, University of California San Diego, La Jolla, California.,9San Diego Gamma Knife Center, San Diego, California
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Tran H, Sagi V, Jarrett S, Palzer EF, Badgaiyan RD, Gupta K. Diet and companionship modulate pain via a serotonergic mechanism. Sci Rep 2021; 11:2330. [PMID: 33526805 PMCID: PMC7851147 DOI: 10.1038/s41598-021-81654-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 05/30/2018] [Accepted: 01/08/2021] [Indexed: 01/30/2023] Open
Abstract
Treatment of severe chronic and acute pain in sickle cell disease (SCD) remains challenging due to the interdependence of pain and psychosocial modulation. We examined whether modulation of the descending pain pathway through an enriched diet and companionship could alleviate pain in transgenic sickle mice. Mechanical and thermal hyperalgesia were reduced significantly with enriched diet and/or companionship. Upon withdrawal of both conditions, analgesic effects observed prior to withdrawal were diminished. Serotonin (5-hydroxytryptamine, 5-HT) was found to be increased in the spinal cords of mice provided both treatments. Additionally, 5-HT production improved at the rostral ventromedial medulla and 5-HT accumulated at the dorsal horn of the spinal cord of sickle mice, suggesting the involvement of the descending pain pathway in the analgesic response. Modulation of 5-HT and its effect on hyperalgesia was also investigated through pharmaceutical approaches. Duloxetine, a serotonin-norepinephrine reuptake inhibitor, showed a similar anti-nociceptive effect as the combination of diet and companionship. Depletion of 5-HT through p-chlorophenylalanine attenuated the anti-hyperalgesic effect of enriched diet and companionship. More significantly, improved diet and companionship enhanced the efficacy of a sub-optimal dose of morphine for analgesia in sickle mice. These findings offer the potential to reduce opioid use without pharmacological interventions to develop effective pain management strategies.
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Affiliation(s)
- Huy Tran
- grid.17635.360000000419368657 Division of Hematology, Oncology and Transplantation, Department of Medicine, Vascular Biology Center, University of Minnesota, Minneapolis, MN USA
| | - Varun Sagi
- grid.17635.360000000419368657 Division of Hematology, Oncology and Transplantation, Department of Medicine, Vascular Biology Center, University of Minnesota, Minneapolis, MN USA
| | - Sarita Jarrett
- grid.16753.360000 0001 2299 3507Northwestern University, Evanston, IL USA
| | - Elise F. Palzer
- grid.17635.360000000419368657Biostatistical Design and Analysis Center, Clinical and Translational Sciences Institute, University of Minnesota, Minneapolis, MN USA
| | - Rajendra D. Badgaiyan
- grid.267309.90000 0001 0629 5880Department of Psychiatry, Long School of Medicine, University of Texas Health Science Center, San Antonio, Texas USA
| | - Kalpna Gupta
- grid.17635.360000000419368657 Division of Hematology, Oncology and Transplantation, Department of Medicine, Vascular Biology Center, University of Minnesota, Minneapolis, MN USA ,Hematology/Oncology, Department of Medicine, University of California, Irvine and Southern California Institute for Research and Education, VA Medical Center, 5901 East 7th St, Long Beach, CA 90822 USA
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13
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Argueta DA, Aich A, Muqolli F, Cherukury H, Sagi V, DiPatrizio NV, Gupta K. Considerations for Cannabis Use to Treat Pain in Sickle Cell Disease. J Clin Med 2020; 9:E3902. [PMID: 33271850 PMCID: PMC7761429 DOI: 10.3390/jcm9123902] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 09/21/2020] [Revised: 11/22/2020] [Accepted: 11/26/2020] [Indexed: 12/18/2022] Open
Abstract
Pain in Sickle Cell Disease (SCD) is a major comorbidity and unique with acute pain due to recurrent and episodic vaso-occlusive crises as well as chronic pain, which can span an individual's entire life. Opioids are the mainstay treatment for pain in SCD. Due to recent health crises raised by adverse effects including deaths from opioid use, pain management in SCD is adversely affected. Cannabis and its products are most widely used for pain in multiple conditions and also by patients with SCD on their own. With the availability of "Medical Cannabis" and approval to use cannabis as medicine across majority of States in the United States as well as over-the-counter preparations, cannabis products are being used increasingly for SCD. The reliability of many of these products remains questionable, which poses a major health risk to the vulnerable individuals seeking pain relief. Therefore, this review provides up to date insights into available categories of cannabis-based treatment strategies, their mechanism of action and pre-clinical and clinical outcomes in SCD. It provides evidence for the benefits and risks of cannabis use in SCD and cautions about the unreliable and unvalidated products that may be adulterated with life-threatening non-cannabis compounds.
