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Mehra R, Ray A, Das S, Biman Kusum Chowdhury, Singh Koshal S, Hora R, Kumari A, Kaur A, Quadri SF, Deb Roy A. Enablers and barriers to rotavirus vaccine coverage in Assam, India- A qualitative study. Vaccine X 2024; 18:100479. [PMID: 38559753 PMCID: PMC10979257 DOI: 10.1016/j.jvacx.2024.100479] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 01/18/2024] [Accepted: 03/18/2024] [Indexed: 04/04/2024] Open
Abstract
Background Estimates suggest that 78,000 children died due to rotavirus gastroenteritis annually between 2011 and 2013 in India. The north eastern state of Assam reported 38.4% pediatric diarrheal admissions testing positive for rotavirus. Rotavirus vaccine (RVV) was introduced in Assam in 2017 following which the National Family Health Survey-5 (NFHS-5) (2019) revealed low RVV coverage in Assam with wide variation between the districts. the current study was conceptualized and undertaken to capture the enablers and barriers to RVV coverage in Assam. Methods Qualitative study conducted in 5 randomly selected districts in Assam. Participants (key informants) were recruited by purposive sampling at each level of the health system including healthcare officials, service providers and caregivers based on availability. Thirty-five in-depth interviews (IDIs) and five focus group discussions (FGDs) were conducted. Interviews were tape recorded and transcribed. Data was coded and analyzed using the thematic framework approach. Results Findings from the qualitative data collection were collated and analyzed under 7 identified themes. Difficult terrain, limited service provider availability and no catch-up training for new recruits were some of the barriers to RVV coverage. In contrast, Information, Education & Communication (IEC) in vernacular language, RVV safety profile, development partner support and adequate RVV supply were identified as some of the enablers of RVV coverage. Conclusion Few broad recommendations to overcome identified barriers include comprehensive inter-sectoral coordination, regular monitoring and frequent refresher training sessions. There is a need for a future study utilizing existing coverage data and larger sample size to triangulate the findings of this study.
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Affiliation(s)
| | - Arindam Ray
- Bill and Melinda Gates Foundation, New Delhi, India
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Mehra R, Patterson BJ, Riley PA, Planche TD, Breathnach AS. Impact of removing the healthcare mask mandate on hospital-acquired COVID-19 rates. J Hosp Infect 2024; 145:59-64. [PMID: 38141666 DOI: 10.1016/j.jhin.2023.12.004] [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: 10/25/2023] [Revised: 11/28/2023] [Accepted: 12/06/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Mandatory mask-wearing policies were one of several measures employed to reduce hospital-acquired SARS-CoV-2 infection throughout the pandemic. Many nations have removed healthcare mask mandates, but there remains a risk of new SARS-CoV-2 variants or epidemics of other respiratory viruses. AIM To demonstrate the impact of removing the healthcare mask mandate. METHODS SARS-CoV-2 infections were analysed in a large teaching hospital for 40 weeks in 2022 using a controlled interrupted time-series design. The intervention was the removal of a staff/visitor surgical mask-wearing policy for the most wards at week 26 (intervention group) with a subset of specific wards retaining the mask policy (control group). The hospital-acquired SARS-CoV-2 infection rate was adjusted by the underlying community infection rate. FINDINGS In the context of a surge in SARS-CoV-2 infection, removal of the mask mandate for staff/visitors was not associated with a statistically significant change in the rate of nosocomial SARS-CoV-2 infection in the intervention group (incidence rate ratio: 1.105; 95% confidence interval: 0.523-2.334; P = 0.79) and there was no post-intervention trend (1.013; 0.932-1.100; P = 0.76) to suggest a delayed effect. The control group also showed no immediate or delayed change in infection rate. CONCLUSION No evidence was found that removal of a staff/visitor mask-wearing policy had a significant effect on the rate of hospital-acquired SARS-CoV-2 infection. This does not demonstrate that masks were ineffective through the pandemic, but provides some objective evidence to justify the removal of healthcare mask mandates once there was widespread immunity and reduced disease severity.
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Affiliation(s)
- R Mehra
- Department of Infection, St George's University Hospitals NHS Foundation Trust, London, UK.
| | - B J Patterson
- Department of Infection, St George's University Hospitals NHS Foundation Trust, London, UK
| | - P A Riley
- Department of Infection, St George's University Hospitals NHS Foundation Trust, London, UK; Institute of Infection and Immunity, St George's University of London, London, UK
| | - T D Planche
- Department of Infection, St George's University Hospitals NHS Foundation Trust, London, UK; Institute of Infection and Immunity, St George's University of London, London, UK
| | - A S Breathnach
- Department of Infection, St George's University Hospitals NHS Foundation Trust, London, UK; Institute of Infection and Immunity, St George's University of London, London, UK
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Harrington KJ, Cohen EEW, Soulières D, Dinis J, Licitra L, Ahn MJ, Soria A, Machiels JP, Mach N, Mehra R, Burtness B, Swaby RF, Lin J, Ge J, Lerman N, Tourneau CL. Pembrolizumab versus methotrexate, docetaxel, or cetuximab in recurrent or metastatic head and neck squamous cell carcinoma (KEYNOTE-040): Subgroup analysis by pattern of disease recurrence. Oral Oncol 2023; 147:106587. [PMID: 37925894 DOI: 10.1016/j.oraloncology.2023.106587] [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: 04/25/2023] [Revised: 09/29/2023] [Accepted: 10/06/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND In the phase 3 KEYNOTE-040 study, pembrolizumab prolonged OS versus chemotherapy in previously treated recurrent or metastatic (R/M) HNSCC. We present a post hoc subgroup analysis by disease recurrence pattern: recurrent-only, recurrent and metastatic (recurrent-metastatic), and metastatic-only HNSCC. MATERIALS AND METHODS Patients had HNSCC that progressed during or after platinum-containing treatment for R/M disease or had recurrence or progression within 3-6 months of previous platinum-containing definitive therapy for locally advanced disease. Patients were randomly assigned (1:1) to pembrolizumab 200 mg Q3W or investigator's choice of standards of care (SOC): methotrexate, docetaxel, or cetuximab. Outcomes included OS, PFS, ORR, and DOR. The data cutoff was May 15, 2017. RESULTS There were 125 patients (pembrolizumab, 53; SOC, 72) in the recurrent-only subgroup, 204 in the recurrent-metastatic subgroup (pembrolizumab, 108; SOC, 96), and 166 in the metastatic-only subgroup (pembrolizumab, 86; SOC, 80). The hazard ratio (95% CI) for death for pembrolizumab versus SOC was 0.83 (0.55-1.25) in the recurrent-only, 0.78 (0.58-1.06) in the recurrent-metastatic, and 0.74 (0.52-1.05) in the metastatic-only subgroups. PFS was similar between treatment arms in all subgroups. ORR was 22.6% for pembrolizumab versus 16.7% for SOC in the recurrent-only, 10.2% versus 6.3% in the recurrent-metastatic, and 15.1% versus 8.8% in the metastatic-only subgroups. DOR was numerically longer with pembrolizumab in all subgroups. CONCLUSION Pembrolizumab provided numerically longer OS and durable responses in all subgroups compared with SOC, suggesting that patients with previously treated R/M HNSCC benefit from pembrolizumab regardless of recurrence pattern.
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Affiliation(s)
- K J Harrington
- 105 Cotswold Road, Division of Radiotherapy and Imaging, The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust National Institute of Health Research Biomedical Research Centre, London SM2 5NG, United Kingdom.
| | - E E W Cohen
- 3855 Health Sciences Dr, Department of Medical Oncology, Moores Cancer Center, UC San Diego Health, La Jolla, CA 92093, United States.
| | - D Soulières
- 1560, rue Sherbrooke estx, Department of Hematology and Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, QC H2L 4MN, Canada.
| | - J Dinis
- R Dr. Antonio Bernardino de Almeida Medicina Oncologica Unidade de Investigacao Clinica, Department of Medical Oncology, Instituto Português de Oncologia do Porto Francisco Gentil, 4200-072 Porto, Portugal.
| | - L Licitra
- Via Giacomo Venezian, 1, Department of Head and Neck Cancer, Fondazione IRCCS Istituto Nazionale dei Tumori and University of Milan, 20133 Milan, Italy
| | - M-J Ahn
- 81 Irwon-Ro Gangnam, Department of Hematology & Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
| | - A Soria
- Ctra. de Colmenar Viejo km. 9,100, Department of Medical Oncology, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain
| | - J-P Machiels
- Avenue Hippocrate 10, Department of Medical Oncology, Institut Roi Albert II, Cliniques Universitaires Saint-Luc and Institut de Recherche Clinique et Expérimentale, Université Catholique de Louvain (UCLouvain), 1200 Brussels, Belgium
| | - N Mach
- Rue Gabrielle-Perret-Gentil 4, Clinical Research Unit, Department of Oncology, Hôpitaux Universitaires de Genève, 1205 Geneva, Switzerland
| | - R Mehra
- 22 South Greene Street, Department of Head and Neck Medical Oncology, Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD 21201, United States
| | - B Burtness
- 25 York Street PO Box 208028, Yale Cancer Center and Department of Medicine, Yale University School of Medicine, New Haven, CT 06510, United States
| | - R F Swaby
- 90 E Scott Ave, Merck & Co., Inc., Rahway, NJ 07065, United States
| | - J Lin
- 90 E Scott Ave, Merck & Co., Inc., Rahway, NJ 07065, United States
| | - J Ge
- 90 E Scott Ave, Merck & Co., Inc., Rahway, NJ 07065, United States
| | - N Lerman
- 90 E Scott Ave, Merck & Co., Inc., Rahway, NJ 07065, United States
| | - C Le Tourneau
- 26 rue d'Ulm, Department of Drug Development and Innovation (D3i), Institut Curie, Paris-Saclay University, 75005 Paris, France
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Mehra R, Meda M, Pichon B, Gentry V, Smith A, Nicholls M, Ryan Y, Woods J, Tote S. Whole-genome sequencing links cases dispersed in time, place, and person while supporting healthcare worker management in an outbreak of Panton-Valentine leucocidin meticillin-resistant Staphylococcus aureus; and a review of literature. J Hosp Infect 2023; 141:88-98. [PMID: 37678435 DOI: 10.1016/j.jhin.2023.08.019] [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: 05/03/2023] [Revised: 08/21/2023] [Accepted: 08/23/2023] [Indexed: 09/09/2023]
Abstract
This is a report on an outbreak of Panton-Valentine leucocidin-producing meticillin-resistant Staphylococcus aureus (PVL-MRSA) in an intensive care unit (ICU) during the COVID-19 pandemic that affected seven patients and a member of staff. Six patients were infected over a period of ten months on ICU by the same strain of PVL-MRSA, and a historic case identified outside of the ICU. All cases were linked to a healthcare worker (HCW) who was colonized with the organism. Failed topical decolonization therapy, without systemic antibiotic therapy, resulted in ongoing transmission and one preventable acquisition of PVL-MRSA. The outbreak identifies the support that may be needed for HCWs implicated in outbreaks. It also demonstrates the role of whole-genome sequencing in identifying dispersed and historic cases related to the outbreak, which in turn aids decision-making in outbreak management and HCW support. This report also includes a review of literature of PVL-MRSA-associated outbreaks in healthcare and highlights the need for review of current national guidance in the management of HCWs' decolonization regimen and return-to-work recommendations in such outbreaks.
