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Howell SJ, Agrawal H, Gerstenfeld EP. A Case of Alcohol Leading to Isolation in the Electrophysiology Laboratory. JACC Clin Electrophysiol 2023; 9:2680-2684. [PMID: 37831031 DOI: 10.1016/j.jacep.2023.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/16/2023] [Accepted: 08/23/2023] [Indexed: 10/14/2023]
Affiliation(s)
- Stacey J Howell
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California-San Francisco, San Francisco, California, USA
| | - Harsh Agrawal
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California-San Francisco, San Francisco, California, USA
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California-San Francisco, San Francisco, California, USA.
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2
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Affiliation(s)
- Stacey J Howell
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California San Francisco (S.J.H.)
| | - Eric C Stecker
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health and Science University, Portland (E.C.S.)
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3
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Wong CX, Howell SJ, Lee RJ. Endocardial-to-Epicardial Wenckebach Conduction in the Left Atrium: Implications for 3-Dimensional Re-Entry During Atrial Fibrillation. JACC Clin Electrophysiol 2023; 9:1836-1837. [PMID: 37354185 DOI: 10.1016/j.jacep.2023.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 04/05/2023] [Accepted: 04/27/2023] [Indexed: 06/26/2023]
Affiliation(s)
- Christopher X Wong
- Division of Electrophysiology, Department of Cardiology, University of California-San Francisco, San Francisco, California, USA
| | - Stacey J Howell
- Division of Electrophysiology, Department of Cardiology, University of California-San Francisco, San Francisco, California, USA
| | - Randall J Lee
- Division of Electrophysiology, Department of Cardiology, University of California-San Francisco, San Francisco, California, USA.
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Thomas C, Ayres M, Pye K, Yassin D, Howell SJ, Alderson S. Process, structural, and outcome quality indicators to support perioperative opioid stewardship: a rapid review. Perioper Med (Lond) 2023; 12:34. [PMID: 37430326 DOI: 10.1186/s13741-023-00312-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 05/19/2023] [Indexed: 07/12/2023] Open
Abstract
Opioids are effective analgesics but can cause harm. Opioid stewardship is key to ensuring that opioids are used effectively and safely. There is no agreed set of quality indicators relating to the use of opioids perioperatively. This work is part of the Yorkshire Cancer Research Bowel Cancer Quality Improvement programme and aims to develop useful quality indicators for the improvement of care and patient outcomes at all stages of the perioperative journey.A rapid review was performed to identify original research and reviews in which quality indicators for perioperative opioid use are described. A data tool was developed to enable reliable and reproducible extraction of opioid quality indicators.A review of 628 abstracts and 118 full-text publications was undertaken. Opioid quality indicators were identified from 47 full-text publications. In total, 128 structure, process and outcome quality indicators were extracted. Duplicates were merged, with the final extraction of 24 discrete indicators. These indicators are based on five topics: patient education, clinician education, pre-operative optimization, procedure, and patient-specific prescribing and de-prescribing and opioid-related adverse drug events.The quality indicators are presented as a toolkit to contribute to practical opioid stewardship. Process indicators were most commonly identified and contribute most to quality improvement. Fewer quality indicators relating to intraoperative and immediate recovery stages of the patient journey were identified. An expert clinician panel will be convened to agree which of the quality indicators identified will be most valuable in our region for the management of patients undergoing surgery for bowel cancer.
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Affiliation(s)
- C Thomas
- Department of Anaesthesia, St. James' University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, LS9 7TF, UK.
| | - M Ayres
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - K Pye
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - D Yassin
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - S J Howell
- Leeds Institute of Health Research, University of Leeds, Leeds, UK
| | - S Alderson
- Primary Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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5
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Howell SJ, Dukes JW, Vittinghoff E, Tang J, Moss JD, Lee RJ, Lee BK, Tseng ZH, Vedantham V, Olgin JE, Scheinman MM, Hsia H, Gerstenfeld EP, Marcus GM. Premature Atrial Contraction Location and Atrial Fibrillation Inducibility. Circ Arrhythm Electrophysiol 2023; 16:e011623. [PMID: 36688298 PMCID: PMC9974680 DOI: 10.1161/circep.122.011623] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Stacey J. Howell
- Section of Electrophysiology, Division of Cardiology, University of California, San Francisco
| | | | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Janet Tang
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Joshua D. Moss
- Section of Electrophysiology, Division of Cardiology, University of California, San Francisco
| | - Randall J. Lee
- Section of Electrophysiology, Division of Cardiology, University of California, San Francisco
| | - Byron K. Lee
- Section of Electrophysiology, Division of Cardiology, University of California, San Francisco
| | - Zian H. Tseng
- Section of Electrophysiology, Division of Cardiology, University of California, San Francisco
| | - Vasanth Vedantham
- Section of Electrophysiology, Division of Cardiology, University of California, San Francisco
| | - Jeffrey E Olgin
- Section of Electrophysiology, Division of Cardiology, University of California, San Francisco
| | - Melvin M. Scheinman
- Section of Electrophysiology, Division of Cardiology, University of California, San Francisco
| | - Henry Hsia
- Section of Electrophysiology, Division of Cardiology, University of California, San Francisco
| | - Edward P. Gerstenfeld
- Section of Electrophysiology, Division of Cardiology, University of California, San Francisco
| | - Gregory M. Marcus
- Section of Electrophysiology, Division of Cardiology, University of California, San Francisco
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Howell SJ, Moss JD. Adding epicardial ablation for ventricular tachycardia: a 1-2 punch, or simply 3rd time's the charm? J Interv Card Electrophysiol 2023; 66:95-97. [PMID: 35403928 DOI: 10.1007/s10840-022-01216-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/05/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Stacey J Howell
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, CA, USA
| | - Joshua D Moss
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, CA, USA.
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7
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Higuchi S, Po SS, Howell SJ, Scheinman MM, Hsia HH. Atrial Activation Detour. JACC Clin Electrophysiol 2022; 8:1173-1184. [DOI: 10.1016/j.jacep.2022.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/11/2022] [Accepted: 05/16/2022] [Indexed: 10/16/2022]
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Howell SJ, Simpson T, Atkinson T, Pellegrini CN, Nazer B. Temporal and geographical trends in women operators of electrophysiology procedures in the United States. Heart Rhythm 2022; 19:807-811. [DOI: 10.1016/j.hrthm.2022.02.015] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/02/2022] [Accepted: 02/04/2022] [Indexed: 11/04/2022]
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Rosenblatt AG, Ayers CR, Rao A, Howell SJ, Hendren NS, Zadikany RH, Ebinger JE, Daniels JD, Link MS, de Lemos JA, Das SR. New-Onset Atrial Fibrillation in Patients Hospitalized With COVID-19: Results From the American Heart Association COVID-19 Cardiovascular Registry. Circ Arrhythm Electrophysiol 2022; 15:e010666. [PMID: 35475654 DOI: 10.1161/circep.121.010666] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [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] [Indexed: 12/30/2022]
Abstract
BACKGROUND New-onset atrial fibrillation (AF) in patients hospitalized with COVID-19 has been reported and associated with poor clinical outcomes. We aimed to understand the incidence of and outcomes associated with new-onset AF in a diverse and representative US cohort of patients hospitalized with COVID-19. METHODS We used data from the American Heart Association COVID-19 Cardiovascular Disease Registry. Patients were stratified by the presence versus absence of new-onset AF. The primary and secondary outcomes were in-hospital mortality and major adverse cardiovascular events (MACE; cardiovascular death, myocardial infarction, stroke, cardiogenic shock, and heart failure). The association of new-onset AF and the primary and secondary outcomes was evaluated using Cox proportional-hazards models for the primary time to event analyses. RESULTS Of the first 30 999 patients from 120 institutions across the United States hospitalized with COVID-19, 27 851 had no history of AF. One thousand five hundred seventeen (5.4%) developed new-onset AF during their index hospitalization. New-onset AF was associated with higher rates of death (45.2% versus 11.9%) and MACE (23.8% versus 6.5%). The unadjusted hazard ratio for mortality was 1.99 (95% CI, 1.81-2.18) and for MACE was 2.23 (95% CI, 1.98-2.53) for patients with versus without new-onset AF. After adjusting for demographics, clinical comorbidities, and severity of disease, the associations with death (hazard ratio, 1.10 [95% CI, 0.99-1.23]) fully attenuated and MACE (hazard ratio, 1.31 [95% CI, 1.14-1.50]) partially attenuated. CONCLUSIONS New-onset AF was common (5.4%) among patients hospitalized with COVID-19. Almost half of patients with new-onset AF died during their index hospitalization. After multivariable adjustment for comorbidities and disease severity, new-onset AF was not statistically significantly associated with death, suggesting that new-onset AF in these patients may primarily be a marker of other adverse clinical factors rather than an independent driver of mortality. Causality between the MACE composites and AF needs to be further evaluated.
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Affiliation(s)
- Anna G Rosenblatt
- Division of Cardiology, Department of Medicine, University of Texas Southwestern, Dallas, TX (A.G.R., C.R.A., A.R., N.S.H., J.D.D., M.S.L., J.A.d.L., S.R.D.)
| | - Colby R Ayers
- Division of Cardiology, Department of Medicine, University of Texas Southwestern, Dallas, TX (A.G.R., C.R.A., A.R., N.S.H., J.D.D., M.S.L., J.A.d.L., S.R.D.)
| | - Anjali Rao
- Division of Cardiology, Department of Medicine, University of Texas Southwestern, Dallas, TX (A.G.R., C.R.A., A.R., N.S.H., J.D.D., M.S.L., J.A.d.L., S.R.D.)
| | - Stacey J Howell
- Division of Cardiology, Department of Medicine, University of San Francisco, CA (S.J.H.)
| | - Nicholas S Hendren
- Division of Cardiology, Department of Medicine, University of Texas Southwestern, Dallas, TX (A.G.R., C.R.A., A.R., N.S.H., J.D.D., M.S.L., J.A.d.L., S.R.D.)
| | - Ronit H Zadikany
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (R.H.Z., J.E.E.)
| | - Joseph E Ebinger
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (R.H.Z., J.E.E.)
| | - James D Daniels
- Division of Cardiology, Department of Medicine, University of Texas Southwestern, Dallas, TX (A.G.R., C.R.A., A.R., N.S.H., J.D.D., M.S.L., J.A.d.L., S.R.D.)
| | - Mark S Link
- Division of Cardiology, Department of Medicine, University of Texas Southwestern, Dallas, TX (A.G.R., C.R.A., A.R., N.S.H., J.D.D., M.S.L., J.A.d.L., S.R.D.)
| | - James A de Lemos
- Division of Cardiology, Department of Medicine, University of Texas Southwestern, Dallas, TX (A.G.R., C.R.A., A.R., N.S.H., J.D.D., M.S.L., J.A.d.L., S.R.D.)
| | - Sandeep R Das
- Division of Cardiology, Department of Medicine, University of Texas Southwestern, Dallas, TX (A.G.R., C.R.A., A.R., N.S.H., J.D.D., M.S.L., J.A.d.L., S.R.D.)
