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Han Z, Barton KC, Ho LC, Yap KZ, Tan DSY, Lee SS, Neo CXR, Tan AHL, Boey BMY, Soon CJY, Gallagher PJ. Applying narrative medicine to prepare empathetic healthcare providers in undergraduate pharmacy education in Singapore: a mixed methods study. BMC Med Educ 2024; 24:292. [PMID: 38491363 PMCID: PMC10943898 DOI: 10.1186/s12909-024-05254-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 03/04/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Narrative medicine demonstrated positive impact on empathy in medicine and nursing students. However, this pedagogical approach had not been evaluated in pharmacy education. This study sought to apply and evaluate the narrative medicine approach in extending empathy in Asian undergraduate pharmacy students. METHODS Narrative medicine was applied through workshops which used narratives of people with different experiences and perspectives. First-year undergraduate pharmacy students who volunteered and attended these workshops formed the intervention group (N = 31) and the remaining first-year cohort formed the control group (N = 112). A sequential explanatory mixed methods approach was adopted in which quantitative methods were first used to measure impact on pharmacy students' empathy using the Jefferson Scale of Empathy- Health Professions Student (JSE-HPS), and qualitative methods (i.e. group interviews) were then used to assess pharmacy students' emotional responses to narratives, and the perspectives of pharmacy students and faculty of this pedagogical approach. RESULTS There was no difference in JSE-HPS scores between intervention and control groups across baseline (i.e. upon matriculation), pre-intervention, and post-intervention timepoints. Pharmacy students in the intervention group had lower scores in Factor 3 ("Standing in People's Shoes") following the intervention. Five themes, guided by internal and external factors in cognition, emerged from the Group Interviews: (1) incongruence between students' motivation and faculty's perception, (2) learning context, (3) academic context, (4) cognitive system, and (5) affective system. Themes 1, 4 and 5 referred to internal factors such as students' motivation, perceived learnings, and feelings. Themes 2 and 3 referred to external factors including workshop materials, activities, content, and facilitation. CONCLUSION This study is the first to demonstrate that pharmacy students engaged with the narrative medicine approach as narratives elicited emotional responses, exposed them to diverse perspectives, and deepened their appreciation of the importance of empathy and complexities of understanding patients' perspectives. Scaffolded educational interventions using narratives and real-life patient encounters, alongside longitudinal measurements of empathy, are necessary to bring about meaningful and sustained improvements in empathy.
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Affiliation(s)
- Zhe Han
- Department of Pharmacy and Pharmaceutical Sciences, Faculty of Science, National University of Singapore, Block S4A, Level 3, 18 Science Drive 4, 117543, Singapore, Singapore.
| | - Keith C Barton
- Department of Curriculum and Instruction, School of Education, Indiana University, 201 N. Rose Avenue, 47405, Bloomington, IN, USA
| | - Li-Ching Ho
- Department of Curriculum and Instruction, School of Education, University of Wisconsin- Madison, 225 N. Mills Street, 53706, Madison, WI, USA
| | - Kai Zhen Yap
- Department of Pharmacy and Pharmaceutical Sciences, Faculty of Science, National University of Singapore, Block S4A, Level 3, 18 Science Drive 4, 117543, Singapore, Singapore
| | - Doreen Su-Yin Tan
- Department of Pharmacy and Pharmaceutical Sciences, Faculty of Science, National University of Singapore, Block S4A, Level 3, 18 Science Drive 4, 117543, Singapore, Singapore
| | - Shuh Shing Lee
- Center for Medical Education, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, 117597, Singapore, Singapore
| | - Constance Xue Rui Neo
- Department of Pharmacy, Khoo Teck Puat Hospital, 90 Yishun Central, 768828, Singapore, Singapore
| | - Amanda Han Lin Tan
- Department of Pharmacy and Pharmaceutical Sciences, Faculty of Science, National University of Singapore, Block S4A, Level 3, 18 Science Drive 4, 117543, Singapore, Singapore
| | - Brian Ming Yao Boey
- Department of Pharmacy and Pharmaceutical Sciences, Faculty of Science, National University of Singapore, Block S4A, Level 3, 18 Science Drive 4, 117543, Singapore, Singapore
| | - Charis Jia Yan Soon
- Department of Pharmacy and Pharmaceutical Sciences, Faculty of Science, National University of Singapore, Block S4A, Level 3, 18 Science Drive 4, 117543, Singapore, Singapore
| | - Paul J Gallagher
- Department of Pharmacy and Pharmaceutical Sciences, Faculty of Science, National University of Singapore, Block S4A, Level 3, 18 Science Drive 4, 117543, Singapore, Singapore
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Etukakpan A, Uzman N, Ozer O, Tofade T, Leite SN, Joda A, Choonara Y, Mwila C, Azzopardi LM, Mantel-Teeuwisse AK, Rahal M, Darwish R, Lee BJ, Shakya R, Gallagher PJ, Moreau P, Lourenço L, McKinnon RA, Altiere RJ. Transforming pharmaceutical education: A needs-based global analysis for policy development. Explor Res Clin Soc Pharm 2023; 9:100234. [PMID: 36876147 PMCID: PMC9981992 DOI: 10.1016/j.rcsop.2023.100234] [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: 11/09/2022] [Revised: 02/08/2023] [Accepted: 02/08/2023] [Indexed: 02/16/2023] Open
Abstract
Background A needs-based approach is desirable for the transformation of pharmaceutical education, and to link pharmaceutical education with the health needs of populations and national priorities. There are varying levels of data in the literature on the status of pharmaceutical education in all six World Health Organization (WHO) regions, especially in the context of needs identification and evidence-based policy interventions. The framework for this study was the FIP Development Goals. Objectives The aim of the study was to develop evidence-based policies through a needs-based approach for pharmaceutical education transformation nationally, regionally and globally by addressing the following objectives: 1. Identify global and regional needs in pharmaceutical education, through a regional SWOT analysis and prioritization of FIP development goals; 2. Develop valid and credible regional roadmaps for pharmaceutical education advancement according to the identified prioritized goals and 3. Develop a global call to action as a policy intervention for advancing pharmaceutical education. Methods This study was conducted between 2020 and 2021 using a mixed methods approach. Surveys of higher education institutions and a series of qualitative interviews were conducted with national professional leadership organizations, with further regional workshops having 284 participants recruited from the International Pharmaceutical Federation (FIP) membership base, spanning all six WHO regions. Results Eleven out of 21 FIP DGs were identified as priorities for regional roadmaps and FIP DG 1 (Academic capacity) was identified as a priority in four regions. All regions had distinctive results with an area of commonality between them. There were common weaknesses in the adoption of competency-based education and inter-professional education. Conclusions It is critical for every country and region to develop needs- and evidence-based policies for the transformation of pharmaceutical education, for which FIP DGs provide a systematic framework.
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Affiliation(s)
- Alison Etukakpan
- International Pharmaceutical Federation, The Hague, the Netherlands
| | - Nilhan Uzman
- International Pharmaceutical Federation, The Hague, the Netherlands
| | - Ozge Ozer
- International Pharmaceutical Federation, The Hague, the Netherlands
| | - Toyin Tofade
- International Pharmaceutical Federation, The Hague, the Netherlands.,Albany College of Pharmacy and Health Sciences, USA
| | - Silvana Nair Leite
- International Pharmaceutical Federation, The Hague, the Netherlands.,Department of Pharmaceutical Sciences, Federal University of Santa Catarina, Brazil
| | - Arinola Joda
- International Pharmaceutical Federation, The Hague, the Netherlands.,Faculty of Pharmacy, University of Lagos, Nigeria
| | - Yahya Choonara
- International Pharmaceutical Federation, The Hague, the Netherlands.,Department of Pharmacy and Pharmacology, University of Witwatersrand, South Africa
| | - Chiluba Mwila
- International Pharmaceutical Federation, The Hague, the Netherlands.,Department of Pharmacy, University of Zambia, Zambia
| | - Lilian M Azzopardi
- International Pharmaceutical Federation, The Hague, the Netherlands.,Department of Pharmacy, University of Malta, Malta
| | - Aukje K Mantel-Teeuwisse
- International Pharmaceutical Federation, The Hague, the Netherlands.,School of Pharmacy, Utrecht University, Utrecht, the Netherlands
| | - Mohammad Rahal
- International Pharmaceutical Federation, The Hague, the Netherlands.,School of Pharmacy, Lebanese International University, Lebanon
| | - Rula Darwish
- International Pharmaceutical Federation, The Hague, the Netherlands.,School of Pharmacy, The University of Jordan, Jordan
| | - Beom-Jin Lee
- International Pharmaceutical Federation, The Hague, the Netherlands.,College of Pharmacy, Ajou University, Republic of Korea
| | - Rajani Shakya
- International Pharmaceutical Federation, The Hague, the Netherlands.,Department of Pharmacy, Kathmandu University, Nepal
| | - Paul J Gallagher
- International Pharmaceutical Federation, The Hague, the Netherlands.,Department of Pharmacy, National University of Singapore, Singapore
| | - Pierre Moreau
- International Pharmaceutical Federation, The Hague, the Netherlands.,Faculty of Pharmacy, Kuwait University, Kuwait
| | - Luis Lourenço
- International Pharmaceutical Federation, The Hague, the Netherlands
| | - Ross A McKinnon
- International Pharmaceutical Federation, The Hague, the Netherlands.,College of Medicine and Public Health, Flinders University, Australia
| | - Ralph J Altiere
- International Pharmaceutical Federation, The Hague, the Netherlands.,Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, USA
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Xu Y, Gallagher PJ, Tan CWY, Tsou KYK, Tan DHY, Ramaya H, Lee JY. Impact of team‐based pharmaceutical care on the humanistic outcomes among patients with long‐standing diabetes: An interim analysis of a randomized, controlled, multicenter study. J Am Coll Clin Pharm 2021. [DOI: 10.1002/jac5.1425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Yingqi Xu
- Department of Pharmacy, Faculty of Science National University of Singapore Singapore Singapore
| | - Paul J. Gallagher
- Department of Pharmacy, Faculty of Science National University of Singapore Singapore Singapore
| | | | | | | | - Henry Ramaya
- National University Polyclinics Singapore Singapore
| | - Joyce Y.‐C. Lee
- Department of Clinical Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences University of California Irvine California USA
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Maher S, Hayden JC, Strawbridge JD, Gallagher PJ, Flood M. 'Both useful in their own way': Video podcasts and typed solutions as feedback on undergraduate pharmaceutical calculations skills assessment. Curr Pharm Teach Learn 2020; 12:367-377. [PMID: 32334751 DOI: 10.1016/j.cptl.2019.12.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 10/18/2019] [Accepted: 12/07/2019] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Accurately completing pharmaceutical calculations is a core professional skill for pharmacists. To date, few studies have focused on to providing feedback on calculations, or the role of technology in feedback provision. This study aimed to develop a theory-informed video podcast-based method of providing formative feedback and evaluate student perceptions. METHODS First-year pharmacy students (n = 53) completed a formative pharmaceutical calculations assessment. Two forms of feedback were designed and evaluated; typed solutions (traditional format commonly used/seen in textbooks) and video podcasts informed by instructional design theory (novel format). RESULTS A survey was completed by 70% (37/53) of students. Specific features of video podcasts reported useful included hearing reasoning, and the ability to pause and rewind. Most (76%) reported positive attitudes towards video podcasts, considered them useful (75%) and helpful for learning (79%). A comparable number (76% and 71% respectively) felt positively about typed solutions. The majority (51%) preferred to receive both types rather than podcasts alone (24%), or typed solutions alone (8%). Free-text responses indicated both were used in different ways; typed solutions for quick verification and video podcasts for clarification. CONCLUSIONS Video podcasts appear to be a potentially helpful additional method of delivering feedback that afford specific advantages. They can be readily developed by faculty with minimal expense/difficulty. However, as respondents indicated that they used both kinds of feedback in different ways to support their learning, and indicated a preference to receive both types, they should be considered an addition rather than replacement for typed solutions.