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Affiliation(s)
- R Mehra
- Department of Infection Prevention and Control, Frimley Health NHS Foundation Trust, Frimley, UK
| | - M Meda
- Department of Infection Prevention and Control, Frimley Health NHS Foundation Trust, Frimley, UK.
| | - B Pichon
- UK Health and Security Agency, UK
| | - V Gentry
- Department of Infection Prevention and Control, Frimley Health NHS Foundation Trust, Frimley, UK
| | - A Smith
- Department of Infection Prevention and Control, Frimley Health NHS Foundation Trust, Frimley, UK
| | | | - Y Ryan
- UK Health and Security Agency, UK
| | - J Woods
- Department of Anaesthetics and ITU, Frimley Health NHS Foundation Trust, Frimley, UK
| | - S Tote
- Department of Anaesthetics and ITU, Frimley Health NHS Foundation Trust, Frimley, UK
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Jia AY, Sun Y, Baydoun A, Zaorsky NG, Vince RA, Shoag JE, Brown J, Barata P, Dess RT, Jackson WC, Roy S, Nguyen PL, Berlin A, Mehra R, Schaeffer EM, Kashani R, Kishan AU, Morgan TM, Spratt DE. Cross-Comparison Individual Patient Level Analysis of Three Gene Expression Signatures in Localized Prostate in over 50,000 Men. Int J Radiat Oncol Biol Phys 2023; 117:S35. [PMID: 37784481 DOI: 10.1016/j.ijrobp.2023.06.301] [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] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Risk stratification guides the management of localized prostate cancer. Multiple commercial gene expression biomarkers have been developed to improve estimates of prognosis, however the 22-gene Decipher genomic classifier (22-GC) is the only test with level 1 evidence supporting its use per NCCN guidelines. It is unknown whether other commercial signatures, Oncotype (GPS) or Prolaris (CCP), are sufficiently correlated to negate the differences in evidence supporting these commercial tests. Herein, we aim to perform a cross-comparison of these signatures in a large cohort of patients diagnosed with localized prostate cancer. MATERIALS/METHODS Patients diagnosed with localized prostate cancer who underwent whole transcriptome gene expression microarray analysis on their primary tumor biopsy specimen were included. The 22-GC score was calculated by Veracyte using a commercially locked model. Individual genes in each of the GPS and CCP gene signatures were identified, and the gene weights in each signature were retrained for prediction of metastasis in a multi-institutional cohort of 1,574 men with long-term outcome data. This was performed to improve correlation performance of GPS and CCP given only the 22-GC was trained for prediction of metastasis. For each of the three signatures, both continuous and categorical scores were calculated. Linear regression and spearman correlations were calculated both on univariable and multivariable analyses adjusting for age, grade group, PSA, and T-stage. RESULTS A total of 50,881 patients were included (15,379 (30.2%) NCCN low-risk, 14,773 (29.0%) favorable intermediate-risk, 15,544 (30.5%) unfavorable intermediate-risk, and 5,185 (10.2%) high/very high-risk) with a median age of 68 years, and a median PSA of 6.2 ng/mL. On linear regression, the GPS model had poor goodness-of-fit to the 22-GC with an R2 of 0.36, as did the CCP model to the 22-GC with an R2 of 0.32. For CCP, the linear sum of the 31-genes was also tested but had inferior performance (R2 0.28) compared to the reoptimized CCP model. Results were similar on multivariable analysis adjusting for age, PSA, clinical stage and grade group. Spearman correlation between the continuous GPS model scores and the 22-GC was moderate at 0.59, as was the correlation between CCP model and the 22-GC of 0.54. CCP is a measure of proliferation, but in 22-GC high-risk patients, the majority (64.1%) of patients had low-average proliferation and only 35.9% had high proliferation, potentially explaining the lack of strong correlation. CONCLUSION There is minimal to moderate correlation between the 22-GC and GPS or CCP gene expression signatures tested. Therefore, these tests should not be viewed as interchangeable, and utilization should be based on the level of evidence supporting each gene expression biomarker.
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Affiliation(s)
- A Y Jia
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH
| | - Y Sun
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - A Baydoun
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH
| | - N G Zaorsky
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH
| | - R A Vince
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH
| | - J E Shoag
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH
| | - J Brown
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH
| | - P Barata
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH
| | - R T Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - W C Jackson
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - S Roy
- Rush University Medical Centre, Chicago, IL
| | - P L Nguyen
- Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA
| | - A Berlin
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - R Mehra
- Department of Pathology, University of Michigan, Ann Arbor, MI
| | | | - R Kashani
- 4921 Parkview Place, Saint Louis, MO
| | - A U Kishan
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA
| | - T M Morgan
- Department of Urology, University of Michigan, Ann Arbor, MI
| | - D E Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center and Case Western Reserve University, Cleveland, OH
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Krc RF, Mendes W, Molitoris JK, Ferris MJ, Mehra R, Papadimitriou J, Hatten K, Taylor R, Wolf J, Bentzen SM, Sun K, Regine WF, Tran PT, Witek ME. Outcomes of Patients Treated with Re-Irradiation for Recurrent Head and Neck Cancer Using Pencil Beam Scanning Proton Therapy. Int J Radiat Oncol Biol Phys 2023; 117:e594-e595. [PMID: 37785794 DOI: 10.1016/j.ijrobp.2023.06.1949] [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] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Re-irradiation (re-RT) for recurrent head and neck cancer (HNC) after prior HNC radiation therapy (RT) is clinically challenging given prior radiation of nearby organs at risk (OARs). We describe clinical outcomes and toxicity of pencil beam scanning proton therapy (PBS-PT) for recurrent HNC. MATERIALS/METHODS We performed a retrospective analysis of recurrent HNC patients treated at a single institution with PBS-PT. Baseline demographic, disease and treatment characteristics were recorded. Local control (LC), locoregional control (LRC), progression free survival (PFS), distant metastasis free survival (DMFS), and overall survival (OS) were estimated using the Kaplan-Meier method. UVA was completed using logistic regression, and MVA was performed using a backward elimination model. We also report acute and late grade 3+ toxicity outcomes, graded per CTCAE v5.0. RESULTS A total of 89 patients treated with PBS-PT for recurrent HNC between 2016 and 2022 were included. Primary sites included oropharynx (30.0%), oral cavity (22.5%), sinonasal cavity (15.7%), larynx (12.4%) and nasopharynx (6.7%). The most common tumor histology was SCC (73.0%). Median time to re-RT was 47 months. Median dose of PBS-PT was 60 Gy (range: 40-72) with 50.6% receiving BID treatment. Median GTV volume was 30cc (range 4.8-1083cc). 24% of patients received concurrent systemic therapy (46% cytotoxic, 4.5% immunotherapy). Median follow-up after PBS-PT was 8 months (range: 0-71), and median OS was 13 months (95% CI: 9.3-16.7). The median PFS and DMFS were 7 months (95% CI 5.0-9.0) and 9 months (95% CI 5.3-12.7) respectively. The 1- and 2-year LC rates were 80.8% (95% CI: 70.8-90.8) and 66.2% (95% CI: 50.7-81.7). The 1- and 2-year DMFS were 41.0% (95% CI: 30.0-52.0) and 26.3% (95% CI: 15.7-36.9). On UVA and MVA, smaller GTV volume was associated with improved OS (HR 1.002, p = .004), DMFS (HR 1.002, p = 0.004) and PFS (HR 1.002, p = 0.014). In addition, shorter time to re-RT was associated with worse LRC (HR 1.003, p = 0.002), and higher KPS was associated with improved PFS (HR 0.57, p = 0.04). There were 31 acute grade 3 toxicity events (21 patients), the most common being odynophagia (9.0%) followed mucositis (5.6%), dehydration and dermatitis (both 4.5%). One patient had grade 4 toxicity, laryngeal edema requiring intubation 40 days after completion of re-RT. One patient had acute grade 5 toxicity, an oropharyngeal bleed 74 days after completion of re-RT. There were 35 late toxicity events (n = 27), the most common being dysphagia (n = 7, 7.9%). One patient suffered late grade 5 osteoradionecrosis, which resulted in sepsis. CONCLUSION PBS-PT for recurrent HNC results in effective disease control and favorable toxicity. Patients with smaller GTV volume appear to have improved OS, PFS and DMFS, and may be better candidates. Those with shorter time to re-RT also have worse LRC. However, distant failure (DF) comprises a major failure pattern, and biomarkers to identify patients at risk for DF may improve clinical decision making.
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Affiliation(s)
- R F Krc
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD
| | - W Mendes
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - J K Molitoris
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - M J Ferris
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - R Mehra
- University of Maryland Cancer Center, Baltimore, MD, United States
| | | | - K Hatten
- University of Maryland, Baltimore, MD
| | - R Taylor
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - J Wolf
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - S M Bentzen
- Division of Biostatistics and Bioinformatics, University of Maryland Greenebaum Cancer Center, and Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - K Sun
- Division of Biostatistics and Bioinformatics, University of Maryland Greenebaum Cancer Center, and Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - W F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - P T Tran
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - M E Witek
- Department of Radiation Oncology, University of Maryland School of Medicine, Madison, WI
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Rao M, Rana ZH, Redell D, Alicia D, Glass E, Burrows W, Friedberg JS, Scilla K, Mehra R, Rolfo C, Simone CB, Mohindra P. Cardiopulmonary Toxicity from Intensity Modulated Proton Therapy for Thymic Malignancies. Int J Radiat Oncol Biol Phys 2023; 117:e49-e50. [PMID: 37785546 DOI: 10.1016/j.ijrobp.2023.06.757] [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] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Use of radiation therapy for thymic malignancies is limited by excess dose to organs at risk (OARs) including heart, lung, and esophagus. Intensity Modulated Proton Therapy with Pencil Beam Scanning (IMPT/PBS) allows the conformality benefits of volumetric modulated arc therapy (VMAT) combined with dosimetry benefits of protons making it an exciting tool to treat thymic tumors. Very limited clinical data are reported with the use of IMPT/PBS to treat thymic malignancies. This study evaluates the incidence of acute and delayed toxicities among patients who underwent IMPT/PBS for thymic tumors. MATERIALS/METHODS Our single center retrospective study identified 27 patients with diagnosis of either thymic carcinoma or thymoma who received IMPT/PBS between 2015 and 2022. Patient demographics, IMPT treatment details and clinical outcomes (toxicity, recurrence, and survival) were recorded. Frequency distributions are described for primary endpoints of acute (≤ 90 days) and late (>90 days) toxicity graded using CTCAE version 5.0. Specific toxicities assessed were dermatitis, esophagitis, pneumonitis, pulmonary fibrosis, and cardiac toxicity. Recurrence and survival data were analyzed as secondary endpoint using Kaplan-Meier method. RESULTS Median follow-up was 22 months. Median age of the patients was 59 years (range, 30-87), predominantly female (55%), and white (66%), and stage ¾ (72%). Histologically showed mainly thymoma (59%) and Masaoka stage ¾ (70%). Surgery prior to IMPT was performed in 19 (70%) patients; of whom 5 patients had positive margins. Chemotherapy was used in 12 (44%) patients. Median IMPT dose was 50.4 GyE. Patients were primarily planned with 2 or 3 fields (81%), coplanar distribution (74%), using SFO technique (70%). Robust planning was performed accounting for 5 mm margin and 3.5-5% range uncertainty. All patients required use of range shifter ranging from 2-5 cm. Median of Heart-mean (10.3 GyE), Heart-max (54 GyE), Lung-mean (8.1 GyE), Lung V20 Gy (16.1%), Lung-V30 Gy (11.4%), Esophagus-mean (10.3 GyE) and Cord-Max (1.4 GyE). QACT was performed in 21 (77%) patients with replan needed in 5 of them. Only 1 (3.7%) patient had a grade 3+ acute toxicity (dermatitis) and only 2 (7.4%) patients had a grade 3+ late toxicity (both pulmonary). No patients had any acute or delayed cardiac-related adverse effects following PBT treatment. One (3.7%) patient had an infield recurrence of malignancy and 6 had out-of-field metastatic failure. Local control and overall survival were 74.1% and 85.2%, respectively. CONCLUSION In this largest single-institution analysis of IMPT/PBS experience, we note extremely low incidence of grade 3+ acute or late toxicity with excellent local control and overall survival. No marginal failures were noted. In a patient population at high risk of cardiopulmonary radiation toxicities, IMPT/PBS should be strongly explored as a possible treatment option.
