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Lang J, Leal AD, Marín-Jiménez JA, Hartman SJ, Shulman J, Navarro NM, Lewis MS, Capasso A, Bagby SM, Yacob BW, MacBeth M, Freed BM, Eckhardt SG, Jordan K, Blatchford PJ, Pelanda R, Lieu CH, Messersmith WA, Pitts TM. Cabozantinib sensitizes microsatellite stable colorectal cancer to immune checkpoint blockade by immune modulation in human immune system mouse models. Front Oncol 2022; 12:877635. [PMID: 36419897 PMCID: PMC9676436 DOI: 10.3389/fonc.2022.877635] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 10/17/2022] [Indexed: 12/23/2023] Open
Abstract
Immune checkpoint inhibitors have been found to be effective in metastatic MSI-high colorectal cancers (CRC), however, have no efficacy in microsatellite stable (MSS) cancers, which comprise the majority of mCRC cases. Cabozantinib is a small molecule multi-tyrosine kinase inhibitor that is FDA approved in advanced renal cell, medullary thyroid, and hepatocellular carcinoma. Using Human Immune System (HIS) mice, we tested the ability of cabozantinib to prime MSS-CRC tumors to enhance the potency of immune checkpoint inhibitor nivolumab. In four independent experiments, we implanted distinct MSS-CRC patient-derived xenografts (PDXs) into the flanks of humanized BALB/c-Rag2nullIl2rγnullSirpαNOD (BRGS) mice that had been engrafted with human hematopoietic stem cells at birth. For each PDX, HIS-mice cohorts were treated with vehicle, nivolumab, cabozantinib, or the combination. In three out of the four models, the combination had a lower tumor growth rate compared to vehicle or nivolumab-treated groups. Furthermore, interrogation of the HIS in immune organs and tumors by flow cytometry revealed increased Granzyme B+, TNFα+ and IFNγ+ CD4+ T cells among the human tumor infiltrating leukocytes (TIL) that correlated with reduced tumor growth in the combination-treated HIS-mice. Notably, slower growth correlated with increased expression of the CD4+ T cell ligand, HLA-DR, on the tumor cells themselves. Finally, the cabozantinib/nivolumab combination was tested in comparison to cobimetinib/atezolizumab. Although both combinations showed tumor growth inhibition, cabozantinib/nivolumab had enhanced cytotoxic IFNγ and TNFα+ T cells. This pre-clinical in vivo data warrants testing the combination in clinical trials for patients with MSS-CRC.
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Affiliation(s)
- Julie Lang
- Department of Immunology and Microbiology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Alexis D. Leal
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Juan A. Marín-Jiménez
- Department of Medical Oncology, Catalan Institute of Oncology (ICO-L´Hospitalet), Barcelona, Spain
| | - Sarah J. Hartman
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Jeremy Shulman
- Department of Immunology and Microbiology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Natalie M. Navarro
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Matthew S. Lewis
- Department of Immunology and Microbiology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Anna Capasso
- Department of Oncology, Livestrong Cancer Institutes, Dell Medical School, University of Texas at Austin, Austin, TX, United States
| | - Stacey M. Bagby
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Bethlehem W. Yacob
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Morgan MacBeth
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Brian M. Freed
- Division of Allergy and Clinical Immunology, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, United States
| | - S. Gail Eckhardt
- Department of Oncology, Livestrong Cancer Institutes, Dell Medical School, University of Texas at Austin, Austin, TX, United States
| | - Kimberly Jordan
- Department of Immunology and Microbiology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Patrick J. Blatchford
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver, Aurora, CO, United States
| | - Roberta Pelanda
- Department of Immunology and Microbiology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Christopher H. Lieu
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Wells A. Messersmith
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Todd M. Pitts
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States
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Scott AJ, Basu Mallick A, Dotan E, Cohen SJ, Gold PJ, Hochster HS, Subramaniam S, Barzi A, Watts GS, Blatchford PJ, Messersmith WA. A Phase II Study Investigating Cabozantinib in Patients with Refractory Metastatic Colorectal Cancer (AGICC 17CRC01). Cancer Research Communications 2022; 2:1188-1196. [PMID: 36969746 PMCID: PMC10035393 DOI: 10.1158/2767-9764.crc-22-0169] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/22/2022] [Accepted: 09/01/2022] [Indexed: 11/16/2022]
Abstract
Abstract
Purpose: Multi-tyrosine kinase inhibitors have shown clinical activity in metastatic colorectal cancer patients. Cabozantinib, a multi-tyrosine kinase inhibitor, exhibited potent antitumor activity superior to regorafenib in preclinical colorectal cancer patient-derived tumor xenograft models. This Phase II study aimed to investigate cabozantinib, a multityrosine kinase inhibitor, in refractory, metastatic colorectal cancer patients. Patients and Methods: A non-randomized, two-stage, phase 2 clinical trial evaluating 12 week PFS was conducted in 8 cancer centers across the United States between May 2018 and July 2020. Results: A total of 44 patients were enrolled between May 2018-May 2019, 40 of which were response evaluable. Of the total 769 reported adverse events (AE), 93 (12%) were ≥ grade 3. Five Grade 5 AEs were reported of which 4 were unrelated to study drug and 1 was reported as possibly related due to bowel perforation. Eighteen patients (45%) achieved 12-week PFS with stable disease or better (CI 0.29-0.62; p<0.001). One patient (3%) had a partial response, and 27 other patients achieved stable disease as best response per RECISTv1.1. Median PFS was 3.0 months, and median OS was 8.3 months. Of the 18 patients who achieved 12-week PFS, 12 had left-sided primary tumors, 11 were RAS wild type,11 were PIK3CA wild type, and 6 had previous regorafenib therapy. The 12-week PFS rate was higher in RAS wild type tumors compared to RAS mutant tumors (0.61 vs 0.32, p=0.11). Conclusions: This phase 2 study demonstrated clinical activity of cabozantinib in heavily pretreated, refractory mCRC patients, and supports further investigation.
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Affiliation(s)
- Aaron J. Scott
- Banner University of Arizona Cancer Center, Tucson, AZ, United States
| | | | - Efrat Dotan
- Fox Chase Cancer Center, Philadelphia, PA, United States
| | | | | | - Howard S. Hochster
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
| | | | - Afsaneh Barzi
- City Of Hope National Medical Center, Duarte, CA, United States
| | | | - Patrick J. Blatchford
- University of Colorado Anschutz Medical Campus and University of Colorado Cancer Center, Aurora, CO, United States
| | - Wells A. Messersmith
- University of Colorado Anschutz Medical Campus and University of Colorado Cancer Center, Aurora, CO, United States
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Wherry SJ, Blatchford PJ, Swanson CM, Wellington T, Boxer RS, Kohrt WM. Maintaining serum ionized calcium during brisk walking attenuates the increase in bone resorption in older adults. Bone 2021; 153:116108. [PMID: 34252605 PMCID: PMC8478867 DOI: 10.1016/j.bone.2021.116108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 04/26/2021] [Accepted: 07/06/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Endurance exercise can cause a decrease in serum ionized calcium (iCa) and increases in parathyroid hormone (PTH) and bone resorption, reflected by serum carboxy-terminal collagen crosslinks (CTX). We developed a calcium clamp to prevent the decrease in iCa during exercise, which attenuated increases in PTH and CTX during vigorous cycling in young men. The goal was to determine whether this occurs in older adults during brisk walking. METHODS Twelve older adults (6 men, 6 women) performed two identical 60-min treadmill walking bouts with Ca gluconate or half-normal saline infusion. Blood sampling for iCa, total calcium (tCa), phosphate (P), PTH, and CTX, occurred before, during, and for 4 h after exercise. RESULTS iCa decreased during exercise with the saline infusion (p = 0.04) and this provoked increases in PTH and CTX (both p < 0.01). The Ca clamp prevented the decrease in serum iCa during exercise and attenuated the PTH and CTX responses. CONCLUSIONS Preventing the exercise-induced decrease in iCa markedly attenuated the increases in PTH and CTX. The cause of the decrease in iCa during exercise remains unclear, but the increases in PTH and CTX are likely counter-regulatory responses to defend serum iCa. This contention is supported by previous observations that the disruption of Ca homeostasis during exercise occurs regardless of training status. It will be important to establish whether this acute catabolic effect of exercise diminishes the potential chronic anabolic effects of exercise on bone.
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Affiliation(s)
- Sarah J Wherry
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, United States of America; VA Eastern Colorado Geriatric Research, Education, and Clinical Center (GRECC), Aurora, CO 80045, United States of America.
| | - Patrick J Blatchford
- VA Eastern Colorado Geriatric Research, Education, and Clinical Center (GRECC), Aurora, CO 80045, United States of America; Department of Biostatistics and Bioinformatics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, United States of America
| | - Christine M Swanson
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, United States of America
| | - Toby Wellington
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, United States of America
| | - Rebecca S Boxer
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, United States of America; VA Eastern Colorado Geriatric Research, Education, and Clinical Center (GRECC), Aurora, CO 80045, United States of America
| | - Wendy M Kohrt
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, United States of America; VA Eastern Colorado Geriatric Research, Education, and Clinical Center (GRECC), Aurora, CO 80045, United States of America
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Marín-Jiménez JA, Capasso A, Lewis MS, Bagby SM, Hartman SJ, Shulman J, Navarro NM, Yu H, Rivard CJ, Wang X, Barkow JC, Geng D, Kar A, Yingst A, Tufa DM, Dolan JT, Blatchford PJ, Freed BM, Torres RM, Davila E, Slansky JE, Pelanda R, Eckhardt SG, Messersmith WA, Diamond JR, Lieu CH, Verneris MR, Wang JH, Kiseljak-Vassiliades K, Pitts TM, Lang J. Testing Cancer Immunotherapy in a Human Immune System Mouse Model: Correlating Treatment Responses to Human Chimerism, Therapeutic Variables and Immune Cell Phenotypes. Front Immunol 2021; 12:607282. [PMID: 33854497 PMCID: PMC8040953 DOI: 10.3389/fimmu.2021.607282] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 03/04/2021] [Indexed: 01/22/2023] Open
Abstract
Over the past decade, immunotherapies have revolutionized the treatment of cancer. Although the success of immunotherapy is remarkable, it is still limited to a subset of patients. More than 1500 clinical trials are currently ongoing with a goal of improving the efficacy of immunotherapy through co-administration of other agents. Preclinical, small-animal models are strongly desired to increase the pace of scientific discovery, while reducing the cost of combination drug testing in humans. Human immune system (HIS) mice are highly immune-deficient mouse recipients rtpeconstituted with human hematopoietic stem cells. These HIS-mice are capable of growing human tumor cell lines and patient-derived tumor xenografts. This model allows rapid testing of multiple, immune-related therapeutics for tumors originating from unique clinical samples. Using a cord blood-derived HIS-BALB/c-Rag2nullIl2rγnullSIRPαNOD (BRGS) mouse model, we summarize our experiments testing immune checkpoint blockade combinations in these mice bearing a variety of human tumors, including breast, colorectal, pancreatic, lung, adrenocortical, melanoma and hematological malignancies. We present in-depth characterization of the kinetics and subsets of the HIS in lymph and non-lymph organs and relate these to protocol development and immune-related treatment responses. Furthermore, we compare the phenotype of the HIS in lymph tissues and tumors. We show that the immunotype and amount of tumor infiltrating leukocytes are widely-variable and that this phenotype is tumor-dependent in the HIS-BRGS model. We further present flow cytometric analyses of immune cell subsets, activation state, cytokine production and inhibitory receptor expression in peripheral lymph organs and tumors. We show that responding tumors bear human infiltrating T cells with a more inflammatory signature compared to non-responding tumors, similar to reports of "responding" patients in human immunotherapy clinical trials. Collectively these data support the use of HIS mice as a preclinical model to test combination immunotherapies for human cancers, if careful attention is taken to both protocol details and data analysis.
