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Hsueh JY, Gallagher L, Koh MJ, Eden S, Shah S, Wells M, Danner M, Zwart A, Ayoob M, Kumar D, Leger P, Dawson NA, Suy S, Rubin R, Collins SP. Impact of neoadjuvant relugolix on patient-reported sexual function and bother. Front Oncol 2024; 14:1377103. [PMID: 38665954 PMCID: PMC11043501 DOI: 10.3389/fonc.2024.1377103] [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: 01/26/2024] [Accepted: 03/27/2024] [Indexed: 04/28/2024] Open
Abstract
Introduction Sexual function following local treatment for prostate cancer is an important quality of life concern. Relugolix is a novel oral GnRH receptor antagonist used in combination with radiation therapy in the treatment of unfavorable prostate cancer. It has been shown to achieve rapid and profound testosterone suppression. As a result, these very low testosterone levels may impact both sexual functioning and perceptions. This prospective study sought to assess neoadjuvant relugolix-induced sexual dysfunction prior to stereotactic body radiation therapy (SBRT). Methods Between March 2021 and September 2023, 87 patients with localized prostate cancer were treated with neoadjuvant relugolix followed by SBRT per an institutional protocol. Sexual function and bother were assessed via the sexual domain of the validated Expanded Prostate Index Composite (EPIC-26) survey. Responses were collected for each patient at pre-treatment baseline and after several months of relugolix. A Utilization of Sexual Medications/Devices questionnaire was administered at the same time points to assess erectile aid usage. Results The median age was 72 years and 43% of patients were non-white. The median baseline Sexual Health Inventory for Men (SHIM) score was 13 and 41.7% of patients utilized sexual aids prior to relugolix. Patients initiated relugolix at a median of 4.5 months (2-14 months) prior to SBRT. 95% and 87% of patients achieved effective castration (≤ 50 ng/dL) and profound castration (< 20 ng/dl) at SBRT initiation, respectively. Ability to have an erection, ability to reach orgasm, quality of erections, frequency of erections, and overall sexual function significantly declined following relugolix. There was a non- significant increase in sexual bother. Discussion In concordance with known side effects of androgen deprivation therapy (ADT), neoadjuvant relugolix was associated with a significant decline in self-reported sexual function. However, patients indicated only a minimal and non-significant increase in bother. Future investigations should compare outcomes while on relugolix directly to GnRH agonist-induced sexual dysfunction.
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Affiliation(s)
- Jessica Y. Hsueh
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Lindsey Gallagher
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Min Ji Koh
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Shaine Eden
- Systems Medicine Program, Department of Biochemistry and Molecular & Cellular Biology, Georgetown University Medical Center, Washington, DC, United States
| | - Sarthak Shah
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Markus Wells
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Malika Danner
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Alan Zwart
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Marilyn Ayoob
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Deepak Kumar
- Biotechnology Research Institute, North Carolina Central University, Durham, NC, United States
| | - Paul Leger
- Department of Oncology, Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Nancy A. Dawson
- Department of Oncology, Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Simeng Suy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Rachel Rubin
- Department of Urology, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Sean P. Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
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Cox ZL, Collins SP, Hernandez GA, McRae AT, Davidson BT, Adams K, Aaron M, Cunningham L, Jenkins CA, Lindsell CJ, Harrell FE, Kampe C, Miller KF, Stubblefield WB, Lindenfeld J. Efficacy and Safety of Dapagliflozin in Patients With Acute Heart Failure. J Am Coll Cardiol 2024; 83:1295-1306. [PMID: 38569758 DOI: 10.1016/j.jacc.2024.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND The primary goals during acute heart failure (AHF) hospitalization are decongestion and guideline-directed medical therapy (GDMT) optimization. Unlike diuretics or other GDMT, early dapagliflozin initiation could achieve both AHF goals. OBJECTIVES The authors aimed to assess the diuretic efficacy and safety of early dapagliflozin initiation in AHF. METHODS In a multicenter, open-label study, 240 patients were randomized within 24 hours of hospital presentation for hypervolemic AHF to dapagliflozin 10 mg once daily or structured usual care with protocolized diuretic titration until day 5 or hospital discharge. The primary outcome, diuretic efficiency expressed as cumulative weight change per cumulative loop diuretic dose, was compared across treatment assignment using a proportional odds model adjusted for baseline weight. Secondary and safety outcomes were adjudicated by a blinded committee. RESULTS For diuretic efficiency, there was no difference between dapagliflozin and usual care (OR: 0.65; 95% CI: 0.41-1.02; P = 0.06). Dapagliflozin was associated with reduced loop diuretic doses (560 mg [Q1-Q3: 260-1,150 mg] vs 800 mg [Q1-Q3: 380-1,715 mg]; P = 0.006) and fewer intravenous diuretic up-titrations (P ≤ 0.05) to achieve equivalent weight loss as usual care. Early dapagliflozin initiation did not increase diabetic, renal, or cardiovascular safety events. Dapagliflozin was associated with improved median 24-hour natriuresis (P = 0.03) and urine output (P = 0.005), expediting hospital discharge over the study period. CONCLUSIONS Early dapagliflozin during AHF hospitalization is safe and fulfills a component of GDMT optimization. Dapagliflozin was not associated with a statistically significant reduction in weight-based diuretic efficiency but was associated with evidence for enhanced diuresis among patients with AHF. (Efficacy and Safety of Dapagliflozin in Acute Heart Failure [DICTATE-AHF]; NCT04298229).
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Affiliation(s)
- Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee, USA; Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center, Nashville, Tennessee, USA
| | - Gabriel A Hernandez
- Division of Cardiology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - A Thomas McRae
- TriStar Centennial Medical Center, Nashville, Tennessee, USA
| | - Beth T Davidson
- TriStar Centennial Medical Center, Nashville, Tennessee, USA
| | - Kirkwood Adams
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Mark Aaron
- Department of Cardiac Sciences, Saint Thomas West Hospital, Nashville, Tennessee, USA
| | - Luke Cunningham
- Department of Cardiology, INTEGRIS Baptist Medical Center, Oklahoma City, Oklahoma, USA
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher J Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christina Kampe
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Karen F Miller
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William B Stubblefield
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - JoAnn Lindenfeld
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Tromp J, Kosiborod MN, Angermann CE, Collins SP, Teerlink JR, Ponikowski P, Biegus J, Ferreira JP, Nassif ME, Psotka MA, Brueckmann M, Blatchford JP, Steubl D, Voors AA. Treatment effects of empagliflozin in hospitalized heart failure patients across the range of left ventricular ejection fraction - Results from the EMPULSE trial. Eur J Heart Fail 2024. [PMID: 38572654 DOI: 10.1002/ejhf.3218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 02/23/2024] [Accepted: 03/12/2024] [Indexed: 04/05/2024] Open
Abstract
AIM The EMPULSE (EMPagliflozin in patients hospitalised with acUte heart faiLure who have been StabilizEd) trial showed that, compared to placebo, the sodium-glucose cotransporter 2 inhibitor empagliflozin (10 mg/day) improved clinical outcomes of patients hospitalized for acute heart failure (HF). We investigated whether efficacy and safety of empagliflozin were consistent across the spectrum of left ventricular ejection fraction (LVEF). METHODS AND RESULTS A total of 530 patients hospitalized for acute de novo or decompensated HF were included irrespective of LVEF. For the present analysis, patients were classified as HF with reduced (HFrEF, LVEF ≤40%), mildly reduced (HFmrEF, LVEF 41-49%) or preserved (HFpEF, LVEF ≥50%) ejection fraction at baseline. The primary endpoint was a hierarchical outcome of death, worsening HF events (HFE) and quality of life over 90 days, assessed by the win ratio. Secondary endpoints included individual components of the primary endpoint and safety. Out of 523 patients with baseline data, 354 (67.7%) had HFrEF, 54 (10.3%) had HFmrEF and 115 (22.0%) had HFpEF. The clinical benefit (hierarchical composite of all-cause death, HFE and Kansas City Cardiomyopathy Questionnaire total symptom score) of empagliflozin at 90 days compared to placebo was consistent across LVEF categories (≤40%: win ratio 1.35 [95% confidence interval 1.04, 1.75]; 41-49%: win ratio 1.25 [0.66, 2.37)] and ≥50%: win ratio 1.40 [0.87, 2.23], pinteraction = 0.96) with a favourable safety profile. Results were consistent across individual components of the hierarchical primary endpoint. CONCLUSION The clinical benefit of empagliflozin proved consistent across LVEF categories in the EMPULSE trial. These results support early in-hospital initiation of empagliflozin regardless of LVEF.
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Affiliation(s)
- Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore & the National University Health System, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
- George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Christiane E Angermann
- Comprehensive Heart Failure Centre and Department of Medicine I (Cardiology), University and University Hospital of Würzburg, Würzburg, Germany
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center and Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville, TN, USA
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Medical University, Wroclaw, Poland
| | - Jan Biegus
- Institute of Heart Diseases, Medical University, Wroclaw, Poland
| | - João Pedro Ferreira
- Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | | | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
- First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Jonathan P Blatchford
- Elderbrook Solutions GmbH on behalf of Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Dominik Steubl
- Boehringer Ingelheim International, Ingelheim, Germany
- Department of Nephrology, Klinikum rechts der Isar, Faculty of Medicine, Technical University, Munich, Germany
| | - Adriaan A Voors
- University of Groningen Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
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Repka MC, Sholklapper T, Zwart AL, Danner M, Ayoob M, Yung T, Lei S, Collins BT, Kumar D, Suy S, Hankins RA, Kishan AU, Collins SP. Prognostic utility of biopsy-based PTEN and ERG status on biochemical progression and overall survival after SBRT for localized prostate cancer. Front Oncol 2024; 14:1381134. [PMID: 38585005 PMCID: PMC10995255 DOI: 10.3389/fonc.2024.1381134] [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: 02/02/2024] [Accepted: 03/12/2024] [Indexed: 04/09/2024] Open
Abstract
Introduction/background Phosphatase and tensin homolog (PTEN) genomic deletions and transmembrane protease, serine 2/v-ets avian erthyroblastosis virus E26 oncogene homolog (ERG) rearrangements are two of the most common genetic abnormalities associated with prostate cancer. Prior studies have demonstrated these alterations portend worse clinical outcomes. Our objective is to evaluate the impact of biopsy-determined PTEN losses and TMPRSS2-ERG fusion on biochemical progression-free survival (bPFS) and overall survival (OS) in patients who receive SBRT for localized prostate cancer. Methods/materials Patients received SBRT for localized prostate cancer on a prospective quality-of-life (QoL) and cancer outcomes study. For each patient, the single biopsy core with the highest grade/volume of cancer was evaluated for PTEN and ERG abnormalities. Differences in baseline patient and disease characteristics between groups were analyzed using ANOVA for age and χ2 for categorical groupings. bPFS and OS were calculated using the Kaplan Meier (KM) method with Log-Rank test comparison between groups. Predictors of bPFS and OS were identified using the Cox proportional hazards method. For all analyses, p <0.05 was considered statistically significant. Results Ninety-nine consecutive patients were included in the analysis with a median follow-up of 72 months. A statistically significant improvement in bPFS (p = 0.018) was observed for wild type ERG patients with an estimated 5-year bPFS of 94.1% vs. 72.4%. Regarding PTEN mutational status, significant improvements in were observed in both bPFS (p = 0.006) and OS (p < 0.001), with estimated 5-year bPFS rates of 91.0% vs. 67.9% and 5-year OS rates of 96.4% vs. 79.4%. When including both ERG and PTEN mutational status in the analysis, there were statistically significant differences in both bPFS (p = 0.011) and OS (p < 0.001). The estimated 5-year bPFS rates were 100%, 76.6%, 72.9%, and 63.8% for patients with ERG+/PTEN+, ERG-/PTEN+, ERG+/PTEN-, and ERG-/PTEN- phenotypes respectively. The estimated 5-year OS rates were 93.9%, 100%, 80.0%, and 78.7% for patients with ERG+/PTEN+, ERG-/PTEN+, ERG+/PTEN-, and ERG-/PTEN- phenotypes respectively. Conclusion ERG rearrangements and PTEN deletions detected on biopsy samples are associated with poorer oncologic outcomes in prostate cancer patients treated with SBRT and merit further study in a dedicated prospective trial.
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Affiliation(s)
- Michael C. Repka
- Department of Radiation Oncology, University of North Carolina (UNC) School of Medicine, Chapel Hill, NC, United States
| | - Tamir Sholklapper
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Alan L. Zwart
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Malika Danner
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Marilyn Ayoob
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Thomas Yung
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Siyuan Lei
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Brian T. Collins
- Department of Radiation Oncology, Tampa General Hospital, Tampa, FL, United States
| | - Deepak Kumar
- Julius L Chambers Research Institute, North Carolina Central University, Durham, NC, United States
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Ryan A. Hankins
- Department of Urology, Georgetown University Hospital, Washington, DC, United States
| | - Amar U. Kishan
- Department of Radiation Oncology, University of California, Los Angeles (UCLA) Health, Los Angeles, CA, United States
| | - Sean P. Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
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Shah S, Pepin A, Jatar S, Hsueh J, Gallagher L, Danner MT, Zwart A, Ayoob M, Yung TM, Kumar D, Aghdam N, Leger PD, Dawson NA, Simeng S, Collins SP. Bothersome Hot Flashes Following Neoadjuvant Androgen Deprivation Therapy and Stereotactic Body Radiotherapy for Localized Prostate Cancer. Cureus 2024; 16:e55729. [PMID: 38586683 PMCID: PMC10998655 DOI: 10.7759/cureus.55729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2024] [Indexed: 04/09/2024] Open
Abstract
BACKGROUND Androgen deprivation therapy (ADT) improves local cancer control in unfavorable localized prostate cancer treated with radiotherapy. ADT is known to cause hormonally related symptoms that resolve with testosterone recovery. Hot flashes are particularly burdensome. This study sought to evaluate the timeline of hot flashes following short-course ADT and stereotactic body radiotherapy (SBRT) as well as its relationship with testosterone recovery. METHODS Institutional IRB approval was obtained for this retrospective review of prospectively collected data (IRB#: 2009-510). ADT was initiated three months prior to the start of SBRT. Hot flashes were self-reported via question 13a of the Expanded Prostate Index Composite (EPIC)-26 prior to ADT initiation, the first day of robotic SBRT, and at each follow-up (one, three, six, nine, 12, 18, 24, and 36 months). The responses were grouped into three relevant categories (no problem, very small-small problem, and moderate-big problem). Scores were transformed to a 0-100 scale with higher scores reflecting less bother. Testosterone levels were measured at each follow-up. RESULTS From 2007 to 2010, 122 localized prostate cancer patients (nine low-, 64 intermediate-, and 49 high-risk according to the D'Amico classification) at a median age of 72 years (range 54.5-88.3) were treated with short course ADT (three to six months) and SBRT (35-36.25 Gy) at Georgetown University Hospital. Thirty-two percent were Black and 27% were obese. Seventy-seven percent of patients received three months of ADT. At baseline, 2% of men experienced hot flashes that were a "moderate to big problem" and that proportion peaked at the start of SBRT (45%) before returning to baseline (2%) nine months post-SBRT with a cumulative incidence of 52.4%. The median baseline EPIC-26 hot flash score of 94 declined to 50 at the start of SBRT but this returned to baseline (92) by six months post SBRT. These changes were both statistically and clinically significant (MID = 9.5083, p<0.01). Testosterone recovery (> 230 ng/dL) occurred in approximately 70% of patients by 12 months post SBRT. Resolution of hot flashes correlated with testosterone recovery. CONCLUSION Bothersome hot flashes occur in greater than 50% of men treated with neoadjuvant ADT. Resolution of hot flashes occurs in the majority of patients within one year after treatment. Reassurance of the temporary nature of hot flashes may assist in reducing patient anxiety. Measuring testosterone levels at follow-up visits may allow for anticipatory counseling that may limit the associated bother.
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Affiliation(s)
- Sarthak Shah
- Radiation Medicine, MedStar Georgetown University Hospital, Washington, USA
| | - Abigail Pepin
- Radiation Oncology, University of Pennsylvania Abramson Cancer Center, Philadelphia, USA
| | - Simran Jatar
- Radiation Medicine, MedStar Georgetown University Hospital, Washington, USA
| | - Jessica Hsueh
- Radiation Medicine, MedStar Georgetown University Hospital, Washington, USA
| | - Lindsey Gallagher
- Radiation Medicine, MedStar Georgetown University Hospital, Washington, USA
| | - Malika T Danner
- Radiation Medicine, MedStar Georgetown University Hospital, Washington, USA
| | - Alan Zwart
- Radiation Medicine, MedStar Georgetown University Hospital, Washington, USA
| | - Marilyn Ayoob
- Radiation Medicine, MedStar Georgetown University Hospital, Washington, USA
| | - Thomas M Yung
- Radiation Medicine, MedStar Georgetown University Hospital, Washington, USA
| | - Deepak Kumar
- Medicine, Biotechnology Research Institute, North Carolina Central University, Durham, USA
| | - Nima Aghdam
- Radiation Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Paul D Leger
- Oncology, MedStar Georgetown University Hospital, Washington, USA
| | - Nancy A Dawson
- Oncology, MedStar Georgetown University Hospital, Washington, USA
| | - Suy Simeng
- Radiation Medicine, MedStar Georgetown University Hospital, Washington, USA
| | - Sean P Collins
- Radiation Medicine, MedStar Georgetown University Hospital, Washington, USA
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Rao VS, Ivey-Miranda JB, Cox ZL, Moreno-Villagomez J, Maulion C, Bellumkonda L, Chang J, Field MP, Wiederin DR, Butler J, Collins SP, Turner JM, Wilson FP, Inzucchi SE, Wilcox CS, Ellison DH, Testani JM. Empagliflozin in Heart Failure: Regional Nephron Sodium Handling Effects. J Am Soc Nephrol 2024; 35:189-201. [PMID: 38073038 PMCID: PMC10843196 DOI: 10.1681/asn.0000000000000269] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 10/25/2023] [Indexed: 02/02/2024] Open
Abstract
SIGNIFICANCE STATEMENT The effect of sodium-glucose cotransporter-2 inhibitors (SGLT2i) on regional tubular sodium handling is poorly understood in humans. In this study, empagliflozin substantially decreased lithium reabsorption in the proximal tubule (PT) (a marker of proximal tubular sodium reabsorption), a magnitude out of proportion to that expected with only inhibition of sodium-glucose cotransporter-2. This finding was not driven by an "osmotic diuretic" effect; however, several parameters changed in a manner consistent with inhibition of the sodium-hydrogen exchanger 3. The large changes in proximal tubular handling were acutely buffered by increased reabsorption in both the loop of Henle and the distal nephron, resulting in the observed modest acute natriuresis with these agents. After 14 days of empagliflozin, natriuresis waned due to increased reabsorption in the PT and/or loop of Henle. These findings confirm in humans that SGLT2i have complex and important effects on renal tubular solute handling. BACKGROUND The effect of SGLT2i on regional tubular sodium handling is poorly understood in humans but may be important for the cardiorenal benefits. METHODS This study used a previously reported randomized, placebo-controlled crossover study of empagliflozin 10 mg daily in patients with diabetes and heart failure. Sodium handling in the PT, loop of Henle (loop), and distal nephron was assessed at baseline and day 14 using fractional excretion of lithium (FELi), capturing PT/loop sodium reabsorption. Assessments were made with and without antagonism of sodium reabsorption through the loop using bumetanide. RESULTS Empagliflozin resulted in a large decrease in sodium reabsorption in the PT (increase in FELi=7.5%±10.6%, P = 0.001), with several observations suggesting inhibition of PT sodium hydrogen exchanger 3. In the absence of renal compensation, this would be expected to result in approximately 40 g of sodium excretion/24 hours with normal kidney function. However, rapid tubular compensation occurred with increased sodium reabsorption both in the loop ( P < 0.001) and distal nephron ( P < 0.001). Inhibition of sodium-glucose cotransporter-2 did not attenuate over 14 days of empagliflozin ( P = 0.14). However, there were significant reductions in FELi ( P = 0.009), fractional excretion of sodium ( P = 0.004), and absolute fractional distal sodium reabsorption ( P = 0.036), indicating that chronic adaptation to SGLT2i results primarily from increased reabsorption in the loop and/or PT. CONCLUSIONS Empagliflozin caused substantial redistribution of intrarenal sodium delivery and reabsorption, providing mechanistic substrate to explain some of the benefits of this class. Importantly, the large increase in sodium exit from the PT was balanced by distal compensation, consistent with SGLT2i excellent safety profile. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER ClinicalTrials.gov ( NCT03027960 ).
