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Maning J, Shah SJ, Patel RB. With Great Data Come Great Responsibilities: The Cardiac Amyloidosis Registry Study. J Card Fail 2024; 30:679-681. [PMID: 38244763 DOI: 10.1016/j.cardfail.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 12/21/2023] [Indexed: 01/22/2024]
Affiliation(s)
- Jennifer Maning
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sanjiv J Shah
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Ravi B Patel
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL.
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Abdelhakiem MK, Bao R, Pifer PM, Molkentine D, Molkentine J, Hefner A, Beadle B, Heymach JV, Luke JJ, Ferris RL, Pickering CR, Wang JH, Patel RB, Skinner HD. Th2 Cells Are Associated with Tumor Recurrence Following Radiation. Cancers (Basel) 2024; 16:1586. [PMID: 38672668 PMCID: PMC11049347 DOI: 10.3390/cancers16081586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/08/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
The curative treatment of multiple solid tumors, including head and neck squamous cell carcinoma (HNSCC), utilizes radiation. The outcomes for HPV/p16-negative HNSCC are significantly worse than HPV/p16-positive tumors, with increased radiation resistance leading to worse locoregional recurrence (LRR) and ultimately death. This study analyzed the relationship between immune function and outcomes following radiation in HPV/p16-negative tumors to identify mechanisms of radiation resistance and prognostic immune biomarkers. A discovery cohort of 94 patients with HNSCC treated uniformly with surgery and adjuvant radiation and a validation cohort of 97 similarly treated patients were utilized. Tumor immune infiltrates were derived from RNAseq gene expression. The immune cell types significantly associated with outcomes in the discovery cohort were examined in the independent validation cohort. A positive association between high Th2 infiltration and LRR was identified in the discovery cohort and validated in the validation cohort. Tumor mutations in CREBBP/EP300 and CASP8 were significantly associated with Th2 infiltration. A pathway analysis of genes correlated with Th2 cells revealed the potential repression of the antitumor immune response and the activation of BRCA1-associated DNA damage repair in multiple cohorts. The Th2 infiltrates were enriched in the HPV/p16-negative HNSCC tumors and associated with LRR and mutations in CASP8, CREBBP/EP300, and pathways previously shown to impact the response to radiation.
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Affiliation(s)
- Mohamed K. Abdelhakiem
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA 15232, USA; (M.K.A.); (P.M.P.); (A.H.); (R.B.P.)
| | - Riyue Bao
- Department of Medicine, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA 15232, USA; (R.B.); (J.J.L.); (J.H.W.)
| | - Phillip M. Pifer
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA 15232, USA; (M.K.A.); (P.M.P.); (A.H.); (R.B.P.)
| | - David Molkentine
- Department of Thoracic-Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (D.M.); (J.M.); (J.V.H.)
| | - Jessica Molkentine
- Department of Thoracic-Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (D.M.); (J.M.); (J.V.H.)
| | - Andrew Hefner
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA 15232, USA; (M.K.A.); (P.M.P.); (A.H.); (R.B.P.)
| | - Beth Beadle
- Department of Radiation Oncology, Stanford University, Stanford, CA 94305, USA;
| | - John V. Heymach
- Department of Thoracic-Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (D.M.); (J.M.); (J.V.H.)
| | - Jason J. Luke
- Department of Medicine, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA 15232, USA; (R.B.); (J.J.L.); (J.H.W.)
| | - Robert L. Ferris
- Department of Otolaryngology, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA 15232, USA;
| | - Curtis R. Pickering
- Department of Surgery—Otolaryngology, Yale University, New Haven, CT 06520, USA;
| | - Jing H. Wang
- Department of Medicine, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA 15232, USA; (R.B.); (J.J.L.); (J.H.W.)
| | - Ravi B. Patel
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA 15232, USA; (M.K.A.); (P.M.P.); (A.H.); (R.B.P.)
| | - Heath D. Skinner
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA 15232, USA; (M.K.A.); (P.M.P.); (A.H.); (R.B.P.)