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Tereshchenko LG, Howell SJ, Stivland TM, Stein K, Ellenbogen KA. REPLY: Reshaping Patient Outcomes With Machine Learning. JACC Clin Electrophysiol 2021; 7:1623-1624. [PMID: 34949428 PMCID: PMC8744148 DOI: 10.1016/j.jacep.2021.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 09/29/2021] [Indexed: 11/15/2022]
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11
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Howell SJ, Marcus GM. Does the holiday heart syndrome extend to the ventricles? Heart Rhythm 2021; 19:185-186. [PMID: 34798353 DOI: 10.1016/j.hrthm.2021.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 11/12/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Stacey J Howell
- Section of Electrophysiology, Division of Cardiology, University of California San Francisco, San Francisco, California
| | - Gregory M Marcus
- Section of Electrophysiology, Division of Cardiology, University of California San Francisco, San Francisco, California.
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12
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Affiliation(s)
| | - A Kotzé
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - S J Howell
- Leeds Institute of Medical Research at St James's University Hospital, Leeds, UK
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13
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Howell SJ, Lee A, Scheinman M. Supraventricular tachycardia with double trouble. Heart Rhythm 2021; 19:1569-1570. [PMID: 34757191 DOI: 10.1016/j.hrthm.2021.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 10/22/2021] [Accepted: 10/22/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Stacey J Howell
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California San Francisco, San Francisco, California.
| | - Adam Lee
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California San Francisco, San Francisco, California
| | - Melvin Scheinman
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California San Francisco, San Francisco, California
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14
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Affiliation(s)
- A Tait
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - S J Howell
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Medical Research at St James's, St James's University Hospital, Leeds, UK
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15
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Howell SJ, Nazer B. Thick Heart, Wide QRS, Broad Differential. JACC Case Rep 2021; 3:1363-1366. [PMID: 34505071 PMCID: PMC8414416 DOI: 10.1016/j.jaccas.2021.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/25/2021] [Accepted: 06/01/2021] [Indexed: 12/03/2022]
Abstract
Routine electrocardiogram in a middle-aged man with left ventricular hypertrophy showed sinus rhythm, a short PR interval, and delta wave, confirming ventricular pre-excitation. Pre-excitation was fixed after a premature atrial complex and in atrial fibrillation, features diagnostic of a fasciculo-ventricular pathway. Genetic testing confirmed a diagnosis of hypertrophic cardiomyopathy. (Level of Difficulty: Intermediate.)
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Affiliation(s)
- Stacey J Howell
- University of California-San Francisco, San Francisco, California, USA
| | - Babak Nazer
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
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16
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Affiliation(s)
- Stacey J Howell
- Electrophysiology Section, Knight Cardiovascular Institute, Oregon Health and Science University, Portland
| | - Eric C Stecker
- Electrophysiology Section, Knight Cardiovascular Institute, Oregon Health and Science University, Portland
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17
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Howell SJ, German D, Bender A, Phan F, Mukundan SV, Perez-Alday EA, Rogovoy NM, Haq KT, Yang K, Wirth A, Jensen K, Tereshchenko LG. Does Sex Modify an Association of Electrophysiological Substrate with Sudden Cardiac Death? The Atherosclerosis Risk in Communities (ARIC) Study. Cardiovasc Digit Health J 2020; 1:80-88. [PMID: 34308405 PMCID: PMC8301262 DOI: 10.1016/j.cvdhj.2020.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background Sex is a well-recognized risk factor for sudden cardiac death (SCD). We hypothesized that sex modifies the association of electrophysiological (EP) substrate with SCD. Objective The purpose of this study was to determine whether there are sex differences in electrocardiographic (ECG) measures and whether sex modifies the association of ECG measures of EP substrate with SCD. Methods Participants from the Atherosclerosis Risk in Communities study with analyzable ECGs (n = 14,725; age 54.2 ± 5.8 years; 55% female; 74% white) were included. EP substrate was characterized by heart rate, QRS, QTc, Cornell voltage, spatial ventricular gradient (SVG), and sum absolute QRST integral (SAI QRST) ECG metrics. Two competing outcomes were adjudicated: SCD and non-SCD. Interaction of ECG metrics with sex was studied in Cox proportional hazards and Fine-Gray competing risk models. Model 1 was adjusted for prevalent cardiovascular disease (CVD) and risk factors. Time-updated model 2 was additionally adjusted for incident nonfatal CVD. Relative hazard ratio (RHR) and relative subhazard ratio with 95% confidence interval (CI) for SCD and non-SCD risk for women relative to men were calculated. Model 1 was adjusted for prevalent CVD and risk factors. Time-updated model 2 was additionally adjusted for incident nonfatal CVD. Results Over median follow-up of 24.4 years, there were 530 SCDs (incidence 1.72; 95% CI 1.58–1.88 per 1000 person-years). Women compared to men experienced a greater risk of SCD associated with Cornell voltage (RHR 1.18; 95% CI 1.06–1.32; P = .003), SAI QRST (RHR 1.16; 95% CI 1.04–1.30; P = .007), and SVG magnitude (RHR 1.24; 95% CI 1.05–1.45; P = .009), independently from incident CVD. Conclusion In women, the global EP substrate is associated with up to 24% greater risk of SCD than in men, suggesting differences in underlying mechanisms and the need for sex-specific SCD risk stratification.
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Affiliation(s)
- Stacey J. Howell
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - David German
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Aron Bender
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Francis Phan
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Srini V. Mukundan
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
- Rush University Medical Center, Chicago, Illinois
| | - Erick A. Perez-Alday
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Nichole M. Rogovoy
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Kazi T. Haq
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Katherine Yang
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
- Sidney Kimmel Medical College, Philadelphia, Pennsylvania
| | - Ashley Wirth
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Kelly Jensen
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Larisa G. Tereshchenko
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
- Cardiovascular Division, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
- Address reprint requests and correspondence: Dr Larisa G. Tereshchenko, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, UHN62, Portland, OR 97239.
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18
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Affiliation(s)
- Kazi T Haq
- Knight Cardiovascular Institute, Department of Medicine, Oregon Health & Science University, School of Medicine, Portland
| | - Stacey J Howell
- Knight Cardiovascular Institute, Department of Medicine, Oregon Health & Science University, School of Medicine, Portland
| | - Larisa G Tereshchenko
- Knight Cardiovascular Institute, Department of Medicine, Oregon Health & Science University, School of Medicine, Portland
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Nazer B, Dale Z, Carrassa G, Reza N, Ustunkaya T, Papoutsidakis N, Gray A, Howell SJ, Elman MR, Pieragnoli P, Ricciardi G, Jacoby D, Frankel DS, Owens A, Olivotto I, Heitner SB. Appropriate and inappropriate shocks in hypertrophic cardiomyopathy patients with subcutaneous implantable cardioverter-defibrillators: An international multicenter study. Heart Rhythm 2020; 17:1107-1114. [PMID: 32084597 DOI: 10.1016/j.hrthm.2020.02.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/06/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Subcutaneous implantable cardioverter-defibrillators (S-ICDs) are attractive for preventing sudden cardiac death in hypertrophic cardiomyopathy (HCM) as they mitigate risks of transvenous leads in young patients. However, S-ICDs may be associated with increased inappropriate shock (IAS) in HCM patients. OBJECTIVE The purpose of this study was to assess the incidence and predictors of appropriate shock and IAS in a contemporary HCM S-ICD cohort. METHODS We collected electrocardiographic and clinical data from HCM patients who underwent S-ICD implantation at 4 centers. Etiologies of all S-ICD shocks were adjudicated. We used Firth penalized logistic regression to derive adjusted odds ratios (aORs) for predictors of IAS. RESULTS Eighty-eight HCM patients received S-ICDs (81 for primary and 7 for secondary prevention) with a mean follow-up of 2.7 years. Five patients (5.7%) had 9 IAS episodes (3.8 IAS per 100 patient-years) most often because of sinus tachycardia and/or T-wave oversensing. Independent predictors of IAS were higher 12-lead electrocardiographic R-wave amplitude (aOR 2.55 per 1 mV; 95% confidence interval 1.15-6.38) and abnormal T-wave inversions (aOR 0.16; 95% confidence interval 0.02-0.97). There were 2 appropriate shocks in 7 secondary prevention patients and none in 81 primary prevention patients, despite 96% meeting Enhanced American College of Cardiology/American Heart Association criteria and the mean European HCM Risk-SCD score predicting 5.7% 5-year risk. No patients had sudden death or untreated sustained ventricular arrhythmias. CONCLUSION In this multicenter HCM S-ICD study, IAS were rare and appropriate shocks confined to secondary prevention patients. The R-wave amplitude increased IAS risk, whereas T-wave inversions were protective. HCM primary prevention implantable cardioverter-defibrillator guidelines overestimated the risk of appropriate shocks in our cohort.
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Affiliation(s)
- Babak Nazer
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon.
| | - Zack Dale
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | | | - Nosheen Reza
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tuna Ustunkaya
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Andrew Gray
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | - Stacey J Howell
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | - Miriam R Elman
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | | | | | - Daniel Jacoby
- Cardiology Division, Yale University, New Haven, Connecticut
| | - David S Frankel
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anjali Owens
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Stephen B Heitner
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
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20
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Jensen K, Howell SJ, Phan F, Khayyat‐Kholghi M, Wang L, Haq KT, Johnson J, Tereshchenko LG. Bringing Critical Race Praxis Into the Study of Electrophysiological Substrate of Sudden Cardiac Death: The ARIC Study. J Am Heart Assoc 2020; 9:e015012. [PMID: 32013706 PMCID: PMC7033892 DOI: 10.1161/jaha.119.015012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 01/08/2020] [Indexed: 12/24/2022]
Abstract
Background Race is an established risk factor for sudden cardiac death (SCD). We sought to determine whether the association of electrophysiological substrate with SCD varies between black and white individuals. Methods and Results Participants from the ARIC (Atherosclerosis Risk in Communities) study with analyzable ECGs (n=14 408; age, 54±6 years; 74% white) were included. Electrophysiological substrate was characterized by ECG metrics. Two competing outcomes were adjudicated: SCD and non-SCD. Interaction of ECG metrics with race was studied in Cox proportional hazards and Fine-Gray competing risk models, adjusted for prevalent cardiovascular disease, risk factors, and incident nonfatal cardiovascular disease. At the baseline visit, adjusted for age, sex, and study center, blacks had larger spatial ventricular gradient magnitude (0.30 mV; 95% CI, 0.25-0.34 mV), sum absolute QRST integral (18.4 mV*ms; 95% CI, 13.7-23.0 mV*ms), and Cornell voltage (0.30 mV; 95% CI, 0.25-0.35 mV) than whites. Over a median follow-up of 24.4 years, SCD incidence was higher in blacks (2.86 per 1000 person-years; 95% CI, 2.50-3.28 per 1000 person-years) than whites (1.37 per 1000 person-years; 95% CI, 1.22-1.53 per 1000 person-years). Blacks with hypertension had the highest rate of SCD: 4.26 (95% CI, 3.66-4.96) per 1000 person-years. Race did not modify an association of ECG variables with SCD, except QRS-T angle. Spatial QRS-T angle was associated with SCD in whites (hazard ratio, 1.38; 95% CI, 1.25-1.53) and hypertension-free blacks (hazard ratio, 1.52; 95% CI, 1.09-2.12), but not in blacks with hypertension (hazard ratio, 1.15; 95% CI, 0.99-1.32) (P-interaction=0.004). Conclusions Race did not modify associations of electrophysiological substrate with SCD and non-SCD. Electrophysiological substrate does not explain racial disparities in SCD rate.
