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Doan TT, Iturralde Chavez A, Valdes SO, Weigand JD, Wilkinson JC, Parthiban A, Stephens SB, Pignatelli RH, Morris SA. Mitral Annular Disjunction and Its Progression during Childhood in Marfan Syndrome. Eur Heart J Cardiovasc Imaging 2024:jeae125. [PMID: 38728377 DOI: 10.1093/ehjci/jeae125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/05/2024] [Accepted: 05/05/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Data on mitral annular disjunction (MAD) in children with Marfan syndrome (MFS) are sparse. OBJECTIVES To investigate the diagnostic yield of MAD by echocardiography and cardiac magnetic resonance imaging (CMR), its prevalence and progression during childhood. METHODS We included patients <21 years old with MFS, defined by 2010 Ghent criteria and a pathogenic FBN1 variant or ectopia lentis. Two readers measured systolic separation between the mitral valve (MV) posterior hinge point and left ventricular (LV) myocardium on initial and subsequent imaging. MAD was defined as MV-LV separation ≥2 mm, MV prolapse (MVP) as atrial displacement ≥2 mm. Kappa coefficients evaluated echocardiogram-CMR agreement. Bland-Altman and intraclass correlation coefficients (ICC) assessed interrater and intermodality reliability. Univariable mixed-effects linear regression was used to evaluate longitudinal changes of MAD. RESULTS MAD was detected in 60% (110/185) eligible patients. MVP was present in 48% (53/110) of MAD and MAD in 90% (53/59) of MVP. MAD detection by CMR and echocardiography had 96% overall agreement (Kappa = 0.89, p < 0.001) and a 0.32-mm estimate bias (95%CI 0.00, 0.65). ICC by echocardiography, CMR, and between modalities were 0.97 (95%CI 0.93, 0.98), 0.92 (95%CI 0.79, 0.97), and 0.91 (95%CI 0.85, 0.94), respectively. MAD was associated with aortic root dilation (p < 0.001). MAD was found in children of all ages, increased +0.18 mm/year (95%CI +0.14, + 0.22) during a median duration of 5.5 years (IQR 3.1, 7.5 years). MAD indexed by height yielded a constant value +0.0002 mm/m/year (95%CI -0.0002, + 0.0005 mm/m/year). CONCLUSIONS MAD was common in pediatric MFS and was associated with aortic root dilation. MAD detection by echocardiography and CMR was highly reliable, suggesting that routine assessment in MFS is feasible. MAD was present in neonates and progressed over time but remained constant when indexing by height. Further studies are needed to evaluate MAD as a biomarker for clinical outcomes in pediatric MFS.
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Affiliation(s)
- Tam T Doan
- Division of Cardiology, Texas Children's Hospital, 6651 Main Street MC-E1920, Houston, Texas 77030, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Alejandra Iturralde Chavez
- Division of Cardiology, Texas Children's Hospital, 6651 Main Street MC-E1920, Houston, Texas 77030, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Santiago O Valdes
- Division of Cardiology, Texas Children's Hospital, 6651 Main Street MC-E1920, Houston, Texas 77030, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Justin D Weigand
- Division of Cardiology, Texas Children's Hospital, 6651 Main Street MC-E1920, Houston, Texas 77030, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - James C Wilkinson
- Division of Cardiology, Texas Children's Hospital, 6651 Main Street MC-E1920, Houston, Texas 77030, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Anitha Parthiban
- Division of Cardiology, Texas Children's Hospital, 6651 Main Street MC-E1920, Houston, Texas 77030, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Sara B Stephens
- Division of Cardiology, Texas Children's Hospital, 6651 Main Street MC-E1920, Houston, Texas 77030, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Ricardo H Pignatelli
- Division of Cardiology, Texas Children's Hospital, 6651 Main Street MC-E1920, Houston, Texas 77030, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Shaine A Morris
- Division of Cardiology, Texas Children's Hospital, 6651 Main Street MC-E1920, Houston, Texas 77030, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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Stephens SB, Novy T, Spurzem GN, Jacob B, Beecroft T, Soludczyk E, Kozel BA, Weigand J, Morris SA. Genetic Testing for Supravalvar Aortic Stenosis: What to Do When It Is Not Williams Syndrome. J Am Heart Assoc 2024; 13:e034048. [PMID: 38591341 DOI: 10.1161/jaha.123.034048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/08/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND We aimed to describe the frequency and yield of genetic testing in supravalvar aortic stenosis (SVAS) following negative evaluation for Williams-Beuren syndrome (WS). METHODS AND RESULTS This retrospective cohort study included patients with SVAS at our institution who had a negative evaluation for WS from May 1991 to September 2021. SVAS was defined as (1) peak supravalvar velocity of ≥2 meters/second, (2) sinotubular junction or ascending aortic Z score <-2.0, or (3) sinotubular junction Z score <-1.5 with family history of SVAS. Patients with complex congenital heart disease, aortic valve disease as the primary condition, or only postoperative SVAS were excluded. Genetic testing and diagnoses were reported. Of 162 patients who were WS negative meeting inclusion criteria, 61 had genetic testing results available (38%). Chromosomal microarray had been performed in 44 of 61 and was nondiagnostic for non-WS causes of SVAS. Sequencing of 1 or more genes was performed in 47 of 61. Of these, 39 of 47 underwent ELN sequencing, 20 of 39 (51%) of whom had a diagnostic variant. Other diagnoses made by gene sequencing were Noonan syndrome (3 PTPN11, 1 RIT1), Alagille syndrome (3 JAG1), neurofibromatosis (1 NF1), and homozygous familial hypercholesterolemia (1 LDLR1). Overall, sequencing was diagnostic in 29 of 47 (62%). CONCLUSIONS When WS is excluded, gene sequencing for SVAS is high yield, with the highest yield for the ELN gene. Therefore, we recommend gene sequencing using a multigene panel or exome analysis. Hypercholesterolemia can also be considered in individuals bearing the stigmata of this disease.