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Patel RB, Silvestry FE, Komtebedde J, Solomon SD, Hasenfuß G, Litwin SE, Borlaug BA, Price MJ, Kawash R, Hummel SL, Cutlip DE, Leon MB, van Veldhuisen DJ, Rieth AJ, McKenzie S, Bugger H, Mazurek JA, Kapadia SR, Vanderheyden M, Ky B, Shah SJ. Atrial Shunt Device Effects on Cardiac Structure and Function in Heart Failure With Preserved Ejection Fraction: The REDUCE LAP-HF II Randomized Clinical Trial. JAMA Cardiol 2024:2817472. [PMID: 38630494 PMCID: PMC11024798 DOI: 10.1001/jamacardio.2024.0520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 02/10/2024] [Indexed: 04/19/2024]
Abstract
Importance Although the results of A Study to Evaluate the Corvia Medical Inc IASD System II to Reduce Elevated Left Atrial Pressure in Patients with Heart Failure (REDUCE LAP-HF II) trial were neutral overall, atrial shunt therapy demonstrated potential efficacy in responders (no latent pulmonary vascular disease and no cardiac rhythm management device). Post hoc analyses were conducted to evaluate the effect of shunt vs sham stratified by responder status. Objective To evaluate the effect of atrial shunt vs sham control on cardiac structure/function in the overall study and stratified by responder status. Design, Setting, and Participants This was a sham-controlled randomized clinical trial of an atrial shunt device in heart failure with preserved ejection fraction (HFpEF)/HF with mildly reduced EF (HFmrEF). Trial participants with evaluable echocardiography scans were recruited from 89 international medical centers. Data were analyzed from April 2023 to January 2024. Interventions Atrial shunt device or sham control. Main Outcome Measures Changes in echocardiographic measures from baseline to 1, 6, 12, and 24 months after index procedure. Results The modified intention-to-treat analysis of the REDUCE LAP-HF II trial included 621 randomized patients (median [IQR] age, 72.0 [66.0-77.0] years; 382 female [61.5%]; shunt arm, 309 [49.8%]; sham control arm, 312 [50.2%]). Through 24 months, 212 of 217 patients (98%) in the shunt arm with evaluable echocardiograms had patent shunts. In the overall trial population, the shunt reduced left ventricular (LV) end-diastolic volume (mean difference, -5.65 mL; P <.001), left atrial (LA) minimal volume (mean difference, -2.8 mL; P =.01), and improved LV systolic tissue Doppler velocity (mean difference, 0.69 cm/s; P <.001) and LA emptying fraction (mean difference, 1.88 percentage units; P =.02) compared with sham. Shunt treatment also increased right ventricular (RV; mean difference, 9.58 mL; P <.001) and right atrial (RA; mean difference, 9.71 mL; P <.001) volumes but had no effect on RV systolic function, pulmonary artery pressure, or RA pressure compared with sham. In the shunt arm, responders had smaller increases in RV end-diastolic volume (mean difference, 5.71 mL vs 15.18 mL; interaction P =.01), RV end-systolic volume (mean difference, 1.58 mL vs 7.89 mL; interaction P =.002), and RV/LV ratio (mean difference, 0.07 vs 0.20; interaction P <.001) and larger increases in transmitral A wave velocity (mean difference, 5.08 cm/s vs -1.97 cm/s; interaction P =.02) compared with nonresponders randomized to the shunt, suggesting greater ability to accommodate shunted blood through the pulmonary circulation enabling LA unloading. Conclusions and Relevance In this post hoc analysis of the REDUCE LAP-HF II trial, over 2 years of follow-up, atrial shunting led to reverse remodeling of left-sided chambers and increases in volume of right-sided chambers consistent with the shunt flow but no change in RV systolic function compared with sham. Changes in cardiac structure/function were more favorable in responders compared with nonresponders treated with the shunt, supporting the previously identified responder group hypothesis and mechanism, although further evaluation with longer follow-up is needed. Trial Registration ClinicalTrials.gov Identifier: NCT03088033.
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Affiliation(s)
- Ravi B. Patel
- Bluhm Cardiovascular Institute, Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Frank E. Silvestry
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia
| | | | - Scott D. Solomon
- Division of Cardiology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Gerd Hasenfuß
- Heart Centre, Georg-August Universitat, Gottigen, Germany
| | - Sheldon E. Litwin
- Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston
| | - Barry A. Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Rami Kawash
- Division of Cardiology, Ohio State Wexner Medical Center, Columbus
| | - Scott L. Hummel
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor
- VA Ann Arbor, Ann Arbor, Michigan
| | - Donald E. Cutlip
- Division of Cardiology, Beth Israel Medical Center, Boston, Massachusetts
| | | | - Dirk J. van Veldhuisen
- Department of Cardiology, University Medical Center, University of Groningen, Groningen, the Netherlands
| | - Andreas J. Rieth
- Department of Cardiology, Kerckhoff-Klinik, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Frankfurt am Main, Germany
| | - Scott McKenzie
- The Prince Charles Hospital, School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Heiko Bugger
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Jeremy A. Mazurek
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | | | | | - Bonnie Ky
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia
| | - Sanjiv J. Shah
- Bluhm Cardiovascular Institute, Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Mathew DT, Peigh G, Lima JA, Bielinski SJ, Larson NB, Allison MA, Shah SJ, Patel RB. Associations of Circulating Vascular Cell Adhesion Molecule-1 and Intercellular Adhesion Molecule-1 With Long-Term Cardiac Function. J Am Heart Assoc 2024; 13:e032213. [PMID: 38497480 PMCID: PMC11009988 DOI: 10.1161/jaha.123.032213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 02/16/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Although VCAM-1 (vascular cell adhesion molecule-1) and ICAM-1 (intercellular adhesion molecule-1) have been associated with incident heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF), the associations of VCAM-1 and ICAM-1 with sensitive measures of cardiac structure/function are unclear. The objective of this study is to evaluate associations between VCAM-1, ICAM-1, and measures of cardiac structure and function as potential pathways through which cellular adhesion molecules promote HFpEF and AF risk. METHODS AND RESULTS In MESA (Multi-Ethnic Study of Atherosclerosis), we evaluated the associations of circulating VCAM-1 and ICAM-1 at examination 2 (2002-2004) with measures of cardiac structure/function on cardiac magnetic resonance imaging at examination 5 (2010-2011) after multivariable adjustment. Mediation analysis of left atrial (LA) strain on the association between VCAM-1 or ICAM-1 and AF or HFpEF was also performed. Overall, 2304 individuals (63±10 years; 47% men) with VCAM-1 or ICAM-1, cardiac magnetic resonance imaging, and covariate data were included in analysis. Higher VCAM-1 and ICAM-1 were associated with lower LA peak longitudinal strain and worse global circumferential left ventricular strain but were not associated with left ventricular myocardial scar or interstitial fibrosis. Lower LA peak longitudinal strain mediated 8% (95% CI, 2-30) of the relationship between VCAM-1 and HFpEF and 9% (95% CI, 2-21) of the relationship between VCAM-1 and AF. CONCLUSIONS Higher VCAM-1 and ICAM-1 were associated with lower LA function and left ventricular systolic function but were not associated with myocardial scar or interstitial fibrosis. VCAM-1 and ICAM-1 may promote HFpEF and AF risk through impaired LA reservoir function.