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Affiliation(s)
- Veena S. Rao
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Juan B. Ivey-Miranda
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Hospital de Cardiologia, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Zachary L. Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Julieta Moreno-Villagomez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Facultad de Estudios Superiores Iztacala, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Christopher Maulion
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Lavanya Bellumkonda
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - John Chang
- Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | | | | | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas
| | - Sean P. Collins
- Department of Emergency Medicine, Geriatric Research, Education and Clinical Center (GRECC), Vanderbilt University Medical Center and Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Jeffrey M. Turner
- Division of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - F. Perry Wilson
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, Connecticut
| | - Silvio E. Inzucchi
- Section of Endocrinology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Christopher S. Wilcox
- Division of Nephrology and Hypertension Center, Georgetown University, Washington, DC
| | - David H. Ellison
- Oregon Clinical and Translational Research Institute, Oregon Health and Science University, Portland, Oregon
| | - Jeffrey M. Testani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
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Collins SP, Mailloux B, Kulkarni S, Gagné M, Long AS, Barton-Maclaren TS. Development and application of consensus in silico models for advancing high-throughput toxicological predictions. Front Pharmacol 2024; 15:1307905. [PMID: 38333007 PMCID: PMC10850302 DOI: 10.3389/fphar.2024.1307905] [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: 10/05/2023] [Accepted: 01/02/2024] [Indexed: 02/10/2024] Open
Abstract
Computational toxicology models have been successfully implemented to prioritize and screen chemicals. There are numerous in silico (quantitative) structure-activity relationship ([Q]SAR) models for the prediction of a range of human-relevant toxicological endpoints, but for a given endpoint and chemical, not all predictions are identical due to differences in their training sets, algorithms, and methodology. This poses an issue for high-throughput screening of a large chemical inventory as it necessitates several models to cover diverse chemistries but will then generate data conflicts. To address this challenge, we developed a consensus modeling strategy to combine predictions obtained from different existing in silico (Q)SAR models into a single predictive value while also expanding chemical space coverage. This study developed consensus models for nine toxicological endpoints relating to estrogen receptor (ER) and androgen receptor (AR) interactions (i.e., binding, agonism, and antagonism) and genotoxicity (i.e., bacterial mutation, in vitro chromosomal aberration, and in vivo micronucleus). Consensus models were created by combining different (Q)SAR models using various weighting schemes. As a multi-objective optimization problem, there is no single best consensus model, and therefore, Pareto fronts were determined for each endpoint to identify the consensus models that optimize the multiple-criterion decisions simultaneously. Accordingly, this work presents sets of solutions for each endpoint that contain the optimal combination, regardless of the trade-off, with the results demonstrating that the consensus models improved both the predictive power and chemical space coverage. These solutions were further analyzed to find trends between the best consensus models and their components. Here, we demonstrate the development of a flexible and adaptable approach for in silico consensus modeling and its application across nine toxicological endpoints related to ER activity, AR activity, and genotoxicity. These consensus models are developed to be integrated into a larger multi-tier NAM-based framework to prioritize chemicals for further investigation and support the transition to a non-animal approach to risk assessment in Canada.
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Affiliation(s)
- Sean P. Collins
- Existing Substances Risk Assessment Bureau, Healthy Environments and Consumer Safety Branch, Health Canada, Ottawa, ON, Canada
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Pang PS, Berger DA, Mahler SA, Li X, Pressler SJ, Lane KA, Bischof JJ, Char D, Diercks D, Jones AE, Hess EP, Levy P, Miller JB, Venkat A, Harrison NE, Collins SP. Short-Stay Units vs Routine Admission From the Emergency Department in Patients With Acute Heart Failure: The SSU-AHF Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2350511. [PMID: 38198141 PMCID: PMC10782263 DOI: 10.1001/jamanetworkopen.2023.50511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/15/2023] [Indexed: 01/11/2024] Open
Abstract
Importance More than 80% of patients who present to the emergency department (ED) with acute heart failure (AHF) are hospitalized. With more than 1 million annual hospitalizations for AHF in the US, safe and effective alternatives are needed. Care for AHF in short-stay units (SSUs) may be safe and more efficient than hospitalization, especially for lower-risk patients, but randomized clinical trial data are lacking. Objective To compare the effectiveness of SSU care vs hospitalization in lower-risk patients with AHF. Design, Setting, and Participants This multicenter randomized clinical trial randomly assigned low-risk patients with AHF 1:1 to SSU or hospital admission from the ED. Patients received follow-up at 30 and 90 days post discharge. The study began December 6, 2017, and was completed on July 22, 2021. The data were analyzed between March 27, 2020, and November 11, 2023. Intervention Randomized post-ED disposition to less than 24 hours of SSU care vs hospitalization. Main Outcomes and Measures The study was designed to detect at least 1-day superiority for a primary outcome of days alive and out of hospital (DAOOH) at 30-day follow-up for 534 participants, with an allowance of 10% participant attrition. Due to the COVID-19 pandemic, enrollment was truncated at 194 participants. Before unmasking, the primary outcome was changed from DAOOH to an outcome with adequate statistical power: quality of life as measured by the 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ-12). The KCCQ-12 scores range from 0 to 100, with higher scores indicating better quality of life. Results Of the 193 patients enrolled (1 was found ineligible after randomization), the mean (SD) age was 64.8 (14.8) years, 79 (40.9%) were women, and 114 (59.1%) were men. Baseline characteristics were balanced between arms. The mean (SD) KCCQ-12 summary score between the SSU and hospitalization arms at 30 days was 51.3 (25.7) vs 45.8 (23.8) points, respectively (P = .19). Participants in the SSU arm had 1.6 more DAOOH at 30-day follow-up than those in the hospitalization arm (median [IQR], 26.9 [24.4-28.8] vs 25.4 [22.0-27.7] days; P = .02). Adverse events were uncommon and similar in both arms. Conclusions and Relevance The findings show that the SSU strategy was no different than hospitalization with regard to KCCQ-12 score, superior for more DAOOH, and safe for lower-risk patients with AHF. These findings of lower health care utilization with the SSU strategy need to be definitively tested in an adequately powered study. Trial Registration ClinicalTrials.gov Identifier: NCT03302910.
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Affiliation(s)
- Peter S. Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - David A. Berger
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, Michigan
| | - Simon A. Mahler
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Xiaochun Li
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis
| | | | - Kathleen A. Lane
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis
| | - Jason J. Bischof
- Department of Emergency Medicine, The Ohio State University, Columbus
| | - Douglas Char
- Department of Emergency Medicine, Washington University in St Louis, St Louis, Missouri
| | - Deborah Diercks
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Alan E. Jones
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson
| | - Erik P. Hess
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Phillip Levy
- Wayne State University School of Medicine and Integrative Biosciences Center, Detroit, Michigan
| | - Joseph B. Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Arvind Venkat
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Nicholas E. Harrison
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Sean P. Collins
- Department of Emergency Medicine, Vanderbilt University School of Medicine and Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center, Nashville, Tennessee
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Gerhardt T, Gerhardt LMS, Ouwerkerk W, Roth GA, Dickstein K, Collins SP, Cleland JGF, Dahlstrom U, Tay WT, Ertl G, Hassanein M, Perrone SV, Ghadanfar M, Schweizer A, Obergfell A, Filippatos G, Lam CSP, Tromp J, Angermann CE. Multimorbidity in patients with acute heart failure across world regions and country income levels (REPORT-HF): a prospective, multicentre, global cohort study. Lancet Glob Health 2023; 11:e1874-e1884. [PMID: 37973338 DOI: 10.1016/s2214-109x(23)00408-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 08/07/2023] [Accepted: 08/16/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Multimorbidity (two or more comorbidities) is common among patients with acute heart failure, but comprehensive global information on its prevalence and clinical consequences across different world regions and income levels is scarce. This study aimed to investigate the prevalence of multimorbidity and its effect on pharmacotherapy and prognosis in participants of the REPORT-HF study. METHODS REPORT-HF was a prospective, multicentre, global cohort study that enrolled adults (aged ≥18 years) admitted to hospital with a primary diagnosis of acute heart failure from 358 hospitals in 44 countries on six continents. Patients who currently or recently participated in a clinical treatment trial were excluded. Follow-up data were collected at 1-year post-discharge. The primary outcome was 1-year post-discharge mortality. All patients in the REPORT-HF cohort with full data on comorbidities were eligible for the present study. We stratified patients according to the number of comorbidities, and countries by world region and country income level. We used one-way ANOVA, χ2 test, or Mann-Whitney U test for comparisons between groups, as applicable, and Cox regression to analyse the association between multimorbidity and 1-year mortality. FINDINGS Between July 23, 2014, and March 24, 2017, 18 553 patients were included in the REPORT-HF study. Of these, 18 528 patients had full data on comorbidities, of whom 11 360 (61%) were men and 7168 (39%) were women. Prevalence rates of multimorbidity were lowest in southeast Asia (72%) and highest in North America (92%). Fewer patients from lower-middle-income countries had multimorbidity than patients from high-income countries (73% vs 85%, p<0·0001). With increasing comorbidity burden, patients received fewer guideline-directed heart failure medications, yet more drugs potentially causing or worsening heart failure. Having more comorbidities was associated with worse outcomes: 1-year mortality increased from 13% (no comorbidities) to 26% (five or more comorbidities). This finding was independent of common baseline risk factors, including age and sex. The population-attributable fraction of multimorbidity for mortality was higher in high-income countries than in upper-middle-income or lower-middle-income countries (for patients with five or more comorbidities: 61% vs 27% and 31%, respectively). INTERPRETATION Multimorbidity is highly prevalent among patients with acute heart failure across world regions, especially in high-income countries, and is associated with higher mortality, less prescription of guideline-directed heart failure pharmacotherapy, and increased use of potentially harmful medications. FUNDING Novartis Pharma. TRANSLATIONS For the Arabic, French, German, Hindi, Mandarin, Russian and Spanish translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Teresa Gerhardt
- Cardiovascular Research Institute and the Department of Medicine, Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Berlin, Germany; Berlin Institute of Health, Berlin, Germany; DZHK German Centre for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Louisa M S Gerhardt
- Fifth Department of Medicine, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Wouter Ouwerkerk
- National Heart Centre Singapore, Singapore; Department of Dermatology, University of Amsterdam Medical Centre, Amsterdam, Netherlands
| | - Gregory A Roth
- Division of Cardiology, Department of Medicine and Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Kenneth Dickstein
- University of Bergen, Stavanger University Hospital, Stavanger, Norway
| | - Sean P Collins
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, TN, USA; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center, Nashville, TN, USA
| | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, Institute of Health & Well-Being, University of Glasgow, Glasgow, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Ulf Dahlstrom
- Department of Cardiology, Linkoping University, Linkoping, Sweden; Department of Health, Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden
| | | | - Georg Ertl
- Comprehensive Heart Failure Center Würzburg, University and University Hospital Würzburg, Würzburg, Germany; Department of Medicine 1, University Hospital Würzburg, Würzburg, Germany
| | - Mahmoud Hassanein
- Alexandria University, Faculty of Medicine, Cardiology Department, Alexandria, Egypt
| | - Sergio V Perrone
- FLENI Institute, Argentine Institute of Diagnosis and Treatment, Hospital El Cruce de Florencio Barela, Universidad Catolica Argentina, Buenos Aires, Argentina
| | | | | | | | - Gerasimos Filippatos
- School of Medicine, University of Cyprus, Nicosia, Cyprus; School of Medicine, Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Carolyn S P Lam
- National Heart Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore; University Medical Centre Groningen, University of Groningen Department of Cardiology, Groningen, Netherlands
| | - Jasper Tromp
- Duke-National University of Singapore Medical School, Singapore; Saw Swee Hock School of Public Health, National University of Singapore and the National University Health System, Singapore
| | - Christiane E Angermann
- Comprehensive Heart Failure Center Würzburg, University and University Hospital Würzburg, Würzburg, Germany; Department of Medicine 1, University Hospital Würzburg, Würzburg, Germany.
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Moskowitz A, Shotwell MS, Collins SP, Self WH. Response. Chest 2023; 164:e158-e159. [PMID: 37945202 DOI: 10.1016/j.chest.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 07/19/2023] [Indexed: 11/12/2023] Open
Affiliation(s)
- Ari Moskowitz
- Department of Medicine, Montefiore Medical Center, The Bronx, NY
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Sean P Collins
- Department of Emergency Medicine and Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN
| | - Wesley H Self
- Department of Emergency Medicine and Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN.
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11
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Cox ZL, Siddiqi HK, Stevenson LW, Bales B, Han JH, Hart K, Imhoff B, Ivey-Miranda JB, Jenkins CA, Lindenfeld J, Shotwell MS, Miller KF, Ooi H, Rao VS, Schlendorf K, Self WH, Siew ED, Storrow A, Walsh R, Wrenn JO, Testani JM, Collins SP. Randomized controlled trial of urinE chemiStry guided aCute heArt faiLure treATmEnt (ESCALATE): Rationale and design. Am Heart J 2023; 265:121-131. [PMID: 37544492 PMCID: PMC10592235 DOI: 10.1016/j.ahj.2023.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/08/2023]
Abstract
Diuresis to achieve decongestion is a central aim of therapy in patients hospitalized for acute decompensated heart failure (ADHF). While multiple clinical trials have investigated initial diuretic strategies for a designated period of time, there is a paucity of evidence to guide diuretic titration strategies continued until decongestion is achieved. The use of urine chemistries (urine sodium and creatinine) in a natriuretic response prediction equation accurately estimates natriuresis in response to diuretic dosing, but a randomized clinical trial is needed to compare a urine chemistry-guided diuresis strategy with a strategy of usual care. The urinE chemiStry guided aCute heArt faiLure treATmEnt (ESCALATE) trial is designed to test the hypothesis that protocolized diuretic therapy guided by spot urine chemistry through completion of intravenous diuresis will be superior to usual care and improve outcomes over the 14 days following randomization. ESCALATE will randomize and obtain complete data on 450 patients with acute heart failure to a diuretic strategy guided by urine chemistry or a usual care strategy. Key inclusion criteria include an objective measure of hypervolemia with at least 10 pounds of estimated excess volume, and key exclusion criteria include significant valvular stenosis, hypotension, and a chronic need for dialysis. Our primary outcome is days of benefit over the 14 days after randomization. Days of benefit combines patient symptoms captured by global clinical status with clinical state quantifying the need for hospitalization and intravenous diuresis. CLINICAL TRIAL REGISTRATION: NCT04481919.
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Affiliation(s)
- Zachary L Cox
- Department of Pharmacy, Lipscomb University College of Pharmacy, Nashville, TN; Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN.
| | - Hasan K Siddiqi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Lynne W Stevenson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Brian Bales
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, TN
| | - Kimberly Hart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Brant Imhoff
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Juan B Ivey-Miranda
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Hospital de Cardiologia, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - JoAnn Lindenfeld
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Karen F Miller
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Henry Ooi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Department of Medicine, Veterans Affairs Tennessee Valley Healthcare System, TN
| | - Veena S Rao
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Kelly Schlendorf
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Edward D Siew
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Alan Storrow
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ryan Walsh
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jesse O Wrenn
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jeffrey M Testani
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, TN
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12
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Gallagher L, Xiao J, Hsueh J, Shah S, Danner M, Zwart A, Ayoob M, Yung T, Simpson T, Fallick M, Kumar D, Leger P, Dawson NA, Suy S, Collins SP. Early biochemical outcomes following neoadjuvant/adjuvant relugolix with stereotactic body radiation therapy for intermediate to high risk prostate cancer. Front Oncol 2023; 13:1289249. [PMID: 37916156 PMCID: PMC10616590 DOI: 10.3389/fonc.2023.1289249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 10/02/2023] [Indexed: 11/03/2023] Open
Abstract
Introduction Injectable GnRH receptor agonists have been shown to improve cancer control when combined with radiotherapy. Prostate SBRT offers an abbreviated treatment course with comparable efficacy to conventionally fractionated radiotherapy. Relugolix is a new oral GnRH receptor antagonist which achieves rapid, sustained testosterone suppression. This prospective study sought to evaluate early testosterone suppression and PSA response following relugolix and SBRT for intermediate to high prostate cancer. Methods Relugolix was initiated at least 2 months prior to SBRT. Interventions to improve adherence were not utilized. PSA and total testosterone levels were obtained prior to and 1-4 months post SBRT. Profound castration was defined as serum testosterone ≤ 20 ng/dL. Early PSA nadir was defined as the lowest PSA value within 4 months of completion of SBRT. Per prior trials, we examined the percentage of patients who achieved PSA level of ≤ 0.5 ng/mL and ≤ 0.2 ng/mL during the first 4 months post SBRT. Results Between July 2021 and January 2023, 52 men were treated at Georgetown with relugolix (4-6 months) and SBRT (36.25-40 Gy in 5 fractions) per an institutional protocol (IRB 12-1775). Median age was 71 years. 26.9% of patients were African American and 28.8% were obese (BMI ≥30 kg/m2). The median pretreatment PSA was 9.1 ng/ml. 67% of patients were ≥ Grade Group 3. 44 patients were intermediate- and 8 were high-risk. Patients initiated relugolix at a median of 3.6 months prior to SBRT with a median duration of 6.2 total months. 92.3% of patients achieved profound castration during relugolix treatment. Poor drug adherence was observed in 2 patients. A third patient chose to discontinue relugolix due to side effects. By post-SBRT month 4, 87.2% and 74.4% of patients achieved PSA levels ≤ 0.5 ng/ml and ≤ 0.2 ng/ml, respectively. Discussion Relugolix combined with SBRT allows for high rates of profound castration with low early PSA nadirs. We observed a 96% testosterone suppresion rate without the utilization of scheduled cues/reminders. This finding supports the notion that patients with localized prostate cancer can consistently and successfully follow an oral ADT protocol without daily reminders. Given relugolix's potential benefits over injectable GnRH receptor agonists, its usage may be preferred in specific patient populations (fear of needles, prior cardiovascular events). Future studies should focus on boundaries to adherence in specific underserved populations.
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Affiliation(s)
- Lindsey Gallagher
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Jerry Xiao
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Jessica Hsueh
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Sarthak Shah
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Malika Danner
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Alan Zwart
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Marilyn Ayoob
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Thomas Yung
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Tiffany Simpson
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, United States
| | - Mark Fallick
- Medical Science Department, Myovant Sciences, Inc, United States
| | - Deepak Kumar
- Biotechnology Research Institute, North Carolina Central University, Durham, NC, United States
| | - Paul Leger
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, United States
| | - Nancy A. Dawson
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, United States
| | - Simeng Suy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Sean P. Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
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Shah S, Jatar SS, Hsueh J, Gallagher L, Pepin A, Danner M, Zwart A, Ayoob MJ, Yung T, Kumar D, Aghdam N, Leger P, Dawson N, Suy S, Collins SP. Bothersome Hot Flashes Following Neoadjuvant Androgen Deprivation Therapy and Stereotactic Body Radiotherapy for Localized Prostate Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e258-e259. [PMID: 37784992 DOI: 10.1016/j.ijrobp.2023.06.1210] [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) Androgen deprivation therapy (ADT) may improve cancer control in unfavorable localized prostate cancer treated with stereotactic body radiotherapy (SBRT). ADT is known to cause hormonally related symptoms that resolve with testosterone recovery. Hot flashes are particularly burdensome. This study sought to evaluate the timeline of hot flashes following short-course ADT and SBRT as well as its relationship with testosterone recovery. MATERIALS/METHODS Institutional IRB approval was obtained for this retrospective review of prospectively collected data (IRB#: 2009-510). ADT was initiated three months prior to the start of SBRT. Hot flashes were self-reported via question 13a a healthcare software prior to ADT initiation, the first day of robotic SBRT, and at each follow-up (1, 3, 6, 9, 12, 18, 24 and 36 months). The responses were grouped into three relevant categories (no problem, very small-small problem and moderate-big problem). Scores were transformed to a 0-100 scale with higher scores reflecting less bother. Testosterone levels were measured at each follow-up. RESULTS From 2007 to 2010, 122 localized prostate cancer patients (9 low-, 64 intermediate-, and 49 high-risk according to the D'Amico classification) at a median age of 72 years (range 54.5-88.3) were treated with short course ADT (3-6 months) and SBRT (35-36.25 Gy) at Georgetown University Hospital. Thirty-two percent were black and 27% were obese. 77% of patient received three months of ADT. At baseline, 2% of men experienced hot flashes that were a "moderate to big problem" and that proportion peaked at the start of SBRT (45%) before returning to baseline 9 months post-SBRT with a cumulative incidence of 52.4%. The median baseline healthcare software hot flash score of 94 declined to 50 at the start of SBRT but this returned to baseline by six months post SBRT. These changes were both statistically and clinically significant (MID = 9.5083). Testosterone recovery (> 230 ng/dL) occurred in approximately 70% of patients by 12 months post SBRT. Resolution of hot flashes correlated with testosterone recovery. CONCLUSION Bothersome hot flashes occur in greater than 50% of men treated with neoadjuvant ADT. Resolution of hot flashes occurs in the majority of patients within one year after treatment. Reassurance of the temporary nature of hot flashes may assist in reducing patient anxiety. Measuring testosterone levels at follow-up visits may allow for anticipatory counseling that may limit the associated bother.