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Affiliation(s)
- Sara B Stephens
- Section of Cardiology, Department of Pediatrics Baylor College of Medicine, Texas Children's Hospital Houston TX
- Department of Epidemiology, Human Genetics & Environmental Sciences, School of Public Health The University of Texas Health Science Center Houston TX
| | - Tyler Novy
- Division of Community and General Pediatrics, Department of Pediatrics, McGovern Medical School The University of Texas Health Science Center Houston TX
| | | | - Benjamin Jacob
- Section of Cardiology, Department of Pediatrics Baylor College of Medicine, Texas Children's Hospital Houston TX
| | - Taylor Beecroft
- Section of Cardiology, Department of Pediatrics Baylor College of Medicine, Texas Children's Hospital Houston TX
| | - Emily Soludczyk
- Section of Cardiology, Department of Pediatrics Baylor College of Medicine, Texas Children's Hospital Houston TX
| | - Beth A Kozel
- Translational Vascular Medicine Branch National Heart, Lung, and Blood Institute, National Institutes of Health Bethesda MD
| | - Justin Weigand
- Section of Cardiology, Department of Pediatrics Baylor College of Medicine, Texas Children's Hospital Houston TX
| | - Shaine A Morris
- Section of Cardiology, Department of Pediatrics Baylor College of Medicine, Texas Children's Hospital Houston TX
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Bascom JT, Stephens SB, Lupo PJ, Canfield MA, Kirby RS, Nestoridi E, Salemi JL, Mai CT, Nembhard WN, Forestieri NE, Romitti PA, St. Louis AM, Agopian AJ. Scientific impact of the National Birth Defects Prevention Network multistate collaborative publications. Birth Defects Res 2024; 116:e2225. [PMID: 37492989 PMCID: PMC10910332 DOI: 10.1002/bdr2.2225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/16/2023] [Accepted: 07/06/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Given the lack of a national, population-based birth defects surveillance program in the United States, the National Birth Defects Prevention Network (NBDPN) has facilitated important studies on surveillance, research, and prevention of major birth defects. We sought to summarize NBDPN peer-reviewed publications and their impact. METHODS We obtained and reviewed a curated list of 49 NBDPN multistate collaborative publications during 2000-2022, as of December 31, 2022. Each publication was reviewed and classified by type (e.g., risk factor association analysis). Key characteristics of study populations and analytic approaches used, along with publication impact (e.g., number of citations), were tabulated. RESULTS NBDPN publications focused on prevalence estimates (N = 17), surveillance methods (N = 11), risk factor associations (N = 10), mortality and other outcomes among affected individuals (N = 6), and descriptive epidemiology of various birth defects (N = 5). The most cited publications were those that reported on prevalence estimates for a spectrum of defects and those that assessed changes in neural tube defects (NTD) prevalence following mandatory folic acid fortification in the United States. CONCLUSIONS Results from multistate NBDPN publications have provided critical information not available through other sources, including US prevalence estimates of major birth defects, folic acid fortification and NTD prevention, and improved understanding of defect trends and surveillance efforts. Until a national birth defects surveillance program is established in the United States, NBDPN collaborative publications remain an important resource for investigating birth defects and informing decisions related to health services planning of secondary disabilities prevention and care.
