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Polovneff A, Shah N, Janardan A, Smith E, Pasillas I, Mortensen N, Holt JM, Somai M, Sparapani R, Crotty B. Scaling care coordination through digital engagement: stepped-wedge trial assessing readmissions. Am J Manag Care 2024; 30:e32-e38. [PMID: 38381546 DOI: 10.37765/ajmc.2024.89498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
OBJECTIVES Transitions of care are pivotal, vulnerable times as patients are discharged from the hospital. Telephonic care coordination is standard care, but labor intensive. We implemented a patient postdischarge digital engagement (PDDE) program to scale coordination. We hypothesized that PDDE could reduce readmissions for low-risk patients and supplement care coordination for medium- and high-risk patients. STUDY DESIGN Pragmatic, stepped-wedge cluster randomization trial with 5 implementation waves based upon primary care clinic region. METHODS All inpatient hospital discharges between March 2020 and November 2020 were stratified by readmission risk. Low-risk patients were offered access to PDDE, and moderate-risk and high-risk patients were offered access to PDDE and care coordination. Readmission was defined as an unplanned inpatient admission within 30 days from discharge. An intention-to-treat primary analysis was conducted using mixed-effects logistic regression clustering for wave; a treatment-on-the-treated analysis was also conducted to assess the impact among program users. RESULTS A total of 5490 patient discharges were examined (2735 control; 2755 intervention); 1949 patients were high risk, 2032 were medium risk, and 1509 were low risk. PDDE intervention did not significantly affect readmission among low-risk (95% CI, -0.23 to 0.90; P = .23), medium-risk (95% CI, -0.14 to 0.60; P = .21), and high-risk (95% CI, -0.32 to 0.64; P = .48) groups after adjustment for time and patient factors. In a treatment-on-the-treated analysis, among patients who activated the PDDE program, readmission was also similar among the low-, medium-, and high-risk cohorts. CONCLUSIONS Our study expanded resource-limited care coordination by offering low-risk patients a service they were unable to receive previously while having no impact on readmission. PDDE efficiently provided additional touch points between patients and providers.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Bradley Crotty
- Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226.
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Brown SA, Sparapani R, Osinski K, Zhang J, Blessing J, Cheng F, Hamid A, MohamadiPour MB, Lal JC, Kothari AN, Caraballo P, Noseworthy P, Johnson RH, Hansen K, Sun LY, Crotty B, Cheng YC, Echefu G, Doshi K, Olson J. Team principles for successful interdisciplinary research teams. Am Heart J Plus 2023; 32:100306. [PMID: 38510201 PMCID: PMC10946054 DOI: 10.1016/j.ahjo.2023.100306] [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] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 05/26/2023] [Accepted: 05/28/2023] [Indexed: 03/22/2024]
Abstract
Interdisciplinary research teams can be extremely beneficial when addressing difficult clinical problems. The incorporation of conceptual and methodological strategies from a variety of research disciplines and health professions yields transformative results. In this setting, the long-term goal of team science is to improve patient care, with emphasis on population health outcomes. However, team principles necessary for effective research teams are rarely taught in health professional schools. To form successful interdisciplinary research teams in cardio-oncology and beyond, guiding principles and organizational recommendations are necessary. Cardiovascular disease results in annual direct costs of $220 billion (about $680 per person in the US) and is the leading cause of death for cancer survivors, including adult survivors of childhood cancers. Optimizing cardio-oncology research in interdisciplinary research teams has the potential to aid in the investigation of strategies for saving hundreds of thousands of lives each year in the United States and mitigating the annual cost of cardiovascular disease. Despite published reports on experiences developing research teams across organizations, specialties and settings, there is no single journal article that compiles principles for cardiology or cardio-oncology research teams. In this review, recurring threads linked to working as a team, as well as optimal methods, advantages, and problems that arise when managing teams are described in the context of career development and research. The worth and hurdles of a team approach, based on practical lessons learned from establishing our multidisciplinary research team and information gleaned from relevant specialties in the development of a successful team are presented.
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Affiliation(s)
- Sherry-Ann Brown
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rodney Sparapani
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kristen Osinski
- Clinical Science and Translational Institute, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jun Zhang
- Department of Electrical Engineering and Computer Science, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Jeffrey Blessing
- Department of Computer Science, Milwaukee School of Engineering, USA
| | - Feixiong Cheng
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | | | - Mehri Bagheri MohamadiPour
- Department of Electrical Engineering and Computer Science, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Jessica Castrillon Lal
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Anai N. Kothari
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Peter Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Louise Y. Sun
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Bradley Crotty
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Yee Chung Cheng
- Cancer Center, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Gift Echefu
- Department of Internal Medicine, Baton Rouge General Medical Center, Baton Rouge, LA, USA
| | - Krishna Doshi
- Department of Internal Medicine, Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Jessica Olson
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - for the Cardio-Oncology Artificial Intelligence Informatics & Precision (CAIP) Research Team Investigators
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
- Clinical Science and Translational Institute, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Electrical Engineering and Computer Science, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
- Department of Computer Science, Milwaukee School of Engineering, USA
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
- Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Cancer Center, Medical College of Wisconsin, Milwaukee, WI, USA
- Green Bay, WI, USA
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Internal Medicine, Baton Rouge General Medical Center, Baton Rouge, LA, USA
- Department of Internal Medicine, Advocate Lutheran General Hospital, Park Ridge, IL, USA
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Brown SA, Sparapani R, Osinski K, Zhang J, Blessing J, Cheng F, Hamid A, Berman G, Lee K, BagheriMohamadiPour M, Castrillon Lal J, Kothari AN, Caraballo P, Noseworthy P, Johnson RH, Hansen K, Sun LY, Crotty B, Cheng YC, Olson J. Establishing an interdisciplinary research team for cardio-oncology artificial intelligence informatics precision and health equity. Am Heart J Plus 2022; 13:100094. [PMID: 35434676 PMCID: PMC9012235 DOI: 10.1016/j.ahjo.2022.100094] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 01/01/2022] [Indexed: 11/23/2022]
Abstract
Study objective A multi-institutional interdisciplinary team was created to develop a research group focused on leveraging artificial intelligence and informatics for cardio-oncology patients. Cardio-oncology is an emerging medical field dedicated to prevention, screening, and management of adverse cardiovascular effects of cancer/ cancer therapies. Cardiovascular disease is a leading cause of death in cancer survivors. Cardiovascular risk in these patients is higher than in the general population. However, prediction and prevention of adverse cardiovascular events in individuals with a history of cancer/cancer treatment is challenging. Thus, establishing an interdisciplinary team to create cardiovascular risk stratification clinical decision aids for integration into electronic health records for oncology patients was considered crucial. Design/setting/participants Core team members from the Medical College of Wisconsin (MCW), University of Wisconsin-Milwaukee (UWM), and Milwaukee School of Engineering (MSOE), and additional members from Cleveland Clinic, Mayo Clinic, and other institutions have joined forces to apply high-performance computing in cardio-oncology. Results The team is comprised of clinicians and researchers from relevant complementary and synergistic fields relevant to this work. The team has built an epidemiological cohort of ~5000 cancer survivors that will serve as a database for interdisciplinary multi-institutional artificial intelligence projects. Conclusion Lessons learned from establishing this team, as well as initial findings from the epidemiology cohort, are presented. Barriers have been broken down to form a multi-institutional interdisciplinary team for health informatics research in cardio-oncology. A database of cancer survivors has been created collaboratively by the team and provides initial insight into cardiovascular outcomes and comorbidities in this population.