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Affiliation(s)
- Kelly Jensen
- Knight Cardiovascular InstituteOregon Health and Science UniversityPortlandOR
| | - Stacey J. Howell
- Knight Cardiovascular InstituteOregon Health and Science UniversityPortlandOR
| | - Francis Phan
- Knight Cardiovascular InstituteOregon Health and Science UniversityPortlandOR
| | | | - Linda Wang
- Knight Cardiovascular InstituteOregon Health and Science UniversityPortlandOR
| | - Kazi T. Haq
- Knight Cardiovascular InstituteOregon Health and Science UniversityPortlandOR
| | - John Johnson
- Knight Cardiovascular InstituteOregon Health and Science UniversityPortlandOR
| | - Larisa G. Tereshchenko
- Knight Cardiovascular InstituteOregon Health and Science UniversityPortlandOR
- Division of CardiologyDepartment of MedicineJohns Hopkins School of MedicineBaltimoreMD
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21
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Rogovoy NM, Howell SJ, Lee TL, Hamilton C, Perez‐Alday EA, Kabir MM, Zhang Y, Kim ED, Fitzpatrick J, Monroy‐Trujillo JM, Estrella MM, Sozio SM, Jaar BG, Parekh RS, Tereshchenko LG. Hemodialysis Procedure-Associated Autonomic Imbalance and Cardiac Arrhythmias: Insights From Continuous 14-Day ECG Monitoring. J Am Heart Assoc 2019; 8:e013748. [PMID: 31564195 PMCID: PMC6806026 DOI: 10.1161/jaha.119.013748] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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] [Indexed: 12/20/2022]
Abstract
Background In patients with end‐stage kidney disease, sudden cardiac death is more frequent after a long interdialytic interval, within 6 hours after the end of a hemodialysis session. We hypothesized that the occurrence of paroxysmal arrhythmias is associated with changes in heart rate and heart rate variability in different phases of hemodialysis. Methods and Results We conducted a prospective ancillary study of the Predictors of Arrhythmic and Cardiovascular Risk in End Stage Renal Disease cohort. Continuous ECG monitoring was performed using an ECG patch, and short‐term heart rate variability was measured for 3 minutes every hour (by root mean square of the successive normal‐to‐normal intervals, spectral analysis, Poincaré plot, and entropy), up to 300 hours. Out of enrolled participants (n=28; age 54±13 years; 57% men; 96% black; 33% with a history of cardiovascular disease; left ventricular ejection fraction 70±9%), arrhythmias were detected in 13 (46%). Nonsustained ventricular tachycardia occurred more frequently during/posthemodialysis than pre‐/between hemodialysis (63% versus 37%, P=0.015). In adjusted for cardiovascular disease time‐series analysis, nonsustained ventricular tachycardia was preceded by a sudden heart rate increase (by 11.2 [95% CI 10.1–12.3] beats per minute; P<0.0001). During every‐other‐day dialysis, root mean square of the successive normal‐to‐normal intervals had a significant circadian pattern (Mesor 10.6 [ 95% CI 0.9–11.2] ms; amplitude 1.5 [95% CI 1.0–3.1] ms; peak at 02:01 [95% CI 20:22–03:16] am; P<0.0001), which was replaced by a steady worsening on the second day without dialysis (root mean square of the successive normal‐to‐normal intervals −1.41 [95% CI −1.67 to −1.15] ms/24 h; P<0.0001). Conclusions Sudden increase in heart rate during/posthemodialysis is associated with nonsustained ventricular tachycardia. Every‐other‐day hemodialysis preserves circadian rhythm, but a second day without dialysis is characterized by parasympathetic withdrawal.
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Affiliation(s)
| | | | | | | | | | - Muammar M. Kabir
- Oregon Health & Science UniversityPortlandOR
- The Hospital for Sick ChildrenThe University of TorontoOntarioCanada
| | | | - Esther D. Kim
- The Hospital for Sick ChildrenThe University of TorontoOntarioCanada
- Johns Hopkins UniversityBaltimoreMD
| | | | | | - Michelle M. Estrella
- Johns Hopkins UniversityBaltimoreMD
- Kidney Health Research CollaborativeUniversity of CaliforniaSan FranciscoCA
- San Francisco VA Health Care SystemSan FranciscoCA
| | | | | | - Rulan S. Parekh
- The Hospital for Sick ChildrenThe University of TorontoOntarioCanada
- Johns Hopkins UniversityBaltimoreMD
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22
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Howell SJ, Waters S, Twelves C, Joffe J, Moon S, Bale C, Venkitaraman R, Bezecny P, Casbard A, Wilhelm-Benartzi C, Carucci M, Butler R, Alchami F, Jones R. Abstract PD1-07: Withdrawn. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-pd1-07] [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: 11/16/2022]
Abstract
Abstract
This abstract was withdrawn by the authors.
Citation Format: Howell SJ, Waters S, Twelves C, Joffe J, Moon S, Bale C, Venkitaraman R, Bezecny P, Casbard A, Wilhelm-Benartzi C, Carucci M, Butler R, Alchami F, Jones R. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD1-07.
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Affiliation(s)
- SJ Howell
- University of Manchester, Manchester, United Kingdom; The Christie NHS Foundation Trust, Manchester, United Kingdom; Velindre Cancer Centre, Cardiff, United Kingdom; University of Leeds and Leeds Teaching Hospitals Trust, Leeds, United Kingdom; Calderdale & Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom; University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, United Kingdom; Betsi Cadwaladr University Health Board, Bangor, United Kingdom; The Ipswich Hospital NHS Trust, Ipswich, United Kingdom; Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom; Centre for Trials Research, Cardiff University, Cardiff, United Kingdom; All Wales Laboratory Genetics Service, University Hospital of Wales, Cardiff, United Kingdom; University Hospital of Wales, Cardiff, United Kingdom; Cardiff University, Cardiff, United Kingdom
| | - S Waters
- University of Manchester, Manchester, United Kingdom; The Christie NHS Foundation Trust, Manchester, United Kingdom; Velindre Cancer Centre, Cardiff, United Kingdom; University of Leeds and Leeds Teaching Hospitals Trust, Leeds, United Kingdom; Calderdale & Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom; University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, United Kingdom; Betsi Cadwaladr University Health Board, Bangor, United Kingdom; The Ipswich Hospital NHS Trust, Ipswich, United Kingdom; Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom; Centre for Trials Research, Cardiff University, Cardiff, United Kingdom; All Wales Laboratory Genetics Service, University Hospital of Wales, Cardiff, United Kingdom; University Hospital of Wales, Cardiff, United Kingdom; Cardiff University, Cardiff, United Kingdom
| | - C Twelves
- University of Manchester, Manchester, United Kingdom; The Christie NHS Foundation Trust, Manchester, United Kingdom; Velindre Cancer Centre, Cardiff, United Kingdom; University of Leeds and Leeds Teaching Hospitals Trust, Leeds, United Kingdom; Calderdale & Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom; University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, United Kingdom; Betsi Cadwaladr University Health Board, Bangor, United Kingdom; The Ipswich Hospital NHS Trust, Ipswich, United Kingdom; Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom; Centre for Trials Research, Cardiff University, Cardiff, United Kingdom; All Wales Laboratory Genetics Service, University Hospital of Wales, Cardiff, United Kingdom; University Hospital of Wales, Cardiff, United Kingdom; Cardiff University, Cardiff, United Kingdom
| | - J Joffe
- University of Manchester, Manchester, United Kingdom; The Christie NHS Foundation Trust, Manchester, United Kingdom; Velindre Cancer Centre, Cardiff, United Kingdom; University of Leeds and Leeds Teaching Hospitals Trust, Leeds, United Kingdom; Calderdale & Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom; University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, United Kingdom; Betsi Cadwaladr University Health Board, Bangor, United Kingdom; The Ipswich Hospital NHS Trust, Ipswich, United Kingdom; Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom; Centre for Trials Research, Cardiff University, Cardiff, United Kingdom; All Wales Laboratory Genetics Service, University Hospital of Wales, Cardiff, United Kingdom; University Hospital of Wales, Cardiff, United Kingdom; Cardiff University, Cardiff, United Kingdom
| | - S Moon
- University of Manchester, Manchester, United Kingdom; The Christie NHS Foundation Trust, Manchester, United Kingdom; Velindre Cancer Centre, Cardiff, United Kingdom; University of Leeds and Leeds Teaching Hospitals Trust, Leeds, United Kingdom; Calderdale & Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom; University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, United Kingdom; Betsi Cadwaladr University Health Board, Bangor, United Kingdom; The Ipswich Hospital NHS Trust, Ipswich, United Kingdom; Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom; Centre for Trials Research, Cardiff University, Cardiff, United Kingdom; All Wales Laboratory Genetics Service, University Hospital of Wales, Cardiff, United Kingdom; University Hospital of Wales, Cardiff, United Kingdom; Cardiff University, Cardiff, United Kingdom
| | - C Bale
- University of Manchester, Manchester, United Kingdom; The Christie NHS Foundation Trust, Manchester, United Kingdom; Velindre Cancer Centre, Cardiff, United Kingdom; University of Leeds and Leeds Teaching Hospitals Trust, Leeds, United Kingdom; Calderdale & Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom; University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, United Kingdom; Betsi Cadwaladr University Health Board, Bangor, United Kingdom; The Ipswich Hospital NHS Trust, Ipswich, United Kingdom; Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom; Centre for Trials Research, Cardiff University, Cardiff, United Kingdom; All Wales Laboratory Genetics Service, University Hospital of Wales, Cardiff, United Kingdom; University Hospital of Wales, Cardiff, United Kingdom; Cardiff University, Cardiff, United Kingdom
| | - R Venkitaraman
- University of Manchester, Manchester, United Kingdom; The Christie NHS Foundation Trust, Manchester, United Kingdom; Velindre Cancer Centre, Cardiff, United Kingdom; University of Leeds and Leeds Teaching Hospitals Trust, Leeds, United Kingdom; Calderdale & Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom; University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, United Kingdom; Betsi Cadwaladr University Health Board, Bangor, United Kingdom; The Ipswich Hospital NHS Trust, Ipswich, United Kingdom; Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom; Centre for Trials Research, Cardiff University, Cardiff, United Kingdom; All Wales Laboratory Genetics Service, University Hospital of Wales, Cardiff, United Kingdom; University Hospital of Wales, Cardiff, United Kingdom; Cardiff University, Cardiff, United Kingdom
| | - P Bezecny