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Affiliation(s)
- Jacqueline T. Bascom
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Houston, Texas, USA
| | - Sara B. Stephens
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Houston, Texas, USA
| | - Philip J. Lupo
- Department of Pediatrics, Section of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Mark A. Canfield
- Birth Defects Epidemiology and Surveillance Branch, Texas Department of State Health Services, Austin, Texas, USA
| | - Russell S. Kirby
- Chiles Center, College of Public Health, University of South Florida, Tampa, Florida, USA
| | - Eirini Nestoridi
- Center for Birth Defects Research and Prevention, Massachusetts Department of Public Health, Boston, Massachusetts, USA
| | - Jason L. Salemi
- Chiles Center, College of Public Health, University of South Florida, Tampa, Florida, USA
| | - Cara T. Mai
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Wendy N. Nembhard
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Nina E. Forestieri
- Birth Defects Monitoring Program, State Center for Health Statistics, Division of Public Health, North Carolina Department of Health and Human Services, Raleigh, North Carolina, USA
| | - Paul A. Romitti
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa, USA
| | - Amanda M. St. Louis
- Birth Defects Registry, Center for Environmental Health, New York State Department of Health, New York, USA
| | - A. J. Agopian
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Houston, Texas, USA
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Stephens SB, Shalhub S, Dodd N, Li J, Huang M, Oda S, Kancherla K, Doan TT, Prakash SK, Weigand JD, Asch FM, Beecroft T, Cecchi A, Shittu T, Preiss L, LeMaire SA, Devereux RB, Pyeritz RE, Holmes KW, Roman MJ, Lacro RV, Shohet RV, Krishnamurthy R, Eagle K, Byers P, Milewicz DM, Morris SA. Vertebral Tortuosity Is Associated With Increased Rate of Cardiovascular Events in Vascular Ehlers-Danlos Syndrome. J Am Heart Assoc 2023; 12:e029518. [PMID: 37776192 PMCID: PMC10727246 DOI: 10.1161/jaha.123.029518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/26/2023] [Indexed: 10/02/2023]
Abstract
Background Arterial tortuosity is associated with adverse events in Marfan and Loeys-Dietz syndromes but remains understudied in Vascular Ehlers-Danlos syndrome. Methods and Results Subjects with a pathogenic COL3A1 variant diagnosed at age <50 years were included from 2 institutions and the GenTAC Registry (National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions). Height-adjusted vertebral artery tortuosity index (VTI-h) using magnetic resonance or computed tomography angiography was calculated. Associations between VTI-h and outcomes of (1) cardiovascular events (arterial dissection/rupture, aneurysm requiring intervention, stroke), or (2) hollow organ collapse/rupture at age <50 years were evaluated using receiver operator curve analysis (using outcome by age 30 years) and mixed-effects Poisson regression for incidence rate ratios. Of 65 subjects (54% male), median VTI-h was 12 (interquartile range, 8-16). Variants were missense in 46%, splice site in 31%, and null/gene deletion in 14%. Thirty-two subjects (49%) had 59 events, including 28 dissections, 5 arterial ruptures, 4 aneurysms requiring intervention, 4 strokes, 11 hollow organ ruptures, and 7 pneumothoraces. Receiver operator curve analysis suggested optimal discrimination at VTI-h ≥15.5 for cardiovascular events (sensitivity 70%, specificity 76%) and no association with noncardiovascular events (area under the curve, 0.49 [95% CI, 0.22-0.78]). By multivariable analysis, older age was associated with increased cardiovascular event rate while VTI-h ≥15.5 was not (incidence rate ratios, 1.79 [95% CI, 0.76-4.24], P=0.185). However, VTI-h ≥15.5 was associated with events among those with high-risk variants <40 years (incidence rate ratios, 4.14 [95% CI, 1.13-15.10], P=0.032), suggesting effect modification by genotype and age. Conclusions Increased arterial tortuosity is associated with a higher incidence rate of cardiovascular events in Vascular Ehlers-Danlos syndrome. Vertebral tortuosity index may be a useful biomarker for prognosis when evaluated in conjunction with genotype and age.