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Affiliation(s)
- Sherry-Ann Brown
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rodney Sparapani
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kristen Osinski
- Clinical Science and Translational Institute, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jun Zhang
- Department of Electrical Engineering and Computer Science, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Jeffrey Blessing
- Department of Computer Science, Milwaukee School of Engineering, USA
| | - Feixiong Cheng
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | | | | | - Kyla Lee
- Tulane School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Mehri BagheriMohamadiPour
- Department of Electrical Engineering and Computer Science, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Jessica Castrillon Lal
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Anai N. Kothari
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Peter Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Louise Y. Sun
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute and School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Bradley Crotty
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Yee Chung Cheng
- Cancer Center, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jessica Olson
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Cardio-Oncology Artificial Intelligence Informatics & Precision (CAIP) Research Team Investigators
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
- Clinical Science and Translational Institute, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Electrical Engineering and Computer Science, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
- Department of Computer Science, Milwaukee School of Engineering, USA
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
- Medical College of Wisconsin, Milwaukee, WI, USA
- Medical College of Wisconsin, Green Bay, WI, USA
- Tulane School of Public Health and Tropical Medicine, New Orleans, LA, USA
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Cancer Center, Medical College of Wisconsin, Milwaukee, WI, USA
- Green Bay, WI, USA
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute and School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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4
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Choudhury A, Crotty B, Asan O. Comparing the Impact of Double and Single Screen Electronic Health Records on Doctor-Patient Non-Verbal Communication. IISE Trans Occup Ergon Hum Factors 2020. [DOI: 10.1080/24725838.2020.1742251] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Avishek Choudhury
- School of Systems and Enterprises, Stevens Institute of Technology, Hoboken, NJ, USA
| | - Bradley Crotty
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Onur Asan
- School of Systems and Enterprises, Stevens Institute of Technology, Hoboken, NJ, USA
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Abstract
OBJECTIVES To explore the perceptions of parents of pediatric patients in a PICU regarding real-time open electronic health record data displayed in patient rooms. DESIGN Cross-sectional qualitative interview study. SETTING PICU in a large Midwestern tertiary-care children's hospital. SUBJECTS Parents of patients in a PICU (n = 33). MEASUREMENTS AND MAIN RESULTS Qualitative data were collected through in-person semi-structured, individual, and small-group interviews. Data were collected from March 2016 to July 2016, with approval from the study hospital's institutional review board. Data were analyzed using inductive thematic analysis. Results included positive effects of accessing real-time open electronic health record data on family empowerment, situation awareness, potential error detection, understanding of medical data, and facilitating discussions during rounds. Concerns were reported regarding privacy of information as well as potential misinterpretation of displayed data. We identified several ways to improve this collaborative technology to make it more family-centered. CONCLUSIONS This study suggests that a new health information technology system providing continuous access to open electronic health record data may be an effective way to empower and engage parents in the PICU, but potential drawbacks were also noted. The results also provide insights into the collaborative use of health information technology in the PICU setting.
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Affiliation(s)
- Onur Asan
- School of Systems and Enterprises, Stevens Institute of Technology, Hoboken, NJ,USA
| | - Matthew C. Scanlon
- Department of Pediatrics, Division of Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Bradley Crotty
- Center for Advancing Population Science, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI,USA
| | - Richard J. Holden
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kathryn E. Flynn
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Quintana Y, Fahy D, Crotty B, Gorenberg M, Jain R, Kaldany E, Lipsitz L, Chen YP, Henao J, Safran C. A Usability Evaluation of the InfoSAGE App for Family-Based Medication Management. Stud Health Technol Inform 2019; 257:352-357. [PMID: 30741222] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The design of a mobile medication manager within a broader family and elder-centric collaboration platform faces challenges of usability and wide applicability. To inform the development and use cases of eldercare apps, we present the preliminary results of a usability study of an iOS and Android app intended for both family members and aging adults for the mobile management of medication lists. Seven participants were recorded during the performance of eight typical use-case scenarios of the medication portion of the InfoSAGE app. Audio and video recordings were analyzed for themes and events. The aim of this paper is to help inform future design choices for eldercare mobile apps.
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Affiliation(s)
- Yuri Quintana
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | - Darren Fahy
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Maxwell Gorenberg
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | - Ruchira Jain
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | - Eli Kaldany
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Yi-Pei Chen
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | - Juan Henao
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | - Charles Safran
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
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7
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Asan O, Crotty B, Nagavally S, Egede LE. Patient Centered Communication and E-Health Information Exchange Patterns: Findings From a National Cross-Sectional Survey. IEEE J Transl Eng Health Med 2018; 7:2200107. [PMID: 30588412 PMCID: PMC6302924 DOI: 10.1109/jtehm.2018.2884925] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/10/2018] [Accepted: 11/19/2018] [Indexed: 11/17/2022]
Abstract
This paper aimed to determine whether there was a connection between patient’s perception of communication with their doctors in the visit and their use of online health information exchange using a nationally representative survey. We used the data from the Health Information National Trends survey pooled HINTS4 Cycle 4 data and assessed outcomes using logistic regression modeling composite communication scores as a continuous variable. We weighted participants to create population-level estimates. We adjusted for age, gender, race, and census region. The 3677 patients were included in the analysis who had an outpatient visit within the previous 12 months. In unadjusted analysis and analysis adjusted for demographic factors, patients who experienced higher communication scores were more likely to use online health information exchange with their providers. In unadjusted analysis, patients had 0.04 higher odds of interest in receiving appointment reminders from health care providers electronically (OR = 1.04 and \documentclass[12pt]{minimal}
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}{}$p=0.04$
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}{}$p=0.02$
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}{}$p=0.02$
\end{document}). Findings suggest that the quality of the communication in the visit might increase use of informatics tool to exchange health information.