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Affiliation(s)
- Sam Maher
- Senior Lecturer in Pharmaceutics, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI), 123 St Stephen's Green, Dublin 2, Ireland.
| | - John C Hayden
- Lecturer in Pharmacy Practice, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI), 123 St Stephen's Green, Dublin 2, Ireland.
| | - Judith D Strawbridge
- Senior Lecturer in Pharmacy Practice, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI), 123 St Stephen's Green, Dublin 2, Ireland.
| | - Paul J Gallagher
- Associate Professor of Pharmacy Practice, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI), Dublin 2, Ireland.
| | - Michelle Flood
- Lecturer in Pharmacy Practice, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI), 123 St Stephen's Green, Dublin 2, Ireland.
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5
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Hayden JC, Bardol M, Doherty DR, Dawkins I, Healy M, Breatnach CV, Gallagher PJ, Cousins G, Standing JF. Optimizing clonidine dosage for sedation in mechanically ventilated children: A pharmacokinetic simulation study. Paediatr Anaesth 2019; 29:1002-1010. [PMID: 31373752 DOI: 10.1111/pan.13715] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 06/28/2019] [Accepted: 07/29/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Clonidine is in widespread off-label use as a sedative in mechanically ventilated children, despite limited evidence of efficacy. A variety of dosage regimens have been utilized in clinical practice and in research studies. Within these studies, clonidine has inconsistently shown useful sedation properties. One of the reasons attributed to the inconsistent signs of efficacy is suboptimal clonidine dosing. AIMS This study aims to propose a target plasma concentration and simulate clonidine pharmacokinetics (PK) in a cohort of mechanically ventilated children to evaluate the adequacy of clonidine dosage regimens used in clinical practice and research studies. METHODS A literature search was undertaken to identify a clonidine pharmaockinetic-pharmacodynamics (PKPD) model, from which a target concentration for sedation was defined. Using a previously published PK model, the projected plasma concentrations of 692 mechanically ventilated children (demographics taken from a recent study) were generated. Doses from recently published clinical studies were investigated. Adequacy of each regimen to attain therapeutic clonidine plasma concentrations was assessed. RESULTS A target plasma concentration of above 2 µg/L was proposed. Nine dosage regimens (four intravenous boluses, four intravenous infusions, and one nasogastric route boluses) were evaluated ranging from 1 µg/kg eight hourly intravenous boluses to a regimen up to 3 µg/kg/hr continuous intravenous infusion. Regimens with a loading dose of 2 µg/kg followed by variable continuous infusion of up to 2 µg/kg/hr titrated according to sedation score appear most suitable. Doses should be halved in neonates. CONCLUSION The variety of dosage regimens in the previous studies of clonidine along with difficulties in the conduct of interventional studies may have contributed to the lack of efficacy data to support its use. Simulations of clonidine plasma concentrations based on known population pharmacokinetic parameters suggest a loading dose followed by higher than current practice maintenance dose infusion is required to achieve adequate steady-state concentrations early in treatment. Further PKPD studies will aid in the determination of the optimal clonidine dosage regimen.
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Affiliation(s)
- John C Hayden
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Maddlie Bardol
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Dermot R Doherty
- Paediatric Intensive Care Unit, Our Lady's Children's Hospital, Dublin, Ireland.,Intensive Care Unit, Children's University Hospital, Dublin, Ireland
| | - Ian Dawkins
- Paediatric Intensive Care Unit, Our Lady's Children's Hospital, Dublin, Ireland.,Intensive Care Unit, Children's University Hospital, Dublin, Ireland
| | - Martina Healy
- Paediatric Intensive Care Unit, Our Lady's Children's Hospital, Dublin, Ireland
| | - Cormac V Breatnach
- Paediatric Intensive Care Unit, Our Lady's Children's Hospital, Dublin, Ireland
| | - Paul J Gallagher
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Gráinne Cousins
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Joseph F Standing
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
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6
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Flood M, Hayden JC, Bourke B, Gallagher PJ, Maher S. Design and Evaluation of Video Podcasts for Providing Online Feedback on Formative Pharmaceutical Calculations Assessments. Am J Pharm Educ 2017; 81:6400. [PMID: 29367779 PMCID: PMC5774199 DOI: 10.5688/ajpe6400] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 06/19/2017] [Indexed: 05/28/2023]
Abstract
Objective. To evaluate worked example video podcasts as a method of providing feedback to pharmacy interns for an online and formative pharmaceutical calculations assessment. Methods. A theory-informed approach based on multimedia learning theory was used to design video podcasts as feedback on a calculations examination. A mixed-methods evaluation completed by pharmacy interns enrolled in Ireland's National Pharmacy Internship Programme was used to establish cognitive and affective attitudes toward video podcasts compared with conventional written solutions. Results. The majority of students found video podcasts were clear, helpful for learning, easy to understand, and useful as a method of feedback. Majority reported that they felt positively about standard written solutions. The evaluation suggested distinct benefits for each kind of feedback, something that has not been previously reported. Thematic analysis of qualitative data indicated useful features of video podcasts, including clear explanation, step-by-step approach, and synchronization of audio and visual information. Conclusion. Respondents reported positive cognitive and affective attitudes toward video podcasts as online feedback. Video podcasts are a helpful and novel way of providing feedback on pharmaceutical calculations. A similar opinion of traditional written solutions suggests that students may benefit from both forms of feedback. Further study is required to identify the particular benefits associated with both kinds.
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Affiliation(s)
- Michelle Flood
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - John C Hayden
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Bernadette Bourke
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Paul J Gallagher
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Sam Maher
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
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Abstract
OBJECTIVES Older adults are particularly vulnerable to adverse effects from concurrent alcohol and medication use. However, there is limited evidence regarding the prevalence of these adverse outcomes among older adults, and there is a lack of consensus regarding what constitutes an alcohol-interactive medicine. The objective of this study was to develop an explicit list of potentially serious alcohol-medication interactions for use in older adults. DESIGN Following a systematic review, review of drug compendia and clinical guidance documents, a two-round Delphi consensus method was conducted. SETTING Ireland and the United Kingdom (UK), primary care and hospital setting. PARTICIPANTS The Project Steering Group developed a list of potentially serious alcohol-medication interactions. The Delphi panel consisted of 19 healthcare professionals (general practitioners, geriatricians, hospital and community pharmacists, clinical pharmacologists and pharmacists, and physicians specialising in substance misuse). RESULTS An inventory of 52 potentially serious alcohol-medication interactions was developed by the Project Steering Group. British National Formulary black dot warnings (n=8) were included in the final criteria as they represent 'potentially serious' interactions. The remaining 44 criteria underwent a two-round Delphi process. In the first round, 13 criteria were accepted into the POtentially Serious Alcohol-Medication INteractions in Older adults (POSAMINO) criteria. Consensus was not reached on the remaining 31 criteria; 9 were removed and 8 additional criteria were included following a review of panellist comments. The remaining 30 criteria went to round 2, with 17 criteria reaching consensus, providing a final list of 38 potentially serious alcohol-medication interactions: central nervous system (n=15), cardiovascular system (n=9), endocrine system (n=5), musculoskeletal system (n=3), infections (n=3), malignant disease and immunosuppression (n=2), and respiratory system (n=1). CONCLUSIONS POSAMINO is the first set of explicit potentially serious alcohol-medication interactions for use in older adults. Following future validation studies, these criteria may allow for the risk stratification of older adults at the point of prescribing.