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Affiliation(s)
- Sara B. Stephens
- Division of Cardiology, Department of Pediatrics, Baylor College of MedicineTexas Children’s HospitalHoustonTXUSA
- Department of Epidemiology, Human Genetics & Environmental Sciences, School of Public HealthThe University of Texas Health Science Center at HoustonHoustonTXUSA
| | - Sherene Shalhub
- Division of Vascular and Endovascular Surgery, Department of SurgeryOregon Health & Science UniversityPortlandORUSA
| | - Nicholas Dodd
- Memorial Health University Medical CenterSavannahGAUSA
| | - Jesse Li
- Division of Medical Genetics, Department of Internal MedicineThe University of Texas Health Science CenterHoustonTXUSA
| | - Michael Huang
- Division of Medical Genetics, Department of Internal MedicineThe University of Texas Health Science CenterHoustonTXUSA
| | - Seitaro Oda
- Department of Diagnostic Radiology, Faculty of Life SciencesKumamoto UniversityKumamotoJapan
- National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC)
| | - Kalyan Kancherla
- National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC)
- MedStar Heart and Vascular InstituteWashingtonDCUSA
- CHI St. VincentLittle RockARUSA
| | - Tam T. Doan
- Division of Cardiology, Department of Pediatrics, Baylor College of MedicineTexas Children’s HospitalHoustonTXUSA
| | - Siddharth K. Prakash
- Division of Medical Genetics, Department of Internal MedicineThe University of Texas Health Science CenterHoustonTXUSA
| | - Justin D. Weigand
- Division of Cardiology, Department of Pediatrics, Baylor College of MedicineTexas Children’s HospitalHoustonTXUSA
| | - Federico M. Asch
- National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC)
- MedStar Heart and Vascular InstituteWashingtonDCUSA
| | - Taylor Beecroft
- Division of Cardiology, Department of Pediatrics, Baylor College of MedicineTexas Children’s HospitalHoustonTXUSA
| | - Alana Cecchi
- Division of Medical Genetics, Department of Internal MedicineThe University of Texas Health Science CenterHoustonTXUSA
| | - Teniola Shittu
- Division of Cardiology, Department of Pediatrics, Baylor College of MedicineTexas Children’s HospitalHoustonTXUSA
| | | | - Scott A. LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of SurgeryBaylor College of MedicineHoustonTXUSA
| | | | - Reed E. Pyeritz
- Division of Translational Medicine and Human GeneticsPerelman School of Medicine at the University of PennsylvaniaPAUSA
| | - Kathryn W. Holmes
- Section of Cardiology, Department of PediatricsOregon Health & Science University and OHSU Doernbecher Children’s HospitalPortlandORUSA
| | - Mary J. Roman
- Department of MedicineWeill Cornell MedicineNew YorkNY
| | - Ronald V. Lacro
- Department of CardiologyBoston Children’s HospitalBostonMAUSA
| | | | | | - Kim Eagle
- National Registry of Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC)
- Division of Cardiovascular Medicine, Frankel Cardiovascular Center, Department of Internal Medicine, Michigan MedicineUniversity of MichiganAnn ArborMIUSA
| | - Peter Byers
- Department of Laboratory Medicine and Pathology, Department of Medicine (Medical Genetics)University of WashingtonSeattleWAUSA
| | - Dianna M. Milewicz
- Division of Medical Genetics, Department of Internal MedicineThe University of Texas Health Science CenterHoustonTXUSA
| | - Shaine A. Morris
- Division of Cardiology, Department of Pediatrics, Baylor College of MedicineTexas Children’s HospitalHoustonTXUSA
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Bar S, Stephens SB, Mathew MS, Messiah SE, Edgar VB. Quality of Life Among Caregivers of Children with Autism Spectrum Disorder and Attention Deficit Hyperactivity Disorder: A Cross Sectional Study. J Autism Dev Disord 2023:10.1007/s10803-023-06129-w. [PMID: 37751095 DOI: 10.1007/s10803-023-06129-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2023] [Indexed: 09/27/2023]
Abstract
Caregivers of children with attention deficit-hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) experience more stress than caregivers of typically developing children but there is limited research evaluating caregivers' quality of life (QoL). This study aimed to describe the association of caregiver QoL in children with ASD and/or ADHD. This study included patients with ADHD and/or ASD seen in one pediatric specialty clinic between September 2018-August 2020. Caregivers were classified as those caring for children with ASD-only, ADHD-only, or youth with both conditions (ADHD + ASD). An adapted version of the PedsQL Family Impact Module was used to measure caregiver QoL. The sample included caregivers of 931 children. The majority of these children were male (74.7%), non-Hispanic white (63.3%), and aged 6 to 12 years (57.8%). Across the groups, significant differences were observed in patient age (p < 0.0001), preferred language (p = 0.005), and insurance (p = 0.001). Caregivers of non-Hispanic Black children had 4-times the odds of reporting feeling isolated from others (OR 4.36, 95% CI 1.19-16.00 p = 0.03). Those caring for children with ADHD-only had significantly lower odds of reporting helplessness or hopelessness (OR 0.45, 95% CI 0.26-0.80, p = 0.004), and difficulty talking about their child's health with others (OR 0.30, 95% CI 0.17-0.54, p < 0.0001). Similarly, caregivers of children who had ADHD + ASD reported higher odds of difficulty making decisions together as a family (OR 14.18, 95% CI 1.15-17.91, p=0.04) and difficulty solving family problems together (OR 45.12, 95% CI 2.70-752.87), p = 0.008). Caring for children with ADHD and/or ASD may affect caregiver QoL.
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Affiliation(s)
- Sari Bar
- Division of Developmental-Behavioral Pediatrics, Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9063, USA.