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Affiliation(s)
- Juan A. Marín-Jiménez
- Department of Medical Oncology, Catalan Institute of Oncology (ICO-L’Hospitalet), Barcelona, Spain
| | - Anna Capasso
- Department of Oncology, Livestrong Cancer Institutes, Dell Medical School, University of Texas at Austin, Austin, TX, United States
| | - Matthew S. Lewis
- Department of Immunology and Microbiology, School of Medicine, University of Colorado, Aurora, CO, United States
| | - Stacey M. Bagby
- Division of Medical Oncology, School of Medicine, University of Colorado, Aurora, CO, United States
| | - Sarah J. Hartman
- Division of Medical Oncology, School of Medicine, University of Colorado, Aurora, CO, United States
| | - Jeremy Shulman
- Department of Immunology and Microbiology, School of Medicine, University of Colorado, Aurora, CO, United States
| | - Natalie M. Navarro
- Division of Medical Oncology, School of Medicine, University of Colorado, Aurora, CO, United States
| | - Hui Yu
- Division of Medical Oncology, School of Medicine, University of Colorado, Aurora, CO, United States
- University of Colorado Cancer Center, Aurora, CO, United States
| | - Chris J. Rivard
- Division of Medical Oncology, School of Medicine, University of Colorado, Aurora, CO, United States
- University of Colorado Cancer Center, Aurora, CO, United States
| | - Xiaoguang Wang
- Department of Immunology and Microbiology, School of Medicine, University of Colorado, Aurora, CO, United States
| | - Jessica C. Barkow
- Department of Immunology and Microbiology, School of Medicine, University of Colorado, Aurora, CO, United States
| | - Degui Geng
- Division of Medical Oncology, School of Medicine, University of Colorado, Aurora, CO, United States
| | - Adwitiya Kar
- Division of Endocrinology, School of Medicine, University of Colorado, Aurora, CO, United States
| | - Ashley Yingst
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, CO, United States
| | - Dejene M. Tufa
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, CO, United States
| | - James T. Dolan
- Rocky Vista College of Osteopathic Medicine – OMS3, Rocky Vista University, Parker, CO, United States
| | - Patrick J. Blatchford
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver, Aurora, CO, United States
| | - Brian M. Freed
- Department of Immunology and Microbiology, School of Medicine, University of Colorado, Aurora, CO, United States
- Division of Allergy and Clinical Immunology, School of Medicine, University of Colorado, Aurora, CO, United States
| | - Raul M. Torres
- Department of Immunology and Microbiology, School of Medicine, University of Colorado, Aurora, CO, United States
- University of Colorado Cancer Center, Aurora, CO, United States
| | - Eduardo Davila
- Division of Medical Oncology, School of Medicine, University of Colorado, Aurora, CO, United States
- University of Colorado Cancer Center, Aurora, CO, United States
| | - Jill E. Slansky
- Department of Immunology and Microbiology, School of Medicine, University of Colorado, Aurora, CO, United States
- University of Colorado Cancer Center, Aurora, CO, United States
| | - Roberta Pelanda
- Department of Immunology and Microbiology, School of Medicine, University of Colorado, Aurora, CO, United States
- University of Colorado Cancer Center, Aurora, CO, United States
| | - S. Gail Eckhardt
- Department of Oncology, Livestrong Cancer Institutes, Dell Medical School, University of Texas at Austin, Austin, TX, United States
| | - Wells A. Messersmith
- Division of Medical Oncology, School of Medicine, University of Colorado, Aurora, CO, United States
- University of Colorado Cancer Center, Aurora, CO, United States
| | - Jennifer R. Diamond
- Division of Medical Oncology, School of Medicine, University of Colorado, Aurora, CO, United States
- University of Colorado Cancer Center, Aurora, CO, United States
| | - Christopher H. Lieu
- Division of Medical Oncology, School of Medicine, University of Colorado, Aurora, CO, United States
| | - Michael R. Verneris
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, CO, United States
| | - Jing H. Wang
- Department of Immunology and Microbiology, School of Medicine, University of Colorado, Aurora, CO, United States
- University of Colorado Cancer Center, Aurora, CO, United States
| | - Katja Kiseljak-Vassiliades
- University of Colorado Cancer Center, Aurora, CO, United States
- Division of Endocrinology, School of Medicine, University of Colorado, Aurora, CO, United States
| | - Todd M. Pitts
- Division of Medical Oncology, School of Medicine, University of Colorado, Aurora, CO, United States
- University of Colorado Cancer Center, Aurora, CO, United States
| | - Julie Lang
- Department of Immunology and Microbiology, School of Medicine, University of Colorado, Aurora, CO, United States
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Swanson CM, Blatchford PJ, Stone KL, Cauley JA, Lane NE, Rogers-Soeder TS, Redline S, Bauer DC, Wright KP, Wierman ME, Kohrt WM, Orwoll ES. Sleep duration and bone health measures in older men. Osteoporos Int 2021; 32:515-527. [PMID: 32930851 PMCID: PMC7933119 DOI: 10.1007/s00198-020-05619-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 09/01/2020] [Indexed: 01/11/2023]
Abstract
UNLABELLED The associations between objective measures of sleep duration and bone outcomes in older men are unknown. No consistent, significant association was identified between sleep duration and bone mineral density (BMD) in the current analysis. However, future research should determine if vitamin D status modifies this relationship. INTRODUCTION Prior studies, predominantly in women, reported that long and short self-reported sleep duration are associated with lower BMD. Associations between actigraphy-determined sleep duration and BMD or bone turnover markers (BTMs) in older men are unknown. METHODS Men in The Osteoporotic Fractures in Men (MrOS) Study with wrist actigraphy and concurrent BMD assessment but without comorbidities affecting bone health were included. Sleep duration was considered as a continuous (N = 1926) and dichotomized variable where men were classified as getting the recommended (7-8 h/night; N = 478) or short (< 6 h/night; N = 577) sleep. The cross-sectional association between BMD, BTMs, and sleep duration was examined using a t test or linear regression, where appropriate, in unadjusted and adjusted models. RESULTS There were no clinically or statistically significant differences in BMD at the L-spine, total hip, or femoral neck between men getting the recommended vs. short sleep duration, using actigraphy or self-reported sleep duration (all p ≥ 0.07). When sleep duration was considered as a continuous variable, femoral neck BMD was higher in men with longer self-reported sleep duration (β = 0.006 ±0.003, p = 0.02), but this was not significant after further adjustment. In men with low 25OHD (< 20 ng/mL), longer actigraphy-determined sleep duration was associated with higher total hip BMD (β = 0.016 ± 0.008; p = 0.04). Sleep duration and BTMs were not associated. CONCLUSION Sleep duration was not associated with hip or L-spine BMD or BTMs in older men. Future research should determine if vitamin D status or other factors modify this relationship.
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Affiliation(s)
- C M Swanson
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, 12801 E. 17th Ave. Mail Stop 8106, Aurora, CO, 80045, USA.
| | - P J Blatchford
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO, USA
| | - K L Stone
- Research Institute, California Pacific Medical Center, San Francisco, CA, USA
- San Francisco Coordinating Center, University of California San Francisco, San Francisco, CA, USA
| | - J A Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - N E Lane
- Center for Musculoskeletal Health, University of California, Davis Health, Davis, CA, USA
| | | | - S Redline
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, MA, USA
- Division of Pulmonary Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - D C Bauer
- San Francisco Coordinating Center, University of California San Francisco, San Francisco, CA, USA
- University of California San Francisco Medical Center, San Francisco, CO, USA
| | - K P Wright
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, 12801 E. 17th Ave. Mail Stop 8106, Aurora, CO, 80045, USA
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, CO, USA
| | - M E Wierman
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, 12801 E. 17th Ave. Mail Stop 8106, Aurora, CO, 80045, USA
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
| | - W M Kohrt
- Division of Geriatric Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Eastern Colorado VA Geriatric, Research, Education, and Clinical Center (GRECC), Aurora, CO, USA
| | - E S Orwoll
- Division of Endocrinology and Bone & Mineral Unit, Oregon Health & Science University, Portland, OR, USA
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Hu J, Blatchford PJ, Goldenberg NA, Kittelson JM. Group sequential designs for clinical trials with bivariate endpoints. Stat Med 2020; 39:3823-3839. [PMID: 33048360 DOI: 10.1002/sim.8696] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 06/17/2020] [Accepted: 06/20/2020] [Indexed: 11/06/2022]
Abstract
Although all clinical trials are designed and monitored using more than one endpoint, methods are needed to assure that decision criteria are chosen to reflect the clinically relevant tradeoffs that assure the trial's scientific integrity. This article presents a framework for the design and monitoring clinical trials in a bivariate outcome space. The framework uses a rectangular hyperbola to define a bivariate null curve that divides outcome space into regions of benefit and lack of benefit. The curve is shown to be a flexible mapping of bivariate space that allows a continuous tradeoff between the two endpoints in a manner that captures many previous bivariate designs. The curve is extended to a distance function in bivariate space that allows different decisions in each of the four quadrants that comprise bivariate space. The distance function forms a statistic ( δ ); the distribution of its estimate is derived and used as a basis for trial design and group sequential monitoring plans in bivariate space. A recursive form of the bivariate group sequential density is used to evaluate and control operating characteristics for the proposed design. The bivariate designs are shown to meet or exceed the usual standards for size and power. The proposed design is illustrated in the ongoing NHLBI-sponsored Kids-DOTT multinational randomized controlled trial comparing shortened versus conventional anticoagulation for the treatment of venous thromboembolism in patients less than 21 years of age. The proposed methods are broadly applicable to a wide range of clinical settings and trial designs.
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Affiliation(s)
- Junxiao Hu
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Patrick J Blatchford
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Neil A Goldenberg
- Departments of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Thrombosis Program, Johns Hopkins All Children's Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.,Johns Hopkins All Children's Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - John M Kittelson
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Christiansen CL, Miller MJ, Kline PW, Fields TT, Sullivan WJ, Blatchford PJ, Stevens-Lapsley JE. Biobehavioral Intervention Targeting Physical Activity Behavior Change for Older Veterans after Nontraumatic Amputation: A Randomized Controlled Trial. PM R 2020; 12:957-966. [PMID: 32248638 PMCID: PMC8229675 DOI: 10.1002/pmrj.12374] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/24/2020] [Accepted: 03/25/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Lower-limb amputation (LLA) due to non-traumatic vascular etiology is linked to extremely low physical activity and high disability. OBJECTIVE To test the feasibility of a biobehavioral intervention designed to promote physical activity. DESIGN A randomized, single-blind feasibility trial with a crossover design. SETTING Veterans Administration Medical Center. PARTICIPANTS Military veterans (age: 65.7 [7.8] years; mean [standard deviation]) with nontraumatic lower-limb amputation (LLA), randomized to two groups: GROUP1 (n = 16) and GROUP2 (n = 15). Both groups had similar baseline amputation characteristics (level of amputation and time since amputation). INTERVENTIONS Twelve weekly, 30-minute telehealth sessions of physical activity behavior-change intervention, with GROUP1 participating in weeks 1-12 and GROUP2 in weeks 13-24. GROUP1 noncontact phase in weeks 13-24 and GROUP2 attention control telehealth phase in weeks 1-12. MAIN OUTCOME MEASURES Feasibility (participant retention, dose goal attainment, intervention acceptability [Intrinsic Motivation Inventory [IMI] Interest and Enjoyment scale], safety) and signal of efficacy (free-living physical activity [accelerometer-based average daily step count], Late Life Function and Disability Index - Disability Scale [LLFDI-DS]). RESULTS Participant retention rate was high (90%), with three participants lost to follow-up during the intervention period. Dose goal attainment was low, with only 10% of participants achieving an a priori walking dose goal. Intervention was rated as acceptable, with mean IMI Interest and Enjoyment score (5.8) statistically higher than the null value of 5.0 (P = .002). There were no between-group differences in adverse event rates (falls: P = .19, lower extremity wounds: P = .60). There was no signal of efficacy for change in average daily step count (d = -0.15) or LLFDI-DS (d = -0.22 and 0.17 for frequency and limitations scales, respectively). CONCLUSIONS Telehealth delivered biobehavioral intervention resulted in acceptable participant retention, low dose goal attainment, high participant acceptability, and low safety risk, while having no signal of efficacy (physical activity, disability) for people with nontraumatic LLA.
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Affiliation(s)
- Cory L Christiansen
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO
- VA Eastern Colorado Geriatric Research, Education, and Clinical Center, Rocky Mountain Regional VA Medical Center, Aurora, CO
| | - Matthew J Miller
- Department of Physical Therapy and Rehabilitation Science, University of California, San Francisco, San Francisco, CA
- Division of Geriatrics, University of California, San Francisco, San Francisco, CA
| | - Paul W Kline
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO
- VA Eastern Colorado Geriatric Research, Education, and Clinical Center, Rocky Mountain Regional VA Medical Center, Aurora, CO
| | - Thomas T Fields
- Department of Physical Medicine and Rehabilitation, Rocky Mountain Regional Medical Center, Aurora, CO
| | - William J Sullivan
- Department of Physical Medicine & Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
| | - Patrick J Blatchford
- VA Eastern Colorado Geriatric Research, Education, and Clinical Center, Rocky Mountain Regional VA Medical Center, Aurora, CO
- Department of Biostatistics and Informatics, University of Colorado, Aurora, CO
| | - Jennifer E Stevens-Lapsley
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO
- VA Eastern Colorado Geriatric Research, Education, and Clinical Center, Rocky Mountain Regional VA Medical Center, Aurora, CO
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8
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Miller MJ, Cook PF, Magnusson DM, Morris MA, Blatchford PJ, Schenkman ML, Christiansen CL. Self-Efficacy and Social Support are Associated with Disability for Ambulatory Prosthesis Users After Lower-Limb Amputation. PM R 2020; 13:453-460. [PMID: 32926546 DOI: 10.1002/pmrj.12464] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/09/2020] [Accepted: 08/04/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Interventions targeting psychosocial factors may improve rehabilitation outcomes for prosthesis users after lower-limb amputation (LLA), but there is a need to identify targeted factors for minimizing disability. OBJECTIVE To identify psychosocial factors related to disability for prosthesis users after LLA in middle age or later. DESIGN Cross-sectional study. SETTING General community. PARTICIPANTS Participants with LLA (N = 122) were included in this cross-sectional study if their most recent LLA was at least 1 year prior, they were ambulating independently with a prosthesis, and they were between 45 and 88 years old. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Disability, the primary outcome, was measured using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS). Candidate psychosocial variables included self-efficacy, social support, and motivation, measured using the Self-Efficacy of Managing Chronic Disease questionnaire (SEMCD), Multidimensional Scale of Perceived Social Support questionnaire (MSPSS), and modified contemplation ladder (mCL), respectively. The hypothesis was that greater self-efficacy, social support, and motivation would be associated with lower disability when controlling for covariates. RESULTS The covariate model, including etiology, age, sex, U.S. military veteran status, LLA characteristics, time since LLA, medical complexity, and perceived functional capacity, explained 66.1% of disability variability (WHODAS 2.0). Backward elimination of candidate psychosocial variables stopped after removal of motivation (P = .10), with self-efficacy (P < .001) and social support (P = .002) variables remaining in the final model. The final model fit was statistically improved (P < .001) and explained an additional 6.1% of disability variability when compared to the covariate model. CONCLUSIONS Greater self-efficacy and social support are related to lower disability after LLA. Findings suggest there may be a role for interventions targeting increased physical function, self-efficacy, and social support for ambulatory prosthesis users after LLA in middle age or later, especially when complicated by multiple chronic conditions.