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Affiliation(s)
- Alice E Holton
- School of Pharmacy, Royal College of Surgeons in Ireland (RCSI), Dublin 2, Ireland
| | - Paul J Gallagher
- School of Pharmacy, Royal College of Surgeons in Ireland (RCSI), Dublin 2, Ireland
| | - Cristín Ryan
- School of Pharmacy, Royal College of Surgeons in Ireland (RCSI), Dublin 2, Ireland
| | - Tom Fahey
- Division of Population Health Science, HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Dublin 2, Ireland
| | - Gráinne Cousins
- School of Pharmacy, Royal College of Surgeons in Ireland (RCSI), Dublin 2, Ireland
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Hayden JC, Dawkins I, Breatnach C, Leacy FP, Foxton J, Healy M, Cousins G, Gallagher PJ, Doherty DR. Effectiveness of α 2agonists for sedation in paediatric critical care: study protocol for a retrospective cohort observational study. BMJ Open 2017; 7:e013858. [PMID: 28566361 PMCID: PMC5640130 DOI: 10.1136/bmjopen-2016-013858] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Mechanically ventilated children in paediatric intensive care units are commonly administered analgesics and sedative agents to minimise pain and distress and facilitate cooperation with medical interventions. Opioids and benzodiazepines are the most common analgesic and sedative agents but have safety concerns. The α2 agonists clonidine and dexmedetomidine are alternative sedatives in use despite neither having robust evidence to support their use. Studies evaluating effectiveness of α2 agonists to date have not focused on sedation-based outcomes instead focusing on opioid-sparing properties and ventilation outcomes. The aim of this study is to evaluate if an opioid-based sedation regimen, with an α2 agonist adjunct (clonidine or dexmedetomidine), produces a non-inferior proportion of time adequately sedated compared with a control group without an α2 agonist adjunct, while conferring potential additional benefits such as reduced opioid administration and less exposure to potential additional agents such as benzodiazepines. METHODS AND ANALYSIS We will conduct a retrospective cohort study in two Irish paediatric intensive care units using clinical information on patient characteristics, sedation scores and drug use. Eligible children admitted between January 2014 and June 2016 who were mechanically ventilated and received an opioid infusion will be included. Patients will be categorised into two exposure categories (received an α2 agonist or did not receive an α2 agonist) and the time adequately sedated (measured using the COMFORT Behaviour Score) will be calculated using interpolation of nursing sedation scores at each recorded time point. At least 150 per group is planned for inclusion to ensure adequate study power. Propensity score matching will be used in analysis to account for potential confounding by indication. ETHICS AND DISSEMINATION The study has been approved by the ethics committees of both hospitals. Dissemination will occur via local, national and international presentations for academic and healthcare audiences as well as through peer reviewed publications.
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Affiliation(s)
- John C Hayden
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ian Dawkins
- Paediatric Intensive Care Unit, Our Lady's Children's Hospital, Dublin, Ireland
- Paediatric Intensive Care Unit, The Children's University Hospital, Dublin, Ireland
| | - Cormac Breatnach
- Paediatric Intensive Care Unit, Our Lady's Children's Hospital, Dublin, Ireland
| | - Finbarr P Leacy
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - June Foxton
- Paediatric Intensive Care Unit, The Children's University Hospital, Dublin, Ireland
| | - Martina Healy
- Paediatric Intensive Care Unit, Our Lady's Children's Hospital, Dublin, Ireland
| | - Gráinne Cousins
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Paul J Gallagher
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Dermot R Doherty
- Paediatric Intensive Care Unit, Our Lady's Children's Hospital, Dublin, Ireland
- Paediatric Intensive Care Unit, The Children's University Hospital, Dublin, Ireland
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9
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Lawlor C, O’Connor G, O’Leary S, Gallagher PJ, Cryan SA, Keane J, O’Sullivan MP. Treatment of Mycobacterium tuberculosis-Infected Macrophages with Poly(Lactic-Co-Glycolic Acid) Microparticles Drives NFκB and Autophagy Dependent Bacillary Killing. PLoS One 2016; 11:e0149167. [PMID: 26894562 PMCID: PMC4760758 DOI: 10.1371/journal.pone.0149167] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 01/08/2016] [Indexed: 12/28/2022] Open
Abstract
The emergence of multiple-drug-resistant tuberculosis (MDR-TB) has pushed our available repertoire of anti-TB therapies to the limit of effectiveness. This has increased the urgency to develop novel treatment modalities, and inhalable microparticle (MP) formulations are a promising option to target the site of infection. We have engineered poly(lactic-co-glycolic acid) (PLGA) MPs which can carry a payload of anti-TB agents, and are successfully taken up by human alveolar macrophages. Even without a drug cargo, MPs can be potent immunogens; yet little is known about how they influence macrophage function in the setting of Mycobacterium tuberculosis (Mtb) infection. To address this issue we infected THP-1 macrophages with Mtb H37Ra or H37Rv and treated with MPs. In controlled experiments we saw a reproducible reduction in bacillary viability when THP-1 macrophages were treated with drug-free MPs. NFκB activity was increased in MP-treated macrophages, although cytokine secretion was unaltered. Confocal microscopy of immortalized murine bone marrow-derived macrophages expressing GFP-tagged LC3 demonstrated induction of autophagy. Inhibition of caspases did not influence the MP-induced restriction of bacillary growth, however, blockade of NFκB or autophagy with pharmacological inhibitors reversed this MP effect on macrophage function. These data support harnessing inhaled PLGA MP-drug delivery systems as an immunotherapeutic in addition to serving as a vehicle for targeted drug delivery. Such “added value” could be exploited in the generation of inhaled vaccines as well as inhaled MDR-TB therapeutics when used as an adjunct to existing treatments.
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Affiliation(s)
- Ciaran Lawlor
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin 2, Ireland
- Department of Clinical Medicine, Institute of Molecular Medicine, Trinity College Dublin, and St. James’ Hospital, Dublin, Ireland
| | - Gemma O’Connor
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin 2, Ireland
- Department of Clinical Medicine, Institute of Molecular Medicine, Trinity College Dublin, and St. James’ Hospital, Dublin, Ireland
| | - Seonadh O’Leary
- Department of Clinical Medicine, Institute of Molecular Medicine, Trinity College Dublin, and St. James’ Hospital, Dublin, Ireland
| | - Paul J. Gallagher
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Sally-Ann Cryan
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin 2, Ireland
- Trinity Centre for Bioengineering, Trinity College Dublin, Dublin 2, Ireland
| | - Joseph Keane
- Department of Clinical Medicine, Institute of Molecular Medicine, Trinity College Dublin, and St. James’ Hospital, Dublin, Ireland
| | - Mary P. O’Sullivan
- Department of Clinical Medicine, Institute of Molecular Medicine, Trinity College Dublin, and St. James’ Hospital, Dublin, Ireland
- * E-mail:
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Gallagher CT, Holton A, McDonald LJ, Gallagher PJ. The fox and the grapes: an Anglo-Irish perspective on conscientious objection to the supply of emergency hormonal contraception without prescription. J Med Ethics 2013; 39:638-642. [PMID: 23365465 DOI: 10.1136/medethics-2012-100975] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Emergency hormonal contraception (EHC) has been available from pharmacies in the UK without prescription for 11 years. In the Republic of Ireland this service was made available in 2011. In both jurisdictions the respective regulators have included 'conscience clauses', which allow pharmacists to opt out of providing EHC on religious or moral grounds providing certain criteria are met. In effect, conscientious objectors must refer patients to other providers who are willing to supply these medicines. Inclusion of such clauses leads to a cycle of cognitive dissonance on behalf of both parties. Objectors convince themselves of the existence of a moral difference between supply of EHC and referral to another supplier, while the regulators must feign satisfaction that a form of regulation lacking universality will not lead to adverse consequences in the long term. We contend that whichever of these two parties truly believes in that which they purport to must act to end this unsatisfactory status quo. Either the regulators must compel all pharmacists to dispense emergency contraception to all suitable patients who request it, or a pharmacist must refuse either to supply EHC or to refer the patient to an alternative supplier and challenge any subsequent sanctions imposed by their regulator.
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Cleary BJ, Reynolds K, Eogan M, O'Connell MP, Fahey T, Gallagher PJ, Clarke T, White MJ, McDermott C, O'Sullivan A, Carmody D, Gleeson J, Murphy DJ. Methadone dosing and prescribed medication use in a prospective cohort of opioid-dependent pregnant women. Addiction 2013; 108:762-70. [PMID: 23216809 DOI: 10.1111/add.12078] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [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: 08/10/2012] [Revised: 09/27/2012] [Accepted: 11/28/2012] [Indexed: 01/12/2023]
Abstract
AIMS This study aimed to (i) describe methadone dosing before, during and after pregnancy, (ii) to compare the incidence of neonatal abstinence syndrome (NAS) between those with dose decreases and those with steady or increasing doses and (iii) to describe prescribed medication use among opioid-dependent pregnant women. DESIGN Prospective cohort study. SETTING Two Irish tertiary care maternity hospitals. PARTICIPANTS A total of 117 pregnant women on methadone maintenance treatment (MMT) recruited between July 2009 and July 2010. MEASUREMENTS Electronic dispensing records from addiction clinics and the Primary Care Reimbursement Service were used to determine methadone doses and dispensed medications in the year preceding and the month following delivery. The Finnegan score was used to determine need for medical treatment of NAS. FINDINGS Of the 117 participants, sufficient dosing data were available for 89 women treated with MMT throughout pregnancy; 36 (40.4%) had their dose decreased from a mean pre-pregnancy dose of 73.3 mg [standard deviation (SD) 25.5] to a third-trimester dose of 58.0 mg (SD 26.0). The corresponding figures for those with increased doses (n = 31, 34.8%) were 70.7 mg (SD 25.3) and 89.7 mg (SD 21.0), respectively. The incidence of medically treated NAS did not differ between dosage groups. Antidepressants were dispensed for 29 women (25.7%) during pregnancy, with the rate decreasing from pre-pregnancy to postpartum. Benzodiazepines were prescribed for 43 women (38.0%). CONCLUSION In the Irish health service, opioid-dependent women frequently have their methadone dose decreased during pregnancy but this does not appear to affect the incidence of the neonatal abstinence syndrome in their babies.
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Affiliation(s)
- Brian J Cleary
- Coombe Women and Infants University Hospital, Dublin 8, Ireland.
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Cleary BJ, Eogan M, O'Connell MP, Fahey T, Gallagher PJ, Clarke T, White MJ, McDermott C, O'Sullivan A, Carmody D, Gleeson J, Murphy DJ. Methadone and perinatal outcomes: a prospective cohort study. Addiction 2012; 107:1482-92. [PMID: 22340442 DOI: 10.1111/j.1360-0443.2012.03844.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS Methadone use in pregnancy has been associated with adverse perinatal outcomes and neonatal abstinence syndrome (NAS). This study aimed to examine perinatal outcomes and NAS in relation to (i) concomitant drug use and (ii) methadone dose. DESIGN Prospective cohort study. SETTING Two tertiary care maternity hospitals. PARTICIPANTS A total of 117 pregnant women on methadone maintenance treatment recruited between July 2009 and July 2010. MEASUREMENTS Information on concomitant drug use was recorded with the Addiction Severity Index. Perinatal outcomes included pre-term birth (<37 weeks' gestation), small-for-gestational-age (<10th centile) and neonatal unit admission. NAS outcomes included: incidence of medically treated NAS, peak Finnegan score, cumulative dose of NAS treatment and duration of hospitalization. FINDINGS Of the 114 liveborn infants 11 (9.6%) were born pre-term, 49 (42.9%) were small-for-gestational-age, 56 (49.1%) had a neonatal unit admission and 29 (25.4%) were treated medically for NAS. Neonates exposed to methadone-only had a shorter hospitalization than those exposed to methadone and concomitant drugs (median 5.0 days versus 6.0 days, P = 0.03). Neonates exposed to methadone doses ≥80 mg required higher cumulative doses of morphine treatment for NAS (median 13.2 mg versus 19.3 mg, P = 0.03). The incidence and duration of NAS did not differ between the two dosage groups. CONCLUSIONS The incidence and duration of the neonatal abstinence syndrome is not associated with maternal methadone dose, but maternal opiate, benzodiazepine or cocaine use is associated with longer neonatal hospitalization.
