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Li B, Verma R, Beaton D, Tamim H, Hussain MA, Hoballah JJ, Lee DS, Wijeysundera DN, de Mestral C, Mamdani M, Al‐Omran M. Predicting Major Adverse Cardiovascular Events Following Carotid Endarterectomy Using Machine Learning. J Am Heart Assoc 2023; 12:e030508. [PMID: 37804197 PMCID: PMC10757546 DOI: 10.1161/jaha.123.030508] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/28/2023] [Indexed: 10/09/2023]
Abstract
Background Carotid endarterectomy (CEA) is a major vascular operation for stroke prevention that carries significant perioperative risks; however, outcome prediction tools remain limited. The authors developed machine learning algorithms to predict outcomes following CEA. Methods and Results The National Surgical Quality Improvement Program targeted vascular database was used to identify patients who underwent CEA between 2011 and 2021. Input features included 36 preoperative demographic/clinical variables. The primary outcome was 30-day major adverse cardiovascular events (composite of stroke, myocardial infarction, or death). The data were split into training (70%) and test (30%) sets. Using 10-fold cross-validation, 6 machine learning models were trained using preoperative features. The primary metric for evaluating model performance was area under the receiver operating characteristic curve. Model robustness was evaluated with calibration plot and Brier score. Overall, 38 853 patients underwent CEA during the study period. Thirty-day major adverse cardiovascular events occurred in 1683 (4.3%) patients. The best performing prediction model was XGBoost, achieving an area under the receiver operating characteristic curve of 0.91 (95% CI, 0.90-0.92). In comparison, logistic regression had an area under the receiver operating characteristic curve of 0.62 (95% CI, 0.60-0.64), and existing tools in the literature demonstrate area under the receiver operating characteristic curve values ranging from 0.58 to 0.74. The calibration plot showed good agreement between predicted and observed event probabilities with a Brier score of 0.02. The strongest predictive feature in our algorithm was carotid symptom status. Conclusions The machine learning models accurately predicted 30-day outcomes following CEA using preoperative data and performed better than existing tools. They have potential for important utility in guiding risk-mitigation strategies to improve outcomes for patients being considered for CEA.
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Affiliation(s)
- Ben Li
- Department of SurgeryUniversity of TorontoCanada
- Division of Vascular Surgery, St. Michael’s Hospital, Unity Health TorontoUniversity of TorontoCanada
- Institute of Medical ScienceUniversity of TorontoCanada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T‐CAIREM)University of TorontoCanada
| | - Raj Verma
- School of Medicine, Royal College of Surgeons in IrelandUniversity of Medicine and Health SciencesDublinIreland
| | - Derek Beaton
- Data Science & Advanced Analytics, Unity Health TorontoUniversity of TorontoCanada
| | - Hani Tamim
- Faculty of Medicine, Clinical Research InstituteAmerican University of Beirut Medical CenterBeirutLebanon
- College of MedicineAlfaisal UniversityRiyadhKingdom of Saudi Arabia
| | - Mohamad A. Hussain
- Division of Vascular and Endovascular Surgery and the Center for Surgery and Public Health, Brigham and Women’s HospitalHarvard Medical SchoolBostonMAUSA
| | - Jamal J. Hoballah
- Division of Vascular and Endovascular Surgery, Department of SurgeryAmerican University of Beirut Medical CenterBeirutLebanon
| | - Douglas S. Lee
- Division of Cardiology, Peter Munk Cardiac CentreUniversity Health NetworkTorontoCanada