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Affiliation(s)
- M Rao
- University of Maryland School of Medicine, Baltimore, MD
| | - Z H Rana
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD
| | - D Redell
- University of Maryland, Baltimore, Baltimore, MD
| | - D Alicia
- Department of Radiation Oncology, Maryland Proton Treatment Center, Baltimore, MD
| | - E Glass
- Maryland Proton Treatment Center, University of Maryland, Baltimore, MD
| | - W Burrows
- University of Maryland Division of Thoracic Surgery, Baltimore, MD
| | - J S Friedberg
- University of Maryland Division of Thoracic Surgery, Baltimore, MD
| | - K Scilla
- Division of Medical Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - R Mehra
- University of Maryland Cancer Center, Baltimore, MD, United States
| | - C Rolfo
- Center for Thoracic Oncology, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - P Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
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8
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Koshal SS, Ray A, Hora R, Kaur A, F Quadri S, Mehra R, Kumari A, Haldar P, Roy AD. Critical factors in the successful expansion of Pneumococcal Conjugate Vaccine in India during the COVID-19 pandemic. Vaccine X 2023; 14:100328. [PMID: 37346081 PMCID: PMC10240905 DOI: 10.1016/j.jvacx.2023.100328] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 05/02/2023] [Accepted: 05/30/2023] [Indexed: 06/23/2023] Open
Abstract
India had decided to roll out PCV in India in 2015, but successful implementation of any new vaccine introduction mandates an enormous effort. PCV was scaled up during the COVID-19 pandemic, which posed new, unprecedented challenges in the vaccine rollout. However, India successfully expanded PCV in the country in record time across all states and Union Territories. During the pandemic, supply-side restrictions, delayed vaccine shipments, staff shortages, and restrictions in conducting training negatively affected the roll-out of PCV across the country. However, despite the ongoing pandemic, India successfully rolled out PCV across the country in 7 months. In this review, the authors have conducted a narrative review to delineate the crucial factors that helped in the successful expansion of PCV.
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Affiliation(s)
| | | | | | | | | | | | | | - Pradeep Haldar
- Former Advisor (RCH), Ministry of Health & Family Welfare, India
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9
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Hora R, Ray A, Mehra R, Priya T, Koshal SS, Agrawal P, Kaur A, Quadri SF, Deb Roy A. Enablers and Barriers to the Scaling Up of Pneumococcal Conjugate Vaccine in India During the COVID-19 Pandemic: A Qualitative Study. Health Serv Insights 2023; 16:11786329231189407. [PMID: 37533503 PMCID: PMC10392212 DOI: 10.1177/11786329231189407] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 07/05/2023] [Indexed: 08/04/2023] Open
Abstract
Background Pneumonia is one of the leading causes of death in under-5 children in India. This led the Ministry of Health & Family Welfare (MoHFW) in India to decide for the nationwide roll-out of the Pneumococcal Conjugate Vaccine (PCV). However, the introduction of PCV became more complex in the face of unprecedented challenges set forth by the COVID-19 pandemic. The study aims to assess enablers and barriers to the introduction of PCV in India during the pandemic. Methodology Qualitative research approach involving key-informant interviews from John Snow India (JSI), the lead technical agency that supported MoHFW in the PCV expansion was employed to delineate the enablers and barriers. Principle of saturation was employed to derive the sample size. Thematic analysis using inductive approach was based on the modified World Health Organization (WHO) framework for new vaccine introduction impact on the Immunization and Health Systems, using NVIVO 12 qualitative data analysis software. Results A total of 11 key informants (4 national-level program managers and 7 state technical officers) were telephonically interviewed. The study found social acceptance, lower cost of the vaccine, and intensive communication activities as potential enablers. Other enablers for PCV introduction included a robust vaccine supply-chain system, ample cold-chain space availability, and strong political commitment, despite the ongoing second wave. Further, the identified barriers included poor physical access, insufficient social mobilization, and limited advocacy along with a stretched workforce. Conclusion The study delineated several enablers and barriers to introducing PCV in the country during the pandemic. The existing barriers in the PCV roll-out prompted the need to address these gaps, making key program-based recommendations to improve future new vaccine introductions during the pandemic.
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Affiliation(s)
| | - Arindam Ray
- Bill and Melinda Gates Foundation, New Delhi, India
| | | | - Tanwi Priya
- Gurugram University, Gurugram, Haryana, India
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10
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Veluswamy R, Bhalla S, Mehra R, Gligich O, Garassino M, Oliva C, Gorcea-Carson C, McCracken N. 78TiP Phase Ib/IIa safety and tolerability study of bemcentinib with pembrolizumab/carboplatin/pemetrexed in subjects with untreated advanced or metastatic non-squamous NSCLC with/without STK11 mutations. J Thorac Oncol 2023. [DOI: 10.1016/s1556-0864(23)00332-5] [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: 04/03/2023]
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11
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Siddiqi K, Elsey H, Khokhar MA, Marshall AM, Pokhrel S, Arora M, Crankson S, Mehra R, Morello P, Collin J, Fong GT. FCTC 2030 - a programme to accelerate the implementation of WHO Framework Convention for Tobacco Control in low- and middle-income countries: A mixed-methods evaluation. Nicotine Tob Res 2023; 25:1074-1081. [PMID: 36757326 DOI: 10.1093/ntr/ntad022] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 12/27/2022] [Accepted: 02/08/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND FCTC 2030 Programme (2017-2021) was launched to accelerate WHO Framework Convention on Tobacco Control (FCTC) implementation in 15 low- and middle-income countries (LMICs). We evaluated the Programme in six domains: Governance; Smoke-Free Policies; Taxation; Packaging and Health Warnings; Tobacco Advertising, Promotion and Sponsorship (TAPS) bans; International and Regional Cooperation. METHODS Following a mixed-methods design, we surveyed (Jun-Sept 2020) FCTC focal persons in 14 of the 15 countries, to understand the Programme's financial and technical inputs and progress made in each of the six domains. The data were coded in terms of inputs (financial=1, technical=1, or both=2) and progress (none=1, some=2, partial=3, or strong=4) and a correlation was computed between the inputs and progress scores for each domain. We conducted semi-structured interviews with key stakeholders in five countries. We triangulated between the survey and interview findings. RESULTS FCTC 2030 offered substantial financial and technical inputs, responsive to country-needs, across all six domains. There was a high positive correlation between technical inputs and progress in five of the six domains, ranging from r=0.61 for Taxation (p<0.05) to r=0.91 for Smoke-Free Policies (p<0.001). The interviews indicated that the Programme provided timely and relevant evidence and created opportunities for influencing tobacco control debates. CONCLUSIONS The FCTC 2030 Programme might have led to variable but significant progress in advancing FCTC implementation in the 15 countries. As expected, much of the progress was in augmenting existing structures and resources for FCTC implementation. The resulting advances are likely to lead to further progress in FCTC policy implementation. IMPLICATIONS What this study adds: In many low- and middle-income countries (LMICs), WHO Framework Convention for Tobacco Control (WHO FCTC) policies are not in place; and even when enshrined in law, they are poorly enforced.It is not clear how financial and technical assistance to high tobacco-burden LMICs can most effectively accelerate the implementation of WHO FCTC policies and offer value for money. Bespoke and responsive assistance, both financial and technical, to LMICs aimed at accelerating the implementation of WHO FCTC policies is likely to lead to progress in tobacco control.
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Affiliation(s)
- Kamran Siddiqi
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, York, UK
| | - Helen Elsey
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, York, UK
| | | | | | | | | | | | | | - Paola Morello
- Institute for Clinical Effectiveness and Health Policy, Argentina
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12
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Mehra R, Stentz F. Fatty acid binding protein 4 as a biomarker for improvement of type 2 diabetes. Am J Med Sci 2023. [DOI: 10.1016/s0002-9629(23)00149-0] [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: 01/28/2023]
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13
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Savla B, Hamza MA, Yacubovich D, Cobbs S, Petrovska L, Scilla KA, Burrows W, Mehra R, Miller RC, Rolfo C, Bentzen SM, Mohindra P, Vyfhuis MAL. The Effect of Body Mass Index and Residence in Food Priority Areas on Patterns-of-Care and Cancer Outcomes in Patients With Stage III Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2023; 116:50-59. [PMID: 36720317 DOI: 10.1016/j.ijrobp.2023.01.032] [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: 11/11/2022] [Revised: 01/23/2023] [Accepted: 01/23/2023] [Indexed: 01/30/2023]
Abstract
PURPOSE Patients living in food priority areas (FPAs), where access to healthy meals is challenging, may be at greater risk of nutritional deficits, leading to poorer cancer outcomes. Currently, there are no published data analyzing how FPAs affect patterns-of-care or outcomes for patients with locally advanced non-small cell lung cancer (NSCLC). We aimed to analyze the effect of residing in an FPA on treatments rendered and cancer outcomes in patients with stage III NSCLC treated at a single institution. METHODS AND MATERIALS This is a retrospective study of 573 patients with locally advanced NSCLC consecutively treated from January 2000 to January 2020. χ2 and Mann-Whitney U tests were performed to determine differences between select variables. Kaplan-Meier analysis and Cox proportional hazard models were used to analyze overall survival (OS) and freedom from recurrence. Cox regression with forward model selection was used for multivariate analysis. RESULTS Thirty-two percent of patients resided in an FPA (n = 183) and were more likely to self-identify as Black (P < .0001), single (P < .001), <60 years of age (P = .001), and uninsured (P < .0001), with a lower median income (P < .001). Patients in FPAs also had lower mean pre-chemoradiation (CRT) albumin (P = .002), lower pre-CRT body mass index (BMI) (P = .026), and were less likely to receive trimodality therapy (P ≤ .001) compared with patients not living in FPAs. There was no difference in OS or freedom from recurrence between the 2 cohorts. However, in patients with a normal BMI, either pre-CRT (median OS, 18.4 vs 25.0 months; P = .005) or after CRT (15.1 vs 28.1 months, P = .002), residing in an FPA resulted in an OS detriment. CONCLUSIONS We demonstrated a clear socioeconomic divide in our patient population with stage III NSCLC, where residing in FPAs was associated with less-aggressive therapy and an OS detriment for patients with a normal-weight BMI. We are currently conducting a prospective study characterizing the nutritional needs of patients, particularly those who live in FPAs.
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Affiliation(s)
- Bansi Savla
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland
| | - M A Hamza
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland
| | - D Yacubovich
- University of Maryland School of Medicine, Baltimore, Maryland
| | - S Cobbs
- University of Maryland School of Medicine, Baltimore, Maryland
| | - L Petrovska
- University of Wisconsin, Milwaukee, Wisconsin
| | - K A Scilla
- Department of Medicine, Division of Hematology/Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - W Burrows
- Division of Thoracic Surgery, University of Maryland, Baltimore, Maryland
| | - R Mehra
- Department of Medicine, Division of Hematology/Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - R C Miller
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - C Rolfo
- Center for Thoracic Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - S M Bentzen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland; Department of Epidemiology and Public Health, Biostatistics and Bioinformatics Division, University of Maryland School of Medicine, Baltimore, Maryland
| | - P Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Melissa A L Vyfhuis
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland; Chesapeake Oncology and Hematology Associates, Glen Burnie, Maryland.