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Affiliation(s)
- Matthew J Miller
- Department of Physical Therapy and Rehabilitation Science, University of California, San Francisco, San Francisco, CA, USA.,Division of Geriatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Paul F Cook
- College of Nursing, University of Colorado, Aurora, CO, USA
| | - Dawn M Magnusson
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA
| | - Megan A Morris
- Adult and Child Consortium of Research and Delivery Science, University of Colorado, Aurora, CO, USA
| | - Patrick J Blatchford
- VA Eastern Colorado Geriatric Research, Education, and Clinical Center, Aurora, CO, USA.,Colorado School of Public Health, University of Colorado, Aurora, CO, USA
| | - Margaret L Schenkman
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA
| | - Cory L Christiansen
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA.,VA Eastern Colorado Geriatric Research, Education, and Clinical Center, Aurora, CO, USA
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9
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Pate A, Lowery J, Kilbourn K, Blatchford PJ, McNulty M, Risendal B. Quality of life and the negative impact of comorbidities in long-term colorectal cancer survivors: a population-based comparison. J Cancer Surviv 2020; 14:653-659. [PMID: 32394045 DOI: 10.1007/s11764-020-00876-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/05/2020] [Indexed: 12/26/2022]
Abstract
PURPOSE Colorectal cancer (CRC) is the third most common cancer in the USA. The objective of this study was to compare quality of life (QoL) across long-term colorectal cancer survivors and unaffected matched controls while adjusting for comorbidities. METHODS The National Cancer Institute (NCI)-funded Colon Cancer Family Registry (CCFR) was used to randomly select and recruit CRC survivors (≥ 5 years from diagnosis) and matched controls for a cross-sectional survey. Nine geographically diverse sites in the USA from the CCFR participated in the study. Telephone interviews were conducted using computer-assisted methods to assess QoL. RESULTS A total of 403 cases and 401 controls were included in the final sample. Unadjusted comparison revealed no significant difference between CRC survivors and controls with respect to measures of fatigue, social, emotional, functional, and physical well-being. Multivariate logistic regression revealed that case status had a significant negative influence on colorectal cancer-specific QoL measures. Higher comorbidity indices had a significant negative influence on overall QoL regardless of case status. CONCLUSIONS Quality of life among long-term CRC survivors is similar to control subjects, with the exception of worse CRC-specific QoL measures. Higher comorbidity indices were independently associated with poor QoL for both cases and controls. IMPLICATIONS FOR CANCER SURVIVORS Survivors and healthcare providers should be aware that long-term QoL is comparable to the general population; however, there is potential that digestive tract-specific issues may persist.
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Affiliation(s)
- Amy Pate
- Preventive Medicine Residency, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Jan Lowery
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Kristin Kilbourn
- Department of Psychology, University of Colorado Denver, Denver, CO, USA
| | - Patrick J Blatchford
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Monica McNulty
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Betsy Risendal
- Department of Community and Behavioral Health, Colorado School of Public Health, 13001 E. 17th Place, Bldg 500, MS F538, Aurora, CO, 80045, USA. .,University of Colorado Comprehensive Cancer Center, Aurora, CO, USA.
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10
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Ozemek C, Hildreth KL, Blatchford PJ, Hurt KJ, Bok R, Seals DR, Kohrt WM, Moreau KL. Effects of resveratrol or estradiol on postexercise endothelial function in estrogen-deficient postmenopausal women. J Appl Physiol (1985) 2020; 128:739-747. [PMID: 32134713 DOI: 10.1152/japplphysiol.00488.2019] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Regular exercise enhances endothelial function in older men, but not consistently in estrogen-deficient postmenopausal women. Estradiol treatment improves basal endothelial function and restores improvements in endothelial function (flow-mediated dilation, FMD) to aerobic exercise training in postmenopausal women; however, estradiol treatment is controversial. Resveratrol, an estrogen receptor ligand, enhances exercise training effects on cardiovascular function and nitric oxide (NO) release in animal models, but impairs exercise training effects in men. We conducted a randomized cross-over, double-blinded, placebo-controlled pilot study to determine whether acute (single dose) resveratrol (250-mg tablet) or estradiol (0.05 mg/day transdermal patch) treatment enhances FMD at rest and after a single bout of moderate-intensity aerobic exercise in healthy estrogen-deficient postmenopausal women (n = 15, 58.1 ± 3.2 yr). FMD was measured before and after (30, 60, and 120 min) a 40-min bout of moderate-intensity treadmill exercise (60-75% peak heart rate) under the respective conditions (separated by 1-2 wk). FMD was higher (P < 0.05) before exercise and at all post-exercise time points in the resveratrol and estradiol conditions compared to placebo. FMD was increased from baseline by 120 min postexercise in the estradiol condition (P < 0.001), but not resveratrol or PL conditions. Consistent with our previous findings, estradiol also enhances endothelial function in response to acute endurance exercise. Although resveratrol improved basal FMD, there was no apparent enhancement of FMD to acute exercise and, therefore, may not act as an estradiol mimetic.NEW & NOTEWORTHY The benefits of endurance exercise training on endothelial function are diminished in estrogen-deficient postmenopausal women, but estradiol treatment appears to restore improvements in endothelial function in this group. We show that basal endothelial function is enhanced with both acute estradiol and resveratrol treatments in estrogen-deficient postmenopausal women, but endothelial function is only enhanced following acute endurance exercise with estradiol treatment.
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Affiliation(s)
- Cemal Ozemek
- Department of Medicine, Division of Geriatric Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.,Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, University of Illinois, Chicago, Illinois
| | - Kerry L Hildreth
- Department of Medicine, Division of Geriatric Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Patrick J Blatchford
- Veterans Affairs Eastern Colorado Geriatric Research, Education and Clinical Center, Denver, Colorado.,Colorado Biostatistical Consortium, Colorado School of Public Health, University of Colorado Denver, Denver, Colorado
| | - K Joseph Hurt
- Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Rachael Bok
- Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Douglas R Seals
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, Colorado
| | - Wendy M Kohrt
- Department of Medicine, Division of Geriatric Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.,Veterans Affairs Eastern Colorado Geriatric Research, Education and Clinical Center, Denver, Colorado
| | - Kerrie L Moreau
- Department of Medicine, Division of Geriatric Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.,Veterans Affairs Eastern Colorado Geriatric Research, Education and Clinical Center, Denver, Colorado
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11
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Swanson CM, Blatchford PJ, Orwoll ES, Cauley JA, LeBlanc ES, Fink HA, Wright KP, Wierman ME, Kohrt WM, Stone KL. Association between objective sleep duration and bone mineral density in older postmenopausal women from the Study of Osteoporotic Fractures (SOF). Osteoporos Int 2019; 30:2087-2098. [PMID: 31139855 PMCID: PMC6800619 DOI: 10.1007/s00198-019-05007-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 05/02/2019] [Indexed: 10/26/2022]
Abstract
Methodological limitations preclude determination of the association between sleep duration and bone mineral density (BMD) from existing literature. This was the first study to use objective sleep duration to determine its association with BMD. Nocturnal sleep duration, assessed objectively (actigraphy) or subjectively (questionnaire), was not independently associated with BMD in postmenopausal women. INTRODUCTION Both long and short self-reported sleep durations are associated with low bone mineral density (BMD) in men and women. The association between sleep duration measured by actigraphy and BMD in postmenopausal women is unknown. METHODS The Study of Osteoporotic Fractures (SOF) ancillary sleep study was used to determine the association between sleep duration and BMD at the total hip and femoral neck in postmenopausal women ≥ 75 years old. Sleep duration was assessed by wrist actigraphy (average 4 nights) and questionnaire. BMD was compared between postmenopausal women with short (< 6 h/night) vs. NIH-recommended (7-8 h/night) sleep durations. Data were analyzed using a 2-sample t test (unadjusted) and multivariate regression model (adjusted). Simple linear regression was used to estimate the difference in BMD per additional hour of sleep when sleep duration was considered as a continuous, rather than dichotomized, variable. RESULTS Total hip BMD was higher in women with actigraphically assessed shorter sleep duration in unadjusted models only. No clinically or statistically significant differences in total hip or femoral neck BMD were observed according to nocturnal sleep duration after adjusting for body mass index (BMI) in dichotomized (N = 874) or continuous (N = 1624) sleep duration models or when subjective sleep duration was used. When sleep duration included daytime naps, longer sleep duration was associated with lower total hip BMD (β = - 0.005, p = 0.04). CONCLUSIONS Nocturnal sleep duration, whether assessed objectively (actigraphy) or subjectively (questionnaire), was not independently associated with BMD in older postmenopausal women.
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Affiliation(s)
- C M Swanson
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA.
| | - P J Blatchford
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO, USA
| | - E S Orwoll
- Division of Endocrinology and Bone & Mineral Unit, Oregon Health & Science University, Portland, OR, USA
| | - J A Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - E S LeBlanc
- Kaiser Permanente Center for Health Research NW, Portland, OR, USA
| | - H A Fink
- Geriatric Research Education and Clinical Center, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - K P Wright
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, CO, USA
| | - M E Wierman
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
- Research Service, Rocky Mountain Regional Veterans Affairs Medical Center Aurora, Aurora, CO, USA
| | - W M Kohrt
- Division of Geriatric Medicine, and Eastern Colorado VA Geriatric, Research, Education, and Clinical Center (GRECC), University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - K L Stone
- Research Institute, California Pacific Medical Center, San Francisco, CA, USA
- San Francisco Coordinating Center, University of California San Francisco, San Francisco, CA, USA
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12
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Keith RL, Blatchford PJ, Merrick DT, Bunn PA, Bagwell B, Dwyer-Nield LD, Jackson MK, Geraci MW, Miller YE. A Randomized Phase II Trial of Pioglitazone for Lung Cancer Chemoprevention in High-Risk Current and Former Smokers. Cancer Prev Res (Phila) 2019; 12:721-730. [PMID: 31308004 DOI: 10.1158/1940-6207.capr-19-0006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 05/01/2019] [Accepted: 07/08/2019] [Indexed: 02/06/2023]
Abstract
Lung cancer chemoprevention, especially in high-risk former smokers, has great potential to reduce lung cancer incidence and mortality. Thiazolidinediones prevent lung cancer in preclinical studies, and diabetics receiving thiazolidinediones have lower lung cancer rates which led to our double-blind, randomized, phase II placebo-controlled trial of oral pioglitazone in high-risk current or former smokers with sputum cytologic atypia or known endobronchial dysplasia. Bronchoscopy was performed at study entry and after completing 6 months of treatment. Biopsies were histologically scored, and primary endpoint analysis tested worst biopsy scores (Max) between groups; Dysplasia index (DI) and average score (Avg) changes were secondary endpoints. Biopsies also received an inflammation score. The trial accrued 92 subjects (47 pioglitazone, 45 placebo), and 76 completed both bronchoscopies (39 pioglitazone, 37 placebo). Baseline dysplasia was significantly worse for current smokers, and 64% of subjects had mild or greater dysplasia at study entry. Subjects receiving pioglitazone did not exhibit improvement in bronchial dysplasia. Former smokers treated with pioglitazone exhibited a slight improvement in Max, while current smokers exhibited slight worsening. While statistically significant changes in Avg and DI were not observed in the treatment group, former smokers exhibited a slight decrease in both Avg and DI. Negligible Avg and DI changes occurred in current smokers. A trend toward decreased Ki-67 labeling index occurred in former smokers with baseline dysplasia receiving pioglitazone. While pioglitazone did not improve endobronchial histology in this high-risk cohort, specific lesions showed histologic improvement, and further study is needed to better characterize responsive dysplasia.