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Affiliation(s)
- Donovan A. Argueta
- Hematology/Oncology, Department of Medicine, University of California, Irvine, CA 92868, USA; (D.A.A.); (A.A.); (F.M.); (H.C.)
| | - Anupam Aich
- Hematology/Oncology, Department of Medicine, University of California, Irvine, CA 92868, USA; (D.A.A.); (A.A.); (F.M.); (H.C.)
| | - Fjolla Muqolli
- Hematology/Oncology, Department of Medicine, University of California, Irvine, CA 92868, USA; (D.A.A.); (A.A.); (F.M.); (H.C.)
| | - Hemanth Cherukury
- Hematology/Oncology, Department of Medicine, University of California, Irvine, CA 92868, USA; (D.A.A.); (A.A.); (F.M.); (H.C.)
| | - Varun Sagi
- Department of Hematology, Oncology, and Transplantation, University of Minnesota, Twin Cities, MN 55455, USA;
| | - Nicholas V. DiPatrizio
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, CA 92521, USA;
| | - Kalpna Gupta
- Hematology/Oncology, Department of Medicine, University of California, Irvine, CA 92868, USA; (D.A.A.); (A.A.); (F.M.); (H.C.)
- Southern California Institute for Research and Education, Long Beach VA Medical Center, Long Beach, CA 90822, USA
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14
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Gupta M, Sagi V, Mittal A, Yekula A, Shimizu J, Duddleston P, Thomas K, Goetsch SJ, Alksne JF, Ott K, Shimizu K, Duma CM, Ben-Haim S. Results of Multiple Gamma Knife Radiosurgery Treatments for Recurrent Trigeminal Neuralgia. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_530] [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: 11/14/2022] Open
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15
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Kiven S, Wang Y, Aich A, Argueta DA, Lei J, Sagi V, Tennakoon M, Bedros SJ, Lambrecht N, Gupta K. Spatiotemporal Alterations in Gait in Humanized Transgenic Sickle Mice. Front Immunol 2020; 11:561947. [PMID: 33178189 PMCID: PMC7593487 DOI: 10.3389/fimmu.2020.561947] [Citation(s) in RCA: 7] [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: 05/14/2020] [Accepted: 09/07/2020] [Indexed: 12/15/2022] Open
Abstract
Sickle cell disease (SCD) is a hemoglobinopathy affecting multiple organs and featuring acute and chronic pain. Purkinje cell damage and hyperalgesia have been demonstrated in transgenic sickle mice. Purkinje cells are associated with movement and neural function which may influence pain. We hypothesized that Purkinje cell damage and/or chronic pain burden provoke compensatory gait changes in sickle mice. We found that Purkinje cells undergoe increased apoptosis as shown by caspase-3 activation. Using an automated gait measurement system, MouseWalker, we characterized spatiotemporal gait characteristics of humanized transgenic BERK sickle mice in comparison to control mice. Sickle mice showed alteration in stance instability and dynamic gait parameters (walking speed, stance duration, swing duration and specific swing indices). Differences in stance instability may reflect motor dysfunction due to damaged Purkinje cells. Alterations in diagonal and all stance indices indicative of hesitation during walking may originate from motor dysfunction and/or arise from fear and/or anticipation of movement-evoked pain. We also demonstrate that stance duration, diagonal swing indices and all stance indices correlate with both mechanical and deep tissue hyperalgesia, while stance instability correlates with only deep tissue hyperalgesia. Therefore, objective analysis of gait in SCD may provide insights into neurological impairment and pain states.