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Affiliation(s)
| | - Graham Peigh
- Division of Cardiology, Department of MedicineNorthwestern University Feinberg School of MedicineChicagoIL
| | - Joao A.C. Lima
- Division of Cardiology, Department of MedicineJohns Hopkins UniversityBaltimoreMD
| | | | | | - Matthew A. Allison
- Division of Preventive Medicine, Department of Family MedicineUniversity of CaliforniaLa JollaCA
| | - Sanjiv J. Shah
- Division of Cardiology, Department of MedicineNorthwestern University Feinberg School of MedicineChicagoIL
- Department of Preventive MedicineNorthwestern University Feinberg School of MedicineChicagoIL
| | - Ravi B. Patel
- Division of Cardiology, Department of MedicineNorthwestern University Feinberg School of MedicineChicagoIL
- Department of Preventive MedicineNorthwestern University Feinberg School of MedicineChicagoIL
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Dalal PJ, Giro P, Rasmussen-Torvik LJ, Yancy CW, Shah SJ, Reiner AP, Haring B, Martin LW, Wells GL, Manson JE, Kooperberg C, Eaton CB, Patel RB. Heart Failure Risk Among African-American Women With an ICAM1 Missense Variant. JACC Heart Fail 2024:S2213-1779(24)00145-8. [PMID: 38530700 DOI: 10.1016/j.jchf.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/12/2024] [Accepted: 02/14/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND A common genetic variant of ICAM1 among African-American individuals (rs5491; p.K56M) is associated with heart failure (HF) hospitalization, but whether this risk is specific to heart failure with preserved ejection fraction (HFpEF) remains unclear. Older women are at high risk for HFpEF, and the relationship between rs5491 and HFpEF across the age spectrum is unknown. OBJECTIVES This study assessed risk of HF and its subtypes conferred by ICAM1 p.K56M (rs5491). METHODS Associations of rs5491 with risk of HF and its subtypes were estimated among African American individuals in WHI (Women's Health Initiative). The study evaluated whether the association between rs5491 and HF hospitalizations was modified by baseline age. Subsequently, African-American women in WHI and MESA (Multi-Ethnic Study of Atherosclerosis) were pooled and analyses were repeated. RESULTS Among 8,401 women in WHI, the minor allele frequency of rs5491 was 20.7%, and 731 HF hospitalizations occurred over 19.2 years. The rs5491 variant was not associated with HF or its subtypes across WHI. Interaction analyses suggested that age as a continuous variable modified the association of rs5491 with HFpEF hospitalization (interaction P = 0.04). Upon categorizing women into age decades, rs5491 conferred increased risk of HFpEF among women ≥70 years (HR per additional rs5491 allele: 1.82 [95% CI: 1.25-2.65]; P = 0.002) but was not associated with HFpEF risk among women <70 years. Pooling African-American women in WHI (n = 8,401) and MESA (n = 856) demonstrated that the effect modification by age on the association of rs5491 with HFpEF became more significant (interaction P = 0.009), with consistent HFpEF risk effect estimates among women ≥70 years. CONCLUSIONS ICAM1 p.K56M (rs5491) is associated with HFpEF among African-American women ≥70 years.
