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Blood AJ, Chang LS, Hassan S, Chasse J, Stern G, Gabovitch D, Zelle D, Colling C, Aronson SJ, Figueroa C, Collins E, Ruggiero R, Zacherle E, Noone J, Robar C, Plutzky J, Gaziano TA, Cannon CP, Wexler DJ, Scirica BM. Randomized Evaluation of a Remote Management Program to Improve Guideline-directed Medical Therapy: The Diabetes Remote Intervention to Improve Use of Evidence-based Medications (DRIVE) Trial. Circulation 2024. [PMID: 38583146 DOI: 10.1161/circulationaha.124.069494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 04/02/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Several sodium-glucose transport protein 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RA) reduce cardiovascular (CV) events and improve kidney outcomes in patients with type 2 diabetes (T2D); however, utilization remains low despite guideline recommendations. METHODS A randomized, remote implementation trial in the Mass General Brigham network enrolled patients with T2D at high CV and /or kidney risk. Patients eligible for, but not prescribed, SGLT2i or GLP-1 RA were randomly assigned to simultaneous virtual patient education with concurrent prescription of SGLT2i or GLP-1 RA ("simultaneous") or two months of virtual education followed by medication prescription ("education-first") delivered by a multi-disciplinary team driven by non-licensed navigators and clinical pharmacists who prescribed SGLT2i or GLP-1 RA using a standardized treatment algorithm. The primary outcome was the proportion of patients with prescriptions for either SGLT2i or GLP-1 RA by 6 months. RESULTS Between March 2021 and December 2022, 200 patients were randomized. Mean age was 66.5 years, 36.5% were female, 22.0% were non-White. Overall, 30.0% had cardiovascular CV disease, 5.0% had cerebrovascular disease, and 1.5% had both. Mean estimated glomerular filtration rate (eGFR) 77.9 mL/min/1.73m2 and mean urine/albumin creatinine ratio (UACR) 88.6mg/g. After two months, 69/200 (34.5%) patients received a new prescription for either SGLT2i or GLP-1 RA: 53.4% of patients in the simultaneous arm vs. 8.3% of patients were in the education-first arm (p<0.001). After six months, 128/200 (64.0%) received a new prescription: 69.8 % of patients in the simultaneous arm vs. 56.0% of patients in education-first (p<0.001). Patient self-report of taking SGLT2i or GLP-1 RA within six months of trial entry was similarly higher in the simultaneous versus education-first arm (69 /116; 59.5% vs 37/84; 44.0%; p<0.001) Median time to first prescription was 24 (IQR 13, 50) vs 85 days (IQR 65, 106), respectively (p<0.001). CONCLUSIONS In this randomized trial, a remote team-based program that identifies patients with T2D and high CV or kidney risk, provides virtual education, and prescribes SGLT2i or GLP-1 RA improves GDMT. These findings support greater utilization of virtual team-based approaches to optimize chronic disease management.
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Affiliation(s)
- Alexander J Blood
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Lee-Shing Chang
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Shahzad Hassan
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Jacqueline Chasse
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Gretchen Stern
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA
| | - Daniel Gabovitch
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA
| | - David Zelle
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA
| | - Caitlin Colling
- Diabetes Center, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Samuel J Aronson
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA; Personalized Medicine, Mass General Brigham, Cambridge, MA
| | - Christian Figueroa
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA
| | - Emma Collins
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA
| | - Ryan Ruggiero
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA
| | | | | | | | - Jorge Plutzky
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Thomas A Gaziano
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Christopher P Cannon
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Deborah J Wexler
- Diabetes Center, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Benjamin M Scirica
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
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Blood AJ, Chang LS, Colling C, Stern G, Gabovitch D, Feldman G, Adan A, Waterman F, Durden E, Hamersky C, Noone J, Aronson SJ, Liberatore P, Gaziano TA, Matta LS, Plutzky J, Cannon CP, Wexler DJ, Scirica BM. Methods, rationale, and design for a remote pharmacist and navigator-driven disease management program to improve guideline-directed medical therapy in patients with type 2 diabetes at elevated cardiovascular and/or kidney risk. Prim Care Diabetes 2024; 18:202-209. [PMID: 38302335 DOI: 10.1016/j.pcd.2024.01.005] [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: 03/10/2023] [Revised: 11/24/2023] [Accepted: 01/09/2024] [Indexed: 02/03/2024]
Abstract
AIM Describe the rationale for and design of Diabetes Remote Intervention to improVe use of Evidence-based medications (DRIVE), a remote medication management program designed to initiate and titrate guideline-directed medical therapy (GDMT) in patients with type 2 diabetes (T2D) at elevated cardiovascular (CV) and/or kidney risk by leveraging non-physician providers. METHODS An electronic health record based algorithm is used to identify patients with T2D and either established atherosclerotic CV disease (ASCVD), high risk for ASCVD, chronic kidney disease, and/or heart failure within our health system. Patients are invited to participate and randomly assigned to either simultaneous education and medication management, or a period of education prior to medication management. Patient navigators (trained, non-licensed staff) are the primary points of contact while a pharmacist or nurse practitioner reviews and authorizes each medication initiation and titration under an institution-approved collaborative drug therapy management protocol with supervision from a cardiologist and/or endocrinologist. Patient engagement is managed through software to support communication, automation, workflow, and standardization. CONCLUSION We are testing a remote, navigator-driven, pharmacist-led, and physician-overseen management strategy to optimize GDMT for T2D as a population-level strategy to close the gap between guidelines and clinical practice for patients with T2D at elevated CV and/or kidney risk.
