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Wannhoff A, Küllmer A, Albers D, Fähndrich M, Ganten T, Wettstein M, Meier B, Schumacher B, Schmidt A, Caca K. Prospective randomized controlled trial comparing a novel and dedicated device with conventional endoscopic techniques for the treatment of buried bumper syndrome (with video). Gastrointest Endosc 2024; 99:23-30.e1. [PMID: 37543062 DOI: 10.1016/j.gie.2023.07.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/27/2023] [Accepted: 07/28/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND AND AIMS Buried bumper syndrome (BBS) is a rare adverse event of PEG tubes. This study compared the newly developed Flamingo device (Fujifilm Medwork GmbH, Höchstadt, Germany) with conventional endoscopic techniques for BBS treatment. METHODS This prospective, randomized controlled trial compared the Flamingo set (study group) with other endoscopic techniques (control group) for BBS treatment in 6 German hospitals. The primary endpoint was procedure time. Further outcome parameters were technical success, adverse event rate, and number and cost of devices used in each group. RESULTS Thirty-six patients (18 in each group; mean age, 73 years; 12 women) were included in this study between March 2018 and December 2022. Median time since placement of the feeding tube was 30 months. The bumper was located in the gastric corpus in 27 patients, and the internal bumper was completely overgrown in 31 patients. The duration of the removal procedure was 17 minutes (range, 3-72) in the study group compared with 38 minutes (range, 12-111) in the control group (P = .046). The primary technical success rate was 77.8% in the study group and 55.6% in the control group (P = .157), whereas the overall technical success rate was 100% compared with 83.3% (P = .070). Adverse events occurred in 4 patients (11.1%). CONCLUSIONS Endoscopic removal of the buried bumper using the Flamingo device was significantly faster than that with other endoscopic techniques and showed a higher technical success rate. This device may become the endoscopic treatment of choice for BBS. (Clinical trial registration number: NCT03186066.).
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Affiliation(s)
- Andreas Wannhoff
- Department of Internal Medicine and Gastroenterology, Hospital Ludwigsburg, Ludwigsburg, Germany
| | - Armin Küllmer
- Department of Medicine II, Medical Center-University of Freiburg, Freiburg, Germany
| | - David Albers
- Department of Gastroenterology, Elisabeth Krankenhaus Essen, Essen, Germany
| | - Martin Fähndrich
- Department of Internal Medicine and Gastroenterology, Hospital Dortmund, Dortmund, Germany
| | - Tom Ganten
- Internal Medicine I and Gastroenterology, Fürst-Stirum Hospital Bruchsal, Bruchsal, Germany
| | | | - Benjamin Meier
- Department of Internal Medicine and Gastroenterology, Hospital Ludwigsburg, Ludwigsburg, Germany
| | | | - Arthur Schmidt
- Department of Medicine II, Medical Center-University of Freiburg, Freiburg, Germany
| | - Karel Caca
- Department of Internal Medicine and Gastroenterology, Hospital Ludwigsburg, Ludwigsburg, Germany
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Keyl J, Bucher A, Jungmann F, Hosch R, Ziller A, Armbruster R, Malkomes P, Reissig TM, Koitka S, Tzianopoulos I, Keyl P, Kostbade K, Albers D, Markus P, Treckmann J, Nassenstein K, Haubold J, Makowski M, Forsting M, Baba HA, Kasper S, Siveke JT, Nensa F, Schuler M, Kaissis G, Kleesiek J, Braren R. Prognostic value of deep learning-derived body composition in advanced pancreatic cancer-a retrospective multicenter study. ESMO Open 2024; 9:102219. [PMID: 38194881 PMCID: PMC10837775 DOI: 10.1016/j.esmoop.2023.102219] [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] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Despite the prognostic relevance of cachexia in pancreatic cancer, individual body composition has not been routinely integrated into treatment planning. In this multicenter study, we investigated the prognostic value of sarcopenia and myosteatosis automatically extracted from routine computed tomography (CT) scans of patients with advanced pancreatic ductal adenocarcinoma (PDAC). PATIENTS AND METHODS We retrospectively analyzed clinical imaging data of 601 patients from three German cancer centers. We applied a deep learning approach to assess sarcopenia by the abdominal muscle-to-bone ratio (MBR) and myosteatosis by the ratio of abdominal inter- and intramuscular fat to muscle volume. In the pooled cohort, univariable and multivariable analyses were carried out to analyze the association between body composition markers and overall survival (OS). We analyzed the relationship between body composition markers and laboratory values during the first year of therapy in a subgroup using linear regression analysis adjusted for age, sex, and American Joint Committee on Cancer (AJCC) stage. RESULTS Deep learning-derived MBR [hazard ratio (HR) 0.60, 95% confidence interval (CI) 0.47-0.77, P < 0.005] and myosteatosis (HR 3.73, 95% CI 1.66-8.39, P < 0.005) were significantly associated with OS in univariable analysis. In multivariable analysis, MBR (P = 0.019) and myosteatosis (P = 0.02) were associated with OS independent of age, sex, and AJCC stage. In a subgroup, MBR and myosteatosis were associated with albumin and C-reactive protein levels after initiation of therapy. Additionally, MBR was also associated with hemoglobin and total protein levels. CONCLUSIONS Our work demonstrates that deep learning can be applied across cancer centers to automatically assess sarcopenia and myosteatosis from routine CT scans. We highlight the prognostic role of our proposed markers and show a strong relationship with protein levels, inflammation, and anemia. In clinical practice, automated body composition analysis holds the potential to further personalize cancer treatment.
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Affiliation(s)
- J Keyl
- Institute for Artificial Intelligence in Medicine, University Hospital Essen (AöR), Essen, Germany; Institute of Pathology, University Hospital Essen (AöR), Essen, Germany.
| | - A Bucher
- Institute for Diagnostic and Interventional Radiology, Goethe University Frankfurt, Frankfurt am Main, Germany; German Cancer Consortium (DKTK), Frankfurt partner site, Heidelberg, Germany
| | - F Jungmann
- Institute of Diagnostic and Interventional Radiology, Technical University of Munich, School of Medicine, Munich, Germany; Artificial Intelligence in Healthcare and Medicine, School of Computation, Information and Technology, Technical University of Munich, Munich, Germany
| | - R Hosch
- Institute for Artificial Intelligence in Medicine, University Hospital Essen (AöR), Essen, Germany
| | - A Ziller
- Institute of Diagnostic and Interventional Radiology, Technical University of Munich, School of Medicine, Munich, Germany; Artificial Intelligence in Healthcare and Medicine, School of Computation, Information and Technology, Technical University of Munich, Munich, Germany
| | - R Armbruster
- Institute for Diagnostic and Interventional Radiology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - P Malkomes
- Department of General, Visceral and Transplant Surgery, Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - T M Reissig
- Department of Medical Oncology, University Hospital Essen (AöR), Essen, Germany; West German Cancer Center, University Hospital Essen (AöR), Essen, Germany; German Cancer Consortium (DKTK), Partner site University Hospital Essen (AöR), Essen, Germany; Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany; Division of Solid Tumor Translational Oncology, German Cancer Consortium (DKTK Partner Site Essen) and German Cancer Research Center, DKFZ, Heidelberg, Germany
| | - S Koitka
- Institute for Artificial Intelligence in Medicine, University Hospital Essen (AöR), Essen, Germany; Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen (AöR), Essen, Germany
| | - I Tzianopoulos
- Department of Medical Oncology, University Hospital Essen (AöR), Essen, Germany; West German Cancer Center, University Hospital Essen (AöR), Essen, Germany; Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany; Division of Solid Tumor Translational Oncology, German Cancer Consortium (DKTK Partner Site Essen) and German Cancer Research Center, DKFZ, Heidelberg, Germany
| | - P Keyl
- Institute of Pathology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - K Kostbade
- Department of Medical Oncology, University Hospital Essen (AöR), Essen, Germany; West German Cancer Center, University Hospital Essen (AöR), Essen, Germany; Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - D Albers
- Department of Gastroenterology, Elisabeth Hospital Essen, Essen, Germany
| | - P Markus
- Department of General Surgery and Traumatology, Elisabeth Hospital Essen, Essen, Germany
| | - J Treckmann
- West German Cancer Center, University Hospital Essen (AöR), Essen, Germany; Medical Faculty, University of Duisburg-Essen, Essen, Germany; Department of General, Visceral and Transplant Surgery, University Hospital Essen, Essen, Germany
| | - K Nassenstein
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen (AöR), Essen, Germany; Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - J Haubold
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen (AöR), Essen, Germany; Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - M Makowski
- Institute of Diagnostic and Interventional Radiology, Technical University of Munich, School of Medicine, Munich, Germany
| | - M Forsting
- German Cancer Consortium (DKTK), Partner site University Hospital Essen (AöR), Essen, Germany; Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen (AöR), Essen, Germany; Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - H A Baba
- Institute of Pathology, University Hospital Essen (AöR), Essen, Germany; Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - S Kasper
- Department of Medical Oncology, University Hospital Essen (AöR), Essen, Germany; West German Cancer Center, University Hospital Essen (AöR), Essen, Germany; German Cancer Consortium (DKTK), Partner site University Hospital Essen (AöR), Essen, Germany; Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - J T Siveke
- Department of Medical Oncology, University Hospital Essen (AöR), Essen, Germany; West German Cancer Center, University Hospital Essen (AöR), Essen, Germany; German Cancer Consortium (DKTK), Partner site University Hospital Essen (AöR), Essen, Germany; Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany; Division of Solid Tumor Translational Oncology, German Cancer Consortium (DKTK Partner Site Essen) and German Cancer Research Center, DKFZ, Heidelberg, Germany; Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - F Nensa
- Institute for Artificial Intelligence in Medicine, University Hospital Essen (AöR), Essen, Germany; German Cancer Consortium (DKTK), Partner site University Hospital Essen (AöR), Essen, Germany; Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen (AöR), Essen, Germany; Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - M Schuler
- Department of Medical Oncology, University Hospital Essen (AöR), Essen, Germany; West German Cancer Center, University Hospital Essen (AöR), Essen, Germany; Medical Faculty, University of Duisburg-Essen, Essen, Germany; National Center for Tumor Diseases (NCT), NCT West, Essen, Germany
| | - G Kaissis
- Institute of Diagnostic and Interventional Radiology, Technical University of Munich, School of Medicine, Munich, Germany; Artificial Intelligence in Healthcare and Medicine, School of Computation, Information and Technology, Technical University of Munich, Munich, Germany
| | - J Kleesiek
- Institute for Artificial Intelligence in Medicine, University Hospital Essen (AöR), Essen, Germany; West German Cancer Center, University Hospital Essen (AöR), Essen, Germany; German Cancer Consortium (DKTK), Partner site University Hospital Essen (AöR), Essen, Germany; Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - R Braren
- Institute of Diagnostic and Interventional Radiology, Technical University of Munich, School of Medicine, Munich, Germany; German Cancer Consortium (DKTK), Munich partner site, Heidelberg, Germany
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Zurloh M, Goetz M, Herold T, Treckmann J, Markus P, Schumacher B, Albers D, Rink A, Rosery V, Zaun G, Kostbade K, Pogorzelski M, Ting S, Schmidt H, Stiens R, Wiesweg M, Schuler M, Kasper S, Virchow I. Impact of encorafenib on survival of patients with BRAF V600E-mutant metastatic colorectal cancer in a real-world setting. J Cancer Res Clin Oncol 2023; 149:12903-12912. [PMID: 37466791 PMCID: PMC10587317 DOI: 10.1007/s00432-023-05141-y] [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] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 07/20/2023]
Abstract
PURPOSE Patients with BRAFV600E-mutant metastatic colorectal cancer (mCRC) have a dismal prognosis. The best strategies in these patients remain elusive. Against this background, we report the clinical course of patients with BRAFV600E-mutant mCRC to retrieve the best treatment strategy. PATIENTS AND METHODS Clinico-pathological data were extracted from the electronic health records. Kaplan-Meier method was used to estimate overall (OS) and progression-free survival (PFS). Objective response rate (ORR) was assessed according to RECIST 1.1. RESULTS In total, 51 patients were enrolled. FOLFOXIRI was administered to 12 patients; 29 patients received FOLFOX or FOLFIRI as first-line treatment. Median OS was 17.6 months. Median PFS with FOLFOXIRI (13.0 months) was significantly prolonged (HR 0.325) as compared to FOLFOX/FOLFIRI (4.3 months). However, this failed to translate into an OS benefit (p = 0.433). Interestingly, addition of a monoclonal antibody to chemotherapy associated with superior OS (HR 0.523). A total of 64.7% patients received further-line therapy, which included a BRAF inhibitor in 17 patients. Targeted therapy associated with very favourable OS (25.1 months). CONCLUSION Patients with BRAFV600E-mutated mCRC benefit from the addition of an antibody to first-line chemotherapy. Further-line treatment including a BRAF inhibitor has a dramatic impact on survival.
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Affiliation(s)
- M Zurloh
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - M Goetz
- West German Cancer Center, Institute of Pathology Essen, University Hospital Essen, Essen, Germany
| | - T Herold
- West German Cancer Center, Institute of Pathology Essen, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - J Treckmann
- West German Cancer Center, Department of General, Visceral and Transplant Surgery, University Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - P Markus
- Department of General Surgery and Traumatology, Elisabeth Hospital, Essen, Germany
| | - B Schumacher
- Department of Gastroenterology, Elisabeth Hospital, Essen, Germany
| | - D Albers
- Department of Gastroenterology, Elisabeth Hospital, Essen, Germany
| | - A Rink
- West German Cancer Center, Department of General, Visceral and Transplant Surgery, University Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - V Rosery
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - G Zaun
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - K Kostbade
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - M Pogorzelski
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - S Ting
- West German Cancer Center, Institute of Pathology Essen, University Hospital Essen, Essen, Germany
- Institute of Pathology Nordhessen, Kassel, Germany
| | - H Schmidt
- Department of Gastroenterology, Hepatology and Transplant Medicine, University Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - R Stiens
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - M Wiesweg
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
- German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - M Schuler
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
- German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - Stefan Kasper
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany.
- German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany.
- Medical Faculty, University Duisburg-Essen, Essen, Germany.
| | - I Virchow
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
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4
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Albers D, Sirlanci M, Levine M, Claassen J, Nigoghossian CD, Hripcsak G. Interpretable physiological forecasting in the ICU using constrained data assimilation and electronic health record data. J Biomed Inform 2023; 145:104477. [PMID: 37604272 DOI: 10.1016/j.jbi.2023.104477] [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: 01/24/2023] [Revised: 08/08/2023] [Accepted: 08/18/2023] [Indexed: 08/23/2023]
Abstract
OBJECTIVE Prediction of physiological mechanics are important in medical practice because interventions are guided by predicted impacts of interventions. But prediction is difficult in medicine because medicine is complex and difficult to understand from data alone, and the data are sparse relative to the complexity of the generating processes. Computational methods can increase prediction accuracy, but prediction with clinical data is difficult because the data are sparse, noisy and nonstationary. This paper focuses on predicting physiological processes given sparse, non-stationary, electronic health record data in the intensive care unit using data assimilation (DA), a broad collection of methods that pair mechanistic models with inference methods. METHODS A methodological pipeline embedding a glucose-insulin model into a new DA framework, the constrained ensemble Kalman filter (CEnKF) to forecast blood glucose was developed. The data include tube-fed patients whose nutrition, blood glucose, administered insulins and medications were extracted by hand due to their complexity and to ensure accuracy. The model was estimated using an individual's data as if they arrived in real-time, and the estimated model was run forward producing a forecast. Both constrained and unconstrained ensemble Kalman filters were estimated to compare the impact of constraints. Constraint boundaries, model parameter sets estimated, and data used to estimate the models were varied to investigate their influence on forecasting accuracy. Forecasting accuracy was evaluated according to mean squared error between the model-forecasted glucose and the measurements and by comparing distributions of measured glucose and forecast ensemble means. RESULTS The novel CEnKF produced substantial gains in robustness and accuracy while minimizing the data requirements compared to the unconstrained ensemble Kalman filters. Administered insulin and tube-nutrition were important for accurate forecasting, but including glucose in IV medication delivery did not increase forecast accuracy. Model flexibility, controlled by constraint boundaries and estimated parameters, did influence forecasting accuracy. CONCLUSION Accurate and robust physiological forecasting with sparse clinical data is possible with DA. Introducing constrained inference, particularly on unmeasured states and parameters, reduced forecast error and data requirements. The results are not particularly sensitive to model flexibility such as constraint boundaries, but over or under constraining increased forecasting errors.
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Affiliation(s)
- David Albers
- Department of Biomedical Informatics, University of Colorado Anschutz Medical Campus, Aurora, 80045, CO, USA; Department of Biomedical Engineering, University of Colorado Anschutz Medical Campus, Aurora, 80045, CO, USA; Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, 80045, CO, USA; Department of Biomedical Informatics, Columbia University, New York, 10032, NY, USA.
| | - Melike Sirlanci
- Department of Biomedical Informatics, University of Colorado Anschutz Medical Campus, Aurora, 80045, CO, USA
| | - Matthew Levine
- Department of Computing and Mathematical Sciences, California Institute of Technology, Pasadena, 91125, CA, USA
| | - Jan Claassen
- Division of Critical Care Neurology, Department of Neurology, Columbia University, New York, 10032, NY, USA
| | | | - George Hripcsak
- Department of Biomedical Informatics, Columbia University, New York, 10032, NY, USA
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5
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Vu Trung K, Abou-Ali E, Caillol F, Paik WH, Napoleon B, Masaryk V, van der Wiel SE, Pérez-Cuadrado-Robles E, Musquer N, Halimi A, Soares K, Souche FR, Seyfried S, Petrone MC, Crippa S, Kleemann T, Albers D, Weismüller TJ, Dugic A, Meier B, Wedi E, Schiemer M, Regner S, Gaujoux S, Hollenbach M. Endoscopic papillectomy for ampullary lesions in patients with familial adenomatous polyposis compared with sporadic lesions: a propensity score-matched cohort. Endoscopy 2023; 55:709-718. [PMID: 36746390 DOI: 10.1055/a-2029-2935] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Familial adenomatous polyposis (FAP) is a rare inherited syndrome that predisposes the patient to cancer. Treatment of FAP-related ampullary lesions is challenging and the role of endoscopic papillectomy has not been elucidated. We retrospectively analyzed the outcomes of endoscopic papillectomy in matched cohorts of FAP-related and sporadic ampullary lesions (SALs). METHODS This retrospective multicenter study included 1422 endoscopic papillectomy procedures. Propensity score matching including age, sex, comorbidity, histologic subtype, and size was performed. Main outcomes were complete resection (R0), technical success, complications, and recurrence. RESULTS Propensity score matching identified 202 patients (101 FAP, 101 SAL) with comparable baseline characteristics. FAP patients were mainly asymptomatic (79.2 % [95 %CI 71.2-87.3] vs. 46.5 % [95 %CI 36.6-56.4]); P < 0.001). The initial R0 rate was significantly lower in FAP patients (63.4 % [95 %CI 53.8-72.9] vs. 83.2 % [95 %CI 75.8-90.6]; P = 0.001). After repeated interventions (mean 1.30 per patient), R0 was comparable (FAP 93.1 % [95 %CI 88.0-98.1] vs. SAL 97.0 % [95 %CI 93.7-100]; P = 0.19). Adverse events occurred in 28.7 %. Pancreatitis and bleeding were the most common adverse events in both groups. Severe adverse events were rare (3.5 %). Overall, 21 FAP patients (20.8 % [95 %CI 12.7-28.8]) and 16 SAL patients (15.8 % [95 %CI 8.6-23.1]; P = 0.36) had recurrence. Recurrences occurred later in FAP patients (25 [95 %CI 18.3-31.7] vs. 2 [95 %CI CI 0.06-3.9] months). CONCLUSIONS Endoscopic papillectomy was safe and effective in FAP-related ampullary lesions. Criteria for endoscopic resection of ampullary lesions can be extended to FAP patients. FAP patients have a lifetime risk of relapse even after complete resection, and require long-time surveillance.