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Affiliation(s)
- Onur Asan
- School of Systems and EnterprisesStevens Institute of TechnologyHobokenNJ07030USA
| | - Bradley Crotty
- Collaborative for Healthcare Delivery Science, Center for Advancing Population ScienceMedical College of WisconsinMilwaukeeWI53226USA
| | - Sneha Nagavally
- Center for Advancing Population ScienceMedical College of WisconsinMilwaukeeWI53226USA
| | - Leonard E Egede
- Center for Advancing Population ScienceMedical College of WisconsinMilwaukeeWI53226USA
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Quintana Y, Fahy D, Crotty B, Jain R, Kaldany E, Gorenberg M, Lipsitz L, Engorn D, Rodriguez J, Orfanos A, Bajracharya A, Henao J, Adra M, Skerry D, Slack WV, Safran C. InfoSAGE: Supporting Elders and Families through Online Family Networks. AMIA Annu Symp Proc 2018; 2018:932-941. [PMID: 30815136 PMCID: PMC6371310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
With an increasingly elderly population, families are finding it increasingly challenging to coordinate care for their older family members. This paper reports on the findings of InfoSAGE, an online private social network that has tools for communication and care coordination for elders and their families. The InfoSAGE system has 257 registered users; 52 of these opted into an in-depth longitudinal study. A descriptive analysis of these early participants, the online family networks, and barriers to participation that were encountered are presented.
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Affiliation(s)
- Yuri Quintana
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Darren Fahy
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Ruchira Jain
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | - Eli Kaldany
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | - Maxwel Gorenberg
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | - Lewis Lipsitz
- Harvard Medical School, Boston, MA
- Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Diane Engorn
- Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Jorge Rodriguez
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Alex Orfanos
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | - Adarsha Bajracharya
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | - Juan Henao
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | - May Adra
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | - David Skerry
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
- Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Medical College of Wisconsin, Milwaukee, WI
| | - Warner V Slack
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Charles Safran
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
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9
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Quintana Y, Crotty B, Fahy D, Lipsitz L, Davis RB, Safran C. Information sharing across generations and environments (InfoSAGE): study design and methodology protocol. BMC Med Inform Decis Mak 2018; 18:105. [PMID: 30458840 PMCID: PMC6245635 DOI: 10.1186/s12911-018-0697-4] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 10/24/2018] [Indexed: 11/29/2022] Open
Abstract
Background Longevity creates increasing care needs for healthcare providers and family caregivers. Increasingly, the burden of care falls to one primary caregiver, increasing stress and reducing health outcomes. Additionally, little has been published on adults’, over the age of 75, preferences in the development of health information sharing with family members using online platforms. This study aims to assess a novel, Internet based, family-centric communication and collaboration platform created to address the information needs of elders and their informal caregivers in a community setting. Methods This study is an internet-based, open prospective cohort study, enrolling dyad pairs of one adult over the age of 75 with one informal caregiver. Dyads will be offered to use the InfoSAGE online platform without prospective assignment. Participants will consent using an online process that enables participation from any location and shares important study and privacy details. The platform will enable the capture of search queries and tracking of functions such as tasks and discussions. Surveys every six months assess health status, health and social needs, and caregiver burden using validated instruments over a two-year period. We will use a mixed methods approach, utilizing qualitative survey data along with website usage analytic data. Discussion Analysis of the longitudinal usage and survey data will help to examine the patterns of family communication and health information seeking as the central older adult ages. We will use the study data to inform design recommendations relevant to a complex mixture of users, with special consideration to the needs of older adult users and potential physical limitations.
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Affiliation(s)
- Yuri Quintana
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02115, USA. .,Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA.
| | - Bradley Crotty
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI, 53226, USA.,Froedtert Hospital, 9200 W Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Darren Fahy
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02115, USA
| | - Lewis Lipsitz
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA.,Hebrew Senior Life, 1200 Centre St, Roslindale, MA, 02131, USA
| | - Roger B Davis
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02115, USA.,Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
| | - Charles Safran
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02115, USA.,Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
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10
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Asan O, Tyszka J, Crotty B. The electronic health record as a patient engagement tool: mirroring clinicians' screen to create a shared mental model. JAMIA Open 2018; 1:42-48. [PMID: 31984318 PMCID: PMC6952027 DOI: 10.1093/jamiaopen/ooy006] [Citation(s) in RCA: 3] [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: 12/21/2017] [Revised: 02/13/2018] [Accepted: 03/14/2018] [Indexed: 11/12/2022] Open
Abstract
Objective Electronic health records (EHRs) in physician offices can both enhance and detract from the patient experience. Best practices have emerged focusing on screen sharing. We sought to determine if adding a second monitor, mirroring the EHR for patients, would be welcome and useful for patients and clinicians. Materials and Methods This mixed-method study was conducted in a general medicine clinic from March to June 2016. Clinicians and patients met in a specially equipped exam room with a patient-facing monitor. Visits were video-recorded to assess time spent viewing the EHR and followed by interviews, which were transcribed and analyzed using established qualitative methods. Results Eight clinicians and 24 patients participated. Main themes included the second screen serving as a catalyst for patient engagement, augmenting the clinic visit in a meaningful way, improving transparency of the care process and documentation, and providing a substantially different experience for patients than a shared single screen. Concerns and suggestions for improvement were also reported. Quantitative results showed high patient engagement times with the EHR (25% of the visit length) compared to reports in previous studies. The median satisfaction score was 5 out of 5 for patients and 3.3 out of 5 for clinicians. Discussion and Conclusion Providing patient access to the EHRs with this design was linked with several benefits including improved patient engagement, education, transparency, comprehension, and trust. Future studies should explore how best to display information in such screens for patients and identify impact on care, safety, and quality.