- University of Manchester, Manchester, United Kingdom; The Christie NHS Foundation Trust, Manchester, United Kingdom; Velindre Cancer Centre, Cardiff, United Kingdom; University of Leeds and Leeds Teaching Hospitals Trust, Leeds, United Kingdom; Calderdale & Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom; University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, United Kingdom; Betsi Cadwaladr University Health Board, Bangor, United Kingdom; The Ipswich Hospital NHS Trust, Ipswich, United Kingdom; Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom; Centre for Trials Research, Cardiff University, Cardiff, United Kingdom; All Wales Laboratory Genetics Service, University Hospital of Wales, Cardiff, United Kingdom; University Hospital of Wales, Cardiff, United Kingdom; Cardiff University, Cardiff, United Kingdom
| | - A Casbard
- University of Manchester, Manchester, United Kingdom; The Christie NHS Foundation Trust, Manchester, United Kingdom; Velindre Cancer Centre, Cardiff, United Kingdom; University of Leeds and Leeds Teaching Hospitals Trust, Leeds, United Kingdom; Calderdale & Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom; University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, United Kingdom; Betsi Cadwaladr University Health Board, Bangor, United Kingdom; The Ipswich Hospital NHS Trust, Ipswich, United Kingdom; Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom; Centre for Trials Research, Cardiff University, Cardiff, United Kingdom; All Wales Laboratory Genetics Service, University Hospital of Wales, Cardiff, United Kingdom; University Hospital of Wales, Cardiff, United Kingdom; Cardiff University, Cardiff, United Kingdom
| | - C Wilhelm-Benartzi
- University of Manchester, Manchester, United Kingdom; The Christie NHS Foundation Trust, Manchester, United Kingdom; Velindre Cancer Centre, Cardiff, United Kingdom; University of Leeds and Leeds Teaching Hospitals Trust, Leeds, United Kingdom; Calderdale & Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom; University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, United Kingdom; Betsi Cadwaladr University Health Board, Bangor, United Kingdom; The Ipswich Hospital NHS Trust, Ipswich, United Kingdom; Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom; Centre for Trials Research, Cardiff University, Cardiff, United Kingdom; All Wales Laboratory Genetics Service, University Hospital of Wales, Cardiff, United Kingdom; University Hospital of Wales, Cardiff, United Kingdom; Cardiff University, Cardiff, United Kingdom
| | - M Carucci
- University of Manchester, Manchester, United Kingdom; The Christie NHS Foundation Trust, Manchester, United Kingdom; Velindre Cancer Centre, Cardiff, United Kingdom; University of Leeds and Leeds Teaching Hospitals Trust, Leeds, United Kingdom; Calderdale & Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom; University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, United Kingdom; Betsi Cadwaladr University Health Board, Bangor, United Kingdom; The Ipswich Hospital NHS Trust, Ipswich, United Kingdom; Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom; Centre for Trials Research, Cardiff University, Cardiff, United Kingdom; All Wales Laboratory Genetics Service, University Hospital of Wales, Cardiff, United Kingdom; University Hospital of Wales, Cardiff, United Kingdom; Cardiff University, Cardiff, United Kingdom
| | - R Butler
- University of Manchester, Manchester, United Kingdom; The Christie NHS Foundation Trust, Manchester, United Kingdom; Velindre Cancer Centre, Cardiff, United Kingdom; University of Leeds and Leeds Teaching Hospitals Trust, Leeds, United Kingdom; Calderdale & Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom; University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, United Kingdom; Betsi Cadwaladr University Health Board, Bangor, United Kingdom; The Ipswich Hospital NHS Trust, Ipswich, United Kingdom; Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom; Centre for Trials Research, Cardiff University, Cardiff, United Kingdom; All Wales Laboratory Genetics Service, University Hospital of Wales, Cardiff, United Kingdom; University Hospital of Wales, Cardiff, United Kingdom; Cardiff University, Cardiff, United Kingdom
| | - F Alchami
- University of Manchester, Manchester, United Kingdom; The Christie NHS Foundation Trust, Manchester, United Kingdom; Velindre Cancer Centre, Cardiff, United Kingdom; University of Leeds and Leeds Teaching Hospitals Trust, Leeds, United Kingdom; Calderdale & Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom; University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, United Kingdom; Betsi Cadwaladr University Health Board, Bangor, United Kingdom; The Ipswich Hospital NHS Trust, Ipswich, United Kingdom; Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom; Centre for Trials Research, Cardiff University, Cardiff, United Kingdom; All Wales Laboratory Genetics Service, University Hospital of Wales, Cardiff, United Kingdom; University Hospital of Wales, Cardiff, United Kingdom; Cardiff University, Cardiff, United Kingdom
| | - R Jones
- University of Manchester, Manchester, United Kingdom; The Christie NHS Foundation Trust, Manchester, United Kingdom; Velindre Cancer Centre, Cardiff, United Kingdom; University of Leeds and Leeds Teaching Hospitals Trust, Leeds, United Kingdom; Calderdale & Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom; University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, United Kingdom; Betsi Cadwaladr University Health Board, Bangor, United Kingdom; The Ipswich Hospital NHS Trust, Ipswich, United Kingdom; Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom; Centre for Trials Research, Cardiff University, Cardiff, United Kingdom; All Wales Laboratory Genetics Service, University Hospital of Wales, Cardiff, United Kingdom; University Hospital of Wales, Cardiff, United Kingdom; Cardiff University, Cardiff, United Kingdom
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23
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Abstract
OBJECTIVE Implementation of the newly approved high-sensitivity cardiac troponin (hs-cTn) in the United States presents a challenge for clinical practice. Sex-specific cutoffs, clinical protocols, and workflows will likely require modifications before implementation. METHODS We conducted a cross-sectional survey of international physicians and laboratorians already utilizing hs-cTn for the evaluation of acute myocardial infarction. RESULTS Twenty-two of 54 (41%) eligible participants completed the survey, representing 9 countries and 18 hospitals. All reported successful hs-cTn implementation and diagnostic utility (mean 8.6 + 1.2 out of 10 for best implementation). The major perceived benefit was more rapid evaluation of acute myocardial infarction (14/19, 74%), and the most frequently cited limitation was an increase in the number of measurable hs-cTn values that required further evaluation (8/18, 44%). Institutions using the hs-cTnI assay favored sex-specific cutoffs (5/6, 83%), whereas institutions employing the hs-cTnT assay favored a combined cutoff (12/12, 100%). Timing of serial hs-cTn measurements varied, with 0-3 hours (8/17, 47%) most frequent, followed by 0-2 hours (4/17, 24%), 0-1 hour (3/17, 18%), and other (2/17, 12%). CONCLUSIONS Our survey of hs-cTn implementation at international institutions reveals satisfaction with new assays but reflects important variations in clinical practice. The use of sex-specific vs. combined cutoffs and timing of serial hs-cTn measurements varies across institutions and are subjects that United States centers must define without consensus from international practices.
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Affiliation(s)
- Stacey J Howell
- From the Department of Internal Medicine, University of California Davis Health, Sacramento, CA
| | - Ezra A Amsterdam
- Division of Cardiovascular Medicine, University of California Davis Health, Sacramento, CA
| | - Bryn E Mumma
- Department of Emergency Medicine, University of California Davis Health, Sacramento, CA
| | - Javier E López
- Division of Cardiovascular Medicine, University of California Davis Health, Sacramento, CA
| | - Nam K Tran
- Department of Pathology and Laboratory Medicine, University of California Davis Health, Sacramento, CA
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24
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Affiliation(s)
- S J Howell
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Clinical Sciences Building, St James's University Hospital, Leeds LS9 7TF, UK
| | - J P Thompson
- Department of Cardiovascular Sciences, University of Leicester; Anaesthesia & Critical Care, University Hospitals of Leicester NHS Trust, Robert Kilpatrick Building, Leicester Royal Infirmary, Leicester LE2 7LX, UK
| | - M G Irwin
- Department of Anaesthesiology, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Pokfulam, Hong Kong
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25
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Howell SJ, Datta Mitra A, Amsterdam EA. What's in a Mass?: Large Native Mitral Valve Mass. Am J Med 2017; 130:e171-e175. [PMID: 28161343 DOI: 10.1016/j.amjmed.2016.12.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 12/25/2016] [Accepted: 12/27/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Stacey J Howell
- Department of Internal Medicine, University of California Davis Medical Center, Sacramento
| | - Ananya Datta Mitra
- Department of Pathology and Laboratory Medicine, University of California Davis Medical Center, Sacramento
| | - Ezra A Amsterdam
- Division of Cardiovascular Medicine, University of California Davis Medical Center, Sacramento
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26
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Howell SJ, Simoes BM, Alferez D, Eyre R, Spence K, Santiago-Gomez A, Sarmiento-Castro A, Tanaka I, Howat D, Clarke RB. Abstract PD2-02: SFX-01 targets Wnt signalling to inhibit stem-like cells in breast cancer patient-derived xenograft tumours. Cancer Res 2017. [DOI: 10.1158/1538-7445.sabcs16-pd2-02] [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: 11/16/2022]
Abstract
Abstract
Background: SFX-01 is a novel therapeutic comprising synthetic sulforaphane (SFN) stabilised within a-cyclodextrin. Breast cancer stem-like cells (CSCs) have been identified in all molecular subtypes and are likely drivers of breast cancer metastasis and treatment resistance. We recently established that CSC activity in ER+ BC, represent a source of therapeutic resistance (Simões et al, Cell Reports, 2015).
Material and methods: We investigated SFX-01 effects on breast CSC activity using mammosphere formation efficiency (MFE) and aldehyde dehydrogenase (ALDH) activity using the ALDEFLUOR assay in patient samples and patient-derived xenograft (PDX) tumours. Cells from primary (n=12) and metastatic (n=15) samples were treated with SFX-01 (5 μM) or vehicle control.Using a 2 or 8 week in vivo treatment, early (HBCx34) and metastatic (BB3RC31) ER+ PDX tumours were treated with SFX-01 (300mg/Kg/day) alone or in combination with tamoxifen (TAM, 10 mg/kg/day) or fulvestrant (FULV, 200 mg/kg/week). Tumours were dissociated and MFE and ALDH activity assessed.