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Affiliation(s)
- S Shah
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - S S Jatar
- Georgetown School Of Medicine, Washington, DC
| | - J Hsueh
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - L Gallagher
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - A Pepin
- Department of Radiation Oncology, Abramson Cancer Center, Hospital of University of Pennsylvania, Philadelphia, PA
| | - M Danner
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - A Zwart
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - M J Ayoob
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - T Yung
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - D Kumar
- Biotechnology Research Institute, North Carolina Central University, Durham, NC
| | - N Aghdam
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Washington, DC
| | - P Leger
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - N Dawson
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - S Suy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - S P Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
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14
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Jatar SS, Shah S, Hsueh J, Gallagher L, Danner M, Zwart A, Ayoob MJ, Yung T, Kumar D, Leger P, Aghdam N, Dawson N, Suy S, Collins SP. Bothersome Gynecomastia Following Neoadjuvant GnRH Agonists and Stereotactic Body Radiotherapy for Localized Prostate Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e238-e239. [PMID: 37784943 DOI: 10.1016/j.ijrobp.2023.06.1163] [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) Androgen deprivation therapy (ADT) is increasingly utilized in combination with stereotactic body radiotherapy (SBRT) for unfavorable prostate cancer. ADT such as gonadotropin releasing hormone (GnRH) agonists are known to cause hormonal-related side effects such as gynecomastia. The incidence of bothersome breast tenderness and/or enlargement following short course GnRH agonists and SBRT is unknown. This study sought to evaluate the timeline of gynecomastia as well as its relationship with testosterone recovery. MATERIALS/METHODS Gynecomastia was self-reported via question 13b of a healthcare software prior to ADT initiation, the first day of robotic SBRT, and at each follow-up (1, 3, 6, 9, 12, 18, 24 and 36 months). The responses were grouped into three relevant categories (no problem, very small-small problem, and moderate-big problem). Scores were transformed to a 0-100 scale with higher scores reflecting less bother. Testosterone levels were measured at each follow-up. RESULTS From 2007 to 2010, 122 localized prostate cancer patients (9 low-, 64 intermediate-, and 49 high-risk according to the D'Amico classification) at a median age of 72 years (range 54.5-88.3) were treated with short course ADT (3-6 months) and SBRT (35-36.25 Gy) at Georgetown University Hospital. Of the participants, 48% percent were non-white and 48% were overweight. 77% of patients received three months of ADT. At baseline, 2% of men experienced gynecomastia that was a "moderate to big problem" and that proportion peaked at 3 and 12 months post-SBRT (7%) before returning to less than baseline (0%) 24 months post-SBRT with a cumulative incidence of 14.75%. The median baseline healthcare software hot flash score of 98 declined to 90 at 3 months post-SBRT but this returned to baseline by 24 months post SBRT. These changes were both statistically and clinically significant (MID = 6.5). Testosterone recovery (> 230 ng/dL) occurred in approximately 70% of patients by 12 months post SBRT. The development and resolution of gynecomastia fluctuated at various timepoints and did not directly correlate with testosterone recovery. CONCLUSION Bothersome gynecomastia occurs in less than 15% of men treated with neoadjuvant ADT. Resolution of gynecomastia occurs in most patients within two years after treatment. Reassurance of the temporary nature of gynecomastia may assist in reducing patient anxiety. Institutional IRB (IRB#: 2009-510) approval was obtained for retrospective review of prospectively collected data.
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Affiliation(s)
- S S Jatar
- Georgetown School Of Medicine, Washington, DC
| | - S Shah
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - J Hsueh
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - L Gallagher
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - M Danner
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - A Zwart
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - M J Ayoob
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - T Yung
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - D Kumar
- Biotechnology Research Institute, North Carolina Central University, Durham, NC
| | - P Leger
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - N Aghdam
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Washington, DC
| | - N Dawson
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - S Suy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - S P Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
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15
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Ferreira JP, Blatchford JP, Teerlink JR, Kosiborod MN, Angermann CE, Biegus J, Collins SP, Tromp J, Nassif ME, Psotka MA, Comin-Colet J, Mentz RJ, Brueckmann M, Nordaby M, Ponikowski P, Voors AA. Mineralocorticoid receptor antagonist use and the effects of empagliflozin on clinical outcomes in patients admitted for acute heart failure: Findings from EMPULSE. Eur J Heart Fail 2023; 25:1797-1805. [PMID: 37540060 DOI: 10.1002/ejhf.2982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/18/2023] [Accepted: 07/18/2023] [Indexed: 08/05/2023] Open
Abstract
AIMS In patients hospitalized for acute heart failure (AHF) empagliflozin produced greater clinical benefit than placebo. Many patients with AHF are treated with mineralocorticoid receptor antagonists (MRAs). The interplay between empagliflozin and MRAs in AHF is yet to be explored. This study aimed to evaluate the efficacy and safety of empagliflozin versus placebo according to MRA use at baseline in the EMPULSE trial (NCT04157751). METHODS AND RESULTS In this analysis all comparisons were performed between empagliflozin and placebo, stratified by baseline MRA use. The primary outcome included all-cause death, heart failure events, and a ≥5 point difference in Kansas City Cardiomyopathy Questionnaire (KCCQ) total symptom score at 90 days, assessed using the win ratio (WR). First heart failure hospitalization or cardiovascular death was a secondary outcome. From the 530 patients randomized, 276 (52%) were receiving MRAs at baseline. MRA users were younger, had lower ejection fraction, better renal function, and higher KCCQ scores. The primary outcome showed benefit of empagliflozin irrespective of baseline MRA use (WR 1.46, 95% confidence interval [CI] 1.08-1.97 and WR 1.27, 95% CI 0.93-1.73 in MRA users and non-users, respectively; interaction p = 0.52). The effect of empagliflozin on first heart failure hospitalization or cardiovascular death was not modified by MRA use (hazard ratio [HR] 0.58, 95% CI 0.30-1.11 and HR 0.85, 95% CI 0.47-1.52 in MRA users and non-users, respectively; interaction p = 0.39). Investigator-reported and severe hyperkalaemia events were infrequent (<6%) irrespective of MRA use. CONCLUSIONS In patients admitted for AHF, initiation of empagliflozin produced clinical benefit and was well tolerated irrespective of background MRA use. These findings support the early use of empagliflozin on top of MRA therapy in patients admitted for AHF.
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Affiliation(s)
- João Pedro Ferreira
- Centre d'Investigations Cliniques Plurithématique 1433, INSERM, Université de Lorraine, Nancy, France
- F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), INSERM U1116, Centre Hospitalier Régional Universitaire de Nancy, Nancy, France
- UnIC@RISE, Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Jonathan P Blatchford
- Elderbrook Solutions GmbH, Bietigheim-Bissingen, Germany on behalf of Boehringer Ingelheim, Pharma GmbH & Co. KG, Biberach, Germany
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas, MO, USA
| | - Christiane E Angermann
- Comprehensive Heart Failure Center Würzburg, University and University Hospital Würzburg, and Department of Medicine 1, University Hospital Würzburg, Würzburg, Germany
| | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville, TN, USA
| | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore, the National University Health System, Singapore, Singapore, Singapore
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas, MO, USA
| | | | - Josep Comin-Colet
- Hospital Universitari de Bellvitge, University of Barcelona, IDIBELL and CIBERCV, Barcelona, Spain
| | - Robert J Mentz
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
- First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Matias Nordaby
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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16
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Bhatnagar A, Collins B, Collins SP, Jean W, Aulisi E, Harris B, Nayar V, Anaizi A, Watson J, Carrasquilla M, Suy S, Conroy D. Marginless 5-Fraction Robotic Radiosurgery for Unfavorable Nonfunctioning Pituitary Macroadenoma: 5-year Outcomes from a Single Institution Protocol. Int J Radiat Oncol Biol Phys 2023; 117:e165. [PMID: 37784765 DOI: 10.1016/j.ijrobp.2023.06.1000] [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) Nonfunctioning macroadenoma is a commonly diagnosed pituitary tumor. Resection is the favored treatment, with radiosurgery often utilized for residual or progressing disease. Long-term outcomes are established for single-session radiosurgery, but mature outcomes are lacking for multisession radiosurgery. We report our institution's 5-year efficacy and safety results for unfavorable nonfunctioning pituitary macroadenoma patients treated with marginless 5-fraction robotic radiosurgery. MATERIALS/METHODS Between 2010-2020, patients who completed marginless 5-fraction radiosurgery for the treatment of unfavorable nonfunctioning pituitary macroadenomas were included. A tumor was considered unfavorable if the gross tumor volume (GTV) was larger than 5 cc or if it closely approached a critical structure (optic apparatus, brainstem or pituitary gland). Local control was calculated using the Kaplan-Meier Method. RESULTS Twenty predominately female patients (60%), age from 21-77 (median: 53 years) were included in this study. All underwent primary resection. Indications for radiosurgery included unresectable recurrence (85%) and residual disease progression (70%). Median tumor volume was 3.4 cm3 (range: 0.3-20.8 cm3) and 40% of the tumors were suprasellar. A mean dose of 28.8 Gy (range: 25 Gy-30 Gy), was delivered to a median isodose line of 80% (range: 75%-89%). The median optic chiasm maximum point dose was 21.8 Gy (range: 12.0-25.9 Gy). Toxicity was minimal with 12 patients (40%) developing acute short-lived headaches and 1 patient (5%) developing a brief ipsilateral 6th nerve palsy. There was no radiation induced optic or pituitary dysfunction identified in this cohort. At a median follow up of 5 years local control was 95%. There was 1 in-field failure pathologically confirmed following surgery for pituitary tumor hemorrhage and 2 radiographically confirmed out-of-field failures in patients with large tumors (>20 cc). CONCLUSION The treatment of unfavorable nonfunctioning pituitary macroadenoma with marginless 5-fraction robotic radiosurgery provides excellent local control to date, with minimal toxicity. However, tumors with GTV's greater than 20 cc may require conventionally fractionated treatment with a margin to optimize local control.
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Affiliation(s)
- A Bhatnagar
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
| | | | - S P Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - W Jean
- Lehigh Valley Health Network, Leigh County, PA
| | - E Aulisi
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - B Harris
- Department of Pathology, Medstar Georgetown University Hospital, Washington, DC
| | - V Nayar
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - A Anaizi
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - J Watson
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - M Carrasquilla
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - S Suy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - D Conroy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
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17
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Khan I, Lee Z, Zwart A, Rechter T, Tettey J, Danner M, Ayoob MJ, Yung T, Kumar D, Li H, Suy S, Collins SP. Low Incidence of Late Lymphopenia Following Stereotactic Body Radiotherapy for Localized Prostate Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e400. [PMID: 37785339 DOI: 10.1016/j.ijrobp.2023.06.1532] [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) Stereotactic body radiotherapy (SBRT) is increasing in use for the treatment of localized prostate cancer. The utilization of highly conformal photon therapy such as SBRT may increase the whole-body integral dose. Lymphocytes are very radiation sensitive. This dose increase could lead to unintended consequences such as lymphopenia. Prior studies have shown that lymphopenia following radiation therapy may negatively impact long-term outcomes. This study sought to evaluate the incidence and timeline of chronic lymphopenia following prostate SBRT. MATERIALS/METHODS Institutional IRB (IRB#: 2012-1175) approval was obtained. The absolute lymphocyte count was measured 1-2 hours prior to robotic SBRT (35-36.25 Gy in 5 fractions) and at each follow-up (3, 6, 12, 18 and 24 months). Lymphopenia was graded using the CTCAEv.4: Grade 1 (1.0-0.8 k/μl), Grade 2 (0.8-0.5 k/μl), Grade 3 (0.5-0.2 k/μl) and Grade 4 (<0.2 k/μl). Late lymphopenia was defined as lymphopenia occurring 3 or more months post-SBRT. RESULTS From 2019 to 2022, 198 localized prostate cancer patients (23 low-, 148 intermediate-, and 27 high-risk according to the D'Amico classification) at a median age of 73.5 years were treated with SBRT (35-36.25 Gy) at Georgetown University Hospital on a prospective clinical trial. Baseline lymphopenia was uncommon: Grade 1 (3.5%), Grade 2 (1.5%) and Grade 3 (0%). The baseline ALC of 1.9 k/μl decreased to 1.5 k/μl at 3 months post-SBRT and then remained stable for the remainder of the two-year follow-up. Overall, 14.6% of men experienced lymphopenia in the two years following SBRT: Grade 1 (7.6%), Grade 2 (6.6%) and Grade 3 (0.5%). No patient experienced Grade 4 lymphopenia. CONCLUSION Prostate SBRT leads to a low rate of late lymphopenia with the vast majority of toxicities being low grade. The peak incidence occurred at 3 months post-SBRT. Resolution of lymphopenia occurs in most patients within two years after SBRT. Future studies should explore the possible impact on quality of life and cancer control outcomes.
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Affiliation(s)
- I Khan
- Georgetown University School of Medicine, Washington, DC
| | - Z Lee
- Georgetown University Hospital, Washington, DC
| | - A Zwart
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - T Rechter
- Georgetown University Hospital Department of Radiation Medicine, Washington, DC
| | - J Tettey
- University of Maryland College Park School of Public Health, College Park, MD
| | - M Danner
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - M J Ayoob
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - T Yung
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC
| | - D Kumar
- Biotechnology Research Institute, North Carolina Central University, Durham, NC
| | - H Li
- Georgetown University Department of Oncology, Washington, DC
| | - S Suy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - S P Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
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18
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Katsanos S, Ouwerkerk W, Farmakis D, Collins SP, Angermann CE, Dickstein K, Tomp J, Ertl G, Cleland J, Dahlström U, Obergfell A, Ghadanfar M, Perrone SV, Hassanein M, Stamoulis K, Parissis J, Lam C, Filippatos G. Hospitalization for acute heart failure during non-working hours impacts on long-term mortality: the REPORT-HF registry. ESC Heart Fail 2023; 10:3164-3173. [PMID: 37649316 PMCID: PMC10567635 DOI: 10.1002/ehf2.14506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/10/2023] [Indexed: 09/01/2023] Open
Abstract
AIMS Hospital admission during nighttime and off hours may affect the outcome of patients with various cardiovascular conditions due to suboptimal resources and personnel availability, but data for acute heart failure remain controversial. Therefore, we studied outcomes of acute heart failure patients according to their time of admission from the global International Registry to assess medical practice with lOngitudinal obseRvation for Treatment of Heart Failure. METHODS AND RESULTS Overall, 18 553 acute heart failure patients were divided according to time of admission into 'morning' (7:00-14:59), 'evening' (15:00-22:59), and 'night' (23:00-06:59) shift groups. Patients were also dichotomized to admission during 'working hours' (9:00-16:59 during standard working days) and 'non-working hours' (any other time). Clinical characteristics, treatments, and outcomes were compared across groups. The hospital length of stay was longer for morning (odds ratio: 1.08; 95% confidence interval: 1.06-1.10, P < 0.001) and evening shift (odds ratio: 1.10; 95% confidence interval: 1.07-1.12, P < 0.001) as compared with night shift. The length of stay was also longer for working vs. non-working hours (odds ratio: 1.03; 95% confidence interval: 1.02-1.05, P < 0.001). There were no significant differences in in-hospital mortality among the groups. Admission during working hours, compared with non-working hours, was associated with significantly lower mortality at 1 year (hazard ratio: 0.88; 95% confidence interval: 0.80-0.96, P = 0.003). CONCLUSIONS Acute heart failure patients admitted during the night shift and non-working hours had shorter length of stay but similar in-hospital mortality. However, patients admitted during non-working hours were at a higher risk for 1 year mortality. These findings may have implications for the health policies and heart failure trials.
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Affiliation(s)
- Spyridon Katsanos
- Department of Emergency MedicineAttikon University Hospital, National and Kapodistrian University of Athens Medical SchoolAthensGreece
| | - Wouter Ouwerkerk
- National Heart Centre SingaporeSingapore
- Department of DermatologyAmsterdam UMC, University of Amsterdam, Amsterdam Infection and Immunity InstituteAmsterdamThe Netherlands
| | - Dimitrios Farmakis
- Cardio‐Oncology Clinic, Heart Failure UnitAttikon University Hospital, National and Kapodistrian University of Athens Medical SchoolAthensGreece
- University of Cyprus Medical SchoolNicosiaCyprus
| | - Sean P. Collins
- Department of Emergency MedicineVanderbilt University Medical Center and Geriatric Research and Education Center, Nashville VANashvilleTNUSA
| | - Christiane E. Angermann
- Department of Medicine 1Comprehensive Heart Failure Center University and University Hospital WürzburgWürzburgGermany
| | | | - Jasper Tomp
- Saw Swee Hock School of Public HealthNational University of Singapore and the National University Health SystemSingapore
- Duke‐NUS Medical SchoolSingapore
- Yong Loo Lin School of MedicineSingapore
| | - Georg Ertl
- Department of Medicine 1Comprehensive Heart Failure Center University and University Hospital WürzburgWürzburgGermany
| | - John Cleland
- Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well‐BeingUniversity of GlasgowGlasgowScotland
- National Heart and Lung InstituteImperial CollegeLondonUK
| | - Ulf Dahlström
- Department of CardiologyLinkoping UniversityLinkopingSweden
- Department of Health, Medicine and Caring SciencesLinkoping UniversityLinkopingSweden
| | | | | | - Sergio V. Perrone
- El Cruce Hospital by Florencio Varela, Lezica Cardiovascular Institute, Sanctuary of the Trinidad MiterBuenos AiresArgentina
| | - Mahmoud Hassanein
- Faculty of Medicine, Department of CardiologyAlexandria UniversityAlexandriaEgypt
| | - Konstantinos Stamoulis
- Second Department of CardiologyAttikon University Hospital, National and Kapodistrian University of Athens Medical SchoolRimini 1 ChardairiAthensGreece
| | - John Parissis
- Department of Emergency MedicineAttikon University Hospital, National and Kapodistrian University of Athens Medical SchoolAthensGreece
| | - Carolyn Lam
- National Heart Centre SingaporeSingapore
- Duke‐NUS Medical SchoolSingapore
| | - Gerasimos Filippatos
- Second Department of CardiologyAttikon University Hospital, National and Kapodistrian University of Athens Medical SchoolRimini 1 ChardairiAthensGreece
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19
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Tromp J, Ezekowitz JA, Ouwerkerk W, Chandramouli C, Yiu KH, Angermann CE, Dahlstrom U, Ertl G, Hassanein M, Perrone SV, Ghadanfar M, Schweizer A, Obergfell A, Dickstein K, Collins SP, Filippatos G, Cleland JGF, Lam CSP. Global Variations According to Sex in Patients Hospitalized for Heart Failure in the REPORT-HF Registry. JACC Heart Fail 2023; 11:1262-1271. [PMID: 37678961 DOI: 10.1016/j.jchf.2023.06.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/09/2023] [Accepted: 06/20/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Previous reports suggest that risk factors, management, and outcomes of acute heart failure (AHF) may differ by sex, but they rarely extended analysis to low- and middle-income countries. OBJECTIVES In this study, the authors sought to analyze sex differences in treatment and outcomes in patients hospitalized for AHF in 44 countries. METHODS The authors investigated differences between men and women in treatment and outcomes in 18,553 patients hospitalized for AHF in 44 countries in the REPORT-HF (Registry to Assess Medical Practice With Longitudinal Observation for the Treatment of Heart Failure) registry stratified by country income level, income disparity, and world region. The primary outcome was 1-year all-cause mortality. RESULTS Women (n = 7,181) were older than men (n = 11,372), were more likely to have heart failure with preserved left ventricular ejection fraction, had more comorbid conditions except for coronary artery disease, and had more severe signs and symptoms at admission. Coronary angiography, cardiac stress tests, and coronary revascularization were less frequently performed in women than in men. Women with AHF and reduced left ventricular ejection fraction were less likely to receive an implanted device, regardless of region or country income level. Women were more likely to receive treatments that could worsen HF than men (18% vs 13%; P < 0.0001). In countries with low-income disparity, women had better 1-year survival than men. This advantage was lost in countries with greater income disparity (Pinteraction < 0.001). CONCLUSIONS Women were less likely to have diagnostic testing or receive guideline-directed care than men. A survival advantage for women was observed only in countries with low income disparity, suggesting that equity of HF care between sexes remains an unmet goal worldwide.
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Affiliation(s)
- Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore; Duke-NUS Medical School, Singapore.
| | - Justin A Ezekowitz
- The Canadian VIGOUR Centre, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Wouter Ouwerkerk
- National Heart Centre, Singapore; Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam Infection and Immunity Institute, Amsterdam, the Netherlands
| | | | - Kai Hang Yiu
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Hong Kong, China; Division of Cardiology, Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Christiane E Angermann
- Comprehensive Heart Failure Center, Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Ulf Dahlstrom
- Departments of Cardiology and Health, Medicine, and Caring Sciences, Linkoping University, Linkoping, Sweden
| | - Georg Ertl
- Comprehensive Heart Failure Center, Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Mahmoud Hassanein
- Cardiology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Sergio V Perrone
- Sanctuary of the Trinidad Miter, Lezica Cardiovascular Institute, El Cruce Hospital by Florencio Varela, Buenos Aires, Argentina
| | | | | | | | | | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gerasimos Filippatos
- School of Medicine, University of Cyprus, Nicosia, Cyprus; Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-Being, University of Glasgow, Scotland, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Carolyn S P Lam
- Duke-NUS Medical School, Singapore; National Heart Centre, Singapore.