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Affiliation(s)
- Prarthana J Dalal
- Division of Hematology and Oncology, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Pedro Giro
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Laura J Rasmussen-Torvik
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Clyde W Yancy
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sanjiv J Shah
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alex P Reiner
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Bernhard Haring
- Department of Medicine III, Saarland University Hospital, Homburg, Saarland, Germany; Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Lisa Warsinger Martin
- Division of Cardiology, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Gretchen L Wells
- Division of Cardiology, University of Alabama Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - JoAnn E Manson
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Charles Kooperberg
- Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Charles B Eaton
- Center for Primary Care and Prevention, Department of Family Medicine, Department of Epidemiology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA; Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Ravi B Patel
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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Vincze SR, Jaswal AP, Frederico SC, Nisnboym M, Li B, Xiong Z, Sever RE, Sneiderman CT, Rodgers M, Day KE, Latoche JD, Foley LM, Hitchens TK, Frederick R, Patel RB, Hadjipanayis CG, Raphael I, Nedrow JR, Edwards WB, Kohanbash G. ImmunoPET imaging of TIGIT in the glioma microenvironment. Sci Rep 2024; 14:5305. [PMID: 38438420 PMCID: PMC10912309 DOI: 10.1038/s41598-024-55296-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 02/22/2024] [Indexed: 03/06/2024] Open
Abstract
Glioblastoma (GBM) is the most common primary malignant brain tumor. Currently, there are few effective treatment options for GBM beyond surgery and chemo-radiation, and even with these interventions, median patient survival remains poor. While immune checkpoint inhibitors (ICIs) have demonstrated therapeutic efficacy against non-central nervous system cancers, ICI trials for GBM have typically had poor outcomes. TIGIT is an immune checkpoint receptor that is expressed on activated T-cells and has a role in the suppression of T-cell and Natural Killer (NK) cell function. As TIGIT expression is reported as both prognostic and a biomarker for anti-TIGIT therapy, we constructed a molecular imaging agent, [89Zr]Zr-DFO-anti-TIGIT (89Zr-αTIGIT), to visualize TIGIT in preclinical GBM by immunoPET imaging. PET imaging and biodistribution analysis of 89Zr-αTIGIT demonstrated uptake in the tumor microenvironment of GBM-bearing mice. Blocking antibody and irrelevant antibody tracer studies demonstrated specificity of 89Zr-αTIGIT with significance at a late time point post-tracer injection. However, the magnitude of 89Zr-αTIGIT uptake in tumor, relative to the IgG tracer was minimal. These findings highlight the features and limitations of using 89Zr-αTIGIT to visualize TIGIT in the GBM microenvironment.
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Affiliation(s)
- Sarah R Vincze
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ambika P Jaswal
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Stephen C Frederico
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michal Nisnboym
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Bo Li
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Zujian Xiong
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - ReidAnn E Sever
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Chaim T Sneiderman
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mikayla Rodgers
- Department of Biochemistry, University of Missouri, Columbia, MO, USA
| | - Kathryn E Day
- In Vivo Imaging Facility, University of Pittsburgh Medical Center, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Joseph D Latoche
- In Vivo Imaging Facility, University of Pittsburgh Medical Center, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Lesley M Foley
- In Vivo Imaging Facility, University of Pittsburgh Medical Center, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - T Kevin Hitchens
- In Vivo Imaging Facility, University of Pittsburgh Medical Center, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
- Department of Neurobiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robin Frederick
- In Vivo Imaging Facility, University of Pittsburgh Medical Center, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Ravi B Patel
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Costas G Hadjipanayis
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Itay Raphael
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jessie R Nedrow
- In Vivo Imaging Facility, University of Pittsburgh Medical Center, UPMC Hillman Cancer Center, Pittsburgh, PA, USA.
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - W Barry Edwards
- Department of Biochemistry, University of Missouri, Columbia, MO, USA.
| | - Gary Kohanbash
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Department of Immunology, University of Pittsburgh, Pittsburgh, PA, USA.
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Fudim M, Litwin SE, Borlaug BA, Mohan RC, Price MJ, Fail P, Zirakashvili T, Shaburishvili T, Goyal P, Hummel SL, Patel RB, Reddy VY, Burkhoff D, Patel MR, Somo SI, Shah SJ. Endovascular Ablation of the Right Greater Splanchnic Nerve in Heart Failure With Preserved Ejection Fraction: Rationale, Design and Lead-in Phase Results of the REBALANCE-HF Trial. J Card Fail 2024:S1071-9164(24)00002-2. [PMID: 38211934 DOI: 10.1016/j.cardfail.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVE Splanchnic vasoconstriction augments transfer of blood volume from the abdomen into the thorax, which may increase filling pressures and hemodynamic congestion in patients with noncompliant hearts. Therapeutic interruption of splanchnic nerve activity holds promise to reduce hemodynamic congestion in patients with heart failure with preserved ejection fraction (HFpEF). Here we describe (1) the rationale and design of the first sham-controlled, randomized clinical trial of splanchnic nerve ablation for HFpEF and (2) the 12-month results of the lead-in (open-label) trial's participants. METHODS REBALANCE-HF is a prospective, multicenter, randomized, double-blinded, sham-controlled clinical trial of endovascular, transcatheter, right-sided greater splanchnic nerve ablation for volume management (SAVM) in patients with HFpEF. The primary objectives are to evaluate the safety and efficacy of SAVM and identify responder characteristics to inform future studies. The trial consists of an open-label lead-in phase followed by the randomized, sham-controlled phase. The primary efficacy endpoint is the reduction in pulmonary capillary wedge pressure (PCWP) at 1-month follow-up compared to baseline during passive leg raise and 20W exercise. Secondary and exploratory endpoints include health status (Kansas City Cardiomyopathy Questionnaire), 6-minute walk test distance, New York Heart Association class, and NTproBNP levels at 3, 6 and 12 months. The primary safety endpoint is device- or procedure-related serious adverse events at the 1-month follow-up. RESULTS The lead-in phase of the study, which enrolled 26 patients with HFpEF who underwent SAVM, demonstrated favorable safety outcomes and reduction in exercise PCWP at 1 month post-procedure and improvements in all secondary endpoints at 6 and 12 months of follow-up. The randomized phase of the trial (n = 44 SAVM; n = 46 sham) has completed enrollment, and follow-up is ongoing. CONCLUSION REBALANCE-HF is the first sham-controlled randomized clinical trial of greater splanchnic nerve ablation in HFpEF. Initial 12-month open-label results are promising, and the results of the randomized portion of the trial will inform the design of a future pivotal clinical trial. SAVM may offer a promising therapeutic option for patients with HFpEF. TRIAL REGISTRATION NCT04592445.