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Affiliation(s)
- Alexander J Blood
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA; Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Lee-Shing Chang
- Endocrinology Division, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Caitlin Colling
- Endocrinology Division, Diabetes Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Gretchen Stern
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel Gabovitch
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA
| | - Guinevere Feldman
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA
| | - Asma Adan
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | | | | | - Samuel J Aronson
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA; Personalized Medicine, Mass General Brigham, Cambridge, MA, USA
| | - Paul Liberatore
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA; Personalized Medicine, Mass General Brigham, Cambridge, MA, USA
| | - Thomas A Gaziano
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA; Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Lina S Matta
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA
| | - Jorge Plutzky
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA; Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Christopher P Cannon
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA; Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Deborah J Wexler
- Endocrinology Division, Diabetes Unit, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Benjamin M Scirica
- Accelerator for Clinical Transformation, Brigham and Women's Hospital, Boston, MA, USA; Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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Dichtel LE, Corey KE, Haines MS, Chicote ML, Lee H, Kimball A, Colling C, Simon TG, Long MT, Husseini J, Bredella MA, Miller KK. Growth Hormone Administration Improves Nonalcoholic Fatty Liver Disease in Overweight/Obesity: A Randomized Trial. J Clin Endocrinol Metab 2023; 108:e1542-e1550. [PMID: 37379033 PMCID: PMC10655511 DOI: 10.1210/clinem/dgad375] [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: 03/08/2023] [Revised: 06/05/2023] [Accepted: 06/20/2023] [Indexed: 06/29/2023]
Abstract
CONTEXT Overweight and obesity are associated with relative growth hormone (GH) deficiency, which has been implicated in the development of nonalcoholic fatty liver disease (NAFLD). NAFLD is a progressive disease without effective treatments. OBJECTIVE We hypothesized that GH administration would reduce hepatic steatosis in individuals with overweight/obesity and NAFLD. METHODS In this 6-month randomized, double-blind, placebo-controlled trial of low-dose GH administration, 53 adults aged 18 to 65 years with BMI ≥25 kg/m2 and NAFLD without diabetes were randomized to daily subcutaneous GH or placebo, targeting insulin-like growth factor 1 (IGF-1) to the upper normal quartile. The primary endpoint was intrahepatic lipid content (IHL) by proton magnetic resonance spectroscopy (1H-MRS) assessed before treatment and at 6 months. RESULTS Subjects were randomly assigned to a treatment group (27 GH; 26 placebo), with 41 completers (20 GH and 21 placebo) at 6 months. Reduction in absolute % IHL by 1H-MRS was significantly greater in the GH vs placebo group (mean ± SD: -5.2 ± 10.5% vs 3.8 ± 6.9%; P = .009), resulting in a net mean treatment effect of -8.9% (95% CI, -14.5 to -3.3%). All side effects were similar between groups, except for non-clinically significant lower extremity edema, which was more frequent in the GH vs placebo group (21% vs 0%, P = .02). There were no study discontinuations due to worsening of glycemic status, and there were no significant differences in change in glycemic measures or insulin resistance between the GH and placebo groups. CONCLUSION GH administration reduces hepatic steatosis in adults with overweight/obesity and NAFLD without worsening glycemic measures. The GH/IGF-1 axis may lead to future therapeutic targets for NAFLD.
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Affiliation(s)
- Laura E Dichtel
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
| | - Kathleen E Corey
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
| | - Melanie S Haines
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
| | - Mark L Chicote
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Hang Lee
- Biostatistics Center, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
| | - Allison Kimball
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
| | - Caitlin Colling
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
| | - Tracey G Simon
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
| | - Michelle T Long
- Section of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, MA 02118, USA
| | - Jad Husseini
- Department of Radiology, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
| | - Miriam A Bredella
- Department of Radiology, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
| | - Karen K Miller
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
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Colling C, Bredella MA, Fazeli PK, Pachón-Peña G, Singh RJ, Rosen CJ, Miller KK. Changes in Serum Cortisol Levels After 10 Days of Overfeeding and Fasting. Am J Physiol Endocrinol Metab 2023; 324:E506-E513. [PMID: 37053050 DOI: 10.1152/ajpendo.00181.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
OBJECTIVE Chronic caloric deprivation and obesity are complicated by hypercortisolemia. The effects of acute overfeeding and fasting on circulating free cortisol levels and conversion of cortisone to free cortisol are unknown. We hypothesized that serum free cortisol and free cortisol-to-cortisone ratio would increase after both overfeeding and fasting. RESEARCH DESIGN AND METHODS Prospective study of 22 healthy volunteers who completed a 10-day high-calorie protocol followed by a 10-day fast, separated by a 2-week wash-out. Morning free and total cortisol and free cortisone levels (LC/MS) were performed at baseline and after 10 days of each intervention. RESULTS Both high-calorie feeding and fasting increased total and free cortisol and the free cortisol-to-free cortisone ratio (p=0.001 to p=0.046). There were sex interactions, with significant effects in men (p<0.001), but not women (p=0.898 and 1.000, respectively) in subset analyses examining the effects of fasting on free cortisol and the free-to-total cortisol ratio. CONCLUSION Overfeeding and fasting both increase circulating free cortisol levels and appear to alter the balance between cortisol and its inactive metabolite, cortisone. Further study is warranted to determine whether elevated cortisol levels contribute to complications of starvation and obesity, such as bone fragility.
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Affiliation(s)
- Caitlin Colling
- Neuroendocrine Unit, Massachusetts General Hospital; Harvard Medical School, Boston, MA, United States
| | - Miriam A Bredella
- Harvard Medical School; Department of Radiology, Massachusetts General Hospital, United States
| | - Pouneh K Fazeli
- Neuroendocrine Unit, Massachusetts General Hospital; Harvard Medical School, United States
| | - Gisela Pachón-Peña
- Maine Medical Center Research Institute, Maine Medical Center Research Institute, United States
| | - Ravinder J Singh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, United States
| | | | - Karen K Miller
- Neuroendocrine Unit, Massachusetts General Hospital; Harvard Medical School, Boston, MA, United States
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Stamou MI, Colling C, Dichtel LE. Adrenal aging and its effects on the stress response and immunosenescence. Maturitas 2023; 168:13-19. [PMID: 36370489 PMCID: PMC10426230 DOI: 10.1016/j.maturitas.2022.10.006] [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: 06/16/2022] [Revised: 10/14/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022]
Abstract
Normal aging is linked to various endocrine gland changes, including changes in the adrenal glands. Aging is linked to alterations of the hypothalamic-pituitary-adrenal (HPA) axis, including an increase in cortisol levels, a disruption of the negative cortisol feedback, and attenuation of cortisol's diurnal pattern. In addition, secretion of aldosterone and adrenal androgens [dehydroepiandrosterone (DHEA) and DHEA sulfate (DHEAS)] from the adrenal cortex decreases with aging. In this review, we describe normal adrenal function, the adrenal response to stress and immunomodulation in aging individuals as well as the effects of adrenal aging on body composition, metabolic profile, bone health and cognition.
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Affiliation(s)
- Maria I Stamou
- Endocrine Division, Massachusetts General Hospital, Boston, MA, USA.
| | - Caitlin Colling
- Endocrine Division, Massachusetts General Hospital, Boston, MA, USA
| | - Laura E Dichtel
- Endocrine Division, Massachusetts General Hospital, Boston, MA, USA
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Haines M, Kimball A, Meenaghan E, Strauch J, Colling C, Singhal V, Eddy K, Misra M, Miller K. RF30 | PSAT172 Effects of 12 Months of Alendronate Therapy Subsequent to 12 Months of Denosumab Administration in Women With Anorexia Nervosa. J Endocr Soc 2022. [DOI: 10.1210/jendso/bvac150.476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Abstract
Low bone mineral density (BMD) and increased fracture risk are common complications of anorexia nervosa. We assessed whether 12 months of alendronate subsequent to 12 months of denosumab would 1) maintain the increases in BMD observed with denosumab and 2) result in higher BMD than alendronate for 12 months alone in 30 ambulatory women with anorexia nervosa and areal BMD (aBMD) Z- or T-score <-1.0. Participants were randomized in a 2: 1 ratio to 12 months of denosumab (60mg subcutaneously q6 months) followed by 12 months of open-label alendronate (70mg orally qweek)("denosumab-to-alendronate" n=20) or 12 months of subcutaneous placebo followed by 12 months of open-label alendronate (70mg orally qweek)("placebo-to-alendronate" n=10). The prespecified primary outcome was PA lumbar spine aBMD by DXA. Secondary outcome measures included tibial and radial volumetric BMD (vBMD) and microarchitecture by high-resolution peripheral quantitative CT (HR-pQCT), and markers of bone turnover. Twelve-month results were reported in abstract form; 24-month results have not been published.