- Institute of Health Policy, Management and EvaluationUniversity of TorontoCanada
- ICESUniversity of TorontoCanada
| | - Duminda N. Wijeysundera
- Institute of Health Policy, Management and EvaluationUniversity of TorontoCanada
- ICESUniversity of TorontoCanada
- Department of AnesthesiaSt. Michael’s Hospital, Unity Health TorontoTorontoCanada
- Li Ka Shing Knowledge InstituteSt. Michael’s Hospital, Unity Health TorontoTorontoCanada
| | - Charles de Mestral
- Department of SurgeryUniversity of TorontoCanada
- Division of Vascular Surgery, St. Michael’s Hospital, Unity Health TorontoUniversity of TorontoCanada
- Institute of Health Policy, Management and EvaluationUniversity of TorontoCanada
- ICESUniversity of TorontoCanada
- Li Ka Shing Knowledge InstituteSt. Michael’s Hospital, Unity Health TorontoTorontoCanada
| | - Muhammad Mamdani
- Institute of Medical ScienceUniversity of TorontoCanada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T‐CAIREM)University of TorontoCanada
- Data Science & Advanced Analytics, Unity Health TorontoUniversity of TorontoCanada
- Institute of Health Policy, Management and EvaluationUniversity of TorontoCanada
- ICESUniversity of TorontoCanada
- Li Ka Shing Knowledge InstituteSt. Michael’s Hospital, Unity Health TorontoTorontoCanada
- Leslie Dan Faculty of PharmacyUniversity of TorontoCanada
| | - Mohammed Al‐Omran
- Department of SurgeryUniversity of TorontoCanada
- Division of Vascular Surgery, St. Michael’s Hospital, Unity Health TorontoUniversity of TorontoCanada
- Institute of Medical ScienceUniversity of TorontoCanada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T‐CAIREM)University of TorontoCanada
- College of MedicineAlfaisal UniversityRiyadhKingdom of Saudi Arabia
- Li Ka Shing Knowledge InstituteSt. Michael’s Hospital, Unity Health TorontoTorontoCanada
- Department of SurgeryKing Faisal Specialist Hospital and Research CenterRiyadhKingdom of Saudi Arabia
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Zamzam A, McLaren A, Ram E, Syed MH, Rave S, Lu SH, Al‐Omran M, de Mestral C. A novel Canadian multidisciplinary acute care pathway for people hospitalised with a diabetic foot ulcer. Int Wound J 2023; 20:3331-3337. [PMID: 37150835 PMCID: PMC10502294 DOI: 10.1111/iwj.14214] [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: 02/20/2023] [Revised: 04/13/2023] [Accepted: 04/14/2023] [Indexed: 05/09/2023] Open
Abstract
This manuscript describes the implementation and initial evaluation of a novel Canadian acute care pathway for people with a diabetic foot ulcer (DFU). A multidisciplinary team developed and implemented an acute care pathway for patients with a DFU who presented to the emergency department (ED) and required hospitalisation at a tertiary care hospital in Canada. Processes of care, length of stay (LOS), and hospitalisation costs were considered through retrospective cohort study of all DFU hospitalizations from pathway launch in December 2018 to December 2020. There were 82 DFU-related hospital admissions through the ED of which 55 required invasive intervention: 28 (34.1%) minor amputations, 16 (19.5%) abscess drainage and debridement, 6 (7.3%) lower extremity revascularisations, 5 (6.1%) major amputations. Mean hospital LOS was 8.8 ± 4.9 days. Mean hospitalisation cost was $20 569 (±14 143): $25 901 (±15 965) when surgical intervention was required and $9279 (±7106) when it was not. LOS and hospitalisation costs compared favourably to historical data. An acute care DFU pathway can support the efficient evaluation and management of patients hospitalised with a DFU. A dedicated multidisciplinary DFU care team is a valuable resource for hospitals in Canada.