- Children's Health, Children's Medical Center, Dallas, TX, USA.
| | - Sara B Stephens
- University of Texas Health Science Center School of Public Health, Houston Campus, Houston, TX, USA
| | - M Sunil Mathew
- Children's Health, Children's Medical Center, Dallas, TX, USA
- University of Texas Health Science Center School of Public Health, Dallas Campus, Dallas, TX, USA
- Center for Pediatric Population Health, Children's Health and UTHealth School of Public Health, Houston, TX, USA
| | - Sarah E Messiah
- Children's Health, Children's Medical Center, Dallas, TX, USA
- University of Texas Health Science Center School of Public Health, Dallas Campus, Dallas, TX, USA
- Center for Pediatric Population Health, Children's Health and UTHealth School of Public Health, Houston, TX, USA
| | - Veronica Bordes Edgar
- Division of Developmental-Behavioral Pediatrics, Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9063, USA
- Children's Health, Children's Medical Center, Dallas, TX, USA
- Division of Psychology, Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Miyake CY, Lay EJ, Soler-Alfonso C, Glinton KE, Houck KM, Tosur M, Moran NE, Stephens SB, Scaglia F, Howard TS, Kim JJ, Pham TD, Valdes SO, Li N, Murali CN, Zhang L, Kava M, Yim D, Beach C, Webster G, Liberman L, Janson CM, Kannankeril PJ, Baxter S, Singer-Berk M, Wood J, Mackenzie SJ, Sacher M, Ghaloul-Gonzalez L, Pedroza C, Morris SA, Ehsan SA, Azamian MS, Lalani SR. Natural history of TANGO2 deficiency disorder: Baseline assessment of 73 patients. Genet Med 2023; 25:100352. [PMID: 36473599 PMCID: PMC10306319 DOI: 10.1016/j.gim.2022.11.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 11/30/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE TANGO2 deficiency disorder (TDD), an autosomal recessive disease first reported in 2016, is characterized by neurodevelopmental delay, seizures, intermittent ataxia, hypothyroidism, and life-threatening metabolic and cardiac crises. The purpose of this study was to define the natural history of TDD. METHODS Data were collected from an ongoing natural history study of patients with TDD enrolled between February 2019 and May 2022. Data were obtained through phone or video based parent interviews and medical record review. RESULTS Data were collected from 73 patients (59% male) from 57 unrelated families living in 16 different countries. The median age of participants at the time of data collection was 9.0 years (interquartile range = 5.3-15.9 years, range = fetal to 31.8 years). A total of 24 different TANGO2 alleles were observed. Patients showed normal development in early infancy, with progressive delay in developmental milestones thereafter. Symptoms included ataxia, dystonia, and speech difficulties, typically starting between the ages of 1 to 3 years. A total of 46/71 (65%) patients suffered metabolic crises, and of those, 30 (65%) developed cardiac crises. Metabolic crises were significantly decreased after the initiation of B-complex or multivitamin supplementation. CONCLUSION We provide the most comprehensive review of natural history of TDD and important observational data suggesting that B-complex or multivitamins may prevent metabolic crises.
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Affiliation(s)
- Christina Y Miyake
- Division of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX; Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston TX.
| | - Erica J Lay
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | | | - Kevin E Glinton
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Kimberly M Houck
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Mustafa Tosur
- Division of Diabetes and Endocrinology, Department of Pediatrics, USDA/ARS Children's Nutrition Research Center, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Nancy E Moran
- USDA/ARS Children's Nutrition Research Center, Division of Nutrition, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Sara B Stephens
- Division of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Fernando Scaglia
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX; BCM-CUHK Center of Medical Genetics, Prince of Wales Hospital, Hong Kong, Special Administrative Region
| | - Taylor S Howard
- Division of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Jeffrey J Kim
- Division of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Tam Dam Pham
- Division of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Santiago O Valdes
- Division of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Na Li
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston TX; Department of Medicine, Section of Cardiovascular Research, Baylor College of Medicine, Houston, TX
| | - Chaya N Murali
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Lilei Zhang
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston TX; Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Maina Kava
- Department of Neurology, Perth Children's Hospital, Perth, Western Australia, Australia; Departments of Metabolic Medicine and Rheumatology, Perth Children's Hospital, Perth, Western Australia, Australia; Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Deane Yim
- Department of Cardiology, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Cheyenne Beach
- Division of Cardiology, Department of Pediatrics, Yale School of Medicine, Yale University, New Haven, CT
| | - Gregory Webster
- Division of Cardiology, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Nortwestern University Feinberg School of Medicine, Chicago, IL
| | - Leonardo Liberman
- Division of Cardiology, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Christopher M Janson
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Prince J Kannankeril
- Center for Pediatric Precision Medicine, Department of Pediatrics, Vanderbilt University Medical Center and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | | | | | - Jordan Wood
- Broad Institute of MIT and Harvard, Cambridge, MA
| | - Samuel J Mackenzie
- Department of Neurology, University of Rochester Medical Center, Rochester, NY
| | - Michael Sacher