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Affiliation(s)
- Stacy Kiven
- Hematology/Oncology, Department of Medicine, University of California, Irvine, Irvine, CA, United States.,Division of Hematology, Oncology and Transplantation, Department of Medicine, Vascular Biology Center, University of Minnesota, Minneapolis, MN, United States
| | - Ying Wang
- Department of Anesthesia, Stark Neuroscience Research Institute, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Anupam Aich
- Hematology/Oncology, Department of Medicine, University of California, Irvine, Irvine, CA, United States
| | - Donovan A Argueta
- Hematology/Oncology, Department of Medicine, University of California, Irvine, Irvine, CA, United States
| | - Jianxun Lei
- Division of Hematology, Oncology and Transplantation, Department of Medicine, Vascular Biology Center, University of Minnesota, Minneapolis, MN, United States
| | - Varun Sagi
- Division of Hematology, Oncology and Transplantation, Department of Medicine, Vascular Biology Center, University of Minnesota, Minneapolis, MN, United States
| | - Madhushan Tennakoon
- Division of Hematology, Oncology and Transplantation, Department of Medicine, Vascular Biology Center, University of Minnesota, Minneapolis, MN, United States
| | - Saad J Bedros
- College of Science & Engineering, University of Minnesota, Minneapolis, MN, United States
| | - Nils Lambrecht
- Pathology and Laboratory Medicine, Long Beach VA Healthcare System, Long Beach, CA, United States
| | - Kalpna Gupta
- Hematology/Oncology, Department of Medicine, University of California, Irvine, Irvine, CA, United States.,Division of Hematology, Oncology and Transplantation, Department of Medicine, Vascular Biology Center, University of Minnesota, Minneapolis, MN, United States.,Southern California Institute for Research and Education, Long Beach VA Healthcare System, Long Beach, CA, United States
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16
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Gupta M, Sagi V, Yekula A, Golts E, Lane JS, Pannell JS. Vertebral Artery Stump Syndrome Due to Chronic Complicated Aortic Dissection. World Neurosurg 2020; 145:295-297. [PMID: 33011356 DOI: 10.1016/j.wneu.2020.09.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 09/27/2020] [Accepted: 09/28/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Vertebral artery (VA) stump syndrome arises when thrombi of an occluded proximal VA propagate to the brain and cause posterior circulation strokes. This phenomenon has been described in limited reports to date. CASE DESCRIPTION A 39-year-old man with a remote history of endovascular repair of a type B aortic dissection experienced type Ia endoleak causing expansion of the false lumen associated with the dissection. This required combined open debranching and endovascular reconstruction of the thoracic aortic arch. He experienced recurrent posterior circulation strokes 6 months postoperatively. The left VA origin was occluded and remained sequestered to the proximal subclavian artery, in continuity with the false lumen of the dissection. We suspected the aortic dissection extended into the VA and caused the occlusion, while pressure from the false lumen propelled thrombi from the occluded VA stump into the posterior circulation. Repeat imaging shortly after symptom onset showed spontaneous recanalization of the VA. Open surgical ligation of the proximal left VA led to symptom resolution. CONCLUSIONS We describe a unique mechanism of VA stump syndrome due to VA occlusion and pressure waves from an aortic dissection and present the first report of VA stump syndrome treatment by surgical exclusion of the VA.
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Affiliation(s)
- Mihir Gupta
- Department of Neurosurgery, University of California San Diego, La Jolla, California.
| | - Varun Sagi
- University of Minnesota Medical School, Twin Cities, Minneapolis, Minnesota
| | - Anudeep Yekula
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eugene Golts
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of California San Diego, La Jolla, California
| | - John S Lane
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, California
| | - J Scott Pannell
- Department of Neurosurgery, University of California San Diego, La Jolla, California
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17
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Gupta M, Duddleston PJ, Sagi V, Powers M, Sang U H. Ectopic Cerebellar Tissue in the Occipital Bone: A Case Report. J Neurol Surg Rep 2020; 81:e42-e45. [PMID: 32782896 PMCID: PMC7414970 DOI: 10.1055/s-0040-1712917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 09/28/2019] [Indexed: 10/28/2022] Open
Abstract
Ectopic cerebellar tissue has only been described in isolated case reports, with only two reported cases in adult patients. We report the case of a 63-year-old woman with progressive, medically refractory headaches. A scan showed an intraosseous lesion of the midline occipital bone. Surgical resection of the soft tissue lesion was undertaken. Her headaches ceased postoperatively. Histopathological analysis revealed cerebellar cortical tissue with a surrounding meningothelial cell layer, characteristic of cerebellar ectopia. This is the second reported case of an intraosseous location of this lesion, and only the third case described in an adult patient. Our findings illustrate a rare cause of headaches and support the therapeutic roles of surgical treatment for this extremely rare condition.