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Affiliation(s)
- Abdelrahman Zamzam
- Division of Vascular Surgery, St. Michael's HospitalUnity Health TorontoTorontoOntarioCanada
| | - Ann‐Marie McLaren
- Chiropody TeamUnity Health Toronto—St. Michael's HospitalTorontoOntarioCanada
| | - Emily Ram
- Li Ka Shing Knowledge InstituteSt. Michael's HospitalTorontoOntarioCanada
| | - Muzammil H. Syed
- Division of Vascular Surgery, St. Michael's HospitalUnity Health TorontoTorontoOntarioCanada
| | - Sreenath Rave
- Chiropody TeamUnity Health Toronto—St. Michael's HospitalTorontoOntarioCanada
| | - Suzanne H. Lu
- Chiropody TeamUnity Health Toronto—St. Michael's HospitalTorontoOntarioCanada
| | - Mohammed Al‐Omran
- Division of Vascular Surgery, St. Michael's HospitalUnity Health TorontoTorontoOntarioCanada
- Li Ka Shing Knowledge InstituteSt. Michael's HospitalTorontoOntarioCanada
- Department of SurgeryKing Faisal Specialist Hospital and Research CenterRiyadhKingdom of Saudi Arabia
- Diabetes Action CanadaTorontoOntarioCanada
- Department of SurgeryUniversity of TorontoTorontoOntarioCanada
| | - Charles de Mestral
- Division of Vascular Surgery, St. Michael's HospitalUnity Health TorontoTorontoOntarioCanada
- Li Ka Shing Knowledge InstituteSt. Michael's HospitalTorontoOntarioCanada
- Department of SurgeryKing Faisal Specialist Hospital and Research CenterRiyadhKingdom of Saudi Arabia
- Diabetes Action CanadaTorontoOntarioCanada
- Department of SurgeryUniversity of TorontoTorontoOntarioCanada
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Verma S, Al‐Omran M, Leiter LA, Mazer CD, Rasmussen S, Saevereid HA, Sejersten Ripa M, Bonaca MP. Cardiovascular efficacy of liraglutide and semaglutide in individuals with diabetes and peripheral artery disease. Diabetes Obes Metab 2022; 24:1288-1299. [PMID: 35332654 PMCID: PMC9325529 DOI: 10.1111/dom.14700] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 03/10/2022] [Accepted: 03/22/2022] [Indexed: 01/14/2023]
Abstract
AIM To evaluate the cardiovascular (CV) efficacy of liraglutide and semaglutide in patients with type 2 diabetes (T2D) and peripheral artery disease (PAD). MATERIALS AND METHODS LEADER and SUSTAIN 6 trials investigated subcutaneous liraglutide (≤1.8 mg/day) and semaglutide (0.5 or 1.0 mg/week), respectively, versus placebo in patients with T2D and high CV risk (median follow-up: 3.8 and 2.1 years, respectively). The primary outcome was a composite of CV death, non-fatal myocardial infarction or non-fatal stroke (major adverse CV event [MACE]) according to the presence of PAD at baseline. RESULTS Overall, 1184/9340 (12.7%) patients in LEADER and 460/3297 (14.0%) in SUSTAIN 6 had PAD at baseline. Patients with PAD were at an ~35% increased risk of MACE versus those without (LEADER: hazard ratio [HR] 1.36, 95% confidence interval [CI] 1.17-1.58; SUSTAIN 6: HR 1.33, 95% CI 0.94-1.83). The effects of both therapies on MACE were consistently beneficial in patients with PAD (liraglutide: HR 0.77, 95% CI 0.58-1.01; semaglutide: 0.61, 0.33-1.13) and without (liraglutide: HR 0.89, 95% CI 0.79-1.00; semaglutide: HR 0.77, 95% CI 0.58-1.01; Pinteraction = .34 for liraglutide and .49 for semaglutide). Absolute risk reductions for MACE were higher in patients with PAD (liraglutide: 4.13%-point, 95% CI -0.15-8.42; semaglutide: 4.63%-point, 95% CI -0.58-9.84) versus without (liraglutide:1.42%-point, 95% CI -0.03-2.87; semaglutide: 1.90%-point, 95% CI 0.00-3.80). CONCLUSION Both liraglutide and semaglutide reduce MACE with consistent CV efficacy regardless of PAD status.