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Affiliation(s)
- Robert L Keith
- Division of Pulmonary Sciences and Critical Care Medicine, Eastern Colorado VA Healthcare System, Rocky Mountain Regional VA Medical Center, Aurora, Colorado. .,Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Patrick J Blatchford
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Daniel T Merrick
- Division of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Paul A Bunn
- Division of Medical Oncology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Brandi Bagwell
- Division of Medical Oncology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Lori D Dwyer-Nield
- Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Mary K Jackson
- Division of Medical Oncology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Mark W Geraci
- Department of Medicine, IU School of Medicine, Indianapolis, Indiana
| | - York E Miller
- Division of Pulmonary Sciences and Critical Care Medicine, Eastern Colorado VA Healthcare System, Rocky Mountain Regional VA Medical Center, Aurora, Colorado.,Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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13
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Kline PW, Melanson EL, Sullivan WJ, Blatchford PJ, Miller MJ, Stevens-Lapsley JE, Christiansen CL. Improving Physical Activity Through Adjunct Telerehabilitation Following Total Knee Arthroplasty: Randomized Controlled Trial Protocol. Phys Ther 2019; 99:37-45. [PMID: 30329126 PMCID: PMC6314331 DOI: 10.1093/ptj/pzy119] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 09/17/2018] [Indexed: 01/08/2023]
Abstract
Background Physical activity remains low and nearly unchanged from preoperative levels following total knee arthroplasty (TKA), and this is thought to underlie long-term functional limitations, secondary health problems, and higher health care costs after TKA. Objective Our objective is to determine whether a telehealth-based intervention could improve physical activity and functional outcomes after TKA. Design The design is a 2-arm, parallel, assessor-blinded, randomized controlled trial with baseline, midintervention, postintervention, and 6-month follow-up assessments. Setting The setting is one academic medical center and one Veterans Affairs health care system. Participants One hundred US military veterans (aged 50-85 years) scheduled for unilateral TKA will participate in this study. Intervention The telehealth-based intervention to change physical activity behavior will be delivered through 10 sessions each of 30 minutes over a 12-week period. Participants will be provided with a wearable physical activity monitor to receive feedback on step count and guide goal-setting. Control participants will receive telehealth-based education on nonbehavioral aspects of health for the same frequency and duration as the intervention group. For both groups, telehealth sessions will occur concurrently with standardized outpatient rehabilitation. Measurements The primary outcome will be change in physical activity, assessed as daily step counts measured using an accelerometer-based sensor. Secondary outcomes will be measured using the Life-Space Assessment questionnaire and change in physical function (30-Second Chair-Stand Test, Timed "Up & Go" Test, Six-Minute Walk Test, Western Ontario and McMaster Universities Osteoarthritis Index, and Veterans RAND 12-Item Health Survey). Limitations Participant and interventionist blinding is not possible. Conclusions This trial will assess the efficacy of a novel behavior-change intervention to improve physical activity and physical function in patients after TKA. Effective physical activity behavior change could provide clinicians with a technique to augment current practice and resolve poor physical activity outcomes, long-term health problems, and high costs following TKA.
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Affiliation(s)
- Paul W Kline
- Geriatric Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, Colorado, and Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, 13121 East 17th Ave, Room 3106, MS C244, Aurora, CO 80045 (USA)
| | - Edward L Melanson
- Division of Endocrinology, Metabolism, and Diabetes; and Division of Geriatric Medicine, School of Medicine, University of Colorado
| | - William J Sullivan
- Geriatric Research Education and Clinical Center, Eastern Colorado Healthcare System, and Department of Physical Medicine and Rehabilitation, University of Colorado
| | | | - Matthew J Miller
- Geriatric Research Education and Clinical Center, Eastern Colorado Healthcare System, and Department of Physical Medicine and Rehabilitation, University of Colorado
| | - Jennifer E Stevens-Lapsley
- Geriatric Research Education and Clinical Center, Eastern Colorado Healthcare System, and Department of Physical Medicine and Rehabilitation, University of Colorado
| | - Cory L Christiansen
- Geriatric Research Education and Clinical Center, Eastern Colorado Healthcare System, and Department of Physical Medicine and Rehabilitation, University of Colorado
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14
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Hildreth KL, Schwartz RS, Vande Griend J, Kohrt WM, Blatchford PJ, Moreau KL. Effects of testosterone and progressive resistance exercise on vascular function in older men. J Appl Physiol (1985) 2018; 125:1693-1701. [PMID: 30188798 PMCID: PMC7474250 DOI: 10.1152/japplphysiol.00165.2018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 09/04/2018] [Accepted: 09/04/2018] [Indexed: 11/22/2022] Open
Abstract
The cardiovascular effects of testosterone (T) are controversial. Low T has been associated with accelerated vascular aging, characterized by large elastic artery stiffening (decreased compliance), intimal-medial thickening (IMT), and endothelial dysfunction. Endurance exercise improves vascular function, but resistance training may increase arterial stiffness. We sought to determine whether T supplementation improved markers of vascular aging in men with low-normal T and whether T supplementation prevented arterial stiffness with resistance exercise. We studied 160 community-dwelling older men (66 ± 5 yr) with low-normal baseline total T levels (200-350 ng/dl). Participants were randomized to transdermal T gel targeting either a lower (400-550 ng/dl) or higher (600-1,000 ng/dl) T range or to placebo gel and to either progressive resistance training (PRT) or to no exercise for 12 mo. Carotid artery stiffness (arterial compliance) and carotid IMT were measured at baseline, 6 mo, and 12 mo. Endothelial function (brachial artery flow-mediated dilation) was measured in a subset (n = 86). Changes in carotid artery compliance, IMT, and endothelial function with either the lower or higher range of T supplementation were not different from placebo at 6 or 12 mo. There were no differences between PRT and no PRT groups, alone or with T supplementation, in changes in any of the vascular measures at either time point. Supplementation of T and PRT in older men with low-normal levels do not appear to improve or harm vascular function.NEW & NOTEWORTHY Increased promotion and prescription of testosterone (T) to aging men has raised concerns about potential adverse cardiovascular effects. We show that in older men with T levels in the low-normal range, 12 mo of T supplementation with or without resistance exercise did not improve or harm vascular function.
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Affiliation(s)
- Kerry L Hildreth
- Department of Medicine, Division of Geriatric Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Robert S Schwartz
- Department of Medicine, Division of Geriatric Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Veterans Affairs Eastern Colorado Geriatric Research, Education and Clinical Center, Denver, Colorado
| | - Joseph Vande Griend
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Wendy M Kohrt
- Department of Medicine, Division of Geriatric Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Veterans Affairs Eastern Colorado Geriatric Research, Education and Clinical Center, Denver, Colorado
| | - Patrick J Blatchford
- Veterans Affairs Eastern Colorado Geriatric Research, Education and Clinical Center, Denver, Colorado
- Colorado Biostatistical Consortium, Colorado School of Public Health, University of Colorado Denver
| | - Kerrie L Moreau
- Department of Medicine, Division of Geriatric Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Veterans Affairs Eastern Colorado Geriatric Research, Education and Clinical Center, Denver, Colorado
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15
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Hildreth KL, Ozemek C, Kohrt WM, Blatchford PJ, Moreau KL. Vascular dysfunction across the stages of the menopausal transition is associated with menopausal symptoms and quality of life. Menopause 2018; 25:1011-1019. [PMID: 29634636 PMCID: PMC6103796 DOI: 10.1097/gme.0000000000001112] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The menopausal transition is associated with somatic symptoms and increased rates of depression, which can impair quality of life (QOL) and increase cardiovascular disease (CVD) risk. This period is also associated with accelerated vascular aging (arterial stiffening and endothelial dysfunction), an antecedent to CVD. This secondary analysis sought to explore associations between depression, menopausal symptoms and QOL, and vascular aging across menopause stages. METHODS Arterial stiffness (carotid artery compliance), endothelial function (brachial artery flow-mediated dilation [FMD]), menopausal symptoms (Menopausal Symptom List [MSL]), depression (Center for Epidemiologic Studies Depression Scale [CES-D]), and QOL (Utian QOL Scale [UQOL]) were measured in 138 women (19-70 years) classified as premenopausal (n = 41, 34 ± 8 years; mean ± SD), early (n = 25, 49 ± 3 years), or late perimenopausal (n = 26, 50 ± 4 years), or early (n = 22, 55 ± 4 years) or late postmenopausal (n = 24, 61 ± 5 years). Differences across menopause stages were determined using one-way analysis of variance; associations between vascular measures and MSL, CES-D, and UQOL were tested using Pearson's correlation analyses. RESULTS Menopausal symptoms, depression, and QOL worsened across menopause stages, particularly in late perimenopausal women. Vasosomatic symptom frequency, and general somatic symptom frequency and severity were inversely correlated with carotid artery compliance and FMD (r = -0.27 to -0.18, all P < 0.05). Only correlations with general somatic symptoms were significant after adjusting for multiple comparisons. Total QOL was positively correlated with carotid artery compliance (r = 0.23, P = 0.01). CES-D scores were not correlated with carotid artery compliance or FMD (r = -0.08, -0.03, P = 0.35). CONCLUSIONS Vascular dysfunction across the stages of menopause was associated with greater frequency and severity of menopausal symptoms, and lower QOL, but not depression. Mechanisms underlying these associations (eg, inflammation, oxidative stress) should be explored.
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Affiliation(s)
- Kerry L. Hildreth
- Department of Medicine, Division of Geriatric Medicine, University of Colorado School of Medicine
| | - Cemal Ozemek
- Department of Physical Therapy and the Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois at Chicago
| | - Wendy M. Kohrt
- Department of Medicine, Division of Geriatric Medicine, University of Colorado School of Medicine
- Eastern Colorado VA Geriatric Research, Education and Clinical Center
| | - Patrick J. Blatchford
- Colorado Biostatistical Consortium, Colorado School of Public Health, University of Colorado Denver
| | - Kerrie L. Moreau
- Department of Medicine, Division of Geriatric Medicine, University of Colorado School of Medicine
- Eastern Colorado VA Geriatric Research, Education and Clinical Center
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16
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Karam SD, Reddy K, Blatchford PJ, Waxweiler T, DeLouize AM, Oweida A, Somerset H, Marshall C, Young C, Davies KD, Kane M, Tan AC, Wang XJ, Jimeno A, Aisner DL, Bowles DW, Raben D. Final Report of a Phase I Trial of Olaparib with Cetuximab and Radiation for Heavy Smoker Patients with Locally Advanced Head and Neck Cancer. Clin Cancer Res 2018; 24:4949-4959. [PMID: 30084837 DOI: 10.1158/1078-0432.ccr-18-0467] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/16/2018] [Accepted: 06/29/2018] [Indexed: 12/13/2022]
Abstract
Purpose: Our goal was to evaluate the safety and toxicity of combining a PARP inhibitor, olaparib, with cetuximab and fractionated intensity-modulated radiotherapy for patients with locally advanced head and neck cancer and heavy smoking histories.Patients and Methods: Patients with ≥10 packs/year history of smoking were treated with olaparib at doses ranging from 25-200 mg orally twice daily beginning approximately 10 days prior to initiation of and with concurrent radiation (69.3 Gy in 33 fractions) using a time-to-event continual reassessment method model. Cetuximab was administered starting approximately 5 days prior to radiation per standard of care.Results: A total of 16 patients were entered onto the study, with 15 evaluable for acute toxicity. The most common treatment-related grade 3-4 side effects were radiation dermatitis and mucositis (38% and 69%, respectively). The MTD was determined to be 50 mg orally twice daily, but the recommended phase II dose was deemed to be 25 mg orally twice daily. At a median follow-up of 26 months, the actuarial median overall survival was 37 months, but was not reached for other endpoints. Two-year overall survival, progression-free survival, local control, and distant control rates were 72%, 63%, 72%, and 79%, respectively. Patients who continued to smoke during therapy experienced higher recurrence rates. MYC and KMT2A were identified as potential correlatives of response on gene amplification and mutational analysis.Conclusions: Olaparib at 25 mg orally twice daily with concurrent cetuximab and radiation was well tolerated with reduced dermatitis within the radiation field. Response rates were promising for this high-risk population. Clin Cancer Res; 24(20); 4949-59. ©2018 AACR.
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Affiliation(s)
- Sana D Karam
- Department of Radiation Oncology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Krishna Reddy
- Department of Radiation Oncology, University of Toledo, Toledo, Ohio
| | - Patrick J Blatchford
- Department of Biostatistics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Tim Waxweiler
- Department of Radiation Oncology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Alicia M DeLouize
- Department of Radiation Oncology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Ayman Oweida
- Department of Radiation Oncology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Hilary Somerset
- Department of Pathology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Carrie Marshall
- Department of Pathology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Christian Young
- Department of Pathology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Kurtis D Davies
- Department of Pathology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Madeleine Kane
- Department of Medicine, Division of Medical Oncology, Anschutz Medical Campus, Aurora, Colorado
| | - Aik Choo Tan
- Department of Medicine, Division of Medical Oncology, Anschutz Medical Campus, Aurora, Colorado
| | - Xiao Jing Wang
- Department of Pathology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado.,Denver Veterans Affairs Medical Center, Eastern Colorado Health Care System, Denver, Colorado
| | - Antonio Jimeno
- Department of Pathology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Dara L Aisner
- Department of Pathology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Daniel W Bowles
- Department of Pathology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado.,Denver Veterans Affairs Medical Center, Eastern Colorado Health Care System, Denver, Colorado
| | - David Raben
- Department of Radiation Oncology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado.