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Affiliation(s)
- Onur Asan
- Division of General Internal Medicine, Department of Medicine, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jeanne Tyszka
- Division of General Internal Medicine, Department of Medicine, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Bradley Crotty
- Division of General Internal Medicine, Department of Medicine, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Quintana Y, Crotty B, Fahy D, Orfanos A, Jain R, Kaldany E, Lipsitz L, Engorn D, Rodriguez J, Pandolfe F, Bajracharya A, Slack WV, Safran C. InfoSAGE: Use of Online Technologies for Communication and Elder Care. Stud Health Technol Inform 2017; 234:280-285. [PMID: 28186055] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Aging creates new information and communication needs for families who are helping to coordinate care for frail parents. To identify how information and communication needs evolve with the aging process, we created a living laboratory of families, supported by an online private social network with tools for care coordination. Site registrants are invite to participate in a more in-depth survey-based longitudinal study. In year one, we assessed the feasibility of an online living laboratory. During this first year, 155 individuals registered on InfoSAGE, and 26% opted into the more in-depth longitudinal study. The survey response rate for those in the study was 61%. We present here a descriptive analysis of our early participants and networks, as well as barriers to participation that the study team encountered.
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Affiliation(s)
- Yuri Quintana
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Darren Fahy
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | - Alex Orfanos
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | - Ruchira Jain
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | - Eli Kaldany
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Diane Engorn
- Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Jorge Rodriguez
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | - Frank Pandolfe
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | - Adarsha Bajracharya
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | - Warner V Slack
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
| | - Charles Safran
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA
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12
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Abstract
BACKGROUND Finding the optimal image intensifier angle of obliquity during renal intervention is important for accurate stent placement but can require multiple catheter rotations and test injections of contrast. OBJECTIVE Explore the usefulness of axial magnetic resonance angiography (MRA) as a roadmap for predicting image intensifier position during subsequent renal intervention. METHODS MRA images were reviewed in 137 consecutive patients (255 renal arteries) undergoing workup for renal artery stenosis. The axial angle of renal artery incidence perpendicular to the spine was estimated by two operators and results averaged. RESULTS The average angle of incidence for the renal artery ostia was +21.24 degrees +/-2.31 degrees for the right and +8.81 degrees +/-2.0 degrees for the left (P < .0001). The positive numbers correlate with left anterior oblique (LAO) and negative right anterior oblique (RAO). CONCLUSIONS MRA can be used to define the origin of the renal artery and is most likely to predict an LAO image window for subsequent angiography of the left and right renal arteries displacing the "ipsilateral oblique" axiom. In patients without baseline MRA the 10 to 20 degree LAO "empiric" position will allow coaxial imaging of both renal ostia in 75% of cases. However, there can be extreme variation in the renal origin (53 degrees RAO to 85 degrees LAO) and we advocate using the simple technique reported herein to define the renal origin in patients with pre-procedure MRA.
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Affiliation(s)
- Mark C Bates
- Vascular Center of Medicine, Charleston Area Medical Center, Charleston, West Virginia, USA.
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13
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Bates MC, Aburahma AF, Crotty B. Successful urgent endovascular surgery for symptomatic subclavian artery aneurysmal compression of the trachea. Catheter Cardiovasc Interv 2005; 64:291-5. [PMID: 15736257 DOI: 10.1002/ccd.20289] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The purpose of this study is to report the progress of a patient who entered the hospital with symptomatic tracheal compression from a large right subclavian artery aneurysm that was treated with a self-expanding stent graft. The patient was at increased risk for traditional surgery, thus endovascular isolation of the aneurysm was felt to be reasonable. A flexible self-expanding stent graft was placed via a brachial artery cutdown and common femoral access without complication. The symptoms improved and the patient remained asymptomatic at 2-year follow-up with serial CT scan confirmation of aneurysm regression. This unusual case illustrates that endovascular decompression of an aneurysm may have some benefit in alleviating subacute symptoms of extrinsic encroachment into other vital structures. Technical and clinical success was achieved with the stent graft deployment and this seems to be a reasonable alternative to surgery in such patients.
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Affiliation(s)
- Mark C Bates
- Cardiovascular Research Charleston Area Medical Center Research Institute, Charleston, West Virginia, USA.
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14
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Bates MC, Kyer PD, Kavasmaneck C, AbuRahma A, Crotty B. Stent-supported angioplasty correction of symptomatic critical carotid angulation. W V Med J 2003; 99:22-4. [PMID: 12762212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Carotid stent-supported angioplasty is currently under investigation in many medical centers, for use in treating extracanial cerebrovascular disease. The early results of CSSA in selected patients appear promising. While carotid endarterectomy (CEA) remains the current standard of care, we believe that a small subgroup of patients at a high risk for surgery can benefit from CSSA. This case report describes a patient with symptomatic high-grade recurrent stenosis due to critical angulation (kinking) and redundancy of the internal carotid artery following CEA with patch angioplasty who was then treated successfully with CSSA.
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Affiliation(s)
- Mark C Bates
- Camcare Health Education and Research Institute, Robert C. Byrd Health Sciences Center, Circulatory Dynamics Laboratory, Charleston Area Medical Center, Charleston, USA
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15
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Bates MC, Shamsham FM, Faulknier B, Crotty B. Successful treatment of iatrogenic renal artery perforation with an autologous vein-covered stent. Catheter Cardiovasc Interv 2002; 57:39-43. [PMID: 12203925 DOI: 10.1002/ccd.10265] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A 72-year-old woman developed severe flank pain associated with hemodynamic compromise immediately after a J-curve guidewire was inadvertently advanced into the right renal artery during cardiac catheterization. Contrast extravasation consistent with perforation of the main renal artery was seen on abdominal angiography. The perforation was successfully sealed using a premounted coronary stent that was covered with an autologous antecubital vein. Wide stent patency without aneurismal dilatation was confirmed on a 2-year follow-up renal angiogram.
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Affiliation(s)
- Mark C Bates
- Charleston Area Medical Center (CAMC) Health Education and Research Institute-Cardiovascular Division, Charleston, West Virginia 25304, USA.