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14
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Hutcheson K, Peterson C, Barbon C, Quon H, Mehra R, Ringash J, Lewin J, Flamand Y, Duvvuri U, Ozer E, Thomas G, Kupferman M, Koch W, Bell R, Saba N, Panwar A, Annino Jr D, Wagner L, Ferris R, Burtness B. Reduced Aspiration Rates for 50 Gy Postoperative Radiation in HPV-Associated Oropharynx Cancer in E3311: A Trial of the ECOG-ACRIN Cancer Research Group. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.380] [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: 10/31/2022]
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15
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Soulieres D, Harrington K, Le Tourneau C, Silva J, Licitra L, Ahn MJ, Soria A, Machiels JP, Mach N, Mehra R, Burtness B, Lin J, Lerman N, Gumuscu B, Cohen E. 658MO Pembrolizumab (pembro) vs standard-of-care (SOC) in previously treated recurrent/metastatic (R/M) head and neck squamous cell carcinoma (HNSCC): 6-year follow-up of KEYNOTE-040. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.07.782] [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: 11/01/2022] Open
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16
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Spira A, Mehra R, Mantia C, Babiker H, Borad M, Cervantes A, Garralda E, Mahipal A, Paz-Ares L, Hatzis C, Liu A, Raue A, Gan J, Adrian F, Manenti L, El-Khoueiry A. 783TiP Phase I study of HFB301001, a novel OX40 agonist monoclonal antibody, in patients with solid tumors selected via Drug Intelligence Science (DIS). Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.07.909] [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: 11/25/2022] Open
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17
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Rolfo C, de Miguel Perez D, Mallapelle U, Grier W, Pepe F, Troncone G, Culligan M, Scilla K, Mehra R, Russo A, Mohindra P, Sachdeva A, Hirsch F, Wolf A, Friedberg J, Pickering E. EP07.01-001 Molecular Profiling Predicts Outcomes in Patients With Resected Malignant Pleural Mesothelioma. J Thorac Oncol 2022. [DOI: 10.1016/j.jtho.2022.07.533] [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: 10/14/2022]
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18
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Cohen J, Dontu P, Hatten K, Mehra R, Wolf J, Taylor R, Papadimitriou J, Witek M. Pathologic Comparison of Locally Advanced p16-Negative and p16-Positive Larynx Squamous Cell Carcinoma. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2021.12.079] [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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19
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Geng X, Yang Z, Liao J, Mirkheshti N, Mehra R, Cullen K, Dan H. Targeting PI3Kα/δ and the ErbB Family of Protein-Tyrosine Kinases in Cisplatin-Resistant Head and Neck Squamous Cell Carcinomas. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2021.12.112] [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: 10/18/2022]
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20
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Jain RA, Gupta R, Verma M, Nanda A, Gill S, Mehra R. Comparative Evaluation of Load-Bearing Capacity and Fracture Analysis of PEEK and Zirconia Three-Unit Fixed Dental Prostheses: An In Vitro Study. INT J PROSTHODONT 2022; 35:225-232. [PMID: 35507533 DOI: 10.11607/ijp.7469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
PURPOSE The purpose of this exploratory in vitro study was to compare and evaluate the load-bearing capacity (LBC) of ceramic-veneered zirconia and composite-veneered polyetheretherketone (PEEK) three-unit fixed dental prostheses (FDPs) with and without thermocycling (TC). MATERIALS AND METHODS The study included 40 samples of three-unit FDPs replacing mandibular first molars. The four groups included were: ceZIR (feldspathic ceramic-layered zirconia), ceZIR TC (feldspathic ceramic-layered thermocycled zirconia), cPEEK (composite-layered PEEK), and cPEEK TC (composite-layered thermocycled PEEK) (n = 10 per group). All frameworks were CAD/CAM milled. Ten PEEK and 10 zirconia samples were subjected to TC (6,000 cycles). All 40 FDP specimens were loaded by applying static load, using a universal testing machine. The maximum load required to fracture the specimens denoted the LBC. The comparison of LBC between the four groups was done by using two-way ANOVA with Tukey's post-hoc analysis (α = .05). RESULTS There was no statistically significant difference between LBC of cPEEK and ceZIR (P > .001) without thermal aging. LBC values decreased considerably for thermally aged specimens. Statistically significant differences were observed between LBC of cPEEK TC and ceZIR TC (P < .001), cPEEK TC and cPEEK (P < .001), and ceZIR TC and ceZIR (P = .001). On fracture analysis, cPEEK showed delamination failures whereas ceZIR displayed catastrophic connector fractures. CONCLUSION This comparative evaluation offers preliminary data highlighting substantial depreciation in the LBC of layered PEEK under simulated intraoral conditions, thus raising a question regarding the clinical longevity of layered PEEK multi-unit restorations. In contrast, feldspathic-layered zirconia can be suitable for use in posterior FDPs.
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21
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Mansfield AS, Wei Z, Mehra R, Shaw AT, Lieu CH, Forde PM, Drilon AE, Mitchell EP, Wright JJ, Takebe N, Sharon E, Hovelson D, Tomlins S, Zeng J, Poorman K, Malik N, Gray RJ, Li S, McShane LM, Rubinstein LV, Patton D, Williams PM, Hamilton SR, Conley BA, Arteaga CL, Harris LN, O’Dwyer PJ, Chen AP, Flaherty KT. Crizotinib in patients with tumors harboring ALK or ROS1 rearrangements in the NCI-MATCH trial. NPJ Precis Oncol 2022; 6:13. [PMID: 35233056 PMCID: PMC8888601 DOI: 10.1038/s41698-022-00256-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 12/16/2021] [Indexed: 01/14/2023] Open
Abstract
The NCI-MATCH was designed to characterize the efficacy of targeted therapies in histology-agnostic driver mutation-positive malignancies. Sub-protocols F and G were developed to evaluate the role of crizotinib in rare tumors that harbored either ALK or ROS1 rearrangements. Patients with malignancies that progressed following at least one prior systemic therapy were accrued to the NCI-MATCH for molecular profiling, and those with actionable ALK or ROS1 rearrangements were offered participation in sub-protocols F or G, respectively. There were five patients who enrolled on Arm F (ALK) and four patients on Arm G (ROS1). Few grade 3 or 4 toxicities were noted, including liver test abnormalities, and acute kidney injury. For sub-protocol F (ALK), the response rate was 50% (90% CI 9.8-90.2%) with one complete response among the 4 eligible patients. The median PFS was 3.8 months, and median OS was 4.3 months. For sub-protocol G (ROS1) the response rate was 25% (90% CI 1.3-75.1%). The median PFS was 4.3 months, and median OS 6.2 months. Data from 3 commercial vendors showed that the prevalence of ALK and ROS1 rearrangements in histologies other than non-small cell lung cancer and lymphoma was rare (0.1% and 0.4% respectively). We observed responses to crizotinib which met the primary endpoint for ALK fusions, albeit in a small number of patients. Despite the limited accrual, some of the patients with these oncogenic fusions can respond to crizotinib which may have a therapeutic role in this setting.
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Affiliation(s)
- A. S. Mansfield
- grid.66875.3a0000 0004 0459 167XDivision of Medical Oncology, Mayo Clinic, Rochester, MN USA
| | - Z. Wei
- grid.65499.370000 0001 2106 9910ECOG-ACRIN Biostatistics Center, Dana-Farber Cancer Institute, Boston, MA USA
| | - R. Mehra
- grid.411024.20000 0001 2175 4264Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD USA
| | - A. T. Shaw
- grid.32224.350000 0004 0386 9924Massachusetts General Hospital, Boston, MA USA
| | - C. H. Lieu
- grid.499234.10000 0004 0433 9255University of Colorado Cancer Center, Aurora, CO USA
| | - P. M. Forde
- grid.280502.d0000 0000 8741 3625Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD USA
| | - A. E. Drilon
- grid.51462.340000 0001 2171 9952Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, NY USA
| | - E. P. Mitchell
- grid.412726.40000 0004 0442 8581Thomas Jefferson University Hospital, Philadelphia, PA USA
| | - J. J. Wright
- grid.48336.3a0000 0004 1936 8075Investigational Drug Branch, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD USA
| | - N. Takebe
- grid.48336.3a0000 0004 1936 8075Investigational Drug Branch, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD USA
| | - E. Sharon
- grid.48336.3a0000 0004 1936 8075Cancer Therapy Evaluation Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD USA
| | | | | | - J. Zeng
- grid.492659.50000 0004 0492 4462Caris Life Sciences, Irving, TX USA
| | - K. Poorman
- grid.492659.50000 0004 0492 4462Caris Life Sciences, Irving, TX USA
| | - N. Malik
- grid.511425.60000 0004 9346 3636Tempus, Chicago, IL USA
| | - R. J. Gray
- grid.65499.370000 0001 2106 9910ECOG-ACRIN Biostatistics Center, Dana-Farber Cancer Institute, Boston, MA USA
| | - S. Li
- grid.65499.370000 0001 2106 9910ECOG-ACRIN Biostatistics Center, Dana-Farber Cancer Institute, Boston, MA USA
| | - L. M. McShane
- grid.48336.3a0000 0004 1936 8075Biometric Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD USA
| | - L. V. Rubinstein
- grid.48336.3a0000 0004 1936 8075Biometric Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD USA
| | - D. Patton
- grid.48336.3a0000 0004 1936 8075Center for Biomedical Informatics & Information Technology, National Cancer Institute, Bethesda, MD USA
| | - P. M. Williams
- grid.418021.e0000 0004 0535 8394Frederick National Laboratory for Cancer Research, Frederick, MD USA
| | - S. R. Hamilton
- grid.410425.60000 0004 0421 8357City of Hope, Duarte, CA USA
| | - B. A. Conley
- grid.48336.3a0000 0004 1936 8075Cancer Diagnosis Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD USA
| | - C. L. Arteaga
- grid.267313.20000 0000 9482 7121Simmons Cancer Center, University of Texas Southwestern, Dallas, TX USA
| | - L. N. Harris
- grid.48336.3a0000 0004 1936 8075Cancer Diagnosis Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD USA
| | - P. J. O’Dwyer
- grid.25879.310000 0004 1936 8972University of Pennsylvania, Philadelphia, PA USA
| | - A. P. Chen
- grid.48336.3a0000 0004 1936 8075Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD USA
| | - K. T. Flaherty
- grid.32224.350000 0004 0386 9924Massachusetts General Hospital, Boston, MA USA
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Cotta B, Nallandhighal S, Mehra R, Cieslik M, Farha M, Kasputis A, Morgan T, Salami S. Characterization of the tumor immune microenvironment between primary and paired asynchronous metastatic clear cell renal cell carcinoma. Eur Urol 2022. [DOI: 10.1016/s0302-2838(22)01198-8] [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: 11/30/2022]
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23
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Mohindra P, Saeed A, Vyfhuis M, Scilla K, Molitoris J, Simone C, Rolfo C, Mehra R. Toxicity and Survival Outcomes From Intensity Modulated Proton Therapy-Based Re-Irradiation in Patients With Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2021.10.167] [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: 11/28/2022]
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Kapoor S, Mehra R, Yadav A, Lal P, Singh RJ. Banning Loose Cigarettes and Other Tobacco Products in India: A Policy Analysis. Asian Pac J Cancer Prev 2021; 22:51-57. [PMID: 34780138 DOI: 10.31557/apjcp.2021.22.s2.51] [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: 06/28/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Sale of single cigarettes (also known as singles or loosies) is a key driver for early initiation of smoking and is a leading contributor to the smoking epidemic in India. Sale of singles additionally deter implementation of tobacco control strategies of pictorial health warnings including plain packaging and defeat effective taxation and promote illicit trade. We review India's tobacco control policy responses towards banning singles and other products sold as loose tobacco and identify opportunities for future policy intervention especially in the context of the ongoing COVID-19 pandemic. METHODS Existing national and sub-national policy documents were analyzed for their content since the inception of the tobacco control laws in the country. RESULTS There are no effective provisions at national level to ban loose tobacco products in India. However, the implementation of multiple legislative and regulatory measures (Acts/circulars/letters/notifications/orders/court judgements) in 16 Indian states and jurisdictions provide sufficient legal framework to substantiate its complete ban pan India. While the majority of state governments have adopted state level measures, Rajasthan had issued specific directive to all the 33 districts banning loose cigarettes and other tobacco products. Himachal Pradesh introduced the most unique and comprehensive legislation, for banning the sale of cigarettes and beedis (Dated November 7, 2016). The most recent notification in the state of Maharashtra (September 24, 2020) is the first to leverage powers using a mix of national and state legislations including the legislation addressing the rapidly emerging challenge of managing COVID-19. CONCLUSION A robust national policy which supports strong provision to deter tobacco companies, their distribution network and vendors from selling singles or loose tobacco products is urgently needed. Such policy should be backed by cautionary messaging for consumers as well. Eliminating singles and loose tobacco sale will help in blunting tobacco use prevalence besides curbing spread of infectious diseases like COVID-19 pandemic.
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Affiliation(s)
- Shivam Kapoor
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | | | - Amit Yadav
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - Pranay Lal
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - Rana J Singh
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
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25
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Koshal SS, Ray A, Mehra R, Kaur A, Quadri SF, Agarwal P, Kapur S, Debroy A, Haldar P. Partnering for rotavirus vaccine introduction in India: A retrospective analysis. Vaccine 2021; 39:6470-6476. [PMID: 34538521 DOI: 10.1016/j.vaccine.2021.09.014] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/31/2021] [Accepted: 09/03/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The pre-existing partner network created in India for the delivery of polio vaccines was initially used to eradicate polio and later on embedded in the health systems network to promote routine immunization and other health interventions efficiently. The experience from this network offered lessons for strengthening the health care systems and provided a well-established network that could be utilized for other vaccine initiatives. It has also been established that successful partnerships between a broad range of stakeholders provide support, strengthen the health system, and accelerate vaccine innovation, introduction, access, logistics, and communication support. However, beyond polio eradication, there have not been too many documented success stories of vaccine introduction, which could be replicated in other new vaccine introductions and allied health initiatives. The authors have reviewed the successful and time-bound introduction of rotavirus vaccine (RVV) in India in the present article. METHODS The review was conducted based on a partnership framework which analysed multiple factors-partnership prerequisites, partnership model, partnership process, and partnership performance, thereby providing a comprehensive insight into the successful utilization of partnership networks for rotavirus vaccine introduction under the Universal Immunization Program in India. RESULTS & CONCLUSION The review also highlights the role of a lead agency in creating a fertile ground for lush, efficient, and effective partnerships amongst different stakeholders. The already existing RVV partnership framework reviewed by the authors can be successfully utilized for future new vaccine introductions.