At baseline, mean age [29±8 y (mean±SD)], BMI (18.6±1.9 kg/m2), and aBMD (PA lumbar spine Z-score -1.6±1.1) were similar between groups. From 12 to 24 months in the denosumab-to-alendronate group, favorable changes in spine aBMD, radial vBMD, and radial and tibial microarchitecture from 12 months of denosumab were maintained after 12 months of alendronate. However, there was a rebound increase in markers of bone turnover (p<0.003), and PA and lateral lumbar spine aBMD decreased in 6 and 9 participants, respectively. Both a greater suppression of bone turnover markers and a greater increase in aBMD from baseline to 12 months were predictors of partial reversal of BMD gains from 12 to 24 months in the denosumab-to-alendronate group. Over 24 months, PA lumbar spine aBMD (3.9±4.3%), femoral neck aBMD (3.1±5.5%), tibial vBMD and failure load increased within the denosumab-to-alendronate group, and PA lumbar spine aBMD (5.8±5.3%) increased within the placebo-to-alendronate group (p<0.05). In a 24-month between-group comparison, there was no difference in change in aBMD at any site; however, the denosumab-to-alendronate group demonstrated favorable changes in tibial vBMD and trabecular microarchitecture compared to the placebo-to-alendronate group (p<0.05).
In conclusion, this pilot study suggests that 12 months of alendronate maintains BMD gains achieved with 12 months of denosumab administration in some, but not all, women with anorexia nervosa. A more robust response to denosumab may be a risk factor for partial reversal of denosumab-related BMD gains despite alendronate. Therefore, a more effective antiresorptive agent may be necessary to maintain gains in BMD achieved with denosumab therapy in some women with anorexia nervosa. Moreover, sequential therapy of denosumab followed by alendronate over 24 months results in greater improvements in tibial vBMD and microarchitecture than 12 months of alendronate, although increases in aBMD were similar between groups.
Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Monday, June 13, 2022 12:30 p.m. - 12:35 p.m.
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Haines MS, Kimball A, Meenaghan E, Santoso K, Colling C, Singhal V, Ebrahimi S, Gleysteen S, Schneider M, Ciotti L, Belfer P, Eddy KT, Misra M, Miller KK. Denosumab increases spine bone density in women with anorexia nervosa: a randomized clinical trial. Eur J Endocrinol 2022; 187:697-708. [PMID: 36134902 PMCID: PMC9746654 DOI: 10.1530/eje-22-0248] [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: 03/21/2022] [Accepted: 09/21/2022] [Indexed: 12/15/2022]
Abstract
Objective Anorexia nervosa is complicated by high bone resorption, low bone mineral density (BMD), and increased fracture risk. We investigated whether off-label antiresorptive therapy with denosumab increases BMD in women with anorexia nervosa. Design Twelve-month, randomized, double-blind, placebo-controlled study. Methods Thirty ambulatory women with anorexia nervosa and areal BMD (aBMD) T-score <-1.0 at ≥1 sites were randomized to 12 months of denosumab (60 mg subcutaneously q6 months)(n = 20) or placebo (n = 10). Primary end point was postero-anterior (PA) lumbar spine aBMD by dual-energy x-ray absorptiometry. Secondary end points included femoral neck aBMD, tibia and radius volumetric BMD and bone microarchitecture by high-resolution peripheral quantitative CT, tibia and radius failure load by finite element analysis (FEA), and markers of bone turnover. Results Baseline mean (±s.d.) age (29 ± 8 (denosumab) vs 29 ± 7 years (placebo)), BMI (19.0 ± 1.7 vs 18.0 ± 2.0 kg/m2), and aBMD (PA spine Z-score -1.6±1.1 vs -1.7±1.4) were similar between groups. PA lumbar spine aBMD increased in the denosumab vs placebo group over 12 months (P = 0.009). The mean (95% CI) increase in PA lumbar spine aBMD was 5.5 (3.8-7.2)% in the denosumab group and 2.2 (-0.3-4.7)% in the placebo group. The change in femoral neck aBMD was similar between groups. Radial trabecular number increased, radial trabecular separation decreased, and tibial cortical porosity decreased in the denosumab vs placebo group (P ≤ 0.006). Serum C-terminal telopeptide of type I collagen and procollagen type I N-terminal propeptide decreased in the denosumab vs placebo group (P < 0.0001). Denosumab was well tolerated. Conclusions Twelve months of antiresorptive therapy with denosumab reduced bone turnover and increased spine aBMD, the skeletal site most severely affected in women with anorexia nervosa.
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Affiliation(s)
- Melanie S Haines
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Allison Kimball
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Erinne Meenaghan
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kate Santoso
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Caitlin Colling
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Vibha Singhal
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Pediatric Endocrinology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Seda Ebrahimi
- Cambridge Eating Disorder Center, Cambridge, Massachusetts, USA
| | - Suzanne Gleysteen
- Harvard Medical School, Boston, Massachusetts, USA
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Marcie Schneider
- Greenwich Adolescent & Young Adult Medicine, Greenwich, Connecticut, USA
| | - Lori Ciotti
- The Renfrew Center, Boston, Massachusetts, USA
| | - Perry Belfer
- Harvard Medical School, Boston, Massachusetts, USA
- Newton-Wellesley Eating Disorders & Behavioral Medicine, Brookline, Massachusetts, USA
- McLean Hospital, Belmont, Massachusetts, USA
| | - Kamryn T Eddy
- Harvard Medical School, Boston, Massachusetts, USA
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Madhusmita Misra
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Pediatric Endocrinology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Karen K Miller
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Colling C, Bredella M, Fazeli P, Pachón-Peña G, Singh R, Klibanski A, Rosen C, Miller K. ODP053 Serum Free Cortisol and Free Cortisol-to-Cortisone Ratio Increase After 10 Days of Overfeeding and After 10 Days of Fasting. J Endocr Soc 2022. [PMCID: PMC9625517 DOI: 10.1210/jendso/bvac150.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introduction Chronic caloric deprivation and obesity are complicated by elevations of serum total cortisol levels. The effects of acute overfeeding and fasting on circulating free cortisol levels and interconversion of cortisone to free cortisol are unknown. We hypothesized that serum free cortisol and free cortisol-to-cortisone ratio (a surrogate measure of 11β-hydroxysteroid dehydrogenase [11β-HSD] activity) would increase after both overfeeding and fasting. Methods We prospectively studied 22 healthy volunteers who underwent a 10-day high-calorie protocol followed by a 10-day fast, separated by a 2-week wash-out period, in a Clinical Research Center. Fasting morning free and total cortisol and free cortisone levels (liquid chromatography-tandem mass spectrometry, Mayo Labs) and percent body fat (dual-energy x-ray absorptiometry) were performed at baseline before and after 10 days of each intervention. Results High-calorie feeding increased total and free cortisol and the free cortisol-to-free cortisone ratio (p<0. 001 to p=0. 046). Total and free cortisol, the free cortisol-to-free cortisone ratio, and the free cortisol-to-total cortisol ratio increased after fasting (p=0. 