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Affiliation(s)
- Brian J Cleary
- Pharmacy Department, Coombe Women and Infants University Hospital, Cork Street, Dublin 8, Ireland.
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Perlis RH, Iosifescu DV, Castro VM, Murphy SN, Gainer VS, Minnier J, Cai T, Goryachev S, Zeng Q, Gallagher PJ, Fava M, Weilburg JB, Churchill SE, Kohane IS, Smoller JW. Using electronic medical records to enable large-scale studies in psychiatry: treatment resistant depression as a model. Psychol Med 2012; 42:41-50. [PMID: 21682950 PMCID: PMC3837420 DOI: 10.1017/s0033291711000997] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Electronic medical records (EMR) provide a unique opportunity for efficient, large-scale clinical investigation in psychiatry. However, such studies will require development of tools to define treatment outcome. METHOD Natural language processing (NLP) was applied to classify notes from 127 504 patients with a billing diagnosis of major depressive disorder, drawn from out-patient psychiatry practices affiliated with multiple, large New England hospitals. Classifications were compared with results using billing data (ICD-9 codes) alone and to a clinical gold standard based on chart review by a panel of senior clinicians. These cross-sectional classifications were then used to define longitudinal treatment outcomes, which were compared with a clinician-rated gold standard. RESULTS Models incorporating NLP were superior to those relying on billing data alone for classifying current mood state (area under receiver operating characteristic curve of 0.85-0.88 v. 0.54-0.55). When these cross-sectional visits were integrated to define longitudinal outcomes and incorporate treatment data, 15% of the cohort remitted with a single antidepressant treatment, while 13% were identified as failing to remit despite at least two antidepressant trials. Non-remitting patients were more likely to be non-Caucasian (p<0.001). CONCLUSIONS The application of bioinformatics tools such as NLP should enable accurate and efficient determination of longitudinal outcomes, enabling existing EMR data to be applied to clinical research, including biomarker investigations. Continued development will be required to better address moderators of outcome such as adherence and co-morbidity.
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Affiliation(s)
- R H Perlis
- Depression Clinic and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
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Lawlor C, O'Sullivan MP, Rice B, Dillon P, Gallagher PJ, O'Leary S, Shoyele S, Keane J, Cryan SA. Therapeutic aerosol bioengineering of targeted, inhalable microparticle formulations to treat Mycobacterium tuberculosis (MTb). J Mater Sci Mater Med 2012; 23:89-98. [PMID: 22183789 DOI: 10.1007/s10856-011-4511-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Accepted: 11/30/2011] [Indexed: 05/31/2023]
Abstract
Therapeutic aerosol bioengineering (TAB) of Mycobacterium tuberculosis (MTb) therapies using inhalable microparticles offers a unique opportunity to target drugs to the site of infection in the alveolar macrophages, thereby increasing dosing in the lungs and limiting systemic exposure to often toxic drugs. Previous work by us used sophisticated, high content analysis to design the optimal poly(lactide-co-glycolic) acid (PLGA) microparticle for delivery of drugs to alveolar macrophages. Herein, we applied this technology to three different anti-MTb drugs. These formulations were then tested for encapsulation efficiency, drug-release, in vitro killing against MTb and aerosol performance. Methods for encapsulating each of the drugs in the PLGA microparticles were successfully developed and found to be capable of controlling the release of the drug for up to 4 days. The efficacy of each of the encapsulated anti-MTb drugs was maintained and in some cases enhanced post-encapsulation. A method of processing these drug-loaded microparticles for inhalation using standard dry powder inhaler devices was successfully developed that enabled a very high respirable dose of the drug to be delivered from a simple dry powder inhaler device. Overall, TAB offers unique opportunities to more effectively treat MTb with many potential clinical and economic benefits resulting.
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Affiliation(s)
- C Lawlor
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin 2, Ireland
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Lawlor C, O’Sullivan MP, Sivadas N, O’Leary S, Gallagher PJ, Keane J, Cryan SA. The Application of High-Content Analysis in the Study of Targeted Particulate Delivery Systems for Intracellular Drug Delivery to Alveolar Macrophages. Mol Pharm 2011; 8:1100-12. [DOI: 10.1021/mp1004178] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Ciaran Lawlor
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin 2, Ireland
- Institute of Molecular Medicine, Trinity College Health Science Building, St. James’ Hospital, Dublin 8, Ireland
| | - Mary P. O’Sullivan
- Institute of Molecular Medicine, Trinity College Health Science Building, St. James’ Hospital, Dublin 8, Ireland
| | - Neera Sivadas
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Seonadh O’Leary
- Institute of Molecular Medicine, Trinity College Health Science Building, St. James’ Hospital, Dublin 8, Ireland
| | - Paul J. Gallagher
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Joseph Keane
- Institute of Molecular Medicine, Trinity College Health Science Building, St. James’ Hospital, Dublin 8, Ireland
| | - Sally-Ann Cryan
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin 2, Ireland
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Cleary BJ, Donnelly JM, Strawbridge JD, Gallagher PJ, Fahey T, White MJ, Murphy DJ. Methadone and perinatal outcomes: a retrospective cohort study. Am J Obstet Gynecol 2011; 204:139.e1-9. [PMID: 21145035 DOI: 10.1016/j.ajog.2010.10.004] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Revised: 08/30/2010] [Accepted: 10/06/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The purpose of this study was to examine the relationship among methadone maintenance treatment, perinatal outcomes, and neonatal abstinence syndrome. STUDY DESIGN This was a retrospective cohort study of 61,030 singleton births at a large maternity hospital from 2000-2007. RESULTS There were 618 (1%) women on methadone at delivery. Methadone-exposed women were more likely to be younger, to book late for antenatal care, and to be smokers. Methadone exposure was associated with an increased risk of very preterm birth <32 weeks of gestation (adjusted odds ratio [aOR], 2.47; 95% confidence interval [CI], 1.40-4.34), being small for gestational age <10th percentile (aOR, 3.27; 95% CI, 2.49-4.28), admission to the neonatal unit (aOR, 9.14; 95% CI, 7.21-11.57), and diagnosis of a major congenital anomaly (aOR, 1.94; 95% CI, 1.10-3.43). There was a dose-response relationship between methadone and neonatal abstinence syndrome. CONCLUSION Methadone exposure is associated with an increased risk of adverse perinatal outcomes, even when known adverse sociodemographic factors have been accounted for. Methadone dose at delivery is 1 of the determinants of neonatal abstinence syndrome.
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Cleary BJ, Donnelly J, Strawbridge J, Gallagher PJ, Fahey T, Clarke M, Murphy DJ. Methadone dose and neonatal abstinence syndrome-systematic review and meta-analysis. Addiction 2010; 105:2071-84. [PMID: 20840198 DOI: 10.1111/j.1360-0443.2010.03120.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIM To determine if there is a relationship between maternal methadone dose in pregnancy and the diagnosis or medical treatment of neonatal abstinence syndrome (NAS). METHODS PubMed, EMBASE, the Cochrane Library and PsychINFO were searched for studies reporting on methadone use in pregnancy and NAS (1966-2009). The relative risk (RR) of NAS was compared for methadone doses above versus below a range of cut-off points. Summary RRs and 95% confidence intervals (CI) were estimated using random effects meta-analysis. Sensitivity analyses explored the impact of limiting meta-analyses to prospective studies or studies using an objective scoring system to diagnose NAS. RESULTS A total of 67 studies met inclusion criteria for the systematic review; 29 were included in the meta-analysis. Any differences in the incidence of NAS in infants of women on higher compared with lower doses were statistically non-significant in analyses restricted to prospective studies or to those using an objective scoring system to diagnose NAS. CONCLUSIONS Severity of the neonatal abstinence syndrome does not appear to differ according to whether mothers are on high- or low-dose methadone maintenance therapy.
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Affiliation(s)
- Brian J Cleary
- Coombe Women and Infants University Hospital, Dublin 8, Ireland School of Pharmacy, Royal College of Surgeons in Ireland, Dublin 2, Ireland.
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Basso C, Burke M, Fornes P, Gallagher PJ, De Gouveia RH, Sheppard M, Thiene G, Van Der Wal A. Guidelines for autopsy investigation of sudden cardiac death. Pathologica 2010; 102:391-404. [PMID: 21361120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Abstract
Although sudden cardiac death is one of the most important mode of death in Western Countries, pathologists and public health physicians have not given this problem the attention it deserves. New methods of preventing potentially fatal arrhythmias have been developed and the accurate diagnosis of the causes of sudden cardiac death is now of particular importance. Pathologists are responsible for determining the precise cause of sudden death but there is considerable variation in the way in which they approach this increasingly complex task. The Association for European Cardiovascular Pathology developed these Guidelines, which represent the minimum standard that is required in the routine autopsy practice for the adequate assessment of sudden cardiac death, including not only a protocol for heart examination and histological sampling, but also for toxicology and molecular investigation. Our recommendations apply to University Medical Centres, Regional and District Hospitals and all types of Forensic Medicine Institutes. If a uniform method of investigation is adopted throughout the European Union, this will lead to improvements in standards of practice, allow meaningful comparisons between different communities and regions and, most importantly, permit future trends in the patterns of disease causing sudden death to be monitored.