Results: SFX-01 in vitro reduced MFE of both primary (0.19%±0.02 vs control 0.52%±0.06: p<0.001) and metastatic patient samples (0.43±0.04 vs control 0.93%±0.07: p<0.001). SFX-01 treatment in vivo for 2 weeks reduced MFE of HBCx34 (0.35%±0.03 vs control 0.64%±0.09; p<0.01) and BB3RC31 (0.78%±0.04 vs control 0.89%±0.06: p<0.05) and also ALDH activity of HBCx34 (3%±0.6 vs control 6.3%±0.4: p<0.01) and BB3RC31 (1%±0.2 vs control 3%±0.6: p<0.05). TAM and FULV increased MFE and ALDH activity after 2 weeks of treatment in vivo, which was abrogated by combination with SFX-01; for example HBCx34 MFE with TAM alone: 0.81%±0.07 vs TAM+SFX-01: 0.34%±0.02 (p<0.01) and ALDH+ with TAM alone 10%±0.4 vs TAM+SFX 4.2%±0.4 (p<0.01). TAM+SFX-01 suppressed tumour growth at 8 weeks vs TAM alone in HBCx34 but not BB3RC31. FULV treatment maintained tumour growth suppression at 8 weeks and no additive effect was seen with SFX-01, although MFE and ALDH activity were suppressed. Mechanistically, SFX-01 potently inhibited the canonical Wnt pathway in MCF-7 cells and their endocrine-resistant derivatives and we are currently exploring SFX-01 activity on other CSC regulatory pathways.
SFX-01 has been shown to be well tolerated in SAD and MAD studies in normal volunteers and clinical studies designed to test tolerability and efficacy in combination with the three major classes of endocrine therapy (AI, TAM and FULV) in advanced BC will begin in Q4 2016.
Conclusions: Our data demonstrate the potential of SFX-01 for clinically meaningful improvements to endocrine therapy in ER+ breast cancer by reversing CSC mediated resistance.
Citation Format: Howell SJ, Simoes BM, Alferez D, Eyre R, Spence K, Santiago-Gomez A, Sarmiento-Castro A, Tanaka I, Howat D, Clarke RB. SFX-01 targets Wnt signalling to inhibit stem-like cells in breast cancer patient-derived xenograft tumours [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD2-02.
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Affiliation(s)
- SJ Howell
- University of Manchester; The Christie NHS Foundation Trust; Evgen Pharma Ltd
| | - BM Simoes
- University of Manchester; The Christie NHS Foundation Trust; Evgen Pharma Ltd
| | - D Alferez
- University of Manchester; The Christie NHS Foundation Trust; Evgen Pharma Ltd
| | - R Eyre
- University of Manchester; The Christie NHS Foundation Trust; Evgen Pharma Ltd
| | - K Spence
- University of Manchester; The Christie NHS Foundation Trust; Evgen Pharma Ltd
| | - A Santiago-Gomez
- University of Manchester; The Christie NHS Foundation Trust; Evgen Pharma Ltd
| | - A Sarmiento-Castro
- University of Manchester; The Christie NHS Foundation Trust; Evgen Pharma Ltd
| | - I Tanaka
- University of Manchester; The Christie NHS Foundation Trust; Evgen Pharma Ltd
| | - D Howat
- University of Manchester; The Christie NHS Foundation Trust; Evgen Pharma Ltd
| | - RB Clarke
- University of Manchester; The Christie NHS Foundation Trust; Evgen Pharma Ltd
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27
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Evans DG, Woodward ER, Howell SJ, Verhoef S, Howell A, Lalloo F. Risk algorithms that include pathology adjustment for HER2 amplification need to make further downward adjustments in likelihood scores. Fam Cancer 2016; 16:173-179. [PMID: 27796713 PMCID: PMC5357509 DOI: 10.1007/s10689-016-9942-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
To assess the need for adjustment in the likelihood of germline BRCA1/2 mutations in women with HER2+ breast cancers. We analysed primary mutation screens on women with breast cancer with unequivocal HER2 overexpression and assessed the likelihood of BRCA1/BRCA2 mutations by age, oestrogen receptor status and Manchester score. Of 1111 primary BRCA screens with confirmed HER2 status only 4/161 (2.5%) of women with HER2 amplification had a BRCA1 mutation identified and 5/161 (3.1%) a BRCA2 mutation. The pathology adjusted Manchester score between 10 and 19% and 20%+ thresholds resulted in a detection rate of only 6.5 and 15% respectively. BOADICEA examples appeared to make even less downward adjustment. There is a very low detection rate of BRCA1 and BRCA2 mutations in women with HER2 amplified breast cancers. The Manchester score and BOADICEA do not make sufficient downward adjustment for HER2 amplification. For unaffected women, assessment of breast cancer risk and BRCA1/2 probability should take into account the pathology of the most relevant close relative. Unaffected women undergoing mutation testing for BRCA1/2 should be advised that there is limited reassurance from a negative test result if their close relative had a HER2+ breast cancer.
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Affiliation(s)
- D G Evans
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester Academic Health Sciences Centre (MAHSC), Institute of Human Development, University of Manchester, Manchester, M13 9WL, UK. .,Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester NHS Trust, Wythenshawe, Manchester, M23 9LT, UK. .,Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester Academic Health Sciences Centre (MAHSC), Central Manchester University Hospitals NHS Foundation Trust, Manchester, M13 9WL, UK. .,Manchester Breast Centre, School of Molecular and Clinical Cancer Sciences, The University of Manchester, Manchester, M20 4BX, UK.
| | - E R Woodward
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester Academic Health Sciences Centre (MAHSC), Institute of Human Development, University of Manchester, Manchester, M13 9WL, UK.,Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester Academic Health Sciences Centre (MAHSC), Central Manchester University Hospitals NHS Foundation Trust, Manchester, M13 9WL, UK
| | - S J Howell
- Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester NHS Trust, Wythenshawe, Manchester, M23 9LT, UK.,Manchester Breast Centre, School of Molecular and Clinical Cancer Sciences, The University of Manchester, Manchester, M20 4BX, UK.,Department of Medical Oncology, The Christie, Manchester, M20 4BX, UK
| | - S Verhoef
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester Academic Health Sciences Centre (MAHSC), Central Manchester University Hospitals NHS Foundation Trust, Manchester, M13 9WL, UK
| | - A Howell
- Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester NHS Trust, Wythenshawe, Manchester, M23 9LT, UK.,Manchester Breast Centre, School of Molecular and Clinical Cancer Sciences, The University of Manchester, Manchester, M20 4BX, UK
| | - F Lalloo
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester Academic Health Sciences Centre (MAHSC), Central Manchester University Hospitals NHS Foundation Trust, Manchester, M13 9WL, UK
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Kirwan CC, Clarke AC, Howell SJ, Castle J. PO-31 - Circulating tumour cells and hypercoagulability: a lethal relationship in metastatic breast cancer. Thromb Res 2016; 140 Suppl 1:S188. [PMID: 27161721 DOI: 10.1016/s0049-3848(16)30164-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Circulating tumour cells (CTCs) are a marker of poor prognosis and are associated with increased risk of venous thromboembolism in metastatic breast cancer. AIM We aimed to correlate presence of CTCs and markers of hyper-coagulability (D-dimer, fibrinogen and thrombin-antithrombin [TAT]) with survival in metastatic breast cancer. MATERIALS AND METHODS In a prospective study, enumeration of CTCs (CellSearch) and D-dimer, fibrinogen and TAT (ELISA) were measured at a single timepoint in 50 MBC (median age 59, range 36-82) patients undergoing active treatment. Survival data was determined at a median follow-up of 366days (range 58-986). RESULTS To date, 25 patients have died (median survival 566days, range 135-978). CTCs (>1/7.5ml) were identified in 13 patients (range 2-31) and were associated with increased markers of hypercoagulability [D-dimer: median 1814 (IQR 2700) vs 755 (IQR 735) ng/ml, p=0.004; fibrinogen: median 4.2 (IQR 1.9) vs 3.2 (1.3) g/l, p=0.05; TAT: median 6.2(IQR 6.3) vs 4.7 (5.2) ng/ml, p=0.1]. CTCs were associated with visceral compared to just bony metastases (p=0.03) and their presence was associated with a trend for reduced survival (295days (CI: 0-652) vs 737days (CI: 186-1288), p=0.1). There was no correlation between CTCs /markers of hypercoagulability and age, oestrogen receptor, progesterone receptor or Her2 status. D-dimer, fibrinogen and TAT all inversely correlated with survival and were all significantly higher in patients dying within 1year (D-dimer: 1098 (IQR 1122) vs 723 (IQR 735) ng/ml, p=0.03; fibrinogen: 4.4 (1.1) vs 3.2 (0.8) g/l, p=0.004; TAT: 8.1 (6.3) vs 4.7(3.1) ng/ml, p=0.03 [analysis excludes patients with <1year follow-up, n=13]). D-dimer >1,500ng/ml was associated with significantly reduced survival (295days [CI: 0-615] vs 836days [404-1267], p=0.05). On Cox regression, D-dimer, but not fibrinogen or TAT was associated with an increased risk of death (HR 1.3 per 1,000ng/ml D-dimer, p=0.07). CONCLUSIONS The correlation between CTCs, hypercoagulability and reduced survival in metastatic breast cancer suggests a possible role for the coagulation system in supporting tumour cell metastasis and is therefore a potential therapeutic target.
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Affiliation(s)
- C C Kirwan
- Institute of Cancer Sciences, University of Manchester; Department of Academic Surgery, University Hospital of South Manchester
| | - A C Clarke
- Institute of Cancer Sciences, University of Manchester
| | - S J Howell
- Institute of Cancer Sciences, University of Manchester; Christie Hospital NHS Foundation Trust, Manchester, United Kingdom
| | - J Castle
- Institute of Cancer Sciences, University of Manchester
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Zucchini G, Armstrong AC, Wardley AM, Wilson G, Misra V, Seif M, Ryder WD, Cope J, Blowers E, Howell A, Palmieri C, Howell SJ. A phase II trial of low-dose estradiol in postmenopausal women with advanced breast cancer and acquired resistance to aromatase inhibition. Eur J Cancer 2015; 51:2725-31. [PMID: 26597446 DOI: 10.1016/j.ejca.2015.08.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [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: 05/19/2015] [Revised: 08/26/2015] [Accepted: 08/29/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND High-dose oestrogen (HDE) is effective but toxic in postmenopausal women with advanced breast cancer (ABC). Prolonged oestrogen deprivation sensitises BC cell lines to estrogen and we hypothesised that third-generation aromatase inhibitors (AIs) would sensitise BCs to low-dose estradiol (LDE). METHODS A single-arm phase II study of LDE (2 mg estradiol valerate daily) in postmenopausal women with estrogen receptor-positive (ER+) ABC. The primary end-point was clinical benefit (CB) rate. If LDE was ineffective, HDE was offered. If LDE was effective, retreatment with the pre-LDE AI was offered on progression. RESULTS Twenty-one patients were recruited before the trial was closed early due to slow accrual; 19 were assessable for efficacy and toxicity. CB was seen in 5 in 19 patients (26%; 95% confidence interval 9.1-51.2%), all with prolonged SD (median duration 16.8 months; range 11.0-29.6). Treatment was discontinued for toxicity in 4 in 19 patients (21%) and 8 in 11 women without hysterectomy experienced vaginal bleeding (VB). After primary LDE failure, three patients received HDE and one achieved a partial response (PR). Following CB on LDE, four patients restarted pre-LDE AI and three achieved CB including one PR. Those with CB to LDE had a significantly longer duration of first-line endocrine therapy for ABC than those without (54.9 versus 16.8 months; p < 0.01) CONCLUSION: LDE is an effective endocrine option in women with evidence of prolonged sensitivity to AI therapy. LDE is reasonably well tolerated although VB is an issue. Re-challenge with the pre-LDE AI following progression confirms re-sensitisation as a true phenomenon.