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Affiliation(s)
| | - A Ray
- Bill and Melinda Gates Foundation, New Delhi, India
| | - R Mehra
- John Snow India, New Delhi, India
| | - A Kaur
- John Snow India, New Delhi, India
| | | | | | - S Kapur
- John Snow India, New Delhi, India
| | - A Debroy
- John Snow India, New Delhi, India
| | - P Haldar
- Ministry of Health and Family Welfare, New Delhi, India
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Bryant A, Dess R, Vince R, Hearn J, Garant A, Morgan T, Mehra R, Hannan R, Folkert M, Spratt D, Desai N, Jackson W. Development of a Novel Prognostic Three-tier Risk Group Stratification in Men Receiving Post-Prostatectomy Radiation Therapy Without Androgen Deprivation Therapy. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.471] [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: 11/26/2022]
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Cohen J, Glass E, Burrows W, Bentzen S, Stewart S, Carr S, Scilla K, Mehra R, Holden V, Pickering E, Sachdeva A, Rolfo C, Friedberg J, Miller R, Mohindra P. Post-Operative Radiotherapy With Intensity Modulated Proton Therapy for Thoracic Malignancies. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.754] [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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Saeed A, Vyfhuis M, Scilla K, Molitoris J, Simone C, Burrows W, Mehra R, Rolfo C, Miller R, Mohindra P. Clinical Outcomes in Non-Small Cell Lung Cancer Patients Treated with Pencil Beam Scanning Proton Reirradiation after Previous Thoracic Radiation. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.1267] [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: 10/23/2022]
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Allen S, Zhang C, Speers C, Malone S, Roy S, Dess R, Jackson W, Wahl D, Mehra R, Alumkal J, Sandler H, Roach M, Sun Y, Lawton C, Feng F, Chinnaiyan A, Spratt D. Impact Of Sequencing Of Androgen Receptor-Signaling Inhibition (ARSI) And Ionizing Radiotherapy (RT) In Prostate Cancer: Importance Of Homologous Recombination (HR) Disruption. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.412] [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: 11/26/2022]
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Hamza M, Mohindra P, Bentzen S, Scilla K, Burrows W, Mehra R, Rolfo C, Miller R, Vyfhuis M. Effects of Living in Food Priority Areas on Treatment and Outcomes in Patients With Stage III Nonsmall Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.2464] [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: 11/24/2022]
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31
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Jairath N, Dal Pra A, Dess R, Jackson W, Mehra R, Feng F, Morgan T, Spratt D. Evaluating the Evidence to Support Clinical Use of the 22-Gene Genomic Classifier (Decipher) in Prostate Cancer. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.522] [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: 12/01/2022]
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32
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Chaudhary A, Malik P, Shukla R, Mehra R, Raina K. Role of SiO2 optically active mediators to tailor optical and electro-optical properties of ferroelectric liquid crystalline nanocomposites. J Mol Liq 2020. [DOI: 10.1016/j.molliq.2020.113580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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33
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Mehra R, Mohanty V, Aswini YB, Kapoor S, Gupta V. Prevalence, patterns and sociocultural factors associated with use of tobacco-based dentifrices ( Gul) in India. Indian J Cancer 2020; 57:311-320. [PMID: 32675444 DOI: 10.4103/ijc.ijc_717_18] [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] [Indexed: 11/04/2022]
Abstract
BACKGROUND India poses a novel tobacco problem with majority of the tobacco users consuming smokeless form of tobacco (21.4%). Gul is one such Smokeless Tobacco (ST) product that is manufactured commercially as a dentifrice to be applied to the teeth and then to gums many times during the day, making it a cheap and easy tobacco source. Hence, the aim of the present study was to estimate the usage of Gul and its social determinants among adults in the capital city of India, Delhi. METHODS The cross-sectional study was conducted among 1300 adults across 27 Delhi government dispensaries across 3 districts of Delhi through multistage stratified random sampling. A structured, close-ended, validated questionnaire inquiring about the tobacco practices was used for all the participants and a specially constructed, structured, close-ended, validated proforma was used for Gul users to assess practice and pattern of use. RESULTS The overall prevalence of Gul users was found to be 4.9% with a mean usage duration of 6.28 ± 6.75 years. The usage was found to be more among males (67.7%) and unskilled workers (45.2%). 74.9% started using Gul to treat dental pain with 93.47% of them reporting pain relief. CONCLUSION Gul usage is an emerging menace in Delhi. Awareness programs and initiatives are the need of the hour to bring this tobacco product under the tobacco control policy radar and at the same time educate people about the actual contents and ill effects of Gul usage.
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Affiliation(s)
- Rashmi Mehra
- Department of Public Health Dentistry, Maulana Azad Institute of Dental Sciences, Maulana Azad Medical College Campus (Govt. of NCT Delhi), B.S. Zafar Marg, New Delhi, India
| | - Vikrant Mohanty
- Department of Public Health Dentistry, Maulana Azad Institute of Dental Sciences, Maulana Azad Medical College Campus (Govt. of NCT Delhi), B.S. Zafar Marg, New Delhi, India
| | - Y B Aswini
- Department of Public Health Dentistry, Maulana Azad Institute of Dental Sciences, Maulana Azad Medical College Campus (Govt. of NCT Delhi), B.S. Zafar Marg, New Delhi, India
| | - Shivam Kapoor
- Department of Public Health Dentistry, Maulana Azad Institute of Dental Sciences, Maulana Azad Medical College Campus (Govt. of NCT Delhi), B.S. Zafar Marg, New Delhi, India
| | - Vaibhav Gupta
- Department of Public Health Dentistry, Maulana Azad Institute of Dental Sciences, Maulana Azad Medical College Campus (Govt. of NCT Delhi), B.S. Zafar Marg, New Delhi, India
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Mehra R, Mohanty VR, Y B A, Mehra K, Kapoor S. Afghan Frontier: Understanding Tobacco Practices among Migrant Population in India. Asian Pac J Cancer Prev 2020; 21:1931-1937. [PMID: 32711418 PMCID: PMC7573433 DOI: 10.31557/apjcp.2020.21.7.1931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Indexed: 11/25/2022] Open
Abstract
Background: Aim: Methodology: Statistical analysis: Results: Conclusion:
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35
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Sharma S, Kumar A, Mehra R, Mishra R. ASSESSMENT OF DOSE DUE TO AMBIENT Rn222/Rn220 PROGENY IN DIFFERENT DWELLINGS OF JAMMU AND KASHMIR STATE, INDIA. Radiat Prot Dosimetry 2020; 188:162-173. [PMID: 31820784 DOI: 10.1093/rpd/ncz271] [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] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 09/19/2019] [Accepted: 10/16/2019] [Indexed: 06/10/2023]
Abstract
The un-attached part of radon (222Rn) progeny is one of the imperative variables for the definitive evaluation of the effective dose from the radon exposure perspective, and it might fluctuate enormously in various ecological conditions. Therefore, estimate dispersion of 222Rn/220Rn progeny, un-attached part and aerosol concentration was estimated in an indoor domain of Jammu and Kashmir State, India utilizing progeny deposition based sensors. Distinctive sorts of residence were picked up for this exploratory examination and maximum 222Rn and thoron (220Rn) descendants concentration was found in working environments or workplaces when contrasted from other abodes because of low ventilation rate. The average evaluated portions of an unattached for 222Rn and 220Rn are 0.29 and 0.26 and in addition, observed to be most extreme in work environments. The age-dependent dose has furthermore been determined utilizing attached and un-attached 222Rn/220Rn progeny concentrations. The dose to trachea-bronchial region and aerosol concentrations has additionally been estimated.
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Affiliation(s)
- S Sharma
- Department of Physics, DAV College, Amritsar, Punjab 143001, India
- Department of Applied Science, Swami Sarvanand Group of Institutes, Dinanagar, Punjab, India
| | - A Kumar
- Department of Physics, DAV College, Amritsar, Punjab 143001, India
| | - R Mehra
- Department of Physics, Dr. B R Ambedkar National Institute of Technology, Jalandhar, Punjab, India
| | - R Mishra
- Radiological Physics & Advisory Division, Bhabha Atomic Research Centre, Mumbai 400085, India
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De A, Bena J, Wang L, Aylor J, Bhambra R, Kaw S, Lance C, Mehra R, Walia H. 0650 Impact of Upper Airway Stimulation Therapy on 24 Hour Ambulatory Blood Pressure Monitoring. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.646] [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] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Upper airway stimulation (UAS) is recommended treatment for moderate to severe obstructive sleep apnea (OSA) in select patients. Existing data have not focused on gold standard 24 hour ambulatory blood pressure monitor (ABPM) to elucidate the impact of UAS. We hypothesize that UAS reduces ABPM indices characterized using objective sleep-wake from actigraphy data over 12-month follow-up period.
Methods
A prospective sub-study of the Inspire ® post-approval study at the Cleveland Clinic was designed to examine the effect of UAS on 24-hour ABPM measures post-implantation by examining blood pressure (BP) at baseline, and-2, 6, and 12 months follow-up. Actigraphy data was contemporaneously collected. Paired T-tests were used to evaluate BP changes over time. Repeated measure correlations measured within-patient associations between BP and actigraphy measures.
Results
Average age and BMI were 62.4 +/-12.9) years and 30.1 +/-3.3 kg/m2, 73.3% males and all Caucasian. The mean baseline systolic, diastolic and mean arterial pressure (MAP) were 119.7+/-12.9 mmHg, 74.3+/-7.4 mmHg and 89.3+/- 8.1 mmHg. There were no changes to number, type or dosage of BP medications.
At 12 months, there were non-significant overall mean reduction in systolic [-0.55mmHg, p=0.75], diastolic [-0.73mmHg, p=0.63], and MAP [-0.55mmHg, p=0.71]. Mean sleeping systolic, diastolic and MAP changed by -4.36(p=0.34), -1.45 (p=0.57), -2.18 (p=0.50), respectively. Positive correlations above 0.25 (p<0.10) were observed between all dipping percentage measures and total sleep time. Negative correlations were seen between overall systolic, diastolic and MAP with sleep latency (-0.22, p=0.19, -0.35, p=0.031 and -0.29, p=0.075 respectively). No significant changes in BMI was observed, but average hours of usage decreased over time.
Conclusion
Although consistent reduction of BP measures were observed post-UAS implantation, findings were not statistically significant. It is unclear whether this is due to insufficient sample size or true lack of effect. Larger-scale clinical and mechanistic studies are needed to enhance understanding of UAS-related vascular influences.
Support
Funded: Inspire Medical Systems
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Affiliation(s)
- A De
- Cleveland Clinic, Cleveland, OH
| | - J Bena
- Cleveland Clinic, Cleveland, OH
| | - L Wang
- Cleveland Clinic, Cleveland, OH
| | - J Aylor
- Cleveland Clinic, Cleveland, OH
| | | | - S Kaw
- Cleveland Clinic, Cleveland, OH
| | - C Lance
- Cleveland Clinic, Cleveland, OH
| | - R Mehra
- Cleveland Clinic, Cleveland, OH
| | - H Walia
- Cleveland Clinic, Cleveland, OH
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Sandhu A, Wang L, Bena J, Kaffashi F, Loparo K, Aylor J, Nawabit R, Chung M, Van Wagoner D, Walia H, Mehra R. 0614 Diurnal Patterning of Autonomic Measures in Sleep Apnea and Paroxysmal Atrial Fibrillation and Response to Continuous Positive Airway Pressure Therapy. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.611] [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] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Diurnal patterning of autonomic function in paroxysmal atrial fibrillation (PAF) and sleep disordered breathing (SDB) is unknown. We hypothesize heart rate variability (HRV) as surrogates of autonomic function, exhibit diurnal differences in PAF relative to SDB severity and treatment.