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Affiliation(s)
- Kien Vu Trung
- Division of Gastroenterology, Medical Department II, University of Leipzig Medical Center, Leipzig, Germany
| | - Einas Abou-Ali
- Department of Gastroenterology, Digestive Oncology and Endoscopy, Cochin Hospital, Paris Descartes University, Paris, France
| | - Fabrice Caillol
- Department of Endoscopy, Institut Paoli Calmettes, Marseille, France
| | - Woo H Paik
- Division of Gastroenterology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | | | - Viliam Masaryk
- Department of Gastroenterology, Hepatology, Diabetes and General Internal Medicine, SRH Wald-Klinikum Gera, Gera, Germany
| | - Sophia E van der Wiel
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Enrique Pérez-Cuadrado-Robles
- Interventional Endoscopy, Hôpital Européen Georges-Pompidou, Department of Gastroenterology, Georges-Pompidou European Hospital, Paris, France
- Department of Gastroenterology, Cliniques universitaires Saint-Luc, Bruxelles, Belgium
| | | | - Asif Halimi
- Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Department of Surgical and Perioperative Sciences, Surgery, University of Umeå, Umeå, Sweden
| | - Kevin Soares
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Francois R Souche
- Department of Digestive Surgery, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Steffen Seyfried
- Interdisciplinary Endoscopy Unit, Mannheim Medical Center, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
- Department of Surgery, Mannheim Medical Center, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
| | - Maria C Petrone
- Endosonography Unit, Pancreato-Biliary Endoscopy and Endosonography Division, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Stefano Crippa
- Department of Pancreatic Surgery, Vita Salute San Raffaele University, Milan, Italy
| | - Tobias Kleemann
- Department of Gastroenterology and Rheumatology, Carl-Thiem-Klinikum Cottbus, Cottbus, Germany
| | - David Albers
- Department of Medicine and Gastroenterology, Contilia Clinic Essen, Essen, Germany
| | - Tobias J Weismüller
- Department of Internal Medicine - Gastroenterology and Oncology, Vivantes Humboldt Hospital, Berlin, Germany
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Ana Dugic
- Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Friedrich-Alexander-University Erlangen-Nuremberg, Medical Campus Oberfranken, Bayreuth, Germany
| | - Benjamin Meier
- Department of Medicine, Gastroenterology, Hematology, Oncology, Pneumology, Diabetes and Infectious Diseases; RKH Clinic Ludwigsburg, Ludwigsburg, Germany
| | - Edris Wedi
- Department of Gastroenterology and Gastrointestinal Oncology, University Medicine Göttingen, Göttingen, Germany
- Department of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Clinic Offenbach, Offenbach, Germany
| | - Moritz Schiemer
- Department of Medicine II, University of Freiburg Medical Center, Freiburg, Germany
| | - Sara Regner
- Department of Clinical Sciences Malmö, Section for Surgery, Lund University, Lund, Sweden
| | - Sebastien Gaujoux
- Department of Digestive and HBP Surgery, Groupe Hospitalier Pitié-Salpêtrière APHP, Médecine Sorbonne Université, Paris, France
| | - Marcus Hollenbach
- Division of Gastroenterology, Medical Department II, University of Leipzig Medical Center, Leipzig, Germany
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Reissig TM, Tzianopoulos I, Liffers ST, Rosery VK, Guyot M, Ting S, Wiesweg M, Kasper S, Meister P, Herold T, Schmidt HH, Schumacher B, Albers D, Markus P, Treckmann J, Schuler M, Schildhaus HU, Siveke JT. Smaller panel, similar results: genomic profiling and molecularly informed therapy in pancreatic cancer. ESMO Open 2023; 8:101539. [PMID: 37148593 DOI: 10.1016/j.esmoop.2023.101539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/12/2023] [Accepted: 03/24/2023] [Indexed: 05/08/2023] Open
Abstract
BACKGROUND Pancreatic cancer has a dismal prognosis. One reason is resistance to cytotoxic drugs. Molecularly matched therapies might overcome this resistance but the best approach to identify those patients who may benefit is unknown. Therefore, we sought to evaluate a molecularly guided treatment approach. MATERIALS AND METHODS We retrospectively analyzed the clinical outcome and mutational status of patients with pancreatic cancer who received molecular profiling at the West German Cancer Center Essen from 2016 to 2021. We carried out a 47-gene DNA next-generation sequencing (NGS) panel. Furthermore, we assessed microsatellite instability-high/deficient mismatch repair (MSI-H/dMMR) status and, sequentially and only in case of KRAS wild-type, gene fusions via RNA-based NGS. Patient data and treatment were retrieved from the electronic medical records. RESULTS Of 190 included patients, 171 had pancreatic ductal adenocarcinoma (90%). One hundred and three patients had stage IV pancreatic cancer at diagnosis (54%). MMR analysis in 94 patients (94/190, 49.5%) identified 3 patients with dMMR (3/94, 3.2%). Notably, we identified 32 patients with KRAS wild-type status (16.8%). To identify driver alterations in these patients, we conducted an RNA-based fusion assay on 13 assessable samples and identified 5 potentially actionable fusions (5/13, 38.5%). Overall, we identified 34 patients with potentially actionable alterations (34/190, 17.9%). Of these 34 patients, 10 patients (10/34, 29.4%) finally received at least one molecularly targeted treatment and 4 patients had an exceptional response (>9 months on treatment). CONCLUSIONS Here, we show that a small-sized gene panel can suffice to identify relevant therapeutic options for pancreatic cancer patients. Informally comparing with previous large-scale studies, this approach yields a similar detection rate of actionable targets. We propose molecular sequencing of pancreatic cancer as standard of care to identify KRAS wild-type and rare molecular subsets for targeted treatment strategies.
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Affiliation(s)
- T M Reissig
- Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, Essen, Germany; Division of Solid Tumor Translational Oncology, German Cancer Research Center (DKFZ) and German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Heidelberg, Germany; Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
| | - I Tzianopoulos
- Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, Essen, Germany; Division of Solid Tumor Translational Oncology, German Cancer Research Center (DKFZ) and German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Heidelberg, Germany; Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - S-T Liffers
- Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, Essen, Germany; Division of Solid Tumor Translational Oncology, German Cancer Research Center (DKFZ) and German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Heidelberg, Germany; German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
| | - V K Rosery
- Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, Essen, Germany; Division of Solid Tumor Translational Oncology, German Cancer Research Center (DKFZ) and German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Heidelberg, Germany; Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
| | - M Guyot
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany; Department of Gastroenterology, Oncology und Hematology, Diabetology and Rheumatology, Marien-Hospital Wesel, Wesel, Germany
| | - S Ting
- Institute of Pathology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - M Wiesweg
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
| | - S Kasper
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
| | - P Meister
- Department of General, Visceral and Transplantation Surgery, Hepatology, and Transplant Medicine, University Hospital Essen, Essen, Germany
| | - T Herold
- Institute of Pathology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - H H Schmidt
- Department of Gastroenterology, Hepatology, and Transplant Medicine, University Hospital Essen, Essen, Germany
| | - B Schumacher
- Department of Gastroenterology, Visceral and Trauma Surgery, Elisabeth Hospital Essen, Essen, Germany
| | - D Albers
- Department of Gastroenterology, Visceral and Trauma Surgery, Elisabeth Hospital Essen, Essen, Germany
| | - P Markus
- Department of General, Visceral and Trauma Surgery, Elisabeth Hospital Essen, Essen, Germany
| | - J Treckmann
- Department of General, Visceral and Transplantation Surgery, Hepatology, and Transplant Medicine, University Hospital Essen, Essen, Germany
| | - M Schuler
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
| | - H-U Schildhaus
- German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany; Institute of Pathology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - J T Siveke
- Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, Essen, Germany; Division of Solid Tumor Translational Oncology, German Cancer Research Center (DKFZ) and German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Heidelberg, Germany; Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany.
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7
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Graham EJ, Elhadad N, Albers D. Reduced model for female endocrine dynamics: Validation and functional variations. Math Biosci 2023; 358:108979. [PMID: 36792027 DOI: 10.1016/j.mbs.2023.108979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 01/19/2023] [Accepted: 02/07/2023] [Indexed: 02/15/2023]
Abstract
A normally functioning menstrual cycle requires significant crosstalk between hormones originating in ovarian and brain tissues. Reproductive hormone dysregulation may cause abnormal function and sometimes infertility. The inherent complexity in this endocrine system is a challenge to identifying mechanisms of cycle disruption, particularly given the large number of unknown parameters in existing mathematical models. We develop a new endocrine model to limit model complexity and use simulated distributions of unknown parameters for model analysis. By employing a comprehensive model evaluation, we identify a collection of mechanisms that differentiate normal and abnormal phenotypes. We also discover an intermediate phenotype-displaying relatively normal hormone levels and cycle dynamics-that is grouped statistically with the irregular phenotype. Results provide insight into how clinical symptoms associated with ovulatory disruption may not be detected through hormone measurements alone.
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Affiliation(s)
- Erica J Graham
- Mathematics Department, Bryn Mawr College, Bryn Mawr, PA 19010, USA.
| | - Noémie Elhadad
- Department of Biomedical Informatics, Columbia University, New York, NY 10032, USA
| | - David Albers
- Pediatrics Department, University of Colorado Denver-Anschutz Medical Campus, Aurora, CO 80045, USA
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8
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Keyl J, Hosch R, Berger A, Ester O, Greiner T, Bogner S, Treckmann J, Ting S, Schumacher B, Albers D, Markus P, Wiesweg M, Forsting M, Nensa F, Schuler M, Kasper S, Kleesiek J. Deep learning-based assessment of body composition and liver tumour burden for survival modelling in advanced colorectal cancer. J Cachexia Sarcopenia Muscle 2023; 14:545-552. [PMID: 36544260 PMCID: PMC9891942 DOI: 10.1002/jcsm.13158] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/16/2022] [Accepted: 11/25/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Personalized therapy planning remains a significant challenge in advanced colorectal cancer care, despite extensive research on prognostic and predictive markers. A strong correlation of sarcopenia or overall body composition and survival has been described. Here, we explore whether automated assessment of body composition and liver metastases from standard of care CT images can add to clinical parameters in personalized survival risk prognostication. METHODS We retrospectively analysed clinical imaging data from 85 patients (50.6% female, mean age 58.9 SD 12.2 years) with colorectal cancer and synchronous liver metastases. Pretrained deep learning models were used to assess body composition and liver metastasis geometry from abdominal CT images before the initiation of systemic treatment. Abdominal muscle-to-bone ratio (MBR) was calculated by dividing abdominal muscle volume by abdominal bone volume. MBR was compared with body mass index (BMI), abdominal muscle volume, and abdominal muscle volume divided by height squared. Differences in overall survival based on body composition and liver metastasis parameters were compared using Kaplan-Meier survival curves. Results were correlated with clinical and biomarker data to develop a machine learning model for survival risk prognostication. RESULTS The MBR, unlike abdominal muscle volume or BMI, was significantly associated with overall survival (HR 0.39, 95% CI: 0.19-0.80, P = 0.009). The MBR (P = 0.022), liver metastasis surface area (P = 0.01) and primary tumour sidedness (P = 0.007) were independently associated with overall survival in multivariate analysis. Body composition parameters did not correlate with KRAS mutational status or primary tumour sidedness. A prediction model based on MBR, liver metastasis surface area and primary tumour sidedness achieved a concordance index of 0.69. CONCLUSIONS Automated segmentation enables to extract prognostic parameters from routine imaging data for personalized survival modelling in advanced colorectal cancer patients.
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Affiliation(s)
- Julius Keyl
- Department of Medical Oncology, West German Cancer CenterUniversity Hospital Essen (AöR)EssenGermany
- Institute for Artificial Intelligence in MedicineUniversity Hospital Essen (AöR)EssenGermany
- German Cancer Consortium (DKTK)Partner site University Hospital Essen (AöR)EssenGermany
| | - René Hosch
- Institute for Artificial Intelligence in MedicineUniversity Hospital Essen (AöR)EssenGermany
- Department of Diagnostic and Interventional Radiology and NeuroradiologyUniversity Hospital Essen (AöR)EssenGermany
| | - Aaron Berger
- Institute for Artificial Intelligence in MedicineUniversity Hospital Essen (AöR)EssenGermany
| | - Oliver Ester
- Institute for Artificial Intelligence in MedicineUniversity Hospital Essen (AöR)EssenGermany
| | | | - Simon Bogner
- Department of Medical Oncology, West German Cancer CenterUniversity Hospital Essen (AöR)EssenGermany
| | - Jürgen Treckmann
- Department of General, Visceral and Transplant Surgery, West German Cancer CenterUniversity Hospital Essen (AöR)EssenGermany
| | - Saskia Ting
- Institute of Pathology EssenWest German Cancer Center, University Hospital Essen (AöR)EssenGermany
| | | | - David Albers
- Department of GastroenterologyElisabeth Hospital EssenEssenGermany
| | - Peter Markus
- Department of General Surgery and TraumatologyElisabeth Hospital EssenEssenGermany
| | - Marcel Wiesweg
- Department of Medical Oncology, West German Cancer CenterUniversity Hospital Essen (AöR)EssenGermany
- Medical FacultyUniversity of Duisburg‐EssenEssenGermany
| | - Michael Forsting
- Department of Diagnostic and Interventional Radiology and NeuroradiologyUniversity Hospital Essen (AöR)EssenGermany
| | - Felix Nensa
- Institute for Artificial Intelligence in MedicineUniversity Hospital Essen (AöR)EssenGermany
- Department of Diagnostic and Interventional Radiology and NeuroradiologyUniversity Hospital Essen (AöR)EssenGermany
| | - Martin Schuler
- Department of Medical Oncology, West German Cancer CenterUniversity Hospital Essen (AöR)EssenGermany
- German Cancer Consortium (DKTK)Partner site University Hospital Essen (AöR)EssenGermany
- Medical FacultyUniversity of Duisburg‐EssenEssenGermany
| | - Stefan Kasper
- Department of Medical Oncology, West German Cancer CenterUniversity Hospital Essen (AöR)EssenGermany
- German Cancer Consortium (DKTK)Partner site University Hospital Essen (AöR)EssenGermany
- Medical FacultyUniversity of Duisburg‐EssenEssenGermany
| | - Jens Kleesiek
- Institute for Artificial Intelligence in MedicineUniversity Hospital Essen (AöR)EssenGermany
- Medical FacultyUniversity of Duisburg‐EssenEssenGermany
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9
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Gerges C, Albers D, Schmitz L, Goni E, Cappello A, Schirra J, Casper M, Dormann AJ, Hartmann D, Hollenbach M, Schneider M, Denzer UW, Dechene A, Dollhopf M, Mayerle J, Schumacher B, van Geenen EJM, Neuhaus H, Siersema PD, Ellrichmann M, Beyna T. Correction: Digital single-operator pancreatoscopy for the treatment of symptomatic pancreatic duct stones: a prospective multicenter cohort trial. Endoscopy 2023; 55:C1. [PMID: 36027902 DOI: 10.1055/a-1905-5046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
| | | | - Lukas Schmitz
- Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | | | | | - Jörg Schirra
- Ludwig-Maximilians-Universität München, Munich, Germany
| | - Markus Casper
- Universitätsklinikum des Saarlandes, Homburg, Germany
| | | | | | | | | | | | | | | | - Julia Mayerle
- Ludwig-Maximilians-Universität München, Munich, Germany
| | | | | | - Horst Neuhaus
- Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | | | | | - Torsten Beyna
- Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
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10
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Gerges C, Albers D, Schmitz L, Goni E, Cappello A, Schirra J, Casper M, Dormann AJ, Hartmann D, Hollenbach M, Schneider M, Denzer UW, Dechene A, Dollhopf M, Mayerle J, Schumacher B, van Geenen EJM, Neuhaus H, Siersema PD, Ellrichmann M, Beyna T. Digital single-operator pancreatoscopy for the treatment of symptomatic pancreatic duct stones: a prospective multicenter cohort trial. Endoscopy 2023; 55:150-157. [PMID: 35672016 DOI: 10.1055/a-1870-3403] [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] [Indexed: 01/31/2023]
Abstract
BACKGROUND Digital single-operator pancreatoscopy (DSOP)-guided lithotripsy is a novel treatment modality for pancreatic endotherapy, with demonstrated technical success in retrospective series of between 88 % and 100 %. The aim of this prospective multicenter trial was to systematically evaluate DSOP in patients with chronic pancreatitis and symptomatic pancreatic duct stones. METHODS Patients with symptomatic chronic pancreatitis and three or fewer stones ≥ 5mm in the main pancreatic duct (MPD) of the pancreatic head or body were included. The primary end point was complete stone clearance (CSC) in three or fewer treatment sessions with DSOP. Current guidelines recommend extracorporeal shock wave lithotripsy (ESWL) for MPD stones > 5 mm. A performance goal was developed to show that the CSC rate of MPD stones using DSOP was above what has been previously reported for ESWL. Secondary end points were pain relief measured with the Izbicki pain score (IPS), number of interventions, and serious adverse events (SAEs). RESULTS 40 chronic pancreatitis patients were included. CSC was achieved in 90 % of patients (36/40) on intention-to-treat analysis, after a mean (SD) of 1.36 (0.64) interventions (53 procedures in total). The mean (SD) baseline IPS decreased from 55.3 (46.2) to 10.9 (18.3). Overall pain relief was achieved in 82.4 % (28/34) after 6 months of follow-up, with complete pain relief in 61.8 % (21/34) and partial pain relief in 20.6 % (7/34). SAEs occurred in 12.5 % of patients (5/40), with all treated conservatively. CONCLUSION DSOP-guided endotherapy is effective and safe for the treatment of symptomatic MPD stones in highly selected patients with chronic pancreatitis. It significantly reduces pain and could be considered as an alternative to standard ERCP techniques for MPD stone treatment in these patients.