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Affiliation(s)
| | - A C Armstrong
- The Christie NHS Foundation Trust, UK; The University of Manchester, UK
| | - A M Wardley
- The Christie NHS Foundation Trust, UK; The University of Manchester, UK
| | - G Wilson
- The Christie NHS Foundation Trust, UK
| | - V Misra
- The Christie NHS Foundation Trust, UK
| | - M Seif
- Central Manchester NHS Foundation Trust, UK
| | - W D Ryder
- The Christie NHS Foundation Trust, UK
| | - J Cope
- The Christie NHS Foundation Trust, UK
| | - E Blowers
- The Christie NHS Foundation Trust, UK
| | - A Howell
- The Christie NHS Foundation Trust, UK; The University of Manchester, UK
| | | | - S J Howell
- The Christie NHS Foundation Trust, UK; The University of Manchester, UK.
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Batterham AM, Bonner S, Wright J, Howell SJ, Hugill K, Danjoux G. Effect of supervised aerobic exercise rehabilitation on physical fitness and quality-of-life in survivors of critical illness: an exploratory minimized controlled trial (PIX study). Br J Anaesth 2014; 113:130-7. [PMID: 24607602 PMCID: PMC4062299 DOI: 10.1093/bja/aeu051] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [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] [Indexed: 01/21/2023] Open
Abstract
Background Evidence is limited for the effectiveness of interventions for survivors of critical illness after hospital discharge. We explored the effect of an 8-week hospital-based exercise-training programme on physical fitness and quality-of-life. Methods In a parallel-group minimized controlled trial, patients were recruited before hospital discharge or in the intensive care follow-up clinic and enrolled 8–16 weeks after discharge. Each week, the intervention comprised two sessions of physiotherapist-led cycle ergometer exercise (30 min, moderate intensity) plus one equivalent unsupervised exercise session. The control group received usual care. The primary outcomes were the anaerobic threshold (in ml O2 kg−1 min−1) and physical function and mental health (SF-36 questionnaire v.2), measured at Weeks 9 (primary time point) and 26. Outcome assessors were blinded to group assignment. Results Thirty patients were allocated to the control and 29 to the intervention. For the anaerobic threshold outcome at Week 9, data were available for 17 control vs 13 intervention participants. There was a small benefit (vs control) for the anaerobic threshold of 1.8 (95% confidence interval, 0.4–3.2) ml O2 kg−1 min−1. This advantage was not sustained at Week 26. There was evidence for a possible beneficial effect of the intervention on self-reported physical function at Week 9 (3.4; −1.4 to 8.2 units) and on mental health at Week 26 (4.4; −2.4 to 11.2 units). These potential benefits should be examined robustly in any subsequent definitive trial. Conclusions The intervention appeared to accelerate the natural recovery process and seems feasible, but the fitness benefit was only short term. Clinical trial registration Current Controlled Trials ISRCTN65176374 (http://www.controlled-trials.com/ISRCTN65176374).
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Affiliation(s)
- A M Batterham
- Teesside University, Health and Social Care Institute, Middlesbrough, UK
| | - S Bonner
- Academic Department of Anaesthesia and Critical Care Medicine, James Cook University Hospital, Middlesbrough, UK
| | - J Wright
- Academic Department of Anaesthesia and Critical Care Medicine, James Cook University Hospital, Middlesbrough, UK
| | - S J Howell
- Division of Clinical Sciences, University of Leeds, Leeds Institute of Molecular Medicine, Leeds, UK
| | - K Hugill
- Academic Department of Anaesthesia and Critical Care Medicine, James Cook University Hospital, Middlesbrough, UK
| | - G Danjoux
- Academic Department of Anaesthesia and Critical Care Medicine, James Cook University Hospital, Middlesbrough, UK
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Alferez D, Clarke RB, Cresta C, Mnene S, Howell SJ. Abstract P5-05-03: Progesterone receptor antagonists as inhibitors of breast cancer stem cell activity. Cancer Res 2013. [DOI: 10.1158/0008-5472.sabcs13-p5-05-03] [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: 11/16/2022]
Abstract
Abstract
Background: Tamoxifen has become the standard of care for premenopausal women with hormone receptor positive breast cancer (BC). However, resistance to Tamoxifen therapy remains a major clinical problem and we have evidence that cancer stem cells (CSCs) may play a role in recurrence in these patients. The progesterone receptor (PR) is a potential therapeutic target in BC but development of steroidal PR antagonists (PRAs) has been halted due to toxicity issues, despite evidence of activity. Recent reports have linked PR activity to the expansion of adult mammary gland stem cells through paracrine effectors such as RANK-L.
Methods: To investigate the effects of PR antagonism on CSCs, we have tested 2 non-steroidal PRAs; onapristone (Schering AG/Arno Therapeutics) and AZPRA (AstraZeneca) in 2 hormone receptor positive BC cell lines (MCF-7 & T47D) and 8 patient-derived samples (PDS; from malignant pleural effusions and ascitic fluid), using a low adherence mammosphere assay. Western and gene expression array analysis of PDS samples were performed to identify predictive biomarkers.
Results: In the presence of 10nM P4 AZPRA inhibited mammosphere forming efficiency (MFE) in MCF-7 cells by 32% (p<0.0001) and in T47D by 21% (p<0.0001). Similar results were seen with onapristone (34% inhibition in MCF-7 (p<0.002) and 34% in T47D cells (p<0.0002). AZPRA or onapristone significantly reduced MFE in 7 of 8 PDS. Tamoxifen affected MFE in 4/6 PDS samples. In 5 of 7 PDS tested additive effects were seen when AZPRA was combined with tamoxifen (>80% reduction in MFE; p<0.001). A similar effect was seen with onapristone (>70% reduction in MFE (p<0.05)). Data from Western analysis of PR A and B isoforms and gene expression analysis of PDS samples will be presented at the conference.
Conclusions: Preliminary data on PR inhibition presented here support the rationale of administration of PRA in the clinic but predictive biomarkers are required to identify which patients are likely to benefit. Combination of PRA with current anti-oestrogen therapies such as Tamoxifen may be a way of overcoming resistance mechanisms by targeting CSCs.
Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-05-03.
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Affiliation(s)
- D Alferez
- Institute of Cancer Studies, University of Manchester, Manchester, United Kingdom; Oncology iMed, AstraZeneca, Macclesfield, United Kingdom; The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - RB Clarke
- Institute of Cancer Studies, University of Manchester, Manchester, United Kingdom; Oncology iMed, AstraZeneca, Macclesfield, United Kingdom; The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - C Cresta
- Institute of Cancer Studies, University of Manchester, Manchester, United Kingdom; Oncology iMed, AstraZeneca, Macclesfield, United Kingdom; The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - S Mnene
- Institute of Cancer Studies, University of Manchester, Manchester, United Kingdom; Oncology iMed, AstraZeneca, Macclesfield, United Kingdom; The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - SJ Howell
- Institute of Cancer Studies, University of Manchester, Manchester, United Kingdom; Oncology iMed, AstraZeneca, Macclesfield, United Kingdom; The Christie NHS Foundation Trust, Manchester, United Kingdom
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Coughlin PA, Jackson D, White AD, Bailey MA, Farrow C, Scott DJA, Howell SJ. Meta-analysis of prospective trials determining the short- and mid-term effect of elective open and endovascular repair of abdominal aortic aneurysms on quality of life. Br J Surg 2012; 100:448-55. [DOI: 10.1002/bjs.9018] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2012] [Indexed: 12/27/2022]
Abstract
Abstract
Background
Repair of an abdominal aortic aneurysm (AAA) is undertaken to prevent rupture. Intervention is by either open repair (OR) or a more minimally invasive endovascular repair (EVAR). Quality-of-life (QoL) analysis is an important health outcome and a number of single studies have assessed QoL following OR and EVAR. This was a meta-analysis of published studies to assess the effect of an intervention on QoL in patients with an AAA.
Methods
A systematic literature search was undertaken for studies prospectively reporting QoL analysis in patients with an AAA undergoing elective intervention. A multivariable meta-analysis model was developed in which the outcomes were mean changes in QoL scores over time, both for all AAA repairs (OR and EVAR) and comparing OR with EVAR.
Results
Data were collated from 16 studies (14 OR, 12 EVAR). The results suggested that treating an AAA had an effect on patient-reported QoL, evident from the statistically significant changes predominantly in domains assessing physical ability and pain. QoL was affected most within the first 3 months after any form of intervention, and was more pronounced following OR. Furthermore, a deterioration in the Physical Component Summary score following an AAA repair (either OR or EVAR) was evident at 12 months after intervention.
Conclusion
Treating an AAA deleteriously affects patient-reported QoL over the first year following intervention.