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Affiliation(s)
- Mihir Gupta
- Department of Neurosurgery, University of California San Diego, San Diego, California, United States
| | - Pate J Duddleston
- Department of Neurosurgery, School of Medicine, Mercer University, Macon, Georgia, United States
| | - Varun Sagi
- Department of Neurosurgery, School of Medicine, University of Minnesota, Minneapolis, Minnesota, United States
| | - Martin Powers
- Division of Neuropathology, Department of Neuropathology, University of California San Diego, San Diego, California, United States
| | - Hoi Sang U
- Department of Neurosurgery, University of California San Diego, San Diego, California, United States
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18
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Gupta M, Yekula A, Sagi V, Mittal A, Schwartz MS. Squamous cell carcinoma of the scalp causing cortical venous thrombosis and Intraparenchymal hematoma. eNeurologicalSci 2020; 20:100251. [PMID: 32613095 PMCID: PMC7317240 DOI: 10.1016/j.ensci.2020.100251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/26/2020] [Accepted: 06/12/2020] [Indexed: 11/29/2022] Open
Abstract
We present a case of squamous cell carcinoma causing cortical venous thrombosis (CoVT) This is the first case of an invasive scalp lesion causing CoVT and brain hemorrhage Some cases of CoVT may be managed conservatively Recurrent, invasive squamous cell carcinoma remains therapeutically challenging
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Affiliation(s)
- Mihir Gupta
- Department of Neurosurgery, University of California San Diego. La Jolla, CA, USA
| | - Anudeep Yekula
- Department of Neurosurgery, Massachusetts General Hospital. Boston, MA, USA
| | - Varun Sagi
- School of Medicine, University of Minnesota Twin Cities. Minneapolis, MN, USA
| | - Aditya Mittal
- School of Medicine, University of Pittsburgh. Pittsburgh, PA, USA
| | - Marc S Schwartz
- Department of Neurosurgery, University of California San Diego. La Jolla, CA, USA
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19
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Abrams DI, Couey P, Dixit N, Sagi V, Hagar W, Vichinsky E, Kelly ME, Connett JE, Gupta K. Effect of Inhaled Cannabis for Pain in Adults With Sickle Cell Disease: A Randomized Clinical Trial. JAMA Netw Open 2020; 3:e2010874. [PMID: 32678452 PMCID: PMC7368173 DOI: 10.1001/jamanetworkopen.2020.10874] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Sickle cell disease (SCD) is characterized by chronic pain and episodic acute pain caused by vasoocclusive crises, often requiring high doses of opioids for prolonged periods. In humanized mouse models of SCD, a synthetic cannabinoid has been found to attenuate both chronic and acute hyperalgesia. The effect of cannabis on chronic pain in adults with SCD is unknown. OBJECTIVE To determine whether inhaled cannabis is more effective than inhaled placebo in relieving chronic pain in adults with SCD. DESIGN, SETTING, AND PARTICIPANTS This pilot randomized clinical trial included participants with SCD with chronic pain admitted to a single inpatient clinical research center for 2 separate 5-day stays from August 2014 to April 2017. Participants inhaled either vaporized cannabis (4.4% Δ-9-tetrahydrocannabinol to 4.9% cannabidiol) 3 times daily or vaporized placebo cannabis. Pain and pain interference ratings using the Brief Pain Inventory were assessed throughout each 5-day period. Participants with SCD and chronic pain on stable analgesics were eligible to enroll. A total of 90 participants were assessed for eligibility; 56 participants were deemed ineligible, and 34 participants were enrolled. Of these, 7 participants dropped out before randomization. Of 27 randomized participants, 23 completed both treatment arms of the crossover study and were included in the final per protocol analysis. Data analysis was completed in June 2019, with the sensitivity analysis conducted in April 2020. INTERVENTIONS Inhalation of vaporized cannabis plant (4.4% Δ-9-tetrahydrocannbinol to 4.9% cannabidiol) or placebo cannabis plant using a vaporizer 3 times daily for 5 days. MAIN OUTCOMES AND MEASURES Daily pain assessed with visual analog scale and Brief Pain Inventory. RESULTS A total of 23 participants (mean [SD] age, 37.6 [11.4] years; 13 [56%] women) completed the trial. The mean (SD) difference in pain rating assessment between the cannabis and placebo groups was -5.3 (8.1) for day 1, -10.9 (7.0) for day 2, -16.5 (9.2) for day 3, -8.9 (6.7) for day 4, and -8.2 (8.1) for day 5; however, none of these differences were statistically significant. There was no statistically significant mean (SD) difference in pain interference ratings between cannabis and placebo between days 1 and 5 for interference in general activities (day 1: 0.27 [0.35]; day 5: -1.0 [0.5]), walking (day 1: 0.14 [0.73]; day 5: -0.87 [0.63]), sleep (day 1: 0.59 [0.74]; day 5: -1.3 [0.8]), or enjoyment (day 1: 0.23 [0.69]; day 5: -0.91 [0.48]), but there was a statistically significant mean (SD) difference in decrease in interference with mood (day 1: 0.96 [0.59]; day 5: -1.4 [0.6]; P = .02). No differences in treatment-related adverse effects were observed. Use of concomitant opioids was similar during both treatment periods. CONCLUSIONS AND RELEVANCE This randomized clinical trial found that, compared with vaporized placebo, vaporized cannabis did not statistically significantly reduce pain and associated symptoms, except interference in mood, in patients with SCD with chronic pain. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01771731.