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Affiliation(s)
| | | | - Lukas Schmitz
- Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | | | | | - Jörg Schirra
- Ludwig-Maximilians-Universität München, Munich, Germany
| | - Markus Casper
- Universitätsklinikum des Saarlandes, Homburg, Germany
| | | | | | | | | | | | | | | | - Julia Mayerle
- Ludwig-Maximilians-Universität München, Munich, Germany
| | | | | | - Horst Neuhaus
- Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | | | | | - Torsten Beyna
- Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
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11
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Roehrle J, Kasper S, Treckmann JW, Markus P, Schumacher B, Albers D, Wendling J, Ting S, Mende B, Maßmann M, Markus M, Virchow I, Rosery V, Laue K, Zaun G, Kostbade K, Pogorzelski M, Reissig TM, Liffers ST, Schmid K, Schildhaus HU, Schuler M, Siveke JT, Wiesweg M. Clinical outcome and treatment sequences of patients with advanced pancreatic cancer treated with contemporary chemotherapy protocols. Oncol Res Treat 2023; 46:140-150. [PMID: 36720216 DOI: 10.1159/000529452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 01/11/2023] [Indexed: 02/02/2023]
Abstract
Introduction Systemic therapy is firmly established in patients with advanced or metastatic pancreatic ductal adenocarcinoma (PDAC). Clinical efficacy is still modest and options are limited. Combination therapy protocols such as FOLFIRINOX and gemcitabine/nab-paclitaxel (Gem/NP) define standard-of-care. Patients may receive a sequence of both regimens as first- and second-line palliative treatment. However, there is no guidance regarding a preferred order. Methods Retrospective analysis of clinical characteristics, treatment trajectories and outcomes of patients with advanced PDAC treated at the West German Cancer Center Essen from 2014 to 2020 to inform treatment decisions with respect to predictive factors, impact of chemotherapy regimen sequence and maintenance treatment. Results We identified 170 patients with available follow-up. Of those, 160 (94.1%) pts received palliative CTX for primary metastatic, locally advanced or recurrent PDAC. Median PFS upon first palliative chemotherapy was 4.1 (3.1 - 5.9) months. First-line FOLFIRINOX associated with superior PFS (median 6.3 months) and OS (9.7 months, HR 0.7, p=0.03) as compared to gemcitabine/nab-paclitaxel or other regimens (PFS 3.0, OS 6.9 months). However, OS benefit of first-line FOLFIRINOX was lost in patients who received at least two treatment lines (median OS 12.1 vs. 13.1 months, p=0.43). A landmark analysis of patients with clinical benefit (defined at CR/PR/SD for at least 20 weeks) upon first-line therapy revealed improved OS (HR 0.53, p=0.02) for patients receiving continued deescalated maintenance therapy. Second-line regimens resulted in similar PFS (overall log-rank p=0.92, median PFS2 2.3 (1.8-2.9), per-regimen median between 1.8 and 3.9 months). A previously established systemic inflammation score proved to be strongly prognostic and allowed identification of a patient subgroup with dismal prognosis (OS 2.9 vs. 11.4 months, HR 5.23, p<0.001), independent of other prognostic factors and with no relevant interaction with the choice of first-line regimen. Conclusion In this real world population of PDAC patients treated with contemporary combination chemotherapies, a positive impact of first line FOLFIRINOX was only observed when no second or further line treatment was administered. Intensity-reduced maintenance therapy may lead to superior survival.
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Affiliation(s)
- Julius Roehrle
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Stefan Kasper
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
| | - Jürgen-Walter Treckmann
- Department of General, Visceral and Transplant Surgery, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Peter Markus
- Department of General Surgery and TraumatologyElisabeth Hospital Essen, Essen, Germany
| | | | - David Albers
- Department of Gastroenterology, Elisabeth Hospital Essen, Essen, Germany
| | - Johanna Wendling
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Saskia Ting
- West German Cancer Center, Institute of Pathology Essen, University Hospital Essen, Essen, Germany
| | - Bastian Mende
- Central Pharmacy, University Hospital Essen, Essen, Germany
| | - Marlene Maßmann
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Maximilian Markus
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Isabel Virchow
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Vivian Rosery
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Katharina Laue
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Gregor Zaun
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Karina Kostbade
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Michael Pogorzelski
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Timm M Reissig
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
- Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, Essen, Germany
- Division of Solid Tumor Translational Oncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Sven-Thorsten Liffers
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
- Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, Essen, Germany
- Division of Solid Tumor Translational Oncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Kurt Schmid
- German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
- West German Cancer Center, Institute of Pathology Essen, University Hospital Essen, Essen, Germany
| | - Hans-Ulrich Schildhaus
- German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
- West German Cancer Center, Institute of Pathology Essen, University Hospital Essen, Essen, Germany
| | - Martin Schuler
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
| | - Jens T Siveke
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
- Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, Essen, Germany
- Division of Solid Tumor Translational Oncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Marcel Wiesweg
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
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12
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Karam E, Hollenbach M, Ali EA, Auriemma F, Gulla A, Heise C, Regner S, Gaujoux S, Regimbeau JM, Kähler G, Seyfried S, Vaillant JC, De Ponthaud C, Sauvanet A, Birnbaum D, Regenet N, Truant S, Pérez-Cuadrado-Robles E, Bruzzi M, Lupinacci RM, Brunel M, Belfiori G, Barbier L, Salamé E, Souche FR, Schwarz L, Maggino L, Salvia R, Gagniére J, Del Chiaro M, Leung G, Hackert T, Kleemann T, Paik WH, Caca K, Dugic A, Muehldorfer S, Schumacher B, Albers D. Outcomes of rescue procedures in the management of locally recurrent ampullary tumors: A Pancreas 2000/EPC study. Surgery 2023; 173:1254-1262. [PMID: 36642655 DOI: 10.1016/j.surg.2022.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 11/15/2022] [Accepted: 12/13/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND Ampullary lesions are rare and can be locally treated either with endoscopic papillectomy or transduodenal surgical ampullectomy. Management of local recurrence after a first-line treatment has been poorly studied. METHODS Patients with a local recurrence of an ampullary lesion initially treated with endoscopic papillectomy or transduodenal surgical ampullectomy were retrospectively included from a multi-institutional database (58 centers) between 2005 and 2018. RESULTS A total of 103 patients were included, 21 (20.4%) treated with redo endoscopic papillectomy, 14 (13.6%) with transduodenal surgical ampullectomy, and 68 (66%) with pancreaticoduodenectomy. Redo endoscopic papillectomy had low morbidity with 4.8% (n = 1) severe to fatal complications and a R0 rate of 81% (n = 17). Transduodenal surgical ampullectomy and pancreaticoduodenectomy after a first procedure had a higher morbidity with Clavien III and more complications, respectively, 28.6% (n = 4) and 25% (n = 17); R0 resection rates were 85.7% (n = 12) and 92.6% (n = 63), both without statistically significant difference compared to endoscopic papillectomy (P = .1 and 0.2). Pancreaticoduodenectomy had 4.4% (n = 2) mortality. No deaths were registered after transduodenal surgical ampullectomy or endoscopic papillectomy. Recurrences treated with pancreaticoduodenectomy were more likely to be adenocarcinomas (79.4%, n = 54 vs 21.4%, n = 3 for transduodenal surgical ampullectomy and 4.8%, n = 1 for endoscopic papillectomy, P < .0001). Three-year overall survival and disease-free survival were comparable. CONCLUSION Endoscopy is appropriate for noninvasive recurrences, with resection rate and survival outcomes comparable to surgery. Surgery applies more to invasive recurrences, with transduodenal surgical ampullectomy rather for carcinoma in situ and early cancers and pancreaticoduodenectomy for more advanced tumors.
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Affiliation(s)
- Elias Karam
- Department of Visceral Surgery, Hepato-Biliary, Pancreatic and Liver Transplantation Unit, Tours University Hospital, France.
| | - Marcus Hollenbach
- University of Leipzig Medical Center, Medical Department II-Gastroenterology, Hepatology, Infectious Diseases, Pulmonology, Leipzig, Germany
| | - Einas Abou Ali
- Department of Gastroenterology, Digestive Oncology, and Endoscopy, Cochin Hospital, Paris, France
| | - Francesco Auriemma
- Humanitas Clinical and Research Hospital, Rozzano, Digestive Endoscopy Unit, Division of Gastroenterology, Milan, Italy
| | - Aiste Gulla
- Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania; Johns Hopkins University, MedStar Georgetown University Hospital, General Surgery, Washington, DC
| | - Christian Heise
- Martin-Luther University Halle-Wittenberg Department of Medicine I-Gastroenterology, Pulmonology, Halle, Germany
| | - Sara Regner
- Department of Clinical Sciences Malmö, Lund University, Sweden
| | - Sébastien Gaujoux
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France; Sorbonne University, Paris, France
| | | | - Jean M Regimbeau
- Department of Digestive Surgery, Center Hospitalo-Universitaire Amiens-Picardie, Amiens, France
| | - Georg Kähler
- Interdisciplinary Endoscopy Unit, Mannheim Medical Center, Ruprecht-Karls-University Heidelberg, Mannheim, Germany; Department of Surgery, Mannheim Medical Center, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
| | - Steffen Seyfried
- Interdisciplinary Endoscopy Unit, Mannheim Medical Center, Ruprecht-Karls-University Heidelberg, Mannheim, Germany; Department of Surgery, Mannheim Medical Center, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
| | - Jean C Vaillant
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France
| | - Charles De Ponthaud
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France
| | - Alain Sauvanet
- Department of Digestive Surgery, Beaujon Hospital, APHP, Clichy, France
| | - David Birnbaum
- Department of Digestive Surgery, Hôpital Nord, Assistance Publique - Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Nicolas Regenet
- Department of Digestive Surgery, Centre Hospitalier Universitaire de Nantes, France
| | - Stéphanie Truant
- Deparment of Digestive Surgery, Centre Hospitalo-Universitaire de Lille, France
| | | | - Matthieu Bruzzi
- Department of Digestive Surgery, Hôpital Européen Georges Pompidou, APHP, Paris, France
| | - Renato M Lupinacci
- Department of Digestive Surgery, Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - Martin Brunel
- Department of Digestive Surgery, Hôpital André Mignot, Versailles, France
| | - Giulio Belfiori
- Department of Pancreatic Surgery, Vita Salute San Raffaele University, Milan, Italy
| | - Louise Barbier
- Department of Visceral Surgery, Hepato-Biliary, Pancreatic and Liver Transplantation Unit, Tours University Hospital, France
| | - Ephrem Salamé
- Department of Visceral Surgery, Hepato-Biliary, Pancreatic and Liver Transplantation Unit, Tours University Hospital, France
| | - Francois R Souche
- Department of Digestive Surgery, Centre Hospitalier Universitaire de Montpellier, France
| | - Lilian Schwarz
- Department of Digestive Surgery, Hôpital Charles-Nicolle, Centre Hospitalier Universitaire de Rouen, France
| | - Laura Maggino
- Unit of General and Pancreatic Surgery, The Pancreas Institute Verona, Department of Surgery, Dentistry, Paediatrics, and Gynaecology, University of Verona, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, The Pancreas Institute Verona, Department of Surgery, Dentistry, Paediatrics, and Gynaecology, University of Verona, Italy
| | - Johan Gagniére
- Department of Digestive and Hepatobiliary Surgery, Estaing University Hospital, Clermont-Ferrand, France; U1071 Inserm / Clermont-Auvergne University, Clermont-Ferrand, France
| | - Marco Del Chiaro
- Department of Surgery, University of Colorado Anschutz Medical Campus, CO
| | - Galen Leung
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, PA
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Germany
| | - Tobias Kleemann
- Department of Gastroenterology and Rheumatology, Carl-Thiem-Klinikum Cottbus, Germany
| | - Woo H Paik
- Division of Gastroenterology, Department of Internal Medicine, Seoul National University Hospital, Republic of Korea
| | - Karel Caca
- Department of Medicine, Gastroenterology, Hematology, Oncology, Pneumology, Diabetes and Infectious Diseases, RKH Clinic Ludwigsburg, Germany
| | - Ana Dugic
- Department of Gastroenterology, Friedrich-Alexander-University Erlangen-Nuremberg, Medical Campus Oberfranken, Bayreuth, Germany
| | - Steffen Muehldorfer
- Department of Gastroenterology, Friedrich-Alexander-University Erlangen-Nuremberg, Medical Campus Oberfranken, Bayreuth, Germany
| | | | - David Albers
- Department of Medicine and Gastroenterology, Contilia Clinic Essen, Germany
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13
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Virchow I, Treckmann JW, Prasnikar N, Linden G, Markus P, Schumacher B, Albers D, Herold T, Ting S, Schmidt H, Radunz S, Wiesweg M, Siveke J, Schuler M, Kasper S. A Phase II Study of Nab-Paclitaxel and Gemcitabine as First-Line Therapy in Patients with Cholangiocarcinoma Ineligible for Cisplatin-Based Chemotherapy (NACHO). Oncol Res Treat 2023; 46:89-99. [PMID: 36623497 DOI: 10.1159/000529012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 01/02/2023] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Gemcitabine and cisplatin is the standard first-line systemic treatment in patients with advanced cholangiocarcinoma (CCA). However, a substantial number of patients do not qualify for cisplatin due to comorbidities or poor performance status. The phase II pilot study NACHO evaluated the efficacy of nab-paclitaxel (125 mg/m2) and gemcitabine (1000 mg/m2) given on days 1, 8, and 15 every 4 weeks as first-line therapy in patients with advanced CCA ineligible for cisplatin-based chemotherapy. METHODS Patients with any comorbidity precluding cisplatin therapy, such as renal impairment, impaired hearing, increased risk or history for thromboembolic events, intolerance of extensive hydration, or significant cardiovascular disease were eligible. Primary endpoint was overall response rate (ORR) per RECIST 1.1. Secondary endpoints were progression-free survival (PFS), overall survival (OS), safety, and patient reported outcome. RESULTS From December 2016 to July 2017, 10 patients were prospectively enrolled and treated. The ORR with nab-paclitaxel/gemcitabine was 50%, the disease control rate (DCR) was 90%. Median PFS was 5.7 months (95% CI: 5.3-6.1), and median OS was 7.8 months (95% CI: 5.4-10.2). In total, 13 SAEs were documented without any new safety signals. There were 14 grade 3-4 treatment-related adverse events (TRAEs) in 10 patients of the ITT population. Exploratory subgroup analyses including known prognostic markers were performed. CONCLUSIONS The NACHO trial supports safety and efficacy of nab-paclitaxel and gemcitabine in patients with advanced CCA ineligible for cisplatin-based therapy and should be further evaluated in a larger prospective trial.
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Affiliation(s)
- Isabel Virchow
- West German Cancer Center, Department of Medical Oncology, University Hospital Essen, Essen, Germany.,Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - Jürgen-Walter Treckmann
- Medical Faculty, University Duisburg-Essen, Essen, Germany.,West German Cancer Center, Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Nicole Prasnikar
- Ambulatory Health Care Center for Haematology and Medical Oncology, Hamburg, Germany
| | - Gabriele Linden
- West German Cancer Center, Department of Medical Oncology, University Hospital Essen, Essen, Germany
| | - Peter Markus
- Department of General, Visceral and Trauma Surgery, Elisabeth Hospital Essen, Essen, Germany
| | | | - David Albers
- Department of Gastroenterology, Elisabeth Hospital Essen, Essen, Germany
| | - Thomas Herold
- Medical Faculty, University Duisburg-Essen, Essen, Germany.,West German Cancer Center, Institute of Pathology, University Hospital Essen, Essen, Germany
| | - Saskia Ting
- Medical Faculty, University Duisburg-Essen, Essen, Germany.,West German Cancer Center, Institute of Pathology, University Hospital Essen, Essen, Germany.,Institute of Pathology Nordhessen, Kassel, Germany
| | - Hartmut Schmidt
- Medical Faculty, University Duisburg-Essen, Essen, Germany.,Department of Gastroenterology, Hepatology and Transplant Medicine, University Hospital Essen, Essen, Germany
| | - Sonja Radunz
- Medical Faculty, University Duisburg-Essen, Essen, Germany.,West German Cancer Center, Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Marcel Wiesweg
- West German Cancer Center, Department of Medical Oncology, University Hospital Essen, Essen, Germany.,Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - Jens Siveke
- West German Cancer Center, Department of Medical Oncology, University Hospital Essen, Essen, Germany.,Medical Faculty, University Duisburg-Essen, Essen, Germany.,German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany.,West German Cancer Center, Bridge Institute of Experimental Tumor Therapy, University Hospital Essen, Essen, Germany.,Division of Solid Tumor Translational Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Martin Schuler
- West German Cancer Center, Department of Medical Oncology, University Hospital Essen, Essen, Germany.,Medical Faculty, University Duisburg-Essen, Essen, Germany.,German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
| | - Stefan Kasper
- West German Cancer Center, Department of Medical Oncology, University Hospital Essen, Essen, Germany.,Medical Faculty, University Duisburg-Essen, Essen, Germany.,German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
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14
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Albers D, Schmidt A, Schiemer M, Caca K, Wannhoff A, Sauer P, Wiesweg M, Schumacher B, Dechene A. Impact of endobiliary radiofrequency ablation on biliary drainage in patients with malignant biliary strictures treated with uncovered self-expandable metal stents: a randomized controlled multicenter trial. Gastrointest Endosc 2022; 96:970-979. [PMID: 35667389 DOI: 10.1016/j.gie.2022.05.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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: 01/31/2022] [Revised: 05/18/2022] [Accepted: 05/24/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endobiliary radiofrequency ablation (RFA), usually combined with endoscopic stent insertion, is a simple procedure with the potential to improve stent patency and patient survival for malignant biliary obstruction. We conducted this randomized multicenter trial to evaluate the impact of RFA on stent patency. METHODS Eighty-six patients with malignant biliary obstruction and nonresectable tumors (pancreatic carcinoma, cholangiocarcinoma, or metastases) were included and randomly assigned to receive a self-expandable metal stent (SEMS) only (n = 44) or RFA followed by SEMS insertion (RFA+SEMS, n = 42). The primary outcome measure was stent patency after 3 and 6 months; secondary outcome measures were patient survival and early adverse events within 30 days. RESULTS Technical success rates for RFA and stent insertion were 100% and 98.8%, respectively. Stent patency after 3 and 6 months did not differ significantly between groups (RFA+SEMS group, 73.1% and 33.3%, respectively; SEMS-only group, 81.8% and 52.4%, respectively; P = .6). Similarly, the addition of RFA did not impact overall survival (hazard ratio, .72; P = .389 for RFA+SEMS). The adverse event rate in the RFA+SEMS group was 10.5% compared with 2.3% in the SEMS-only group, without a statistically significant difference (P = .18). CONCLUSIONS RFA as an addition to SEMS implantation had no positive impact on patency rate or survival. (Clinical trial registration number: DRKS00018993.).
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Affiliation(s)
- David Albers
- Department of Gastroenterology, Elisabeth-Krankenhaus Essen, Essen, Germany; Department of Gastroenterology, Universitätsklinikum Essen, Essen, Germany
| | - Arthur Schmidt
- Department of Gastroenterology, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Moritz Schiemer
- Department of Gastroenterology, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Karel Caca
- Department of Gastroenterology, Klinkum Ludwigsburg, Ludwigsburg, Germany
| | - Andreas Wannhoff
- Department of Gastroenterology, Klinkum Ludwigsburg, Ludwigsburg, Germany
| | - Peter Sauer
- Department of Gastroenterology, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Marcel Wiesweg
- Department of Medical Oncology, Universitätsklinikum Essen, Essen, Germany
| | | | - Alexander Dechene
- Department of Gastroenterology, Klinikum Nürnberg, Nürnberg, Germany
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15
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Martin B, DeWitt PE, Albers D, Bennett TD. Development of a Pediatric Blood Pressure Percentile Tool for Clinical Decision Support. JAMA Netw Open 2022; 5:e2236918. [PMID: 36251296 PMCID: PMC9577675 DOI: 10.1001/jamanetworkopen.2022.36918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This diagnostic study assesses the ability of a pediatric blood pressure percentile tool to accelerate identification of children with hypertension and hypotension by clinicians and researchers.