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Affiliation(s)
- C Basso
- Department of Medical Diagnostic Sciences and Special Therapies, University of Padua, Italy
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Cleary BJ, Butt H, Strawbridge JD, Gallagher PJ, Fahey T, Murphy DJ. Medication use in early pregnancy-prevalence and determinants of use in a prospective cohort of women. Pharmacoepidemiol Drug Saf 2010; 19:408-17. [PMID: 20099251 DOI: 10.1002/pds.1906] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
PURPOSE To examine the extent, nature and determinants of medication use in early pregnancy. METHODS We reviewed early pregnancy medication use, as reported to a midwife at the booking interview, in women delivering between 2000 and 2007 in a large maternity hospital in Dublin, Ireland (n = 61 252). RESULTS Excluding folic acid, at least one medication was reported in 23 989 (39.2%) pregnancies. Over the counter (OTC) medications were reported in 11 970 (19.5%) pregnancies, illicit drugs or methadone in 545 (0.9%) and herbal medicines/supplements in 352 (0.58%). FDA category D and X medications were reported by 1532 (2.5%) and 1987 (3.2%) women. Asthma, depression and hypertension were among the most commonly reported chronic medical disorders. Medications with potential for foetal harm were reported by 86 (15.7%) women treated for depression and 68 (20%) women treated for hypertension. Factors associated with reporting the use of medications with potential for foetal harm included unplanned pregnancy (adjusted odds ratio [aOR] 1.31, 95% confidence interval [CI] 1.12-1.52), booking at less than 12 weeks gestation (aOR 1.83, 95%CI 1.58-2.13), being above 25 years of age, unemployed (aOR 2.58, 95%CI 2.03-3.29), nulliparous (aOR 1.41; 95%CI 1.22-1.63), single (aOR 1.28; 95%CI 1.06-1.54) or smoking during pregnancy (aOR 1.96, 95%CI 1.67-2.28). CONCLUSIONS Women frequently report medication use in early pregnancy. Women and prescribers need to be aware of the lack of pregnancy safety data for many medications, and the need for pre-pregnancy planning. Prescribers should ensure that optimal medications are used when treating women of childbearing potential with chronic medical disorders.
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Affiliation(s)
- Brian J Cleary
- Coombe Women and Infants University Hospital, Dublin, Republic of Ireland.
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Affiliation(s)
- M F Hickling
- Department of Pathology and The Wessex Cardio-Thoracic Centre, Southampton University Hospitals, Southampton, UK
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Abstract
Atherosclerosis is no longer considered a disorder of lipid accumulation, but a disease process characterized by the dynamic interaction between endothelial dysfunction, subendothelial inflammation and the 'wound healing response' of the vascular smooth muscle cells. Prospective epidemiological studies have unequivocally demonstrated increased vascular risk in individuals with elevated levels of (i) cytokines such as interleukin-6 and tumour necrosis factor-alpha, (ii) cell adhesion molecules such as intercellular adhesion molecule-1 and P-selectin, and (iii) acute-phase proteins such as C-reactive protein, fibrinogen and serum amyloid A. Furthermore, evidence from clinical trials have demonstrated that risk reduction achieved with anti-inflammatory agents such as statins is significantly greater in patients with evidence of inflammation. A number of risk factors for atherogenesis, including infectious agents, have been shown to exert their influence via inflammatory mechanisms. However, despite compelling experimental evidence, clinical studies looking at the role of infection in atherogenesis have lacked consistency. The clinical product of this dynamic process is variable and unpredictable between individuals, even those with apparently similar risk profiles.
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Affiliation(s)
- M Mahmoudi
- Wessex Cardiac Unit, Southampton University Hospitals, Southampton, UK
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22
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Redgrave JNE, Lovett JK, Gallagher PJ, Rothwell PM. Histological assessment of 526 symptomatic carotid plaques in relation to the nature and timing of ischemic symptoms: the Oxford plaque study. Circulation 2006; 113:2320-8. [PMID: 16651471 DOI: 10.1161/circulationaha.105.589044] [Citation(s) in RCA: 374] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Atherosclerotic plaque at the carotid bifurcation is often associated with transient ischemic attack (TIA) and ischemic stroke, but the mechanisms are not completely understood. Previous histological studies have been too small or insufficiently detailed to reliably determine the temporal course of features of plaque instability or to stratify analyses by the nature of presenting symptoms. METHODS AND RESULTS We performed the largest-ever histological study of symptomatic carotid plaques from consecutive patients (n=526) undergoing endarterectomy and related detailed reproducible histological assessments to the nature and timing of presenting symptoms. There was a high prevalence of many features of coronary-type plaque instability. Dense plaque inflammation (especially infiltration with macrophages) was the feature most strongly associated with both cap rupture (odds ratio 3.39, 95% confidence interval 2.31 to 4.98, P<0.001) and time since stroke (P=0.001). Strong negative associations with time since stroke were also seen for cap rupture (P=0.02), overall plaque inflammation (P=0.003), and "unstable plaque" (P=0.001). Although plaques removed < or =60 days after the most recent event were more unstable after a stroke than after a TIA, the instability persisted after a TIA, and plaques removed >180 days after most recent event were less unstable after a stroke than after a TIA (plaque inflammation: < or =60 days, odds ratio 2.33 [95% confidence interval 0.76 to 7.19]; >180 days, 0.36 [0.16 to 0.84]; P=0.008; unstable plaque: odds ratio 3.27 [95% confidence interval 0.93 to 11.50] versus 0.74 [0.33 to 1.69], P=0.05). CONCLUSIONS Pathology of recently symptomatic carotid plaques is similar to that of culprit coronary plaques, with strong correlations between macrophage infiltration and plaque instability. The tendency for plaque inflammation and overall instability to persist with time after a TIA but to decrease with time after a stroke suggests that the nature of the underlying pathology may differ.
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Affiliation(s)
- J N E Redgrave
- Department of Clinical Neurology, Radcliffe Infirmary, Oxford, OX2 6HE, United Kingdom
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Affiliation(s)
- J Sandilla
- Department of Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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Abstract
BACKGROUND Carotid angiographic plaque surface morphology is a powerful risk factor for stroke and systemic vascular risk. However, the underlying pathology is unclear, and a better understanding is required both to evaluate other forms of carotid imaging and to develop new treatments. Previous studies comparing angiographic plaque surface morphology with pathology have been small and unblinded, and the vast majority assessed only the crude macroscopic appearance of the plaque. We performed the first large study comparing angiographic surface morphology with detailed histology. METHODS AND RESULTS Carotid plaque surface morphology was classified as ulcerated, irregular, or smooth on 128 conventional selective carotid artery angiograms from consecutive patients undergoing endarterectomy for severe symptomatic stenosis. Blinded angiographic assessments were compared with 10 histological features recorded on detailed microscopy of the plaque using reproducible semiquantitative scales. Angiographic ulceration was associated with plaque rupture (P=0.001), intraplaque hemorrhage (P=0.001), large lipid core (P=0.005), less fibrous tissue (P=0.003), and increased instability overall (P=0.001). For example, angiographically ulcerated plaques were much more likely than smooth plaques to be ruptured (OR=15.4, 95% CI=2.7 to 87.3, P<0.001), show a large lipid core (OR=26.7, 95% CI=2.6 to 270, P<0.001) or a large hemorrhage (OR=17.0, 95% CI=2.0 to 147, P=0.02). The equivalent odds ratios for angiographically irregular versus smooth plaque were 6.3 (1.3 to 31, P=0.02), 6.7 (1.5 to 30, P=0.008), and 9.2 (1.1 to 77, P=0.02), respectively. CONCLUSIONS In contrast to previous studies based on macroscopic assessment, we found very strong associations between detailed histology and carotid angiographic plaque surface morphology. Plaque surface morphology on carotid angiography is a highly sensitive marker of plaque instability. Studies of the predictive value of MR- and CT-based lumen contrast plaque surface imaging are required.
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Affiliation(s)
- J K Lovett
- Stroke Prevention Research Unit, Department of Clinical Neurology, Radcliffe Infirmary, Oxford, UK
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Lovett JK, Gallagher PJ, Rothwell PM. Reproducibility of histological assessment of carotid plaque: implications for studies of carotid imaging. Cerebrovasc Dis 2004; 18:117-23. [PMID: 15218276 DOI: 10.1159/000079259] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2003] [Accepted: 01/22/2004] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Thromboembolism from carotid plaque is an important cause of stroke. Identification of unstable plaque would therefore be clinically useful. Unfortunately, studies of carotid plaque imaging have shown poor agreement with histology. However, this may be due to inconsistent methods and the variability of assessments of carotid plaque histology, rather than inadequate imaging. METHODS We assessed the reproducibility of histological assessment in 60 plaques, and section-to-section variability along the length of 26 plaques. RESULTS Kappa values ranged from 0.35 to 0.89 and from 0.44 to 0.68, respectively, for intra- and inter-observer reproducibility. There was considerable section-to-section variability within plaques. CONCLUSIONS The accuracy of imaging of carotid plaque morphology will be underestimated unless variability in the histology assessment is taken into account.
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Affiliation(s)
- J K Lovett
- Stroke Prevention Research Unit, University Department of Clinical Neurology, Radcliffe Infirmary, Oxford OX2 6HE, UK
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Burnley HM, McCormick D, Hurren J, Gallagher PJ. Primary venous dissecting aneurysm arising during pregnancy: a case report and review of the literature. J Clin Pathol 2003; 56:634-635. [PMID: 12890822 DOI: 10.1136/jcp.56.8.634.pmid:12890822;pmcid:pmc1770022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
This report describes a case of venous dissecting aneurysm presenting as a popliteal mass, in a 33 year old woman. A 1 x 1 x 0.5 cm lump developed early in the course of a second pregnancy. Primary venous aneurysms are rare vascular abnormalities that can affect either the superficial or deep veins, and have been described throughout the venous system. Most commonly found in the neck and central thoracic veins, they have also been found in visceral veins and extremities. There is a tendency for vascular disturbances to occur during pregnancy. The haemodynamic changes and hormonal milieu may be the cause of vascular alterations, which can lead to new aneurysm formation, or weakening of pre-existing aneurysms. This is the first reported case of a dissecting venous aneurysm, and has the added interest that it occurred during pregnancy.
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Burnley HM, McCormick D, Hurren J, Gallagher PJ. Primary venous dissecting aneurysm arising during pregnancy: a case report and review of the literature. J Clin Pathol 2003; 56:634-5. [PMID: 12890822 PMCID: PMC1770022 DOI: 10.1136/jcp.56.8.634] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
This report describes a case of venous dissecting aneurysm presenting as a popliteal mass, in a 33 year old woman. A 1 x 1 x 0.5 cm lump developed early in the course of a second pregnancy. Primary venous aneurysms are rare vascular abnormalities that can affect either the superficial or deep veins, and have been described throughout the venous system. Most commonly found in the neck and central thoracic veins, they have also been found in visceral veins and extremities. There is a tendency for vascular disturbances to occur during pregnancy. The haemodynamic changes and hormonal milieu may be the cause of vascular alterations, which can lead to new aneurysm formation, or weakening of pre-existing aneurysms. This is the first reported case of a dissecting venous aneurysm, and has the added interest that it occurred during pregnancy.