Methods
We leveraged the Sleep Apnea and Atrial Fibrillation Biomarkers and Electrophysiologic Atrial Triggers (SAFEBEAT,NCT02576587) study focused on participants with PAF and SDB (apnea hypopnea index,AHI≥15,3% oxygen desaturation hypopnea). Attended 16-channel polysomnography (PSG) and continuous ECG monitoring (Heartrak Telemetry®) for 7-21 days was performed at baseline and after 3-months of continuous positive airway pressure (CPAP). Linear mixed-effects models (least square means,95%CI) were used to assess relationships between daily average HRV measures (frequency domain:LF,HF,LF/HF;time domain:MNN,RMSSD,SD1,SD ratio and novel non-linear:DFA-alpha measures) with SDB (AHI),%sleep time with SaO2<90%(TRT<90): per 5-unit increase),effect of 3-month CPAP relative to sleep-wake and statistical interaction of sleep-wake. Analyses were conducted using SAS version v.9.4, Cary, NC.
Results
The analytic sample was comprised of 33 cases with PAF and SDB:61.1±11.7 years,62.5% male, BMI:33.9±7.2kg/m2,75% Caucasian,AHI 15.1 (IQR: 4.4,29.4) and 68.8% on atrioventricular nodal blocking medications. AHI was associated with frequency (HF:0.08[0.01,0.16] and LF/HF:-0.11[-0.20, -0.01]), time (SD1:0.08[0.02,0.14] and SD ratio: 0.09[0.04,0.14]) and non-linear (DFA-alpha1: -0.02[-0.036,-0.003]) domain measures during wake, but not sleep. Significant sleep-wake and AHI as well as TRT<90 interactions relative to HRV measures were observed (p≤0.001). Only SD ratio was associated with TRT<90 (0.12[0.03,0.24]). Baseline to follow-up CPAP time domain measures were altered mainly during wake versus sleep with MNN increased 0.13: [0.08,0.19],p<0.001; RMSSD increased 0.13 [0.08,0.19], p<0.001; SD1 increased 30% [0.09,0.55], p=0.004; SD ratio increased 20% [0.01,0.43], p=0.033,and also frequency domain: HF increased 33%[0.03,0.72], p=0.028.
Conclusion
SDB defined by AHI--more so than nocturnal hypoxia--was associated with surrogate autonomic measures impacted by CPAP intervention during wake and not sleep in PAF. SDB-related autonomic influences in PAF appear to be more pronounced during wakefulness suggesting long-term potentiation-like influences.
Support
This study was supported by the National Heart, Lung and Blood Institute (NHLBI) [Grant R01 HL108493] and National Institutes of Health (NIH) National Center for Research Resources [Grant UL1 RR024989]
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Affiliation(s)
- A Sandhu
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - L Wang
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - J Bena
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - F Kaffashi
- School of Engineering, Case Western Reserve University, Cleveland, OH
| | - K Loparo
- School of Engineering, Case Western Reserve University, Cleveland, OH
| | - J Aylor
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - R Nawabit
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - M Chung
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - D Van Wagoner
- Department of Molecular Cardiology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - H Walia
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - R Mehra
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
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Bhat AS, Wang L, Kaur S, Nawabit R, Highland K, Park M, Jellis C, Kwon D, Hill N, Mehra R, Pvdomics P. 0558 Sleep Disordered Breathing and Right Ventricular Electrocardiographic and Functional Characteristics in Group 1 Pulmonary Arterial Hypertension. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.555] [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] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Right ventricular (RV) electrophysiologic and functional alterations related to sleep disordered breathing (SDB) in pulmonary arterial hypertension (PAH) are not well understood. We hypothesize an association between SDB and RV electrophysiological/functional measures in World Symposium of Pulmonary Hypertension (WSPH) Group 1 PAH.
Methods
The NHLBI multicenter PVDOMICS study (NCT02980887) enrolls patients with PAH undergoing a battery of assessments including home sleep apnea testing(NOX-T3, Carefusion®) or with historical sleep study data. Logistic(OR,95%CI) and linear(beta coefficients,95%CI) regression models adjusted for age, sex, race, body mass index (BMI, kg/m2), PAH medications, supplemental oxygen(O2), positive airway pressure(PAP) were used to assess associations of SDB(apnea hypopnea index,(AHI), ≥3% desaturations(hypopnea), percentage recording time with SaO2<90% (TRT<90%) with electrocardiographic measures: RV hypertrophy(RVH), right bundle branch block(RBBB), and right axis deviation(RAD), echocardiographically-derived RV systolic pressure(RVSP) and RV ejection fraction(RVEF) from cardiac MRI. Analyses were performed based on an overall significance level of 0.05, using SAS software (version 9.4, Cary, NC).
Results
The analysis consisted of 182 PAH participants with age: 52.5±13.9 years, 71.4% female, 88.9% Caucasian, BMI:30.3±7.8 kg/m2, RVEF: 37.3±11.6, and RVSP: 67.0±23.4. None of the electrocardiographic measures were associated with AHI and only RVH was significantly associated with TRT<90% (1.25:1.09,1.43),p=0.001. Although AHI was not associated with RVSP, a 10% increase in TRT<90% was associated with a 2.60mmHg increase in RVSP (2.60:1.44,3.76),p<0.001. Each 10-unit increase in AHI was associated with a 2.72% reduction of RVEF (-2.72:-4.89,-0.56),p=0.014, and each 10-unit increase in TRT<90% was associated with a 0.72% reduction of RVEF (-0.72:-1.38,-0.06),p=0.033.
Conclusion
We identify nocturnal hypoxia as a predictor of RV electrophysiological and functional alterations even after consideration of confounding factors. SDB as determined by AHI was also more so associated with reduced RVEF than hypoxia. Future mechanistic studies should focus on further elucidation of SDB and nocturnal hypoxia on pathogenesis of RV dysfunction in PAH.
Support
U01HL125218/U01HL125205/U01HL125212/U01HL125208/U01HL125175/U01HL125215, U01HL125177/Pulmonary Hypertension Association
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Affiliation(s)
- A S Bhat
- Cleveland Clinic Neurologic Institute, Cleveland, OH
| | - L Wang
- Cleveland Clinic Lerner Research Institute, Cleveland, OH
| | - S Kaur
- Cleveland Clinic Neurologic Institute, Cleveland, OH
| | - R Nawabit
- Cleveland Clinic Neurologic Institute, Cleveland, OH
| | - K Highland
- Cleveland Clinic Respiratory Institute, Cleveland, OH
| | - M Park
- Cleveland Clinic Heart and Vascular Institute, Cleveland, OH
| | - C Jellis
- Cleveland Clinic Heart and Vascular Institute, Cleveland, OH
| | - D Kwon
- Cleveland Clinic Heart and Vascular Institute, Cleveland, OH
| | - N Hill
- Tufts Medical Center Pulmonary, Critical Care & Sleep Divission, Boston, MA
| | - R Mehra
- Cleveland Clinic Neurologic Institute, Cleveland, OH
| | - P Pvdomics
- National Heart, Lung, Blood Institute (NHLBI), Bethesda, MD
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Srisawart P, Wang L, Bena J, Drerup M, Mehra R, Barwick F, Moul D. 0463 Cluster Analysis in Perimenopausal and Menopausal Women with Insomnia. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.460] [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] [Indexed: 11/15/2022] Open
Abstract
Abstract
Introduction
Women in perimenopause or menopause report higher rates of insomnia, with depression, pain and sleep apnea common comorbidities. Identifying clinically relevant subtypes of women with similar symptom patterns might help target treatment more precisely and optimize outcomes more successfully.
Methods
Participants were woman >50 years with insomnia (ISI>10) who were recruited from 12,108 patients visiting the Cleveland Clinic Sleep Disorders Center between 2008-2012. Patients completed questionnaires at initial clinic visit, and comorbidity data was extracted from medical records. K-method cluster analysis of cross-sectional data with PAM (portioning around medoids) was performed to identify clusters of patients based on insomnia (ISI), depression (PHQ2), and pain (EQ5D) symptoms as well as presence or absence of diabetes or sleep disorders (OSA, RLS). Silhouette widths and visualization using factoextra in R identified the optimal number of clusters. Characteristics of each cluster were compared using Pearson chi-square, Kruskal-Wallis or ANOVA models in SAS.
Results
Sample comprised 374 women. Average age was 60.5 years and 81.6% were White. A three-cluster solution was the most plausible. Clusters with mild (N=155, ISI=14.1±1.9), moderate (N=131, ISI=19.7±1.6) and severe (N=88, ISI=25.4±1.9) insomnia showed significant differences in characteristic. Clusters differed on depression level (PHQ2≥4 mild 19%, moderate 38%, severe 60%), and pain (ED5D=3 mild 3%, moderate 12%, severe 23%). Although the mild insomnia cluster reported better overall health, it showed higher rates of OSA compared to the moderate insomnia cluster, along with significantly older age and higher BMI.
Conclusion
Perimenopausal and menopausal women divided into three clusters with mild, moderate and severe insomnia, with levels of reported depression and pain symptoms increasing with insomnia symptoms. Clusters also differed on age, BMI and prevalence of OSA, suggesting that specific symptom clusters might indicate more precise and targeted treatment of common comorbid conditions during menopause transition.
Support
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Affiliation(s)
- P Srisawart
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - L Wang
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - J Bena
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - M Drerup
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - R Mehra
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - F Barwick
- Department of Psychiatry & Behavioral Sciences, Stanford School of Medicine, Stanford, CA
| | - D Moul
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
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Chindamporn P, Bena J, Wang L, Zajichek A, Milinovich A, Kaw R, Kashyap S, Cetin D, Aminian A, Kempke N, Foldvary-Schaefer N, Aboussouan LS, Mehra R. 0583 Obesity-Associated Sleep Hypoventilation Syndrome and Adverse Post-Operative Bariatric Surgery Outcomes. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.580] [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] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Although obesity hypoventilation syndrome (OHS) is associated with right ventricular dysfunction and increased mortality, its contribution to post-bariatric surgery risk remains unclear due to non-systematic OHS assessments. We hypothesize that patients with obesity-associated sleep hypoventilation (OASH) have increased adverse post-bariatric surgery outcomes than those without.
Methods
Patients undergoing polysomnography (PSG) prior to bariatric surgery at the Cleveland Clinic from 2011-2018 were retrospectively examined. OASH was defined by body mass index (BMI) ≥30kg/m2 and either PSG-based end-tidal CO2 ≥45mmHg or serum bicarbonate ≥27mEq/L. The following were considered individually and as a composite outcome: ICU stay, re-intubation, tracheostomy, discharge disposition or 30-day readmission. All-cause mortality was also examined. Outcomes were compared using two-sample t-test or Wilcoxon rank sum test and Chi-square or Fisher exact test. A multivariable logistic regression model included age, sex, BMI, apnea hypopnea index(AHI) and diabetes to examine OAHS and the composite outcome. All-cause mortality was compared using Kaplan-Meier estimation and hazard ratios from Cox proportional hazards models. SAS software (version 9.4) was used with overall significance level of 0.05.
Results
The sample comprised 1665 patients: age 45.2±12 years, 20.4% male, BMI=48.7±9 kg/m2, and 63.6% Caucasian. OASH prevalence was 68.5%. OAHS patients were older and more likely to be male with higher BMI, AHI and HbA1c. Although some individual outcomes were higher in OASH vs. non-OASH, findings were not statistically significant: re-intubation (1.5%vs.1.3%, p=0.81) and 30-day readmission (13.8% vs.11.3%, p=0.16). The composite outcome remained significantly associated with OAHS in the multivariable model: OR=1.36, 95%CI:1.005,1.845. Mortality was 2% in OASH and not significantly higher than non-OAHS (HR=1.39, 95%CI:0.56,3.42).
Conclusion
In this largest sample to date of systematically phenotyped OASH in patients undergoing bariatric surgery, we identify increased post-operative morbidity in those with OASH. Further study is needed to identify whether peri-operative treatment of OASH improves surgical outcomes.