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Affiliation(s)
- P A Coughlin
- Department of Vascular Surgery, Addenbrooke's Hospital, Leeds, UK
| | - D Jackson
- Medical Research Council Biostatistics Unit, Cambridge, Leeds, UK
| | | | | | - C Farrow
- Department of Anaesthesia, Leeds General Infirmary, Leeds, UK
| | | | - S J Howell
- Department of Anaesthesia, Leeds General Infirmary, Leeds, UK
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Kirkman MA, Forgacs B, Heap S, Howell SJ, Davis JRE, McWilliam L, Prescott M, Augustine T. Third resection of pheochromocytoma aided by preoperative ¹²³I-MIBG scintigraphy and intraoperative gamma probe measurements. Nuklearmedizin 2011; 50:N8-N11. [PMID: 21336418] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Accepted: 10/14/2010] [Indexed: 05/30/2023]
Affiliation(s)
- M A Kirkman
- Department of Transplant and Endocrine Surgery, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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Howell SM, Howell SJ, Hull ML. Assessment of the radii of the medial and lateral femoral condyles in varus and valgus knees with osteoarthritis. J Bone Joint Surg Am 2010; 92:98-104. [PMID: 20048101 DOI: 10.2106/jbjs.h.01566] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Understanding the relationship between the radii of the medial and lateral femoral condyles in varus and valgus knees is important for aligning the femoral component and for restoring kinematics in total knee arthroplasty. The purpose of this study was to test the hypothesis that the asymmetry between the radii of the medial and lateral femoral condyles in varus and valgus knees with osteoarthritis is small enough to be clinically unimportant. METHODS A magnetic resonance imaging scan was obtained with use of a biplanar, rotational alignment protocol in a consecutive series of subjects with end-stage osteoarthritis prior to total knee arthroplasty. The alignment protocol oriented the scanning plane so that both condyles were imaged in a plane perpendicular to the primary femoral axis of the knee about which the tibia flexes and extends. The study included 155 varus knees and forty-four valgus knees. Radii were calculated from the area of the best-fit circle overlaid from 10 degrees to 160 degrees on the subchondral corticocancellous bone interface of the medial and lateral femoral condyles. The radius of a condyle was the average of the radii on four adjacent images that showed the femoral condyle with the largest curvature. RESULTS In the 155 varus knees, the radius of the lateral condyle was an average of 0.1 mm larger than that of the medial condyle (p = 0.003). In the forty-four valgus knees, the radius of the lateral condyle was an average of 0.2 mm larger than that of the medial condyle (p < 0.006). There was a strong association between the radii of the medial and lateral femoral condyles in both the varus (r(2) = 0.9210) and the valgus (r(2) = 0.9129) knees. CONCLUSIONS As determined by imaging of the femoral condyles perpendicular to the primary femoral axis of the knee, the asymmetry between the radii of the medial and lateral femoral condyles in varus and valgus knees with end-stage osteoarthritis was < or =0.2 mm, which is small enough to be considered clinically unimportant when aligning a total knee prosthesis.
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Affiliation(s)
- Stephen M Howell
- Mechanical and Aeronautical Engineering, University of California at Davis, Davis, California, USA.
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Howell SJ, Chapman GA, Dellagrammaticas D, Gough MJ. The cerebrovascular response to hypercarbia does not support vasoparesis as a mechanism for increases in middle cerebral artery blood flow velocity after carotid endarterectomy. Br J Surg 2009. [DOI: 10.1002/bjs.6499] [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] [Indexed: 11/10/2022]
Affiliation(s)
- S J Howell
- Leeds Vascular Institute and the Academic Unit of Anaesthesia, The General Infirmary at Leeds, Leeds
| | - G A Chapman
- Leeds Vascular Institute and the Academic Unit of Anaesthesia, The General Infirmary at Leeds, Leeds
| | - D Dellagrammaticas
- Leeds Vascular Institute and the Academic Unit of Anaesthesia, The General Infirmary at Leeds, Leeds
| | - M J Gough
- Leeds Vascular Institute and the Academic Unit of Anaesthesia, The General Infirmary at Leeds, Leeds
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Turner S, Derham C, Orsi NM, Bosomworth M, Bellamy MC, Howell SJ. Randomized clinical trial of the effects of methylprednisolone on renal function after major vascular surgery. Br J Surg 2008; 95:50-6. [PMID: 18027383 DOI: 10.1002/bjs.5978] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Perioperative renal dysfunction following abdominal aortic aneurysm (AAA) repair is multifactorial and may involve hypotension, hypoxia and ischaemia-reperfusion injury. Studies of cardiac and hepatic transplant surgery have demonstrated beneficial effects on renal function of high-dose methylprednisolone administered before surgery. METHODS Twenty patients undergoing elective open AAA repair were randomized to receive either methylprednisolone 10 mg/kg or dextrose (control) before induction of anaesthesia. Blood was analysed for a panel of cytokines representative of T helper cell type 1 and 2 subsets. Urine was analysed for subclinical markers of renal dysfunction (albumin, alpha(1)-microglobulin and N-acetyl-beta-D-glucosaminidase). RESULTS Data from 18 patients were analysed. Both groups demonstrated glomerular and proximal convoluted tubular dysfunction that was unaffected by steroid treatment. Steroid administration increased serum levels of urea and creatinine (both P < 0.001). The steroid group had increased interleukin 10 levels (P = 0.005 compared to controls). There were no differences between groups in overall surgical complications, length of intensive care unit (P = 0.821) and hospital (P = 0.719) stay, or 30-day mortality. CONCLUSION Methylprednisolone administration altered the cytokine profile favourably but adversely affected postoperative renal function.
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Affiliation(s)
- S Turner
- Academic Unit of Anaesthesia, Leeds General Infirmary, Leeds, UK
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Howell SJ, Vohra RS. Perioperative Management of Patients Undergoing Non-cardiac Vascular Surgery. Eur J Vasc Endovasc Surg 2007; 34:625-31. [PMID: 17888691 DOI: 10.1016/j.ejvs.2007.06.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [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: 04/25/2007] [Accepted: 06/26/2007] [Indexed: 11/30/2022]
Abstract
Patients undergoing non-cardiac vascular surgery have arterial disease affecting more than one vascular bed and commonly have multiple significant co-morbidities. The surgical and anaesthetic teams are asked to address pre-, peri- and postoperative management issues relating not only to the surgery but arising from these co-morbidities. Here we review the strategies and rationale for the optimisation of these high risk patients.
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Affiliation(s)
- S J Howell
- Academic Unit of Anaesthetics, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK.
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Abstract
Carotid endarterectomy (CEA) is performed to prevent embolic stroke in patients with atheromatous disease at the carotid bifurcation. There is now substantial evidence to support early operation in symptomatic patients, ideally within 2 weeks of the last neurological symptoms. Thus, the anaesthetist may be faced with a high risk patient in whom there has been limited time for preoperative preparation. The operation may be performed under local or general anaesthesia. The advantages and disadvantages of both are explored in this review. Carotid shunting may offer a degree of cerebral protection, but carries its own risks and has not been proved to reduce morbidity and mortality. The use of carotid shunts is based on clinical judgement, awake neurological monitoring, and the use of monitors of cerebral perfusion. There is no ideal monitor of cerebral perfusion in the patient receiving general anaesthesia. Both the intraoperative and postoperative periods may be witness to dramatic haemodynamic changes that may compromise the cerebral or myocardial circulations. In particular, postoperative hypotension may compromise both myocardial and cerebral perfusion, and severe hypertension can cause cerebral hyperperfusion. There is as yet limited evidence to guide the management of these problems. In summary, CEA can yield significant benefit, but those with the most to gain from the operation also present the greatest challenge to the anaesthetist.
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Affiliation(s)
- S J Howell
- Academic Unit of Anaesthesia, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK.
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Spahn DR, Howell SJ, Delabays A, Chassot PG. Coronary stents and perioperative anti-platelet regimen: dilemma of bleeding and stent thrombosis. Br J Anaesth 2006; 96:675-7. [PMID: 16698866 DOI: 10.1093/bja/ael098] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
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Howell SJ, Thompson JP, Nimmo AF, Snowden C, Edwards ND, Carlisle J, Suleiman MS, Baumbach A. Relationship between perioperative troponin elevation and other indicators of myocardial injury in vascular surgery patients. Br J Anaesth 2006; 96:303-9. [PMID: 16415314 DOI: 10.1093/bja/aei317] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In 2000 the European Society of Cardiology and the American College of Cardiology published a consensus document revising the definition of myocardial infarction. The usefulness of this revised definition has been challenged. It has been suggested that, rather than any release of cardiac troponin being potentially diagnostic of myocardial infarction, a diagnostic threshold consistent with significant myocardial injury should be defined. METHODS We studied 65 patients undergoing elective major vascular surgery to examine the relationship between the magnitude of cardiac troponin I (cTnI) and creatine kinase MB fraction (CK-MB) release and clinical signs or symptoms of myocardial injury. cTnI and CK-MB concentrations were measured preoperatively and on the first 4 postoperative days using the ACCESS assay (Beckmann). Patients were considered to have suffered a perioperative myocardial infarction if they had either symptoms or ECG changes consistent with this diagnosis, together with cTnI release. RESULTS Peak postoperative cTnI concentrations above the lower detection limit of the ACCESS assay (0.06 microg litre(-1)) occurred in 26 patients. Eight of these patients displayed symptoms or ECG changes consistent with myocardial injury. A cTnI level greater than 0.68 microg litre(-1) was found to be consistent with the clinical diagnosis of myocardial infarction. The optimal cut-off for the diagnosis of MI using CK-MB was 40.4 microg litre(-1). CONCLUSIONS These data suggest that further studies are required to define the optimal cardiac troponin diagnostic threshold for the diagnosis of myocardial infarction in the non-cardiac surgery population.
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Affiliation(s)
- S J Howell
- Academic Unit of Anaesthesia, Leeds General Infirmary, Leeds LS1 3EX, UK.
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Abstract
Treatment with cytotoxic chemotherapy and radiotherapy is associated with significant gonadal damage in men, and alkylating agents are the most common agents implicated. The vast majority of men receiving procarbazine-containing regimens for the treatment of lymphomas are rendered permanently infertile, whereas treatment with doxorubicin hydrochloride (Adriamycin), bleomycin, vinblastine, and dacarbazine appears to have a significant advantage, with a return to normal fertility in the vast majority of patients. Cisplatin-based chemotherapy for testicular cancer results in temporary azoospermia in most men, with a recovery of spermatogenesis in about 50% of the patients after 2 years and 80% after 5 years. The germinal epithelium is very sensitive to radiation-induced damage, with changes to spermatogonia following as little as 0.2 Gy. Testicular doses of less than 0.2 Gy had no significant effect on FSH levels or sperm counts, whereas doses between 0.2 and 0.7 Gy caused a transient dose-dependent increase in FSH and reduction in sperm concentration, with a return to normal values within 12-24 months. No radiation dose threshold has been defined above which permanent azoospermia is inevitable; however, doses of 1.2 Gy and above are likely to be associated with a reduced risk of recovery of spermatogenesis; the time to recovery, if it is to occur, is also likely to be dose dependent.
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Affiliation(s)
- S J Howell
- Department of Endocrinology, Christie Hospital NHS Trust, Withington, Manchester, UK M20 4BX
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Affiliation(s)
- S J Howell
- Academic Unit of Anaesthesia, University of Leeds, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK.