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Affiliation(s)
- Blake Martin
- Section of Critical Care, Department of Pediatrics, University of Colorado School of Medicine, Aurora
- Children’s Hospital Colorado, Aurora
| | - Peter E. DeWitt
- Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - David Albers
- Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - Tellen D. Bennett
- Section of Critical Care, Department of Pediatrics, University of Colorado School of Medicine, Aurora
- Children’s Hospital Colorado, Aurora
- Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Aurora
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16
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Rosery V, Mika S, Schmid KW, Reis H, Stuschke M, Treckmann J, Markus P, Schumacher B, Albers D, Mende B, Lahner H, Wiesweg M, Schuler M, Siveke JT, Kasper S. Identification of a new prognostic score for patients with high-grade metastatic GEP-NEN treated with palliative chemotherapy. J Cancer Res Clin Oncol 2022:10.1007/s00432-022-04314-5. [PMID: 36071236 DOI: 10.1007/s00432-022-04314-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 08/19/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE High-grade gastroenteropancreatic neuroendocrine neoplasms (GEP-NEN G3) are rare and heterogeneous malignancies with poor prognosis. Aim of this study was to develop prognosticators identifying those patients that derive the most benefit from currently available systemic therapies. METHODS This retrospective analysis included 78 patients with metastatic GEP-NEN G3. For patients with imaging data available (n = 52), the overall response rate (ORR) and disease control rate (DCR) were evaluated according to the Response Evaluation Criteria in Solid Tumors 1.1 (RECIST 1.1). A Cox proportional hazard model was used to analyze the prognostic value of selected clinical and blood-based biomarkers. The impact of palliative chemotherapy regimens on time-to-treatment-failure (TTF) and overall survival (OS) was assessed. RESULTS Median OS of the study cohort was 9.0 months (95% CI 7.0-11.1). The majority of patients received first-line treatment with platinum plus etoposide (83.3%). The ORR and DCR of the RECIST-evaluable subgroup were 34.6% and 76.9%. Median TTF upon first-line treatment was 4.9 months (95% CI 3.4-6.4). Multivariate analysis identified the Eastern Cooperative Oncology Group performance status (ECOG PS), lactate dehydrogenase (LDH) and absolute lymphocyte count as independent prognostic factors. A prognostic score based on these parameters discriminated patients with favorable and unfavorable outcomes. CONCLUSION Outcomes of patients with GEP-NEN G3 are still limited. A new prognostic score identifying those patients benefitting from current platinum/etoposide-based chemotherapy protocols may help as stratification factor in future trial design.
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Affiliation(s)
- Vivian Rosery
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen (AöR), Essen, Germany.,Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen (AöR), Essen, Germany
| | - Stephan Mika
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen (AöR), Essen, Germany
| | - Kurt Werner Schmid
- Institute of Pathology, West German Cancer Center, University Hospital Essen (AöR), Essen, Germany
| | - Henning Reis
- Institute of Pathology, West German Cancer Center, University Hospital Essen (AöR), Essen, Germany.,Institute of Pathology, University Hospital Frankfurt, Frankfurt, Germany
| | - Martin Stuschke
- Department of Radiotherapy, West German Cancer Center, University Hospital Essen (AöR), Essen, Germany
| | - Jürgen Treckmann
- General, Visceral and Transplantation Surgery, University Hospital Essen (AöR), Essen, Germany
| | - Peter Markus
- Department of General Surgery and Traumatology, Elisabeth Hospital Essen, Essen, Germany
| | | | - David Albers
- Department of Gastroenterology, Elisabeth Hospital Essen, Essen, Germany
| | - Bastian Mende
- Central Pharmacy, University Hospital Essen (AöR), Essen, Germany
| | - Harald Lahner
- Department of Endocrinology and Metabolism, University Hospital Essen (AöR), Essen, Germany
| | - Marcel Wiesweg
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen (AöR), Essen, Germany.,German Cancer Consortium (DKTK), Partner Site University Hospital Essen (AöR), Essen, Germany
| | - Martin Schuler
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen (AöR), Essen, Germany.,German Cancer Consortium (DKTK), Partner Site University Hospital Essen (AöR), Essen, Germany
| | - Jens T Siveke
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen (AöR), Essen, Germany.,Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen (AöR), Essen, Germany.,Division of Solid Tumor Translational Oncology, German Cancer Consortium (DKTK), Partner site University Hospital Essen, and German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), Partner Site University Hospital Essen (AöR), Essen, Germany
| | - Stefan Kasper
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen (AöR), Essen, Germany. .,German Cancer Consortium (DKTK), Partner Site University Hospital Essen (AöR), Essen, Germany.
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17
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Karamched BR, Hripcsak G, Leibel RL, Albers D, Ott W. Delay-induced uncertainty in the glucose-insulin system: Pathogenicity for obesity and type-2 diabetes mellitus. Front Physiol 2022; 13:936101. [PMID: 36117719 PMCID: PMC9476552 DOI: 10.3389/fphys.2022.936101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/05/2022] [Indexed: 11/13/2022] Open
Abstract
We have recently shown that physiological delay can induce a novel form of sustained temporal chaos we call delay-induced uncertainty (DIU) (Karamched et al. (Chaos, 2021, 31, 023142)). This paper assesses the impact of DIU on the ability of the glucose-insulin system to maintain homeostasis when responding to the ingestion of meals. We address two questions. First, what is the nature of the DIU phenotype? That is, what physiological macrostates (as encoded by physiological parameters) allow for DIU onset? Second, how does DIU impact health? We find that the DIU phenotype is abundant in the space of intrinsic parameters for the Ultradian glucose-insulin model—a model that has been successfully used to predict glucose-insulin dynamics in humans. Configurations of intrinsic parameters that correspond to high characteristic glucose levels facilitate DIU onset. We argue that DIU is pathogenic for obesity and type-2 diabetes mellitus by linking the statistical profile of DIU to the glucostatic theory of hunger.
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Affiliation(s)
- Bhargav R. Karamched
- Department of Mathematics, Florida State University, Tallahassee, FL, United States
- Institute of Molecular Biophysics, Florida State University, Tallahassee, FL, United States
- Program in Neuroscience, Florida State University, Tallahassee, FL, United States
- *Correspondence: William Ott, ; Bhargav R. Karamched,
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
| | - Rudolph L. Leibel
- Division of Molecular Genetics, Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, NY, NY, United States
- Naomi Berrie Diabetes Center, Columbia University Irving Medical Center, NY, NY, United States
| | - David Albers
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
- Section of Informatics and Data Science, Department of Pediatrics, Department of Biomedical Engineering, and Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - William Ott
- Department of Mathematics, University of Houston, Houston, TX, United States
- *Correspondence: William Ott, ; Bhargav R. Karamched,
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18
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Keyl J, Kasper S, Wiesweg M, Götze J, Schönrock M, Sinn M, Berger A, Nasca E, Kostbade K, Schumacher B, Markus P, Albers D, Treckmann J, Schmid KW, Schildhaus HU, Siveke JT, Schuler M, Kleesiek J. Multimodal survival prediction in advanced pancreatic cancer using machine learning. ESMO Open 2022; 7:100555. [PMID: 35988455 PMCID: PMC9588888 DOI: 10.1016/j.esmoop.2022.100555] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/04/2022] [Accepted: 07/05/2022] [Indexed: 11/23/2022] Open
Abstract
Background Existing risk scores appear insufficient to assess the individual survival risk of patients with advanced pancreatic ductal adenocarcinoma (PDAC) and do not take advantage of the variety of parameters that are collected during clinical care. Methods In this retrospective study, we built a random survival forest model from clinical data of 203 patients with advanced PDAC. The parameters were assessed before initiation of systemic treatment and included age, CA19-9, C-reactive protein, metastatic status, neutrophil-to-lymphocyte ratio and total serum protein level. Separate models including imaging and molecular parameters were built for subgroups. Results Over the entire cohort, a model based on clinical parameters achieved a c-index of 0.71. Our approach outperformed the American Joint Committee on Cancer (AJCC) staging system and the modified Glasgow Prognostic Score (mGPS) in the identification of high- and low-risk subgroups. Inclusion of the KRAS p.G12D mutational status could further improve the prediction, whereas radiomics data of the primary tumor only showed little benefit. In an external validation cohort of PDAC patients with liver metastases, our model achieved a c-index of 0.67 (mGPS: 0.59). Conclusions The combination of multimodal data and machine-learning algorithms holds potential for personalized prognostication in advanced PDAC already at diagnosis. We developed a machine-learning-based prediction model that outperforms the AJCC staging system and mGPS. Applying our model to an external validation cohort demonstrates generalizability. Explainable machine learning enables to understand the decision making of our model and identifies relevant parameters. Combining clinical, imaging and genetic data holds potential for personalized prognostication in advanced PDAC.
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Affiliation(s)
- J Keyl
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen (AöR), University of Duisburg-Essen, Essen, Germany; Institute for AI in Medicine (IKIM), University Hospital Essen (AöR), Essen, Germany; German Cancer Consortium (DKTK), Partner site University Hospital Essen (AöR), Essen, Germany.
| | - S Kasper
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen (AöR), University of Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner site University Hospital Essen (AöR), Essen, Germany; Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - M Wiesweg
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen (AöR), University of Duisburg-Essen, Essen, Germany; Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - J Götze
- Department of Internal Medicine II, Oncology, Hematology, BMT and Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M Schönrock
- Department of Internal Medicine II, Oncology, Hematology, BMT and Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M Sinn
- Department of Internal Medicine II, Oncology, Hematology, BMT and Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Berger
- Institute for AI in Medicine (IKIM), University Hospital Essen (AöR), Essen, Germany
| | - E Nasca
- Institute for AI in Medicine (IKIM), University Hospital Essen (AöR), Essen, Germany
| | - K Kostbade
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen (AöR), University of Duisburg-Essen, Essen, Germany; Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - B Schumacher
- Department of Gastroenterology, Elisabeth Hospital Essen, Essen, Germany
| | - P Markus
- Department of General Surgery and Traumatology, Elisabeth Hospital Essen, Essen, Germany
| | - D Albers
- Department of Gastroenterology, Elisabeth Hospital Essen, Essen, Germany
| | - J Treckmann
- Department of General, Visceral and Transplant Surgery, West German Cancer Center, University Hospital Essen (AöR), Essen, Germany
| | - K W Schmid
- Medical Faculty, University of Duisburg-Essen, Essen, Germany; Institute of Pathology, West German Cancer Center, University Hospital Essen (AöR), Essen, Germany
| | - H-U Schildhaus
- Medical Faculty, University of Duisburg-Essen, Essen, Germany; Institute of Pathology, West German Cancer Center, University Hospital Essen (AöR), Essen, Germany
| | - J T Siveke
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen (AöR), University of Duisburg-Essen, Essen, Germany; Medical Faculty, University of Duisburg-Essen, Essen, Germany; Bridge Institute of Experimental Tumor Therapy (BIT), West German Cancer Center, University Hospital Essen (AöR), Essen, Germany; Division of Solid Tumor Translational Oncology, German Cancer Consortium (DKTK) Partner site Essen, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - M Schuler
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen (AöR), University of Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner site University Hospital Essen (AöR), Essen, Germany; Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - J Kleesiek
- Institute for AI in Medicine (IKIM), University Hospital Essen (AöR), Essen, Germany; Medical Faculty, University of Duisburg-Essen, Essen, Germany
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19
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Meier B, Wannhoff A, Denzer U, Stathopoulos P, Schumacher B, Albers D, Hoffmeister A, Feisthammel J, Walter B, Meining A, Wedi E, Zachäus M, Pickartz T, Küllmer A, Schmidt A, Caca K. Over-the-scope-clips versus standard treatment in high-risk patients with acute non-variceal upper gastrointestinal bleeding: a randomised controlled trial (STING-2). Gut 2022; 71:1251-1258. [PMID: 35321938 DOI: 10.1136/gutjnl-2021-325300] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [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: 06/01/2021] [Accepted: 02/26/2022] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Acute non-variceal upper gastrointestinal bleeding (NVUGIB) is managed by standard endoscopic combination therapy, but a few cases remain difficult and carry a high risk of persistent or recurrent bleeding. The aim of our study was to compare first-line over-the-scope-clips (OTSC) therapy with standard endoscopic treatment in these selected patients. DESIGN We conducted a prospective, randomised, controlled, multicentre study (NCT03331224). Patients with endoscopic evidence of acute NVUGIB and high risk of rebleeding (defined as complete Rockall Score ≥7) were included. Primary endpoint was clinical success defined as successful endoscopic haemostasis without evidence of recurrent bleeding. RESULTS 246 patients were screened and 100 patients were finally randomised (mean of 5 cases/centre and year; 70% male, 30% female, mean age 78 years; OTSC group n=48, standard group n=52). All but one case in the standard group were treated with conventional clips. Clinical success was 91.7% (n=44) in the OTSC group compared with 73.1% (n=38) in the ST group (p=0.019), with persistent bleeding occurring in 0 vs 6 in the OTSC versus standard group (p=0.027), all of the latter being successfully managed by rescue therapy with OTSC. Recurrent bleeding was observed in four patients (8.3%) in the OTSC group and in eight patients (15.4%) in the standard group (p=0.362). CONCLUSION OTSC therapy appears to be superior to standard treatment with clips when used by trained physicians for selected cases of primary therapy of NVUGIB with high risk of rebleeding. Further studies are necessary with regards to patient selection to identify subgroups benefiting most from OTSC haemostasis. TRIAL REGISTRATION NUMBER NCT03331224.
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Affiliation(s)
- Benjamin Meier
- Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | | | - Ulrike Denzer
- Gastroenterology, University of Marburg, Marburg, Germany
| | | | | | - David Albers
- Gastroenterology, Elisabeth-Krankenhaus-Essen, Essen, Germany
| | | | | | | | - Alexander Meining
- Gastroenterology, University of Ulm, Ulm, Germany.,Gastroenterology, University of Würzburg, Würzburg, Germany
| | - Edris Wedi
- Gastroenterology, Sana Klinikum Offenbach, Offenbach, Germany.,Gastroenterology, University of Göttingen, Göttingen, Germany
| | - Markus Zachäus
- Gastroenterology, Helios Park-Klinikum Leipzig, Leipzig, Germany
| | - Tilman Pickartz
- Gastroenterology, University of Greifswald, Greifswald, Germany
| | - Armin Küllmer
- Gastroenterology, University of Freiburg, Freiburg im Breisgau, Germany
| | - Arthur Schmidt
- Gastroenterology, University of Freiburg, Freiburg im Breisgau, Germany
| | - Karel Caca
- Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg, Germany
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20
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Rossetti SC, Dykes PC, Knaplund C, Kang MJ, Schnock K, Garcia JP, Fu LH, Chang F, Thai T, Fred M, Korach TZ, Zhou L, Klann JG, Albers D, Schwartz J, Lowenthal G, Jia H, Liu F, Cato K. The Communicating Narrative Concerns Entered by Registered Nurses (CONCERN) Clinical Decision Support Early Warning System: Protocol for a Cluster Randomized Pragmatic Clinical Trial. JMIR Res Protoc 2021; 10:e30238. [PMID: 34889766 PMCID: PMC8709914 DOI: 10.2196/30238] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 09/01/2021] [Accepted: 09/16/2021] [Indexed: 11/13/2022] Open
Abstract
Background Every year, hundreds of thousands of inpatients die from cardiac arrest and sepsis, which could be avoided if those patients’ risk for deterioration were detected and timely interventions were initiated. Thus, a system is needed to convert real-time, raw patient data into consumable information that clinicians can utilize to identify patients at risk of deterioration and thus prevent mortality and improve patient health outcomes. The overarching goal of the COmmunicating Narrative Concerns Entered by Registered Nurses (CONCERN) study is to implement and evaluate an early warning score system that provides clinical decision support (CDS) in electronic health record systems. With a combination of machine learning and natural language processing, the CONCERN CDS utilizes nursing documentation patterns as indicators of nurses’ increased surveillance to predict when patients are at the risk of clinical deterioration. Objective The objective of this cluster randomized pragmatic clinical trial is to evaluate the effectiveness and usability of the CONCERN CDS system at 2 different study sites. The specific aim is to decrease hospitalized patients’ negative health outcomes (in-hospital mortality, length of stay, cardiac arrest, unanticipated intensive care unit transfers, and 30-day hospital readmission rates). Methods A multiple time-series intervention consisting of 3 phases will be performed through a 1-year period during the cluster randomized pragmatic clinical trial. Phase 1 evaluates the adoption of our algorithm through pilot and trial testing, phase 2 activates optimized versions of the CONCERN CDS based on experience from phase 1, and phase 3 will be a silent release mode where no CDS is viewable to the end user. The intervention deals with a series of processes from system release to evaluation. The system release includes CONCERN CDS implementation and user training. Then, a mixed methods approach will be used with end users to assess the system and clinician perspectives. Results Data collection and analysis are expected to conclude by August 2022. Based on our previous work on CONCERN, we expect the system to have a positive impact on the mortality rate and length of stay. Conclusions The CONCERN CDS will increase team-based situational awareness and shared understanding of patients predicted to be at risk for clinical deterioration in need of intervention to prevent mortality and associated harm. Trial Registration ClinicalTrials.gov NCT03911687; https://clinicaltrials.gov/ct2/show/NCT03911687 International Registered Report Identifier (IRRID) DERR1-10.2196/30238
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Affiliation(s)
- Sarah Collins Rossetti
- Department of Biomedical Informatics, Columbia University, New York, NY, United States.,School of Nursing, Columbia University Medical Center, New York, NY, United States
| | - Patricia C Dykes
- Brigham and Women's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Christopher Knaplund
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
| | - Min-Jeoung Kang
- Brigham and Women's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Kumiko Schnock
- Brigham and Women's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | | | - Li-Heng Fu
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
| | - Frank Chang
- Brigham and Women's Hospital, Boston, MA, United States
| | - Tien Thai
- Brigham and Women's Hospital, Boston, MA, United States
| | - Matthew Fred
- Working Diagnosis, Haddonfield, NJ, United States
| | - Tom Z Korach
- Brigham and Women's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Li Zhou
- Brigham and Women's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | | | - David Albers
- Department of Biomedical Informatics, Columbia University, New York, NY, United States.,Anschutz Medical Campus, University of Colorado, Aurora, CO, United States
| | - Jessica Schwartz
- School of Nursing, Columbia University Medical Center, New York, NY, United States
| | | | - Haomiao Jia
- School of Nursing, Columbia University Medical Center, New York, NY, United States
| | - Fang Liu
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
| | - Kenrick Cato
- School of Nursing, Columbia University Medical Center, New York, NY, United States
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21
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Fu LH, Knaplund C, Cato K, Perotte A, Kang MJ, Dykes PC, Albers D, Collins Rossetti S. Utilizing timestamps of longitudinal electronic health record data to classify clinical deterioration events. J Am Med Inform Assoc 2021; 28:1955-1963. [PMID: 34270710 DOI: 10.1093/jamia/ocab111] [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] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 05/03/2021] [Accepted: 05/19/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To propose an algorithm that utilizes only timestamps of longitudinal electronic health record data to classify clinical deterioration events. MATERIALS AND METHODS This retrospective study explores the efficacy of machine learning algorithms in classifying clinical deterioration events among patients in intensive care units using sequences of timestamps of vital sign measurements, flowsheets comments, order entries, and nursing notes. We design a data pipeline to partition events into discrete, regular time bins that we refer to as timesteps. Logistic regressions, random forest classifiers, and recurrent neural networks are trained on datasets of different length of timesteps, respectively, against a composite outcome of death, cardiac arrest, and Rapid Response Team calls. Then these models are validated on a holdout dataset. RESULTS A total of 6720 intensive care unit encounters meet the criteria and the final dataset includes 830 578 timestamps. The gated recurrent unit model utilizes timestamps of vital signs, order entries, flowsheet comments, and nursing notes to achieve the best performance on the time-to-outcome dataset, with an area under the precision-recall curve of 0.101 (0.06, 0.137), a sensitivity of 0.443, and a positive predictive value of 0. 092 at the threshold of 0.6. DISCUSSION AND CONCLUSION This study demonstrates that our recurrent neural network models using only timestamps of longitudinal electronic health record data that reflect healthcare processes achieve well-performing discriminative power.