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16
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Abstract
BACKGROUND A screening programme to detect polyps or early carcinoma would significantly reduce the mortality and morbidity of colorectal cancer (CRC). The aims of the present study were to evaluate: (i) the feasibility of training general practitioners in flexible sigmoidoscopy (FS) for CRC screening; (ii) the acceptability of screening by faecal occult blood testing (FOBT) and FS in asymptomatic standard risk Australians aged over 50 years; and (iii) the yield of such screening. METHODS Subjects were recruited by general practitioner (GP) referral, newspaper advertisement or by a direct approach to retirement villages. Participants were mailed a FOBT kit and a prescreening questionnaire. Flexible sigmoidoscopy was performed by a GP supervised by an experienced endoscopist. Subjects then completed a second questionnaire. General practitioners were assessed after 50 unassisted procedures. RESULTS A total of 264 individuals contacted the study coordinator; 169 were screened. Screening was accepted well by the participants. Fifteen per cent of subjects had polyps and 4% had a positive FOBT. Training in FS was adversely affected by the availability of resources. Three GPs completed 50 unassisted procedures over a 15-month period, but none were able to reliably assess the distal bowel. CONCLUSIONS Although the three trainees and their supervisors did not consider that the GPs were adequately trained after 50 unassisted procedures, training was adversely affected by limited resources within the Victorian public hospital system. Screening by FOBT and FS was considered to be acceptable by the patients undergoing these procedures. Existing facilities are not adequate if GPs are to be trained in FS as part of a national CRC screening program.
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Affiliation(s)
- J A Martin
- Austin and Repatriation Medical Centre, Heidelberg, Victoria, Australia
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17
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Abstract
BACKGROUND It has been suggested that there is an increased risk of gastric cancer following partial gastrectomy. This question has not been studied in an Australian population. METHODS The records of a total of 569 patients who had a partial gastrectomy for peptic ulcer disease at Repatriation General Hospital, Heidelberg, between 1957 and 1976 were reviewed. All were followed to date of death or 31 December 1996. The expected rate of gastric cancer for this population was estimated from published Australian age-and sex-specific gastric cancer mortality rates over this period, and a standardized incidence ratio was calculated. RESULTS The mean age at surgery was 53.5 years (range 27-83 years). There were 547 male (96.4%) and 22 female (3.6%) patients. Five hundred and seven (83.5%) had a Billroth II procedure. Thirty-eight patients (6.3%) were lost to follow up and were not included in the analysis. From the records of the Department of Veterans' Affairs, it was established that 125 (20.6%) were alive in December 1996, a mean survival after surgery of 18.8 years. The mean documented duration of follow up was 17.3 years (range 1-41 years). Nine patients developed cancer in the gastric remnant. The expected number of cancers in this population was 6.5. Assuming all survivors were free of gastric cancer, the standardized incidence ratio was 1.39 (95% confidence intervals 0.64-2.65, P=0.313). CONCLUSION The risk of gastric cancer was not increased after partial gastrectomy in this Australian population.
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Affiliation(s)
- R Bassily
- Department of Gastroenterology, Austin & Repatriation Medical Centre, West Heidelberg, Victoria, Australia
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18
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Abstract
Reduced energy intake is the most important reason for weight loss in advanced human immunodeficiency virus (HIV) infection. From January 1989 to August 1995 enteral feeding via a percutaneous endoscopic gastrostomy tube (PEG) was offered to all human immunodeficiency virus(HIV)/AIDS patients attending Fairfield Hospital, Melbourne who were unable to maintain 85% ideal body weight. A total of 71 patients received enteral feeding (1000-2000 kcal/day) for a median period of 161 days (range 4-644 days). Fifty-one (72%) patients gained 5.8 +/- 4.4kg (range 0.4-19.2 kg). Nine gained 10 kg or more. The median time to maximum weight was 74 days after PEG insertion. Those who gained weight had a longer median survival, but this difference was not statistically significant (210 vs 109 days, P = 0.07). The only predictor of weight gain was a CD4 count greater than 100/microL. Patients who gained weight reported improved quality of life and increased independence. However, early complications, especially wound infection, were common. Although these data have been gathered retrospectively, our experience suggests that enteral feeding can maintain or improve nutritional status and may improve quality of life in advanced HIV infection.
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Affiliation(s)
- B Crotty
- University of Melbourne Department of Medicine, Austin and Repatriation Medical Centre, Victoria, Australia.
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19
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20
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Thomson A, Naidoo P, Crotty B. Bowel preparation for colonoscopy: a randomized prospective trail comparing sodium phosphate and polyethylene glycol in a predominantly elderly population. J Gastroenterol Hepatol 1996; 11:103-7. [PMID: 8672752 DOI: 10.1111/j.1440-1746.1996.tb00044.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Many patients find polyethylene glycol-based preparations (PEG) difficult to take because of the large volume of fluid they are required to consume. One hundred and sixteen predominantly elderly patients were randomized to receive either sodium phosphate (n = 61) or PEG (n = 55) bowel preparations before colonoscopy. Patients with a history of symptomatic ischaemic heart disease or cerebrovascular disease in the preceding 6 months, severe liver disease or heart failure, or serum creatinine above 200 micrograms/L were excluded from the study. Each patient filled in a questionnaire about the bowel preparation prior to the procedure. The colonoscopists, who were not aware which preparation had been used, were asked to complete a questionnaire about the quality of the bowel preparation after the procedure. The patients found the sodium phosphate preparation slightly more tolerable than PEG. Side effects were slightly more common with sodium phosphate. Neither difference was statistically significant. However, 91% of patients who had previously had PEG found sodium phosphate easier to take. Approximately 25% of patients in each group experienced at least one episode of incontinence. The colonoscopists found no difference in the overall quality of the bowel preparation. The amount of fluid in the colon was greater in patients prepared with PEG. As expected, patients taking sodium phosphate developed hyperphosphataemia (mean phosphate level before colonoscopy 1.56 mmol/L, normal 0.8 -1.3). They also had a lower mean serum potassium level (3.8 mmol/L) than the PEG group (4.2 mmol/L). However, there were no clinically significant consequences. Sodium phosphate was a safe and effective bowel preparation for colonoscopy in this carefully selected group of patients. It was preferred by patients who had previously had PEG. Many elderly patients were found to develop faecal incontinence, irrespective of the type of bowel preparation used.