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Affiliation(s)
- Marat Fudim
- Department of Medicine, Division of Cardiology, Duke University Medical Center Durham, NC, USA; Duke Clinical Research Institute, Division of Cardiology, Durham, NC, USA; Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | | | | | | | | | - Peter Fail
- Cardiovascular Institute of the South, Houma, LA, USA
| | | | | | | | - Scott L Hummel
- University of Michigan and VA, Ann Arbor, Ann Arbor, MI, USA
| | - Ravi B Patel
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Vivek Y Reddy
- Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Manesh R Patel
- Department of Medicine, Division of Cardiology, Duke University Medical Center Durham, NC, USA; Duke Clinical Research Institute, Division of Cardiology, Durham, NC, USA
| | | | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Giro P, Taylor KD, Shah SJ, Patel RB. The pK56M ICAM1 HFpEF risk variant and inflammatory biomarkers. Am Heart J Plus 2023; 36:100346. [PMID: 38074621 PMCID: PMC10704861 DOI: 10.1016/j.ahjo.2023.100346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 01/31/2024]
Abstract
Introduction The ICAM1 variant rs5491 (p.K56M) is common among Black individuals and has been associated with risk of heart failure with preserved ejection fraction (HFpEF). The pathways by which rs5491 leads to HFpEF are not known. Methods Among Black individuals within the Multi-Ethnic Study of Atherosclerosis, we evaluated associations of rs5491 with 3 inflammatory biomarkers (high-sensitivity C-reactive protein [hsCRP], interleukin-6 [IL-6], and tumor necrosis factor-α receptor 1 [TNFR-1]). Results Among 1558 Black participants (mean age 62 ± 10 y, 47 % female), each additional rs5491 allele was associated with higher hsCRP after covariate adjustment (β: 0.15, SE: 0.07, P = 0.02). Each additional rs5491 allele was associated with higher TNFR-1 (β: 0.06, SE: 0.02, P = 0.02), but not IL-6 (β: 0.04, SE: 0.04, P = 0.29). The association between rs5491 and HFpEF remained significant after adjustment for hsCRP. Conclusion In Black individuals, rs5491 (p.K56M) is associated with higher hsCRP and higher TNFR-1, but not IL-6.
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Affiliation(s)
- Pedro Giro
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Kent D. Taylor
- The Institute for Translational Genomics and Population Sciences, Department of Pediatrics, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, United States of America
| | - Sanjiv J. Shah
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | - Ravi B. Patel
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
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9
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Beckta JM, Patel RB, White GA, Boike T, Escorcia FE. Radiation Oncologists and Radiopharmaceutical Therapy: Strategies for Addressing Fair Compensation. Pract Radiat Oncol 2023; 13:496-498. [PMID: 37923492 DOI: 10.1016/j.prro.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 08/06/2023] [Indexed: 11/07/2023]
Affiliation(s)
- Jason M Beckta
- Cold Light Legacy Company and Department of Radiation Oncology, University of Vermont, Burlington, Vermont.
| | - Ravi B Patel
- Department of Radiation Oncology, University of Pittsburg Medical Center, Pittsburg, Pennsylvania
| | - Gerald A White
- Department of Radiation Oncology, Colorado Associates Medical Physics, Colorado Springs, Colorado
| | - Tom Boike
- Department of Radiation Oncology, Michigan Healthcare Professionals, Troy, Michigan
| | - Freddy E Escorcia
- Department of Radiation Oncology, National Cancer Institute, Bethesda, Maryland.