001 to 0. 021). During the high-calorie protocol, there was no significant interaction between sex and time for any of the cortisol parameters. During the fasting visit, the changes in free cortisol and free-to-total cortisol ratio were modified by sex (p=0. 014 and 0. 004, respectively for interaction term), with a trend toward a significant interaction between sex and time in the change in free cortisol-to-free cortisone ratio (p=0. 054). In subset analyses stratified by sex examining the effect of fasting on free cortisol and the free-to-total cortisol ratio, there were significant increases in men (p<0. 001) but not women (p=0.898 and 1. 000, respectively). Baseline percent body fat, measured at the start of the fasting visit, was inversely associated with change in free cortisol (ρ=-0.52, p=0. 013), free cortisol-to-total cortisol ratio (ρ=-0.49, p=0. 021) and free cortisol-to-cortisone ratio (ρ=-0.47, p=0. 029) during fasting. Conclusion Overfeeding and fasting both increase circulating free cortisol levels and appear to alter 11β-HSD activity. The effect of fasting, but not overfeeding, on free cortisol levels is modified by sex. Greater percent fat mass may be relatively protective against starvation-induced hypercortisolemia in women. Further study is warranted to determine whether elevated cortisol levels contribute to complications of starvation and obesity, such as bone fragility. Presentation: No date and time listed
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Dichtel LE, Corey KE, Haines MS, Chicote ML, Kimball A, Colling C, Simon TG, Long MT, Husseini J, Bredella MA, Miller KK. The GH/IGF-1 Axis Is Associated With Intrahepatic Lipid Content and Hepatocellular Damage in Overweight/Obesity. J Clin Endocrinol Metab 2022; 107:e3624-e3632. [PMID: 35779256 PMCID: PMC9387707 DOI: 10.1210/clinem/dgac405] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [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: 02/03/2022] [Indexed: 01/25/2023]
Abstract
CONTEXT Obesity is a state of relative growth hormone (GH) deficiency, and GH has been identified as a candidate disease-modifying target in nonalcoholic fatty liver disease (NAFLD) because of its lipolytic and anti-inflammatory properties. However, the GH/IGF-1 axis has not been well characterized in NAFLD. OBJECTIVE We aimed to investigate serum GH and IGF-1 levels in relation to intrahepatic lipid content (IHL) and markers of hepatocellular damage and fibrosis in NAFLD. METHODS This cross-sectional study included 102 adults (43% women; age 19-67; BMI ≥ 25 kg/m2) without type 2 diabetes. IHL was measured by magnetic resonance spectroscopy; NAFLD was defined by ≥ 5% IHL. Peak-stimulated GH in response to GH releasing hormone and arginine was assessed as was serum IGF-1 (LC/MS). RESULTS There was no difference in mean age, BMI, or sex distribution in NAFLD vs controls. Mean (± SD) IHL was higher in NAFLD vs controls (21.8 ± 13.3% vs 2.9 ± 1.1%, P < 0.0001). Mean peak-stimulated GH was lower in NAFLD vs controls (9.0 ± 6.3 vs 15.4 ± 11.2 ng/mL, P = 0.003), including after controlling for age, sex, visceral adipose tissue, and fasting glucose. In a stepwise model, peak-stimulated GH predicted 14.6% of the variability in IHL (P = 0.004). Higher peak-stimulated GH was also associated with lower ALT. Higher serum IGF-1 levels were associated with lower risk of liver fibrosis by Fibrosis-4 scores. CONCLUSION Individuals with NAFLD have lower peak-stimulated GH levels but similar IGF-1 levels as compared to controls. Higher peak-stimulated GH levels are associated with lower IHL and less hepatocellular damage. Higher IGF-1 levels are associated with more favorable fibrosis risk scores. These data implicate GH and IGF-1 as potential disease modifiers in the development and progression of NAFLD.
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Affiliation(s)
- Laura E Dichtel
- Correspondence: Laura Dichtel, MD, Neuroendocrine Unit, Massachusetts General Hospital, 55 Fruit Street, BUL457, Boston, MA 02114, USA.
| | - Kathleen E Corey
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
| | - Melanie S Haines
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
| | - Mark L Chicote
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Allison Kimball
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
| | - Caitlin Colling
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
| | - Tracey G Simon
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
| | - Michelle T Long
- Section of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Jad Husseini
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, 02114, USA
| | - Miriam A Bredella
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, 02114, USA
| | - Karen K Miller
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
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Kimball A, Colling C, Haines MS, Meenaghan E, Eddy KT, Misra M, Miller KK. Dehydroepiandrosterone sulfate levels predict weight gain in women with anorexia nervosa. Int J Eat Disord 2022; 55:1100-1107. [PMID: 35779065 PMCID: PMC9357210 DOI: 10.1002/eat.23767] [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: 03/15/2022] [Revised: 06/17/2022] [Accepted: 06/18/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Anorexia nervosa (AN) is a serious condition characterized by undernutrition, complicated by endocrine dysregulation, and with few predictors of recovery. Urinary free cortisol (UFC) is a predictor of weight gain, but 24-h urine samples are challenging to collect. We hypothesized that serum dehydroepiandrosterone sulfate (DHEAS), which like cortisol is regulated by adrenocorticotropic hormone (ACTH), would predict weight gain and increases in fat mass in women with AN. METHODS We prospectively studied 34 women with AN and atypical AN, mean age 27.4 ± 7.7 years (mean ± SD), who received placebo in a 6-month randomized trial. Baseline DHEAS and 24-h UFC were measured by liquid chromatography with tandem mass spectrometry. Body composition was assessed at baseline and 6 months by DXA and cross-sectional abdominal CT at L4. RESULTS Mean baseline DHEAS level was 173 ± 70 μg/dl (0.7 ± 0.3 times the mean normal range for age) and mean baseline UFC (n = 15) was 20 ± 18 μg/24 h (normal: 0-50 μg/24 h). Higher DHEAS levels predicted weight gain over 6 months (r = 0.61, p < .001). DHEAS levels also predicted increases in fat mass (r = 0.40, p = .03), appendicular lean mass (r = 0.38, p = .04), and abdominal adipose tissue (r = 0.60, p < .001). All associations remained significant after controlling for age, baseline BMI, OCP use, duration of AN, and SSRI/SNRI use. DHEAS levels correlated with UFC (r = 0.61, p = .02). DISCUSSION In women with AN, higher serum DHEAS predicts weight gain and increases in fat and muscle mass. Additional studies are needed to confirm these findings and further elucidate the association between DHEAS and weight gain. PUBLIC SIGNIFICANCE Anorexia nervosa is a severe psychiatric condition, and predictors of weight recovery are needed to improve prognostication and guide therapeutic decision making. While urinary cortisol is a predictor of weight gain, 24-h urine collections are challenging to obtain. Like cortisol, dehydroepiandrosterone sulfate (DHEAS) is a hormone produced by the adrenal glands. As a readily available blood test, DHEAS holds promise as more practical biomarker of weight gain in anorexia nervosa.