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Affiliation(s)
- A Thomson
- Department of Gastroenterology, Heidelberg Repatriation Hospitals, Melbourne, Victoria, Australia
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21
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Abstract
Gamma interferon (IFN gamma) impairs epithelial barrier function and induces HLA-DR expression on colonic cancer cell lines. Salicylates have been shown to reduce IFN gamma induced HLA-DR expression. The effect of 5-aminosalicylic acid (5-ASA) on IFN gamma induced changes in transepithelial resistance and permeability was investigated in HT29 clone 19A and Caco 2 monolayers. Monolayers were incubated with different concentrations of IFN gamma (100, 500, 1000, and 3000 U/ml) and 5-ASA. IFN gamma induced class II expression in a time and dose dependent manner in HT29:19A but not Caco 2 cells. HT29:19A monolayers incubated with both IFN gamma and 5-ASA showed lower HLA-DR expression compared with monolayers incubated with IFN gamma alone. Electrical resistance and 14C-mannitol flux across HT29:19A monolayers were significantly changed by IFN gamma. Addition of both IFN gamma and 5-ASA to the basolateral surface of the monolayers significantly reduced paracellular permeability compared with addition of IFN gamma alone. These data show that IFN gamma is able to induce HLA-DR expression and to impair the barrier function of HT29:19A monolayers, and that 5-ASA reduces IFN gamma induced HLA-DR expression and inhibits the effects of IFN gamma on epithelial barrier function.
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Affiliation(s)
- M C Di Paolo
- Gastroenterology Unit, Radcliffe Infirmary, Oxford
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22
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23
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Crotty B. Ethanol and upper gastrointestinal bleeding. Am J Gastroenterol 1995; 90:1038-9. [PMID: 7611192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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24
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Affiliation(s)
- B Crotty
- Australian Gastroenterology Institute, Sydney, NSW
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25
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Affiliation(s)
- M J Richards
- Infectious Disease Services, Austin Repatriation Hospital, Melbourne, VIC
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26
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Abstract
Drug therapy for upper gastrointestinal disease in the elderly must be moderated by the likelihood of increased sensitivity to the side effects of drugs. For example, in the frail elderly with helicobacter-associated duodenal ulcers, maintenance therapy with an H2-receptor antagonist or omeprazole may be preferable to attempting to eradicate Helicobacter pylori with the current antimicrobial regimens.
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Affiliation(s)
- B Crotty
- Department of Medicine, University of Melbourne, Heidelberg Repatriation Hospital, VIC
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27
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Abstract
1. To determine how platelet-activating factor stimulates colonic anion secretion and increases epithelial permeability, epithelial sheets of rabbit distal colon excluding the submucosal neural plexus were mounted in Ussing chambers. The influence of specific inhibitors and 50 nmol/l platelet-activating factor on short-circuit current and transepithelial resistance was then investigated. 2. Pretreatment with 1 mumol/l indomethacin or 1 mumol/l doxantrazole abolished the biphasic stimulation of the short-circuit current and decrease in transepithelial resistance induced by platelet-activating factor. Addition of 10 mumol/l mepyramine attenuated the early phase and completely inhibited the late phase. Pretreatment with 1 mumol/l ranitidine, 0.1 mumol/l tetrodotoxin, 0.1 mumol/l ritanserin or a 5-lipoxygenase inhibitor (1 mumol/l MK886) had no effect. 3. To assess the influence of platelet-activating factor on epithelial function isolated from lamina propria elements, monolayers were cultured from a human colonic epithelial cell line (T-84). 4. The short-circuit current across monolayers mounted in Ussing chambers stimulated by 10 mumol/l ionomycin could be inhibited by pretreatment with ouabain or frusemide, consistent with the capacity for chloride secretion. Addition of platelet-activating factor (up to 500 nmol/l) had no effect on short-circuit current or transepithelial resistance. Receptor expression was examined with [3H] platelet-activating factor in isolated T-84 and HT-29 cells and found to be absent. 5. The influence of physiological concentrations of platelet-activating factor on colonic epithelial anion secretion and increased permeability in rabbit distal colon is indirect and consistent with mediation by prostaglandins released from mucosal mast cells.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- S P Travis
- Gastroenterology Unit, Radcliffe Infirmary, Oxford, U.K
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28
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Abstract
Bleeding from hepatocellular carcinoma (HCC) invading the gastrointestinal tract is very uncommon. We report the case of a 61 year old man who had a large bleed from HCC invading the fundus of the stomach. Diagnosis was eventually made at laparotomy and he is still alive 7 months after local resection.
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Affiliation(s)
- A J Nicoll
- Department of Gastroenterology, Austin Hospital, Heidelberg, Australia
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29
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Abstract
Any hypothesis on the cause of ulcerative colitis must account for genetic influences, geographic and ethnic variations, effects of smoking and oral contraception, anatomical distribution, the relapsing and remitting nature of the disease, and association with primary sclerosing cholangitis. This hypothesis proposes that ulcerative colitis is caused by a reactive xenobiotic metabolite which is conjugated before excretion into bile. The amount of metabolite produced is determined by exposure to its parent compound, by the inherited pattern of metabolism, and by inhibition and induction of enzymes catalysing alternative pathways. Deconjugation by bacteria within the colonic lumen releases the reactive metabolite, damaging the colonic epithelial barrier and exposing the mucosal immune system to luminal contents. Biliary epithelial damage by the metabolite leads to an immune response in those individuals carrying appropriate HLA molecules, thereby initiating an inflammatory process within the biliary tree.
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Affiliation(s)
- B Crotty
- University of Melbourne, Department of Medicine, Heidelberg Repartriation Hospital, Victoria, Australia
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30
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Affiliation(s)
- B Crotty
- University of Melbourne, Department of Medicine, Heidelberg Repatriation Hospital, West Heidelberg, Vic
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31
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Dalton HR, Dipaolo MC, Sachdev GK, Crotty B, Hoang P, Jewell DP. Human colonic intraepithelial lymphocytes from patients with inflammatory bowel disease fail to down-regulate proliferative responses of primed allogeneic peripheral blood mononuclear cells after rechallenge with antigens. Clin Exp Immunol 1993; 93:97-102. [PMID: 8324909 PMCID: PMC1554734 DOI: 10.1111/j.1365-2249.1993.tb06503.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Human colonic intraepithelial lymphocytes from control subjects down-regulate the proliferative responses of primed allogeneic peripheral blood mononuclear cells on rechallenge with antigens or phytohaemagglutinin (PHA). In contrast, human colonic intraepithelial lymphocytes from patients with inflammatory bowel disease fail to down-regulate the proliferative responses of primed allogeneic peripheral blood mononuclear cells on rechallenge with antigens. These findings may be important in the development and maintenance of the mucosal immunological activation of inflammatory bowel disease.