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Abstract
Senior house officer schools in histopathology have been established in Leeds, Leicester and Southampton, each training six new recruits each year. Nine hours of protected teaching time is provided each week giving a ratio of apprenticeship learning to formal teaching of 3:1. Evaluations have been very positive. Much of this success is attributed to careful planning and adequate funding. This may be a useful model for other specialties to follow.
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Affiliation(s)
- P J Gallagher
- Department of Pathology, Southampton University Hospitals, Southampton.
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Saw RPM, Koorey D, Painter D, Gallagher PJ, Solomon MJ. p53, DCC and thymidylate synthase as predictors of survival after resection of hepatic metastases from colorectal cancer. Br J Surg 2002; 89:1409-15. [PMID: 12390383 DOI: 10.1046/j.1365-2168.2002.02222.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hepatic metastasis from colorectal cancer is a common problem. Hepatic resection offers the only chance of cure. Prognosis of patients following hepatic resection is currently based on clinicopathological factors (of both the primary cancer and the hepatic metastasis), which do not accurately predict the subsequent behaviour of the tumour. The aim of this study was to evaluate three molecular genetic markers - p53, DCC (deleted in colonic cancer) and thymidylate synthase - in both the primary colorectal tumour and the resected hepatic metastases, and to determine their correlation, if any, with survival in patients with resected hepatic metastases from colorectal cancer. METHODS Sixty-three patients with hepatic metastases and 40 corresponding colorectal primary tumours were studied using immunohistochemical staining for p53, DCC and thymidylate synthase, as well as p53 gene mutations using polymerase chain reaction-single-stranded conformational polymorphism (PCR-SSCP) analysis. The results were correlated with survival. RESULTS There was no correlation between p53, DCC or thymidylate synthase immunohistochemical staining, or between p53 PCR-SSCP analysis, and survival for either hepatic metastases or the colorectal primary tumour. CONCLUSION Prediction of prognosis in patients having resection of hepatic metastases from colorectal cancer continues to be problematic. Other genetic markers or combination of markers need to be evaluated.
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Affiliation(s)
- R P M Saw
- University of Sydney Department of Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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31
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Gallagher PJ. More histological information in acute coronary death. Eur Heart J 2002; 23:1406-8. [PMID: 12208216 DOI: 10.1053/euhj.2002.3253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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32
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Abstract
OBJECTIVE To determine the localization of 3-nitrotyrosine (3-NT), a footprint marker of peroxynitrite (ONOO-) and other reactive nitrogen species, to the inflamed human synovium and to compare this with normal synovial and nonsynovial tissue of human and animal origin. METHODS Monoclonal and polyclonal antibodies were used to investigate for 3-NT, inducible nitric oxide synthase (iNOS), macrophage marker CD68, and the vascular smooth muscle marker alpha-actin by avidin-biotin immunocytochemistry. RESULTS In the inflamed synovium, 3-NT was found in the vascular smooth muscle and macrophages. In normal human synovium, 3-NT was present in the vascular smooth muscle and some lining cells and was not associated with immunoreactivity for iNOS. Similarly, 3-NT could be demonstrated in the vascular smooth muscle cells of normal rats and iNOS knockout mice. It was not present in the vascular smooth muscle of healthy, nonsynovial tissue. CONCLUSION The synovial vasculature in histologically normal human and naive rodent synovium was alone among the normal tissues studied in exhibiting iNOS-independent immunoreactivity for 3-NT. These findings suggest a physiologic role for ONOO- in normal synovial vascular function.
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MESH Headings
- Actins/analysis
- Aged
- Aged, 80 and over
- Animals
- Antigens, CD/analysis
- Antigens, Differentiation, Myelomonocytic/analysis
- Arthritis, Rheumatoid/pathology
- Female
- Humans
- Immunohistochemistry
- Macrophages/chemistry
- Male
- Mice
- Mice, Knockout
- Middle Aged
- Muscle, Smooth, Vascular/chemistry
- Muscle, Smooth, Vascular/pathology
- Nitric Oxide Synthase/analysis
- Nitric Oxide Synthase/genetics
- Nitric Oxide Synthase Type II
- Rats
- Synovial Membrane/chemistry
- Synovial Membrane/pathology
- Tyrosine/analogs & derivatives
- Tyrosine/analysis
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Affiliation(s)
- P I Mapp
- Department of Medical Sciences, University of Bath, Claverton Down, UK
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33
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Abstract
PURPOSE Long-term clinical studies have now shown that tight control of blood pressure in type 2 diabetes reduces the risk of diabetes-related death and common diabetic complications, including diabetic retinopathy. However, the mechanisms by which hypertension enhances diabetic microvascular disease, especially diabetic retinopathy, are poorly understood. We developed an experimental model of hypertension in diabetic rats and studied the early ultrastructural changes in retinal capillaries under these conditions. METHODS Hypertension was induced in diabetic BioBreeding (BB) rats by unilateral nephrectomy, weekly subcutaneous mineralocorticoid and 0.9% oral saline. Serial blood pressures and ultrastructural features of retinal capillaries were recorded in four groups: normotensive Wistar rats, normotensive diabetic rats, hypertensive Wistar rats and hypertensive diabetic rats. RESULTS A significant and sustained increase in systolic blood pressure occurred in both groups of nephrectomised rats. There was a significant increase in the number of caveolae (i) in both pericytes and endothelial cells in animals with hypertension and diabetes together compared with all other groups and (ii) in pericytes in animals with diabetes alone. The number of direct contacts between pericytes and endothelial cells was reduced in diabetic and hypertensive diabetic animals. Hypertension and diabetes had an interactive effect in producing retinal capillary basement membrane thickening. CONCLUSIONS In the BB rat hypertension and diabetes have an interactive effect in increasing the number of caveolae in both endothelial cells and pericytes. We speculate that this may be a reflection of changes in calcium and nitric oxide metabolism in these animals.
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Affiliation(s)
- N Hillman
- Department of Pathology, University of Southampton, UK
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34
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Abstract
Telokin is a 17-kDa protein with an amino acid sequence that is identical to the COOH terminus of the 130-kDa myosin light chain kinase (MLCK). Telokin mRNA is transcribed from a second promoter, located within an intron, in the 3' region of the MLCK gene. In the current study, we show by in situ mRNA hybridization that telokin mRNA is restricted to the smooth muscle cell layers within adult smooth muscle tissues. In situ mRNA analysis of mouse embryos also revealed that telokin expression is restricted to smooth muscle tissues during embryonic development. Telokin mRNA expression was first detected in mouse gut at embryonic day 11.5; no telokin expression was detected in embryonic cardiac or skeletal muscle. Expression of telokin was also found to be regulated during postnatal development of the male and female reproductive tracts. In both uterus and vas deferens, telokin protein expression greatly increased between days 7 and 14 of postnatal development. The increase in telokin expression correlated with an increase in the expression of several other smooth muscle-restricted proteins, including smooth muscle myosin and alpha-actin.
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MESH Headings
- Amino Acid Sequence/physiology
- Animals
- Base Sequence/physiology
- Cloning, Molecular/methods
- DNA, Complementary/genetics
- Female
- Gene Expression Regulation, Developmental/physiology
- Genitalia, Female/cytology
- Genitalia, Female/growth & development
- Genitalia, Female/metabolism
- Genitalia, Male/cytology
- Genitalia, Male/growth & development
- Genitalia, Male/metabolism
- Male
- Mice
- Molecular Sequence Data
- Muscle Development
- Muscle Proteins/genetics
- Muscle Proteins/metabolism
- Muscle, Smooth/cytology
- Muscle, Smooth/embryology
- Muscle, Smooth/growth & development
- Muscle, Smooth/metabolism
- Myosin-Light-Chain Kinase
- Peptide Fragments
- Peptides
- RNA, Messenger/genetics
- RNA, Messenger/metabolism
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Affiliation(s)
- B P Herring
- Department of Physiology, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA.
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35
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Abstract
Previous studies have demonstrated that the divalent cation manganese (Mn) causes PC12 cells to form neurites in the absence of NGF. Since divalent cations modulate the binding affinity and specificity of integrins, and integrin function affects neurite outgrowth, we tested the hypothesis that Mn induces neurite outgrowth through an integrin-dependent signaling pathway. Our studies support this hypothesis. Function-blocking antisera specific for beta(1) integrins block the neurite-promoting activity of Mn by 90-95%. Bioassays and biochemical studies with antisera specific for the alpha(v), alpha(5), or alpha(8) integrin subunit suggest that the alpha(v)beta(1) heterodimer is one of the principal beta(1) integrins mediating the response of PC12 cells to Mn. This is corroborated by studies in which Mn failed to induce neurite outgrowth in a clone of PC12 cells that does not express alpha(v) at levels detectable by immunoprecipitation or immunocytochemistry. SDS-PAGE analysis of biotinylated surface proteins immunoprecipitated from Mn-responsive PC12 cells, as well as confocal laser microscopy of PC12 immunostained for surface alpha(v) indicate that Mn increases the surface expression of alpha(v) integrins. This increase appears to be due in part to synthesis of alpha(v) since specific inhibitors of RNA and protein synthesis block the neurite-promoting activity of Mn. These data indicate that Mn induces neurite outgrowth in PC12 cells by upregulating alpha(v) integrins, suggesting that Mn potentially represents an additional mechanism for regulating the rate and direction of neurite outgrowth during development and regeneration.