- Department of Biology, Concordia University, Montreal, Quebec, Canada; Department of Anatomy and Cell Biology, McGill University, Montreal, Quebec, Canada
| | - Lina Ghaloul-Gonzalez
- Division of Genetic and Genomic Medicine, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Claudia Pedroza
- Department of Pediatrics, McGovern Medical School, University of Texas Health Center at Houston, Houston, TX
| | - Shaine A Morris
- Division of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | | | - Mahshid S Azamian
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Seema R Lalani
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
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Miyake CY, Lay EJ, Beach CM, Ceresnak SR, Delauz CM, Howard TS, Janson CM, Jardine K, Kannankeril PJ, Kava M, Kim JJ, Liberman L, Macicek SL, Pham TD, Robertson T, Valdes SO, Webster G, Stephens SB, Milewicz DM, Azamian M, Ehsan SA, Houck KM, Soler-Alfonso C, Glinton KE, Tosur M, Li N, Xu W, Lalani SR, Zhang L. Cardiac crises: Cardiac arrhythmias and cardiomyopathy during TANGO2 deficiency related metabolic crises. Heart Rhythm 2022; 19:1673-1681. [PMID: 35568137 PMCID: PMC10642301 DOI: 10.1016/j.hrthm.2022.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 05/05/2022] [Accepted: 05/06/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND TANGO2 deficiency disorder (TDD) is an autosomal recessive disease associated with metabolic crisis, lethal cardiac arrhythmias, and cardiomyopathy. Data regarding treatment, management, and outcomes of cardiac manifestations of TDD are lacking. OBJECTIVE The purpose of this study was to describe TDD-related cardiac crises. METHODS Retrospective multicenter chart review was made of TDD patients admitted with cardiac crises, defined as development of ventricular tachycardia (VT), cardiomyopathy, or cardiac arrest during metabolic crises. RESULTS Twenty-seven children were admitted for 43 cardiac crises (median age 6.4 years; interquartile range [IQR] 2.4-9.8 years) at 14 centers. During crisis, QTc prolongation occurred in all (median 547 ms; IQR 504-600 ms) and a type I Brugada pattern in 8 (26%). Arrhythmias included VT in 21 (78%), supraventricular tachycardia in 3 (11%), and heart block in 1 (4%). Nineteen patients (70%) developed cardiomyopathy, and 20 (74%) experienced a cardiac arrest. There were 10 deaths (37%), 6 related to arrhythmias. In 5 patients, recalcitrant VT occurred despite use of antiarrhythmic drugs. In 6 patients, arrhythmias were controlled after extracorporeal membrane oxygenation (ECMO) support; 5 of these patients survived. Among 10 patients who survived VT without ECMO, successful treatment included intravenous magnesium, isoproterenol, and atrial pacing in multiple cases and verapamil in 1 patient. Initiation of feeds seemed to decrease VT events. CONCLUSION TDD-related cardiac crises are associated with a high risk of arrhythmias, cardiomyopathy, cardiac arrest, and death. Although further studies are needed, early recognition and appropriate treatment are critical. Acutely, intravenous magnesium, isoproterenol, atrial pacing, and ECMO as a last resort seem to be the best current treatment options, and early initiation of feeds may prevent VT events.
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Affiliation(s)
- Christina Y Miyake
- Department of Pediatrics, Division of Pediatric Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas; Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston Texas.
| | - Erica J Lay
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | | | - Scott R Ceresnak
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, California
| | | | - Taylor S Howard
- Department of Pediatrics, Division of Pediatric Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | | | - Kate Jardine
- John Hunter Children's Hospital, Newcastle, New South Wales, Australia
| | | | - Maina Kava
- Department of Neurology and Metabolic Medicine, Perth Children's Hospital, Perth, Western Australia
| | - Jeffrey J Kim
- Department of Pediatrics, Division of Pediatric Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Leonardo Liberman
- New York Presbyterian, Morgan Stanley Children's Hospital, New York, New York
| | | | - Tam Dam Pham
- Department of Pediatrics, Division of Pediatric Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | | | - Santiago O Valdes
- Department of Pediatrics, Division of Pediatric Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | | | - Sara B Stephens
- Department of Pediatrics, Division of Pediatric Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Diana M Milewicz
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Center at Houston, Houston, Texas
| | - Mahshid Azamian
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | - Saad A Ehsan
- Baylor College School of Medicine, Houston, Texas
| | - Kimberly M Houck
- Department of Pediatrics, Division of Neurology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Claudia Soler-Alfonso
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | - Kevin E Glinton
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | - Mustafa Tosur
- Department of Pediatrics, Division of Endocrinology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Na Li
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Center at Houston, Houston, Texas
| | - Weiyi Xu
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | - Seema R Lalani
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | - Lilei Zhang
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston Texas; Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