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Ritchie CS, Kutner JS, Blatchford PJ, Abernethy AP. Response to Davis and Behm (doi: 10.1089/jpm.2017.0608): Discontinuation of Statins. J Palliat Med 2018; 21:283. [DOI: 10.1089/jpm.2017.0661] [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: 11/12/2022] Open
Affiliation(s)
- Christine S. Ritchie
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Jean S. Kutner
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Patrick J. Blatchford
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado
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18
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Stokes WA, Stumpf PK, Jones BL, Blatchford PJ, Karam SD, Lanning RM, Raben D. Patterns of fractionation for patients with T2N0M0 glottic larynx cancer undergoing definitive radiotherapy in the United States. Oral Oncol 2017; 72:110-116. [DOI: 10.1016/j.oraloncology.2017.07.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 07/09/2017] [Indexed: 01/29/2023]
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Abstract
OBJECTIVES To enhance understanding of the relationship between multimorbidity, symptom burden, and functional status in individuals with life-limiting illness. DESIGN Secondary analysis of baseline data from a randomized clinical trial conducted in the Palliative Care Research Cooperative Group. Group differences were tested using a t-test; multivariate regression analysis was used to determine the effect of multiple variables on functional status and symptom burden. SETTING Fifteen Palliative Care Research Cooperation sites. PARTICIPANTS Adults who participated in a parent statin-discontinuation clinical trial were included in the analysis (N = 381). Inclusion criteria were diagnosis of a life-limiting illness, statin use for 3 months or longer, life expectancy longer than 1 month, and declining functional status. MEASUREMENTS Cancer diagnosis (solid organ and hematologic malignancies), multimorbidity (Charlson Comorbidity Index (CCI) score), symptom burden (Edmonton Symptom Assessment Scale (ESAS) score, number of symptoms with ESAS severity score >4), functional status (Australia-modified Karnofsky Performance Scale (AKPS)). RESULTS Fifty-one percent had a primary diagnosis of cancer; mean age 74.1 ± 11.6. Participants had multiple comorbid illnesses (CCI score 4.9 ± 2.8), multiple symptoms (ESAS score 27.2 ± 15.9), and poor functional status (AKPS = 53 ± 13). In univariate and multivariate analyses, multimorbidity was associated with greater symptom burden (4.2 vs 3.1 moderate or severe symptoms (t = -3.2, P = .002), 12% vs 6% with severe symptoms (t = -3.7, P < .001)), but cancer diagnosis was not. In univariate and multivariate analyses, higher symptom burden was associated with poorer functional status (F = 11.6, P < .001), but multimorbidity was not. CONCLUSION Symptoms cannot be attributed solely to a diagnosis of cancer. The association between symptom burden and functional status underscores the importance of clinical attention to symptoms in individuals with multimorbidity.
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Affiliation(s)
- Jennifer D Portz
- Internal Medicine, School of Medicine, University of Colorado, Aurora, Colorado
| | - Jean S Kutner
- Internal Medicine, School of Medicine, University of Colorado, Aurora, Colorado
| | | | - Christine S Ritchie
- Internal Medicine, University of California, San Francisco, San Francisco, California
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20
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Binswanger IA, Blatchford PJ, Forsyth SJ, Stern MF, Kinner SA. Epidemiology of Infectious Disease-Related Death After Release from Prison, Washington State, United States, and Queensland, Australia: A Cohort Study. Public Health Rep 2017; 131:574-82. [PMID: 27453602 DOI: 10.1177/0033354916662216] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES People in prison may be at high risk for infectious diseases and have an elevated risk of death immediately after release compared with later; their risk of death is elevated for at least a decade after release. We compared rates, characteristics, and prison-related risk factors for infectious disease-related mortality among people released from prisons in Queensland, Australia, and Washington State, United States, regions with analogous available data. METHODS We analyzed data from retrospective cohort studies of people released from prison in Queensland (1997-2007, n=37,180) and Washington State (1999-2009, n=76,208) and linked identifiers from each cohort to its respective national death index. We estimated infectious disease-related mortality rates (deaths per person-years in community) and examined associations using Cox proportional hazard models. RESULTS The most frequent infectious disease-related underlying cause of death after release from prison was pneumonia (43%, 23/54 deaths) in the Australian cohort and viral hepatitis (40%, 69/171 deaths) in the U.S. cohort. The infectious disease-related mortality rate was significantly higher in the U.S. cohort than in the Australian cohort (51.2 vs. 26.5 deaths per 100,000 person-years; incidence rate ratio = 1.93, 95% confidence interval 1.42, 2.62). In both cohorts, increasing age was strongly associated with mortality from infectious diseases. CONCLUSION Differences in the epidemiology of infectious disease-related mortality among people released from prison may reflect differences in patterns of community health service delivery in each region. These findings highlight the importance of preventing and treating hepatitis C and other infectious diseases during the transition from prison to the community.
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Affiliation(s)
- Ingrid A Binswanger
- Kaiser Permanente Colorado, Institute for Health Research, Denver, CO; University of Colorado Denver, School of Medicine, Department of Psychiatry, Division of General Internal Medicine, Aurora, CO
| | - Patrick J Blatchford
- University of Colorado Denver, Colorado School of Public Health, Department of Biostatistics and Informatics, Denver, CO
| | - Simon J Forsyth
- University of Queensland, School of Public Health, Brisbane, Australia
| | - Marc F Stern
- University of Washington School of Public Health, Department of Health Services, Seattle, WA
| | - Stuart A Kinner
- University of Melbourne, Melbourne School of Population and Global Health, Melbourne, Australia; University of Queensland, Mater Research Institute, Brisbane, Australia; Monash University School of Public Health and Preventive Medicine, Melbourne, Australia; Griffith University, Griffith Criminology Institute & Menzies Health Institute Queensland, Brisbane, Australia
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21
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Tjia J, Kutner JS, Ritchie CS, Blatchford PJ, Bennett Kendrick RE, Prince-Paul M, Somers TJ, McPherson ML, Sloan JA, Abernethy AP, Furuno JP. Perceptions of Statin Discontinuation among Patients with Life-Limiting Illness. J Palliat Med 2017; 20:1098-1103. [PMID: 28520522 DOI: 10.1089/jpm.2016.0489] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Optimal management of chronic medications for patients with life-limiting illness is uncertain. Medication deprescribing may improve outcomes in this population, but patient concerns regarding deprescribing are unclear. OBJECTIVE The aim of this study was to quantify the perceived benefits and concerns of statin discontinuation among patients with life-limiting illness. DESIGN Baseline data from a multicenter, pragmatic clinical trial of statin discontinuation were used. SETTING/SUBJECTS Cognitively intact participants with a life expectancy of 1-12 months receiving statin medications for primary or secondary prevention were enrolled. MEASUREMENTS Responses to a 9-item questionnaire addressing patient concerns about discontinuing statins were collected. We used Pearson chi-square tests to compare responses by primary life-limiting diagnosis (cancer, cardiovascular disease, other). RESULTS Of 297 eligible participants, 58% had cancer, 8% had cardiovascular disease, and 30% other primary diagnoses. Mean (standard deviation) age was 72 (11) years. Fewer than 5% of participants expressed concern that statin deprescribing indicated physician abandonment. About one in five participants reported being told to take statins for the rest of their life (18%) or feeling that discontinuation represented prior wasted effort (18%). Many participants reported benefits of stopping statins, including spending less money on medications (63%), potentially stopping other medications (34%), and having a better quality of life (25%). More participants with cardiovascular disease as a primary diagnosis perceived that quality-of-life benefits related to statin discontinuation (52%) than participants with cancer (27%) or noncardiovascular disease diagnoses (27%) [p = 0.034]. CONCLUSION Few participants expressed concerns about discontinuing statins; many perceived potential benefits. Cardiovascular disease patients perceived greater potential positive impact from statin discontinuation.
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Affiliation(s)
- Jennifer Tjia
- 1 Department of Quantitative Health Sciences, University of Massachusetts Medical School , Worcester, Massachusetts
| | - Jean S Kutner
- 2 Department of Medicine, University of Colorado School of Medicine , Aurora, Colorado
| | - Christine S Ritchie
- 3 Department of Medicine, University of California San Francisco School of Medicine , San Francisco, California
| | - Patrick J Blatchford
- 4 Department of Biostatistics and Informatics, University of Colorado School of Medicine , Aurora, Colorado
| | | | - Maryjo Prince-Paul
- 6 Frances Payne Bolton School of Nursing, Case Western Reserve University , Cleveland, Ohio
| | - Tamara J Somers
- 7 Department of Psychiatry and Behavioral Sciences, Duke University Medical Center , Durham, North Carolina
| | - Mary Lynn McPherson
- 8 Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy , Baltimore, Maryland
| | - Jeff A Sloan
- 9 Department of Health Sciences Research, Mayo Clinic , Rochester, Minnesota
| | | | - Jon P Furuno
- 11 Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy , Portland, Oregon
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22
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Binswanger IA, Stern MF, Yamashita TE, Mueller SR, Baggett TP, Blatchford PJ. Clinical risk factors for death after release from prison in Washington State: a nested case-control study. Addiction 2016; 111:499-510. [PMID: 26476210 PMCID: PMC4834273 DOI: 10.1111/add.13200] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 09/09/2015] [Accepted: 09/28/2015] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND AIMS While mortality rates after prison release are high, little is known about clinical risk factors for death. We sought to identify risk and protective factors for all-cause and accidental poisoning (overdose) death. DESIGN Nested case-control study of people released from prison. SETTING Washington State Department of Corrections, Washington, USA. PARTICIPANTS Cases (699 all-cause deaths, of which 88 were among women, and 196 additional overdose deaths, of which 76 were among women) between 1999 and 2009 matched 1 : 1 to controls on sex, age and year of release using risk set sampling. MEASUREMENTS Prison medical charts were abstracted for clinical information. Independent associations between clinical characteristics and all-cause and overdose mortality were assessed using conditional logistic regression. FINDINGS Key independent risk factors for all-cause mortality included homelessness [odds ratio (OR) = 1.53, 95% confidence interval (CI) = 1.06, 2.23], injection drug use (OR = 1.54, 95% CI = 1.16, 2.06), tobacco use (OR = 1.51, 95% CI = 1.07, 2.13), cirrhosis (OR = 4.42, 95% CI = 1.63, 11.98) and psychiatric medications before release (OR = 2.38, 95% CI = 1.71, 3.30). Independent risk factors for overdose mortality included substance use disorder (OR = 2.33, 95% CI = 1.32, 4.11), injection drug use (OR = 2.43, 95% CI = 1.53, 3.86), panic disorder (OR = 3.87, 95% CI = 1.62, 9.21), psychiatric prescriptions before release (OR = 2.44, 95% CI = 1.55, 3.85) and problems with opiates/sedatives (OR = 2.81, 95% CI = 1.40, 5.63). Substance use disorder treatment during the index incarceration was protective for all-cause (OR = 0.67, 95% CI = 0.49, 0.91) and overdose (OR = 0.57, 95% CI = 0.36, 0.90) mortality. CONCLUSIONS Injection drug use and substance use disorders are risk factors for death after release from prison. In-prison substance use disorder treatment services may reduce the risk.
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23
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Merrick DT, Gao D, Miller YE, Keith RL, Baron AE, Feser W, Kennedy TC, Blatchford PJ, Braudrick S, Hirsch FR, Heasley L, Bunn PA, Franklin WA. Persistence of Bronchial Dysplasia Is Associated with Development of Invasive Squamous Cell Carcinoma. Cancer Prev Res (Phila) 2016; 9:96-104. [PMID: 26542061 PMCID: PMC4706769 DOI: 10.1158/1940-6207.capr-15-0305] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [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: 08/05/2015] [Accepted: 10/26/2015] [Indexed: 12/22/2022]
Abstract
Bronchial dysplasia (BD), a presumed precursor of pulmonary squamous cell carcinoma (SCC), rarely progresses to invasive cancer. A high-risk cohort at the University of Colorado provided an opportunity to directly sample airway epithelium at mapped sites on successive bronchoscopies. We have hypothesized that persistent dysplastic lesions showing a similar or higher level of dysplasia on follow-up biopsy, are associated with increased risk for the development of SCC. Endoscopic biopsies from 188 high-risk subjects were histologically classified according to the current WHO classification for BD using a numeric histology score ranging from 1 to 8 representing normal bronchial mucosa through invasive lung cancer. Differences in follow-up histology scores were compared between sites classified by clinical, histologic, and immunohistochemical variables. Subjects with a higher frequency of sites that persist or progress to high-grade dysplasia (≥37.5% persist/progress, N = 35 versus <37.5% persist/progress, N = 114) show a significant association with development of incident invasive SCC (adjusted HR, 7.84; 95% confidence interval, 1.56-39.39), and those with incident lung SCC have adjusted mean follow-up histology scores 1.55 U higher than in subjects without lung cancer. Current smoking, elevated Ki67 growth fraction, histologic features of angiogenic squamous dysplasia (ASD) and higher histology score in baseline biopsies are significantly associated with increased follow-up histology scores. These results show that persistent BD is associated with the development of invasive SCC. Furthermore, increased expression of Ki67, the presence of angiogenic change and degree of baseline atypia are associated with persistence of BD.