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10
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Patel RB, Reddy VY, Komtebedde J, Wegerich SW, Sekaric J, Swarup V, Walton A, Laurent G, Chetcuti S, Rademann M, Bergmann M, McKenzie S, Bugger H, Bruno RR, Herrmann HC, Nair A, Gupta DK, Lim S, Kapadia S, Gordon R, Vanderheyden M, Noel T, Bailey S, Gertz ZM, Trochu JN, Cutlip DE, Leon MB, Solomon SD, van Veldhuisen DJ, Auricchio A, Shah SJ. Atrial Fibrillation Burden and Atrial Shunt Therapy in Heart Failure With Preserved Ejection Fraction. JACC Heart Fail 2023; 11:1351-1362. [PMID: 37480877 DOI: 10.1016/j.jchf.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/12/2023] [Accepted: 05/17/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is a common comorbidity in patients with heart failure with preserved ejection fraction (HFpEF) and in heart failure with mildly reduced ejection fraction (HFmrEF). OBJECTIVES This study sought to describe AF burden and its clinical impact among individuals with HFpEF and HFmrEF who participated in a randomized clinical trial of atrial shunt therapy (REDUCE LAP-HF II [A Study to Evaluate the Corvia Medical, Inc IASD System II to Reduce Elevated Left Atrial Pressure in Patients with Heart Failure]) and to evaluate the effect of atrial shunt therapy on AF burden. METHODS Study investigators characterized AF burden among patients in the REDUCE LAP-HF II trial by using ambulatory cardiac patch monitoring at baseline (median patch wear time, 6 days) and over a 12-month follow-up (median patch wear time, 125 days). The investigators determined the association of baseline AF burden with long-term clinical events and examined the effect of atrial shunt therapy on AF burden over time. RESULTS Among 367 patients with cardiac monitoring data at baseline and follow-up, 194 (53%) had a history of AF or atrial flutter (AFL), and median baseline AF burden was 0.012% (IQR: 0%-1.3%). After multivariable adjustment, baseline AF burden ≥0.012% was significantly associated with heart failure (HF) events (HR: 2.00; 95% CI: 1.17-3.44; P = 0.01) both with and without a history of AF or AFL (P for interaction = 0.68). Adjustment for left atrial reservoir strain attenuated the baseline AF burden-HF event association (HR: 1.71; 95% CI: 0.93-3.14; P = 0.08). Of the 367 patients, 141 (38%) had patch-detected AF during follow-up without a history of AF or AFL. Atrial shunt therapy did not change AF incidence or burden during follow-up. CONCLUSIONS In HFpEF and HFmrEF, nearly 40% of patients have subclinical AF by 1 year. Baseline AF burden, even at low levels, is associated with HF events. Atrial shunt therapy does not affect AF incidence or burden. (A Study to Evaluate the Corvia Medical, Inc IASD System II to Reduce Elevated Left Atrial Pressure in Patients with Heart Failure [REDUCE LAP-HF II]; NCT03088033).
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Affiliation(s)
- Ravi B Patel
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Illinois, USA
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | | | - Gabriel Laurent
- Department of Cardiology, Dijon University Hospital, Dijon, France
| | - Stanley Chetcuti
- Division of Cardiology, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Matthias Rademann
- Department of Cardiology, University of Giessen, Bad Nauheim, Germany
| | - Martin Bergmann
- Department of Interventional Cardiology, Cardiologicum, Hamburg, Germany
| | - Scott McKenzie
- School of Medicine, University of Queensland, The Prince Charles Hospital, Brisbane, Australia
| | - Heiko Bugger
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Raphael Romano Bruno
- Division of Cardiology, Pulmonology, and Vascular Medicine, Faculty of Medicine, University Hospital Dusseldorf, Heinrich-Heine-University Dusseldorf, Dusseldorf, Germany
| | - Howard C Herrmann
- Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ajith Nair
- Division of Cardiology, Baylor College of Medicine, Houston, Texas, USA
| | - Deepak K Gupta
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott Lim
- Division of Cardiology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Samir Kapadia
- Division of Cardiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert Gordon
- Division of Cardiology, NorthShore University Health System, Evanston, Illinois, USA
| | | | - Thomas Noel
- Southern Medical Group, P.A., Tallahassee, Florida, USA
| | - Steven Bailey
- Division of Cardiology, Louisiana State University School of Medicine, Baton Rouge, Louisiana, USA
| | - Zachary M Gertz
- Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Jean-Noël Trochu
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France
| | - Donald E Cutlip
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Martin B Leon
- Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, New York, USA
| | - Scott D Solomon
- Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Angelo Auricchio
- Division of Cardiology, Ticino Cardiocentro Institute, Lugano, Switzerland
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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Ellsworth SG, Ross A, Shiue K, Murthy P, Patel RB, Zellars RC, Miller AC, Russ KA, Lotze M. Influence of Radiation Fractionation on Immune Repertoire Diversity in Solid Tumor Patients. Int J Radiat Oncol Biol Phys 2023; 117:S157. [PMID: 37784394 DOI: 10.1016/j.ijrobp.2023.06.582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Radiation (RT)-induced lymphopenia (RIL) occurs in up to 75% of patients undergoing RT and is associated with worse tumor control and survival across a spectrum of solid tumors. Patients undergoing hypofractionated RT are at lower risk of RIL compared with patients treated with more prolonged RT courses. However, it is unknown whether immune repertoire diversity is similarly affected by fractionation scheme in patients undergoing RT. This prospective study analyzed RT-induced changes in immune repertoire diversity in patients treated with conventionally (CFRT) vs hypofractionated RT (HFRT). MATERIALS/METHODS RNA-based T and B cell receptor sequencing was performed on peripheral lymphocytes collected prospectively before RT and within 4 weeks of the last RT fraction from 23 patients (18 men, 5 women, median age 67 y) with primary solid tumors undergoing CFRT (≤3 Gy/day x ≥10 days, n = 13) or HFRT (≥5 Gy/day x ≤5 days, n = 10). Absolute lymphocyte counts (ALC; cells/μL) were obtained from clinical laboratory data. The number of unique CDR3 receptors (uCDR3) and Shannon entropy were used to monitor changes in T (TCR Vβ) and B (BCR IgH) receptor diversity. RESULTS ALC decreased after RT in 90% (20/22) of patients (mean pre-RT ALC 1830 vs 1040 post-RT, p <0.001). Mean % ALC loss was greater in CFRT vs HFRT patients (44.3 vs. 35.2%). After RT, entropy in IgH and Vβ decreased in 18/23 (78%) and 17/23 (74%) patients, respectively; uCDR3 in IgH and Vβ decreased in 14/23 (61%) and 15/23 (65%). Among patients with concordant decreases in ALC and uCDR3, a moderate correlation between magnitude of ALC loss and uCDR3 levels in the T-cell receptor Vβ was observed (r = 0.64, p = 0.02). For both receptor species studied (IgH and Vβ), HFRT patients were more likely to have an increase in either entropy or uCDR3 in the face of decreased ALC (36 vs 15%, X2 p = 0.03). Furthermore, while decreases in entropy were observed among the CFRT patients for both IgH (median entropy 10.4 vs 9.4, p = 0.06) and Vβ (9.7 vs 8.1, p = 0.02), entropy did not significantly change following RT in the HFRT patients (IgH 10.6 vs 10.4, p = 0.74 and Vβ 10.9 vs 10.8, p = 0.24). CONCLUSION RT-induced changes in immune repertoire diversity are variably reflected in the peripheral ALC. Both HFRT and CFRT depleted circulating lymphocytes, but patients undergoing HFRT were more likely to experience increases in T and B cell diversity metrics despite lymphopenia. It is therefore possible that relative sparing of repertoire diversity among patients undergoing HFRT could increase the likelihood of tumor antigen recognition by peripheral blood lymphocytes. As immune repertoire diversity is associated with the likelihood of response to immunotherapy, these findings also have implications for RT-immunotherapy combinations. Further study is required to understand the relationship between RT exposure to circulating lymphocyte populations and immune repertoire diversity.