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Moore JA, Stephens SB, Kertesz NJ, Evans DL, Kim JJ, Howard TS, Pham TD, Valdés SO, de la Uz CM, Raymond TT, Morris SA, Miyake CY. Clinical Predictors of Recurrent Supraventricular Tachycardia in Infancy. J Am Coll Cardiol 2022; 80:1159-1172. [PMID: 36109110 DOI: 10.1016/j.jacc.2022.06.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 02/07/2022] [Revised: 06/16/2022] [Accepted: 06/23/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Data regarding recurrence risk among infants with supraventricular tachycardia (SVT) are limited. OBJECTIVES The purpose of this study was to determine incidence and factors associated with SVT recurrence. METHODS This was a retrospective single-center study (1984-2020) with prospective phone follow-up of infants with structurally normal hearts diagnosed at age ≤1 year with re-entrant SVT. Primary outcome was first SVT recurrence after hospital discharge. Classification and regression tree analysis was performed to determine a risk algorithm. RESULTS Among 460 infants (62% male), 87% were diagnosed at ≤60 days of age (median 13 days; IQR: 1-31 days). During a median follow-up of 5.2 years (IQR: 1.8-11.2 years), 33% had recurrence. On multivariable analysis, factors associated with recurrence included: fetal or late (>60 days) diagnosis (HR: 1.90; 95% CI: 1.26-2.86; and HR: 1.73; 95% CI: 1.07-2.77, respectively), Wolff-Parkinson-White (WPW) syndrome (HR: 2.46; 95% CI: 1.75-3.45), and need for multi-antiarrhythmic or second-line therapy (HR: 2.08; 95% CI: 1.45-2.99). Based on the classification and regression tree analysis, WPW incurred the highest risk. Among those without WPW, age at diagnosis was the most important factor predicting risk. Fetal or late diagnosis incurred higher risk, and if multi-antiarrhythmic or second-line therapy was also required, risk nearly doubled. Infants without WPW, who were diagnosed early (0-60 days), and who were discharged on propranolol were at lowest recurrence risk. CONCLUSIONS Infants with SVT are most likely to be diagnosed at ≤60 days and be male. Risk factors for recurrence (occurred in 33%), present at time of diagnosis, include WPW, fetal or late diagnosis, and multi-antiarrhythmic or second-line therapy. Infants with early diagnosis, without WPW, and discharged on first-line monotherapy are at lowest recurrence risk.
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Affiliation(s)
- Judson A Moore
- Department of Pediatrics and the Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Houston, Texas, USA
| | - Sara B Stephens
- Department of Pediatrics and the Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Houston, Texas, USA
| | - Naomi J Kertesz
- Department of Pediatrics and Section of Pediatric Cardiology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Danyelle L Evans
- Department of Pediatrics and the Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Houston, Texas, USA
| | - Jeffrey J Kim
- Department of Pediatrics and the Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Houston, Texas, USA
| | - Taylor S Howard
- Department of Pediatrics and the Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Houston, Texas, USA
| | - Tam Dan Pham
- Department of Pediatrics and the Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Houston, Texas, USA
| | - Santiago O Valdés
- Department of Pediatrics and the Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Houston, Texas, USA
| | - Caridad M de la Uz
- Department of Pediatrics, Division of Pediatric Cardiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Tia T Raymond
- Department of Pediatrics, Cardiac Critical Care, Medical City Children's Hospital, Dallas, Texas, USA
| | - Shaine A Morris
- Department of Pediatrics and the Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Houston, Texas, USA
| | - Christina Y Miyake
- Department of Pediatrics and the Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Houston, Texas, USA; Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, Texas, USA.
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Stephens SB, Raphael JL, Zimmerman CT, Garland BH, de Guzman MM, Walsh SM, Hergenroeder AC, Wiemann CM. The Utility of Self-Determination Theory in Predicting Transition Readiness in Adolescents With Special Healthcare Needs. J Adolesc Health 2021; 69:653-659. [PMID: 34059429 DOI: 10.1016/j.jadohealth.2021.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 11/19/2020] [Revised: 03/10/2021] [Accepted: 04/07/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Adolescents and young adults with chronic health conditions must learn skills to successfully manage their health as they prepare to transition into adult-based care. Self-determination theory (SDT), an empirically based theory of human motivation, posits that competence (feeling effective), autonomy (volition to perform behaviors), and relatedness (support for autonomy from others) influence behavioral change. This study evaluates the utility of SDT constructs in predicting transition readiness among adolescents and young adults recruited into an intervention to promote successful healthcare transition. METHODS Baseline assessments were completed by 137 patients aged 17-23 years recruited from pediatric renal, gastroenterology, or rheumatology clinical services. Surveys measured transition readiness (Transition Readiness Assessment Questionnaire) as well as SDT constructs, including competence (Patient Activation Measure); provider relatedness and parent autonomy support (Health Care Climate Questionnaire); and health care-related autonomy (Treatment Self-Regulation Questionnaire). Relationships between SDT constructs and transition readiness were evaluated using linear regression. RESULTS Between 44 and 48 participants were recruited from each service. Bivariate correlation coefficients between transition readiness and SDT constructs were competence (r = .44), autonomous autonomy (r = .34), controlled autonomy (r = .27), provider relatedness (r = .46), and parental autonomy support (r = .35) (p < .01). Age positively correlated with transition readiness (r = .47, p < .001). After controlling for age, gender, and clinical service, competence (p < .001) and provider relatedness (p = .008) successfully predicted transition readiness (R2 = .423; F change; p < .001). CONCLUSIONS Findings from this cross-sectional study support the utility of SDT constructs in promoting transition readiness among adolescents and young adults with chronic conditions, underscoring the importance of building competence and provider support for autonomy during this critical period.