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Affiliation(s)
- Subodh Verma
- St. Michael's Hospital, University of TorontoTorontoOntarioCanada
| | | | | | - C. David Mazer
- St. Michael's Hospital, University of TorontoTorontoOntarioCanada
| | | | | | | | - Marc P. Bonaca
- CPC Clinical ResearchUniversity of Colorado School of MedicineAuroraColoradoUSA
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Khan H, Zamzam A, Gallant RC, Syed MH, Rand ML, Ni H, Forbes TL, Al‐Omran M, Qadura M. Aspirin nonsensitivity in patients with vascular disease: Assessment by light transmission aggregometry (aspirin nonsensitivity in vascular patients). Res Pract Thromb Haemost 2021; 5:e12618. [PMID: 34816074 PMCID: PMC8595963 DOI: 10.1002/rth2.12618] [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] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 08/19/2021] [Accepted: 10/05/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Aspirin is a key antiplatelet therapy for the prevention of thrombotic events in patients with cardiovascular disease. Studies suggest that ≈20% of patients with cardiac disease suffer from aspirin nonsensitivity, a phenomenon characterized by the inability of 81 mg aspirin to inhibit platelet aggregation and/or prevent adverse cardiovascular events. OBJECTIVES To investigate aspirin nonsensitivity in patients with vascular disease and assess the consequences of aspirin nonsensitivity. METHODS One hundred fifty patients presenting to St. Michael's Hospital's outpatient clinics with evidence of vascular disease (peripheral arterial disease or carotid artery stenosis) and a previous prescription of 81 mg of aspirin were recruited in this study. Light transmission aggregometry with arachidonic acid induction was used to determine sensitivity to aspirin. Patients with a maximum aggregation ≥20% in response to arachidonic acid were considered aspirin nonsensitive, as per previous studies. RESULTS Of the 150 patients recruited, 36 patients (24%) were nonsensitive to 81 mg of aspirin. Of these 36 nonsensitive patients, 30 patients provided a urine sample for urine salicyluric acid analysis (a major metabolite of aspirin). Urine analysis demonstrated that 14 patients were compliant and 16 were noncompliant with their aspirin therapy. Major adverse cardiovascular events and major adverse limb events were significantly higher in the nonsensitive patients compared to sensitive patients (hazard ratio, 3.68; P < 0.001). CONCLUSION These data highlight the high prevalence of aspirin nonsensitivity and noncompliance in patients with vascular disease and emphasizes the urgent need for improved medical management options for this patient population.
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Affiliation(s)
- Hamzah Khan
- Division of Vascular SurgerySt. Michael's HospitalTorontoONCanada
| | | | - Reid C. Gallant
- Keenan Research Centre for Biomedical ScienceLi Ka Shing Knowledge Institute of St. Michael's HospitalTorontoONCanada
| | - Muzammil H. Syed
- Division of Vascular SurgerySt. Michael's HospitalTorontoONCanada
| | - Margaret L. Rand
- Department of Laboratory Medicine & PathobiologyUniversity of TorontoTorontoONCanada
| | - Heyu Ni
- Department of Laboratory Medicine & PathobiologyUniversity of TorontoTorontoONCanada
| | - Thomas L. Forbes
- Division of Vascular SurgeryToronto General Hospital (UHN)TorontoONCanada
| | | | - Mohammad Qadura
- Division of Vascular SurgerySt. Michael's HospitalTorontoONCanada
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Verma S, Ji Q, Bhatt DL, Mazer CD, Al‐Omran M, Inzucchi SE, Wanner C, Ofstad AP, Zwiener I, George JT, Zinman B, Fitchett D. Association between uric acid levels and cardio-renal outcomes and death in patients with type 2 diabetes: A subanalysis of EMPA-REG OUTCOME. Diabetes Obes Metab 2020; 22:1207-1214. [PMID: 32030863 PMCID: PMC7317186 DOI: 10.1111/dom.13991] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 01/23/2020] [Accepted: 01/31/2020] [Indexed: 12/18/2022]
Abstract