Support
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Affiliation(s)
- P Chindamporn
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - J Bena
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - L Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - A Zajichek
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - A Milinovich
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - R Kaw
- Medicine Institute, Cleveland Clinic, Cleveland, OH
| | - S Kashyap
- Endocrinology, Cleveland Clinic, Cleveland, OH
| | - D Cetin
- Obesity Medicine Specialist, Bariatric Metabolic Institute, Cleveland Clinic, Cleveland, OH
| | - A Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - N Kempke
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - N Foldvary-Schaefer
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - L S Aboussouan
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - R Mehra
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
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Bhambra R, Pascoe M, Kominsky A, Mehra R, Aylor J, Wang L, Phillips K, Waters T, Walia HK. 0687 Comparative Changes Of Patient Reported Outcomes In Positive Airway Pressure And Upper Airway Stimulation For Obstructive Sleep Apnea. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.683] [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] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Upper Airway Stimulation (UAS) is increasingly being used for obstructive sleep apnea (OSA) treatment, however, data comparing changes in patient reported outcomes (PROs) in response to positive airway pressure (PAP) versus UAS are limited. We hypothesize that there will be no difference in PROs between the two groups after treatment.
Methods
UAS and PAP groups were 1:3 matched on age, sex, Body Mass Index (BMI) and Apnea Hypopnea Index (AHI, category 15-30, >30). Linear mixed models assessed the difference of change in Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire (FOSQ), Patient Health Questionnaire (PHQ9) and Insomnia Severity Index (ISI) measures on matched strata of UAS versus PAP groups with adjustment of baseline and matching factors. All analysis was performed in SAS software (version 9.4, Cary, NC).
Results
The analytic sample comprised 193 PAP patients and 69 UAS patients, with mean age=62.9+/-9.4 years, 27.5% female, mean BMI=29.1+/-3.2kg/m2, and median AHI 42.7, IQR: 31.5, 57.2. ESS in PAP (n=190) reduced by -2.63 (-3.38,-1.88) and in UAS (n=56) reduced by -2.22 (-3.34, -1.10), with a mean difference of 0.41 (-0.70, 1.52, p=.46). FOSQ in PAP (n=188) showed a change of 1.38 (0.99, 1.78) and in UAS (n=49) a change of 1.82 (1.17, 2.46), with a mean difference of 0.43 (-0.23, 1.09, p=.19). PHQ9 in PAP (n=185) showed a significant change of -2.24(-3.00, 1.47) and in UAS (n=45) a change of -3.75(-5.07,-2.42), with a mean difference of -1.51(-2.93,-0.088, p=.038). ISI in PAP (n=193) showed a significant change of -3.20(-4.39,-2.02) and in UAS (n=47) a change of -4.83(-6.77,-2.90), with a mean difference of -1.63(-3.62, 0.37, p=.11).
Conclusion
Similar improvements in PROs were observed in both UAS and PAP patient groups, however UAS appeared to confer greater benefit in depressive symptoms relative to PAP. Randomized clinical trials should be designed to confirm these findings.
Support
N/A
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Affiliation(s)
- R Bhambra
- Sleep Disorders Center, Cleveland, OH
| | - M Pascoe
- Sleep Disorders Center, Cleveland, OH
| | - A Kominsky
- Department of Otolaryngology, Cleveland, OH
| | - R Mehra
- Sleep Disorders Center, Cleveland, OH
| | - J Aylor
- Sleep Disorders Center, Cleveland, OH
| | - L Wang
- Department of Quantitative Health Sciences, Cleveland, OH
| | | | - T Waters
- Sleep Disorders Center, Cleveland, OH
| | - H K Walia
- Sleep Disorders Center, Cleveland, OH
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Mehra R, Bhambra R, Bena J, Bekris L, Leverenz J, Rao S, Foldvary-Schaefer N, Rao S, Pillai J. 0057 Actigraphy-Based Circadian Measures and Cerebrospinal Fluid Biomarkers of Neurodegeneration in Alzheimer’s Disease with Mild Cognitive Impairment. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.055] [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] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Although recent data implicates sleep and circadian disruption to neurodegeneration in Alzheimer’s Disease (AD), the association of objective circadian biomarkers and neurodegeneration remains understudied. We hypothesize that actigraphy-based circadian measures are associated with cerebrospinal fluid (CSF) biomarkers of neurodegeneration in those mild cognitive impairment due to AD (MCI-AD).
Methods
Eighteen patients with CSF biomarker-confirmed MCI-AD underwent actigraphy monitoring generating the following circadian measures: amplitude, F-ratio and mesor and morning collection of CSF biomarkers of neurodegeneration (Aβ42,t-tau,p-tau). Linear models were used to evaluate the association of circadian and CSF measures; logarithmic transformations were performed on neurodegenerative markers for greater normality. Analysis was performed using SAS software. A significance level of 0.05 was assumed for all tests.
Results
Eighteen MCI-AD patients who were 68± 6.2 years, 44% female, with median AHI=12 and underwent actigraphy monitoring for 8.2+/-3.2 days were included. There was no significant association of circadian measures and Aβ42 nor with mesor and neurodegeneration biomarkers. Amplitude was associated with both p-tau and t-tau, such that each 10 unit increase in amplitude resulted in a predicted increase in p-tau of 8% (95% CI:1%-15%, p=0.018) and an increase of 13% (3%-23%; p=0.01) in t-tau. F-ratio was positively associated with p-tau and t-tau; each 1000 unit increase in F-ratio resulted in a predicted 12% (4%-22%; p=0.007) increase in P-tau and 20%(6%-35%; p=0.005) increase in t-tau. Associations of these circadian measures and CSF levels of p-tau and t-tau remained statistically significant after adjustment for age and sex.
Conclusion
Among patients with symptomatic MCI stages of AD, objective measures of circadian rhythm disruption are associated with CSF-based biomarkers of neurodegeneration even after consideration of age and sex. Future investigation should clarify directionality of this association and potential utility of circadian-based interventions in the mitigation of AD progression.
Support
N/A
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Affiliation(s)
- R Mehra
- Sleep Disorders Center, Cleveland, OH
| | - R Bhambra
- Sleep Disorders Center, Cleveland, OH
| | - J Bena
- Quantitative Health Sciences, Cleveland, OH
| | - L Bekris
- Genomics Medicine Institute, Cleveland, OH
| | - J Leverenz
- Lou Ruvo Center for Brain Health, Cleveland, OH
| | - S Rao
- Lou Ruvo Center for Brain Health, Cleveland, OH
| | | | - S Rao
- Cole Eye Institute, Cleveland, OH
| | - J Pillai
- Lou Ruvo Center for Brain Health, Cleveland, OH
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Benca R, Ferziger R, Wickwire EM, Bertisch S, Biddle J, Boustani M, Culpepper L, Gooneratne N, Lett J, Manderscheid R, Mehra R, Reynolds C, Grandner MA. 0543 Implementing Insomnia Care Paths for Older Adults and People with Dementia. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.540] [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] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Despite the high prevalence of insomnia in older adults and those with dementia, screening and treatment remain inconsistent and suboptimal. Implementing a care path in a health system, though, is difficult. To determine what issues are relevant for implementation, a consensus meeting was convened, which included discussion, voting on components, and further consensus-building.
Methods
All N=20 participants, representing a wide range of stakeholders including research, industry, sleep, primary care, implementation science, and others, voted whether they agreed or disagreed with 36 different statements regarding what issues are important for implementing geriatric insomnia care paths. These represented a range of items addressing strategies for identifying and incentivizing stakeholders, identifying patients in most need and who would receive benefit, addressing comorbidities and multiple specialties, understanding how specific organizations make decisions about and changes to care, size and scope of the care path, determining the process for implementation, how it will improve outcomes, addressing specific needs of primary care, and addressing costs, reimbursements, and liabilities. Items were scored as 0=strongly agree, 1=agree, 2=disagree, and 3=strongly disagree. Mean scores were evaluated and responses were dichotomized to agree/disagree).
Results
Despite the diversity among attendees, median rate of agreement for was 95% (IQR=90-95%). All items were endorsed by >=80% of respondents. Mean score was 0.48 (SD=1.85). 95%CIs were computed for each proportion and compared to the mean. The only item that significantly differed from the mean score indicated that understanding benefits of a care path to the general community is less important of an issue than others (M=0.85).
Conclusion
Implementing an insomnia care path for older adults in an institution will likely require addressing a wide range of issues, including questions about stakeholders, the health system/context, patients, and practical considerations.
Support
Merck Research Labs provided support
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Affiliation(s)
- R Benca
- University of California, Irvine, Irvine, CA
| | - R Ferziger
- Merck Research Laboratories, Upper Gwynedd, PA
| | | | | | - J Biddle
- University of Pennsylvania, Philadelphia, PA
| | | | | | | | - J Lett
- Avar Consulting, Rockville, MD
| | - R Manderscheid
- National Association of County Behavioral Health and Developmental Disability Directors, Washington, DC
| | - R Mehra
- Cleveland Clinic, Cleveland, OH
| | - C Reynolds
- University of Pittsburgh, Pittsburgh, PA
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Bowman MA, Buysse DJ, Marsland AL, Wright AG, Foust J, Mehra R, Srinivasan S, Kohli N, Carroll L, Jasper A, Hall MH. 0820 Meta-Analysis of the Association of Age and Actigraphy-Assessed Sleep Across the Lifespan. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.816] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Sleep quantity and continuity vary across the lifespan. Actigraphy is reliable, ecologically valid, and is the most widely-used behavioral measure of sleep in research and personal health monitoring. The extent to which age is associated with actigraphy-assessed sleep has not been evaluated across the lifespan. The aim of this meta-analysis was to evaluate the associations between age and actigraphy-assessed sleep in relatively healthy individuals.
Methods
A systematic search of PubMed, Embase.com, Cochrane CENTRAL, and PsycINFO using “actigraphy” and “sleep” terms provided 7,079 titles/abstracts, which were screened to exclude studies of only individuals with mental health disorders, medical conditions, sleep disorders, or shift workers. We evaluated 1,379 full-text articles for reports on the association between age and actigraphy-assessed sleep duration, efficiency, timing, and/or regularity. Overall, 88 articles met these criteria (182 effect sizes; N=18,443). Four meta-analyses were conducted, examining sleep duration (k=86), sleep efficiency (k=58), bedtime (k=27), and wake-up time (k=11). There were insufficient numbers of studies (less than 5) to evaluate sleep midpoint or sleep regularity. We tested continent of the study, study design, actigraphy device type, and number of nights of data collection as moderators of meta-analytic associations.
Results
With increasing age, sleep duration was shorter (r = -0.13) and sleep efficiency was lower (r = -0.06). Bedtime was later with age for ages 6-21 (r = 0.31) and earlier for ages 22 and up (r = -0.65). Wake-up time was not associated with age for ages 6-21 (r = 0.20) but was earlier with increasing age for ages 22 and up (r = -0.71). The strength of these associations was modified by continent and study design, but not by type of actigraphy device or number of nights of data collection.
Conclusion
Weak associations between age and actigraphy-assessed duration and efficiency suggest that inadequate sleep quantity or poor sleep continuity should not be dismissed as typical consequences of aging. Large associations between age and sleep timing, despite a small literature, highlights a promising area for further study, particularly to determine the age at which sleep timing shifts from delaying to advancing.
Support
MAB was supported by T32 HL07560.
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Affiliation(s)
- M A Bowman
- University of Pittsburgh, Pittsburgh, PA
| | - D J Buysse
- University of Pittsburgh, Pittsburgh, PA
| | | | - A G Wright
- University of Pittsburgh, Pittsburgh, PA
| | - J Foust
- University of Pittsburgh, Pittsburgh, PA
| | - R Mehra
- University of Pittsburgh, Pittsburgh, PA
| | | | - N Kohli
- University of Pittsburgh, Pittsburgh, PA
| | - L Carroll
- University of Pittsburgh, Pittsburgh, PA
| | - A Jasper
- University of Pittsburgh, Pittsburgh, PA
| | - M H Hall
- University of Pittsburgh, Pittsburgh, PA
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Ajisebutu A, Kak I, Thompson N, Honomichl R, Moul D, Mehra R, Shah V. 0906 Identification Of Physical Exam Findings With High Predictive Value For Moderate To Severe Pediatric Obstructive Sleep Apnea(osa) In Overweight/obese Children. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.902] [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] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Obstructive sleep apnea(OSA) is highly prevalent and under-diagnosed in the overweight/obese pediatric population largely due to limitations of existing pediatric OSA screening instruments including lack of efficiency and practical implementation and lack of careful consideration of physical examination(PE) findings with high predictive value for OSA. We sought to identify PE finding(s) predictive of pediatric OSA in overweight/obese patients to inform development of an OSA screening tool.