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Affiliation(s)
- Li-Heng Fu
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
| | - Chris Knaplund
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
| | - Kenrick Cato
- School of Nursing, Columbia University, New York, New York, USA
| | - Adler Perotte
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
| | - Min-Jeoung Kang
- The Catholic University of Korea, College of Nursing, Seoul, Republic of Korea
| | - Patricia C Dykes
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - David Albers
- Department of Biomedical Informatics, Columbia University, New York, New York, USA.,Department of Pediatrics, Section of Informatics and Data Science, University of Colorado, Aurora, Colorado, USA
| | - Sarah Collins Rossetti
- Department of Biomedical Informatics, Columbia University, New York, New York, USA.,School of Nursing, Columbia University, New York, New York, USA
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22
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Wilke L, Moustakis C, Blanck O, Albers D, Albrecht C, Avcu Y, Boucenna R, Buchauer K, Etzelstorfer T, Henkenberens C, Jeller D, Jurianz K, Kornhuber C, Kretschmer M, Lotze S, Meier K, Pemler P, Riegler A, Röser A, Schmidhalter D, Spruijt KH, Surber G, Vallet V, Wiehle R, Willner J, Winkler P, Wittig A, Guckenberger M, Tanadini-Lang S. Improving interinstitutional and intertechnology consistency of pulmonary SBRT by dose prescription to the mean internal target volume dose. Strahlenther Onkol 2021; 197:836-846. [PMID: 34196725 PMCID: PMC8397670 DOI: 10.1007/s00066-021-01799-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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 05/10/2021] [Indexed: 11/16/2022]
Abstract
Purpose Dose, fractionation, normalization and the dose profile inside the target volume vary substantially in pulmonary stereotactic body radiotherapy (SBRT) between different institutions and SBRT technologies. Published planning studies have shown large variations of the mean dose in planning target volume (PTV) and gross tumor volume (GTV) or internal target volume (ITV) when dose prescription is performed to the PTV covering isodose. This planning study investigated whether dose prescription to the mean dose of the ITV improves consistency in pulmonary SBRT dose distributions. Materials and methods This was a multi-institutional planning study by the German Society of Radiation Oncology (DEGRO) working group Radiosurgery and Stereotactic Radiotherapy. CT images and structures of ITV, PTV and all relevant organs at risk (OAR) for two patients with early stage non-small cell lung cancer (NSCLC) were distributed to all participating institutions. Each institute created a treatment plan with the technique commonly used in the institute for lung SBRT. The specified dose fractionation was 3 × 21.5 Gy normalized to the mean ITV dose. Additional dose objectives for target volumes and OAR were provided. Results In all, 52 plans from 25 institutions were included in this analysis: 8 robotic radiosurgery (RRS), 34 intensity-modulated (MOD), and 10 3D-conformal (3D) radiation therapy plans. The distribution of the mean dose in the PTV did not differ significantly between the two patients (median 56.9 Gy vs 56.6 Gy). There was only a small difference between the techniques, with RRS having the lowest mean PTV dose with a median of 55.9 Gy followed by MOD plans with 56.7 Gy and 3D plans with 57.4 Gy having the highest. For the different organs at risk no significant difference between the techniques could be found. Conclusions This planning study pointed out that multiparameter dose prescription including normalization on the mean ITV dose in combination with detailed objectives for the PTV and ITV achieve consistent dose distributions for peripheral lung tumors in combination with an ITV concept between different delivery techniques and across institutions. Supplementary Information The online version of this article (10.1007/s00066-021-01799-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- L Wilke
- Klinik für Radio-Onkologie, Universitätsspital Zürich, Zürich, Switzerland.
| | - C Moustakis
- Klinik für Strahlentherapie, Universitätsklinikum Münster, Münster, Germany
| | - O Blanck
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein - Campus Kiel, Kiel, Germany
| | - D Albers
- Klinik für Strahlentherapie und Radioonkologie, Universtitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - C Albrecht
- CyberKnife Centrum Süd, Schwarzwald-Baar Klinikum Villingen-Schwenningen, Villingen-Schwenningen, Germany
| | - Y Avcu
- Klinik für Strahlentherapie und Radioonkologie, Universitätsspital Basel, Basel, Switzerland
| | - R Boucenna
- Institut de radio-oncologie, Hislanden Lausanne, Lausanne, Switzerland
| | - K Buchauer
- Klinik für Radio-Onkologie, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - T Etzelstorfer
- Radio-Onkologie, Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
| | - C Henkenberens
- Klinik für Strahlentherapie und Spezielle Onkologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - D Jeller
- Radio-Onkologie, Kantonsspital Luzern, Luzern, Switzerland
| | - K Jurianz
- MVZ Gamma-Knife Zentrum Krefeld, Krefeld, Germany
| | - C Kornhuber
- Klinik für Strahlentherapie, Universitätsklinikum Halle, Halle, Germany
| | | | - S Lotze
- Klinik für Radioonkologie und Strahlentherapie, Uniklinik RWTH Aachen, Aachen, Germany
| | - K Meier
- Strahlentherapie, Klinikum Wolfsburg, Wolfsburg, Germany
| | - P Pemler
- Klinik für Radioonkologie, Stadtspital Triemli, Zürich, Switzerland
| | - A Riegler
- Institut für Radioonkologie und Strahlentherapie, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - A Röser
- Strahlentherapie und Radio-Onkologie, Helios Universitätsklinikum Wuppertal, Wuppertal, Germany
| | - D Schmidhalter
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern, Switzerland.,University Hospital, and University of Bern, Bern, Switzerland
| | - K H Spruijt
- Institut de radio-oncologie, Clinique des Grangettes, Geneva, Switzerland
| | - G Surber
- Institut für Radiochirurgie und Präzisionsbestrahlung, CyberKnife Centrum Mitteldeutschland, Erfurt, Germany
| | - V Vallet
- Service de radio-oncologie, Centre hospitalier universitaire vaudois, Lausanne, Switzerland
| | - R Wiehle
- Klinik für Strahlenheilkunde, Universitätsklinikum Freiburg, Freiburg, Germany
| | - J Willner
- Klinik für Strahlentherapie, Klinikum Bayreuth, Bayreuth, Germany
| | - P Winkler
- Universitätsklinik für Strahlentherapie-Radioonkologie, LKH-Univ. Klinikum Graz, Graz, Austria
| | - A Wittig
- Departent of Radiotherapy and Radiation Oncology, University Hospital Jena, Friedrich-Schiller-University Jena, Jena, Germany
| | - M Guckenberger
- Klinik für Radio-Onkologie, Universitätsspital Zürich, Zürich, Switzerland
| | - S Tanadini-Lang
- Klinik für Radio-Onkologie, Universitätsspital Zürich, Zürich, Switzerland
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23
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Spaander MCW, van der Bogt RD, Baron TH, Albers D, Blero D, de Ceglie A, Conio M, Czakó L, Everett S, Garcia-Pagán JC, Ginès A, Jovani M, Repici A, Rodrigues-Pinto E, Siersema PD, Fuccio L, van Hooft JE. Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy 2021; 53:751-762. [PMID: 33930932 DOI: 10.1055/a-1475-0063] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [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] [Indexed: 12/24/2022]
Abstract
MALIGNANT DISEASE 1: ESGE recommends placement of partially or fully covered self-expandable metal stents (SEMSs) for palliation of malignant dysphagia over laser therapy, photodynamic therapy, and esophageal bypass.Strong recommendation, high quality evidence. 2 : ESGE recommends brachytherapy as a valid alternative, alone or in addition to stenting, in esophageal cancer patients with malignant dysphagia and expected longer life expectancy.Strong recommendation, high quality evidence. 3: ESGE recommends esophageal SEMS placement for sealing malignant tracheoesophageal or bronchoesophageal fistulas. Strong recommendation, low quality evidence. 4 : ESGE does not recommend SEMS placement as a bridge to surgery or before preoperative chemoradiotherapy because it is associated with a high incidence of adverse events. Other options such as feeding tube placement are preferable. Strong recommendation, low quality evidence. BENIGN DISEASE 5: ESGE recommends against the use of SEMSs as first-line therapy for the management of benign esophageal strictures because of the potential for adverse events, the availability of alternative therapies, and their cost. Strong recommendation, low quality evidence. 6: ESGE suggests consideration of temporary placement of self-expandable stents for refractory benign esophageal strictures. Weak recommendation, moderate quality evidence. 7: ESGE suggests that fully covered SEMSs be preferred over partially covered SEMSs for the treatment of refractory benign esophageal strictures because of their very low risk of embedment and ease of removability. Weak recommendation, low quality evidence. 8: ESGE recommends the stent-in-stent technique to remove partially covered SEMSs that are embedded in the esophageal wall. Strong recommendation, low quality evidence. 9: ESGE recommends that temporary stent placement can be considered for the treatment of leaks, fistulas, and perforations. No specific type of stent can be recommended, and the duration of stenting should be individualized. Strong recommendation, low quality of evidence. 10 : ESGE recommends considering placement of a fully covered large-diameter SEMS for the treatment of esophageal variceal bleeding refractory to medical, endoscopic, and/or radiological therapy, or as initial therapy for patients with massive bleeding. Strong recommendation, moderate quality evidence.
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Affiliation(s)
- Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Ruben D van der Bogt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Todd H Baron
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - David Albers
- Department of Internal Medicine and Gastroenterology, Elisabeth-Krankenhaus Academic Hospital, University of Duisburg-Essen, Essen, Germany
| | - Daniel Blero
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasme Hospital, ULB (Free University of Brussels), Brussels, Belgium
| | - Antonella de Ceglie
- Department of Gastroenterology, Ospedale Civile di Sanremo, Sanremo (IM), Italy
| | - Massimo Conio
- Department of Gastroenterology, Ospedale Santa Corona, Pietra Ligure (SV), Italy
| | - László Czakó
- First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Simon Everett
- Department of Gastroenterology and Hepatology, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Juan-Carlos Garcia-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit - Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver) - Hospital Clinic, IDIBAPS and CIBERehd, University of Barcelona, Barcelona, Spain
| | - Angels Ginès
- Gastroenterology Department, Hospital Clinic of Barcelona, IDIBAPS and CIBERehd, University of Barcelona, Barcelona, Spain
| | - Manol Jovani
- Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Alessandro Repici
- Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | | | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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24
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Kuellmer A, Behn J, Beyna T, Schumacher B, Meining A, Messmann H, Neuhaus H, Albers D, Birk M, Probst A, Faehndrich M, Frieling T, Goetz M, Thimme R, Caca K, Schmidt A. Endoscopic full-thickness resection and its treatment alternatives in difficult-to-treat lesions of the lower gastrointestinal tract: a cost-effectiveness analysis. BMJ Open Gastroenterol 2021; 7:bmjgast-2020-000449. [PMID: 32816955 PMCID: PMC7437695 DOI: 10.1136/bmjgast-2020-000449] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/19/2020] [Accepted: 07/20/2020] [Indexed: 11/05/2022] Open
Abstract
Objective Endoscopic full-thickness resection (EFTR) has shown efficacy and safety in the colorectum. The aim of this analysis was to investigate whether EFTR is cost-effective in comparison with surgical and endoscopic treatment alternatives. Design Real data from the study cohort of the prospective, single-arm WALL RESECT study were used. A simulated comparison arm was created based on a survey that included suggested treatment alternatives to EFTR of the respective lesions. Treatment costs and reimbursement were calculated in euro according to the coding rules of 2017 and 2019 (EFTR). R0 resection rate was used as a measure of effectiveness. To assess cost-effectiveness, the average cost-effectiveness ratio (ACER) and the incremental cost-effectiveness ratio (ICER) were determined. Calculations were made both from the perspective of the care provider as well as of the payer. Results The cost per case was €2852.20 for the EFTR group, €1712 for the standard endoscopic resection (SER) group, €8895 for the surgical resection group and €5828 for the pooled alternative treatment to EFTR. From the perspective of the care provider, the ACER (mean cost per R0 resection) was €3708.98 for EFTR, €3115.10 for SER, €8924.05 for surgical treatment and €7169.30 for all pooled and weighted alternatives to EFTR. The ICER (additional cost per R0 resection compared with EFTR) was €5196.47 for SER, €26 533.13 for surgical resection and €67 768.62 for the pooled rate of alternatives. Results from the perspective of the payer were similar. Conclusion EFTR is cost-effective in comparison with surgical and endoscopic treatment alternatives in the colorectum.
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Affiliation(s)
- Armin Kuellmer
- Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Juliane Behn
- Department of Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg, Baden-Württemberg, Germany
| | - Torsten Beyna
- Department of Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Dusseldorf, Nordrhein-Westfalen, Germany
| | - Brigitte Schumacher
- Department of Internal Medicine and Gastroenterology, Elisabeth Hospital, Essen, Nordrhein-Westfalen, Germany
| | - Alexander Meining
- Department of Medicine II, Interventional and Experimental Endoscopy (InExEn), University Hospital Wurzburg, Wurzburg, Bayern, Germany
| | - Helmut Messmann
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Bayern, Germany
| | - Horst Neuhaus
- Department of Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Dusseldorf, Nordrhein-Westfalen, Germany
| | - David Albers
- Department of Internal Medicine and Gastroenterology, Elisabeth Hospital, Essen, Nordrhein-Westfalen, Germany
| | - Michael Birk
- Department of Gastroenterology, University Hospital Ulm, Ulm, Baden-Württemberg, Germany
| | - Andreas Probst
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Bayern, Germany
| | - Martin Faehndrich
- Department of Gastroenterology, Klinikum Dortmund, Dortmund, Nordrhein-Westfalen, Germany
| | - Thomas Frieling
- Department of Gastroenterology, HELIOS Klinikum Krefeld, Krefeld, Nordrhein-Westfalen, Germany
| | - Martin Goetz
- Department of Gastroenterology/Oncology, Klinikum Sindelfingen-Böblingen, Sindelfingen, Baden-Württemberg, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Karel Caca
- Department of Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg, Baden-Württemberg, Germany
| | - Arthur Schmidt
- Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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25
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Sottile PD, Albers D, DeWitt PE, Russell S, Stroh JN, Kao DP, Adrian B, Levine ME, Mooney R, Larchick L, Kutner JS, Wynia MK, Glasheen JJ, Bennett TD. Real-Time Electronic Health Record Mortality Prediction During the COVID-19 Pandemic: A Prospective Cohort Study. J Am Med Inform Assoc 2021; 28:2354-2365. [PMID: 33973011 PMCID: PMC8136054 DOI: 10.1093/jamia/ocab100] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/19/2021] [Accepted: 05/06/2021] [Indexed: 11/24/2022] Open
Abstract
Objective To rapidly develop, validate, and implement a novel real-time mortality score for the COVID-19 pandemic that improves upon sequential organ failure assessment (SOFA) for decision support for a Crisis Standards of Care team. Materials and Methods We developed, verified, and deployed a stacked generalization model to predict mortality using data available in the electronic health record (EHR) by combining 5 previously validated scores and additional novel variables reported to be associated with COVID-19-specific mortality. We verified the model with prospectively collected data from 12 hospitals in Colorado between March 2020 and July 2020. We compared the area under the receiver operator curve (AUROC) for the new model to the SOFA score and the Charlson Comorbidity Index. Results The prospective cohort included 27 296 encounters, of which 1358 (5.0%) were positive for SARS-CoV-2, 4494 (16.5%) required intensive care unit care, 1480 (5.4%) required mechanical ventilation, and 717 (2.6%) ended in death. The Charlson Comorbidity Index and SOFA scores predicted mortality with an AUROC of 0.72 and 0.90, respectively. Our novel score predicted mortality with AUROC 0.94. In the subset of patients with COVID-19, the stacked model predicted mortality with AUROC 0.90, whereas SOFA had AUROC of 0.85. Discussion Stacked regression allows a flexible, updatable, live-implementable, ethically defensible predictive analytics tool for decision support that begins with validated models and includes only novel information that improves prediction. Conclusion We developed and validated an accurate in-hospital mortality prediction score in a live EHR for automatic and continuous calculation using a novel model that improved upon SOFA.
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Affiliation(s)
- Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - David Albers
- Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Peter E DeWitt
- Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Seth Russell
- Data Science to Patient Value Initiative, University of Colorado School of Medicine, Aurora, CO, USA
| | - J N Stroh
- Department of Bioengineering, University of Colorado-Denver College of Engineering, Design, and Computing, Denver, CO, USA
| | - David P Kao
- Divisions of Cardiology and Bioinformatics/Personalized Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Bonnie Adrian
- UCHealth Clinical Informatics and University of Colorado College of Nursing, Aurora, CO, USA
| | - Matthew E Levine
- Department of Computational and Mathematical Sciences, California Institute of Technology, Pasadena, CA, USA
| | | | | | - Jean S Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Chief Medical Officer, University of Colorado Hospital/UCHealth, Aurora, CO, USA
| | - Matthew K Wynia
- Center for Bioethics and Humanities, University of Colorado and Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jeffrey J Glasheen
- Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine and Chief Quality Officer, UCHealth, Aurora, CO, USA
| | - Tellen D Bennett
- Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.,Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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Stroh JN, Bennett TD, Kheyfets V, Albers D. Clinical Decision Support for Traumatic Brain Injury: Identifying a Framework for Practical Model-Based Intracranial Pressure Estimation at Multihour Timescales. JMIR Med Inform 2021; 9:e23215. [PMID: 33749613 PMCID: PMC8077603 DOI: 10.2196/23215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The clinical mitigation of intracranial hypertension due to traumatic brain injury requires timely knowledge of intracranial pressure to avoid secondary injury or death. Noninvasive intracranial pressure (nICP) estimation that operates sufficiently fast at multihour timescales and requires only common patient measurements is a desirable tool for clinical decision support and improving traumatic brain injury patient outcomes. However, existing model-based nICP estimation methods may be too slow or require data that are not easily obtained. OBJECTIVE This work considers short- and real-time nICP estimation at multihour timescales based on arterial blood pressure (ABP) to better inform the ongoing development of practical models with commonly available data. METHODS We assess and analyze the effects of two distinct pathways of model development, either by increasing physiological integration using a simple pressure estimation model, or by increasing physiological fidelity using a more complex model. Comparison of the model approaches is performed using a set of quantitative model validation criteria over hour-scale times applied to model nICP estimates in relation to observed ICP. RESULTS The simple fully coupled estimation scheme based on windowed regression outperforms a more complex nICP model with prescribed intracranial inflow when pulsatile ABP inflow conditions are provided. We also show that the simple estimation data requirements can be reduced to 1-minute averaged ABP summary data under generic waveform representation. CONCLUSIONS Stronger performance of the simple bidirectional model indicates that feedback between the systemic vascular network and nICP estimation scheme is crucial for modeling over long intervals. However, simple model reduction to ABP-only dependence limits its utility in cases involving other brain injuries such as ischemic stroke and subarachnoid hemorrhage. Additional methodologies and considerations needed to overcome these limitations are illustrated and discussed.