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Affiliation(s)
- Donald I Abrams
- Division of Hematology-Oncology, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco
| | - Paul Couey
- Division of Hematology-Oncology, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco
| | - Niharika Dixit
- Division of Hematology-Oncology, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco
| | - Varun Sagi
- Vascular Biology Center, Division of Hematology-Oncology-Transplantation, Department of Medicine, University of Minnesota Medical School, Minneapolis
| | - Ward Hagar
- UCSF Benioff Children's Hospital Oakland, Oakland, California
| | | | - Mary Ellen Kelly
- Division of Hematology-Oncology, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco
| | - John E Connett
- School of Public Health, University of Minnesota, Minneapolis
| | - Kalpna Gupta
- Vascular Biology Center, Division of Hematology-Oncology-Transplantation, Department of Medicine, University of Minnesota Medical School, Minneapolis
- Hemtology/Oncology Division, Department of Medicine, University of California, Irvine
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20
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Sagi V, Argueta DA, Kiven S, Gupta K. Integrative approaches to treating pain in sickle cell disease: Pre-clinical and clinical evidence. Complement Ther Med 2020; 51:102394. [PMID: 32507420 DOI: 10.1016/j.ctim.2020.102394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 02/02/2023] Open
Abstract
Sickle cell disease (SCD) is a genetic disorder characterized by hemolysis, end-organ damage, inflammation, and pain. Recurrent and unpredictable episodes of acute pain due to vaso-occlusive crises are a unique feature of SCD. Many patients also develop lifelong chronic pain. Opioids are the primary method of pain treatment in SCD; however, continued use is associated with several adverse effects. Integrative approaches to treating pain in SCD are increasingly being explored to prevent the side effects associated with opioids. In this review, we highlight the mechanisms of pain in SCD and describe mechanism-based integrative approaches for treating pain.
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Affiliation(s)
- Varun Sagi
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Donovan A Argueta
- Hematology/Oncology, Department of Medicine, University of California, Irvine and Southern California Institute for Research and Education, VA Medical Center, Long Beach, CA, United States
| | - Stacy Kiven
- Hematology/Oncology, Department of Medicine, University of California, Irvine and Southern California Institute for Research and Education, VA Medical Center, Long Beach, CA, United States
| | - Kalpna Gupta
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, United States; Hematology/Oncology, Department of Medicine, University of California, Irvine and Southern California Institute for Research and Education, VA Medical Center, Long Beach, CA, United States.
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21
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Garweg C, Khelae SK, Chan JYS, Chinitz L, Ritter P, Johansen JB, Sagi V, Epstein LM, Piccini JP, Pascual M, Mont L, Splett V, Stromberg K, Kristiansen N, Steinwender C. 298Atrioventricular synchronous pacing in leadless ventricular pacemaker is safe and effective in patients with paroxysmal AV block and atrial arrhythmias. Europace 2020. [DOI: 10.1093/europace/euaa162.288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Medtronic, Inc.