In the EMPA-REG OUTCOME trial, we explored the association between pre-randomization uric acid level tertile (<309.30 μmol/L; 309.30 to <387.21 μmol/L; ≥387.21 μmol/L) and cardiovascular (CV) death, hospitalization for heart failure (HHF), HHF or CV death, all-cause mortality, three-point major adverse CV events (MACE), and incident or worsening nephropathy. Patients with type 2 diabetes and CV disease received empagliflozin or placebo. The median baseline plasma uric acid level was 344.98 μmol/L, and patients' baseline characteristics were mainly balanced across tertiles. Baseline uric acid levels were associated with cardio-renal outcomes: in the placebo group, for the highest versus lowest tertile, the multivariable hazard ratios for three-point MACE, HHF or CV death, and incident or worsening nephropathy were 1.22 (95% confidence interval [CI] 0.89-1.67; P = 0.2088), 1.51 (95% CI 1.02-2.23; P = 0.0396) and 1.77 (95% CI 1.33-2.34; P < 0.0001), respectively. When tested as a continuous variable, baseline uric acid was associated with all outcomes in the placebo group. Empagliflozin improved all cardio-renal outcomes across tertiles, with all interaction P values >0.05. Further investigation of these relationships is required.
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Affiliation(s)
- Subodh Verma
- St Michael's Hospital, Division of Cardiac SurgeryUniversity of TorontoTorontoOntarioCanada
| | - Qiuhe Ji
- Xijing HospitalFourth Military Medical University, Xi'anChina
| | - Deepak L. Bhatt
- Brigham and Women's Hospital Heart and Vascular Centre and Harvard Medical SchoolBostonMassachusettsUSA
| | - C. David Mazer
- St Michael's Hospital, Department of AnaesthesiaUniversity of TorontoTorontoOntarioCanada
| | - Mohammed Al‐Omran
- St Michael's Hospital, Division of Vascular SurgeryUniversity of TorontoTorontoOntarioCanada
| | | | | | | | | | | | - Bernard Zinman
- Lunenfeld‐Tanenbaum Research Institute, Mount Sinai HospitalUniversity of TorontoTorontoOntarioCanada
| | - David Fitchett
- St Michael's Hospital, Division of CardiologyUniversity of TorontoTorontoOntarioCanada
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Hussain MA, Saposnik G, Raju S, Salata K, Mamdani M, Tu JV, Bhatt DL, Verma S, Al‐Omran M. Association Between Statin Use and Cardiovascular Events After Carotid Artery Revascularization. J Am Heart Assoc 2018; 7:e009745. [PMID: 30369318 PMCID: PMC6201401 DOI: 10.1161/jaha.118.009745] [Citation(s) in RCA: 24] [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: 05/09/2018] [Accepted: 07/09/2018] [Indexed: 01/27/2023]
Abstract
Background Statins are commonly used for the prevention of cardiovascular events; however, statins are underutilized in patients with noncoronary atherosclerosis. We sought to establish the rates of statin use in patients with carotid artery disease and to examine the association between statin therapy and outcomes after carotid revascularization. Methods and Results In this population-level retrospective cohort study, we identified all individuals aged ≥66 years who underwent carotid endarterectomy or stenting in Ontario, Canada (2002-2014). The primary outcome was a composite of 1-year stroke, myocardial infarction, or death (major adverse cardiac and cerebrovascular events). Five-year risks were also examined. Adjusted hazard ratios were computed using inverse probability of treatment weighting based on propensity scores. A total of 7893 of 10 723 patients (73.6%) who underwent carotid revascularization were on preprocedural statin therapy; moderate- or high-dose therapy was utilized by 7384 patients (68.9%). The composite rate of 1-year major adverse cardiac and cerebrovascular events was lower among statin users (adjusted hazard ratio: 0.76; 95% confidence interval, 0.70-0.83). Patients who were on persistent long-term statin therapy after the carotid procedure continued to experience significantly lower risk of major adverse cardiac and cerebrovascular events at 5 years (adjusted hazard ratio: 0.75, 95% confidence interval, 0.71-0.80). The beneficial associations with statin use were observed regardless of type of carotid revascularization procedure, carotid artery symptom status, or statin dose. Conclusions Continuous statin therapy was associated with a 25% lower risk of long-term adverse cardiovascular events in patients with significant carotid disease. Along with other supportive evidence, statins should be considered in patients undergoing carotid revascularization, and efforts are required to increase statin use in this undertreated population.