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Affiliation(s)
- H R Dalton
- Gastroenterology Unit, Radcliffe Infirmary, Oxford, UK
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32
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Sachdev GK, Dalton HR, Hoang P, DiPaolo MC, Crotty B, Jewell DP. Human colonic intraepithelial lymphocytes suppress in vitro immunoglobulin synthesis by autologous peripheral blood lymphocytes and lamina propria lymphocytes. Gut 1993; 34:257-63. [PMID: 8432483 PMCID: PMC1373981 DOI: 10.1136/gut.34.2.257] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Human colonic intraepithelial lymphocytes have been shown to suppress the proliferation of autologous lamina propria lymphocytes and allogeneic peripheral blood mononuclear cells. This study has shown that, in vitro, intraepithelial lymphocytes suppress IgA and total immunoglobulin synthesis (but not IgG or IgM production) by autologous peripheral blood and lamina propria lymphocytes. This down regulation of IgA production is mediated by a soluble factor secreted by the intraepithelial lymphocytes. There is no difference in immunoglobulin down regulation by intraepithelial lymphocytes of control subjects and patients with inflammatory bowel disease.
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Affiliation(s)
- G K Sachdev
- Department of Gastroenterology, Radcliffe Infirmary, Oxford
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33
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Abstract
5-Aminosalicylic acid (5ASA), 4ASA, their N-acetylated metabolites N-acetyl-5ASA and N-acetyl-4ASA, olsalazine, and colchicine impair interferon-gamma (IFN gamma) induced HLA-DR expression on a colonic cell line, HT-29. The mechanism of this effect is now reported. HT-29 cells were cultured with 50 U/ml IFN gamma with or without drug, and northern blot analysis was performed using a probe for the beta chain of the DR molecule. IFN gamma led to a noticeable increase in HLA-DR mRNA which was attenuated by the drugs. Analysis of the specific binding of increasing concentrations of 125I-IFN gamma by non-linear regression showed a Kd of 1.35 x 10(-10) M and 2.3 x 10(5) binding sites per HT-29 cell. Binding of 125I-IFN gamma was reduced by incubation with increasing concentrations of unlabelled IFN gamma but not with IFN alpha. Incubation with therapeutic concentrations of drugs led to the following reductions in binding: 10 mM 5ASA, 20% (p < 0.001); 10 mM N-acetyl-5ASA, 24% (p < 0.01); 10 mM 4ASA, 21% (p < 0.005); 10 mM N-acetyl-4ASA, 29% (p < 0.001); and 1 mM olsalazine, 29% (p < 0.001). Colchicine (10(-7) M) and 10(-5) M prednisolone had no effect. Incubation with higher concentrations of the drugs revealed a dose-response effect on binding with complete inhibition by 100 mM 4ASA and 10 mM olsalazine, and lesser degrees of inhibition by 100 mM 5ASA, N-acetyl-5ASA, and N-acetyl-4ASA. At concentrations found in the rectal lumen, the salicylates used in inflammatory bowel disease impair the binding of IFN gamma to its receptor on colonic epithelial cells.
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Affiliation(s)
- B Crotty
- Gastroenterology Unit, Radcliffe Infirmary, Oxford
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34
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Affiliation(s)
- B Crotty
- Gastroenterology Unit, Radcliffe Infirmary, Oxford
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35
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Abstract
HLA-DR+ gut epithelial cells may present antigen to intraepithelial lymphocytes (IEL). This study aimed to isolate an IEL population from the human colon to activate CD3 + IEL by a human colonic epithelial cell line (HT-29), bearing different concentrations of class II antigen (HLA-DR). IEL were isolated by a mechanical method from six patients with ulcerative colitis (UC) and from 14 control patients. IEL were cocultured with HT-29 which had been induced to express class II molecules by gamma-interferon (IFN-gamma) in a dose dependent manner. The phenotype and the subsequent expression of activation markers by the IEL were determined to two colour flow cytometry. The IEL population had a CD4/CD8 ratio similar to that seen in tissue sections. In the mixed cell culture, the degree of IEL activation showed a positive correlation with the degree of HLA-DR expression by the HT29 cells and the IEL secreted a IFN-gamma like factor that in turn stimulated the HT-29. Thus, depending on their expression of HLA molecules, colonic epithelial cells are able to activate CD3+CD8+IEL.
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Affiliation(s)
- P Hoang
- Gastroenterology Unit, Radcliffe Infirmary, Oxford
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36
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Esler M, Dudley F, Jennings G, Debinski H, Lambert G, Jones P, Crotty B, Colman J, Willett I. Increased sympathetic nervous activity and the effects of its inhibition with clonidine in alcoholic cirrhosis. Ann Intern Med 1992; 116:446-55. [PMID: 1739234 DOI: 10.7326/0003-4819-116-6-446] [Citation(s) in RCA: 89] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To study disturbances in sympathetic nervous system function in patients with alcoholic cirrhosis and the effect of clonidine on such disturbances. DESIGN Cross-sectional physiologic and neurochemical evaluation of patients with cirrhosis and of healthy controls; an uncontrolled trial of intravenous clonidine in the cirrhotic patients. PATIENTS Forty-four hospitalized patients with biopsy-proven alcoholic cirrhosis and 31 healthy controls. INTERVENTIONS Intravenous clonidine. MAIN OUTCOME MEASURES Radiotracer-derived measures of norepinephrine release to plasma, central hemodynamics, wedge hepatic vein pressure, and measures of renal function. MAIN RESULTS In patients with cirrhosis, clonidine reduced previously elevated norepinephrine overflow rates for the whole body, kidneys, and hepatomesenteric circulation. This sympathetic inhibition was accompanied by the following potentially clinically beneficial effects: the lowering of renal vascular resistance (median reduction, 24%; 95% CI, 14% to 31%), the elevation of glomerular filtration rate (median increase, 27%; CI, 14% to 39%), and the reduction of portal venous pressure (median reduction, 25%; CI, 18% to 32%). The norepinephrine and hemodynamic responses to graded clonidine dosing (1, 2, and 3 micrograms/kg body weight intravenously) indicated that the sympathetic outflow to the hepatomesenteric circulation was more sensitive to pharmacologic suppression with clonidine than was the sympathetic outflow to the systemic circulation. CONCLUSIONS The sympathetic nerves to the kidneys, heart, and hepatomesenteric circulation are stimulated in patients with cirrhosis. Clonidine inhibits these activated sympathetic outflows differentially, which could possibly provide a basis for the selective pharmacologic treatment of portal hypertension in patients with cirrhosis.