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Affiliation(s)
- J N Stroh
- Department of Bioengineering, University of Colorado Denver
- Anschutz Medical Campus, Aurora, CO, United States
| | - Tellen D Bennett
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
| | - Vitaly Kheyfets
- Department of Bioengineering, University of Colorado Denver
- Anschutz Medical Campus, Aurora, CO, United States
| | - David Albers
- Department of Bioengineering, University of Colorado Denver
- Anschutz Medical Campus, Aurora, CO, United States.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
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Albers D, Meining A, Hann A, Ayoub YK, Schumacher B. Direct endoscopic necrosectomy in infected pancreatic necrosis using lumen-apposing metal stents: Early intervention does not compromise outcome. Endosc Int Open 2021; 9:E490-E495. [PMID: 33655055 PMCID: PMC7899788 DOI: 10.1055/a-1341-0654] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 11/23/2020] [Indexed: 12/12/2022] Open
Abstract
Background and study aims Infection of pancreatic necrosis is a dreaded complication requiring an intervention. Nevertheless, the optimal timing of the first intervention is unclear, and consensus data are sparse. This retrospective two-center study evaluated direct endoscopic necrosectomy using lumen apposing metal stents in case of proven or suspected infected pancreatic necrosis in an early stage of the disease. Patients and methods Forty-nine patients with infected pancreatic necrosis were included. Sequent direct endoscopic necrosectomies after lumen apposing metal stent insertion (LAMS) were performed until the resolution of necrosis. In all patients, the first endoscopic intervention was performed within the first 30 days after first proof of pancreatic necrosis. Primary outcome parameters were inflammatory activity, days spent in the Intensive Care Unit (ICU), and mortality. Results The patient cohort received median 4 necrosectomies (3-5) after a median of 7 days (3-11) after first proof of pancreatic necrosis. Technical and clinical success were achieved in 98.3 % and 87.8 %, respectively; the mortality rate was 8.2 %. The median C-reactive protein level decreased from 241 mg/L (182.9-288.9) before the intervention to a median of 23.3 mg/L (18-60) after therapy. The median time period in the ICU was 5 days (3-9). Conclusions Early endoscopic therapy in the form of direct endoscopic necrosectomy after LAMS placement within the first 30 days after proof of pancreatic necrosis is effective and does not result in poor outcome. Our retrospective data suggest that early intervention before walled-off necrosis is formed is tenable when it is essential due to the patient's clinical deterioration.
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Affiliation(s)
- David Albers
- Department of Gastroenterology, Elisabeth-Krankenhaus Essen, academic hospital of the University of Duisburg-Essen, Germany
| | - Alexander Meining
- Department of Gastroenterology, University Hospital Wuerzburg, Germany
| | - Alexander Hann
- Department of Gastroenterology, University Hospital Wuerzburg, Germany
| | | | - Brigitte Schumacher
- Department of Gastroenterology, Elisabeth-Krankenhaus Essen, academic hospital of the University of Duisburg-Essen, Germany
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Karamched B, Hripcsak G, Albers D, Ott W. Delay-induced uncertainty for a paradigmatic glucose-insulin model. Chaos 2021; 31:023142. [PMID: 33653035 PMCID: PMC7910007 DOI: 10.1063/5.0027682] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 02/02/2021] [Indexed: 06/12/2023]
Abstract
Medical practice in the intensive care unit is based on the assumption that physiological systems such as the human glucose-insulin system are predictable. We demonstrate that delay within the glucose-insulin system can induce sustained temporal chaos, rendering the system unpredictable. Specifically, we exhibit such chaos for the ultradian glucose-insulin model. This well-validated, finite-dimensional model represents feedback delay as a three-stage filter. Using the theory of rank one maps from smooth dynamical systems, we precisely explain the nature of the resulting delay-induced uncertainty (DIU). We develop a framework one may use to diagnose DIU in a general oscillatory dynamical system. For infinite-dimensional delay systems, no analog of the theory of rank one maps exists. Nevertheless, we show that the geometric principles encoded in our DIU framework apply to such systems by exhibiting sustained temporal chaos for a linear shear flow. Our results are potentially broadly applicable because delay is ubiquitous throughout mathematical physiology.
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Affiliation(s)
- Bhargav Karamched
- Department of Mathematics and Institute of Molecular Biophysics, Florida State University, Tallahassee, Florida 32306, USA
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University, New York, New York 10032, USA
| | | | - William Ott
- Department of Mathematics, University of Houston, Houston, Texas 77204, USA
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Sottile PD, Albers D, DeWitt PE, Russell S, Stroh JN, Kao DP, Adrian B, Levine ME, Mooney R, Larchick L, Kutner JS, Wynia MK, Glasheen JJ, Bennett TD. Real-Time Electronic Health Record Mortality Prediction During the COVID-19 Pandemic: A Prospective Cohort Study. medRxiv 2021. [PMID: 33469601 DOI: 10.1101/2021.01.14.21249793] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background The SARS-CoV-2 virus has infected millions of people, overwhelming critical care resources in some regions. Many plans for rationing critical care resources during crises are based on the Sequential Organ Failure Assessment (SOFA) score. The COVID-19 pandemic created an emergent need to develop and validate a novel electronic health record (EHR)-computable tool to predict mortality. Research Questions To rapidly develop, validate, and implement a novel real-time mortality score for the COVID-19 pandemic that improves upon SOFA. Study Design and Methods We conducted a prospective cohort study of a regional health system with 12 hospitals in Colorado between March 2020 and July 2020. All patients >14 years old hospitalized during the study period without a do not resuscitate order were included. Patients were stratified by the diagnosis of COVID-19. From this cohort, we developed and validated a model using stacked generalization to predict mortality using data widely available in the EHR by combining five previously validated scores and additional novel variables reported to be associated with COVID-19-specific mortality. We compared the area under the receiver operator curve (AUROC) for the new model to the SOFA score and the Charlson Comorbidity Index. Results We prospectively analyzed 27,296 encounters, of which 1,358 (5.0%) were positive for SARS-CoV-2, 4,494 (16.5%) included intensive care unit (ICU)-level care, 1,480 (5.4%) included invasive mechanical ventilation, and 717 (2.6%) ended in death. The Charlson Comorbidity Index and SOFA scores predicted overall mortality with an AUROC of 0.72 and 0.90, respectively. Our novel score predicted overall mortality with AUROC 0.94. In the subset of patients with COVID-19, we predicted mortality with AUROC 0.90, whereas SOFA had AUROC of 0.85. Interpretation We developed and validated an accurate, in-hospital mortality prediction score in a live EHR for automatic and continuous calculation using a novel model, that improved upon SOFA. Take Home Points Study Question: Can we improve upon the SOFA score for real-time mortality prediction during the COVID-19 pandemic by leveraging electronic health record (EHR) data?Results: We rapidly developed and implemented a novel yet SOFA-anchored mortality model across 12 hospitals and conducted a prospective cohort study of 27,296 adult hospitalizations, 1,358 (5.0%) of which were positive for SARS-CoV-2. The Charlson Comorbidity Index and SOFA scores predicted all-cause mortality with AUROCs of 0.72 and 0.90, respectively. Our novel score predicted mortality with AUROC 0.94.Interpretation: A novel EHR-based mortality score can be rapidly implemented to better predict patient outcomes during an evolving pandemic.
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Rodrigues-Pinto E, Ferreira-Silva J, Fugazza A, Capogreco A, Repici A, Everett S, Albers D, Schumacher B, Gines A, Siersema PD, Macedo G. Upper gastrointestinal stenting during the SARS-CoV-2 outbreak: impact of mitigation measures and risk of contamination for patients and staff. Endosc Int Open 2021; 9:E76-E86. [PMID: 33403239 PMCID: PMC7775809 DOI: 10.1055/a-1319-1201] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/19/2020] [Indexed: 02/06/2023] Open
Abstract
Background and study aims The impact of COVID-19 mitigation measures on stent placement procedures has not yet been reported. The aim of this study was to assess the impact of COVID-19 mitigation measures on upper stenting during SARS-CoV-2 outbreak, as well as the use of personal protection equipment (PPE) and risk of contamination for patients and staff. Patients and methods This was a multicenter, retrospective study of consecutive patients who underwent stent placement for upper gastrointestinal obstruction during the second half of SARS-CoV-2 outbreak period in comparison to same period one year before. Results A total of 29 stents were placed for upper gastrointestinal obstruction during the study period, corresponding to an increase of 241 % comparing to the same period in 2019 (n = 12). No significant major differences were found between the two time periods regarding patients' baseline characteristics, post-stenting management and number of staff involved in stent placement. Fellows' involvement was significantly lower in 2020 compared to 2019 (21 % vs 67 %; P = 0.01). The majority of procedures were performed using FFP2 /FFP3 mask (76 %), protective eyewear (86 %), two pairs of gloves (65 %), hairnet (76 %) and full disposable gowns (90 %). One patient tested positive for SARS-CoV-2 after the procedure. None of the medical staff involved in stenting procedures developed COVID-19 14 days after procedure. Conclusion Upper gastrointestinal stenting increased during the SARS-CoV-2 outbreak period, which could be related to yearly variation on the number of procedures or reflect a change of oncologic treatment practice during COVID times.
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Affiliation(s)
- Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal,Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Joel Ferreira-Silva
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal,Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center – IRCCS, Milan, Italy,Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - Antonio Capogreco
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center – IRCCS, Milan, Italy,Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center – IRCCS, Milan, Italy,Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - Simon Everett
- Department of Gastroenterology and Hepatology, Leeds Teaching Hospital NHS Trust, Leeds, United Kingdom
| | - David Albers
- Department of Gastroenterology, Elisabeth-Krankenhaus Essen, Teaching Hospital of the University of Duisburg-Essen, Essen, Germany
| | - Brigitte Schumacher
- Department of Gastroenterology, Elisabeth-Krankenhaus Essen, Teaching Hospital of the University of Duisburg-Essen, Essen, Germany
| | - Angels Gines
- Endoscopy Unit, Gastroenterology Department, ICMDiM, Hospital Clinic. IDIBAPS. CIBERehd.University of Barcelona, Catalonia, Spain
| | - Peter D. Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal,Faculty of Medicine of the University of Porto, Porto, Portugal
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Horenkamp-Sonntag D, Liebentraut J, Engel S, Skupnik C, Albers D, Schumacher B, Koop H. Use of over-the-scope clips in the colon in clinical practice: results from a German administrative database. Endoscopy 2020; 52:1103-1110. [PMID: 32869229 PMCID: PMC7688408 DOI: 10.1055/a-1206-0778] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
UNLABELLED BACKGROUND : The efficacy and safety of over-the-scope (OTS) clips in the colon is limited. This study aimed to evaluate OTS clip use in the colon in routine colonoscopy. METHODS Using administrative data from a large health insurance company, patients with OTS clip placement during colonoscopy were identified and analyzed by specific administrative codes. Indication for OTS clipping was analyzed, and follow-up was evaluated for surgical and repeat endoscopic interventions. RESULTS In 505 patients, indications for OTS clips were iatrogenic perforations (n = 80; Group A), polypectomy (n = 315; Group B), colonic bleeding (n = 51; Group C), and various underlying diseases (n = 59; Group D). In 11 Group A patients (13.8 %), surgical interventions occurred, mostly within 24 hours after clipping (n = 9), predominantly overstitching (n = 8). OTS clipping during polypectomy (Group B) was for complications (e. g. bleeding in 27 %) or was applied prophylactically. Only five patients required early surgery, three of whom had colorectal cancer. In four Group C patients (7.8 %), surgical resections were performed (persistent bleeding n = 1, colorectal cancer n = 2), while six patients underwent early repeat colonoscopy for recurrent bleeding. During further follow-up (days 11-30), 17 patients underwent resection for colonic neoplasms (n = 12) or persistent bleeding (n = 4), but only one case could be directly traced back to local OTS clip complication. CONCLUSION Colonic OTS clipping appears safe and effective in selected indications and complications in clinical routine but must be anatomically and technically feasible, avoiding overuse.
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Affiliation(s)
| | | | | | | | - David Albers
- Department of Internal Medicine and Gastroenterology, Elisabeth-Krankenhaus Academic Hospital, University of Duisburg-Essen, Essen, Germany
| | - Brigitte Schumacher
- Department of Internal Medicine and Gastroenterology, Elisabeth-Krankenhaus Academic Hospital, University of Duisburg-Essen, Essen, Germany
| | - Herbert Koop
- Formerly Department of General Internal Medicine and Gastroenterology, Helios Klinikum Berlin-Buch, Academic Hospital, Berlin, Germany
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Sottile PD, Albers D, Smith BJ, Moss MM. Ventilator dyssynchrony - Detection, pathophysiology, and clinical relevance: A Narrative review. Ann Thorac Med 2020; 15:190-198. [PMID: 33381233 PMCID: PMC7720746 DOI: 10.4103/atm.atm_63_20] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 07/05/2020] [Indexed: 01/21/2023] Open
Abstract
Mortality associated with the acute respiratory distress syndrome remains unacceptably high due in part to ventilator-induced lung injury (VILI). Ventilator dyssynchrony is defined as the inappropriate timing and delivery of a mechanical breath in response to patient effort and may cause VILI. Such deleterious patient–ventilator interactions have recently been termed patient self-inflicted lung injury. This narrative review outlines the detection and frequency of several different types of ventilator dyssynchrony, delineates the different mechanisms by which ventilator dyssynchrony may propagate VILI, and reviews the potential clinical impact of ventilator dyssynchrony. Until recently, identifying ventilator dyssynchrony required the manual interpretation of ventilator pressure and flow waveforms. However, computerized interpretation of ventilator waive forms can detect ventilator dyssynchrony with an area under the receiver operating curve of >0.80. Using such algorithms, ventilator dyssynchrony occurs in 3%–34% of all breaths, depending on the patient population. Moreover, two types of ventilator dyssynchrony, double-triggered and flow-limited breaths, are associated with the more frequent delivery of large tidal volumes >10 mL/kg when compared with synchronous breaths (54% [95% confidence interval (CI), 47%–61%] and 11% [95% CI, 7%–15%]) compared with 0.9% (95% CI, 0.0%–1.9%), suggesting a role in propagating VILI. Finally, a recent study associated frequent dyssynchrony-defined as >10% of all breaths-with an increase in hospital mortality (67 vs. 23%, P = 0.04). However, the clinical significance of ventilator dyssynchrony remains an area of active investigation and more research is needed to guide optimal ventilator dyssynchrony management.
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Affiliation(s)
- Peter D Sottile
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - David Albers
- Department of Pediatrics, Division of Clinical Informatics, University of Colorado, Aurora, Colorado, USA
| | - Bradford J Smith
- Department of Bioengineering, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Marc M Moss
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Woldaregay AZ, Launonen IK, Albers D, Igual J, Årsand E, Hartvigsen G. A Novel Approach for Continuous Health Status Monitoring and Automatic Detection of Infection Incidences in People With Type 1 Diabetes Using Machine Learning Algorithms (Part 2): A Personalized Digital Infectious Disease Detection Mechanism. J Med Internet Res 2020; 22:e18912. [PMID: 32784179 PMCID: PMC7450372 DOI: 10.2196/18912] [Citation(s) in RCA: 2] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/06/2020] [Accepted: 06/11/2020] [Indexed: 01/23/2023] Open
Abstract
Background Semisupervised and unsupervised anomaly detection methods have been widely used in various applications to detect anomalous objects from a given data set. Specifically, these methods are popular in the medical domain because of their suitability for applications where there is a lack of a sufficient data set for the other classes. Infection incidence often brings prolonged hyperglycemia and frequent insulin injections in people with type 1 diabetes, which are significant anomalies. Despite these potentials, there have been very few studies that focused on detecting infection incidences in individuals with type 1 diabetes using a dedicated personalized health model. Objective This study aims to develop a personalized health model that can automatically detect the incidence of infection in people with type 1 diabetes using blood glucose levels and insulin-to-carbohydrate ratio as input variables. The model is expected to detect deviations from the norm because of infection incidences considering elevated blood glucose levels coupled with unusual changes in the insulin-to-carbohydrate ratio. Methods Three groups of one-class classifiers were trained on target data sets (regular days) and tested on a data set containing both the target and the nontarget (infection days). For comparison, two unsupervised models were also tested. The data set consists of high-precision self-recorded data collected from three real subjects with type 1 diabetes incorporating blood glucose, insulin, diet, and events of infection. The models were evaluated on two groups of data: raw and filtered data and compared based on their performance, computational time, and number of samples required. Results The one-class classifiers achieved excellent performance. In comparison, the unsupervised models suffered from performance degradation mainly because of the atypical nature of the data. Among the one-class classifiers, the boundary and domain-based method produced a better description of the data. Regarding the computational time, nearest neighbor, support vector data description, and self-organizing map took considerable training time, which typically increased as the sample size increased, and only local outlier factor and connectivity-based outlier factor took considerable testing time. Conclusions We demonstrated the applicability of one-class classifiers and unsupervised models for the detection of infection incidence in people with type 1 diabetes. In this patient group, detecting infection can provide an opportunity to devise tailored services and also to detect potential public health threats. The proposed approaches achieved excellent performance; in particular, the boundary and domain-based method performed better. Among the respective groups, particular models such as one-class support vector machine, K-nearest neighbor, and K-means achieved excellent performance in all the sample sizes and infection cases. Overall, we foresee that the results could encourage researchers to examine beyond the presented features into other additional features of the self-recorded data, for example, continuous glucose monitoring features and physical activity data, on a large scale.
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Affiliation(s)
| | | | - David Albers
- Department of Pediatrics, Informatics and Data Science, University of Colorado, Aurora, CO, United States.,Department of Biomedical Informatics, Columbia University, New York, NY, United States
| | - Jorge Igual
- Universitat Politècnica de València, Valencia, Spain
| | - Eirik Årsand
- Department of Computer Science, University of Tromsø - The Arctic University of Norway, Tromsø, Norway
| | - Gunnar Hartvigsen
- Department of Computer Science, University of Tromsø - The Arctic University of Norway, Tromsø, Norway
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Woldaregay AZ, Launonen IK, Årsand E, Albers D, Holubová A, Hartvigsen G. Toward Detecting Infection Incidence in People With Type 1 Diabetes Using Self-Recorded Data (Part 1): A Novel Framework for a Personalized Digital Infectious Disease Detection System. J Med Internet Res 2020; 22:e18911. [PMID: 32784178 PMCID: PMC7450374 DOI: 10.2196/18911] [Citation(s) in RCA: 2] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/06/2020] [Accepted: 06/11/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Type 1 diabetes is a chronic condition of blood glucose metabolic disorder caused by a lack of insulin secretion from pancreas cells. In people with type 1 diabetes, hyperglycemia often occurs upon infection incidences. Despite the fact that patients increasingly gather data about themselves, there are no solid findings that uncover the effect of infection incidences on key parameters of blood glucose dynamics to support the effort toward developing a digital infectious disease detection system. OBJECTIVE The study aims to retrospectively analyze the effect of infection incidence and pinpoint optimal parameters that can effectively be used as input variables for developing an infection detection algorithm and to provide a general framework regarding how a digital infectious disease detection system can be designed and developed using self-recorded data from people with type 1 diabetes as a secondary source of information. METHODS We retrospectively analyzed high precision self-recorded data of 10 patient-years captured within the longitudinal records of three people with type 1 diabetes. Obtaining such a rich and large data set from a large number of participants is extremely expensive and difficult to acquire, if not impossible. The data set incorporates blood glucose, insulin, carbohydrate, and self-reported events of infections. We investigated the temporal evolution and probability distribution of the key blood glucose parameters within a specified timeframe (weekly, daily, and hourly). RESULTS Our analysis demonstrated that upon infection incidence, there is a dramatic shift in the operating point of the individual blood glucose dynamics in all the timeframes (weekly, daily, and hourly), which clearly violates the usual norm of blood glucose dynamics. During regular or normal situations, higher insulin and reduced carbohydrate intake usually results in lower blood glucose levels. However, in all infection cases as opposed to the regular or normal days, blood glucose levels were elevated for a prolonged period despite higher insulin and reduced carbohydrates intake. For instance, compared with the preinfection and postinfection weeks, on average, blood glucose levels were elevated by 6.1% and 16%, insulin (bolus) was increased by 42% and 39.3%, and carbohydrate consumption was reduced by 19% and 28.1%, respectively. CONCLUSIONS We presented the effect of infection incidence on key parameters of blood glucose dynamics along with the necessary framework to exploit the information for realizing a digital infectious disease detection system. The results demonstrated that compared with regular or normal days, infection incidence substantially alters the norm of blood glucose dynamics, which are quite significant changes that could possibly be detected through personalized modeling, for example, prediction models and anomaly detection algorithms. Generally, we foresee that these findings can benefit the efforts toward building next generation digital infectious disease detection systems and provoke further thoughts in this challenging field.