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Affiliation(s)
- Daniel T Merrick
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | - Dexiang Gao
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - York E Miller
- Division of Pulmonary Medicine, Department of Medicine, Denver Veterans Affairs Medical Center, Denver, Colorado. Division of Pulmonary Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Robert L Keith
- Division of Pulmonary Medicine, Department of Medicine, Denver Veterans Affairs Medical Center, Denver, Colorado. Division of Pulmonary Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Anna E Baron
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado
| | - William Feser
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado
| | - Timothy C Kennedy
- Division of Pulmonary Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Patrick J Blatchford
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Sarah Braudrick
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado
| | - Fred R Hirsch
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Lynn Heasley
- Department of Craniofacial Biology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Paul A Bunn
- Division of Medical Oncology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Wilbur A Franklin
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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24
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Goldenberg NA, Abshire T, Blatchford PJ, Fenton LZ, Halperin JL, Hiatt WR, Kessler CM, Kittelson JM, Manco-Johnson MJ, Spyropoulos AC, Steg PG, Stence NV, Turpie AGG, Schulman S. Multicenter randomized controlled trial on Duration of Therapy for Thrombosis in Children and Young Adults (the Kids-DOTT trial): pilot/feasibility phase findings. J Thromb Haemost 2015; 13:1597-605. [PMID: 26118944 PMCID: PMC4561031 DOI: 10.1111/jth.13038] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [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: 02/17/2015] [Accepted: 06/10/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND Randomized controlled trials (RCTs) on pediatric venous thromboembolism (VTE) treatment have been challenged by unsubstantiated design assumptions and/or poor accrual. Pilot/feasibility (P/F) studies are critical to future RCT success. METHODS The Kids-DOTT trial is a multicenter RCT investigating non-inferiority of a 6-week (shortened) versus 3-month (conventional) duration of anticoagulation in patients aged < 21 years with provoked venous thrombosis. Primary efficacy and safety endpoints are symptomatic recurrent VTE at 1 year and anticoagulant-related, clinically relevant bleeding. In the P/F phase, 100 participants were enrolled in an open, blinded-endpoint, parallel-cohort RCT design. RESULTS No eligibility violations or randomization errors occurred. Of the enrolled patients, 69% were randomized, 3% missed the randomization window, and 28% were followed in prespecified observational cohorts for completely occlusive thrombosis or persistent antiphospholipid antibodies. Retention at 1 year was 82%. Interobserver agreement between local and blinded central determination of venous occlusion by imaging at 6 weeks after diagnosis was strong (k-statistic = 0.75; 95% confidence interval [CI] 0.48-1.0). The primary efficacy and safety event rates were 3.3% (95% CI 0.3-11.5%) and 1.4% (95% CI 0.03-7.4%). CONCLUSIONS The P/F phase of the Kids-DOTT trial has demonstrated the validity of vascular imaging findings of occlusion as a randomization criterion, and defined randomization, retention and endpoint rates to inform the fully powered RCT.
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Affiliation(s)
- N A Goldenberg
- All Children's Research Institute, All Children's Hospital Johns Hopkins Medicine, St Petersburg, FL, USA
- Departments of Pediatrics and Medicine, Divisions of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - T Abshire
- Department of Pediatrics, Section of Hematology/Oncology/BMT, Medical College of Wisconsin, Milwaukee, WI, USA
- BloodCenter of Wisconsin, Milwaukee, WI, USA
| | - P J Blatchford
- Department of Biostatistics, School of Public Health, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
| | - L Z Fenton
- Department of Pediatric Radiology, School of Medicine, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
| | - J L Halperin
- The Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - W R Hiatt
- Department of Medicine, Division of Cardiology, School of Medicine, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
- CPC Clinical Research, Aurora, CO, USA
| | - C M Kessler
- Department of Medicine, Division of Hematology, Georgetown University School of Medicine, Washington, DC, USA
| | - J M Kittelson
- Department of Biostatistics, School of Public Health, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
| | - M J Manco-Johnson
- Department of Pediatrics, Section of Hematology/Oncology/BMT, and Hemophilia and Thrombosis Center, School of Medicine, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
| | - A C Spyropoulos
- Department of Medicine, Division of Hematology, Hofstra North Shore - Long Island Jewish School of Medicine, Manhasset, NY, USA
| | - P G Steg
- Department of Cardiology, Département Hospitalo-Universitaire FIRE (Fibrosis-Inflammation-REmodelling), University Paris-Diderot, Paris, France
| | - N V Stence
- Department of Biostatistics, School of Public Health, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
| | - A G G Turpie
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - S Schulman
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
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25
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Lambert-Kerzner A, Havranek EP, Plomondon ME, Fagan KM, McCreight MS, Fehling KB, Williams DJ, Hamilton AB, Albright K, Blatchford PJ, Mihalko-Corbitt R, Bryson CL, Bosworth HB, Kirshner MA, Giacco EJD, Ho PM. Perspectives of patients on factors relating to adherence to post-acute coronary syndrome medical regimens. Patient Prefer Adherence 2015; 9:1053-9. [PMID: 26244013 PMCID: PMC4521673 DOI: 10.2147/ppa.s84546] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
PURPOSE Poor adherence to cardioprotective medications after acute coronary syndrome (ACS) hospitalization is associated with increased risk of rehospitalization and mortality. Clinical trials of multifaceted interventions have improved medication adherence with varying results. Patients' perspectives on interventions could help researchers interpret inconsistent outcomes. Identifying factors that patients believe would improve adherence might inform the design of future interventions and make them more parsimonious and sustainable. The objective of this study was to obtain patients' perspectives on adherence to medical regimens after experiencing an ACS event and their participation in a medication adherence randomized control trial following their hospitalization. PATIENTS AND METHODS Sixty-four in-depth interviews were conducted with ACS patients who participated in an efficacious, multifaceted, medication adherence randomized control trial. Interview transcripts were analyzed using the constant comparative approach. RESULTS Participants described their post-ACS event experiences and how they affected their adherence behaviors. Patients reported that adherence decisions were facilitated by mutually respectful and collaborative provider-patient treatment planning. Frequent interactions with providers and medication refill reminder calls supported improved adherence. Additional facilitators included having social support, adherence routines, and positive attitudes toward an ACS event. The majority of patients expressed that being active participants in health care decision-making contributed to their health. CONCLUSION Our findings demonstrate that respectful collaborative communication can contribute to medication adherence after ACS hospitalization. These results suggest a potential role for training health-care providers, including pharmacists, social workers, registered nurses, etc, to elicit and acknowledge the patients' views regarding medication treatment in order to improve adherence. Future research is needed with providers to understand how they elicit and acknowledge patients' views, particularly in the face of nonadherence, and with patients to understand how to empower them to share their opinions with their providers.
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Affiliation(s)
- Anne Lambert-Kerzner
- Department of Crdiology, Veterans Health Administration (VA) Eastern Colorado Health Care System, Denver, CO, USA
- School of Public Health or School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Edward P Havranek
- School of Public Health or School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
- Cardiology, Denver Health Medical Center, Denver, CO, USA
| | - Mary E Plomondon
- Department of Crdiology, Veterans Health Administration (VA) Eastern Colorado Health Care System, Denver, CO, USA
- School of Public Health or School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Katherine M Fagan
- Department of Crdiology, Veterans Health Administration (VA) Eastern Colorado Health Care System, Denver, CO, USA
| | - Marina S McCreight
- Department of Crdiology, Veterans Health Administration (VA) Eastern Colorado Health Care System, Denver, CO, USA
| | - Kelty B Fehling
- Department of Crdiology, Veterans Health Administration (VA) Eastern Colorado Health Care System, Denver, CO, USA
| | - David J Williams
- School of Public Health or School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Alison B Hamilton
- Health Services Research, Veterans Health Administration (VA) Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Karen Albright
- School of Public Health or School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Patrick J Blatchford
- School of Public Health or School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Renee Mihalko-Corbitt
- Internal Medicine, John L. McClellan Memorial Veterans Hospital, Little Rock, AR, USA
| | - Chris L Bryson
- Health Services Research, Veterans Health Administration (VA) Puget Sound Health Care System, Seattle, WA, USA
| | - Hayden B Bosworth
- Health Services Research, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Miriam A Kirshner
- Health Services Research, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Eric J Del Giacco
- Internal Medicine, John L. McClellan Memorial Veterans Hospital, Little Rock, AR, USA
| | - P Michael Ho
- Department of Crdiology, Veterans Health Administration (VA) Eastern Colorado Health Care System, Denver, CO, USA
- School of Public Health or School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
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26
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Arcaroli JJ, Tai WM, McWilliams R, Bagby S, Blatchford PJ, Varella-Garcia M, Purkey A, Quackenbush KS, Song EK, Pitts TM, Gao D, Lieu C, McManus M, Tan AC, Zheng X, Zhang Q, Ozeck M, Olson P, Jiang ZQ, Kopetz S, Jimeno A, Keysar S, Eckhardt G, Messersmith WA. A NOTCH1 gene copy number gain is a prognostic indicator of worse survival and a predictive biomarker to a Notch1 targeting antibody in colorectal cancer. Int J Cancer 2015; 138:195-205. [PMID: 26152787 DOI: 10.1002/ijc.29676] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 06/10/2015] [Accepted: 06/17/2015] [Indexed: 12/28/2022]
Abstract
Dysregulation of the Notch1 receptor has been shown to facilitate the development and progression of colorectal cancer (CRC) and has been identified as an independent predictor of disease progression and worse survival. Although mutations in the NOTCH1 receptor have not been described in CRC, we have previously discovered a NOTCH1 gene copy number gain in a portion of CRC tumor samples. Here, we demonstrated that a NOTCH1 gene copy number gain is significantly associated with worse survival and a high percentage of gene duplication in a cohort of patients with advanced CRC. In our CRC patient-derived tumor xenograft (PDTX) model, tumors harboring a NOTCH1 gain exhibited significant elevation of the Notch1 receptor, JAG1 ligand and cleaved Notch1 activity. In addition, a significant association was identified between a gain in NOTCH1 gene copy number and sensitivity to a Notch1-targeting antibody. These findings suggest that patients with metastatic CRC that harbor a gain in NOTCH1 gene copy number have worse survival and that targeting this patient population with a Notch1 antibody may yield improved outcomes.