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Affiliation(s)
- P Lein
- Department of Biology, Canisius College, Buffalo, NY 14208, USA
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36
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Abstract
The purpose of this study was to characterize myosin light chain kinase (MLCK) expression in cardiac and skeletal muscle. The only classic MLCK detected in cardiac tissue, purified cardiac myocytes, and in a cardiac myocyte cell line (AT1) was identical to the 130-kDa smooth muscle MLCK (smMLCK). A complex pattern of MLCK expression was observed during differentiation of skeletal muscle in which the 220-kDa-long or "nonmuscle" form of MLCK is expressed in undifferentiated myoblasts. Subsequently, during myoblast differentiation, expression of the 220-kDa MLCK declines and expression of this form is replaced by the 130-kDa smMLCK and a skeletal muscle-specific isoform, skMLCK in adult skeletal muscle. These results demonstrate that the skMLCK is the only tissue-specific MLCK, being expressed in adult skeletal muscle but not in cardiac, smooth, or nonmuscle tissues. In contrast, the 130-kDa smMLCK is ubiquitous in all adult tissues, including skeletal and cardiac muscle, demonstrating that, although the 130-kDa smMLCK is expressed at highest levels in smooth muscle tissues, it is not a smooth muscle-specific protein.
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Affiliation(s)
- B P Herring
- Department of Physiology and Biophysics, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA.
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37
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Gallagher PJ, Jin Y, Killough G, Blue EK, Lindner V. Alterations in expression of myosin and myosin light chain kinases in response to vascular injury. Am J Physiol Cell Physiol 2000; 279:C1078-87. [PMID: 11003588 PMCID: PMC2824508 DOI: 10.1152/ajpcell.2000.279.4.c1078] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [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] [Indexed: 01/12/2023]
Abstract
Histochemical analysis of balloon-injured rat carotid arteries revealed a coordinated expression of nonmuscle myosin heavy chain-A and -B (NM-A and NM-B) in response to injury. Expression of these nonmuscle myosin forms shifts from the media to the adventitia and intima. In contrast, expression of smooth muscle myosin heavy chain-1 (SM-1) within the media is not altered, whereas smooth muscle myosin heavy chain-2 (SM-2) expression declines. Western blotting shows a statistically significant increase in expression of NM-A that occurs within 6 h in response to carotid injury, suggesting this myosin form may be an appropriate experimental marker for proliferating, migrating cells in injured vessels. No overall change in the relative expression level of NM-B was detected, suggesting that compensatory declines in media expression are balanced by increases in the intima and adventitia. Expression of SM-1 did not change in response to injury, whereas the expression of SM-2 significantly declined between 24 h and 7 days. Expression of myosin light chain kinase is also negatively regulated, and the decline in its expression parallels downregulation of SM-2.
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Affiliation(s)
- P J Gallagher
- Department of Physiology, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA.
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38
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Affiliation(s)
- A H Lee
- Department of Histopathology, Southampton General Hospital, Southampton, UK
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39
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Abstract
Endometriosis is a relatively common condition usually found in the pelvis. However, lesions do occur outside the pelvis and, more rarely, in the upper abdomen. In the case reported here, the patient presented with chronic right shoulder tip pain. The diagnosis of extrapelvic endometriosis is often not considered in such circumstances. This patient's symptoms were relieved by surgical excision of the diaphragmatic lesion.
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40
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Herring BP, Hoggatt AM, Smith AF, Gallagher PJ. Targeted expression of SV40 large T-antigen to visceral smooth muscle induces proliferation of contractile smooth muscle cells and results in megacolon. J Biol Chem 1999; 274:17725-32. [PMID: 10364214 PMCID: PMC2824515 DOI: 10.1074/jbc.274.25.17725] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Many pathological conditions result from the proliferation and de-differentiation of smooth muscle cells leading to impaired contractility of the muscle. Here we show that targeted expression of SV40 large T-antigen to visceral smooth muscle cells in vivo results in increased smooth muscle cell proliferation without de-differentiation or decreased contractility. These data suggest that the de-differentiation and proliferation of smooth muscle cells, seen in many pathological states, may be independently regulated. In the T-antigen transgenic mice the increased smooth muscle cell proliferation results in thickening of the distal colon. Consequently the distal colon becomes hyper-contractile and impedes the flow of digesta through the colon resulting in enlargement of the colon oral to the obstruction. These transgenic mice thus represent a novel model of megacolon that results from increased smooth muscle cell proliferation rather than altered neuronal innervation.
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Affiliation(s)
- B P Herring
- Department of Physiology and Biophysics, Indiana University School of Medicine, Indianapolis, Indiana 46202-5120, USA.
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41
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Thomas M, Wong Y, Thomas D, Ajaz M, Tsang V, Gallagher PJ, Ward ME. Relation between direct detection of Chlamydia pneumoniae DNA in human coronary arteries at postmortem examination and histological severity (Stary grading) of associated atherosclerotic plaque. Circulation 1999; 99:2733-6. [PMID: 10351965 DOI: 10.1161/01.cir.99.21.2733] [Citation(s) in RCA: 71] [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: 11/16/2022]
Abstract
BACKGROUND Numerous studies have suggested a link between Chlamydia pneumoniae infection, atherosclerosis, and coronary artery disease. However, it is still unclear whether C pneumoniae plays a causal role in the pathogenesis of these conditions. Accordingly, we have performed a systematic dissection of the 3 coronary arteries on 33 postmortem subjects and studied the relationship in individual artery segments between the presence of C pneumoniae DNA and the severity of associated atherosclerosis. METHODS AND RESULTS The prevalence of C pneumoniae DNA in arterial segments was determined by polymerase chain reaction (PCR) after controlling for the presence of PCR inhibitors. Atherosclerosis in each arterial segment was graded histologically with the Stary classification. C pneumoniae was detected by PCR in 78.8% of subjects, but there was no association between the presence of this DNA and cause of death or grade of atherosclerosis. When paired mild and severe atherosclerotic lesions within subjects were compared, mild lesions were as likely to be positive for C pneumoniae as severe lesions. CONCLUSIONS This study demonstrates that C pneumoniae can frequently be detected in atheromatous plaques in coronary arteries. However, its distribution did not correlate with severity or extent of disease.
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Affiliation(s)
- M Thomas
- Molecular Microbiology Group, Department of Pathology, Southampton University Medical School, Southampton, UK.
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42
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Chin PT, Gallagher PJ, Stephen MS. Inferior vena caval resection with autogenous peritoneo-fascial patch graft caval repair: a new technique. Aust N Z J Surg 1999; 69:391-2. [PMID: 10353558 DOI: 10.1046/j.1440-1622.1999.01579.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND In the course of oncological surgery, resection of the inferior vena cava (IVC) may be required to obtain an adequate resection margin and to offer the best opportunity of cure. The remaining defect in the IVC may be managed by: (i) primary repair which may lead to subsequent narrowing of the lumen, possibly leading to turbulent flow and thrombus formation; (ii) patch grafting of the defect, which may prevent narrowing. Several synthetic and biosynthetic materials are available as patch grafts and autologous pericardium has also been used. METHODS The harvesting and use of the autogenous peritoneo-fascial (APF) graft as an alternative caval patch graft material in the management of defects in the caval wall is proposed. Autogenous peritoneo-fascial caval patch graft repair in six patients was undertaken. RESULTS One patient with leiomyosarcoma secondaries in the liver eventually succumbed to the disease. The other five patients are clinically well with no evidence of IVC obstruction or venous aneurysms. CONCLUSION Preliminary results show that this new technique of utilizing an APF patch graft for caval repair is clinically a suitable alternative to current biosynthetic and synthetic materials and may in fact be superior in many aspects.
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Affiliation(s)
- P T Chin
- Department of Upper Gastrointestinal Surgery and Total Parenteral Nutrition, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.
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43
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Morgan JM, Roberts PR, Allen S, Gallagher PJ, Gibson C, Cunningham AD. Catheter mounted coaxially moveable ablation electrode for the creation of linear transmural endocardial lesions. J Cardiovasc Electrophysiol 1999; 10:566-73. [PMID: 10355699 DOI: 10.1111/j.1540-8167.1999.tb00714.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [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: 11/28/2022]
Abstract
INTRODUCTION Use of a novel ablation catheter for the creation of linear transmural endocardial lesions, which uses a coaxially moving ablation electrode mounted on the terminal portion of a catheter shaft and able to move axially for a distance of up to 4 cm, is reported. METHODS AND RESULTS The coaxially moving ablation electrode is moved by a sliding mechanism in the catheter handle. The distal portion of the catheter shaft is steerable. Bipolar or unipolar electrograms can be recorded from electrodes on the catheter tip and the coaxially moving ablation. Radiofrequency (RF) current is delivered to the coaxially moving ablation electrode with thermocouple temperature control. This ablation catheter was evaluated in five (30 to 65 kg) anesthetized pigs and introduced via the venous/arterial systems into the right and left atrium (1 lesion) (using the retrograde aortic approach). The catheter was maneuvered to bring the slide range into apposition with atrial endocardium. The coaxially moving ablation electrode was deployed to the terminal portion of the catheter's slide range and then withdrawn in 2-mm steps. RF current was delivered to the coaxially moving ablation electrode at each point (maximum temperature 70 degrees C). Postmortem examination of eight endocardial linear lesions (2.2 to 4.1 cm length) was made 1 to 3 hours after creation. Histopathologic examination confirmed transmural myocyte necrosis along the length of the lesion, that included the trabeculated right atrium. CONCLUSION We conclude that a catheter using a moveable electrode creates continuous linear transmural lesions and could find clinical application in the therapy of a variety of reentry tachycardia mechanisms.
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Affiliation(s)
- J M Morgan
- Wessex Cardiothoracic Center, Southampton University Hospital, United Kingdom.
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44
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Barakate MS, Stephen MS, Waugh RC, Gallagher PJ, Solomon MJ, Storey DW, Sheldon DM. Pyogenic liver abscess: a review of 10 years' experience in management. Aust N Z J Surg 1999; 69:205-9. [PMID: 10075360 DOI: 10.1046/j.1440-1622.1999.01523.x] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
BACKGROUND Over the past 15 years, diagnostic and interventional radiology techniques have allowed accurate localization of liver abscesses and image-guided percutaneous drainage. This review examines whether these technical advances improve clinical results and discusses the selection of treatment for patients with liver abscesses. METHODS Ninety-eight patients were treated for pyogenic liver abscess (PLA) at the Royal Prince Alfred Hospital, Sydney, between January 1987 and June 1997. The hospital records were examined and clinical presentation, laboratory, radiological and microbiological findings were recorded. Associations between these findings and failure of initial non-operative management were determined using odds ratios with 95% confidence intervals. Independent predictors were then determined by logistic regression. This analysis was repeated to determine factors associated with mortality. RESULTS Cholelithiasis and previous hepatobiliary surgery were the most frequently identifiable causes of PLA, each responsible in 15 patients. All 98 patients were treated with intravenous antibiotics and in 13 patients this was the only therapy. Of the remaining 85 patients, six proceeded straight to laparotomy and 79 had percutaneous drainage, of whom 15 required subsequent laparotomy. Factors predicting failure of initial non-operative management were unresolving jaundice, renal impairment secondary to clinical deterioration, multiloculation of the abscess, rupture on presentation and biliary communication. The overall hospital mortality rate was 8%. CONCLUSION Pyogenic liver abscess remains a disease with significant mortality. Image-guided percutaneous drainage is appropriate treatment for single unilocular PLA. Surgical drainage is more likely to be required in patients who have abscess rupture, incomplete percutaneous drainage or who have uncorrected primary pathology.