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Affiliation(s)
- Allison Kimball
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Caitlin Colling
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Melanie S. Haines
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Erinne Meenaghan
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Kamryn T. Eddy
- Harvard Medical School, Boston, MA, USA,Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, MA, USA
| | - Madhusmita Misra
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
| | - Karen K. Miller
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, USA,Harvard Medical School, Boston, MA, USA
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Cromer SJ, Colling C, Schatoff D, Leary M, Stamou MI, Selen DJ, Putman MS, Wexler DJ. Newly diagnosed diabetes vs. pre-existing diabetes upon admission for COVID-19: Associated factors, short-term outcomes, and long-term glycemic phenotypes. J Diabetes Complications 2022; 36:108145. [PMID: 35148936 PMCID: PMC8813764 DOI: 10.1016/j.jdiacomp.2022.108145] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/10/2022] [Accepted: 01/30/2022] [Indexed: 01/08/2023]
Abstract
AIMS High rates of newly diagnosed diabetes mellitus (NDDM) have been reported in association with coronavirus disease-2019 (COVID-19). Factors associated with NDDM and long-term glycemic outcomes are not known. METHODS Retrospective review of individuals admitted with COVID-19 and diabetes mellitus (DM; based on labs, diagnoses, outpatient insulin use, or severe inpatient hyperglycemia) between March and September 2020, with follow-up through July 2021. RESULTS Of 1902 individuals admitted with COVID-19, 594 (31.2%) had DM; 77 (13.0%) of these had NDDM. Compared to pre-existing DM, NDDM was more common in younger patients and less common in those of non-Hispanic White race/ethnicity. Glycemic parameters were lower and inflammatory markers higher in patients with NDDM. In adjusted models, NDDM was associated with lower insulin requirements, longer length of stay, and intensive care unit admission but not death. Of 64 survivors with NDDM, 36 (56.3%) continued to have DM, 26 (40.6%) regressed to normoglycemia or pre-diabetes, and 2 were unable to be classified at a median follow-up of 323 days. CONCLUSIONS Diabetes diagnosed at COVID-19 presentation is associated with lower glucose but higher inflammatory markers and ICU admission, suggesting stress hyperglycemia as a major physiologic mechanism. Approximately half of such individuals experience regression of DM.
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Affiliation(s)
- Sara J Cromer
- Division of Endocrinology, Diabetes, and Metabolism, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America.
| | - Caitlin Colling
- Division of Endocrinology, Diabetes, and Metabolism, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Daria Schatoff
- Division of Endocrinology, Diabetes, and Metabolism, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Michael Leary
- Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL, United States of America
| | - Maria I Stamou
- Division of Endocrinology, Diabetes, and Metabolism, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Daryl J Selen
- Division of Endocrinology, Diabetes, and Metabolism, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Melissa S Putman
- Division of Endocrinology, Diabetes, and Metabolism, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America; Division of Endocrinology, Boston Children's Hospital, Boston, MA, United States of America
| | - Deborah J Wexler
- Division of Endocrinology, Diabetes, and Metabolism, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
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12
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Colling C, Rosen CJ. Precision Diagnostics for Type 2 Diabetes Mellitus - Have We Arrived? NEJM Evid 2022; 1:EVIDe2200039. [PMID: 38319223 DOI: 10.1056/evide2200039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Type 2 diabetes mellitus (T2DM) is defined by a common end point: hyperglycemia diagnosed by fasting plasma glucose, plasma glucose during an oral glucose tolerance test, or hemoglobin A1c without autoimmune β-cell destruction.1 Historically, little attention has been paid to the etiologies driving hyperglycemia; as a result, there has been an absence of an elegant pathophysiologically directed diagnostic and therapeutic approach. T2DM has simply been thought to be a result of insulin deficiency and/or peripheral insulin resistance. However, the phenotype of T2DM is heterogeneous, as is the pathophysiology.2,3.
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13
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Colling C, Nachtigall L, Biller BMK, Miller KK. The biochemical diagnosis of adrenal insufficiency with modern cortisol assays: Reappraisal in the setting of opioid exposure and hospitalization. Clin Endocrinol (Oxf) 2022; 96:21-29. [PMID: 34498295 DOI: 10.1111/cen.14587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/19/2021] [Accepted: 08/24/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE We aimed to (1) examine the diagnosis of opioid-induced adrenal insufficiency, and (2) investigate the diagnostic value of a morning cortisol <83 nmol/L (3 µg/dl) for the diagnosis of adrenal insufficiency, using newer more specific cortisol assays and cut-offs. DESIGN Retrospective study (5/2015-10/2020). PARTICIPANTS Cohort 1 (N = 75): adults who underwent cosyntropin stimulation testing and opioid exposure for >30 days. Cohort 2 (N = 854): adults, with or without opioid exposure, who had a morning cortisol level measured the same day as stimulation testing. MEASUREMENTS Peak cortisol during cosyntropin stimulation testing. Sensitivity and specificity of morning serum cortisol for adrenal insufficiency. RESULTS The prevalence of adrenal insufficiency in patients with chronic opioid exposure who underwent cosyntropin stimulation testing was 4.0% using a cortisol cutoff of <405 nmol/L (14.7 µg/dl) versus 19% using the traditional cutoff of <500 nmol/L (18.1 µg/dl). For hospitalized patients with and without opioid-exposure, 14 of 22 (64%) patients with morning cortisol levels of <83 nmol/L (3 µg/dl) passed cosyntropin stimulation testing. A morning cortisol level of <348 nmol/L (12.6 µg/dl) had 100% sensitivity (95% confidence interval: 84.5%-100%) for the diagnosis of adrenal insufficiency. CONCLUSION Applying a cutoff of <405 nmol/L (14.7 µg/dl), opioid-induced adrenal insufficiency is rare. Nearly 1 out of 6 patients would be reclassified as having adrenal insufficiency applying the guideline-recommended cutoff of <500 nmol/L (18.1 µg/dl). Serum morning cortisol <83 nmol/L (3 µg/dl) is not a valid diagnostic test for adrenal insufficiency in hospitalized patients, whether or not receiving opioids.