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Howell SJ, Sear JW, Young JD. Editorial. Br J Anaesth 2004; 93:1-2. [PMID: 15192001 DOI: 10.1093/bja/aeh173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
The evidence for an association between hypertensive disease, elevated admission arterial pressure, and perioperative cardiac outcome is reviewed. A systematic review and meta-analysis of 30 observational studies demonstrated an odds ratio for the association between hypertensive disease and perioperative cardiac outcomes of 1.35 (1.17-1.56). This association is statistically but not clinically significant. There is little evidence for an association between admission arterial pressures of less than 180 mm Hg systolic or 110 mm Hg diastolic and perioperative complications. The position is less clear in patients with admission arterial pressures above this level. Such patients are more prone to perioperative ischaemia, arrhythmias, and cardiovascular lability, but there is no clear evidence that deferring anaesthesia and surgery in such patients reduces perioperative risk. We recommend that anaesthesia and surgery should not be cancelled on the grounds of elevated preoperative arterial pressure. The intraoperative arterial pressure should be maintained within 20% of the best estimate of preoperative arterial pressure, especially in patients with markedly elevated preoperative pressures. As a result, attention should be paid to the presence of target organ damage, such as coronary artery disease, and this should be taken into account in preoperative risk evaluation. The anaesthetist should be aware of the potential errors in arterial pressure measurements and the impact of white coat hypertension on them. A number of measurements of arterial pressure, obtained by competent staff (ideally nursing staff), may be required to obtain an estimate of the "true" preoperative arterial pressure.
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Affiliation(s)
- S J Howell
- Academic Unit of Anaesthesia, University of Leeds, Leeds General Infirmary, Leeds LS1 3EX, UK.
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47
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Abstract
Treatment with cytotoxic chemotherapy and radiotherapy is associated with significant gonadal damage in men. Alkylating agents, such as cyclophosphamide and procarbazine, are the most common agents implicated. The vast majority of men receiving procarbazine-containing regimens for the treatment of lymphomas are rendered permanently infertile. Treatment with adriamycin, bleomycin, vinblastine and dacarbazine (ABVD) appears to have a significant advantage in terms of testicular function, with a return to normal fertility in the vast majority of patients. Cisplatin-based chemotherapy for testicular cancer results in temporary azoospermia in most men with a recovery of spermatogenesis in about 50% after 2 years and 80% after 5 years. There is also evidence of chemotherapy-induced Leydig cell impairment in a proportion of these men, although this appears to be of no clinical significance in the majority of patients. The germinal epithelium is very sensitive to radiation-induced damage with changes to spermatogonia following as little as 0.1 Gy, and permanent infertility after fractionated doses of 2 Gy and above, whereas clinically significant Leydig cell impairment occurs rarely with doses of less than 20 Gy.
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Affiliation(s)
- S J Howell
- Department of Endocrinology, Christie Hospital NHS Trust, Withington, Manchester, UK
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48
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Howell A, Howell SJ, Clarke R, Anderson E. Where do selective estrogen receptor modulators (SERMs) and aromatase inhibitors (AIs) now fit into breast cancer treatment algorithms? J Steroid Biochem Mol Biol 2001; 79:227-37. [PMID: 11850229 DOI: 10.1016/s0960-0760(01)00140-6] [Citation(s) in RCA: 23] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The agents used for endocrine therapy in patients with breast cancer have changed markedly over the past decade. Tamoxifen remains the anti-oestrogen of choice, but could be replaced by the oestrogen receptor down-regulator ICI 182780 or by the fixed ring triphenylethylene arzoxifene (previously SERM III) soon. Whilst aminoglutethimide and 4-OH androstenedione were the aromatase inhibitors of choice, they have been replaced by non-steroidal (anastrozole and letrozole) and steroidal (exemestane) inhibitors of high potency and low side effect profile. Previously, often used treatments such as progestogens (megestrol acetate and medroxyprogesterone acetate) and androgens are now rarely used or confined to fourth or fifth line treatments. The LHRH agonist, goserelin, remains the treatment of choice for pre-menopausal patients with advanced breast cancer although recent randomised trials indicate a response, time to progression and survival advantage for the combination of goserelin and tamoxifen compared with goserelin alone. The newer treatments have led to questions concerning the optimum sequence of agents to use in advanced breast cancer and as neo-adjuvant and adjuvant therapy in relation to surgery. Two trials of anastrozole compared with tamoxifen and one trial of letrozole compared with tamoxifen indicate that the new triazole aromatase inhibitors have a significant advantage over the anti-oestrogen with respect to time to progression and survival. Similarly, triazole aromatase inhibitors give faster and more complete responses compared with tamoxifen when used in post-menopausal women before surgery. Major research questions remain with respect to the aromatase inhibitors used as adjuvant therapy. Anastrozole is being tested alone or in combination with tamoxifen compared with tamoxifen in the 'so-called' ATAC trial. Over 9000 patients have been randomised to this important study: the results will be available late-2001. A similar study comparing letrozole and tamoxifen started recently under the auspices of the Breast International Group. Importantly, this trial is also comparing the sequence of tamoxifen followed by letrozole (or vice versa). A similar trial of exemestane given after 2-3 years of tamoxifen compared with 5 years of tamoxifen is recruiting well as is a study comparing letrozole (or placebo) for 5 years after 5 years of adjuvant tamoxifen. These studies may show that aromatase inhibitors are superior to tamoxifen or that a sequence is preferable.ICI 182780 causes complete oestrogen receptor down-regulation leading to a the lack of agonist activity of the drug. Two trials of ICI 182780 compared with anastrozole for advanced disease will report later this year and a comparison with tamoxifen next year. Arzoxifene (SERM III) is being tested against tamoxifen. These studies are likely to result in new anti-oestrogens being introduced into the clinic. Most of our endocrine treatments deprived the tumour cell of oestradiol. In vitro experiments with MCF-7 cells indicate that tumour cells can adapt and then grow in response to low oestrogen concentrations in the tissue--culture medium. Importantly, the cells were shown to apoptose in response to high oestrogen concentrations. A recent clinical trial has demonstrated a high response rate to stilboestrol given after a median of four previous oestrogen depriving endocrine therapies. These data and the newer treatments available indicate a need to re-think our general approach to endocrine therapy and endocrine prevention.
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Affiliation(s)
- A Howell
- CRC Department of Medical Oncology, Christie Hospital NHS Trust, M20 4BX, Manchester, UK.
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49
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Howell SJ, Radford JA, Adams JE, Smets EM, Warburton R, Shalet SM. Randomized placebo-controlled trial of testosterone replacement in men with mild Leydig cell insufficiency following cytotoxic chemotherapy. Clin Endocrinol (Oxf) 2001; 55:315-24. [PMID: 11589674 DOI: 10.1046/j.1365-2265.2001.01297.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Testosterone deficiency is associated with significant morbidity, and androgen replacement in overt hypogonadism is clearly beneficial. However, there are few data concerning the response to therapy in young men with mild testosterone deficiency. DESIGN AND PATIENTS We have identified a cohort of 35 men, mean age 40.9 years, with mild Leydig cell dysfunction, defined by a raised LH level (LH >or= 8 IU/l) and a testosterone level in the lower half of the normal range or frankly subnormal (testosterone < 20 nmol/l), following treatment with cytotoxic chemotherapy for malignancy. Patients were assigned randomly to 12 months treatment with transdermal testosterone (n = 16) (Andropatch 2.5 mg patches, 1-2 patches per day) or placebo patches (n = 19) in a single blinded manner. MEASUREMENTS Measurements of bone mineral density (BMD) and body composition were performed at baseline, 6 months and 12 months using single and dual energy X-ray absorptiometry (SXA, DXA). In addition, spinal BMD was assessed at baseline and 12 months by quantitative CT (QCT). Subjects were reviewed at 3-monthly intervals; at each visit blood was taken for measurement of testosterone, SHBG, LH, FSH, oestradiol, lipids and IGF-1 and patients completed three questionnaires which assessed energy levels, mood and sexual function. RESULTS Total testosterone and calculated free testosterone increased significantly in the testosterone-treated group compared with the placebo-treated group (13.3 nmol/l and 342.9 pmol/l at baseline compared with 17.3 nmol/l and 454.8 pmol/l during the study period in the testosterone-treated group; P = 0.05 and P = 0.02, respectively). LH was suppressed into the normal range in 15 of the 16 testosterone-treated men and mean LH significantly reduced from 11.1 IU/l at baseline to 6.8 IU/l during the study. There was no significant change in BMD at the hip, spine or forearm and no change in fat or lean body mass. There was a significant reduction in physical fatigue in the testosterone-treated group compared with the placebo-treated group (P = 0.008) and a borderline improvement in activity score (P = 0.05). There were no significant effects of treatment on mood or sexual function. Neither oestradiol nor IGF-1 levels differed between the two groups during the study. There was no significant change in mean total cholesterol, HDL cholesterol or triglyceride levels, but there was a small, but significant reduction in LDL cholesterol levels in the testosterone-treated group compared with the placebo group (P = 0.02). CONCLUSIONS These results suggest that testosterone therapy in young men with raised LH levels and low/normal testosterone levels does not result in significant changes in BMD, body composition, lipids or quality of life, apart from a reduction in physical fatigue and a small reduction in LDL cholesterol. This implies that mild hypogonadism defined on this basis is not of clinical importance in the majority of men, and that androgen replacement cannot be recommended for routine use in these patients.
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Affiliation(s)
- S J Howell
- Department of Endocrinology, Christie Hospital NHS Trust, Withington, Manchester, UK
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50
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Abstract
Until the advent of modern neuroradiological imaging techniques in 1989, a diagnosis of GH deficiency in adults carried little significance other than as a marker of hypothalamo-pituitary disease. The relatively recent recognition of a characteristic clinical syndrome associated with failure of spontaneous GH secretion and the potential reversal of many of its features with recombinant human GH has prompted a closer examination of the physiological role of GH after linear growth is complete. The safe clinical practice of GH replacement demands a method of judging overall GH status, but there is no biological marker in adults that is the equivalent of linear growth in a child by which to judge the efficacy of GH replacement. Assessment of optimal GH replacement is made difficult by the apparent diverse actions of GH in health, concern about the avoidance of iatrogenic acromegaly, and the growing realization that an individual's risk of developing certain cancers may, at least in part, be influenced by cumulative exposure to the chief mediator of GH action, IGF-I. As in all areas of clinical practice, strategies and protocols vary between centers, but most physicians experienced in the management of pituitary disease agree that GH is most appropriately begun at low doses, building up slowly to the final maintenance dose. This, in turn, is best determined by a combination of clinical response and measurement of serum IGF-I, avoiding supraphysiological levels of this GH-dependent peptide. Numerous studies have helped define the optimum management of GH replacement during childhood. The recent requirement to measure and monitor GH status in adult life has called into question the appropriateness of simplistic weight- and surface area-based dosing regimens for the management of GH deficiency in childhood, with reliance on linear growth as the sole marker of GH action. It is clear that the monitoring of parameters other than linear growth to help refine GH therapy should now be incorporated into childhood GH treatment protocols. Further research will be required to define the optimal management of the transition from pediatric to adult GH replacement; this transition will only be possible once the benefits of GH in mature adults are defined and accepted by pediatric and adult endocrinologists alike.
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Affiliation(s)
- W M Drake
- Department of Endocrinology, St. Bartholomew's Hospital, London EC1A 7BE, United Kingdom.
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