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Affiliation(s)
- M Esler
- Alfred Hospital, Prahran, Australia
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37
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Abstract
Colonic epithelial cells express HLA-DR in inflammatory bowel disease. The effect of drugs used in the treatment of inflammatory bowel disease and colchicine on interferon-gamma (IFN-gamma) induced DR expression has been investigated. HT-29 cells were cultured in 25 cm2 flasks. At 48 hours interferon-gamma (0, 50, or 100 U/ml) +/- drug were added. At 120 hours the cells were stained for HLA-DR and analysed by flow cytometry. 10(-2) M 5ASA reduced DR expression induced by 50 U/ml interferon-gamma from 62 (12)% of cells (mean SD) to 29 (20)% (p less than 0.005). Corresponding figures for 10(-2) M N-acetyl 5ASA were 68 (16)% to 39 (17)% (p less than 0.05); for 10(-2) M 4ASA, 61 (4)% to 57 (4)% (p = 0.6); for 10(-2) M N-acetyl 4ASA, 60 (12)% to 35 (13)% (p less than 0.05); for 10(-2) M olsalazine, 72 (9)% to 3 (1)% (p less than 0.001); for 10(-3) M olsalazine, 72 (9)% to 16 (10)% (p less than 0.001); for 10(-6) M colchicine, 62 (13)% to 5 (3)% (p less than 0.001); and for 10(-7) M colchicine, 62 (13)% to 10 (3)%. Similar results were obtained when DR was induced by 100 U/ml of interferon-gamma except with 10(-2) M 4ASA which reduced expression from 77 (4)% to 68 (3)% (p less than 0.05). Sulphapyridine, prednisolone, indomethacin and cyclosporin A had no effect. Concurrent staining with propidium iodide showed that these results were unchanged when viable cells alone were analysed. Prior incubation of cells with drug, followed by washing, had no effect on interferon-gamma induced DR expression. 5ASA, N-acetyl 5ASA, 4ASA, N-acetyl 4ASA, olsalazine and colchicine reduce interferon-gamma induced HLA-DR expression. In inflammatory bowel disease these compounds may impair antigen presentation by the colonic epithelium.
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Affiliation(s)
- B Crotty
- Gastroenterology Unit, Radcliffe Infirmary, Oxford
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38
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Abstract
Epidural opioids provide high quality analgesia with no clinically apparent effect on the circulation or on specific organ blood flow. Little investigative data is available to support these impressions of circulatory stability. Ten patients presenting for thoracotomy were studied at rest preoperatively to determine if epidural fentanyl had any effect on the systemic circulation or hepatic blood flow. Intravascular pressure measurements, cardiac output estimation using the dye-dilution technique and estimation of altered hepatic blood flow by measuring the clearance of indocyanine green were performed. No significant changes in heart rate, perfusion pressure, cardiac output or hepatic blood flow were detected following the administration of fentanyl 50 micrograms into the epidural space.
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Affiliation(s)
- R E Beavis
- Department of Anaesthesia, Royal Melbourne Hospital, Victoria
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39
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Abstract
Using hepatic vein catheterization this study has provided the first direct measurement of morphine hepatic extraction in 8 controls and 8 cirrhotics. The extraction ratio was 0.52 in the control group and was reduced by 25% in the cirrhotics. This reduction is due to impaired enzyme capacity rather than reduced blood flow. The effect of cirrhosis is less than that reported in similar studies of high clearance oxidized drugs and this lends support to the concept that glucuronidation may be relatively spared in cirrhosis. A discrepancy between the systemic clearance and the hepatic clearance provides indirect support for extra-hepatic metabolism of morphine.
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Affiliation(s)
- B Crotty
- Department of Gastroenterology, St. Vincent's Hospital, Fitzroy, Victoria, Australia
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40
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Abstract
Acutely bleeding varices present a therapeutic dilemma because of the limited efficacy and high complication rates of conventional treatments. Over a period of 26 months, 56 episodes of acutely bleeding varices were treated with injection sclerotherapy as the initial management. Immediate control of haemorrhage was achieved in 91% of patients and control of bleeding during the hospital admission in 84%. Balloon tamponade and surgery were reserved for those patients in whom bleeding was not controlled by sclerotherapy; in 66% of patients the bleeding was controlled by sclerotherapy alone. Of the 56 episodes, 75% survived their admission to hospital. Acute injection sclerotherapy is as least as effective as conventional therapies in the control of bleeding with a low incidence of complications. The technique can be used in all patients irrespective of the severity of their liver disease and, when bleeding is controlled, allows the physician the choice of all the available prophylactic therapies.
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Byrne E, Dennett X, Crotty B, Trounce I, Sands JM, Hawkins R, Hammond J, Anderson S, Haan EA, Pollard A. Dominantly inherited cardioskeletal myopathy with lysosomal glycogen storage and normal acid maltase levels. Brain 1986; 109 ( Pt 3):523-36. [PMID: 3087571 DOI: 10.1093/brain/109.3.523] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
A family is presented in which 7 members over 3 generations were affected by cardioskeletal myopathy. A vacuolar myopathy with excessive free and intralysosomal glycogen storage in skeletal and cardiac striated muscle was identified in biopsy studies. Post-mortem studies in several patients revealed changes of a congestive cardiomyopathy with myocardial fibrosis. Acid maltase, phosphorylase, debrancher and lysosomal enzyme screens, and glycolytic enzyme levels in skeletal muscle, were normal in 1 case. This is the third report of non-acid maltase deficient lysosomal glycogen storage disease and adds to previous reports with the presentation of detailed family studies, examined of ante- and post-mortem cardiac histology and reports of detailed glycolytic and lysosomal enzyme analysis. This syndrome is unusual among glycogenoses in having a dominant inheritance pattern.
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