Background/Introduction
Accelerometer (ACC)-based AV synchronous pacing by tracking atrial activity is feasible using a leadless ventricular pacemaker. Patients may experience variable AV conduction (AVC) and/or atrial arrhythmias during the lifetime of their device. ACC-based AV synchronous pacing should facilitate AVC and pace appropriately in those two common rhythms.
Purpose
To characterize the behavior of ACC-based AV synchronous pacing algorithms during paroxysmal AV block (AVB) and atrial arrhythmias.
Methods
The MARVEL2 (Micra Atrial tRacking using a Ventricular accELerometer) was a 5-hour acute study to assess the efficacy of atrial tracking with a temporarily downloaded algorithm into a Micra leadless pacemaker. Patients with a history of AVB were eligible for inclusion. The MARVEL2 algorithm included a mode-switching algorithm that switched between VDD and VVI-40 depending upon AVC status. The AVC algorithm requires 2 ventricular paces (VP) at 40 bpm out of 4 pacing cycles to switch to VDD.
Results
Overall, 75 patients (age 77.5 ± 11.8 years, 40% female, median time from Micra implant 9.7 months) from 12 centers worldwide were enrolled. During study procedures, 40 patients (53%) had normal sinus rhythm with complete AVB, 18 (24%) had 1:1 AVC, 5 (7%) had varying AVC status, 8 (11%) had atrial arrhythmias, and 2 other rhythms. Two patients with complete AVB had the AVC mode switch feature disabled due to an idioventricular rate >40 bpm. Among the 40 subjects with a predominant 3rd degree AVB and normal sinus function the median %VP was 99.9% compared to 0.2% among those with 1:1 AVC (Figure). In the patients with 1:1 AVC, there were 64 opportunities to AVC mode switch with 48 switching to VDI-40. In the other 16 cases (2 patients) the mode remained VDD due to sinus bradycardia varying between 40-45 bpm. High %VP was observed in 2 patients with 1:1 AVC and sinus bradycardia <40 bpm. The AVC mode switch minimized %VP (<1%) in patients with PR intervals > 300 ms (N = 2). Among patients with varying AVC, the algorithm appropriately switched to VDD when the ventricular rate was paced at 40 bpm. During infrequent AVB or AF with ventricular response >40 bpm, VVI-40 mode was maintained.
In patients with AF, the ACC signal was of low amplitude and there was infrequent sensing, resulting in VP at the lower rate (50 bpm). In the one patient with atrial flutter, the ACC was intermittently detected, resulting in VP at 67 bpm (IQR 66-67 bpm).
Conclusion(s)
The mode switching algorithm in the MARVEL2 reduced %VP in patients with 1:1 AVC and appropriately switched to VDD during complete AVB. If greater AV synchrony or rate support is required, disabling the AVC algorithm may be appropriate for low grade AVB or idioventricular rhythms. In the presence of atrial arrhythmias, the algorithm paced near the lower rate.
Abstract Figure. Distribution of VP% by heart rhythm
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Affiliation(s)
- C Garweg
- University Hospitals (UZ) Leuven, Cardiology, Leuven, Belgium
| | - S K Khelae
- Institut Jantung Negara, Kuala Lumpur, Malaysia
| | - J Y S Chan
- Prince of Wales University Hospital, Shatin, Hong Kong
| | - L Chinitz
- New York University Langone Medical Center, New York, United States of America
| | - P Ritter
- HAUT-LEVEQUE HOSPITAL - University Hospital Centre, Pessac, France
| | | | - V Sagi
- Baptist Medical Center Jacksonville, Jacksonville, United States of America
| | - L M Epstein
- North Shore University Hospital, Manhasset, United States of America
| | - J P Piccini
- Duke University Medical Center, Durham, United States of America
| | - M Pascual
- Baptist Hospital Miami, Miami, United States of America
| | - L Mont
- Hospital Clínic. Universitat de Barcelona, Catalonia, Spain
| | - V Splett
- Medtronic, Mounds View, United States of America
| | - K Stromberg
- Medtronic, Mounds View, United States of America
| | - N Kristiansen
- Bakken Research Center, Maastricht, Netherlands (The)
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22
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Abstract
Cannabidiol (CBD), the major non-psychoactive constituent of Cannabis sativa L., has gained traction as a potential treatment for intractable chronic pain in many conditions. Clinical evidence suggests that CBD provides therapeutic benefit in certain forms of epilepsy and imparts analgesia in certain conditions, and improves quality of life. CBD continues to be Schedule I or V on the list of controlled substances of the Drug Enforcement Agency of the United States. However, preparations labeled CBD are available publicly in stores and on the streets. However, use of CBD does not always resolve pain. CBD purchased freely entails the risk of adulteration by potentially hazardous chemicals. As well, CBD use by pregnant women is rising and poses a major health-hazard for future generations. In this mini-review, we present balanced and unbiased pre-clinical and clinical findings for the beneficial effects of CBD treatment on chronic pain and its deleterious effects on prenatal development.