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Affiliation(s)
- S G Ellsworth
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA
| | - A Ross
- University of Pittsburgh, Pittsburgh, PA
| | - K Shiue
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN
| | - P Murthy
- University of Pittsburgh Hillman Cancer Center, Pittsburgh, PA
| | - R B Patel
- UPMC Hillman Cancer Center, Pittsburgh, PA
| | - R C Zellars
- Indiana University Department of Radiation Oncology, Indianapolis, IN
| | | | - K A Russ
- Indiana University School of Medicine, Indianapolis, IN
| | - M Lotze
- University of Pittsburgh Hillman Cancer Center, Pittsburgh, PA
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Koerner SA, Rajkumar H, Edinger R, Lalonde RJ, Patel RB. Combination Immunotherapy with Partial Versus Whole Tumor Radiotherapy in a Preclinical Melanoma Tumor Model. Int J Radiat Oncol Biol Phys 2023; 117:e241. [PMID: 37784952 DOI: 10.1016/j.ijrobp.2023.06.1169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Partial tumor radiotherapy (PTRT) with immune checkpoint inhibition (ICI) is currently the subject of clinical trials and may be used clinically for large volume tumors when the full gross tumor volume (GTV) cannot be safely treated with full dose. PTRT delivers RT to a portion of the GTV, underdosing or not treating the remainder of the GTV, hypothesizing that ICI-mediated tumor infiltrating lymphocyte (TIL) infiltration will produce adequate disease control in un- or under-irradiated GTV. Standard treatment is whole tumor radiotherapy (WTRT), and potential differences in disease control between PTRT and WTRT with ICI have not been robustly assessed. We hypothesized that PTRT with ICI and WTRT with ICI will demonstrate similar tumor regression, and both RT regimens will demonstrate superior tumor regression as compared to ICI alone. MATERIALS/METHODS B78 melanoma flank tumors were generated in C57B/L6 mice, with randomization at tumor size of 1 cm to experimental cohorts of PTRT + ICI and WTRT + ICI and control groups of no RT ± ICI. Custom lead shields were fabricated to deliver 16 Gy single fraction PTRT (50% tumor treatment) and WTRT, with dosimetry confirmation via radiochromic film. ICI was delivered through I.P. injection of murine anti-CTLA4 and anti-PD-L1 at days 0, 3, and 6 post-RT. Tumor regression was assessed via differences in tumor volume at ten days post completion of ICI, and mean cohort tumor volumes were compared with ANOVA (α <0.05). Variances between individual cohorts were assessed via t-test (α <0.05). RESULTS Treatment cohorts demonstrated significant variance in tumor volume at ten days following treatment completion (p = 0.007, Table 1). WTRT + ICI demonstrated superior tumor regression when compared to PTRT + ICI (p = 0.006), ICI alone (p = 0.002), and control cohorts (p = 0.013). There was no difference in tumor regression between PTRT + ICI and ICI alone (p = 0.709), and PTRT + ICI did not achieve significant regression when compared to control (p = 0.083). Tumor regression did not differ between cohorts receiving no RT ± ICI (p = 0.103). CONCLUSION Our results in this ICI resistant melanoma model demonstrated superior tumor regression with WTRT + ICI as compared to PTRT + ICI and ICI alone, suggesting that even with concurrent ICI, PTRT may not be sufficient treatment for melanoma. PTRT + ICI tumor regression was similar to ICI alone, suggesting that PTRT may not overcome immune resistance in the unirradiated tumor volume. Further investigation of optimal RT regimens to potentiate ICI response is warranted and correlative studies examining spatial immunomodulation in unirradiated and irradiated portions of the same tumor are underway.