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20
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Han JH, Jackson JC, Orun OM, Brown SM, Casey JD, Clark L, Collins SP, Cordero K, Ginde AA, Gong MN, Hough CL, Iwashyna TJ, Kiehl AL, Lauck A, Leither LM, Lindsell CJ, Patel MB, Raman R, Rice TW, Ringwood NJ, Sheppard KL, Semler MW, Thompson BT, Ely EW, Self WH. Modifiable in-hospital factors for 12-month global cognition, post-traumatic stress disorder symptoms, and depression symptoms in adults hospitalized with COVID-19. Influenza Other Respir Viruses 2023; 17:e13197. [PMID: 37752063 PMCID: PMC10522479 DOI: 10.1111/irv.13197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 08/22/2023] [Accepted: 08/23/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND We sought to identify potentially modifiable in-hospital factors associated with global cognition, post-traumatic stress disorder (PTSD) symptoms, and depression symptoms at 12 months. METHODS This was a multi-center prospective cohort study in adult hospitalized patients with acute COVID-19. The following in-hospital factors were assessed: delirium; frequency of in-person and virtual visits by friends and family; and hydroxychloroquine, corticosteroid, and remdesivir administration. Twelve-month global cognition was characterized by the MOCA-Blind. Twelve-month PTSD and depression were characterized using the PTSD Checklist for the DSM-V and Hospital Anxiety Depression Scale, respectively. FINDINGS Two hundred three patients completed the 12-month follow-up assessments. Remdesivir use was associated with significantly higher cognition at 12 months based on the MOCA-Blind (adjusted odds ratio [aOR] = 1.98, 95% CI: 1.06, 3.70). Delirium was associated with worsening 12-month PTSD (aOR = 3.44, 95% CI: 1.89, 6.28) and depression (aOR = 2.18, 95% CI: 1.23, 3.84) symptoms. Multiple virtual visits per day during hospitalization was associated with lower 12-month depression symptoms compared to those with less than daily virtual visits (aOR = 0.40, 95% CI: 0.19, 0.85). CONCLUSION Potentially modifiable factors associated with better long-term outcomes included remdesivir use (associated with better cognitive function), avoidance of delirium (associated with less PTSD and depression symptoms), and increased virtual interactions with friends and family (associated with less depression symptoms).
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Affiliation(s)
- Jin H. Han
- Critical Illness, Brain Dysfunction, and Survivorship CenterVanderbilt University Medical CenterNashvilleTennesseeUSA
- Geriatric Research, Education, and Clinical Center (GRECC)Tennessee Valley Healthcare SystemNashvilleTennesseeUSA
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - James C. Jackson
- Critical Illness, Brain Dysfunction, and Survivorship CenterVanderbilt University Medical CenterNashvilleTennesseeUSA
- Geriatric Research, Education, and Clinical Center (GRECC)Tennessee Valley Healthcare SystemNashvilleTennesseeUSA
- Division of Allergy, Pulmonary, and Critical Care, Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Onur M. Orun
- Critical Illness, Brain Dysfunction, and Survivorship CenterVanderbilt University Medical CenterNashvilleTennesseeUSA
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Samuel M. Brown
- Division of Pulmonary/Critical Care Medicine, Department of MedicineIntermountain Medical Center and the University of UtahSalt Lake CityUtahUSA
| | - Jonathan D. Casey
- Division of Allergy, Pulmonary, and Critical Care, Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Lindsay Clark
- Division of Geriatrics and GerontologyUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Geriatric Research, Education, and Clinical Center (GRECC)William S Middleton Memorial Veterans HospitalMadisonWisconsinUSA
| | - Sean P. Collins
- Geriatric Research, Education, and Clinical Center (GRECC)Tennessee Valley Healthcare SystemNashvilleTennesseeUSA
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Kemberlyne Cordero
- Critical Illness, Brain Dysfunction, and Survivorship CenterVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Adit A. Ginde
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Michelle N. Gong
- Division of Critical Care, Division of Pulmonary Medicine, Department of MedicineAlbert Einstein College of MedicineBronxNew YorkUSA
| | - Catherine L. Hough
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of MedicineOregon Health & Science UniversityPortlandOregonUSA
| | - Theodore J. Iwashyna
- Division of Pulmonary and Critical Care, Department of MedicineJohns Hopkins UniversityBaltimoreMarylandUSA
- Health Policy & Management in the Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Amy L. Kiehl
- Critical Illness, Brain Dysfunction, and Survivorship CenterVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Alana Lauck
- Critical Illness, Brain Dysfunction, and Survivorship CenterVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Lindsay M. Leither
- Division of Pulmonary/Critical Care Medicine, Department of MedicineIntermountain Medical Center and the University of UtahSalt Lake CityUtahUSA
| | | | - Mayur B. Patel
- Critical Illness, Brain Dysfunction, and Survivorship CenterVanderbilt University Medical CenterNashvilleTennesseeUSA
- Geriatric Research, Education, and Clinical Center (GRECC)Tennessee Valley Healthcare SystemNashvilleTennesseeUSA
- Division of Acute Care Surgery, Department of Surgery, Section of Surgical SciencesVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Rameela Raman
- Critical Illness, Brain Dysfunction, and Survivorship CenterVanderbilt University Medical CenterNashvilleTennesseeUSA
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Todd W. Rice
- Division of Allergy, Pulmonary, and Critical Care, Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
- Vanderbilt Institute for Clinical and Translational Research (VICTR)Vanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Nancy J. Ringwood
- Division of Pulmonary and Critical Care MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Karen L. Sheppard
- Critical Illness, Brain Dysfunction, and Survivorship CenterVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Matthew W. Semler
- Division of Allergy, Pulmonary, and Critical Care, Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - B. Taylor Thompson
- Division of Pulmonary and Critical Care MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship CenterVanderbilt University Medical CenterNashvilleTennesseeUSA
- Geriatric Research, Education, and Clinical Center (GRECC)Tennessee Valley Healthcare SystemNashvilleTennesseeUSA
- Division of Allergy, Pulmonary, and Critical Care, Department of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Wesley H. Self
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
- Division of Acute Care Surgery, Department of Surgery, Section of Surgical SciencesVanderbilt University Medical CenterNashvilleTennesseeUSA
- Vanderbilt Institute for Clinical and Translational Research (VICTR)Vanderbilt University Medical CenterNashvilleTennesseeUSA
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21
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Chioncel O, Adamo M, Nikolaou M, Parissis J, Mebazaa A, Yilmaz MB, Hassager C, Moura B, Bauersachs J, Harjola VP, Antohi EL, Ben-Gal T, Collins SP, Iliescu VA, Abdelhamid M, Čelutkienė J, Adamopoulos S, Lund LH, Cicoira M, Masip J, Skouri H, Gustafsson F, Rakisheva A, Ahrens I, Mortara A, Janowska EA, Almaghraby A, Damman K, Miro O, Huber K, Ristic A, Hill L, Mullens W, Chieffo A, Bartunek J, Paolisso P, Bayes-Genis A, Anker SD, Price S, Filippatos G, Ruschitzka F, Seferovic P, Vidal-Perez R, Vahanian A, Metra M, McDonagh TA, Barbato E, Coats AJS, Rosano GMC. Acute heart failure and valvular heart disease: A scientific statement of the Heart Failure Association, the Association for Acute CardioVascular Care and the European Association of Percutaneous Cardiovascular Interventions of the European Society of Cardiology. Eur J Heart Fail 2023; 25:1025-1048. [PMID: 37312239 DOI: 10.1002/ejhf.2918] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/09/2023] [Accepted: 05/18/2023] [Indexed: 06/15/2023] Open
Abstract
Acute heart failure (AHF) represents a broad spectrum of disease states, resulting from the interaction between an acute precipitant and a patient's underlying cardiac substrate and comorbidities. Valvular heart disease (VHD) is frequently associated with AHF. AHF may result from several precipitants that add an acute haemodynamic stress superimposed on a chronic valvular lesion or may occur as a consequence of a new significant valvular lesion. Regardless of the mechanism, clinical presentation may vary from acute decompensated heart failure to cardiogenic shock. Assessing the severity of VHD as well as the correlation between VHD severity and symptoms may be difficult in patients with AHF because of the rapid variation in loading conditions, concomitant destabilization of the associated comorbidities and the presence of combined valvular lesions. Evidence-based interventions targeting VHD in settings of AHF have yet to be identified, as patients with severe VHD are often excluded from randomized trials in AHF, so results from these trials do not generalize to those with VHD. Furthermore, there are not rigorously conducted randomized controlled trials in the setting of VHD and AHF, most of the data coming from observational studies. Thus, distinct to chronic settings, current guidelines are very elusive when patients with severe VHD present with AHF, and a clear-cut strategy could not be yet defined. Given the paucity of evidence in this subset of AHF patients, the aim of this scientific statement is to describe the epidemiology, pathophysiology, and overall treatment approach for patients with VHD who present with AHF.
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Affiliation(s)
- Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania
- University of Medicine Carol Davila, Bucharest, Romania
| | - Marianna Adamo
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Maria Nikolaou
- Cardiology Department, General Hospital 'Sismanogleio-Amalia Fleming', Athens, Greece
| | - John Parissis
- Heart Failure Unit and University Clinic of Emergency Medicine, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Alexandre Mebazaa
- Université Paris Cité, MASCOT Inserm, Hôpitaux Universitaires Saint Louis Lariboisière, APHP, Paris, France
| | - Mehmet Birhan Yilmaz
- Division of Cardiology, Department of Internal Medical Sciences, School of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet and Dept of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Brenda Moura
- Armed Forces Hospital, Faculty of Medicine of Porto, Porto, Portugal
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki and Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - Elena-Laura Antohi
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania
- University of Medicine Carol Davila, Bucharest, Romania
| | - Tuvia Ben-Gal
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center and Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA
| | - Vlad Anton Iliescu
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania
- University of Medicine Carol Davila, Bucharest, Romania
| | - Magdy Abdelhamid
- Faculty of Medicine, Kasr Al Ainy, Cardiology Department, Cairo University, Cairo, Egypt
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius; Centre of Innovative Medicine, Vilnius, Lithuania
| | | | - Lars H Lund
- Karolinska Institute, Department of Medicine, and Karolinska University Hospital, Department of Cardiology, Stockholm, Sweden
| | | | - Josep Masip
- Research Direction, Consorci Sanitari Integral, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
| | - Hadi Skouri
- Division of Cardiology, Internal Medicine Department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Amina Rakisheva
- Scientific and Research Institute of Cardiology and Internal Disease, Almaty, Kazakhstan
| | - Ingo Ahrens
- Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital, Cologne, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andrea Mortara
- Department of Cardiology, Policlinico di Monza, Monza, Italy
| | - Ewa A Janowska
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Abdallah Almaghraby
- Cardiology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Oscar Miro
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Kurt Huber
- Medical Faculty, Sigmund Freud University, Vienna, Austria
- 3rd Medical Department, Wilhelminen Hospital, Vienna, Austria
| | - Arsen Ristic
- Department of Cardiology of the University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Loreena Hill
- School of Nursing & Midwifery, Queen's University, Belfast, UK
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- UHasselt, Biomedical Research Institute, Faculty of Medicine and Life Sciences, LCRC, Diepenbeek, Belgium
| | - Alaide Chieffo
- Vita Salute-San Raffaele University, Milan, Italy
- IRCCS San Raffaele Scientific, Institute, Milan, Italy
| | - Jozef Bartunek
- Cardiovascular Center Aalst, OLV Hospital, Aalst, Belgium
| | - Pasquale Paolisso
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Antoni Bayes-Genis
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Stefan D Anker
- Department of Cardiology (CVK) of German Heart Center Charité, Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Susanna Price
- Royal Brompton Hospital & Harefield NHS Foundation Trust, London, UK
| | - Gerasimos Filippatos
- Heart Failure Unit, Department of Cardiology, Athens University Hospital, Attikon, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Department of Cardiology, Center for Translational and Experimental Cardiology (CTEC), University Hospital Zurich, Zurich, Switzerland
| | - Petar Seferovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Rafael Vidal-Perez
- Department of Cardiology, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Alec Vahanian
- University Paris Cite, INSERM LVTS U 1148 Bichat, Paris, France
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Theresa A McDonagh
- Department of Cardiology, King's College Hospital London, London, UK
- School of Cardiovascular Medicine and Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
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22
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Pocock SJ, Ferreira JP, Collier TJ, Angermann CE, Biegus J, Collins SP, Kosiborod M, Nassif ME, Ponikowski P, Psotka MA, Teerlink JR, Tromp J, Gregson J, Blatchford JP, Zeller C, Voors AA. The win ratio method in heart failure trials: lessons learnt from EMPULSE. Eur J Heart Fail 2023; 25:632-641. [PMID: 37038330 PMCID: PMC10330107 DOI: 10.1002/ejhf.2853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/28/2023] [Accepted: 04/08/2023] [Indexed: 04/12/2023] Open
Abstract
AIMS The EMPULSE trial evaluated the clinical benefit of empagliflozin versus placebo using the stratified win ratio approach in 530 patients with acute heart failure (HF) after initial stabilization. We aim to elucidate how this method works and what it means, thereby giving guidance for use of the win ratio in future trials. METHODS AND RESULTS The primary trial outcome is a hierarchical composite of death, number of HF events, time to first HF event, or a ≥5-point difference in Kansas City Cardiomyopathy Questionnaire (KCCQ) total symptom score change at 90 days. In an overall (unstratified) analysis we show how comparison of all 265 x 265 patients pairs contribute to 'wins' for empagliflozin and placebo at all four levels of the hierarchy, leading to an unstratified win ratio of 1.38 (95% confidence interval [CI] 1.11-1.71; p = 0.0036). How such a win ratio should (and should not) be interpreted is then described. The more complex primary analysis using a stratified win ratio is then presented in detail leading to a very similar overall result. Win ratios for de novo acute HF and decompensated chronic HF patients were 1.29 and 1.39, respectively, their weighted combination yielding an overall stratified win ratio of 1.36 (95% CI 1.09-1.68) (p = 0.0054). Alternative ways of including HF events and KCCQ scores in the clinical hierarchy are presented, leading to recommendations for their use in future trials. Specifically, inclusion of both number of HF events and time-to-first HF event appears an unnecessary complication. Also, the use of a 5-point margin for KCCQ score paired comparisons is not statistically necessary. CONCLUSIONS The EMPULSE trial findings illustrate how deaths, clinical events and patient-reported outcomes can be integrated into a win ratio analysis strategy that yields clinically meaningful findings of patient benefit. This has implications for future trial designs that recognize the clinical priorities of patient evaluation and the need for efficient progress towards approval of new treatments.
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Affiliation(s)
- Stuart J Pocock
- Medical Statistics Department, London School of Hygiene & Tropical Medicine, London, UK
| | - João Pedro Ferreira
- Heart Failure Clinic, Internal Medicine Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
- Inserm, Centre d'Investigations Cliniques-Plurithématique 14-33, Université de Lorraine, and Inserm U1116, CHRU, Nancy, France
| | - Timothy J Collier
- Medical Statistics Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Christiane E Angermann
- Comprehensive Heart Failure Centre, University and University Hospital of Würzburg, and Department of Medicine I, University Hospital of Würzburg, Würzburg, Germany
| | - Jan Biegus
- Institute of Heart Diseases, Medical University, Wroclaw, Poland
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center and Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville, TN, USA
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
- George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Medical University, Wroclaw, Poland
| | | | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore, and the National University Health System, Singapore, Singapore
| | - John Gregson
- Medical Statistics Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Jonathan P Blatchford
- Elderbrook Solutions GmbH on behalf of Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Cordula Zeller
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
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23
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Self WH, Shotwell MS, Gibbs KW, de Wit M, Files DC, Harkins M, Hudock KM, Merck LH, Moskowitz A, Apodaca KD, Barksdale A, Safdar B, Javaheri A, Sturek JM, Schrager H, Iovine N, Tiffany B, Douglas IS, Levitt J, Busse LW, Ginde AA, Brown SM, Hager DN, Boyle K, Duggal A, Khan A, Lanspa M, Chen P, Puskarich M, Vonderhaar D, Venkateshaiah L, Gentile N, Rosenberg Y, Troendle J, Bistran-Hall AJ, DeClercq J, Lavieri R, Joly MM, Orr M, Pulley J, Rice TW, Schildcrout JS, Semler MW, Wang L, Bernard GR, Collins SP. Renin-Angiotensin System Modulation With Synthetic Angiotensin (1-7) and Angiotensin II Type 1 Receptor-Biased Ligand in Adults With COVID-19: Two Randomized Clinical Trials. JAMA 2023; 329:1170-1182. [PMID: 37039791 PMCID: PMC10091180 DOI: 10.1001/jama.2023.3546] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/24/2023] [Indexed: 04/12/2023]
Abstract
Importance Preclinical models suggest dysregulation of the renin-angiotensin system (RAS) caused by SARS-CoV-2 infection may increase the relative activity of angiotensin II compared with angiotensin (1-7) and may be an important contributor to COVID-19 pathophysiology. Objective To evaluate the efficacy and safety of RAS modulation using 2 investigational RAS agents, TXA-127 (synthetic angiotensin [1-7]) and TRV-027 (an angiotensin II type 1 receptor-biased ligand), that are hypothesized to potentiate the action of angiotensin (1-7) and mitigate the action of the angiotensin II. Design, Setting, and Participants Two randomized clinical trials including adults hospitalized with acute COVID-19 and new-onset hypoxemia were conducted at 35 sites in the US between July 22, 2021, and April 20, 2022; last follow-up visit: July 26, 2022. Interventions A 0.5-mg/kg intravenous infusion of TXA-127 once daily for 5 days or placebo. A 12-mg/h continuous intravenous infusion of TRV-027 for 5 days or placebo. Main Outcomes and Measures The primary outcome was oxygen-free days, an ordinal outcome that classifies a patient's status at day 28 based on mortality and duration of supplemental oxygen use; an adjusted odds ratio (OR) greater than 1.0 indicated superiority of the RAS agent vs placebo. A key secondary outcome was 28-day all-cause mortality. Safety outcomes included allergic reaction, new kidney replacement therapy, and hypotension. Results Both trials met prespecified early stopping criteria for a low probability of efficacy. Of 343 patients in the TXA-127 trial (226 [65.9%] aged 31-64 years, 200 [58.3%] men, 225 [65.6%] White, and 274 [79.9%] not Hispanic), 170 received TXA-127 and 173 received placebo. Of 290 patients in the TRV-027 trial (199 [68.6%] aged 31-64 years, 168 [57.9%] men, 195 [67.2%] White, and 225 [77.6%] not Hispanic), 145 received TRV-027 and 145 received placebo. Compared with placebo, both TXA-127 (unadjusted mean difference, -2.3 [95% CrI, -4.8 to 0.2]; adjusted OR, 0.88 [95% CrI, 0.59 to 1.30]) and TRV-027 (unadjusted mean difference, -2.4 [95% CrI, -5.1 to 0.3]; adjusted OR, 0.74 [95% CrI, 0.48 to 1.13]) resulted in no difference in oxygen-free days. In the TXA-127 trial, 28-day all-cause mortality occurred in 22 of 163 patients (13.5%) in the TXA-127 group vs 22 of 166 patients (13.3%) in the placebo group (adjusted OR, 0.83 [95% CrI, 0.41 to 1.66]). In the TRV-027 trial, 28-day all-cause mortality occurred in 29 of 141 patients (20.6%) in the TRV-027 group vs 18 of 140 patients (12.9%) in the placebo group (adjusted OR, 1.52 [95% CrI, 0.75 to 3.08]). The frequency of the safety outcomes was similar with either TXA-127 or TRV-027 vs placebo. Conclusions and Relevance In adults with severe COVID-19, RAS modulation (TXA-127 or TRV-027) did not improve oxygen-free days vs placebo. These results do not support the hypotheses that pharmacological interventions that selectively block the angiotensin II type 1 receptor or increase angiotensin (1-7) improve outcomes for patients with severe COVID-19. Trial Registration ClinicalTrials.gov Identifier: NCT04924660.