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Affiliation(s)
- Donovan A Argueta
- Hematology/Oncology, Department of Medicine, University of California, Irvine, Irvine, CA, United States
| | - Christopher M Ventura
- Hematology/Oncology, Department of Medicine, University of California, Irvine, Irvine, CA, United States
| | - Stacy Kiven
- Hematology/Oncology, Department of Medicine, University of California, Irvine, Irvine, CA, United States
| | - Varun Sagi
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Kalpna Gupta
- Hematology/Oncology, Department of Medicine, University of California, Irvine, Irvine, CA, United States.,Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, United States.,Southern California Institute for Research and Education, Long Beach VA Healthcare System, Long Beach, CA, United States
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23
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Tran H, Sagi V, Leonce Song-Naba W, Wang Y, Mittal A, Lamarre Y, Zhang L, Gupta K. Effect of chronic opioid therapy on pain and survival in a humanized mouse model of sickle cell disease. Blood Adv 2019; 3:869-873. [PMID: 30885998 PMCID: PMC6436015 DOI: 10.1182/bloodadvances.2018024299] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 08/02/2018] [Accepted: 02/21/2019] [Indexed: 12/22/2022] Open
Abstract
Chronic morphine treatment leads to decreased survival in control mice, but not in sickle mice. Chronic morphine treatment leads to hyperalgesia in sickle mice, but does not lead to analgesic tolerance.
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Affiliation(s)
- Huy Tran
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, and
| | - Varun Sagi
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, and
| | - Waogwende Leonce Song-Naba
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, and
| | - Ying Wang
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, and
| | - Aditya Mittal
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, and
| | - Yann Lamarre
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, and
| | - Lei Zhang
- Biostatistical Design and Analysis Center, Clinical and Translational Sciences Institute, University of Minnesota, Minneapolis, MN
| | - Kalpna Gupta
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, and
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24
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Abstract
Mast cells (MCs) are located in the periphery as well as the central nervous system (CNS). Known for sterile inflammation, MCs play a critical role in neuroinflammation, which is facilitated by their close proximity to nerve fibers in the periphery and meninges of the spinal cord and the brain. Multifaceted activation of MCs releasing neuropeptides, cytokines and other mediators has direct effects on the neural system as well as neurovascular interactions. Emerging studies have identified the release of extracellular traps, a phenomenon traditionally meant to ensnare invading pathogens, as a cause of MC-induced neural injury. In this review article, we will discuss mechanisms of MC interaction with the nervous system through degranulation, de novo synthesis, extracellular vesicles (EVs), tunneling nanotubes, and extracellular traps with implications across a variety of pathological conditions.