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Affiliation(s)
- Sara B Stephens
- Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Jean L Raphael
- Center for Child Health Policy and Advocacy, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Cortney T Zimmerman
- Section of Psychology, Renal Service, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Beth H Garland
- Sections of Adolescent Medicine & Sports Medicine and Psychology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Marietta M de Guzman
- Section of Rheumatology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Seema M Walsh
- Section of Gastroenterology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Albert C Hergenroeder
- Section of Adolescent Medicine & Sports Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Constance M Wiemann
- Section of Adolescent Medicine & Sports Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas.
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Reuhs BL, Stephens SB, Geller DP, Kim JS, Glenn J, Przytycki J, Ojanen-Reuhs T. Epitope identification for a panel of anti-Sinorhizobium meliloti monoclonal antibodies and application to the analysis of K antigens and lipopolysaccharides from bacteroids. Appl Environ Microbiol 1999; 65:5186-91. [PMID: 10543844 PMCID: PMC91702 DOI: 10.1128/aem.65.11.5186-5191.1999] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [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] Open
Abstract
In two published reports using monoclonal antibodies (MAbs) generated against whole cells, Olsen et al. showed that strain-specific antigens on the surface of cultured cells of Sinorhizobium meliloti were diminished or absent in the endophytic cells (bacteroids) recovered from alfalfa nodules, whereas two common antigens were not affected by bacterial differentiation (P. Olsen, M. Collins, and W. Rice, Can. J. Microbiol. 38:506-509, 1992; P. Olsen, S. Wright, M. Collins, and W. Rice, Appl. Environ. Microbiol. 60:654-661, 1994). The nature of the antigens (i.e., the MAb epitopes), however, were not determined in those studies. For this report, the epitopes for five of the anti-S. meliloti MAbs were identified by polyacrylamide gel electrophoresis-immunoblot analyses of the polysaccharides extracted from S. meliloti and Sinorhizobium fredii. This showed that the strain-specific MAbs recognized K antigens, whereas the strain-cross-reactive MAbs recognized the lipopolysaccharide (LPS) core. The MAbs were then used in the analysis of the LPS and K antigens extracted from S. meliloti bacteroids, which had been recovered from the root nodules of alfalfa, and the results supported the findings of Olsen et al. The size range of the K antigens from bacteroids of S. meliloti NRG247 on polyacrylamide gels was altered, and the epitope was greatly diminished in abundance compared to those from the cultured cells, and no K antigens were detected in the S. meliloti NRG185 bacteroid extract. In contrast to the K antigens, the LPS core appeared to be similar in both cultured cells and bacteroids, although a higher proportion of the LPS fractionated into the organic phase during the phenol-water extraction of the bacteroid polysaccharides. Importantly, immunoblot analysis with an anti-LPS MAb showed that smooth LPS production was modified in the bacteroids.
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Affiliation(s)
- B L Reuhs
- Complex Carbohydrate Research Center, University of Georgia, Athens, Georgia 30602-4712, USA.
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Christian ES, Schreeder M, Salter MM, Stephens SB, Carpenter JT, Wheeler RH. Phase I-II study of cisplatin, VP-16, MGBG, mitomycin, and vinblastine with radiation therapy for non-small-cell lung cancer. Am J Clin Oncol 1988; 11:502-5. [PMID: 2841845 DOI: 10.1097/00000421-198808000-00018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Nineteen patients with locoregional non-small-cell lung cancer (NSCLC) were treated with two courses of cisplatin/VP-16/MGBG, followed by involved field radiotherapy and, subsequently, the same chemotherapy alternating with mitomycin-C/vinblastine. Five of 17 patients obtained a response (CR + PR) after induction chemotherapy. Following radiotherapy, an additional two patients responded. The median survival was 7.5 months, with the two longest survivors at 30 and 32 months. Hematologic toxicity was severe, with two deaths from severe neutropenia. Renal and gastrointestinal toxicities were moderate. This program of aggressive therapy did not increase the response rate or median survival compared with those of comparable patients treated in recent trials using radiotherapy alone or combined radiotherapy plus chemotherapy.
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Affiliation(s)
- E S Christian
- Department of Medicine, University of Alabama Medical Center, Birmingham 35294
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