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Affiliation(s)
- Wesley H. Self
- Vanderbilt Institute for Clinical and Translational Research, Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew S. Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kevin W. Gibbs
- Department of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Marjolein de Wit
- Department of Medicine, Virginia Commonwealth University, Richmond
| | - D. Clark Files
- Department of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Michelle Harkins
- Department of Internal Medicine, University of New Mexico, Albuquerque
| | | | - Lisa H. Merck
- Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond
| | - Ari Moskowitz
- Department of Medicine, Montefiore Medical Center, Bronx, New York
| | | | - Aaron Barksdale
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha
| | - Basmah Safdar
- Department of Emergency Medicine, Yale University, New Haven, Connecticut
| | - Ali Javaheri
- Department of Medicine, Washington University, St Louis, Missouri
| | | | - Harry Schrager
- Department of Medicine, Tufts School of Medicine, Newton-Wellesley Hospital, Newton, Massachusetts
| | - Nicole Iovine
- Department of Medicine, University of Florida, Gainesville
| | | | - Ivor S. Douglas
- Department of Medicine, Denver Health Medical Center, Denver, Colorado
| | - Joseph Levitt
- Department of Medicine, Stanford University, Stanford, California
| | | | - Adit A. Ginde
- Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora
| | - Samuel M. Brown
- Department of Pulmonary/Critical Care Medicine, Intermountain Medical Center, Murray, Utah
| | - David N. Hager
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Katherine Boyle
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Abhijit Duggal
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Akram Khan
- Department of Medicine, Oregon Health & Science University, Portland
| | - Michael Lanspa
- Department of Pulmonary/Critical Care Medicine, Intermountain Medical Center, Murray, Utah
| | - Peter Chen
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis
| | - Derek Vonderhaar
- Department of Medicine, Ochsner Medical Center, New Orleans, Louisiana
| | | | - Nina Gentile
- Department of Emergency Medicine, Temple University, Philadelphia, Pennsylvania
| | - Yves Rosenberg
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - James Troendle
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Amanda J. Bistran-Hall
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Josh DeClercq
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert Lavieri
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Meghan Morrison Joly
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael Orr
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jill Pulley
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd W. Rice
- Vanderbilt Institute for Clinical and Translational Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Matthew W. Semler
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gordon R. Bernard
- Vanderbilt Institute for Clinical and Translational Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sean P. Collins
- Vanderbilt Institute for Clinical and Translational Research, Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville
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24
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Naggie S, Milstone A, Castro M, Collins SP, Lakshmi S, Anderson DJ, Cahuayme-Zuniga L, Turner KB, Cohen LW, Currier J, Fraulo E, Friedland A, Garg J, George A, Mulder H, Olson RE, O'Brien EC, Rothman RL, Shenkman E, Shostak J, Woods CW, Anstrom KJ, Hernandez AF. Hydroxychloroquine for pre-exposure prophylaxis of COVID-19 in health care workers: a randomized, multicenter, placebo-controlled trial Healthcare Worker Exposure Response and Outcomes of Hydroxychloroquine (HERO-HCQ). Int J Infect Dis 2023; 129:40-48. [PMID: 36682681 PMCID: PMC9851717 DOI: 10.1016/j.ijid.2023.01.019] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 01/06/2023] [Accepted: 01/12/2023] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES To determine whether hydroxychloroquine (HCQ) is safe and effective at preventing COVID-19 infections among health care workers (HCWs). METHODS In a 1: 1 randomized, placebo-controlled, double-blind, parallel-group, superiority trial at 34 US clinical centers, 1360 HCWs at risk for COVID-19 infection were enrolled between April and November 2020. Participants were randomized to HCQ or matched placebo. The HCQ dosing included a loading dose of HCQ 600 mg twice on day 1, followed by 400 mg daily for 29 days. The primary outcome was a composite of confirmed or suspected COVID-19 clinical infection by day 30, defined as new-onset fever, cough, or dyspnea and either a positive SARS-CoV-2 polymerase chain reaction test (confirmed) or a lack of confirmatory testing due to local restrictions (suspected). RESULTS Study enrollment closed before full accrual due to recruitment challenges. The primary end point occurred in 41 (6.0%) participants receiving HCQ and 53 (7.8%) participants receiving placebo. No difference in the proportion of participants experiencing clinical infection (estimated difference of -1.8%, 95% confidence interval -4.6-0.9%, P = 0.20) was identified nor any significant safety issues. CONCLUSION Oral HCQ taken as prescribed appeared safe among HCWs. No significant clinical benefits were observed. The study was not powered to detect a small but potentially important reduction in infection. TRIAL REGISTRATION NCT04334148.
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Affiliation(s)
- Susanna Naggie
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA.
| | | | - Mario Castro
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Sean P Collins
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | | | | | - Lauren W Cohen
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Judith Currier
- University of California Los Angeles, Los Angeles, California, USA
| | - Elizabeth Fraulo
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Anne Friedland
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Jyotsna Garg
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Anoop George
- Temple University, Philadelphia, Pennsylvania, USA
| | - Hillary Mulder
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Rachel E Olson
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Emily C O'Brien
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | | | | | - Jack Shostak
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Christopher W Woods
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Kevin J Anstrom
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
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Farmakis D, Tromp J, Marinaki S, Ouwerkerk W, Angermann CE, Bistola V, Dahlstrom U, Dickstein K, Ertl G, Ghadanfar M, Hassanein M, Obergfell A, Perrone SV, Polyzogopoulou E, Schweizer A, Boletis I, Cleland JG, Collins SP, Lam CS, FIlippatos G. Impact of left ventricular ejection fraction phenotypes on healthcare-resource utilization in hospitalized heart failure: A secondary analysis of REPORT-HF. Eur J Heart Fail 2023. [PMID: 36974770 DOI: 10.1002/ejhf.2833] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 03/23/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Evidence on healthcare resource utilization (HCRU) for hospitalized patients with heart failure (HF) and reduced (HFrEF), mildly-reduced (HFmrEF) and preserved (HFpEF) left ventricular ejection fraction (LVEF) is limited. METHODS We analysed HCRU in relation to LVEF phenotypes, clinical features and in-hospital and 12-month outcomes in 16,943 patients hospitalized for HF in a worldwide registry. RESULTS HFrEF was more prevalent (53%) than HFmrEF (17%) or HFpEF (30%). Patients with HFmrEF and HFpEF were older, more often women, with milder symptoms and more comorbidities, but differences were not pronounced. HCRU was high in all three groups; 2 or more in- and out-hospital services were required by 51%, 49% and 52% of patients with HFrEF, HFmrEF and HFpEF, respectively, and ICU by 41%, 41% and 37%, respectively.Hospitalization length was similar (median, 8 days). Discharge prescription of neurohormonal inhibitors was <80% for each agent in HFrEF and only slightly lower in HFmrEF and HFpEF (74% and 67%, respectively for beta-blockers). Compared to HFrEF, 12-month all-cause and cardiovascular mortality were lower for HFmrEF [adjusted hazard ratios, 0.76 (0.68-0.84) and 0.77 (0.68-0.88)] and HFpEF [0.62 (0.56-0.68) and 0.60 (0.53-0.68)]; 12-month HF hospitalization was also lower for HFpEF and HFmrEF (21% and 20% versus 25% for HFrEF). In-hospital mortality, 12-month non-cardiovascular mortality and 12-month all-cause hospitalization were similar among groups. CONCLUSIONS In patients hospitalized for HF, overall HCRU was similarly high across LVEF spectrum, reflecting the subtle clinical differences among LVEF phenotypes during hospitalization. Discharge prescription of neurohormonal inhibitors were suboptimal in HFrEF and lower but significant in patients with HFpEF and HFmrEF, who had better long-term cardiovascular outcomes than HFrEF, but similar risk for non-cardiovascular events. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - Jasper Tromp
- National Heart Centre Singapore, Singapore
- Duke-National University of Singapore, Singapore
- University Medical Centre Groningen, Groningen, Netherlands
- Saw Swee Hock school of Public Health, National University of Singapore, Singapore
| | - Smaragdi Marinaki
- National and Kapodistrian University of Athens Medical School, Laiko Hospital, Athens, Greece
| | - Wouter Ouwerkerk
- National Heart Centre Singapore, Singapore
- Amsterdam University Medical Centre
| | | | - Vasiliki Bistola
- Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ulf Dahlstrom
- Department of Cardiology, and Department of Health, Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden
| | | | - Georg Ertl
- National Heart Centre Singapore, Singapore
- Amsterdam University Medical Centre
| | | | - Mahmoud Hassanein
- Alexandria University, Faculty of Medicine, Cardiology Department, Alexandria, Egypt
| | | | - Sergio V Perrone
- El Cruce Hospital by Florencio Varela, Lezica Cardiovascular Institute, Sanctuary of the Trinidad Miter, Buenos Aires, Argentina
| | - Eftihia Polyzogopoulou
- Department of Emergency Medicine, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | | | - Ioannis Boletis
- National and Kapodistrian University of Athens Medical School, Laiko Hospital, Athens, Greece
| | - John Gf Cleland
- Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-Being, University of Glasgow, Glasgow, UK
- National Heart and Lung Institute, Imperial College, London, UK
| | - Sean P Collins
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, TN, USA
| | - Carolyn Sp Lam
- National Heart Centre Singapore, Singapore
- Duke-National University of Singapore, Singapore
- University Medical Centre Groningen, Groningen, Netherlands
- Saw Swee Hock school of Public Health, National University of Singapore, Singapore
| | - Gerasimos FIlippatos
- Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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Stolldorf DP, Jones AB, Miller KF, Paz HH, Mumma BE, Danesh VC, Collins SP, Dietrich MS, Storrow AB. Medication Discussions With Patients With Cardiovascular Disease in the Emergency Department: An Opportunity for Emergency Nurses to Engage Patients to Support Medication Reconciliation. J Emerg Nurs 2023; 49:275-286. [PMID: 36623969 PMCID: PMC9992264 DOI: 10.1016/j.jen.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 01/09/2023]
Abstract
INTRODUCTION This study aimed to investigate the level of patient involvement in medication reconciliation processes and factors associated with that involvement in patients with cardiovascular disease presenting to the emergency department. METHODS An observational and cross-sectional design was used. Patients with cardiovascular disease presenting to the adult emergency department of an academic medical center completed a structured survey inclusive of patient demographics and measures related to the study concepts. Data abstracted from the electronic health record included the patient's medical history and emergency department visit data. Our multivariable model adjusted for age, gender, education, difficulty paying bills, health status, numeracy, health literacy, and medication knowledge and evaluated patient involvement in medication discussions as an outcome. RESULTS Participants' (N = 93) median age was 59 years (interquartile range 51-67), 80.6% were white, 96.8% were not Hispanic, and 49.5% were married or living with a partner. Approximately 41% reported being employed and 36.9% reported an annual household income of <$25,000. Almost half (n = 44, 47.3%) reported difficulty paying monthly bills. Patients reported moderate medication knowledge (median 3.8, interquartile range 3.4-4.2) and perceived involvement in their care (41.8 [SD = 9.1]). After controlling for patient characteristics, only difficulty paying monthly bills (b = 0.36, P = .005) and medication knowledge (b = 0.30, P = .009) were associated with involvement in medication discussions. DISCUSSION Some patients presenting to the emergency department demonstrated moderate medication knowledge and involvement in medication discussions, but more work is needed to engage patients.
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Repka MC, Carrasquilla M, Paydar I, Wu B, Lei S, Suy S, Collins SP, Kole TP. Dosimetric predictors of acute bowel toxicity after Stereotactic Body Radiotherapy (SBRT) in the definitive treatment of localized prostate cancer. Acta Oncol 2023; 62:174-179. [PMID: 36826994 DOI: 10.1080/0284186x.2023.2180661] [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] [Indexed: 02/25/2023]
Abstract
INTRODUCTION SBRT is an increasingly popular treatment for localized prostate cancer, though considerable variation in technical approach is common and optimal dose constraints are uncertain. In this study, we sought to identify dosimetric and patient-related predictors of acute rectal toxicity. METHODS Patients included in this study were treated with prostate SBRT on a prospective institutional protocol. Physician-graded toxicity and patient-reported outcomes were captured at one week, one month, and three months following SBRT. DVH data were extracted and converted into relative volume differential DVHs for NTCP modeling. Patient- and disease-related covariates along with NTCP model predictions were independently tested for significant association with physician-graded toxicity or a decline in bowel-related QoL. A multivariate model was constructed using forward selection, and significant parameter cutoff values were obtained with Fischer's exact test to group patients by risk of developing physician-graded toxicity or detriments in patient-reported QoL. RESULTS One hundred and three patients treated for localized prostate cancer with SBRT were included in our analysis. 52% of patients experienced a clinically significant decline in bowel-related QOL within 1 week of completion of treatment, while only 27.5% of patients developed grade 2+ physician-graded rectal toxicity. Sequential feature selection multivariate logistic regression identified rectal V22.5 Gy (p = 0.001) and D19% (p = 0.001) as independent predictors of clinically significant toxicity, while rectal V20Gy (p = 0.004) and D25.3% (p = 0.007) were independently correlated with physician-graded toxicity. Global multivariate step-wise logistic regression identified only D19% (p = 0.001) and V20Gy (p = 0.004) as independent predictors of acute bowel bother or physician-graded rectal toxicity respectively. CONCLUSIONS Moderate doses to large rectal volumes, D19% and V20Gy, were associated with an increased incidence of a clinically significant decrease in patient-reported bowel QOL and physician-scored grade 2+ rectal toxicity, respectively. These dosimetric parameters may help practitioners mitigate acute toxicity in patients treated with prostate SBRT.
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Affiliation(s)
- Michael C Repka
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Michael Carrasquilla
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | | | - Binbin Wu
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Siyuan Lei
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Simeng Suy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Sean P Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Thomas P Kole
- Department of Radiation Oncology, Valley Mount Sinai Comprehensive Cancer Care, Paramus, NJ, USA
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Collins SP, Maculaitis MC, Hauber B, Hunsche E, Kopenhafer L, Nwokeji E, Beusterien KM. Identifying prostate cancer patient subgroups based on their preferences for key attributes of androgen deprivation therapies. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.6_suppl.94] [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: 03/17/2023] Open
Abstract
94 Background: Androgen deprivation therapies (ADTs) for prostate cancer (PC) vary in delivery mode, T (testosterone) surge occurrence, time to T recovery, adverse event profile, and costs. Data are limited on how men differ in their evaluation of ADT attributes. This study identified subgroups of men who vary in their preferences for key ADT attributes. Methods: A cross-sectional survey of US men aged >40 years, who had healthcare coverage for the past 3 years and self-reported a PC diagnosis, were recruited via healthcare research panels. Men were ineligible if they did not know/recall whether they had received ADT or were unable to complete the survey independently. Quotas ensured an approximate even split of ADT-experienced and ADT-naïve men. A discrete choice experiment assessed preferences for ADT attributes. In a series of choice tasks, men were presented with 2 ADT treatment profiles side-by-side and asked to select the one they prefer. Hierarchical Bayes models computed attribute level preference weights. Relative importance (RI), based on differences between the most and least favorable attribute level preference weight and standardized to sum to 100%, was estimated for each attribute; the higher the RI value, the more influential an attribute is to treatment choice. Latent class analysis (LCA) identified groups (Gs) of men with similar ADT preferences. Results: 304 men were included in the analyses, their mean age was 64.4±7.2 years, and 16.8% were African American. Mean PC duration was 5.4±4.8 years, 55.3% reported organ-confined PC, and 49.0% had prior ADT use. LCA identified 4 preference Gs. While impact on sexual activity was most important to G1, out-of-pocket (OOP) costs, mode of administration, and time to T recovery were choice drivers for G2. Mode of administration and OOP costs predominated in importance for G3 and G4, respectively. More than half of men in G1 and G3 were <65 years; G1, but not G3, included mainly men who planned to be sexually active. G2 and G4 were predominantly composed of men aged ≥65 years who often had Medicare insurance. Conclusions: Younger, sexually active men consider the potential impact on sexual activity when choosing PC therapy, while for older men administration burden or OOP costs are important choice drivers. Thus, ADT attributes often vary in salience to men and should be considered in shared PC treatment decision-making. [Table: see text]
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Biegus J, Voors AA, Collins SP, Kosiborod MN, Teerlink JR, Angermann CE, Tromp J, Ferreira JP, Nassif ME, Psotka MA, Brueckmann M, Salsali A, Blatchford JP, Ponikowski P. Impact of empagliflozin on decongestion in acute heart failure: the EMPULSE trial. Eur Heart J 2023; 44:41-50. [PMID: 36254693 PMCID: PMC9805406 DOI: 10.1093/eurheartj/ehac530] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 08/25/2022] [Accepted: 09/13/2022] [Indexed: 02/06/2023] Open
Abstract
AIMS Effective and safe decongestion remains a major goal for optimal management of patients with acute heart failure (AHF). The effects of the sodium-glucose cotransporter 2 inhibitor empagliflozin on decongestion-related endpoints in the EMPULSE trial (NCT0415775) were evaluated. METHODS AND RESULTS A total of 530 patients hospitalized for AHF were randomized 1:1 to either empagliflozin 10 mg once daily or placebo for 90 days. The outcomes investigated were: weight loss (WL), WL adjusted for mean daily loop diuretic dose (WL-adjusted), area under the curve of change from baseline in N-terminal pro-B-type natriuretic peptide levels, hemoconcentration, and clinical congestion score after 15, 30, and 90 days of treatment. Compared with placebo, patients treated with empagliflozin demonstrated significantly greater reductions in all studied markers of decongestion at all time-points, adjusted mean differences (95% confidence interval) at Days 15, 30, and 90 were: for WL -1.97 (-2.86, -1.08), -1.74 (-2.73, -0.74); -1.53 (-2.75, -0.31) kg; for WL-adjusted: -2.31 (-3.77, -0.85), -2.79 (-5.03, -0.54), -3.18 (-6.08, -0.28) kg/40 mg furosemide i.v. or equivalent; respectively (all P < 0.05). Greater WL at Day 15 (i.e. above the median WL in the entire population) was associated with significantly higher probability for clinical benefit at Day 90 (hierarchical composite of all-cause death, heart failure events, and a 5-point or greater difference in Kansas City Cardiomyopathy Questionnaire total symptom score change from baseline to 90 days) with the win ratio of 1.75 (95% confidence interval 1.37, 2.23; P < 0.0001). CONCLUSION Initiation of empagliflozin in patients hospitalized for AHF resulted in an early, effective and sustained decongestion which was associated with clinical benefit at Day 90.
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Affiliation(s)
- Jan Biegus
- Corresponding author. Tel: +48 71 733 11 12,
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O Box 30001, 9700 RB Groningen, HPC AB 31, The Netherlands
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville, TN, USA
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA
- The George Institute for Global Health and the University of New South Wales, Sydney, New South Wales, Australia
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, 4150 Clement Street San Francisco, CA 94121, USA
| | - Christiane E Angermann
- Comprehensive Heart Failure Center Würzburg, University and University Hospital Würzburg, and Department of Medicine 1, University Hospital Würzburg, Am Schwarzenberg 15, Haus A15 97078 Würzburg, Germany
| | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore, the National University Health System, Singapore; 12 Science Drive 2, #10-01, Singapore 117549
| | - Joao Pedro Ferreira
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques Plurithématique 1433, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
- UnIC@RISE, Department of Surgery and Physiology, Cardiovascular Research and Development Center, University of Porto, Porto, Portugal
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City, MO, USA
| | - Mitchell A Psotka
- Inova Heart and Vascular Institute, Falls Church, VA, 3300 Gallows Road Falls Church, Virginia 22042, USA
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Binger Straße 173, 55216 Ingelheim am Rhein, Germany
- First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Afshin Salsali
- Novo Nordisk pharmaceutical company, Vandtårnsvej 110, 2860 Søborg, Copenhagen, Denmark
- Faculty of Medicine, Rutgers University, New Brunswick, NJ, 125 Paterson street, New Brunswick, NJ 08901, USA
| | - Jonathan P Blatchford
- Elderbrook Solutions GmbH, Sky Tower, Borsigstr. 4, D-74321 Bietigheim-Bissingen, Germany
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, ul. Borowska 213, Wroclaw 50-556, Poland
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Ouwerkerk W, Tromp J, Cleland JGF, Angermann CE, Dahlstrom U, Ertl G, Hassanein M, Perrone SV, Ghadanfar M, Schweizer A, Obergfell A, Dickstein K, Filippatos G, Collins SP, Lam CSP. Association of time-to-intravenous furosemide with mortality in acute heart failure: data from REPORT-HF. Eur J Heart Fail 2023; 25:43-51. [PMID: 36196060 PMCID: PMC10099670 DOI: 10.1002/ejhf.2708] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/08/2022] [Accepted: 09/27/2022] [Indexed: 02/03/2023] Open
Abstract
AIM Acute heart failure can be a life-threatening medical condition. Delaying administration of intravenous furosemide (time-to-diuretics) has been postulated to increase mortality, but prior reports have been inconclusive. We aimed to evaluate the association between time-to-diuretics and mortality in the international REPORT-HF registry. METHODS AND RESULTS We assessed the association of time-to-diuretics within the first 24 h with in-hospital and 30-day post-discharge mortality in 15 078 patients from seven world regions in the REPORT-HF registry. We further tested for effect modification by baseline mortality risk (ADHERE risk score), left ventricular ejection fraction (LVEF) and region. The median time-to-diuretics was 67 (25th-75th percentiles 17-190) min. Women, patients with more signs and symptoms of heart failure, and patients from Eastern Europe or Southeast Asia had shorter time-to-diuretics. There was no significant association between time-to-diuretics and in-hospital mortality (p > 0.1). The 30-day mortality risk increased linearly with longer time-to-diuretics (administered between hospital arrival and 8 h post-hospital arrival) (p = 0.016). This increase was more significant in patients with a higher ADHERE risk score (pinteraction = 0.008), and not modified by LVEF or geographic region (pinteraction > 0.1 for both). CONCLUSION In REPORT-HF, longer time-to-diuretics was not associated with higher in-hospital mortality. However, we did found an association with increased 30-day mortality, particularly in high-risk patients, and irrespective of LVEF or geographic region. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT02595814.