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Affiliation(s)
- Mohamad A. Hussain
- Division of Vascular SurgerySt. Michael's HospitalTorontoOntarioCanada
- Department of SurgeryUniversity of TorontoOntarioCanada
| | - Gustavo Saposnik
- Division of NeurologySt. Michael's HospitalTorontoOntarioCanada
- Li Ka Shing Knowledge Institute of St. Michael's HospitalTorontoOntarioCanada
- Department of MedicineUniversity of TorontoOntarioCanada
- Institute of Health Policy, Management, and EvaluationUniversity of TorontoOntarioCanada
- Institute for Clinical Evaluative SciencesTorontoOntarioCanada
| | - Sneha Raju
- Department of SurgeryUniversity of TorontoOntarioCanada
| | - Konrad Salata
- Division of Vascular SurgerySt. Michael's HospitalTorontoOntarioCanada
- Department of SurgeryUniversity of TorontoOntarioCanada
| | - Muhammad Mamdani
- Li Ka Shing Knowledge Institute of St. Michael's HospitalTorontoOntarioCanada
- Institute of Health Policy, Management, and EvaluationUniversity of TorontoOntarioCanada
- Leslie Dan Faculty of PharmacyUniversity of TorontoOntarioCanada
- Institute for Clinical Evaluative SciencesTorontoOntarioCanada
- King Saud University‐Li Ka Shing Collaborative Research ProgramKing Saud UniversityRiyadhKingdom of Saudi Arabia
| | - Jack V. Tu
- Department of MedicineUniversity of TorontoOntarioCanada
- Institute of Health Policy, Management, and EvaluationUniversity of TorontoOntarioCanada
- Institute for Clinical Evaluative SciencesTorontoOntarioCanada
- Division of CardiologySchulich Heart CentreSunnybrook Health Sciences CentreTorontoOntarioCanada
| | - Deepak L. Bhatt
- Brigham and Women's Hospital Heart & Vascular CenterHarvard Medical SchoolBostonMA
| | - Subodh Verma
- Division of Cardiac SurgerySt. Michael's HospitalTorontoOntarioCanada
- Li Ka Shing Knowledge Institute of St. Michael's HospitalTorontoOntarioCanada
- Department of SurgeryUniversity of TorontoOntarioCanada
- King Saud University‐Li Ka Shing Collaborative Research ProgramKing Saud UniversityRiyadhKingdom of Saudi Arabia
| | - Mohammed Al‐Omran
- Division of Vascular SurgerySt. Michael's HospitalTorontoOntarioCanada
- Li Ka Shing Knowledge Institute of St. Michael's HospitalTorontoOntarioCanada
- Department of SurgeryUniversity of TorontoOntarioCanada
- King Saud University‐Li Ka Shing Collaborative Research ProgramKing Saud UniversityRiyadhKingdom of Saudi Arabia
- Department of SurgeryKing Saud UniversityRiyadhKingdom of Saudi Arabia
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Torisu K, Singh KK, Torisu T, Lovren F, Liu J, Pan Y, Quan A, Ramadan A, Al‐Omran M, Pankova N, Boyd SR, Verma S, Finkel T. Intact endothelial autophagy is required to maintain vascular lipid homeostasis. Aging Cell 2016; 15:187-91. [PMID: 26780888 PMCID: PMC4717267 DOI: 10.1111/acel.12423] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2015] [Indexed: 12/16/2022] Open
Abstract
The physiological role of autophagic flux within the vascular endothelial layer remains poorly understood. Here, we show that in primary endothelial cells, oxidized and native LDL stimulates autophagosome formation. Moreover, by both confocal and electron microscopy, excess native or modified LDL appears to be engulfed within autophagic structures. Transient knockdown of the essential autophagy gene ATG7 resulted in higher levels of intracellular (125) I-LDL and oxidized LDL (OxLDL) accumulation, suggesting that in endothelial cells, autophagy may