Methods
Overweight/obese patients presenting to the Cleveland Clinic weight-management clinic between 2013-2018 with polysomnogram (PSG) data were included. The association of PE predictors: age, sex, race (white, black, other), neck (NC), waist circumference (WC), tonsil size (TS), height, systolic and diastolic blood pressure (BP) percentiles) in relation to OSA defined by apnea-hypopnea index (AHI)≥5,i.e. clinically significant pediatric OSA, were assessed using univariate and multivariate logistic regression models (OR,95%CI).
Results
Retrospective analysis of 180 overweight/obese patients (BMI percentile>85th for age and sex) and age 12.5±3.7 years were included. The multivariate model showed that only WC was significantly associated (1.03, 1.00 - 1.07, p=0.038) with OSA defined as AHI≥5. A statistically significant interaction of age and sex was observed such that the likelihood of OSA increased in males with older age and conversely decreased in females with older age. (1.26,1.04 -1.52, p=0.038) The reduced multivariate model, which included age, sex, WC, and age*sex interaction term, correctly discriminated AHI <5 vs. ≥ 5 66.5% of the time.
Conclusion
In this large clinic-based overweight/obese pediatric sample, males, older age and WC were significant predictors of OSA and TS was not. A significant interaction of age and sex was observed supporting increased OSA with increasing age in males. Data generated supports value of PE findings of age, sex and WC to incorporate in development of an OSA screening tool for overweight/obese children.
Support
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Affiliation(s)
- A Ajisebutu
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - I Kak
- Department of Pediatrics, Cleveland Clinic, Cleveland, OH
| | - N Thompson
- Section of Biostatistics, Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - R Honomichl
- Section of Biostatistics, Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - D Moul
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - R Mehra
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - V Shah
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
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46
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Benca R, Ferziger R, Wickwire EM, Bertisch S, Biddle J, Boustani M, Culpepper L, Gooneratne N, Lett J, Manderscheid R, Mehra R, Reynolds C, Grandner M. 1185 Developing A Care Pathway For Insomnia In Older Adults And Adults With Dementia: Results Of A Consensus Meeting. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.1179] [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] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Insomnia among older adults and dementia patients carries a high public health burden. Yet, treatment is inconsistent or absent. Standardized, programmatic carepaths can be implemented in clinics/systems/communities to address this after tailoring to local environments. To determine what elements should be included, a consensus meeting was convened, which included discussion, voting on components, and further consensus-building among diverse stakeholders.
Methods
Participants represented a wide range of stakeholders and specialties, including academic research, clinical care, industry, government, payors, sleep medicine, primary care, geriatrics, psychiatry, neurology, nursing, pharmacy, quality, and implementation science. 27 statements regarding key components of carepaths for insomnia in elderly and dementia populations were presented and discussed. These represented items addressing identification of patients, screening and assessment, deciding treatment modality and delivery, providing behavioral treatment, providing pharmacotherapy, addressing combined therapy, addressing comorbidities, and incorporating outcome evaluation. All N=20 participants voted individually whether they agreed or disagreed with each statement. Items were scored as 0=strongly agree, 1=agree, 2=disagree, and 3=strongly disagree. Mean scores were evaluated and responses were dichotomized to agree/disagree.
Results
Despite diversity among attendees, median rate of agreement was 95% (IQR=85-95%). Mean score was 0.69 (SD=0.31). 95%CIs were computed for each proportion and compared to the mean. The following elements were significantly different from the mean (p<0.05): medication decision trees (M=0.25), accounting for comorbidities (M=0.26), include outcome evaluation (M=0.30), utilization of EMR (M=0.40), incorporate caregiver (M=0.42), and differ across parts of the system (M=1.79).
Conclusion
Insomnia carepaths for older adults should address identification, screening and assessment, treatment decisions, treatment type and delivery, and evaluation. Organizations should consider these elements when designing carepaths for insomnia among older adults and dementia patients. Consensus-building should begin during the process of prioritizing care path components.
Support
Merck Research Labs provided support
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Affiliation(s)
- R Benca
- University of California, Irvine, Irvine, CA
| | - R Ferziger
- Merck Research Laboratories, Upper Gwynedd, PA
| | | | | | - J Biddle
- University of Pennsylvania, Philadelphia, PA
| | | | | | | | - J Lett
- Avar Consulting, Rockville, MD
| | - R Manderscheid
- National Association of County Behavioral Health and Developmental Disability Directors, Washington, DC
| | - R Mehra
- Cleveland Clinic, Cleveland, OH
| | - C Reynolds
- University of Pittsburgh, Pittsburgh, PA
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Walia HK, Mehra R, Kominsky A, Kent D, Pham H, Upender R, Manchanda S. 0681 Comparison Of Upper Airway Stimulation Outcomes Between Regions And Bmi Groups From The Adhere Registry. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.677] [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] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
As factors influencing Upper Airway Stimulation (UAS) effectiveness in obstructive sleep apnea (OSA) patients are of interest, we compared changes in apnea hypopnea index (AHI) and Epworth Sleepiness Scale (ESS) based on region and baseline body mass index (BMI).
Methods
Patients (15≥AHI≤65) of the ADHERE registry with AHI at one-year were grouped by region (Europe (EU) vs United States (US)), and BMI (≤32kg/m2 vs 32-35kg/m2). T-tests and equivalence testing (if the former non-significant) was performed using two-one-sided t-tests. Equivalence margin for AHI was set between -5 and 5 and -2 and 2 for ESS.
Results
By December 2019, 553 of 1600 patients completed 1-year follow-up. Average age was 60±11, 75% male, BMI 29±4 kg/m2, ESS=11±6. Median AHI decreased from 33 to 10, median ESS decreased from 11 to 6. Response defined by 50% AHI reduction and <20 was 70%. Both regions had similar improvements in median AHI (EU: 33 to 10, US: 34 to 10, p < 0.001 vs baseline), median ESS (EU: 12 to 7; US: 11 to 6, p<0.001 vs baseline), and treatment response (EU: 71%, US: 68%). The mean AHI and ESS difference between regions met the equivalence margin. (AHI: mean difference: 0.34, CI:-1.78, 2.46, ESS: mean difference: 0.57, CI:-0.04, 1.19). Mean change in AHI at 1-year was equivalent in BMI groups (≤32 kg/m2 vs 32-35 kg/m2 respectively) median difference: -19.6 vs. -18.8; mean difference: -0.48, (CI:-3.95, 2.97) However, treatment response ratio was different; 73% vs. 60%, p=0.02, i.e. higher BMI patients were less likely to achieve AHI < 20. ESS scores were equivalent; median: 6 vs. 7; mean difference: -0.33, CI: [-1.16, 0.47].
Conclusion
UAS influence on OSA severity defined by AHI and sleepiness was similar irrespective of region and BMI category, however, treatment response defined by 50% AHI reduction and <20 was greater in those with lower BMI.
Support
The statistical support was provided by Inspire Medical System.
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Affiliation(s)
| | - R Mehra
- Cleveland Clinic, Cleveland, OH
| | | | - D Kent
- Vanderbilt University Medical Center, Nashville, TN
| | - H Pham
- Vanderbilt University Medical Center, Nashville, TN
| | - R Upender
- Vanderbilt University Medical Center, Nashville, TN
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Ghosh M, Gupta R, Jain RA, Mehra R, Verma M. Role and influence of growth factors on early osseointegration in animal jaw bone: A meta-analysis. J Indian Prosthodont Soc 2020; 20:153-161. [PMID: 32655219 PMCID: PMC7335027 DOI: 10.4103/jips.jips_385_19] [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: 10/15/2019] [Revised: 12/25/2019] [Accepted: 02/29/2020] [Indexed: 11/20/2022] Open
Abstract
Aim: Growth factors (GFs) are polypeptides, which are intricately involved in the regulation of bone formation, preservation, and regeneration through gene expression. However, the role of these bioactive agents in osseointegration of dental implants has not been substantially proven. The objective of this systematic review (SR) and meta-analysis was to explore the effect of GFs on early osseointegration of dental implants in animal jaws. An attempt to decipher an adjunctive role of GFs in modulating predictable bone growth in peri-implant areas was done. Materials and Methods: An electronic and manual search of different databases was performed. Only randomized controlled trials (RCTs) were included and reviewed. The risk of bias (ROB) of the selected studies was assessed using the SR Centre for Laboratory Animal Experimentation (Cochrane) tool. A meta-analysis was also performed to evaluate the different study characteristics quantitatively. Statistical Analysis used: The total Weighted mean difference was evaluated using the Rev-Manv5.3 algorithm. Chi-square test and I2 test were done to assess the heterogeneity between the studies. Results: Seven RCTs were included in the study. These were associated with a high ROB. The total weighted mean difference (WMD) of the percentage of bone–implant contact was 3.25% (95% confidence interval [CI] = 1.49%–6.03%; P = 0.001; I2 = 91%) between groups with and without exogenous application of GFs. The total WMD of the percentage of newly formed bone area was 4.48% (95% CI = 2.31%–5.90%; P < 0.00001, I2 = 84%). A high level of heterogeneity (P < 0.001 for Chi-square test; I2>50 %) among comparable studies was observed. Conclusion: The ancillary application of external GFs exhibited evidence of early osseointegration, resulting in more predictable and faster results. However, a careful discernment of conclusions drawn from this SR is a must before conducting any human trials.
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Affiliation(s)
- Modhupa Ghosh
- Department of Prosthodontics, Maulana Azad Institute of Dental Sciences, New Delhi, India
| | - Rekha Gupta
- Department of Prosthodontics, Maulana Azad Institute of Dental Sciences, New Delhi, India
| | - Radhika A Jain
- Department of Prosthodontics, Maulana Azad Institute of Dental Sciences, New Delhi, India
| | - Rashmi Mehra
- Department of Public Health Dentistry, Maulana Azad Institute of Dental Sciences, New Delhi, India
| | - Mahesh Verma
- Department of Prosthodontics, Guru Gobind Singh Indraprastha University, New Delhi, India
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Weiss J, Vincent B, Deal A, Grilley-Olson J, Patel S, Hackman T, Blumberg J, Galloway T, Patel S, Zanation A, Shen C, Hayes D, Hilliard C, Mehra R, McKinnon K, Wang H, Weissler M, Bauman J, Sheth S, Chera B. Progression-free survival, overall survival and immunophenotyping outcomes for patients with stage III-IV head and neck cancer and cisplatin contraindication treated with definitive radiotherapy plus pembrolizumab. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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50
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Mehra R, Mohanty V, Balappanavar AY, Kapoor S. Bacterial contamination of packaged smokeless tobacco sold in India. Tob Prev Cessat 2020; 6:11. [PMID: 32548348 PMCID: PMC7291906 DOI: 10.18332/tpc/115064] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 03/27/2019] [Revised: 09/28/2019] [Accepted: 12/04/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION About 21.4% of India's population uses smokeless tobacco products (SLT), yet limited data are available on their microbial contamination. To understand the potential microbiological risks associated with SLT use, the present study aims to investigate bacterial contamination of tobacco and the types of microbes that could be cultured from SLT products. METHODS Twenty-two brands of SLT products, including paan masala, khaini, gutka and tobacco-containing dentifrices were examined and cultured by using appropriate selective and differential media including MacConkey agar and CLED agar. This was followed by a sequence of further identification by biochemical tests. RESULTS All 22 types of SLT products showed growth of aerobic bacteria. The most common bacteria isolated were Pseudomonas aeruginosa followed by Streptococcus faecalis. Other bacteria that were isolated from products, in traces, included Klebsiella spp., E. coli, and Bacillus subtilus. CONCLUSIONS This study raises and addresses the issue of bacterial contamination of packaged SLT products. SLT users might be subjected to a significant health hazard, especially those who are immunocompromised.
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Affiliation(s)
- Rashmi Mehra
- Department of Public Health Dentistry, Maulana Azad Institute of Dental Sciences, New Delhi, India
| | - Vikrant Mohanty
- Department of Public Health Dentistry, Maulana Azad Institute of Dental Sciences, New Delhi, India
| | - Aswini Y Balappanavar
- Department of Public Health Dentistry, Maulana Azad Institute of Dental Sciences, New Delhi, India
| | - Shivam Kapoor
- Department of Public Health Dentistry, Maulana Azad Institute of Dental Sciences, New Delhi, India
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