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Affiliation(s)
- Caitlin Colling
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Lisa Nachtigall
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Beverly M K Biller
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Karen K Miller
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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14
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Colling C, Atlas SJ, Wexler DJ. Application of 2021 American Diabetes Association Glycemic Treatment Clinical Practice Recommendations in Primary Care. Diabetes Care 2021; 44:1443-1446. [PMID: 34016618 PMCID: PMC8247510 DOI: 10.2337/dc21-0013] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/06/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We aimed to identify the proportion of primary care patients meeting criteria for sodium-glucose cotransporter 2 inhibitors (SGLT2is) and glucagon-like peptide 1 receptor agonists (GLP-1 RAs) for cardiorenal comorbidities per 2021 American Diabetes Association (ADA) Standards of Care recommendations using readily available electronic health record (EHR) characteristics. RESEARCH DESIGN AND METHODS We applied 2021 ADA recommendations to a primary care cohort of 13,350 adults with type 2 diabetes (T2D). RESULTS We found that 33% of patients with diabetes would be eligible for an SGLT2i or GLP-1 RA based on cardiorenal comorbidities, 13% of patients met criteria for an SGLT2i based on heart failure or albuminuric chronic kidney disease (CKD), and 18% of patients met criteria for either agent based on atherosclerotic cardiovascular disease or CKD with an albumin-to-creatinine ratio of ≤300 mg/g. CONCLUSIONS This EHR algorithm identified one-third of primary care patients with T2D as meeting criteria for SGLT2i and GLP-1 RA based on strict comorbidity definitions according to 2021 ADA recommendations.
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Affiliation(s)
- Caitlin Colling
- Diabetes Unit, Massachusetts General Hospital, Boston, MA .,Harvard Medical School, Boston, MA
| | - Steven J Atlas
- Harvard Medical School, Boston, MA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA
| | - Deborah J Wexler
- Diabetes Unit, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
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Agarwal A, Garimall S, Colling C, Ahmad NA, Kochman ML, Ginsberg GG, Chandrasekhara V. Incidence and risk factors of advanced neoplasia after endoscopic mucosal resection of colonic laterally spreading lesions. Int J Colorectal Dis 2018; 33:1333-1340. [PMID: 29744577 DOI: 10.1007/s00384-018-3075-x] [Citation(s) in RCA: 4] [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] [Accepted: 05/02/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE To investigate advanced neoplasia (AN) after endoscopic mucosal resection (EMR) of colonic laterally spreading lesions (LSLs). METHODS A retrospective study of patients who underwent injection-assisted EMR of colonic LSLs ≥ 10 mm was performed. Primary outcome was overall rate of AN at initial surveillance colonoscopy. Secondary outcomes were the rates of residual AN (rAN) at the EMR site and metachronous AN (mAN), and analysis of risk factors for AN, including effect of surveillance guidance. RESULTS Three hundred seventy-four patients underwent successful EMR for 388 LSLs. AN occurred in 66/374 (17.6%) patients on initial surveillance colonoscopy at median follow-up of 364.5 days. Two patients had both rAN and mAN, for a total of 68 instances of AN, including 30/374 (8.0%) cases of rAN and 38/374 (10.2%) cases of mAN. On multivariate analysis, use of piecemeal resection was associated with increased likelihood of residual AN (P = 0.003, OR 9.2, 95% CI 2.1-33.3). Twenty-nine out of thirty cases (96.7%) of rAN were successfully endoscopically managed at surveillance colonoscopy. CONCLUSIONS AN occurred in 17.6% of all patients at initial surveillance colonoscopy at a median of 1 year after EMR. Roughly half of the instances of AN were metachronous lesions. Our data support a 1-year surveillance interval after EMR of LSLs ≥ 10 mm with careful inspection of the entire colon, not just the prior resection site.
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Affiliation(s)
- Amol Agarwal
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sidyarth Garimall
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Caitlin Colling
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Nuzhat A Ahmad
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael L Kochman
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Gregory G Ginsberg
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Vinay Chandrasekhara
- Division of Gastroenterology, Mayo School of Medicine, 200 First St. SW, Rochester, MN, 55905, USA.
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Colling C, Holthoff-Detto V, Falkai P, Musil R. NADA-Auriculoacupuncture as a Symptomatic Treatment for Agitation in People with Dementia: A Randomized, Controlled, Rater-Blind Pilot Study. J Acupunct Meridian Stud 2018. [DOI: 10.1016/j.jams.2018.08.164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Eisenhardt A, Schneider T, Scheithe K, Colling C, Heidenreich A. [Quality of life of patients with prostate cancer under androgen deprivation with GnRH analogues: Results of the noninterventional study TRIPTOSIX]. Urologe A 2016; 55:176-83. [PMID: 26518305 DOI: 10.1007/s00120-015-3989-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND In Germany, data on the quality of life (QoL) of patients with advanced prostate cancer (PCa) under therapy with gonadotropin-releasing hormone (GnRH) analogues are limited. OBJECTIVES Androgen deprivation (ADT) is a palliative therapy for patients with advanced PCa, which is given over long periods and usually continued in combination with other therapies even after progression of the disease. The present study aimed to assess prospectively (over 1 year) different aspects of patients' QoL therapy with triptorelin in daily practice. PATIENTS AND METHODS This prospective, noninterventional study at 129 centers in Germany included 608 patients with advanced PCa treated with triptorelin. Quality of life was assessed at baseline and after 6 and 12 months, using validated EORTC QLQ-C30 and QLQ-PR25 questionnaires. Predefined subgroup analyses were performed to assess the impact of demographics, anamnestic and clinical parameters on QoL. RESULTS AND DISCUSSION The majority of patients with PCa under therapy with triptorelin showed generally stable global QoL over 1 year; approximately one-quarters of the patients had a clinically relevant improvement of their global QoL. In patients without previous PCa therapy and GnRH analogue treatment, significant improvements in global QoL were seen. At the same time, these patients also reported increased treatment-related symptoms. These data indicate that the perception of global QoL is not only influenced by subjective impairment through ADT-related side effects.
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Affiliation(s)
- A Eisenhardt
- Praxisklinik Urologie Rhein Ruhr, Schulstraße 11, 45468, Mülheim an der Ruhr, Deutschland.
| | - T Schneider
- Praxisklinik Urologie Rhein Ruhr, Schulstraße 11, 45468, Mülheim an der Ruhr, Deutschland
| | - K Scheithe
- GKM Gesellschaft für Therapieforschung, München, Deutschland
| | - C Colling
- Ipsen Pharma GmbH, Ettlingen, Deutschland
| | - A Heidenreich
- Klinik für Urologie, Universitätsklinikum Aachen, Aachen, Deutschland
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Hurley SL, Colling C, Bender L, Harris PS, Harrold JK, Teno JM, Ache KA, Casarett D. Increasing inpatient hospice use versus patient preferences in the USA: are patients able to die in the setting of their choice? BMJ Support Palliat Care 2014; 7:46-52. [PMID: 25394918 DOI: 10.1136/bmjspcare-2013-000599] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 09/24/2014] [Accepted: 10/27/2014] [Indexed: 11/03/2022]
Abstract
BACKGROUND Growth in hospice utilisation has been accompanied by an increase in the proportion of hospice patients who die in an inpatient hospice setting rather than at home. OBJECTIVE To determine whether this increase in inpatient utilisation is consistent with patient preferences. DESIGN Retrospective cohort study. SETTING Seven hospices in the Coalition of Hospices Organised to Investigate Comparative Effectiveness (CHOICE) network. PATIENTS 70 488 patients admitted between 1 July 2008 and 31 May 2012. MEASUREMENTS We measured changes in patients' stated preferences at the time of admission regarding site of death, including weights to adjust for non-response bias. We also assessed patients' actual site of death and concordance with patients' preferences. RESULTS More patients died receiving inpatient care in 2012 as compared to 2008 (1920 (32.7%), 2537 (18.5%); OR 1.21; 95% CI 1.19 to 1.22; p<0.001). However, patients also expressed an increasing preference for dying in inpatient settings (weighted preferences 27.5% in 2012 vs 7.9% in 2008; p<0.001). The overall proportion of patients who died in the setting of their choice (weighted preferences) increased from 74% in 2008 to 78% in 2012 (p<0.001). LIMITATIONS This study included only seven hospices, and results may not be representative of the larger hospice population. CONCLUSIONS Although more patients are dying while receiving inpatient care, these changes in site of death seem to reflect changing patient preferences. The net effect is that patients in this sample were more likely to die in the setting of their choice in 2012 than they were in 2008.