represent an important mechanism to regulate excess, exogenous lipids. The physiological importance of these observations was assessed using mice containing a conditional deletion of ATG7 within the endothelium. Following acute intravenous infusion of fluorescently labeled OxLDL, mice lacking endothelial expression of ATG7 demonstrated prolonged retention of OxLDL within the retinal pigment epithelium (RPE) and choroidal endothelium of the eye. In a chronic model of lipid excess, we analyzed atherosclerotic burden in ApoE(-/-) mice with or without endothelial autophagic flux. The absence of endothelial autophagy markedly increased atherosclerotic burden. Thus, in both an acute and chronic in vivo model, endothelial autophagy appears critically important in limiting lipid accumulation within the vessel wall. As such, strategies that stimulate autophagy, or prevent the age-dependent decline in autophagic flux, might be particularly beneficial in treating atherosclerotic vascular disease.
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Affiliation(s)
- Kumiko Torisu
- Center for Molecular MedicineNational Heart, Lung and Blood InstituteNIH10 Center DriveBethesdaMD 20892USA
| | - Krishna K. Singh
- Division of Cardiac SurgeryKeenan Research Centre for Biomedical SciencesSt. Michael's HospitalUniversity of Toronto30 Bond StreetTorontoON M5B 1W8Canada
- Division of Vascular SurgeryKeenan Research Centre for Biomedical SciencesSt. Michael's HospitalUniversity of Toronto30 Bond StreetTorontoON M5B 1W8Canada
| | - Takehiro Torisu
- Center for Molecular MedicineNational Heart, Lung and Blood InstituteNIH10 Center DriveBethesdaMD 20892USA
| | - Fina Lovren
- Division of Cardiac SurgeryKeenan Research Centre for Biomedical SciencesSt. Michael's HospitalUniversity of Toronto30 Bond StreetTorontoON M5B 1W8Canada
| | - Jie Liu
- Center for Molecular MedicineNational Heart, Lung and Blood InstituteNIH10 Center DriveBethesdaMD 20892USA
| | - Yi Pan
- Division of Cardiac SurgeryKeenan Research Centre for Biomedical SciencesSt. Michael's HospitalUniversity of Toronto30 Bond StreetTorontoON M5B 1W8Canada
| | - Adrian Quan
- Division of Cardiac SurgeryKeenan Research Centre for Biomedical SciencesSt. Michael's HospitalUniversity of Toronto30 Bond StreetTorontoON M5B 1W8Canada
| | - Azza Ramadan
- Division of Cardiac SurgeryKeenan Research Centre for Biomedical SciencesSt. Michael's HospitalUniversity of Toronto30 Bond StreetTorontoON M5B 1W8Canada
| | - Mohammed Al‐Omran
- Division of Vascular SurgeryKeenan Research Centre for Biomedical SciencesSt. Michael's HospitalUniversity of Toronto30 Bond StreetTorontoON M5B 1W8Canada
| | - Natalie Pankova
- Department of Ophthalmology and Vision SciencesKeenan Research Centre for Biomedical SciencesSt. Michael's HospitalUniversity of Toronto30 Bond StreetTorontoON M5B 1W8Canada
| | - Shelley R. Boyd
- Department of Ophthalmology and Vision SciencesKeenan Research Centre for Biomedical SciencesSt. Michael's HospitalUniversity of Toronto30 Bond StreetTorontoON M5B 1W8Canada
| | - Subodh Verma
- Division of Cardiac SurgeryKeenan Research Centre for Biomedical SciencesSt. Michael's HospitalUniversity of Toronto30 Bond StreetTorontoON M5B 1W8Canada
| | - Toren Finkel
- Center for Molecular MedicineNational Heart, Lung and Blood InstituteNIH10 Center DriveBethesdaMD 20892USA
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8
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Abstract