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Affiliation(s)
| | | | - Eirik Årsand
- Department of Computer Science, University of Tromsø - The Arctic University of Norway, Tromsø, Norway
| | - David Albers
- Department of Pediatrics, Informatics and Data Science, University of Colorado, Aurora, CO, United States.,Department of Biomedical Informatics, Columbia University, New York, NY, United States
| | - Anna Holubová
- Department of ICT in Medicine, Faculty of Biomedical Engineering, Czech Technical University, Prague, Czech Republic.,Spin-off Company and Research Results Commercialization Center of the First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Gunnar Hartvigsen
- Department of Computer Science, University of Tromsø - The Arctic University of Norway, Tromsø, Norway
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Fu LH, Schwartz J, Moy A, Knaplund C, Kang MJ, Schnock KO, Garcia JP, Jia H, Dykes PC, Cato K, Albers D, Rossetti SC. Development and validation of early warning score system: A systematic literature review. J Biomed Inform 2020; 105:103410. [PMID: 32278089 PMCID: PMC7295317 DOI: 10.1016/j.jbi.2020.103410] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 03/19/2020] [Accepted: 03/21/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVES This review aims to: 1) evaluate the quality of model reporting, 2) provide an overview of methodology for developing and validating Early Warning Score Systems (EWSs) for adult patients in acute care settings, and 3) highlight the strengths and limitations of the methodologies, as well as identify future directions for EWS derivation and validation studies. METHODOLOGY A systematic search was conducted in PubMed, Cochrane Library, and CINAHL. Only peer reviewed articles and clinical guidelines regarding developing and validating EWSs for adult patients in acute care settings were included. 615 articles were extracted and reviewed by five of the authors. Selected studies were evaluated based on the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) checklist. The studies were analyzed according to their study design, predictor selection, outcome measurement, methodology of modeling, and validation strategy. RESULTS A total of 29 articles were included in the final analysis. Twenty-six articles reported on the development and validation of a new EWS, while three reported on validation and model modification. Only eight studies met more than 75% of the items in the TRIPOD checklist. Three major techniques were utilized among the studies to inform their predictive algorithms: 1) clinical-consensus models (n = 6), 2) regression models (n = 15), and 3) tree models (n = 5). The number of predictors included in the EWSs varied from 3 to 72 with a median of seven. Twenty-eight models included vital signs, while 11 included lab data. Pulse oximetry, mental status, and other variables extracted from electronic health records (EHRs) were among other frequently used predictors. In-hospital mortality, unplanned transfer to the intensive care unit (ICU), and cardiac arrest were commonly used clinical outcomes. Twenty-eight studies conducted a form of model validation either within the study or against other widely-used EWSs. Only three studies validated their model using an external database separate from the derived database. CONCLUSION This literature review demonstrates that the characteristics of the cohort, predictors, and outcome selection, as well as the metrics for model validation, vary greatly across EWS studies. There is no consensus on the optimal strategy for developing such algorithms since data-driven models with acceptable predictive accuracy are often site-specific. A standardized checklist for clinical prediction model reporting exists, but few studies have included reporting aligned with it in their publications. Data-driven models are subjected to biases in the use of EHR data, thus it is particularly important to provide detailed study protocols and acknowledge, leverage, or reduce potential biases of the data used for EWS development to improve transparency and generalizability.
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Affiliation(s)
- Li-Heng Fu
- Department of Biomedical Informatics, Columbia University, New York, NY, United States.
| | - Jessica Schwartz
- School of Nursing, Columbia University, New York, NY, United States
| | - Amanda Moy
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
| | - Chris Knaplund
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
| | - Min-Jeoung Kang
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Kumiko O Schnock
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Jose P Garcia
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States
| | - Haomiao Jia
- School of Nursing, Columbia University, New York, NY, United States; Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Patricia C Dykes
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Kenrick Cato
- School of Nursing, Columbia University, New York, NY, United States
| | - David Albers
- Department of Biomedical Informatics, Columbia University, New York, NY, United States; Department of Pediatrics, Section of Informatics and Data Science, University of Colorado, Aurora, CO, United States
| | - Sarah Collins Rossetti
- Department of Biomedical Informatics, Columbia University, New York, NY, United States; School of Nursing, Columbia University, New York, NY, United States
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Walter B, Schmidbaur S, Rahman I, Albers D, Schumacher B, Meining A. The BougieCap - a new method for endoscopic treatment of complex benign esophageal stenosis: results from a multicenter study. Endoscopy 2019; 51:866-870. [PMID: 31342473 DOI: 10.1055/a-0959-1535] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND A major limitation of current treatment strategies for nonmalignant upper gastrointestinal stenoses is the lack of either optical or haptic feedback during dilation. Wire guidance and fluoroscopy is often necessary to control the position. METHODS A novel device for endoscopic dilation, the BougieCap (Ovesco Endoscopy AG, Tübingen, Germany) was evaluated in a prospective multicenter trial. Primary outcome was successful dilation of stenosis and secondary outcome was alteration in dysphagia symptoms in short-term follow-up. RESULTS: 50 patients with benign esophageal strictures were included. Endoscopic bougienage was successful in 96 %. Bougienage failed in two cases because of high resistance. Symptoms of dysphagia decreased significantly after bougienage (59.0 points at Day 0 vs. 28.6 points at Day 14; P < 0.001). Adverse events were loss of BougieCap into the stomach in two cases; no severe adverse events were reported. CONCLUSIONS Endoscopic treatment of benign stenoses using the BougieCap enabled direct visual control of the bougienage procedure. This might help to adapt treatment more precisely to the stricture. Symptoms of dysphagia were improved in short-term follow-up. Additional wire guidance may be used for selected cases (e. g. narrow lumen, pediatric scope).
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Affiliation(s)
- Benjamin Walter
- InExEn, Klinik für Innere Medizin I, Universitätsklinikum Ulm, Ulm, Germany
| | - Simone Schmidbaur
- InExEn, Klinik für Innere Medizin I, Universitätsklinikum Ulm, Ulm, Germany
| | - Imdadur Rahman
- University Hospital of Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - David Albers
- Klinik für Innere Medizin und Gastroenterologie, Elisabethkrankenhaus, Essen, Germany
| | - Brigitte Schumacher
- Klinik für Innere Medizin und Gastroenterologie, Elisabethkrankenhaus, Essen, Germany
| | - Alexander Meining
- InExEn, Klinik für Innere Medizin I, Universitätsklinikum Ulm, Ulm, Germany
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Woldaregay AZ, Årsand E, Walderhaug S, Albers D, Mamykina L, Botsis T, Hartvigsen G. Data-driven modeling and prediction of blood glucose dynamics: Machine learning applications in type 1 diabetes. Artif Intell Med 2019; 98:109-134. [DOI: 10.1016/j.artmed.2019.07.007] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 08/22/2018] [Accepted: 07/19/2019] [Indexed: 10/26/2022]
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Kuellmer A, Mueller J, Caca K, Aepli P, Albers D, Schumacher B, Glitsch A, Schäfer C, Wallstabe I, Hofmann C, Erhardt A, Meier B, Bettinger D, Thimme R, Schmidt A. Endoscopic full-thickness resection for early colorectal cancer. Gastrointest Endosc 2019; 89:1180-1189.e1. [PMID: 30653939 DOI: 10.1016/j.gie.2018.12.025] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [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: 09/29/2018] [Accepted: 12/29/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Current international guidelines recommend endoscopic resection for T1 colorectal cancer (CRC) with low-risk histology features and oncologic resection for those at high risk of lymphatic metastasis. Exact risk stratification is therefore crucial to avoid under-treatment as well as over-treatment. Endoscopic full-thickness resection (EFTR) has shown to be effective for treatment of non-lifting benign lesions. In this multicenter, retrospective study we aimed to evaluate efficacy, safety, and clinical value of EFTR for early CRC. METHODS Records of 1234 patients undergoing EFTR for various indications at 96 centers were screened for eligibility. A total of 156 patients with histologic evidence of adenocarcinoma were identified. This cohort included 64 cases undergoing EFTR after incomplete resection of a malignant polyp (group 1) and 92 non-lifting lesions (group 2). Endpoints of the study were: technical success, R0-resection, adverse events, and successful discrimination of high-risk versus low-risk tumors. RESULTS Technical success was achieved in 144 out of 156 (92.3%). Mean procedural time was 42 minutes. R0 resection was achieved in 112 of 156 (71.8%). Subgroup analysis showed a R0 resection rate of 87.5% in Group 1 and 60.9% in Group 2 (P < .001). Severe procedure-related adverse events were recorded in 3.9% of patients. Discrimination between high-risk versus low-risk tumor was successful in 155 of 156 cases (99.3%). In Group 1, 84.1% were identified as low-risk lesions, whereas 16.3% in group 2 had low-risk features. In total, 53 patients (34%) underwent oncologic resection due to high-risk features whereas 98 patients (62%) were followed endoscopically. CONCLUSIONS In early colorectal cancer, EFTR is technically feasible and safe. It allows exact histological risk stratification and can avoid surgery for low-risk lesions. Prospective studies are required to further define indications for EFTR in malignant colorectal lesions and to evaluate long-term outcome.
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Affiliation(s)
- Armin Kuellmer
- Department of Medicine II, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg
| | - Julius Mueller
- Department of Medicine II, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg
| | - Karel Caca
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Patrick Aepli
- Gastroenterology and Hepatology Unit, Luzerner Kantonsspital, Lucerne, Switzerland
| | - David Albers
- Department of Gastroenterology, Elisabeth-Krankenhaus Essen, Teaching Hospital of the University of Duisburg-Essen, Essen
| | - Brigitte Schumacher
- Department of Gastroenterology, Elisabeth-Krankenhaus Essen, Teaching Hospital of the University of Duisburg-Essen, Essen
| | - Anne Glitsch
- Department of Surgery, University Hospital Greifswald, Greifswald
| | | | - Ingo Wallstabe
- Department for Gastroenterology, Hepatology, Diabetology und Endocrinology, Klinikum St. Georg gGmbH, Leipzig
| | | | - Andreas Erhardt
- Department for Gastroenterology, Hepatology und Diabetology, Petrus-Krankenhaus, Wuppertal, Germany
| | - Benjamin Meier
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg
| | - Robert Thimme
- Department of Medicine II, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg
| | - Arthur Schmidt
- Department of Medicine II, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg
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Woldaregay AZ, Årsand E, Botsis T, Albers D, Mamykina L, Hartvigsen G. Data-Driven Blood Glucose Pattern Classification and Anomalies Detection: Machine-Learning Applications in Type 1 Diabetes. J Med Internet Res 2019; 21:e11030. [PMID: 31042157 PMCID: PMC6658321 DOI: 10.2196/11030] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 11/27/2018] [Accepted: 01/30/2019] [Indexed: 01/23/2023] Open
Abstract
Background Diabetes mellitus is a chronic metabolic disorder that results in abnormal blood glucose (BG) regulations. The BG level is preferably maintained close to normality through self-management practices, which involves actively tracking BG levels and taking proper actions including adjusting diet and insulin medications. BG anomalies could be defined as any undesirable reading because of either a precisely known reason (normal cause variation) or an unknown reason (special cause variation) to the patient. Recently, machine-learning applications have been widely introduced within diabetes research in general and BG anomaly detection in particular. However, irrespective of their expanding and increasing popularity, there is a lack of up-to-date reviews that materialize the current trends in modeling options and strategies for BG anomaly classification and detection in people with diabetes. Objective This review aimed to identify, assess, and analyze the state-of-the-art machine-learning strategies and their hybrid systems focusing on BG anomaly classification and detection including glycemic variability (GV), hyperglycemia, and hypoglycemia in type 1 diabetes within the context of personalized decision support systems and BG alarm events applications, which are important constituents for optimal diabetes self-management. Methods A rigorous literature search was conducted between September 1 and October 1, 2017, and October 15 and November 5, 2018, through various Web-based databases. Peer-reviewed journals and articles were considered. Information from the selected literature was extracted based on predefined categories, which were based on previous research and further elaborated through brainstorming. Results The initial results were vetted using the title, abstract, and keywords and retrieved 496 papers. After a thorough assessment and screening, 47 articles remained, which were critically analyzed. The interrater agreement was measured using a Cohen kappa test, and disagreements were resolved through discussion. The state-of-the-art classes of machine learning have been developed and tested up to the task and achieved promising performance including artificial neural network, support vector machine, decision tree, genetic algorithm, Gaussian process regression, Bayesian neural network, deep belief network, and others. Conclusions Despite the complexity of BG dynamics, there are many attempts to capture hypoglycemia and hyperglycemia incidences and the extent of an individual’s GV using different approaches. Recently, the advancement of diabetes technologies and continuous accumulation of self-collected health data have paved the way for popularity of machine learning in these tasks. According to the review, most of the identified studies used a theoretical threshold, which suffers from inter- and intrapatient variation. Therefore, future studies should consider the difference among patients and also track its temporal change over time. Moreover, studies should also give more emphasis on the types of inputs used and their associated time lag. Generally, we foresee that these developments might encourage researchers to further develop and test these systems on a large-scale basis.
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Affiliation(s)
| | - Eirik Årsand
- Norwegian Centre for E-health Research, University Hospital of North Norway, Tromsø, Norway
| | - Taxiarchis Botsis
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - David Albers
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
| | - Lena Mamykina
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
| | - Gunnar Hartvigsen
- Department of Computer Science, University of Tromsø - The Arctic University of Norway, Tromsø, Norway
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Albers D, Frieling T, Dakkak D, Kuhlbusch-Zicklam R, Töx U, Gittinger M, Schumacher B. Peroral endoscopic myotomy (POEM) is effective in treatment of noncardiac chest pain caused by hypercontractile esophageal motility disorders: results of the POEM-HYPE-Study. Z Gastroenterol 2018; 56:1337-1342. [PMID: 30296811 DOI: 10.1055/a-0668-2605] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Noncardiac chest pain (NCCP) is recurrent angina pectoris-like pain without evidence of coronary heart disease in conventional diagnostic evaluation. In gastroenterology, managing of patients with NCCP is ambiguous to detect gastroesophageal reflux and hypercontractile esophageal motility disorders. Recently, peroral endoscopic myotomy (POEM) was established as treatment option in achalasia. However, limited data exist on the effectivity of POEM in NCCP with hypercontractile esophageal motility disorders. MATERIAL AND METHODS In this prospective study (POEM-HYPE), we evaluated 14 patients with NCCP and hypercontractile esophageal motility disorders (type III achalasia, n = 7; hypercontractile esophagus, n = 6; distal esophageal spasm, n = 1). All patients underwent standardized diagnostic work-up including esophagogastroduodenoscopy with esophageal biopsies, high-resolution esophageal manometry, and combined intraluminal impedance and pH testing before and 3 weeks after POEM. A standardized symptom questionnaire was disposed before POEM, 3 weeks after, and every 6 months after the POEM. RESULTS After POEM, 12 patients showed significant symptom relief (pre-Eckardt score: 7.78 ± 1.47, 3 weeks post: 1.64 ± 1.44, 6 months: 2.0 ± 1.84 and 1.86 ± 1.89 after 15.0 ± 10.0 months post-intervention). High-resolution manometry showed significant reduction in integrated relaxation pressure (pre-POEM: 24.74 ± 18.9 mm Hg, post-POEM: 13.8 ± 16.5 mm Hg) and distal contractile integral (pre-POEM: 2880 ± 3700 mmHg*s*cm, post-POEM: 1109 ± 1042 mmHg*s*cm). One lesion of the submucosal tunnel occurred as a moderate adverse event and was handled endoscopically. The long-term clinical success rate was 85.7 %. No severe gastroesophageal reflux occurred after interventions. Two patients required secondary therapy with injection of botulinum toxin in the tubular esophagus and balloon dilation. CONCLUSION The results suggest that POEM is an effective and safe therapeutic option for patients with NCCP and hypercontractile esophageal motility disorders.
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Affiliation(s)
- David Albers
- Department of Internal Medicine and Gastroenterology, Elisabeth-Krankenhaus Essen, Essen, Germany
| | - Thomas Frieling
- Department of Internal Medicine and Gastroenterology, Helios Klinikum Krefeld, Krefeld, Germany
| | - Dani Dakkak
- Department of Internal Medicine and Gastroenterology, Elisabeth-Krankenhaus Essen, Essen, Germany
| | - Rita Kuhlbusch-Zicklam
- Department of Internal Medicine and Gastroenterology, Helios Klinikum Krefeld, Krefeld, Germany
| | - Ulrich Töx
- Department of Gastroenterology, University of Cologne, Germany
| | - Mathis Gittinger
- Department of Internal Medicine and Gastroenterology, Elisabeth-Krankenhaus Essen, Essen, Germany
| | - Brigitte Schumacher
- Department of Internal Medicine and Gastroenterology, Elisabeth-Krankenhaus Essen, Essen, Germany
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Schmidt A, Beyna T, Schumacher B, Meining A, Richter-Schrag HJ, Messmann H, Neuhaus H, Albers D, Birk M, Thimme R, Probst A, Faehndrich M, Frieling T, Goetz M, Riecken B, Caca K. Colonoscopic full-thickness resection using an over-the-scope device: a prospective multicentre study in various indications. Gut 2018; 67:1280-1289. [PMID: 28798042 DOI: 10.1136/gutjnl-2016-313677] [Citation(s) in RCA: 174] [Impact Index Per Article: 29.0] [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: 12/28/2016] [Revised: 06/14/2017] [Accepted: 07/06/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Endoscopic full-thickness resection (EFTR) is a novel treatment of colorectal lesions not amenable to conventional endoscopic resection. The aim of this prospective multicentre study was to assess the efficacy and safety of the full-thickness resection device. DESIGN 181 patients were recruited in 9 centres with the indication of difficult adenomas (non-lifting and/or at difficult locations), early cancers and subepithelial tumours (SET). Primary endpoint was complete en bloc and R0 resection. RESULTS EFTR was technically successful in 89.5%, R0 resection rate was 76.9%. In 127 patients with difficult adenomas and benign histology, R0 resection rate was 77.7%. In 14 cases, lesions harboured unsuspected cancer, another 15 lesions were primarily known as cancers. Of these 29 cases, R0 resection was achieved in 72.4%; 8 further cases had deep submucosal infiltration >1000 µm. Therefore, curative resection could only be achieved in 13/29 (44.8%). In the subgroup with SET (n=23), R0 resection rate was 87.0%. In general, R0 resection rate was higher with lesions ≤2 cm vs >2 cm (81.2% vs 58.1%, p=0.0038). Adverse event rate was 9.9% with a 2.2% rate of emergency surgery. Three-month follow-up was available from 154 cases and recurrent/residual tumour was evident in 15.3%. CONCLUSION EFTR has a reasonable technical efficacy especially in lesions ≤2 cm with acceptable complication rates. Curative resection rate for early cancers was too low to recommend its primary use in this indication. Further comparative studies have to show the clinical value and long-term outcome of EFTR in benign colorectal lesions. TRIAL REGISTRATION NUMBER NCT02362126; Results.