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Affiliation(s)
- Wouter Ouwerkerk
- National Heart Centre Singapore, Singapore.,Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam Infection & Immunity Institute, Amsterdam, The Netherlands
| | - Jasper Tromp
- Duke-National University of Singapore, Singapore.,Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, Institute of Health & Well-Being, University of Glasgow and National Heart & Lung Institute, Imperial College, London, UK
| | - Christiane E Angermann
- University and University Hospital Würzburg, Comprehensive Heart Failure Center, Würzburg, Germany
| | - Ulf Dahlstrom
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden
| | - Georg Ertl
- University and University Hospital Würzburg, Comprehensive Heart Failure Center, Würzburg, Germany
| | - Mahmoud Hassanein
- Department of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Sergio V Perrone
- El Cruce Hospital by Florencio Varela, Lezica Cardiovascular Institute, Sanctuary of the Trinidad Miter, Buenos Aires, Argentina
| | | | | | | | - Kenneth Dickstein
- University of Bergen, Stavanger University Hospital, Stavanger, Norway
| | - Gerasimos Filippatos
- School of Medicine, Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore, Singapore.,Duke-National University of Singapore, Singapore
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Simhal RK, Sholklapper TN, Simhal AK, Zwart AL, Danner MT, Kumar D, Aghdam N, Suy S, Hankins RA, Kowalczyk KJ, Collins SP. Association of baseline self-reported fatigue with overall survival after stereotactic body radiation therapy for localized prostate cancer. Front Oncol 2022; 12:1015264. [PMID: 36620537 PMCID: PMC9816795 DOI: 10.3389/fonc.2022.1015264] [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: 08/09/2022] [Accepted: 11/21/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Stereotactic Body Radiation Therapy (SBRT) has emerged as a definitive therapy for localized prostate cancer (PCa). However, more data is needed to predict patient prognosis to help guide which patients will benefit most from treatment. The FACIT-Fatigue (FACIT-F) is a well validated, widely used survey for assessing fatigue. However, the role of fatigue in predicting PCa survival has yet to be studied. Herein, we investigate the role of FACIT-F as a baseline predictor for overall survival (OS) in patients undergoing SBRT for localized PCa. Methods A retrospective review was conducted of 1358 patients who received SBRT monotherapy between January 2008 to April 2021 at an academic, tertiary referral center. FACIT-F scores (range 0 to 52) were summed for patients who answered all 13-items on the survey. FACIT-F total scores of ≥35 represented severe fatigue. Patients receiving androgen deprivation therapy were excluded. Differences in fatigue groups were evaluated using chi-squared tests. OS rates were determined using the Kaplan-Meier method and predictors of OS were evaluated using Cox proportional hazard method. Results Baseline full FACIT-F scores and survival data was available for 891 patients. 5-year OS was 87.6% and 95.2%, respectively, for the severely fatigued and non-fatigued groups. Chi-squared analysis of fatigue groups showed no significant difference in the following categories: D'Amico risk group, age, ethnicity, grade group, T-stage, or PSA density. Severe fatigue was associated with a significant decrease in OS (hazard ratio 2.76; 95%CI 1.55 - 4.89). The Cox proportional hazard model revealed that age and FACIT-F were both statistically significant (p <0.05). Conclusion Baseline FACIT-F scores are significantly associated with OS. Higher FACIT-F scores, representing less fatigued patients, are associated with an overall survival benefit. These results indicate that the FACIT-F survey could serve as an additional metric for clinicians in determining prognostic factors for patients undergoing SBRT.
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Affiliation(s)
- Rishabh K. Simhal
- School of Medicine, Georgetown University, Washington, DC, United States,*Correspondence: Rishabh K. Simhal,
| | | | - Anish K. Simhal
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Alan L. Zwart
- Department of Radiation Oncology, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Malika T. Danner
- Department of Radiation Oncology, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Deepak Kumar
- Julius L. Chambers Research Institute, North Carolina Central University, Durham, NC, United States
| | - Nima Aghdam
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Simeng Suy
- Department of Radiation Oncology, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Ryan A. Hankins
- School of Medicine, Georgetown University, Washington, DC, United States,Department of Urology, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Keith J. Kowalczyk
- School of Medicine, Georgetown University, Washington, DC, United States,Department of Urology, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Sean P. Collins
- School of Medicine, Georgetown University, Washington, DC, United States,Department of Radiation Oncology, MedStar Georgetown University Hospital, Washington, DC, United States
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Casey JD, Beskow LM, Self WH, Mebazaa A, Collins SP. The approach to informed consent in acute care research - Authors' reply. Lancet Respir Med 2022; 10:e108. [PMID: 36335955 PMCID: PMC9633074 DOI: 10.1016/s2213-2600(22)00411-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | - Laura M Beskow
- Vanderbilt Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA; Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Alexandre Mebazaa
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France; INSERM UMR-S 942, MASCOT, Université Paris Cité, Paris, France
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA; Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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Voors AA, Damman K, Teerlink JR, Angermann CE, Collins SP, Kosiborod M, Biegus J, Ferreira JP, Nassif ME, Psotka MA, Tromp J, Brueckmann M, Blatchford JP, Salsali A, Ponikowski P. Renal effects of empagliflozin in patients hospitalized for acute heart failure: from the EMPULSE trial. Eur J Heart Fail 2022; 24:1844-1852. [PMID: 36066557 PMCID: PMC9828037 DOI: 10.1002/ejhf.2681] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 01/12/2023] Open
Abstract
AIM The sodium-glucose cotransporter 2 (SGLT2) inhibitor empagliflozin improved clinical outcomes in patients hospitalized for acute heart failure. In patients with chronic heart failure, SGLT2 inhibitors cause an early decline in estimated glomerular filtration rate (eGFR) followed by a slower eGFR decline over time than placebo. However, the effects of SGLT2 inhibitors on renal function during a hospital admission for acute heart failure remain largely unknown. METHODS AND RESULTS Between 1 and 5 days after a hospitalization for acute heart failure, 530 patients with an eGFR >20 ml/min/1.73 m2 were randomized to 10 mg of empagliflozin or placebo and treated for 90 days. Renal function and electrolytes were measured at baseline, and after 15, 30 and 90 days. We evaluated the effect of empagliflozin on eGFR over time and the impact of baseline eGFR on the primary hierarchical outcome of death, worsening heart failure events and quality of life. Mean baseline eGFR was 52.4 ml/min/1.73 m2 in the empagliflozin group and 55.7 ml/min/1.73 m2 in the placebo group. Empagliflozin caused an initial decline in eGFR (-2 ml/min/1.73 m2 at day 15 compared to placebo). At day 90, eGFR was similar between empagliflozin and placebo. Investigator-reported acute renal failure occurred in 7.7% of empagliflozin versus 12.1% of placebo patients. The overall clinical benefit (hierarchical composite of all-cause death, heart failure events and quality of life) of empagliflozin was unaffected by baseline eGFR. CONCLUSION In patients hospitalized for acute heart failure, empagliflozin caused an early modest decline in renal function which was no longer evident after 90 days. Acute renal events were similar in both groups. The clinical benefit of empagliflozin was consistent regardless of baseline renal function.
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Affiliation(s)
- Adriaan A. Voors
- Department of Cardiology, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Kevin Damman
- Department of Cardiology, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - John R. Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Christiane E. Angermann
- Comprehensive Heart Failure CentreUniversity & University Hospital of WürzburgWürzburgGermany
| | - Sean P. Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center and Geriatric Research and Education Clinical CareTennessee Valley Healthcare Facility VA Medical CenterNashvilleTNUSA
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri‐Kansas CityKansas CityMSUSA,The George Institute for Global Health and The University of New South WalesSydneyNSWAustralia
| | - Jan Biegus
- Institute of Heart DiseasesMedical UniversityWroclawPoland
| | - João Pedro Ferreira
- Inserm INI‐CRCT, CHRUUniversité de LorraineNancyFrance,Cardiovascular Research and Development Center, Department of Surgery and PhysiologyFaculty of Medicine of the University of PortoPortoPortugal
| | - Michael E. Nassif
- Saint Luke's Mid America Heart Institute and the University of MissouriKansas CityMSUSA
| | | | - Jasper Tromp
- Saw Swee Hock School of Public HealthNational University of Singapore, and the National University Health SystemSingapore
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbHIngelheimGermany,First Department of Medicine faculty of Medicine MannheimUniversity of HeidelbergMannheimGermany
| | - Jonathan P. Blatchford
- Elderbrook Solutions GmbH on behalf of Boehringer Ingelheim Pharma GmbH & Co. KGBiberachGermany
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals Inc.RidgefieldCTUSA,Faculty of MedicineRutgers UniversityNew BrunswickNJUSA
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Moskowitz A, Shotwell MS, Gibbs KW, Harkins M, Rosenberg Y, Troendle J, Merck LH, Files DC, de Wit M, Hudock K, Thompson BT, Gong MN, Ginde AA, Douin DJ, Brown SM, Rubin E, Joly MM, Wang L, Lindsell CJ, Bernard GR, Semler MW, Collins SP, Self WH. Oxygen-Free Days as an Outcome Measure in Clinical Trials of Therapies for COVID-19 and Other Causes of New-Onset Hypoxemia. Chest 2022; 162:804-814. [PMID: 35504307 PMCID: PMC9055785 DOI: 10.1016/j.chest.2022.04.145] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/09/2022] [Accepted: 04/22/2022] [Indexed: 11/21/2022] Open
Abstract
Mortality historically has been the primary outcome of choice for acute and critical care clinical trials. However, undue reliance on mortality can limit the scope of trials that can be performed. Large sample sizes are usually needed for trials powered for a mortality outcome, and focusing solely on mortality fails to recognize the importance that reducing morbidity can have on patients' lives. The COVID-19 pandemic has highlighted the need for rapid, efficient trials to rigorously evaluate new therapies for hospitalized patients with acute lung injury. Oxygen-free days (OFDs) is a novel outcome for clinical trials that is a composite of mortality and duration of new supplemental oxygen use. It is designed to characterize recovery from acute lung injury in populations with a high prevalence of new hypoxemia and supplemental oxygen use. In these populations, OFDs captures two patient-centered consequences of acute lung injury: mortality and hypoxemic lung dysfunction. Power to detect differences in OFDs typically is greater than that for other clinical trial outcomes, such as mortality and ventilator-free days. OFDs is the primary outcome for the Fourth Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV-4) Host Tissue platform, which evaluates novel therapies targeting the host response to COVID-19 among adults hospitalized with COVID-19 and new hypoxemia. This article outlines the rationale for use of OFDs as an outcome for clinical trials, proposes a standardized method for defining and analyzing OFDs, and provides a framework for sample size calculations using the OFD outcome.
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Affiliation(s)
- Ari Moskowitz
- Department of Medicine, Montefiore Medical Center, The Bronx, NY
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Kevin W Gibbs
- Department of Medicine, Wake Forest University, Winston-Salem, NC
| | - Michelle Harkins
- Department of Medicine, University of New Mexico, Albuquerque, NM
| | | | | | - Lisa H Merck
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond, VA
| | - D Clark Files
- Department of Medicine, Wake Forest University, Winston-Salem, NC
| | - Marjolein de Wit
- Department of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Kristin Hudock
- Department of Medicine, University of Cincinnati, Cincinnati, OH
| | | | - Michelle N Gong
- Department of Medicine, Montefiore Medical Center, The Bronx, NY
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - David J Douin
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO
| | - Samuel M Brown
- Department of Medicine, Intermountain Medical Center, Murray, UT; Office of Research, Intermountain Medical Center, Murray, UT
| | | | - Meghan Morrison Joly
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | | | - Gordon R Bernard
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew W Semler
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Sean P Collins
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN; Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN
| | - Wesley H Self
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN; Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN.
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Collins SP, Barton-Maclaren TS. Novel machine learning models to predict endocrine disruption activity for high-throughput chemical screening. Front Toxicol 2022; 4:981928. [PMID: 36204696 PMCID: PMC9530987 DOI: 10.3389/ftox.2022.981928] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/02/2022] [Indexed: 11/13/2022] Open
Abstract
An area of ongoing concern in toxicology and chemical risk assessment is endocrine disrupting chemicals (EDCs). However, thousands of legacy chemicals lack the toxicity testing required to assess their respective EDC potential, and this is where computational toxicology can play a crucial role. The US (United States) Environmental Protection Agency (EPA) has run two programs, the Collaborative Estrogen Receptor Activity Project (CERAPP) and the Collaborative Modeling Project for Receptor Activity (CoMPARA) which aim to predict estrogen and androgen activity, respectively. The US EPA solicited research groups from around the world to provide endocrine receptor activity Qualitative (or Quantitative) Structure Activity Relationship ([Q]SAR) models and then combined them to create consensus models for different toxicity endpoints. Random Forest (RF) models were developed to cover a broader range of substances with high predictive capabilities using large datasets from CERAPP and CoMPARA for estrogen and androgen activity, respectively. By utilizing simple descriptors from open-source software and large training datasets, RF models were created to expand the domain of applicability for predicting endocrine disrupting activity and help in the screening and prioritization of extensive chemical inventories. In addition, RFs were trained to conservatively predict the activity, meaning models are more likely to make false-positive predictions to minimize the number of False Negatives. This work presents twelve binary and multi-class RF models to predict binding, agonism, and antagonism for estrogen and androgen receptors. The RF models were found to have high predictive capabilities compared to other in silico modes, with some models reaching balanced accuracies of 93% while having coverage of 89%. These models are intended to be incorporated into evolving priority-setting workflows and integrated strategies to support the screening and selection of chemicals for further testing and assessment by identifying potential endocrine-disrupting substances.
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Palazzuoli A, Metra M, Collins SP, Adamo M, Ambrosy AP, Antohi LE, Ben Gal T, Farmakis D, Gustafsson F, Hill L, Lopatin Y, Tramonte F, Lyon A, Masip J, Miro O, Moura B, Mullens W, Radu RI, Abdelhamid M, Anker S, Chioncel O. Heart failure during the COVID-19 pandemic: clinical, diagnostic, management, and organizational dilemmas. ESC Heart Fail 2022; 9:3713-3736. [PMID: 36111511 PMCID: PMC9773739 DOI: 10.1002/ehf2.14118] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 07/13/2022] [Accepted: 08/04/2022] [Indexed: 01/19/2023] Open
Abstract
The coronavirus 2019 (COVID-19) infection pandemic has affected the care of patients with heart failure (HF). Several consensus documents describe the appropriate diagnostic algorithm and treatment approach for patients with HF and associated COVID-19 infection. However, few questions about the mechanisms by which COVID can exacerbate HF in patients with high-risk (Stage B) or symptomatic HF (Stage C) remain unanswered. Therefore, the type of HF occurring during infection is poorly investigated. The diagnostic differentiation and management should be focused on the identification of the HF phenotype, underlying causes, and subsequent tailored therapy. In this framework, the relationship existing between COVID and onset of acute decompensated HF, isolated right HF, and cardiogenic shock is questioned, and the specific management is mainly based on local hospital organization rather than a standardized model. Similarly, some specific populations such as advanced HF, heart transplant, patients with left ventricular assist device (LVAD), or valve disease remain under investigated. In this systematic review, we examine recent advances regarding the relationships between HF and COVID-19 pandemic with respect to epidemiology, pathogenetic mechanisms, and differential diagnosis. Also, according to the recent HF guidelines definition, we highlight different clinical profile identification, pointing out the main concerns in understudied HF populations.
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Affiliation(s)
- Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio Thoracic and Vascular Department, S. Maria alle Scotte HospitalUniversity of Siena53100SienaItaly
| | - Marco Metra
- Cardiology, Cardio‐Thoracic Department, Civil Hospitals, Brescia, Italy; Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Sean P. Collins
- Department of Emergency MedicineVanderbilt University Medical CentreNashvilleTNUSA
| | - Marianna Adamo
- Cardiology, Cardio‐Thoracic Department, Civil Hospitals, Brescia, Italy; Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Andrew P. Ambrosy
- Department of CardiologyKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA,Division of ResearchKaiser Permanente Northern CaliforniaOaklandCAUSA
| | - Laura E. Antohi
- Emergency Institute for Cardiovascular Diseases “Prof. Dr. C.C.Iliescu” BucharestBucharestRomania
| | - Tuvia Ben Gal
- Department of Cardiology, Rabin Medical Center (Beilinson Campus), Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael
| | - Dimitrios Farmakis
- Cardio‐Oncology Clinic, Heart Failure Unit, “Attikon” University HospitalNational and Kapodistrian University of Athens Medical SchoolAthensGreece,University of Cyprus Medical SchoolNicosiaCyprus
| | | | - Loreena Hill
- School of Nursing and MidwiferyQueen's UniversityBelfastUK
| | - Yuri Lopatin
- Volgograd Medical UniversityCardiology CentreVolgogradRussia
| | - Francesco Tramonte
- Cardiovascular Diseases Unit, Cardio Thoracic and Vascular Department, S. Maria alle Scotte HospitalUniversity of Siena53100SienaItaly
| | - Alexander Lyon
- Cardio‐Oncology ServiceRoyal Brompton Hospital and Imperial College LondonLondonUK
| | - Josep Masip
- Intensive Care Department, Consorci Sanitari IntegralUniversity of BarcelonaBarcelonaSpain,Department of CardiologyHospital Sanitas CIMABarcelonaSpain
| | - Oscar Miro
- Emergency Department, Hospital Clínic de BarcelonaUniversity of BarcelonaBarcelonaSpain
| | - Brenda Moura
- Armed Forces Hospital, Porto, & Faculty of MedicineUniversity of PortoPortoPortugal
| | - Wilfried Mullens
- Cardiovascular PhysiologyHasselt University, Belgium, & Heart Failure and Cardiac Rehabilitation Specialist, Ziekenhuis Oost‐LimburgGenkBelgium
| | - Razvan I. Radu
- Emergency Institute for Cardiovascular Diseases “Prof. Dr. C.C.Iliescu” BucharestBucharestRomania
| | - Magdy Abdelhamid
- Cardiology Department, Kasr Alainy School of MedicineCairo UniversityNew Cairo, 5th settlementCairo11865Egypt
| | - Stefan Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin BerlinBerlinGermany
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases “Prof. Dr. C.C. Iliescu” Bucharest; University for Medicine and Pharmacy “Carol Davila” BucharestBucharestRomania
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Ward MJ, Kripalani S, Muñoz D, Collins SP, Moser K, Jenkins CA, Liu D, Vogus TJ. Association of Physician Coordination With Interfacility Transfer Acceptance Timeliness. Am J Accountable Care 2022; 10:7-15. [PMID: 38617098 PMCID: PMC11014424 DOI: 10.37765/ajac.2022.89231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Objectives Interfacility transfer for time-sensitive emergencies involves rapid and complex care transitions between facilities. We sought to validate relational coordination, a 7-dimension measure of coordination in which a higher score reflects higher-quality coordination, to examine how the quality of coordination affects timeliness in an emergency care setting. Study Design Retrospective observational cohort design. Methods We used a novel method to examine how the quality of coordination between physicians at the time of transfer affects timeliness of physician acceptance. We recorded physician-to-physician conversations from the transfer of patients with ST-segment elevation myocardial infarction (STEMI), a time-sensitive emergency requiring immediate intervention to prevent morbidity and mortality. Results We identified 81 patients experiencing STEMI who were transferred between August 1, 2016, and March 31, 2018. Descriptive statistics, interrater reliability (Spearman correlation coefficients), and generalized linear models were used to examine the association between relational coordination and the physician time-to-acceptance duration. Median (IQR) relational coordination score was 445 (403-493) of a maximum of 700, and median (IQR) time to acceptance was 90.4 (60.2-140.8) seconds. Agreement between abstractors was high (ρ = 0.76). There was a significant, negative relationship between relational coordination and time to acceptance (ρ = -0.38; P < .001). Every 40-point increase in relational coordination was associated with a 25% reduction in time to acceptance. Conclusions Relational coordination not only demonstrated high interrater reliability, but we also found that higher-quality coordination was associated with faster physician acceptance during time-sensitive transfers. Use of such measures may provide a mechanism to improve the quality of care and outcomes for patients with STEMI who experience interfacility transfers.