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Affiliation(s)
| | - Caitlin Colling
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Laura Bender
- Penn Home Care & Hospice Services, Penn Medicine, Bala Cynwyd, Pennsylvania, USA
| | - Pamela S Harris
- Kansas City Hospice and Palliative Care, Kansas City, Missouri, USA
| | | | - Joan M Teno
- Brown University School of Public Health, Providence, Rhode Island, USA
| | | | - David Casarett
- Division of Geriatric Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Treiman DM, Meyers PD, Walton NY, Collins JF, Colling C, Rowan AJ, Handforth A, Faught E, Calabrese VP, Uthman BM, Ramsay RE, Mamdani MB. A comparison of four treatments for generalized convulsive status epilepticus. Veterans Affairs Status Epilepticus Cooperative Study Group. N Engl J Med 1998; 339:792-8. [PMID: 9738086 DOI: 10.1056/nejm199809173391202] [Citation(s) in RCA: 805] [Impact Index Per Article: 31.0] [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: 11/19/2022]
Abstract
BACKGROUND AND METHODS Although generalized convulsive status epilepticus is a life-threatening emergency, the best initial drug treatment is uncertain. We conducted a five-year randomized, double-blind, multicenter trial of four intravenous regimens: diazepam (0.15 mg per kilogram of body weight) followed by phenytoin (18 mg per kilogram), lorazepam (0.1 mg per kilogram), phenobarbital (15 mg per kilogram), and phenytoin (18 mg per kilogram). Patients were classified as having either overt generalized status epilepticus (defined as easily visible generalized convulsions) or subtle status epilepticus (indicated by coma and ictal discharges on the electroencephalogram, with or without subtle convulsive movements such as rhythmic muscle twitches or tonic eye deviation). Treatment was considered successful when all motor and electroencephalographic seizure activity ceased within 20 minutes after the beginning of the drug infusion and there was no return of seizure activity during the next 40 minutes. Analyses were performed with data on only the 518 patients with verified generalized convulsive status epilepticus as well as with data on all 570 patients who were enrolled. RESULTS Three hundred eighty-four patients had a verified diagnosis of overt generalized convulsive status epilepticus. In this group, lorazepam was successful in 64.9 percent of those assigned to receive it, phenobarbital in 58.2 percent, diazepam plus phenytoin in 55.8 percent, and phenytoin in 43.6 percent (P=0.02 for the overall comparison among the four groups). Lorazepam was significantly superior to phenytoin in a pairwise comparison (P=0.002). Among the 134 patients with a verified diagnosis of subtle generalized convulsive status epilepticus, no significant differences among the treatments were detected (range of success rates, 7.7 to 24.2 percent). In an intention-to-treat analysis, the differences among treatment groups were not significant, either among the patients with overt status epilepticus (P=0.12) or among those with subtle status epilepticus (P=0.91). There were no differences among the treatments with respect to recurrence during the 12-hour study period, the incidence of adverse reactions, or the outcome at 30 days. CONCLUSIONS As initial intravenous treatment for overt generalized convulsive status epilepticus, lorazepam is more effective than phenytoin. Although lorazepam is no more efficacious than phenobarbital or diazepam plus phenytoin, it is easier to use.
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Affiliation(s)
- D M Treiman
- Neurology Services of the Veterans Affairs Medical Center in West Los Angeles, Calif, USA
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Jabs T, Tschope M, Colling C, Hahlbrock K, Scheel D. Elicitor-stimulated ion fluxes and O2- from the oxidative burst are essential components in triggering defense gene activation and phytoalexin synthesis in parsley. Proc Natl Acad Sci U S A 1997; 94:4800-5. [PMID: 9114072 PMCID: PMC20805 DOI: 10.1073/pnas.94.9.4800] [Citation(s) in RCA: 340] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Fungal elicitor stimulates a multicomponent defense response in cultured parsley cells (Petroselinum crispum). Early elements of this receptor-mediated response are ion fluxes across the plasma membrane and the production of reactive oxygen species (ROS), sequentially followed by defense gene activation and phytoalexin accumulation. Omission of Ca2+ from the culture medium or inhibition of elicitor-stimulated ion fluxes by ion channel blockers prevented the latter three reactions, all of which were triggered in the absence of elicitor by amphotericin B-induced ion fluxes. Inhibition of elicitor-stimulated ROS production using diphenylene iodonium blocked defense gene activation and phytoalexin accumulation. O2- but not H2O2 stimulated phytoalexin accumulation, without inducing proton fluxes. These results demonstrate a causal relationship between early and late reactions of parsley cells to the elicitor and indicate a sequence of signaling events from receptor-mediated activation of ion channels via ROS production and defense gene activation to phytoalexin synthesis. Within this sequence, O2- rather than H2O2 appears to trigger the subsequent reactions.
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Affiliation(s)
- T Jabs
- Max-Planck-Institut fur Zuchtungsforschung, Abteilung Biochemie, Carl-von-Linne-Weg 10, D-50829 Cologne, Germany
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Singh SN, Fletcher RD, Fisher SG, Singh BN, Lewis HD, Deedwania PC, Massie BM, Colling C, Lazzeri D. Amiodarone in patients with congestive heart failure and asymptomatic ventricular arrhythmia. Survival Trial of Antiarrhythmic Therapy in Congestive Heart Failure. N Engl J Med 1995; 333:77-82. [PMID: 7539890 DOI: 10.1056/nejm199507133330201] [Citation(s) in RCA: 916] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Asymptomatic ventricular arrhythmias in patients with congestive heart failure are associated with increased rates of overall mortality and sudden death. Amiodarone is now used widely to prevent ventricular tachycardia and fibrillation. We conducted a trial to determine whether amiodarone can reduce overall mortality in patients with congestive heart failure and asymptomatic ventricular arrhythmias. METHODS We used a double-blind, placebo-controlled protocol in which 674 patients with symptoms of congestive heart failure, cardiac enlargement, 10 or more premature ventricular contractions per hour, and a left ventricular ejection fraction of 40 percent or less were randomly assigned to receive amiodarone (336 patients) or placebo (338 patients). The primary end point was overall mortality, and the median follow-up was 45 months (range, 0 to 54). RESULTS There was no significant difference in overall mortality between the two treatment groups (P = 0.6). The two-year actuarial survival rate was 69.4 percent (95 percent confidence interval, 64.2 to 74.6) for the patients in the amiodarone group and 70.8 percent (95 percent confidence interval, 65.7 to 75.9) for those in the placebo group. At two years, the rate of sudden death was 15 percent in the amiodarone group and 19 percent in the placebo group (P = 0.43). There was a trend toward a reduction in overall mortality among the patients with nonischemic cardiomyopathy who received amiodarone (P = 0.07). Amiodarone was significantly more effective in suppressing ventricular arrhythmias and increased the left ventricular ejection fraction by 42 percent at two years. CONCLUSIONS Although amiodarone was effective in suppressing ventricular arrhythmias and improving ventricular function, it did not reduce the incidence of sudden death or prolong survival among patients with heart failure, except for a trend toward reduced mortality among those with nonischemic cardiomyopathy.