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Affiliation(s)
- M S Barakate
- University of Sydney, Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, New South Wales, Australia.
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45
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Abstract
OBJECTIVE To review the literature for evidence that chronic infection with Chlamydia pneumoniae is associated with atherosclerosis and acute coronary syndromes. DATA SOURCES MEDLINE and Institute of Science and Information bibliographic databases were searched at the end of September 1998. Indexing terms used were chlamydi*, heart, coronary, and atherosclerosis. Serological and pathological studies published as papers in any language since 1988 or abstracts since 1997 were selected. DATA EXTRACTION It was assumed that chronic C pneumoniae infection is characterised by the presence of both specific IgG and IgA, and serological studies were examined for associations that fulfilled these criteria. Pathological studies were also reviewed for evidence that the presence of C pneumoniae in diseased vessels is associated with the severity and extent of atherosclerosis. DATA SYNTHESIS The majority of serological studies have shown an association between C pneumoniae and atherosclerosis. However, the number of cases in studies that have reported a positive association when using strict criteria for chronic infection is similar to the number of cases in studies which found no association. Nevertheless, the organism is widely found in atherosclerotic vessels, although it may not be at all diseased sites and is not confined to the most severe lesions. Rabbit models and preliminary antibiotic trials suggest that the organism might exacerbate atherosclerosis. CONCLUSION More evidence is required before C pneumoniae can be accepted as playing a role in atherosclerosis. Although use of antibiotics in routine practice is not justified, large scale trials in progress will help to elucidate the role of C pneumoniae.
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Affiliation(s)
- Y K Wong
- Wessex Cardiothoracic Unit, Southampton General Hospital, Tremona Road, Southampton, Hampshire SO16 6YD, UK.
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46
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Wong Y, Thomas M, Tsang V, Gallagher PJ, Ward ME. The prevalence of Chlamydia pneumoniae in atherosclerotic and nonatherosclerotic blood vessels of patients attending for redo and first time coronary artery bypass graft surgery. J Am Coll Cardiol 1999; 33:152-6. [PMID: 9935022 DOI: 10.1016/s0735-1097(98)00547-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVES To determine if Chlamydia pneumoniae (C. pneumoniae) is more prevalent in atherosclerotic compared with normal blood vessels of patients requiring redo and first time coronary artery bypass graft surgery (CABG). BACKGROUND Serological and pathological studies have associated atherosclerosis with C. pneumoniae infection. As atherosclerosis is one of the causes of graft failure following CABG, then it may be expected that the prevalence of the organism in failed grafts and diseased native vessels should be greater than in the new grafts. METHODS Endarterectomy specimens and failed and new grafts were collected from 49 patients with late graft failure. Endarterectomy specimens and new grafts were also collected from nine patients having first time CABG. The presence of C. pneumoniae DNA was then checked for using a nested polymerase chain reaction. RESULTS The prevalence of C. pneumoniae DNA in failed venous grafts (38.2%) was similar to that in endarterectomy specimens from native coronary arteries (38.5%) and greater than that in new saphenous vein grafts (11.8%). However, it was similar to that in new internal mammary artery grafts (30.0%). Also, the interval between surgery in redo patients was the same regardless of whether C. pneumoniae was present or not. CONCLUSIONS Cross sectional studies cannot determine whether C. pneumoniae is a cause of atherosclerosis since they do not show whether infection precedes or follows its development. However, our results suggest that the organism is not an important factor in graft failure or atherosclerosis.
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Affiliation(s)
- Y Wong
- Molecular Microbiology, Southampton University Medical School, England, United Kingdom.
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47
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Abstract
Following a recent enquiry into surgery at a paediatric cardiac centre in England, there will be substantial changes in the way that the success and failure of surgical procedures will be monitored and investigated. Post-mortem examinations on patients dying after cardiac surgery are likely to be performed and reported in more detail. This review describes the protocol that we have developed and summarizes recent clinical and pathological studies that have increased our understanding of postoperative pathophysiology. Close attention should be paid to the history, particularly the operation note. Cardiac failure is the commonest cause of death. We believe this is a clinicopathological diagnosis and provide definitions of preoperative and perioperative cardiac failure. Haemorrhage, stroke, pulmonary emboli and infection are other important causes of death. Methods of dissection are suggested for bypass grafts and valve replacements. Two recent studies show that the post-mortem examination provides answers to most clinical questions and reveals an unexpected cause of death in 10-15% of patients. There are limitations however: an incomplete or indeterminate cause of death is found in 14-25% of patients, most commonly sudden clinically unexplained death or clinically unexplained cardiac failure soon after surgery.
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Affiliation(s)
- A H Lee
- Department of Pathology, Southampton University Hospital, UK
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48
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Abstract
We identified immunohistochemically vessels within cutaneous scars to test the hypothesis that they are qualitatively and quantitatively different in pathological and normally healing scars. The vascular density within and adjacent to 58 cutaneous scars was measured on histological sections stained for factor VIII-related antigen. Four scar types were studied; surgical scars (n = 25), hypertrophic scars (n = 10), keloid (n = 12), and periocular scars (n = 11). Statistical analyses were performed to test the hypothesis that vessel numbers were different in the varying types of scar. Results were also compared with mast cell counts previously derived from the same tissues. A significant reduction was found in the vascular density in keloids compared with surgical and hypertrophic scars (P < .05). No correlation was found between the vascular density and the number of mast cells in the lesions. We have shown quantitatively that keloids have a reduced vascular component compared with hypertrophic scars and normally healing surgical scars at periocular and systemic sites. The formation of keloid scars may be related to their reduced level of vascularization mediated through tissue hypoxia.
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Affiliation(s)
- T W Beer
- Department of Histopathology, Southampton University Trust Hospital, United Kingdom
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49
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Buckley MG, Gallagher PJ, Walls AF. Mast cell subpopulations in the synovial tissue of patients with osteoarthritis: selective increase in numbers of tryptase-positive, chymase-negative mast cells. J Pathol 1998; 186:67-74. [PMID: 9875142 DOI: 10.1002/(sici)1096-9896(199809)186:1<67::aid-path132>3.0.co;2-d] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Although there is relatively little evidence of inflammation in osteoarthritis (OA), increases in mast cell numbers and mast cell activation are prominent features of the synovial tissue. As little is known of the types of mast cells which may be involved, the numbers and distribution of mast cell subpopulations have been investigated as defined according to their content of proteases. Tissue was obtained from patients with OA undergoing total knee replacement surgery (n = 14) and from control subjects either post-mortem (n = 11) or following leg amputation for peripheral vascular disease (n = 3); a double-labelling immunocytochemical procedure with monoclonal antibodies specific for tryptase and chymase was applied to identify those mast cells which contain both tryptase and chymase (MCTC) and those with tryptase but not chymase (MCT). There was considerable variation between individual tissues and between sites of tissue sampling, but cells of the MCTC subset were predominant in the synovial layer of both groups of subjects without joint disease, accounting for some 60 per cent of all mast cells present. In tissue from OA patients, however, there appeared to have been a striking shift in the relative proportions of mast cells from the MCTC to the MCT phenotype, with many more MCT cells present in the synovial tissues of OA patients (median 53 MCT/mm2) than in tissue from post-mortem (7.5 MCT/mm2, P < 0.0001) or amputation controls (12 MCT/mm2). In contrast, numbers of synovial MCTC cells in the synovium of OA patients (20 MCTC/mm2) differed little from those in either of the control groups (both 12 MCTC/mm2). In several other conditions, the MCT cells have been linked with inflammatory events, but it seems that in OA, other factors may be operating to induce a selective expansion of this subpopulation.
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Affiliation(s)
- M G Buckley
- Immunopharmacology Group, University of Southampton, Southampton General Hospital, U.K
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Michalowski K, Bornman PC, Krige JE, Gallagher PJ, Terblanche J. Laparoscopic subtotal cholecystectomy in patients with complicated acute cholecystitis or fibrosis. Br J Surg 1998; 85:904-6. [PMID: 9692560 DOI: 10.1046/j.1365-2168.1998.00749.x] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The open subtotal cholecystectomy technique has simplified removal of the difficult gallbladder. Increasing laparoscopic experience has made laparoscopic subtotal cholecystectomy (LSC) a feasible option in patients with complicated acute or chronic cholecystitis. METHODS LSC was performed in 29 patients with severe inflammation or fibrosis of the gallbladder associated with gallstone disease over a 23-month period. These 29 patients (mean age 53 years; 22 women) constituted 8.5 per cent of the total number of laparoscopic cholecystectomies performed (n = 340) and 15.6 per cent of 186 patients with acute cholecystitis. Eighteen patients in the latter group underwent conversion to open cholecystectomy. The indications for LSC were acute cholecystitis/empyema (n = 23) and severe fibrosis (n = 6). RESULTS The cystic duct was either clipped before division (n = 15), sutured (n = 2) or ligated using an Endoloop (n = 10). In two patients the gallbladder bed was drained without isolating the cystic duct. The posterior wall of the gallbladder was left intact to avoid excessive bleeding or damage to bile ducts in the gallbladder bed. A suction drain was inserted in 14 cases. Median operating time was 73 (range 45-130) min. One patient died after operation from a myocardial infarction. Six patients had local complications (two haematomas, three bile leaks, one minor wound sepsis) and nine developed respiratory infections. Median hospital stay was 5 (range 2-28) days. CONCLUSION LSC is a safe, relatively simple and definitive procedure allowing removal of a difficult gallbladder and reducing the need for open conversion or cholecystostomy in the majority of patients.
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Affiliation(s)
- K Michalowski
- Department of Surgery and The Medical Research Council Liver Research Centre, University of Cape Town and Groote Schuur Hospital, Observatory, South Africa
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