BACKGROUND Acute pancreatitis creates a catabolic stress state promoting a systemic inflammatory response and nutritional deterioration. Adequate supply of nutrients plays an important role in recovery. Total parenteral nutrition (TPN) has been standard practice for providing exogenous nutrients to patients with severe acute pancreatitis. However, recent data suggest that enteral nutrition (EN) is not only feasible, but safer and more effective.Therefore, we sought to update our systematic review to re-evaluate the level of evidence. OBJECTIVES To compare the effect of TPN versus EN on mortality, morbidity and length of hospital stay in patients with acute pancreatitis. SEARCH STRATEGY Trials were identified by computerized searches of The Cochrane Controlled Trials Register, MEDLINE, and EMBASE. Additional studies were identified by searching Scisearch, bibliographies of review articles and identified trials. The search was undertaken in August 2000 and updated in September 2002, October 2003, November 2004 and November 2008. No language restrictions were applied. SELECTION CRITERIA Randomized clinical trials comparing TPN to EN in patients with acute pancreatitis. DATA COLLECTION AND ANALYSIS Two reviewers independently abstracted data and assessed trial quality. A standardized form was used to extract relevant data. MAIN RESULTS Eight trials with a total of 348 participants were included. Comparing EN to TPN for acute pancreatitis, the relative risk (RR) for death was 0.50 (95% CI 0.28 to 0.91), for multiple organ failure (MOF) was 0.55 (95% CI 0.37 to 0.81), for systemic infection was 0.39 (95% CI 0.23 to 0.65), for operative interventions was 0.44 (95% CI 0.29 to 0.67), for local septic complications was 0.74 (95% CI 0.40 to 1.35), and for other local complications was 0.70 (95% CI 0.43 to 1.13). Mean length of hospital stay was reduced by 2.37 days in EN vs TPN groups (95% CI -7.18 to 2.44). Furthermore, a subgroup analysis for EN vs TPN in patients with severe acute pancreatitis showed a RR for death of 0.18 (95% CI 0.06 to 0.58) and a RR for MOF of 0.46 (95% CI 0.16 to 1.29). AUTHORS' CONCLUSIONS In patients with acute pancreatitis, enteral nutrition significantly reduced mortality, multiple organ failure, systemic infections, and the need for operative interventions compared to those who received TPN. In addition, there was a trend towards a reduction in length of hospital stay. These data suggest that EN should be considered the standard of care for patients with acute pancreatitis requiring nutritional support.
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Affiliation(s)
- Mohammed Al‐Omran
- College of Medicine, King Saud UniversityDepartment of Surgery and Peripheral Vascular Disease Research ChairP.O.Box 7805(37)RiyadhSaudi Arabia11472
| | - Zaina H AlBalawi
- College of Medicine, King Saud UniversitySheikh Abdullah S. Bahamdan Research Chair for Evidence‐Based Health Care and Knowledge TranslationP.O. Box 68639RiyadhCentralSaudi Arabia11537
| | - Mariam F Tashkandi
- LKSKI St. Michael's HospitalApplied Health Research Centre10 Queens Quay ‐ 1211TorontoOntarioCanadaM5J2R9
| | - Lubna A Al‐Ansary
- College of Medicine, King Saud UniversityDepartment of Family & Community Medicine, Holder of "Shaikh Abdullah S. Bahamdan" Research Chair for Evidence‐Based Health Care and Knowledge TranslationP.O.Box 2925RiyadhSaudi Arabia11461
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