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Affiliation(s)
- John J Arcaroli
- Division of Medical Oncology, University of Colorado Denver Anschutz Medical Campus and University of Colorado Cancer Center, Aurora, CO
| | - W M Tai
- Division of Medical Oncology, University of Colorado Denver Anschutz Medical Campus and University of Colorado Cancer Center, Aurora, CO
| | - Ryan McWilliams
- Division of Medical Oncology, University of Colorado Denver Anschutz Medical Campus and University of Colorado Cancer Center, Aurora, CO
| | - Stacey Bagby
- Division of Medical Oncology, University of Colorado Denver Anschutz Medical Campus and University of Colorado Cancer Center, Aurora, CO
| | - Patrick J Blatchford
- Department of Biostatistics & Informatics, University of Colorado Denver Anschutz Medical Campus and University of Colorado Cancer Center, Aurora, CO
| | - Marileila Varella-Garcia
- Division of Medical Oncology, University of Colorado Denver Anschutz Medical Campus and University of Colorado Cancer Center, Aurora, CO
| | - Alicia Purkey
- Division of Medical Oncology, University of Colorado Denver Anschutz Medical Campus and University of Colorado Cancer Center, Aurora, CO
| | - Kevin S Quackenbush
- Division of Medical Oncology, University of Colorado Denver Anschutz Medical Campus and University of Colorado Cancer Center, Aurora, CO
| | - Eun-Kee Song
- Division of Medical Oncology, University of Colorado Denver Anschutz Medical Campus and University of Colorado Cancer Center, Aurora, CO
| | - Todd M Pitts
- Division of Medical Oncology, University of Colorado Denver Anschutz Medical Campus and University of Colorado Cancer Center, Aurora, CO
| | - Dexiang Gao
- Department of Biostatistics & Informatics, University of Colorado Denver Anschutz Medical Campus and University of Colorado Cancer Center, Aurora, CO
| | - Chris Lieu
- Division of Medical Oncology, University of Colorado Denver Anschutz Medical Campus and University of Colorado Cancer Center, Aurora, CO
| | - Martine McManus
- Division of Medical Oncology, University of Colorado Denver Anschutz Medical Campus and University of Colorado Cancer Center, Aurora, CO
| | - Aik Choon Tan
- Division of Medical Oncology, University of Colorado Denver Anschutz Medical Campus and University of Colorado Cancer Center, Aurora, CO
| | - Xianxian Zheng
- Pfizer Oncology Research Unit, Translational Research, Pfizer, La Jolla, CA
| | - Qin Zhang
- Pfizer Oncology Research Unit, Translational Research, Pfizer, La Jolla, CA
| | - Mark Ozeck
- Pfizer Oncology Research Unit, Translational Research, Pfizer, La Jolla, CA
| | - Peter Olson
- Pfizer Oncology Research Unit, Translational Research, Pfizer, La Jolla, CA
| | - Zhi-Qin Jiang
- MD Anderson Cancer Center, Texas Medical Center, Houston, TX
| | - Scott Kopetz
- MD Anderson Cancer Center, Texas Medical Center, Houston, TX
| | - Antonio Jimeno
- Division of Medical Oncology, University of Colorado Denver Anschutz Medical Campus and University of Colorado Cancer Center, Aurora, CO
| | - Stephen Keysar
- Division of Medical Oncology, University of Colorado Denver Anschutz Medical Campus and University of Colorado Cancer Center, Aurora, CO
| | - Gail Eckhardt
- Division of Medical Oncology, University of Colorado Denver Anschutz Medical Campus and University of Colorado Cancer Center, Aurora, CO
| | - Wells A Messersmith
- Division of Medical Oncology, University of Colorado Denver Anschutz Medical Campus and University of Colorado Cancer Center, Aurora, CO
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Kutner JS, Blatchford PJ, Taylor DH, Ritchie CS, Bull JH, Fairclough DL, Hanson LC, LeBlanc TW, Samsa GP, Wolf S, Aziz NM, Currow DC, Ferrell B, Wagner-Johnston N, Zafar SY, Cleary JF, Dev S, Goode PS, Kamal AH, Kassner C, Kvale EA, McCallum JG, Ogunseitan AB, Pantilat SZ, Portenoy RK, Prince-Paul M, Sloan JA, Swetz KM, Von Gunten CF, Abernethy AP. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial. JAMA Intern Med 2015; 175:691-700. [PMID: 25798575 PMCID: PMC4618294 DOI: 10.1001/jamainternmed.2015.0289] [Citation(s) in RCA: 337] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
IMPORTANCE For patients with limited prognosis, some medication risks may outweigh the benefits, particularly when benefits take years to accrue; statins are one example. Data are lacking regarding the risks and benefits of discontinuing statin therapy for patients with limited life expectancy. OBJECTIVE To evaluate the safety, clinical, and cost impact of discontinuing statin medications for patients in the palliative care setting. DESIGN, SETTING, AND PARTICIPANTS This was a multicenter, parallel-group, unblinded, pragmatic clinical trial. Eligibility included adults with an estimated life expectancy of between 1 month and 1 year, statin therapy for 3 months or more for primary or secondary prevention of cardiovascular disease, recent deterioration in functional status, and no recent active cardiovascular disease. Participants were randomized to either discontinue or continue statin therapy and were monitored monthly for up to 1 year. The study was conducted from June 3, 2011, to May 2, 2013. All analyses were performed using an intent-to-treat approach. INTERVENTIONS Statin therapy was withdrawn from eligible patients who were randomized to the discontinuation group. Patients in the continuation group continued to receive statins. MAIN OUTCOMES AND MEASURES Outcomes included death within 60 days (primary outcome), survival, cardiovascular events, performance status, quality of life (QOL), symptoms, number of nonstatin medications, and cost savings. RESULTS A total of 381 patients were enrolled; 189 of these were randomized to discontinue statins, and 192 were randomized to continue therapy. Mean (SD) age was 74.1 (11.6) years, 22.0% of the participants were cognitively impaired, and 48.8% had cancer. The proportion of participants in the discontinuation vs continuation groups who died within 60 days was not significantly different (23.8% vs 20.3%; 90% CI, -3.5% to 10.5%; P=.36) and did not meet the noninferiority end point. Total QOL was better for the group discontinuing statin therapy (mean McGill QOL score, 7.11 vs 6.85; P=.04). Few participants experienced cardiovascular events (13 in the discontinuation group vs 11 in the continuation group). Mean cost savings were $3.37 per day and $716 per patient. CONCLUSIONS AND RELEVANCE This pragmatic trial suggests that stopping statin medication therapy is safe and may be associated with benefits including improved QOL, use of fewer nonstatin medications, and a corresponding reduction in medication costs. Thoughtful patient-provider discussions regarding the uncertain benefit and potential decrement in QOL associated with statin continuation in this setting are warranted. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01415934.
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Affiliation(s)
- Jean S Kutner
- Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Patrick J Blatchford
- Department of Biostatistics and Informatics, Colorado School of Public Health, Denver
| | - Donald H Taylor
- Sanford School of Public Policy, Duke University, Durham, North Carolina
| | - Christine S Ritchie
- San Francisco Veterans Affairs Medical Center, Center for Research on Aging, Jewish Home of San Francisco, San Francisco, California5Division of Geriatrics, Department of Medicine, University of California, San Francisco
| | - Janet H Bull
- Four Seasons Compassion for Life, Flat Rock, North Carolina
| | - Diane L Fairclough
- Department of Biostatistics and Informatics, Colorado School of Public Health, Denver
| | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina, Chapel Hill
| | - Thomas W LeBlanc
- Center for Learning Health Care, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Greg P Samsa
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Steven Wolf
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Noreen M Aziz
- National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland
| | - David C Currow
- Discipline, Palliative, and Supportive Services, Flinders University, Adelaide, Australia
| | - Betty Ferrell
- Department of Nursing Research, City of Hope Medical Center, City of Hope, California
| | | | - S Yousuf Zafar
- Center for Learning Health Care, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - James F Cleary
- Division of Hematology/Oncology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison
| | - Sandesh Dev
- Department of Medicine, Phoenix Veterans Affairs Health Care System, Phoenix, Arizona
| | - Patricia S Goode
- Veterans Affairs Geriatric Research, Education, and Clinical Center, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama17Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham
| | - Arif H Kamal
- Center for Learning Health Care, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - Elizabeth A Kvale
- Veterans Affairs Geriatric Research, Education, and Clinical Center, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama17Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham
| | | | - Adeboye B Ogunseitan
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Russell K Portenoy
- Metropolitan Jewish Health System, Hospice and Palliative Care, New York, New York
| | - Maryjo Prince-Paul
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio
| | - Jeff A Sloan
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Keith M Swetz
- Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Amy P Abernethy
- Center for Learning Health Care, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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Ginde AA, Blatchford PJ, Trzeciak S, Hollander JE, Birkhahn R, Otero R, Osborn TM, Moretti E, Nguyen HB, Gunnerson KJ, Milzman D, Gaieski DF, Goyal M, Cairns CB, Rivers EP, Shapiro NI. Age-related differences in biomarkers of acute inflammation during hospitalization for sepsis. Shock 2015; 42:99-107. [PMID: 24978893 DOI: 10.1097/shk.0000000000000182] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The authors aimed to evaluate age-related differences in inflammation biomarkers during the first 72 h of hospitalization for sepsis. This was a secondary analysis of a prospective observational cohort of adult patients (n = 855) from 10 urban academic emergency departments with confirmed infection and two or more systemic inflammatory response syndrome criteria. Six inflammation-related biomarkers were analyzed-chemokine (CC-motif) ligand-23, C-reactive protein, interleukin-1 receptor antagonist, neutrophil gelatinase-associated lipocalin (NGAL), peptidoglycan recognition protein, and tumor necrosis factor receptor-1a (TNFR-1a)-measured at presentation and 3, 6, 12, 24, 48, or 72 h later. The median age was 56 (interquartile range, 43 - 72) years, and sepsis severity was 38% sepsis, 16% severe sepsis without shock, and 46% septic shock; the overall 30-day mortality was 12%. Older age was associated with higher sepsis severity: 41% of subjects aged 18 to 34 years had severe sepsis or septic shock compared with 71% for those aged 65 years or older (P < 0.001). In longitudinal models adjusting for demographics, comorbidities, and infection source, older age was associated with higher baseline values for chemokine (CC-motif) ligand-23, interleukin-1 receptor antagonist, NGAL, and TNFR-1a (all P < 0.05). However, older adults had higher mean values during the entire 72-h period only for NGAL and TNFR-1a and higher final 72-h values only for TNFR-1a. Adjustment or stratification by sepsis severity did not change the age-inflammation associations. Although older adults had higher levels of inflammation at presentation and an increased incidence of severe sepsis and septic shock, these age-related differences in inflammation largely resolved during the first 72 h of hospitalization.
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Affiliation(s)
- Adit A Ginde
- *Department of Emergency Medicine, University of Colorado School of Medicine; and †Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado; ‡Department of Emergency Medicine, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, New Jersey; §Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; ∥New York Methodist Hospital, Brooklyn; and Weill Cornell Medical Center, New York, New York; ¶Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan; **Department of Surgery, Washington University School of Medicine, St. Louis, Missouri; ††Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; ‡‡Departments of Emergency Medicine and Medicine, Loma Linda University Medical Center, Loma Linda, California; §§Departments of Anesthesiology and Internal Medicine, University of Michigan, Ann Arbor, Michigan; ∥∥Departments of Emergency Medicine, and ¶¶Internal Medicine, MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, District of Columbia; ***Department of Emergency Medicine, University of North Carolina, Chapel Hill, North Carolina; †††Department of Emergency Medicine, Wayne State University, Detroit, Michigan; and ‡‡‡Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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De Jesus-Acosta A, Laheru D, Maitra A, Arcaroli J, Rudek MA, Dasari A, Blatchford PJ, Quackenbush K, Messersmith W. A phase II study of the gamma secretase inhibitor RO4929097 in patients with previously treated metastatic pancreatic adenocarcinoma. Invest New Drugs 2014; 32:739-45. [PMID: 24668033 PMCID: PMC4292847 DOI: 10.1007/s10637-014-0083-8] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [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: 02/19/2014] [Accepted: 02/28/2014] [Indexed: 12/18/2022]
Abstract
PURPOSE The notch pathway is overexpressed in pancreatic adenocarcinoma. RO4929097, an oral inhibitor of the γ-secretase enzyme has been safely given as a single agent in patients with advanced solid tumors. We aimed to evaluate the efficacy of RO4929097 in patients with pancreatic adenocarcinoma (PDA). METHODS A two-stage, single-arm Phase II trial was conducted in patients with previously treated metastatic PDA. RO4929097 was administered at a dose of 20 mg daily on days 1-3, 8-10 and 15-17 of 21-day cycles. The primary endpoint was survival at 6 months. Secondary endpoints included overall survival (OS), response rate, toxicities, pharmacokinetic and pharmacodynamic analyses. RESULTS Eighteen patients were recruited, 17 in the first stage and one in the 2nd stage. It was decided to stop further enrollment after RO4929097 was discontinued by the sponsor and was no longer a development candidate. Three (25 %) of 12 evaluable patients achieved stable disease. The 6-month survival rate was 27.8 % (95 % CI 9.7-53.5). The median OS was 4.1 months (95 % CI 2.7-5.8 months) and median progression-free survival was 1.5 months (95 % CI 1.3-1.6 months). Pharmacokinetic properties of RO4929097 in patients (n = 5) with PDA was similar to that previously reported in other patient populations. There was a trend towards a decrease in HeyL (p = 0.08) gene expression in three patients following study drug administration. CONCLUSIONS RO4929097 was well-tolerated in patients with previously treated PDA. Development of RO4929097 has been discontinued, but development of other notch-targeting agents in pancreatic cancer is continuing.
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Affiliation(s)
- Ana De Jesus-Acosta
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, 1650 Orleans St. CRB1-4M08, Baltimore, MD, 21287, USA,
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Abstract
BACKGROUND Among former prisoners, a high rate of death has been documented in the early postrelease period, particularly from drug-related causes. Little is known about risk factors and trends in postrelease mortality in the past decade, especially given general population increases in overdose deaths from pharmaceutical opioids. OBJECTIVE To determine postrelease mortality between 1999 and 2009; cause-specific mortality rates; and whether sex, calendar year, and custody factors were risk factors for all-cause, overdose, and opioid-related deaths. DESIGN Cohort study. SETTING Prison system of the Washington State Department of Corrections. PARTICIPANTS 76 208 persons released from prison. MEASUREMENTS Identities were linked probabilistically to the National Death Index to identify deaths and causes of death, and mortality rates were calculated. Cox proportional hazards regression estimated the effect of age, sex, race or ethnicity, whether the incarceration resulted from a violation of terms of the person's community supervision, length of incarceration, release type, and calendar year on the hazard ratio (HR) for death. RESULTS The all-cause mortality rate was 737 per 100 000 person-years (95% CI, 708 to 766) (n = 2462 deaths). Opioids were involved in 14.8% of all deaths. Overdose was the leading cause of death (167 per 100 000 person-years [CI, 153 to 181]), and overdose deaths in former prisoners accounted for 8.3% of the overdose deaths among persons aged 15 to 84 years in Washington from 2000 to 2009. Women were at increased risk for overdose (HR, 1.38 [CI, 1.12 to 1.69]) and opioid-related deaths (HR, 1.39 [CI, 1.09 to 1.79]). LIMITATION The study was done in only 1 state. CONCLUSION Innovation is needed to reduce the risk for overdose among former prisoners. PRIMARY FUNDING SOURCE National Institute on Drug Abuse and the Robert Wood Johnson Foundation.