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Affiliation(s)
- Aditya Mittal
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Varun Sagi
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Mihir Gupta
- Department of Neurosurgery, University of California, San Diego, San Diego, CA, United States
| | - Kalpna Gupta
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
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Tran H, Mittal A, Sagi V, Luk K, Nguyen A, Gupta M, Nguyen J, Lamarre Y, Lei J, Guedes A, Gupta K. Mast Cells Induce Blood Brain Barrier Damage in SCD by Causing Endoplasmic Reticulum Stress in the Endothelium. Front Cell Neurosci 2019; 13:56. [PMID: 30837844 PMCID: PMC6389721 DOI: 10.3389/fncel.2019.00056] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [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: 10/09/2018] [Accepted: 02/05/2019] [Indexed: 12/21/2022] Open
Abstract
Endothelial dysfunction underlies the pathobiology of cerebrovascular disease. Mast cells are located in close proximity to the vasculature, and vasoactive mediators released upon their activation can promote endothelial activation leading to blood brain barrier (BBB) dysfunction. We examined the mechanism of mast cell-induced endothelial activation via endoplasmic reticulum (ER) stress mediated P-selectin expression in a transgenic mouse model of sickle cell disease (SCD), which shows BBB dysfunction. We used mouse brain endothelial cells (mBECs) and mast cells-derived from skin of control and sickle mice to examine the mechanisms involved. Compared to control mouse mast cell conditioned medium (MCCM), mBECs incubated with sickle mouse MCCM showed increased, structural disorganization and swelling of the ER and Golgi, aggregation of ribosomes, ER stress marker proteins, accumulation of galactose-1-phosphate uridyl transferase, mitochondrial dysfunction, reactive oxygen species (ROS) production, P-selectin expression and mBEC permeability. These effects of sickle-MCCM on mBEC were inhibited by Salubrinal, a reducer of ER stress. Histamine levels in the plasma, skin releasate and in mast cells of sickle mice were higher compared to control mice. Compared to control BBB permeability was increased in sickle mice. Treatment of mice with imatinib, Salubrinal, or P-selectin blocking antibody reduced BBB permeability in sickle mice. Mast cells induce endothelial dysfunction via ER stress-mediated P-selectin expression. Mast cell activation contributes to ER stress mediated endothelial P-selectin expression leading to increased endothelial permeability and impairment of BBB. Targeting mast cells and/or ER stress has the potential to ameliorate endothelial dysfunction in SCD and other pathobiologies.
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Affiliation(s)
- Huy Tran
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, United States
| | - Aditya Mittal
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, United States
| | - Varun Sagi
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, United States
| | - Kathryn Luk
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, United States
| | - Aithanh Nguyen
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, United States
| | - Mihir Gupta
- Department of Neurosurgery, University of California, San Diego, San Diego, CA, United States
| | - Julia Nguyen
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, United States
| | - Yann Lamarre
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, United States
| | - Jianxun Lei
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, United States
| | - Alonso Guedes
- Anesthesia and Pain Medicine, Veterinary Clinical Science Department, College of Veterinary Medicine, University of Minnesota Twin Cities, St. Paul, MN, United States
| | - Kalpna Gupta
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, United States
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Sagi V, Mittal A, Gupta M, Gupta K. Immune cell neural interactions and their contributions to sickle cell disease. Neurosci Lett 2019; 699:167-171. [PMID: 30738871 DOI: 10.1016/j.neulet.2019.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 01/09/2019] [Accepted: 02/06/2019] [Indexed: 12/24/2022]
Abstract
Sickle cell disease (SCD) is characterized by hemolysis, inflammation, and pain. Mechanisms of pain manifestation are complex, and there is a major gap in knowledge of how the nervous and immune systems interact to contribute to pain and other comorbidities in SCD. Sterile inflammation in the periphery and central nervous system contributes to vascular and neural activation. Cellular and soluble mediators create an inflammatory and neuroinflammatory microenvironment contributing to neurogenic inflammation and acute and chronic pain. In this review we highlight relevant neuro-immune interactions that contribute to the pathobiology of SCD.
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Affiliation(s)
- Varun Sagi
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Aditya Mittal
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Mihir Gupta
- Department of Neurosurgery, University of California San Diego, La Jolla, CA, USA
| | - Kalpna Gupta
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA.
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Abstract
Sickle cell disease (SCD) is a genetic blood disorder that impacts millions of individuals worldwide. SCD is characterized by debilitating pain that can begin during infancy and may continue to increase throughout life. This pain can be both acute and chronic. A characteristic feature specific to acute pain in SCD occurs during vaso-occlusive crisis (VOC) due to the blockade of capillaries with sickle red blood cells. The acute pain of VOC is intense, unpredictable, and requires hospitalization. Chronic pain occurs in a significant population with SCD. Treatment options for sickle pain are limited and primarily involve the use of opioids. However, long-term opioid use is associated with numerous side effects. Thus, pain management in SCD remains a major challenge. Humanized transgenic mice expressing exclusively human sickle hemoglobin show features of pain and pathobiology similar to that in patients with SCD. Therefore, these mice offer the potential for investigating the mechanisms of pain in SCD and allow for development of novel targeted analgesic therapies. © 2018 by John Wiley & Sons, Inc.
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Affiliation(s)
- Varun Sagi
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Waogwende L Song-Naba
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Barbara A Benson
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Sonal S Joshi
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Kalpna Gupta
- Vascular Biology Center, Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
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