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Affiliation(s)
- Arthur Schmidt
- Department of Gastroenterology, Klinikum Ludwigsburg, University of Heidelberg, Ludwigsburg, Germany.,Department of Medicine II, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Torsten Beyna
- Department of Internal Medicine and Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Dusseldorf, Germany
| | - Brigitte Schumacher
- Department of Internal Medicine and Gastroenterology, Elisabeth Hospital, Essen, Germany
| | | | - Hans-Juergen Richter-Schrag
- Department of Medicine II, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Helmut Messmann
- Department of Gastroenterology, Klinikum Augsburg, Augsburg, Germany
| | - Horst Neuhaus
- Department of Internal Medicine and Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Dusseldorf, Germany
| | - David Albers
- Department of Internal Medicine and Gastroenterology, Elisabeth Hospital, Essen, Germany
| | - Michael Birk
- Department of Gastroenterology, University Hospital, Ulm, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andreas Probst
- Department of Gastroenterology, Klinikum Augsburg, Augsburg, Germany
| | - Martin Faehndrich
- Department of Gastroenterology, Klinikum Dortmund, Dortmund, Germany
| | - Thomas Frieling
- Department of Gastroenterology, Helios Klinikum Krefeld, Krefeld, Germany
| | - Martin Goetz
- Department of Gastroenterology, University Hospital of Tuebingen, Tuebingen, Germany
| | - Bettina Riecken
- Department of Gastroenterology, Klinikum Ludwigsburg, University of Heidelberg, Ludwigsburg, Germany
| | - Karel Caca
- Department of Gastroenterology, Klinikum Ludwigsburg, University of Heidelberg, Ludwigsburg, Germany
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Sottile PD, Albers D, Moss MM. Neuromuscular blockade is associated with the attenuation of biomarkers of epithelial and endothelial injury in patients with moderate-to-severe acute respiratory distress syndrome. Crit Care 2018. [PMID: 29523157 PMCID: PMC5845220 DOI: 10.1186/s13054-018-1974-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Background Neuromuscular blockade (NMB) is a therapy for acute respiratory distress syndrome (ARDS). However, the mechanism by which NMB may improve outcome for ARDS patients remains unclear. We sought to determine whether NMB attenuates biomarkers of epithelial and endothelial lung injury and systemic inflammation in ARDS patients, and whether the association is dependent on tidal volume size and the initial degree of hypoxemia. Methods We performed a secondary analysis of patients enrolled in the ARDS network low tidal volume ventilation (ARMA) study. Our primary predictor variable was the number of days receiving NMB between study enrollment and day 3. Our primary outcome variables were the change in concentration of biomarkers of epithelial injury (serum surfactant protein-D (SP-D)), endothelial injury (von Willebrand factor (VWF)), and systemic inflammation (interleukin (IL)-8). Multivariable regression analysis was used to compare the change in biomarker concentration controlling for multiple covariates. Patients were stratified by treatment arm (12 versus 6 cm3/kg) and by an initial arterial oxygen tension (PaO2) to fractional inspired oxygen (FiO2) (P/F) ratio of 120. Results A total of 446 (49%) patients had complete SP-D, VWF, and IL-8 measurements on study enrollment and day 3. After adjusting for baseline differences, each day of NMB was associated with a decrease in SP-D (−23.7 ng/ml/day, p = 0.029), VWF (−33.5% of control/day, p = 0.015), and IL-8 (−362.6 pg/ml/day, p = 0.030) in patients with an initial P/F less than or equal to 120 and receiving low tidal volume ventilation. However, patients with a P/F ratio of greater than 120 or receiving high tidal volume ventilation had either no change or an increase in SP-D, WVF, or IL-8 concentrations. Conclusion NBM is associated with decreased biomarkers of epithelial and endothelial lung injury and systemic inflammation in ARDS patients receiving low tidal volume ventilation and those with a P/F ratio less than or equal to 120. Electronic supplementary material The online version of this article (10.1186/s13054-018-1974-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, 12700 E. 19th Ave., RC2 9th Floor, C272, Aurora, CO, 80045, USA.
| | - David Albers
- Department of Biomedical Informatics, Columbia University Medical Center, 622 W. 168th Street, Presbyterian Building 20th Floor, New York, NY, 10032, USA
| | - Marc M Moss
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, 12700 E. 19th Ave., RC2 9th Floor, C272, Aurora, CO, 80045, USA
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Foreman B, Albers D, Schmidt JM, Falo CM, Velasquez A, Connolly ES, Claassen J. Intracortical electrophysiological correlates of blood flow after severe SAH: A multimodality monitoring study. J Cereb Blood Flow Metab 2018; 38:506-517. [PMID: 28387139 PMCID: PMC5851141 DOI: 10.1177/0271678x17700433] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [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] [Indexed: 01/25/2023]
Abstract
Subarachnoid hemorrhage (SAH) is a devastating form of stroke. Approximately one in four patients develop progressive neurological deterioration and silent infarction referred to as delayed cerebral ischemia (DCI). DCI is a complex, multifactorial secondary brain injury pattern and its pathogenesis is not fully understood. We aimed to study the relationship between cerebral blood flow (CBF) and neuronal activity at both the cortex and in scalp using electroencephalography (EEG) in poor-grade SAH patients undergoing multimodality intracranial neuromonitoring. Twenty patients were included, of whom half had DCI median 4.7 days (interquartile range (IQR): 4.0-5.6) from SAH bleed. The rate of decline in regional cerebral blood flow (rCBF) was significant in both those with and without DCI and occurred between days 4 and 7 post-SAH. The scalp EEG alpha-delta ratio declined early in those with DCI. In the group without DCI, CBF and cortical EEG alpha-delta ratio were correlated (r = 0.53; p < 0.01) and in the group without DCI, inverse neurovascular coupling was observed at CPP < 80 mmHg. We found preliminary evidence that as patients enter the period of highest risk for the development of DCI, the absence of neurovascular coupling may act as a possible pathomechanism in the development of ischemia following SAH.
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Affiliation(s)
- Brandon Foreman
- 1 Department of Neurology, Columbia University, New York, USA.,2 Department of Neurology & Rehabilitation Medicine, University of Cincinnati, Cincinnati, USA
| | - David Albers
- 3 Department of Biomedical Informatics, Columbia University, New York, USA
| | | | | | | | | | - Jan Claassen
- 1 Department of Neurology, Columbia University, New York, USA.,4 Department of Neurosurgery, Columbia University, New York, USA
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Albers D, Dakkak D, Sterlacci W, Vieth M, Schumacher B. Digital single-operator pancreatoscopy for evaluation of intraductal papillary mucinous neoplasm. VideoGIE 2016; 2:147-148. [PMID: 29905307 PMCID: PMC5991425 DOI: 10.1016/j.vgie.2016.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- David Albers
- Department of Gastroenterology, Elisabeth-Krankenhaus Essen, Teaching Hospital of the University of Duisburg-Essen, Essen, Germany
- Department of Pathology, Klinikum Bayreuth, Bayreuth, Germany, Teaching Hospital of the University of Erlangen, Erlangen, Germany
- Department of Gastroenterology, Elisabeth-Krankenhaus Essen, Teaching Hospital of the University of Duisburg-Essen, Essen, Germany
| | - Dani Dakkak
- Department of Gastroenterology, Elisabeth-Krankenhaus Essen, Teaching Hospital of the University of Duisburg-Essen, Essen, Germany
- Department of Pathology, Klinikum Bayreuth, Bayreuth, Germany, Teaching Hospital of the University of Erlangen, Erlangen, Germany
- Department of Gastroenterology, Elisabeth-Krankenhaus Essen, Teaching Hospital of the University of Duisburg-Essen, Essen, Germany
| | - William Sterlacci
- Department of Pathology, Klinikum Bayreuth, Bayreuth, Germany, Teaching Hospital of the University of Erlangen, Erlangen, Germany
- Department of Gastroenterology, Elisabeth-Krankenhaus Essen, Teaching Hospital of the University of Duisburg-Essen, Essen, Germany
| | - Michael Vieth
- Department of Pathology, Klinikum Bayreuth, Bayreuth, Germany, Teaching Hospital of the University of Erlangen, Erlangen, Germany
- Department of Gastroenterology, Elisabeth-Krankenhaus Essen, Teaching Hospital of the University of Duisburg-Essen, Essen, Germany
| | - Brigitte Schumacher
- Department of Gastroenterology, Elisabeth-Krankenhaus Essen, Teaching Hospital of the University of Duisburg-Essen, Essen, Germany
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Claassen J, Rahman SA, Huang Y, Frey HP, Schmidt JM, Albers D, Falo CM, Park S, Agarwal S, Connolly ES, Kleinberg S. Causal Structure of Brain Physiology after Brain Injury from Subarachnoid Hemorrhage. PLoS One 2016; 11:e0149878. [PMID: 27123582 PMCID: PMC4849773 DOI: 10.1371/journal.pone.0149878] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 02/06/2016] [Indexed: 11/19/2022] Open
Abstract
High frequency physiologic data are routinely generated for intensive care patients. While massive amounts of data make it difficult for clinicians to extract meaningful signals, these data could provide insight into the state of critically ill patients and guide interventions. We develop uniquely customized computational methods to uncover the causal structure within systemic and brain physiologic measures recorded in a neurological intensive care unit after subarachnoid hemorrhage. While the data have many missing values, poor signal-to-noise ratio, and are composed from a heterogeneous patient population, our advanced imputation and causal inference techniques enable physiologic models to be learned for individuals. Our analyses confirm that complex physiologic relationships including demand and supply of oxygen underlie brain oxygen measurements and that mechanisms for brain swelling early after injury may differ from those that develop in a delayed fashion. These inference methods will enable wider use of ICU data to understand patient physiology.
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Affiliation(s)
- Jan Claassen
- Division of Critical Care Neurology, Department of Neurology, Columbia University, New York, NY, United States of America
- * E-mail:
| | - Shah Atiqur Rahman
- Computer Science Department, Stevens Institute of Technology, Hoboken, NJ, United States of America
| | - Yuxiao Huang
- Computer Science Department, Stevens Institute of Technology, Hoboken, NJ, United States of America
| | - Hans-Peter Frey
- Division of Critical Care Neurology, Department of Neurology, Columbia University, New York, NY, United States of America
| | - J. Michael Schmidt
- Division of Critical Care Neurology, Department of Neurology, Columbia University, New York, NY, United States of America
| | - David Albers
- Department of Biomedical Informatics, Columbia University, New York, NY, United States of America
| | - Cristina Maria Falo
- Division of Critical Care Neurology, Department of Neurology, Columbia University, New York, NY, United States of America
| | - Soojin Park
- Division of Critical Care Neurology, Department of Neurology, Columbia University, New York, NY, United States of America
| | - Sachin Agarwal
- Division of Critical Care Neurology, Department of Neurology, Columbia University, New York, NY, United States of America
| | - E. Sander Connolly
- Department of Neurosurgery, Columbia University, New York, NY, United States of America
| | - Samantha Kleinberg
- Computer Science Department, Stevens Institute of Technology, Hoboken, NJ, United States of America
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Albers D, Toermer T, Charton JP, Neuhaus H, Schumacher B. Endoscopic therapy for infected pancreatic necrosis using fully covered self-expandable metal stents: combination of transluminal necrosectomy, transluminal and percutaneous drainage. Z Gastroenterol 2016; 54:26-30. [PMID: 26751114 DOI: 10.1055/s-0041-104228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND/AIMS Endoscopic transluminal therapy has become the standard of care as a less invasive alternative to surgery. In a retrospective case series of two tertiary referral centers we report on an individualized concept combining EUS-guided drainage with self-expanding metal stents, direct transluminal debridement und percutaneous drainage. METHODS We treated 13 patients with infected pancreatic necrosis. Initially in all patients an EUS-guided drainage with plastic stents was performed under antibiotic protection (transduodenal: 2, transgastral: 11). After clinical consolidation (after 9.6 ± 9.4 days) a covered self-expanding metal stent (Niti-S, Taewoong medical Co., Seoul, Korea) was inserted by performing direct endoscopic necrosectomy in 2.9 ± 1.7 sessions through the stent. In cases of disrupted duct syndromes a pancreatic plastic stent was inserted (5 of 13 patients). In 5 of 13 cases additional percutaneous drainage was applied because of extended necrosis. In one patient percutaneous endoscopic drainage using the percutaneous access was needed. RESULTS A sustained clinical success was achieved in 12 of 13 cases (CRP before therapy 23.5 ± 14.4 mg/L, after 3.1 ± 2.6 mg/lL). Discharge occurred after 2.5 ± 22.4 days. The self-expanding metal stent was extracted after 82.5 ± 56.6 days. Mean follow up was 8.5 ± 5.9 months. CONCLUSION Our concept of combining transluminal drainage, direct endoscopic necrosectomy and percutaneuos drainage offers a safe and reliable alternative to surgery, even in case of extended necrosis.
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Affiliation(s)
- D Albers
- Department of Gastroenterology, Elisabeth-Krankenhaus Essen, Germany
| | - T Toermer
- Department of Gastroenterology, Elisabeth-Krankenhaus Essen, Germany
| | - J P Charton
- Department of Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Germany
| | - H Neuhaus
- Department of Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Germany
| | - B Schumacher
- Department of Gastroenterology, Elisabeth-Krankenhaus Essen, Germany
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Moustakis C, Ernst I, Kittel C, Eich H, Krieger T, Duma M, Oechsner M, Ganswindt U, Heinz C, Alheit H, Blank H, Nestle U, Wiehle R, Kornhuber C, Ostheimer C, Petersen C, Albers D, Pollul G, Baus W, Altenstein G, Blanck O, Beckers E, Sterzing F, Kretschmer M, Seegenschmiedt H, Maass T, Droege S, Wolf U, Schoeffler J, Thiele M, Ciernik I, Ebrahimi F, Guckenberger M. Results of the Planning Comparison Study SBRT of NSCLC. Int J Radiat Oncol Biol Phys 2015. [DOI: 10.1016/j.ijrobp.2015.07.2012] [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: 11/16/2022]
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Hagar Y, Albers D, Pivovarov R, Chase H, Dukic V, Elhadad N. Survival Analysis with Electronic Health Record Data: Experiments with Chronic Kidney Disease. Stat Anal Data Min 2014; 7:385-403. [PMID: 33981381 PMCID: PMC8112603 DOI: 10.1002/sam.11236] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
This paper presents a detailed survival analysis for chronic kidney disease (CKD). The analysis is based on the EHR data comprising almost two decades of clinical observations collected at New York-Presbyterian, a large hospital in New York City with one of the oldest electronic health records in the United States. Our survival analysis approach centers around Bayesian multiresolution hazard modeling, with an objective to capture the changing hazard of CKD over time, adjusted for patient clinical covariates and kidney-related laboratory tests. Special attention is paid to statistical issues common to all EHR data, such as cohort definition, missing data and censoring, variable selection, and potential for joint survival and longitudinal modeling, all of which are discussed alone and within the EHR CKD context.
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Affiliation(s)
- Yolanda Hagar
- Yolanda Hagar is a postdoctoral researcher in applied mathematics at the University of Colorado at Boulder. David Albers is an associate research scientist in biomedical informatics at Columbia University. Rimma Pivovarov is a doctoral candidate in biomedical informatics at Columbia University. Herbert Chase is a professor of clinical medicine in biomedical informatics at Columbia University. Vanja Dukic is an associate professor in applied mathematics at the University of Colorado at Boulder. Noémie Elhadad is an assistant professor in biomedical informatics at Columbia University
| | - David Albers
- Yolanda Hagar is a postdoctoral researcher in applied mathematics at the University of Colorado at Boulder. David Albers is an associate research scientist in biomedical informatics at Columbia University. Rimma Pivovarov is a doctoral candidate in biomedical informatics at Columbia University. Herbert Chase is a professor of clinical medicine in biomedical informatics at Columbia University. Vanja Dukic is an associate professor in applied mathematics at the University of Colorado at Boulder. Noémie Elhadad is an assistant professor in biomedical informatics at Columbia University
| | - Rimma Pivovarov
- Yolanda Hagar is a postdoctoral researcher in applied mathematics at the University of Colorado at Boulder. David Albers is an associate research scientist in biomedical informatics at Columbia University. Rimma Pivovarov is a doctoral candidate in biomedical informatics at Columbia University. Herbert Chase is a professor of clinical medicine in biomedical informatics at Columbia University. Vanja Dukic is an associate professor in applied mathematics at the University of Colorado at Boulder. Noémie Elhadad is an assistant professor in biomedical informatics at Columbia University
| | - Herbert Chase
- Yolanda Hagar is a postdoctoral researcher in applied mathematics at the University of Colorado at Boulder. David Albers is an associate research scientist in biomedical informatics at Columbia University. Rimma Pivovarov is a doctoral candidate in biomedical informatics at Columbia University. Herbert Chase is a professor of clinical medicine in biomedical informatics at Columbia University. Vanja Dukic is an associate professor in applied mathematics at the University of Colorado at Boulder. Noémie Elhadad is an assistant professor in biomedical informatics at Columbia University
| | - Vanja Dukic
- Yolanda Hagar is a postdoctoral researcher in applied mathematics at the University of Colorado at Boulder. David Albers is an associate research scientist in biomedical informatics at Columbia University. Rimma Pivovarov is a doctoral candidate in biomedical informatics at Columbia University. Herbert Chase is a professor of clinical medicine in biomedical informatics at Columbia University. Vanja Dukic is an associate professor in applied mathematics at the University of Colorado at Boulder. Noémie Elhadad is an assistant professor in biomedical informatics at Columbia University
| | - Noémie Elhadad
- Yolanda Hagar is a postdoctoral researcher in applied mathematics at the University of Colorado at Boulder. David Albers is an associate research scientist in biomedical informatics at Columbia University. Rimma Pivovarov is a doctoral candidate in biomedical informatics at Columbia University. Herbert Chase is a professor of clinical medicine in biomedical informatics at Columbia University. Vanja Dukic is an associate professor in applied mathematics at the University of Colorado at Boulder. Noémie Elhadad is an assistant professor in biomedical informatics at Columbia University
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Abstract
Many bioinformatics applications construct classifiers that are validated in experiments that compare their results to known ground truth over a corpus. In this paper, we introduce an approach for exploring the results of such classifier validation experiments, focusing on classifiers for regions of molecular surfaces. We provide a tool that allows for examining classification performance patterns over a test corpus. The approach combines a summary view that provides information about an entire corpus of molecules with a detail view that visualizes classifier results directly on protein surfaces. Rather than displaying miniature 3D views of each molecule, the summary provides 2D glyphs of each protein surface arranged in a reorderable, small-multiples grid. Each summary is specifically designed to support visual aggregation to allow the viewer to both get a sense of aggregate properties as well as the details that form them. The detail view provides a 3D visualization of each protein surface coupled with interaction techniques designed to support key tasks, including spatial aggregation and automated camera touring. A prototype implementation of our approach is demonstrated on protein surface classifier experiments.
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Affiliation(s)
- A Sarikaya
- Department of Computer Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - D Albers
- Department of Computer Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - J Mitchell
- Department of Biochemistry, University of Wisconsin-Madison, Madison, WI, USA ; Department of Mathematics, University of Wisconsin-Madison, Madison, WI, USA
| | - M Gleicher
- Department of Computer Sciences, University of Wisconsin-Madison, Madison, WI, USA
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