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Affiliation(s)
- Michael J Ward
- Department of Emergency Medicine (MJW, SPC, KM) and Department of Biomedical Informatics (MJW), Vanderbilt University Medical Center, Nashville, TN; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee (MJW, SPC), Nashville, TN; Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Center for Clinical Quality and Implementation Research, Vanderbilt University School of Medicine (SK), Nashville, TN; Division of Cardiology, Vanderbilt University School of Medicine (DM), Nashville, TN; Department of Biostatistics, Vanderbilt University School of Medicine (CAJ, DL), Nashville, TN; Owen Graduate School of Management, Vanderbilt University (TJV), Nashville, TN
| | - Sunil Kripalani
- Department of Emergency Medicine (MJW, SPC, KM) and Department of Biomedical Informatics (MJW), Vanderbilt University Medical Center, Nashville, TN; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee (MJW, SPC), Nashville, TN; Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Center for Clinical Quality and Implementation Research, Vanderbilt University School of Medicine (SK), Nashville, TN; Division of Cardiology, Vanderbilt University School of Medicine (DM), Nashville, TN; Department of Biostatistics, Vanderbilt University School of Medicine (CAJ, DL), Nashville, TN; Owen Graduate School of Management, Vanderbilt University (TJV), Nashville, TN
| | - Daniel Muñoz
- Department of Emergency Medicine (MJW, SPC, KM) and Department of Biomedical Informatics (MJW), Vanderbilt University Medical Center, Nashville, TN; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee (MJW, SPC), Nashville, TN; Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Center for Clinical Quality and Implementation Research, Vanderbilt University School of Medicine (SK), Nashville, TN; Division of Cardiology, Vanderbilt University School of Medicine (DM), Nashville, TN; Department of Biostatistics, Vanderbilt University School of Medicine (CAJ, DL), Nashville, TN; Owen Graduate School of Management, Vanderbilt University (TJV), Nashville, TN
| | - Sean P Collins
- Department of Emergency Medicine (MJW, SPC, KM) and Department of Biomedical Informatics (MJW), Vanderbilt University Medical Center, Nashville, TN; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee (MJW, SPC), Nashville, TN; Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Center for Clinical Quality and Implementation Research, Vanderbilt University School of Medicine (SK), Nashville, TN; Division of Cardiology, Vanderbilt University School of Medicine (DM), Nashville, TN; Department of Biostatistics, Vanderbilt University School of Medicine (CAJ, DL), Nashville, TN; Owen Graduate School of Management, Vanderbilt University (TJV), Nashville, TN
| | - Kelly Moser
- Department of Emergency Medicine (MJW, SPC, KM) and Department of Biomedical Informatics (MJW), Vanderbilt University Medical Center, Nashville, TN; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee (MJW, SPC), Nashville, TN; Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Center for Clinical Quality and Implementation Research, Vanderbilt University School of Medicine (SK), Nashville, TN; Division of Cardiology, Vanderbilt University School of Medicine (DM), Nashville, TN; Department of Biostatistics, Vanderbilt University School of Medicine (CAJ, DL), Nashville, TN; Owen Graduate School of Management, Vanderbilt University (TJV), Nashville, TN
| | - Cathy A Jenkins
- Department of Emergency Medicine (MJW, SPC, KM) and Department of Biomedical Informatics (MJW), Vanderbilt University Medical Center, Nashville, TN; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee (MJW, SPC), Nashville, TN; Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Center for Clinical Quality and Implementation Research, Vanderbilt University School of Medicine (SK), Nashville, TN; Division of Cardiology, Vanderbilt University School of Medicine (DM), Nashville, TN; Department of Biostatistics, Vanderbilt University School of Medicine (CAJ, DL), Nashville, TN; Owen Graduate School of Management, Vanderbilt University (TJV), Nashville, TN
| | - Dandan Liu
- Department of Emergency Medicine (MJW, SPC, KM) and Department of Biomedical Informatics (MJW), Vanderbilt University Medical Center, Nashville, TN; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee (MJW, SPC), Nashville, TN; Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Center for Clinical Quality and Implementation Research, Vanderbilt University School of Medicine (SK), Nashville, TN; Division of Cardiology, Vanderbilt University School of Medicine (DM), Nashville, TN; Department of Biostatistics, Vanderbilt University School of Medicine (CAJ, DL), Nashville, TN; Owen Graduate School of Management, Vanderbilt University (TJV), Nashville, TN
| | - Timothy J Vogus
- Department of Emergency Medicine (MJW, SPC, KM) and Department of Biomedical Informatics (MJW), Vanderbilt University Medical Center, Nashville, TN; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee (MJW, SPC), Nashville, TN; Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Center for Clinical Quality and Implementation Research, Vanderbilt University School of Medicine (SK), Nashville, TN; Division of Cardiology, Vanderbilt University School of Medicine (DM), Nashville, TN; Department of Biostatistics, Vanderbilt University School of Medicine (CAJ, DL), Nashville, TN; Owen Graduate School of Management, Vanderbilt University (TJV), Nashville, TN
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Davison BA, Takagi K, Edwards C, Adams KF, Butler J, Collins SP, Dorobantu MI, Ezekowitz JA, Filippatos G, Greenberg BH, Levy PD, Masip J, Metra M, Pang PS, Ponikowski P, Severin TM, Teerlink JR, Teichman SL, Voors AA, Werdan K, Cotter G. Neutrophil-to-Lymphocyte Ratio and Outcomes in Patients Admitted for Acute Heart Failure (As Seen in the BLAST-AHF, Pre-RELAX-AHF, and RELAX-AHF Studies). Am J Cardiol 2022; 180:72-80. [PMID: 35933224 DOI: 10.1016/j.amjcard.2022.06.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/13/2022] [Accepted: 06/22/2022] [Indexed: 11/01/2022]
Abstract
Previous studies have suggested that the neutrophil-to-lymphocyte ratio (NLR) is a novel yet readily evaluable inflammatory biomarker that may be useful for determining cardiovascular prognosis during acute episodes. The study investigated the role of NLR in predicting cardiovascular (CV) outcomes in patients with acute heart failure (HF). Individual patient data from the BLAST-AHF (phase 2b study of the biased ligand of the angiotensin 2 type 1 receptor, TRV027), Pre-RELAX-AHF (phase 2b study of recombinant human relaxin-2, serelaxin), and RELAX-AHF (phase 3 study of serelaxin) randomized, placebo-controlled studies for patients with acute HF were pooled for analysis. Dyspnea visual analog scale area under the curve through day 5, worsening HF through day 5, 30-day all-cause mortality, 60-day HF/renal failure rehospitalizations or CV death, 180-day all-cause mortality, and 180-day CV death were assessed. There were several differences in the baseline characteristics of the patients divided by NLR tertile, with patients in the higher NLR having worse clinical characteristics. NLR was an independent predictor of 30-day all-cause mortality (adjusted hazard ratio [HR] per log2 NLR increment: 1.66 [1.22 to 2.25], p = 0.001), 60-day HF/renal failure rehospitalizations or CV death: 1.33 [1.12 to 1.57], p = 0.001), 180-day all-cause mortality (adjusted HR 1.27 [1.08 to 1.50], p = 0.003), and 180-day CV death (adjusted HR 1.24 [1.04 to 1.49], p = 0.018). NLR, a readily available inflammatory biomarker, was associated with independent risk for short- and long-term adverse outcomes in acute HF, surpassing traditional markers, such as natriuretic peptides.
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Affiliation(s)
- Beth A Davison
- Momentum Research, Inc., Chapel Hill, North Carolina; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, Paris, France
| | - Koji Takagi
- Momentum Research, Inc., Chapel Hill, North Carolina
| | | | - Kirkwood F Adams
- Department of Medicine and Radiology, University of North Carolina Chapel Hill, Chapel Hill, North Carolina
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, Mississippi
| | - Sean P Collins
- Vanderbilt University Medical Center Department of Emergency Medicine, Nashville, Tennessee; Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Maria I Dorobantu
- Department 4-Cardiothoracic Pathology, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania; Department of Cardiology, Clinical Emergency Hospital of Bucharest, Bucharest, Romania
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens, Greece
| | - Barry H Greenberg
- Department of Cardiology, University of California, San Diego Medical Center, San Diego, California; Sulpizio Family Cardiovascular Center, University of California, San Diego Medical Center, San Diego, California
| | - Phillip D Levy
- Integrative Biosciences Center, Department of Emergency Medicine, Wayne State University, Detroit, Michigan
| | - Josep Masip
- Research direction, Consorci Sanitari Integral, University of Barcelona, Spain
| | - Marco Metra
- Cardiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Piotr Ponikowski
- Department of Heart Diseases, Wrocław Medical University, Wroclaw, Poland; Center for Heart Diseases, University Hospital in Wrocław, Wroclaw, Poland
| | | | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, California
| | - Sam L Teichman
- Teichman Drug Development Consulting, Lafayette, California
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Karl Werdan
- Clinic for Internal Medicine III, University Hospital Halle (Saale), Martin-Luther University, Halle-Wittenberg, Germany
| | - Gad Cotter
- Momentum Research, Inc., Chapel Hill, North Carolina; Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, Paris, France.
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39
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Kosiborod MN, Angermann CE, Collins SP, Teerlink JR, Ponikowski P, Biegus J, Comin-Colet J, Ferreira JP, Mentz RJ, Nassif ME, Psotka MA, Tromp J, Brueckmann M, Blatchford JP, Salsali A, Voors AA. Effects of Empagliflozin on Symptoms, Physical Limitations, and Quality of Life in Patients Hospitalized for Acute Heart Failure: Results From the EMPULSE Trial. Circulation 2022; 146:279-288. [PMID: 35377706 PMCID: PMC9311476 DOI: 10.1161/circulationaha.122.059725] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients hospitalized for acute heart failure experience poor health status, including a high burden of symptoms and physical limitations, and poor quality of life. SGLT2 (sodium-glucose cotransporter 2) inhibitors improve health status in chronic heart failure, but their effect on these outcomes in acute heart failure is not well characterized. We investigated the effects of the SGLT2 inhibitor empagliflozin on symptoms, physical limitations, and quality of life, using the Kansas City Cardiomyopathy Questionnaire (KCCQ) in the EMPULSE trial (Empagliflozin in Patients Hospitalized With Acute Heart Failure Who Have Been Stabilized). METHODS Patients hospitalized for acute heart failure were randomized to empagliflozin 10 mg daily or placebo for 90 days. The KCCQ was assessed at randomization and 15, 30, and 90 days. The effects of empagliflozin on the primary end point of clinical benefit (hierarchical composite of all-cause death, heart failure events, and a 5-point or greater difference in KCCQ Total Symptom Score [TSS] change from baseline to 90 days) were examined post hoc across the tertiles of baseline KCCQ-TSS. In prespecified analyses, changes (randomization to day 90) in KCCQ domains, including TSS, physical limitations, quality of life, clinical summary, and overall summary scores were evaluated using a repeated measures model. RESULTS In total, 530 patients were randomized (265 each arm). Baseline KCCQ-TSS was low overall (mean [SD], 40.8 [24.0] points). Empagliflozin-treated patients experienced greater clinical benefit across the range of KCCQ-TSS, with no treatment effect heterogeneity (win ratio [95% CIs] from lowest to highest tertile: 1.49 [1.01-2.20], 1.37 [0.94-1.99], and 1.48 [1.00-2.20], respectively; P for interaction=0.94). Beneficial effects of empagliflozin on health status were observed as early as 15 days and persisted through 90 days, at which point empagliflozin-treated patients experienced a greater improvement in KCCQ TSS, physical limitations, quality of life, clinical summary, and overall summary (placebo-adjusted mean differences [95% CI]: 4.45 [95% CI, 0.32-8.59], P=0.03; 4.80 [95% CI, 0.00-9.61], P=0.05; 4.66 [95% CI, 0.32-9.01], P=0.04; 4.85 [95% CI, 0.77-8.92], P=0.02; and 4.40 points [95% CI, 0.33-8.48], P=0.03, respectively). CONCLUSIONS Initiation of empagliflozin in patients hospitalized for acute heart failure produced clinical benefit regardless of the degree of symptomatic impairment at baseline, and improved symptoms, physical limitations, and quality of life, with benefits seen as early as 15 days and maintained through 90 days. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT0415775.
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Affiliation(s)
- Mikhail N. Kosiborod
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (M.N.K., M.E.N.).,School of Medicine, University of Missouri-Kansas City (M.N.K., M.E.N.).,The George Institute for Global Health, University of New South Wales, Sydney, Australia (M.N.K.)
| | - Christiane E. Angermann
- Comprehensive Heart Failure Centre, University and University Hospital of Würzburg, Germany (C.E.A.)
| | - Sean P. Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN (S.P.C.).,Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville (S.P.C.)
| | - John R. Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco (J.R.T.)
| | - Piotr Ponikowski
- Institute of Heart Diseases, Medical University, Wroclaw, Poland (P.P., J.B.)
| | - Jan Biegus
- Institute of Heart Diseases, Medical University, Wroclaw, Poland (P.P., J.B.)
| | - Josep Comin-Colet
- Hospital Universitari de Bellvitge, The Institute of Biomedical Research of Bellvitge (IDIBELL), Barcelona, Spain (J.C.-C.)
| | - João Pedro Ferreira
- Université de Lorraine, Inserm INI-CRCT, CHRU, Nancy, France (J.P.F.).,Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Portugal (J.P.F.)
| | - Robert J. Mentz
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC (R.J.M.)
| | - Michael E. Nassif
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (M.N.K., M.E.N.).,School of Medicine, University of Missouri-Kansas City (M.N.K., M.E.N.)
| | | | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore (J.T.)
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Germany (M.B.).,First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany (M.B.)
| | - Jonathan P. Blatchford
- Elderbrook Solutions GmbH on behalf of Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany (J.P.B.)
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.).,Faculty of Medicine, Rutgers University, New Brunswick, NJ (A.S.)
| | - Adriaan A. Voors
- University of Groningen, Department of Cardiology, University Medical Center Groningen, The Netherlands (A.A.V.)
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Casey JD, Beskow LM, Brown J, Brown SM, Gayat É, Ng Gong M, Harhay MO, Jaber S, Jentzer JC, Laterre PF, Marshall JC, Matthay MA, Rice TW, Rosenberg Y, Turnbull AE, Ware LB, Self WH, Mebazaa A, Collins SP. Use of pragmatic and explanatory trial designs in acute care research: lessons from COVID-19. Lancet Respir Med 2022; 10:700-714. [PMID: 35709825 PMCID: PMC9191864 DOI: 10.1016/s2213-2600(22)00044-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 12/21/2021] [Accepted: 01/20/2022] [Indexed: 12/15/2022]
Abstract
Unique challenges arise when conducting trials to evaluate therapies already in common clinical use, including difficulty enrolling patients owing to widespread open-label use of trial therapies and the need for large sample sizes to detect small but clinically meaningful treatment effects. Despite numerous successes in trials evaluating novel interventions such as vaccines, traditional explanatory trials have struggled to provide definitive answers to time-sensitive questions for acutely ill patients with COVID-19. Pragmatic trials, which can increase efficiency by allowing some or all trial procedures to be embedded into clinical care, are increasingly proposed as a means to evaluate therapies that are in common clinical use. In this Personal View, we use two concurrently conducted COVID-19 trials of hydroxychloroquine (the US ORCHID trial and the UK RECOVERY trial) to contrast the effects of explanatory and pragmatic trial designs on trial conduct, trial results, and the care of patients managed outside of clinical trials. In view of the potential advantages and disadvantages of explanatory and pragmatic trial designs, we make recommendations for their optimal use in the evaluation of therapies in the acute care setting.
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Affiliation(s)
- Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Laura M Beskow
- Vanderbilt Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeremy Brown
- Office of Emergency Care Research, National Institute of Neurological Disorders and Stroke, Division of Clinical Research, National Institutes of Health, Bethesda, MD, USA
| | - Samuel M Brown
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center and University of Utah, Salt Lake City, UT, USA
| | - Étienne Gayat
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France; INSERM UMR-S 942, MASCOT, Université Paris Cité, Paris, France
| | - Michelle Ng Gong
- Division of Critical Care Medicine and Division of Pulmonary Medicine, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Michael O Harhay
- Palliative and Advanced Illness Research (PAIR) Center Clinical Trials Methods and Outcomes Lab, and Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Samir Jaber
- Saint Eloi Intensive Care Unit, Montpellier University Hospital, and PhyMedExp, INSERM, CNRS, Université de Montpellier, Montpellier, France
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Pierre-François Laterre
- Department of Intensive Care, Cliniques St-Luc, Université catholique de Louvain, Brussels, Belgium
| | - John C Marshall
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health, Toronto, ON, Canada
| | - Michael A Matthay
- Cardiovascular Research Institute, University of California, San Francisco, CA, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yves Rosenberg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alexandre Mebazaa
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France; INSERM UMR-S 942, MASCOT, Université Paris Cité, Paris, France
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research, Education,and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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Nigogosyan Z, Ippolito JE, Collins SP, Wang EC. Prostate MRI in Stereotactic Body Radiation Treatment Planning and Delivery for Localized Prostate Cancer. Radiographics 2022; 42:1251-1264. [PMID: 35714039 DOI: 10.1148/rg.210114] [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: 11/11/2022]
Abstract
Prostate MRI is increasingly being used to make diagnoses and guide management for patients receiving definitive radiation treatment for prostate cancer. Radiologists should be familiar with the potential uses of prostate MRI in radiation therapy planning and delivery. Radiation therapy is an established option for the definitive treatment of localized prostate cancer. Stereotactic body radiation therapy (SBRT) is an external-beam radiation therapy method used to deliver a high dose of radiation to an extracranial target in the body, often in five or fewer fractions. SBRT is increasingly being used for prostate cancer treatment and has been recognized by the National Comprehensive Cancer Network as an acceptable definitive treatment regimen for low-, intermediate-, and high-risk prostate cancer. MRI is commonly used to aid in prostate radiation therapy. The authors review the uses of prostate MRI in SBRT treatment planning and delivery. Specific topics discussed include the use of prostate MRI for identification of and dose reduction to the membranous and prostatic urethra, which can decrease the risk of acute and late toxicities. MRI is also useful for identification and appropriate dose coverage of the prostate apex and areas of extraprostatic extension or seminal vesicle invasion. In prospective studies, prostate MRI is being validated for identification of and dose intensification to dominant intraprostatic lesions, which potentially can improve oncologic outcomes. It also can be used to evaluate the placement of fiducial markers and hydrogel spacers for radiation therapy planning and delivery. ©RSNA, 2022.
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Affiliation(s)
- Zack Nigogosyan
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (Z.N., J.E.I.); and Department of Radiation Medicine, MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC 20007 (S.P.C., E.C.W.)
| | - Joseph E Ippolito
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (Z.N., J.E.I.); and Department of Radiation Medicine, MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC 20007 (S.P.C., E.C.W.)
| | - Sean P Collins
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (Z.N., J.E.I.); and Department of Radiation Medicine, MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC 20007 (S.P.C., E.C.W.)
| | - Edina C Wang
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (Z.N., J.E.I.); and Department of Radiation Medicine, MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC 20007 (S.P.C., E.C.W.)
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Rios-Colon L, Chijioke J, Niture S, Afzal Z, Qi Q, Srivastava A, Ramalinga M, Kedir H, Cagle P, Arthur E, Sharma M, Moore J, Deep G, Suy S, Collins SP, Kumar D. Leptin modulated microRNA-628-5p targets Jagged-1 and inhibits prostate cancer hallmarks. Sci Rep 2022; 12:10073. [PMID: 35710817 PMCID: PMC9203512 DOI: 10.1038/s41598-022-13279-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 05/23/2022] [Indexed: 02/07/2023] Open
Abstract
MicroRNAs (miRNAs) are single-stranded non-coding RNA molecules that play a regulatory role in gene expression and cancer cell signaling. We previously identified miR-628-5p (miR-628) as a potential biomarker in serum samples from men with prostate cancer (PCa) (Srivastava et al. in Tumour Biol 35:4867–4873, 10.1007/s13277-014-1638-1, 2014). This study examined the detailed cellular phenotypes and pathways regulated by miR-628 in PCa cells. Since obesity is a significant risk factor for PCa, and there is a correlation between levels of the obesity-associated hormone leptin and PCa development, here we investigated the functional relationship between leptin and miR-628 regulation in PCa. We demonstrated that exposure to leptin downregulated the expression of miR-628 and increased cell proliferation/migration in PCa cells. We next studied the effects on cancer-related phenotypes in PCa cells after altering miR-628 expression levels. Enforced expression of miR-628 in PCa cells inhibited cell proliferation, reduced PCa cell survival/migration/invasion/spheroid formation, and decreased markers of cell stemness. Mechanistically, miR-628 binds with the JAG1-3′UTR and inhibits the expression of Jagged-1 (JAG1). JAG1 inhibition by miR-628 downregulated Notch signaling, decreased the expression of Snail/Slug, and modulated epithelial-mesenchymal transition and invasiveness in PC3 cells. Furthermore, expression of miR-628 in PCa cells increased sensitivity towards the drugs enzalutamide and docetaxel by induction of cell apoptosis. Collectively our data suggest that miR-628 is a key regulator of PCa carcinogenesis and is modulated by leptin, offering a novel therapeutic opportunity to inhibit the growth of advanced PCa.
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Affiliation(s)
- Leslimar Rios-Colon
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA.,Department of Cancer Biology, Wake Forest Baptist Medical Center, Winston-Salem, NC, 27157, USA
| | - Juliet Chijioke
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA
| | - Suryakant Niture
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA
| | - Zainab Afzal
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA
| | - Qi Qi
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA
| | - Anvesha Srivastava
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA
| | - Malathi Ramalinga
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA
| | - Habib Kedir
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA
| | - Patrice Cagle
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA
| | - Elena Arthur
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA
| | - Mitu Sharma
- Department of Cancer Biology, Wake Forest Baptist Medical Center, Winston-Salem, NC, 27157, USA
| | - John Moore
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA
| | - Gagan Deep
- Department of Cancer Biology, Wake Forest Baptist Medical Center, Winston-Salem, NC, 27157, USA.,Wake Forest Baptist Comprehensive Cancer Center, Wake Forest Baptist Medical Center, Winston-Salem, NC, 27157, USA
| | - Simeng Suy
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, 20057, USA
| | - Sean P Collins
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, 20057, USA
| | - Deepak Kumar
- Julius L. Chambers Biomedical/Biotechnology Research Institute (BBRI), North Carolina Central University, 1801 Fayetteville St., Durham, NC, 27707, USA.
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Sax DR, Mark DG, Rana JS, Collins SP, Huang J, Reed ME. Risk adjusted 30‐day mortality and serious adverse event rates among a large, multi‐center cohort of emergency department patients with acute heart failure. J Am Coll Emerg Physicians Open 2022; 3:e12742. [PMID: 35706908 PMCID: PMC9182626 DOI: 10.1002/emp2.12742] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/18/2022] [Accepted: 04/27/2022] [Indexed: 12/02/2022] Open
Abstract
Background Admission rates for emergency department (ED) patients with acute heart failure (AHF) remain elevated. Use of a risk stratification tool could improve disposition decision making by identifying low‐risk patients who may be safe for outpatient management. Methods We performed a secondary analysis of a retrospective, multi‐center cohort of 26,189 ED patients treated for AHF from January 1, 2017 to December 31, 2018. We applied a 30‐day risk model we previously developed and grouped patients into 4 categories (low, low/moderate, moderate, and high) of predicted 30‐day risk of a serious adverse event (SAE). SAE consisted of death or cardiopulmonary resuscitation (CPR), intra‐aorta balloon pump, endotracheal intubation, renal failure requiring dialysis, or acute coronary syndrome. We measured the 30‐day mortality and composite SAE rates among patients by risk category according to ED disposition: direct discharge, discharge after observation, and hospital admission. Results The observed 30‐day mortality and total SAE rates were less than 1% and 2%, respectively, among 25% of patients in the low and low/moderate risk groups. These rates did not vary significantly by ED disposition. An additional 23% of patients were moderate risk and experienced an approximate 2% 30‐day mortality rate. Conclusion Use of a risk stratification tool could help identify lower risk AHF patients who may be appropriate for ED discharge. These findings will help inform prospective testing to determine how this risk tool can augment ED decision making.