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Affiliation(s)
- S N Singh
- Department of Cardiology, Veterans Affairs Medical Center, Washington, D.C. 20422, USA
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Singh SN, Fletcher RD, Fisher S, Lazzeri D, Deedwania P, Lewis D, Massie B, Singh BN, Colling C. Veterans Affairs congestive heart failure antiarrhythmic trial. CHF STAT Investigators. Am J Cardiol 1993; 72:99F-102F. [PMID: 8237838 DOI: 10.1016/0002-9149(93)90971-e] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
This is a prospective, double-blind, placebo-controlled trial to determine the effect of antiarrhythmic drug therapy on mortality in patients with congestive heart failure and ventricular arrhythmia. Patients will be assigned to receive either amiodarone or placebo. Eligible patients include those with ischemic and nonischemic congestive heart failure and with > or = 10 ventricular premature beats per hour. All patients must have shortness of breath with minimal exertion or paroxysmal nocturnal dyspnea, a left ventricular internal dimension (LVIDd) by echocardiogram of > or = 55 mm or a cardiothoracic ratio of > 0.5 and an ejection fraction of < or = 40%. All patients will receive vasodilator therapy, unless they find it intolerable. Patients will be entered into the study for 2.5 years and followed for an additional 2 years. Drug therapy will be continued for all patients throughout the entire study unless adverse reactions occur that necessitate individualized treatment. The expectation is that 674 patients will be entered into the study from 25 participating centers. This sample size will allow for the detection of a 33% decrease in 2-year mortality (20% vs 30%) in the treated patients compared with those in the placebo group, with a power of 0.90 and a 2-sided alpha level of 0.05. Intermittent Holter monitoring, radionuclide ventriculograms, pulmonary function tests, echocardiograms, and blood tests, including arterial blood gases, will be required for each patient.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- S N Singh
- Cardiovascular Research, Veterans Affairs Medical Center, Washington, DC 20422
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Nass N, Colling C, Cramer M, Genieser HG, Butt E, Winkler E, Jaenicke L, Jastorff B. Mapping of the epitope/paratope interactions of a monoclonal antibody directed against adenosine 3',5'-monophosphate. Biochem J 1992; 285 ( Pt 1):129-36. [PMID: 1379038 PMCID: PMC1132755 DOI: 10.1042/bj2850129] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
A series of systematically modified cyclic AMP (cAMP) analogues, including newly synthesized benzimidazole ribofuranosyl 3',5'-monophosphates was used to map the essential molecular interactions between cAMP and the monoclonal antibody 4/2C2 (mab 4/2C2) directed against 2'-O-succinoyl cAMP [Colling, Gilles, Nass, Moka & Jaenicke (1988) Second Messengers Phosphoproteins 12, 123-133]. Its paratope binds the purine base in syn conformation by dipole-dipole interactions and hydrophobic forces and/or stacking interactions. The ribose phosphate moiety is recognized by a combination of charge interactions and H-bonds to the exocyclic and the 5'-oxygen atoms and a hydrophobic interaction at the 2'-position. There is no regioselectivity for the exocyclic oxygen atoms. Compared with the known types of binding, mab 4/2C2 thus shows a new combination of molecular interactions which may be the basis of its strikingly specific recognition and binding of the cyclic adenylates. On this account mab 4/2C2 may become an important tool in studies on cAMP metabolism.
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Affiliation(s)
- N Nass
- Institute of Biochemistry, University of Cologne, Köln, Federal Republic of Germany
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Mayberg MR, Wilson SE, Yatsu F, Weiss DG, Messina L, Hershey LA, Colling C, Eskridge J, Deykin D, Winn HR. Carotid endarterectomy and prevention of cerebral ischemia in symptomatic carotid stenosis. Veterans Affairs Cooperative Studies Program 309 Trialist Group. JAMA 1991. [PMID: 1960828 DOI: 10.1001/jama.1991.03470230047029] [Citation(s) in RCA: 490] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To determine whether carotid endarterectomy provides protection against subsequent cerebral ischemia in men with ischemic symptoms in the distribution of significant (greater than 50%) ipsilateral internal carotid artery stenosis. DESIGN Prospective, randomized, multicenter trial. SETTING Sixteen university-affiliated Veterans Affairs medical centers. PATIENTS Men who presented within 120 days of onset of symptoms that were consistent with transient ischemic attacks, transient monocular blindness, or recent small completed strokes between July 1988 and February 1991. Among 5000 patients screened, 189 individuals were randomized with angiographic internal carotid artery stenosis greater than 50% ipsilateral to the presenting symptoms. Forty-eight eligible patients who refused entry were followed up outside of the trial. OUTCOME MEASURES Cerebral infarction or crescendo transient ischemic attacks in the vascular distribution of the original symptoms or death within 30 days of randomization. INTERVENTION Carotid endarterectomy plus the best medical care (n = 91) vs the best medical care alone (n = 98). RESULTS At a mean follow-up of 11.9 months, there was a significant reduction in stroke or crescendo transient ischemic attacks in patients who received carotid endarterectomy (7.7%) compared with nonsurgical patients (19.4%), or an absolute risk reduction of 11.7% (P = .011). The benefit of surgery was more profound in patients with internal carotid artery stenosis greater than 70% (absolute risk reduction, 17.7%; P = .004). The benefit of surgery was apparent within 2 months after randomization, and only one stroke was noted in the surgical group beyond the 30-day perioperative period. CONCLUSIONS For a selected cohort of men with symptoms of cerebral or retinal ischemia in the distribution of a high-grade internal carotid artery stenosis, carotid endarterectomy can effectively reduce the risk of subsequent ipsilateral cerebral ischemia. The risk of cerebral ischemia in this subgroup of patients is considerably higher than previously estimated.
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Affiliation(s)
- M R Mayberg
- Department of Neurological Surgery, University of Washington, Seattle 98195
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