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Binswanger IA, Blatchford PJ, Mueller SR, Stern MF. Mortality after prison release: opioid overdose and other causes of death, risk factors, and time trends from 1999 to 2009. Ann Intern Med 2013; 159:592-600. [PMID: 24189594 PMCID: PMC5242316 DOI: 10.7326/0003-4819-159-9-201311050-00005] [Citation(s) in RCA: 355] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Among former prisoners, a high rate of death has been documented in the early postrelease period, particularly from drug-related causes. Little is known about risk factors and trends in postrelease mortality in the past decade, especially given general population increases in overdose deaths from pharmaceutical opioids. OBJECTIVE To determine postrelease mortality between 1999 and 2009; cause-specific mortality rates; and whether sex, calendar year, and custody factors were risk factors for all-cause, overdose, and opioid-related deaths. DESIGN Cohort study. SETTING Prison system of the Washington State Department of Corrections. PARTICIPANTS 76 208 persons released from prison. MEASUREMENTS Identities were linked probabilistically to the National Death Index to identify deaths and causes of death, and mortality rates were calculated. Cox proportional hazards regression estimated the effect of age, sex, race or ethnicity, whether the incarceration resulted from a violation of terms of the person's community supervision, length of incarceration, release type, and calendar year on the hazard ratio (HR) for death. RESULTS The all-cause mortality rate was 737 per 100 000 person-years (95% CI, 708 to 766) (n = 2462 deaths). Opioids were involved in 14.8% of all deaths. Overdose was the leading cause of death (167 per 100 000 person-years [CI, 153 to 181]), and overdose deaths in former prisoners accounted for 8.3% of the overdose deaths among persons aged 15 to 84 years in Washington from 2000 to 2009. Women were at increased risk for overdose (HR, 1.38 [CI, 1.12 to 1.69]) and opioid-related deaths (HR, 1.39 [CI, 1.09 to 1.79]). LIMITATION The study was done in only 1 state. CONCLUSION Innovation is needed to reduce the risk for overdose among former prisoners. PRIMARY FUNDING SOURCE National Institute on Drug Abuse and the Robert Wood Johnson Foundation.
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Keith RL, Wilson DO, Bunn PA, Miller YE, Blatchford PJ, Jackson MK, Kittelson JK, Franklin WA, Hirsch FR, Minna J, Mao J, Massion P. Abstract PL04-02: Oral iloprost for the chemoprevention of lung cancer: A multicenter, SPORE-initiated trial. Cancer Prev Res (Phila) 2011. [DOI: 10.1158/1940-6207.prev-11-pl04-02] [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: Tissue microarray studies have shown that the majority of NSCLC have decreased expression of prostacyclin synthase (PGIS) and prostacyclin supplementation (genetic overexpression and the oral prostacyclin analogue iloprost) chemoprevent lung cancer in a variety of murine models, including cigarette smoke exposure. Based on these promising results, a multi-center, double-blind, placebo controlled, phase II trial of iloprost in subjects at increased risk for lung cancer conducted at SPORE in lung cancer sites.
Methods: Subjects were selected for the trial if they meet the following criteria: current or former smoker (> 20 pack years); at least mild cytologic atypia on sputum cytology; no previous history of cancer. Fluorescent bronchoscopy was performed with 6 standard endobronchial sites biopsied, along with all other abnormally appearing areas. Subjects were then randomized to oral iloprost (in escalating doses) or placebo for 6 months and then a repeat bronchoscopy with biopsy of all the central airway areas sampled on the first bronchoscopy. The primary endpoints for the study are bronchial histology and Ki-67 labeling index.
Results: For the iloprost study, 152 subjects were randomized and 125 completed both bronchoscopies (60/75 iloprost, 65/77 placebo). Treatment groups were well matched for age, tobacco exposure and baseline histology. Endobronchial histology was summarized within patients using three separate measures: worst biopsy score (Max), dysplasia index (DI - defined as the percentage of biopsies with a score of at least 4 (mild dysplasia) or worse), and average of all biopsy scores (Avg). 74% of subjects had at least one biopsy displaying mild dysplasia (score 4.0) or worse on the initial bronchoscopy. A reproducibility study with two independent pathologists demonstrated that 85% of readings were within one histologic grade. Baseline histology was significantly worse for current smokers (Avg 3.0) than former smokers (Avg 2.1). Former smokers receiving oral iloprost exhibited a significant improvement in Avg (0.41 better, p=0.010), Max (1.10 units, p=0.002), and an improvement in DI (12.45%, p=0.006). No histologic improvement occurred in current smokers. Proliferation by Ki-67 index was a secondary endpoint and demonstrated no change with iloprost administration. There were no differences in dropout rates or SAEs between treatment groups. Analyses for other biomarkers in iloprost samples (including urinary prostaglandin metabolites, miRNAs, and EMT markers) are in progress.
Conclusions: Oral iloprost significantly improves endobronchial dysplasia in former smokers and deserves further study to determine if it can prevent the development of lung cancer.
Citation Information: Cancer Prev Res 2011;4(10 Suppl):PL04-02.
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Affiliation(s)
| | | | - Paul A. Bunn
- 3University of Colorado Comprehensive Cancer Center, Denver, CO
| | | | | | - Mary K. Jackson
- 3University of Colorado Comprehensive Cancer Center, Denver, CO
| | | | | | - Fred R. Hirsch
- 3University of Colorado Comprehensive Cancer Center, Denver, CO
| | - John Minna
- 5University of Texas Southwestern Medical Center, Dallas, TX
| | - Jenny Mao
- 6University of California, Los Angeles, CA
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Keith RL, Blatchford PJ, Kittelson J, Minna JD, Kelly K, Massion PP, Franklin WA, Mao J, Wilson DO, Merrick DT, Hirsch FR, Kennedy TC, Bunn PA, Geraci MW, Miller YE. Oral iloprost improves endobronchial dysplasia in former smokers. Cancer Prev Res (Phila) 2011; 4:793-802. [PMID: 21636546 DOI: 10.1158/1940-6207.capr-11-0057] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
There are no established chemopreventive agents for lung cancer, the leading cause of cancer death in the United States. Prostacyclin levels are low in lung cancer and supplementation prevents lung cancer in preclinical models. We carried out a multicenter double-blind, randomized, phase II placebo-controlled trial of oral iloprost in current or former smokers with sputum cytologic atypia or endobronchial dysplasia. Bronchoscopy was performed at study entry and after completion of six months of therapy. Within each subject, the results were calculated by using the average score of all biopsies (Avg), the worst biopsy score (Max), and the dysplasia index (DI). Change in Avg was the primary end point, evaluated in all subjects, as well as in current and former smokers. The accrual goal of 152 subjects was reached and 125 completed both bronchoscopies (60/75 iloprost, 65/77 placebo). Treatment groups were well matched for age, tobacco exposure, and baseline histology. Baseline histology was significantly worse for current smokers (Avg 3.0) than former smokers (Avg 2.1). When compared with placebo, former smokers receiving oral iloprost exhibited a significantly greater improvement in Avg (0.41 units better, P = 0.010), in Max (1.10 units better, P = 0.002), and in DI (12.45%, P = 0.006). No histologic improvement occurred in current smokers. Oral iloprost significantly improves endobronchial histology in former smokers and deserves further study to determine if it can prevent the development of lung cancer.
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Affiliation(s)
- Robert L Keith
- Division of Pulmonary Sciences and Critical Care Medicine, Eastern Colorado VA Healthcare System, University of Colorado Denver, USA.
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Bayliss EA, Blatchford PJ, Newcomer SR, Steiner JF, Fairclough DL. The effect of incident cancer, depression and pulmonary disease exacerbations on type 2 diabetes control. J Gen Intern Med 2011; 26:575-81. [PMID: 21203859 PMCID: PMC3101974 DOI: 10.1007/s11606-010-1600-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2010] [Revised: 10/13/2010] [Accepted: 11/22/2010] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Little is known about how the development of a new chronic health condition affects management of existing chronic conditions over time. New conditions might worsen management of existing conditions because of competing demands or improve management of existing conditions because of increased engagement with heath care. We assessed the effect of incident stage 0, 1, 2 or 3 breast, colon or prostate cancer; incident depression; or an exacerbation of chronic pulmonary disease on control of type 2 diabetes (DM2). METHODS We conducted a longitudinal, historical cohort study within an integrated, not-for-profit HMO. Of a cohort of persons with diagnoses of DM2 between 1998 and 2008, 582, 2,959 and 2,332 developed incident cancer, depression or pulmonary disease exacerbation, respectively. We assessed change in hemoglobin A1c (A1c) as a function of the occurrence of the incident comorbidity in each subcohort for a period of 1 to 5 years after the occurrence of the incident comorbidity. Secondary outcomes were systolic blood pressure (SBP) and low density lipoprotein (LDL) levels. Multivariate linear regression was adjusted for demographics, morbidity level, BMI, numbers of primary and specialty visits, and continuity of primary care. Latent class analyses assessed post-comorbidity outcome trajectories. All time-varying covariates were calculated for a 24-month pre-diagnosis period and 0 to 24- and 24 to 60-month post-diagnosis periods. RESULTS For each condition, A1c did not change significantly from before to after the incident comorbidity. This was confirmed by latent class growth curve analyses that grouped patients by their A1c trajectories. SBP and LDL were also not significantly changed pre- and post-diagnosis of the incident comorbidities. DISCUSSION Although incident comorbidities inevitably will affect patients' and clinicians' care priorities, we did not observe changes in these particular outcomes. Additional investigation of interactions between diseases will inform changes in care that benefit complex patient populations.
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Affiliation(s)
- Elizabeth A Bayliss
- Kaiser Permanente Colorado, Institute for Health Research, 10065 E. Harvard Ave. Ste 300, Denver, CO 80231, USA.
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Keith RL, Blatchford PJ, Kittelson JK, Jackson M, Franklin WA, Minna J, Kelly K, Mao J, Massion P, Wilson DO, Hirsch FR, Bunn PA, Geraci MW, Miller YE. Abstract LB-90: Oral iloprost improves endobronchial dysplasia in former smokers. Cancer Res 2011. [DOI: 10.1158/1538-7445.am2011-lb-90] [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
Introduction: Prostacyclin supplementation by either genetic overexpression or the oral prostacyclin analogue iloprost prevents development of lung cancer in a variety of murine models, including cigarette smoke exposure. We conducted a multi-center, double-blind, placebo controlled, phase II trial of iloprost in subjects at increased risk for lung cancer.
Methods: Entry criteria included: current or former smoker (> 20 pack years); at least mild cytologic atypia on sputum cytology; no previous history of cancer. Autofluorescence and white light bronchoscopy was performed with 6 standard endobronchial sites biopsied, along with all other abnormally appearing areas. Subjects were then randomized to oral iloprost (in escalating doses) or placebo for 6 months and then a second bronchoscopy with repeat biopsy of all the central airway areas sampled during the first bronchoscopy, as well as any new areas suspicious for dysplasia. The predetermined primary endpoint for the study was average bronchial histologic score (based on the WHO classification of premalignant lesions) in all subjects, as well as in current and ex-smokers separately.
Results: The accrual goal of 152 subjects was reached and 125 completed both bronchoscopies (60/75 iloprost, 65/77 placebo). Treatment groups were well matched for age, tobacco exposure and baseline histology. Endobronchial histology was summarized within patients using three separate measures: worst biopsy score (Max), dysplasia index (DI – defined as the percentage of biopsies with a score of at least 4 (mild dysplasia) or worse), and average of all biopsy scores (Avg). 74% of subjects had at least one biopsy displaying mild dysplasia (score 4.0) or worse on the initial bronchoscopy. A reproducibility study with two independent pathologists demonstrated that 85% of readings were within one histologic grade. Baseline histology was significantly worse for current smokers (Avg 3.0) than former smokers (Avg 2.1). Former smokers receiving oral iloprost exhibited a significant improvement in Avg (0.41 better, p=0.010), Max (1.10 units, p=0.002), and an improvement in DI (12.45%, p=0.006). No histologic improvement occurred in current smokers. Proliferation by Ki-67 index was a secondary endpoint and demonstrated no change with iloprost administration. There were no differences in dropout rates or SAEs between treatment groups.
Conclusions: Oral iloprost significantly improves endobronchial dysplasia in former smokers and deserves further study to determine if it can prevent the development of lung cancer.
Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr LB-90. doi:10.1158/1538-7445.AM2011-LB-90
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Affiliation(s)
| | | | | | - Mary Jackson
- 3University of Colorado Comprehensive Cancer Center, Aurora, CO
| | | | - John Minna
- 4University of Texas Southwestern Medical Center, Dallas, TX
| | - Karen Kelly
- 3University of Colorado Comprehensive Cancer Center, Aurora, CO
| | - Jenny Mao
- 5University of California, Los Angeles, Los Angeles, CA
| | | | | | - Fred R. Hirsch
- 3University of Colorado Comprehensive Cancer Center, Aurora, CO
| | - Paul A. Bunn
- 3University of Colorado Comprehensive Cancer Center, Aurora, CO
| | - Mark W. Geraci
- 3University of Colorado Comprehensive Cancer Center, Aurora, CO
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