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Affiliation(s)
- Dana R. Sax
- Department of Emergency Medicine Kaiser Permanente Northern California Oakland and Richmond Medical Centers Oakland California USA
- Division of Research Kaiser Permanente Northern California Oakland California USA
| | - Dustin G. Mark
- Department of Emergency Medicine Kaiser Permanente Northern California Oakland and Richmond Medical Centers Oakland California USA
- Division of Research Kaiser Permanente Northern California Oakland California USA
| | - Jamal S. Rana
- Division of Research Kaiser Permanente Northern California Oakland California USA
- Department of Cardiology Kaiser Permanente Northern California Oakland and Richmond Medical Centers Oakland California USA
| | - Sean P. Collins
- Department of Emergency Medicine Vanderbilt University Medical Center Vanderbilt Tennessee USA
| | - Jie Huang
- Division of Research Kaiser Permanente Northern California Oakland California USA
| | - Mary E. Reed
- Division of Research Kaiser Permanente Northern California Oakland California USA
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Joshi M, Kim SE, Solanki AA, Miyamoto DT, Degraff D, Zou JW, Meeks JJ, Mitin T, Collins SP, Trabulsi EJ, Hahn NM, Efstathiou JA, Carducci MA. EA8185: Phase 2 study of bladder-sparing chemoradiation (chemoRT) with durvalumab in clinical stage III, node-positive urothelial carcinoma (INSPIRE), an ECOG-ACRIN/NRG collaboration. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.tps4617] [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: 11/20/2022] Open
Abstract
TPS4617 Background: Patients [pts] withlymph node positive (LN+), non-metastatic bladder cancer (BC) have a better prognosis than those with metastatic (M1) disease. However, this population is under-represented in advanced bladder trials and ineligible for bladder-sparing trials. Therefore, there have been no larger prospective trials establishing the standard of care in LN+ BC. Given the promise of immunotherapy in advanced BC and potential synergy between immunotherapy and radiation, INSPIRE was designed to determine the role of concurrent and adjuvant durvalumab (durva) in this patient population when treated with induction chemotherapy (IC) followed by concurrent chemoRT. Methods: This is a randomized phase II study that is enrolling BC pts with stage III [N1-3 M0], pure or mixed urothelial cancer. Pts must have received ≥3 cycles of IC [either before or after registration, prior to randomization] without progression. LN+ is defined as radiologically LN ≥1.0 cm in short axis, with or without biopsy prior to IC. As long as pts do not progress on induction chemotherapy, they will be randomized to chemoRT+/- durva using 5 stratification factors (Simon Pocock minimization method) a) IC prior vs. post registration b) cisplatin vs non-cisplatin regimen during RT c) LN size d) response to IC e) extent of TURBT. Pts on the chemoRT+durva arm will get chemotherapy per physician choice + IMRT + 3 x doses of Q3wk durva for 6.5-8 wks, whereas those on the control arm will get chemoRT alone. The primary end point is clinical complete response [CR], defined as no radiologically measurable disease in the LNs and negative cystoscopy and bladder biopsy 8-10 weeks post-chemoRT +/- durva. Pts on the chemoRT + durva arm who have a CR or clinical benefit ( > T0 and ≤T2 in bladder per cystoscopy, biopsy + CR/PR/SD in LN by imaging) will get adjuvant Q4wk durva for 9 doses, while those on the chemoRT arm will undergo observation. Secondary end points include OS, PFS, bladder-intact event-free survival, rate of toxicity and salvage cystectomy. This study is designed to detect an improvement of 25% in clinical CR between both arms (37.5% to 62.5%). A total accrual of 114 pts (in order to enroll 92 evaluable pts) will provide 81% power to detect this difference using a Fisher’s exact test (assuming 10% drop out + anticipating that 20% chemotherapy-naïve pts will progress post IC). We are banking blood and primary tumor tissue pre- and post-chemoRT in both groups. The study was activated in August 2020 and accrual is ongoing. We expanded eligibility to include N3 in 9/2021. INSPIRE is the first prospective study designed for only LN+ BC and will define both short-term and long-term outcomes for bladder sparing in this patient population and has the potential to define a new treatment strategy for stage III BC. Clinical trial information: NCT04216290.
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Affiliation(s)
| | - Se Eun Kim
- Dana Farber Cancer Institute-ECOG-ACRIN Biostatistics Center, Boston, MA
| | | | | | - David Degraff
- Pennsylvania State University College of Medicine, Hershey, PA
| | | | | | - Timur Mitin
- Department of Radiation Medicine, Oregon Health and Science University, Portland, OR
| | | | - Edouard John Trabulsi
- Department of Urology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - Noah M. Hahn
- Johns Hopkins Greenberg Bladder Center Institute, Johns Hopkins School of Medicine, Baltimore, MD
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Nelson LA, Spieker AJ, Kripalani S, Rothman RL, Roumie CL, Coco J, Fabbri D, Levy P, Collins SP, McNaughton CD. User preferences for and engagement with text messages to support antihypertensive medication adherence: Findings from a pilot study evaluating an emergency department-based behavioral intervention. Patient Educ Couns 2022; 105:1606-1613. [PMID: 34690012 PMCID: PMC9001748 DOI: 10.1016/j.pec.2021.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 07/22/2021] [Accepted: 10/08/2021] [Indexed: 05/07/2023]
Abstract
OBJECTIVE We examined users' preferences for and engagement with text messages delivered as part of an emergency department (ED)-based intervention to improve antihypertensive medication adherence. METHODS We recruited ED patients with elevated blood pressure for a pilot randomized trial evaluating a medication adherence intervention with text messages. Intervention participants chose text content and frequency, received texts for 45 days, and completed a feedback survey. We defined engagement via responses to texts. We examined participant characteristics associated with text preferences, engagement, and feedback. RESULTS Participants (N = 101) were 57% female and 46% non-White. Most participants (71%) chose to receive both reminder and informational texts; 94% chose reminder texts once per day and 97% chose informational texts three times per week. Median text message response rate was 56% (IQR 26-80%). Participants who were Black (p < 0.01), had lower income (p = 0.03), or had lower medication adherence (p < 0.01) rated the program as more helpful and wanted additional functionalities for adherence support. CONCLUSIONS AND PRACTICE IMPLICATIONS While overall engagement was modest, participants at risk of worse health outcomes expressed more value and interest in the program. Findings inform the design of text messaging interventions for antihypertensive medication adherence and support targeting vulnerable patients to reduce health disparities. CLINICAL TRIALS REGISTRATION NCT02672787.
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Affiliation(s)
- Lyndsay A Nelson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, USA; Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, USA.
| | - Andrew J Spieker
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, USA
| | - Sunil Kripalani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, USA; Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, USA
| | - Russell L Rothman
- Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, USA
| | - Christianne L Roumie
- Department of Medicine, Vanderbilt University Medical Center, Nashville, USA; Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, USA; Geriatric Research Education Clinical Center, Tennessee Valley Healthcare System VA Medical Center, Nashville, USA
| | - Joseph Coco
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, USA
| | - Daniel Fabbri
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, USA
| | - Phillip Levy
- Department of Emergency Medicine, Wayne State University, Detroit, USA
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, USA; Geriatric Research Education Clinical Center, Tennessee Valley Healthcare System VA Medical Center, Nashville, USA
| | - Candace D McNaughton
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, USA; Geriatric Research Education Clinical Center, Tennessee Valley Healthcare System VA Medical Center, Nashville, USA
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Sax DR, Mark DG, Rana JS, Reed ME, Lindenfeld J, Stevenson LW, Storrow AB, Butler J, Pang PS, Collins SP. Current Emergency Department Disposition of Patients with Acute Heart Failure: An Opportunity for Improvement. J Card Fail 2022; 28:1545-1559. [DOI: 10.1016/j.cardfail.2022.05.006] [Citation(s) in RCA: 1] [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] [Received: 02/24/2022] [Revised: 05/06/2022] [Accepted: 05/12/2022] [Indexed: 12/26/2022]
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Repka MC, Creswell M, Lischalk JW, Carrasquilla M, Forsthoefel M, Lee J, Lei S, Aghdam N, Kataria S, Obayomi-Davies O, Collins BT, Suy S, Hankins RA, Collins SP. Rationale for Utilization of Hydrogel Rectal Spacers in Dose Escalated SBRT for the Treatment of Unfavorable Risk Prostate Cancer. Front Oncol 2022; 12:860848. [PMID: 35433457 PMCID: PMC9008358 DOI: 10.3389/fonc.2022.860848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
In this review we outline the current evidence for the use of hydrogel rectal spacers in the treatment paradigm for prostate cancer with external beam radiation therapy. We review their development, summarize clinical evidence, risk of adverse events, best practices for placement, treatment planning considerations and finally we outline a framework and rationale for the utilization of rectal spacers when treating unfavorable risk prostate cancer with dose escalated Stereotactic Body Radiation Therapy (SBRT).
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Affiliation(s)
- Michael C Repka
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Michael Creswell
- Georgetown University School of Medicine, Washington, DC, United States
| | - Jonathan W Lischalk
- Department of Radiation Oncology at New York University (NYU) Long Island School of Medicine, Perlmutter Cancer Center at NYCyberKnife, New York, NY, United States
| | - Michael Carrasquilla
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Matthew Forsthoefel
- Department of Radiation Oncology, Radiotherapy Centers of Kentuckiana, Louisville, KY, United States
| | - Jacqueline Lee
- Georgetown University School of Medicine, Washington, DC, United States
| | - Siyuan Lei
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Nima Aghdam
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Shaan Kataria
- Department of Radiation Oncology, Arlington & Reston Radiation Oncology, Arlington, VA, United States
| | - Olusola Obayomi-Davies
- Department of Radiation Oncology, Wellstar Kennestone Hospital, Marietta, GA, United States
| | - Brian T Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Simeng Suy
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Ryan A Hankins
- Department of Urology, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Sean P Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, United States
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Sholklapper TN, Creswell ML, Payne AT, Markel M, Pepin A, Carrasquilla M, Zwart A, Danner M, Ayoob M, Yung T, Collins B, Kumar D, Aghdam N, Suy S, Hankins RA, Kowalczyk K, Collins SP. Patient-Reported Financial Burden Following Stereotactic Body Radiation Therapy for Localized Prostate Cancer. Front Oncol 2022; 12:852844. [PMID: 35402242 PMCID: PMC8990911 DOI: 10.3389/fonc.2022.852844] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/28/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction and Objectives In patients with localized prostate cancer, 5-fraction, stereotactic body radiation therapy (SBRT) has been found to offer comparable oncologic outcomes and potential for improved treatment compliance compared to conventional, 40-plus fraction radiation therapy (RT). Recent studies of oncologic patient experiences have highlighted both the impact of therapy-associated financial toxicity (FT) on treatment adherence and health-related quality of life (HRQOL). Methods A cross-sectional assessment of FT after SBRT was performed using the 12-item COST questionnaire. The total questionnaire score (range 0–44) was used to evaluate the FT grade (0–3), with a higher COST value representing lower grade. The patient zip code was used to approximate the distance from the index hospital. Univariate and multivariate analyses of the average COST score (0–4) are performed. Results The response rate was 57.5% (332 of 575 consented patients) with 90.7%, 8.2%, and 1.1% experiencing grade 0, 1, and 2 FT, respectively, with no grade 3. Unemployment or disability, non-white race, low income, and concurrent hormonal therapy were associated with a statistically significant worse FT (lower COST value) on univariate and multivariate analyses (p < 0.05). Education level and insurance status significant were evaluated on univariate analysis only. There was a non-statistically significant difference in age, marital status, time since treatment, and distance from the index hospital. Conclusions SBRT was associated with low FT. However, statistically significant socioeconomic disparities in FT remain despite ultra-hypofractionated treatment.
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Affiliation(s)
| | | | - Alexandra T Payne
- Georgetown University School of Medicine, Washington, DC, United States
| | - Michael Markel
- Georgetown University School of Medicine, Washington, DC, United States
| | - Abigail Pepin
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Michael Carrasquilla
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Alan Zwart
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Malika Danner
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Marilyn Ayoob
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Thomas Yung
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Brian Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Deepak Kumar
- Julius L. Chambers Biomedical Biotechnology Research Institute, North Carolina Central University, Durham, NC, United States
| | - Nima Aghdam
- Department of Radiation Medicine, Beth Israel Deaconess, Boston, MA, United States
| | - Simeng Suy
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
| | - Ryan A Hankins
- Department of Urology, Georgetown University Hospital, Washington, DC, United States
| | - Keith Kowalczyk
- Department of Urology, Georgetown University Hospital, Washington, DC, United States
| | - Sean P Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, United States
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49
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Fermann GJ, Schrock JW, Levy PD, Pang P, Butler J, Chang AM, Char D, Diercks D, Han JH, Hiestand B, Hogan C, Jenkins CA, Kampe C, Khan Y, Kumar VA, Lee S, Lindenfeld J, Liu D, Miller KF, Peacock WF, Reilly CM, Robichaux C, Rothman RL, Self WH, Singer AJ, Sterling SA, Storrow AB, Stubblefield WB, Walsh C, Wilburn J, Collins SP. Troponin is unrelated to outcomes in heart failure patients discharged from the emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12695. [PMID: 35434709 PMCID: PMC8994616 DOI: 10.1002/emp2.12695] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/03/2022] [Accepted: 02/10/2022] [Indexed: 11/26/2022] Open
Abstract
Background Prior data has demonstrated increased mortality in hospitalized patients with acute heart failure (AHF) and troponin elevation. No data has specifically examined the prognostic significance of troponin elevation in patients with AHF discharged after emergency department (ED) management. Objective Evaluate the relationship between troponin elevation and outcomes in patients with AHF who are treated and released from the ED. Methods This was a secondary analysis of the Get with the Guidelines to Reduce Disparities in AHF Patients Discharged from the ED (GUIDED‐HF) trial, a randomized, controlled trial of ED patients with AHF who were discharged. Patients with elevated conventional troponin not due to acute coronary syndrome (ACS) were included. Our primary outcome was a composite endpoint: time to 30‐day cardiovascular death and/or heart failure‐related events. Results Of the 491 subjects included in the GUIDED‐HF trial, 418 had troponin measured during the ED evaluation and 66 (16%) had troponin values above the 99th percentile. Median age was 63 years (interquartile range, 54‐70), 62% (n = 261) were male, 63% (n = 265) were Black, and 16% (n = 67) experienced our primary outcome. There were no differences in our primary outcome between those with and without troponin elevation (12/66, 18.1% vs 55/352, 15.6%; P = 0.60). This effect was maintained regardless of assignment to usual care or the intervention arm. In multivariable regression analysis, there was no association between our primary outcome and elevated troponin (hazard ratio, 1.00; 95% confidence interval, 0.49–2.01, P = 0.994) Conclusion If confirmed in a larger cohort, these findings may facilitate safe ED discharge for a group of patients with AHF without ACS when an elevated troponin is the primary reason for admission.
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Affiliation(s)
- Gregory J. Fermann
- Department of Emergency Medicine University of Cincinnati Cincinnati Ohio USA
| | - Jon W. Schrock
- Department of Emergency Medicine Metro Health Cleveland Ohio USA
| | - Phillip D. Levy
- Department of Emergency Medicine Wayne State University Detroit Michigan USA
| | - Peter Pang
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis Indiana USA
| | - Javed Butler
- Division of Cardiovascular Medicine Stony Brook University Stony Brook New York USA
| | - Anna Marie Chang
- Department of Emergency Medicine Thomas Jefferson University Philadelphia Pennsylvania USA
| | - Douglas Char
- Division of Emergency Medicine Washington University St. Louis Missouri USA
| | - Deborah Diercks
- Department of Emergency Medicine University of Texas‐Southwestern Dallas Texas USA
| | - Jin H. Han
- Department of Emergency Medicine Metro Health Cleveland Ohio USA
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis Indiana USA
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - Brian Hiestand
- Department of Emergency Medicine Wake Forest University Winston‐Salem North Carolina USA
| | - Chris Hogan
- Department of Emergency Medicine Virginia Commonwealth University Richmond Virginia USA
| | - Cathy A. Jenkins
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - Christy Kampe
- Department of Biostatistics Vanderbilt University Nashville Tennessee USA
| | - Yosef Khan
- American Heart Association/American Stroke Association Dallas Texas USA
| | - Vijaya A. Kumar
- Department of Emergency Medicine Wayne State University Detroit Michigan USA
| | - Sangil Lee
- Department of Emergency Medicine University of Iowa Iowa City Iowa USA
| | - JoAnn Lindenfeld
- Division of Cardiovascular Disease Vanderbilt University Medical Center Nashville Tennessee USA
| | - Dandan Liu
- Department of Biostatistics Vanderbilt University Nashville Tennessee USA
| | - Karen F. Miller
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - W. Frank Peacock
- Department of Emergency Medicine Baylor College of Medicine Houston Texas USA
| | - Carolyn M. Reilly
- Department of Emergency Medicine Emory University Atlanta Georgia USA
| | - Chad Robichaux
- Department of Medicine Emory University School of Medicine Atlanta Georgia USA
| | - Russell L. Rothman
- Department of Internal Medicine Pediatrics & Health Policy Vanderbilt University Nashville Tennessee USA
| | - Wesley H. Self
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - Adam J. Singer
- Department of Emergency Medicine Renaissance School of Medicine at Stony Brook University Stony Brook New York USA
| | - Sarah A. Sterling
- Department of Emergency Medicine University of Mississippi Medical Center Jackson Mississippi USA
| | - Alan B. Storrow
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - William B. Stubblefield
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
| | - Cheryl Walsh
- Geriatric Research Education and Clinical Center Tennessee Valley Healthcare System Nashville Tennessee USA
| | - John Wilburn
- Department of Emergency Medicine Wayne State University Detroit Michigan USA
| | - Sean P. Collins
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville Tennessee USA
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50
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Forsthoefel M, Hankins R, Ballew E, Frame C, DeBlois D, Pang D, Krishnan P, Unger K, Kowalczyk K, Lynch J, Dritschilo A, Collins SP, Lischalk JW. Prostate Cancer Treatment with Pencil Beam Proton Therapy Using Rectal Spacers sans Endorectal Balloons. Int J Part Ther 2022; 9:28-41. [PMID: 35774493 PMCID: PMC9238133 DOI: 10.14338/ijpt-21-00039] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 02/01/2022] [Indexed: 11/21/2022] Open
Abstract
Purpose Proton beam radiotherapy (PBT) has been used for the definitive treatment of localized prostate cancer with low rates of high-grade toxicity and excellent patient-reported quality-of-life metrics. Technological advances such as pencil beam scanning (PBS), Monte Carlo dose calculations, and polyethylene glycol gel rectal spacers have optimized prostate proton therapy. Here, we report the early clinical outcomes of patients treated for localized prostate cancer using modern PBS–PBT with hydrogel rectal spacing and fiducial tracking without the use of endorectal balloons. Materials and Methods This is a single institutional review of consecutive patients treated with histologically confirmed localized prostate cancer. Prior to treatment, all patients underwent placement of fiducials into the prostate and insertion of a hydrogel rectal spacer. Patients were typically given a prescription dose of 7920 cGy at 180 cGy per fraction using a Monte Carlo dose calculation algorithm. Acute and late toxicity were evaluated using the Common Terminology Criteria for Adverse Events (CTCAE), version 5. Biochemical failure was defined using the Phoenix definition. Results From July 2018 to April 2020, 33 patients were treated (median age, 75 years). No severe acute toxicities were observed. The most common acute toxicity was urinary frequency. With a median follow-up of 18 months, there were no high-grade genitourinary late toxicities; however, one grade 3 gastrointestinal toxicity was observed. Late erectile dysfunction was common. One treatment failure was observed at 21 months in a patient treated for high-risk prostate cancer. Conclusion Early clinical outcomes of patients treated with PBS–PBT using Monte Carlo–based planning, fiducial placement, and rectal spacers sans endorectal balloons demonstrate minimal treatment-related toxicity with good oncologic outcomes. Rectal spacer stabilization without the use of endorectal balloons is feasible for the use of PBS–PBT.
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Affiliation(s)
- Matthew Forsthoefel
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Ryan Hankins
- Department of Urology, Georgetown University Hospital, Washington, DC, USA
| | - Elizabeth Ballew
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Cara Frame
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA
| | - David DeBlois
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Dalong Pang
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Pranay Krishnan
- Department of Radiology, Georgetown University Hospital, Washington, DC, USA
| | - Keith Unger
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Keith Kowalczyk
- Department of Urology, Georgetown University Hospital, Washington, DC, USA
| | - John Lynch
- Department of Urology, Georgetown University Hospital, Washington, DC, USA
| | - Anatoly Dritschilo
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Sean P. Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA
| | - Jonathan W. Lischalk
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Hospital – Long Island, New York, NY, USA
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