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Affiliation(s)
- S A Koerner
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA
| | - H Rajkumar
- University of Pittsburgh, Pittsburgh, PA
| | - R Edinger
- University of Pittsburgh, Pittsburgh, PA
| | | | - R B Patel
- UPMC Hillman Cancer Center, Pittsburgh, PA
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13
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Basel Allaw M, Sinha A, Ghafourian K, Avery R, Weinberg RL, Lomasney JW, Shah SJ, Patel RB. Don't judge a book by its cover: a case report of apolipoprotein A-IV cardiac amyloidosis. Eur Heart J Case Rep 2023; 7:ytad341. [PMID: 37681056 PMCID: PMC10481775 DOI: 10.1093/ehjcr/ytad341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 07/05/2023] [Accepted: 07/19/2023] [Indexed: 09/09/2023]
Abstract
Background To date, at least 20 different amyloidogenic proteins have been documented. Growing evidence suggests that despite being part of the universal amyloid proteome, apolipoprotein A-IV can be amyloidogenic, accounting for less than 1% of cases. Case summary A 75-year-old woman was admitted for paroxysmal nocturnal dyspnoea and intermittent exertional shortness of breath and was found to be in acute heart failure. The patient underwent intravenous diuretic therapy and was discharged after decongestion. She then underwent a battery of outpatient tests to determine aetiology of her heart failure. Cardiac magnetic resonance imaging showed severe concentric left ventricular hypertrophy and diffuse late gadolinium enhancement, concerning for amyloidosis, but serologic evaluation for amyloidogenic light chain (AL) amyloidosis was negative. Tc 99m pyrophosphate (PYP) scan showed Grade 2 uptake at 1 h that was only moderately suggestive of transthyretin (TTR) amyloidosis. She ultimately received a right heart catheterization and endomyocardial biopsy, which showed apolipoprotein A-IV amyloid deposition within Congo red-positive areas of the endomyocardial specimen. The patient continues to report dyspnoea on exertion but has avoided additional heart failure admissions with intensification of her diuretic regimen. Discussion In this case, nuclear PYP scan to evaluate for TTR amyloidosis demonstrated focal PYP uptake, but endomyocardial biopsy demonstrated apolipoprotein A-IV deposition without evidence of TTR amyloidosis. Our case increases knowledge of this rare form of amyloidosis, suggests that it may result in false positive nuclear PYP results, and highlights the importance of its evaluation, particularly in circumstances in which investigations do not reveal definitive evidence of AL or TTR amyloidosis.
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Affiliation(s)
- Mohammed Basel Allaw
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 N St Clair St, Suite 600, Chicago, IL 60611, USA
| | - Arjun Sinha
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 N St Clair St, Suite 600, Chicago, IL 60611, USA
| | - Kambiz Ghafourian
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 N St Clair St, Suite 600, Chicago, IL 60611, USA
| | - Ryan Avery
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Richard L Weinberg
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 N St Clair St, Suite 600, Chicago, IL 60611, USA
| | - Jon W Lomasney
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 N St Clair St, Suite 600, Chicago, IL 60611, USA
| | - Ravi B Patel
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 N St Clair St, Suite 600, Chicago, IL 60611, USA
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Giro P, Cunningham JW, Rasmussen-Torvik L, Bielinski SJ, Larson NB, Colangelo LA, Jacobs DR, Gross M, Reiner AP, Lloyd-Jones DM, Guo X, Taylor K, Vaduganathan M, Post WS, Bertoni A, Ballantyne C, Shah A, Claggett B, Boerwinkle E, Yu B, Solomon SD, Shah SJ, Patel RB. Missense Genetic Variation of ICAM1 and Incident Heart Failure. J Card Fail 2023; 29:1163-1172. [PMID: 36882149 PMCID: PMC10477308 DOI: 10.1016/j.cardfail.2023.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Intercellular adhesion molecule-1 (ICAM-1) is a cell surface protein that participates in endothelial activation and is hypothesized to play a central role in heart failure (HF). We evaluated associations of ICAM1 missense genetic variants with circulating ICAM-1 levels and with incident HF. METHODS AND RESULTS We identified 3 missense variants within ICAM1 (rs5491, rs5498 and rs1799969) and evaluated their associations with ICAM-1 levels in the Coronary Artery Risk Development in Young Adults Study and the Multi-Ethnic Study of Atherosclerosis (MESA). We determined the association among these 3 variants and incident HF in MESA. We separately evaluated significant associations in the Atherosclerosis Risk in Communities (ARIC) study. Of the 3 missense variants, rs5491 was common in Black participants (minor allele frequency [MAF] > 20%) and rare in other race/ethnic groups (MAF < 5%). In Black participants, the presence of rs5491 was associated with higher levels of circulating ICAM-1 at 2 timepoints separated by 8 years. Among Black participants in MESA (n = 1600), the presence of rs5491 was associated with an increased risk of incident HF with preserved ejection fraction (HFpEF; HR = 2.30; [95% CI 1.25-4.21; P = 0.007]). The other ICAM1 missense variants (rs5498 and rs1799969) were associated with ICAM-1 levels, but there were no associations with HF. In ARIC, rs5491 was significantly associated with incident HF (HR = 1.24 [95% CI 1.02 - 1.51]; P = 0.03), with a similar direction of effect for HFpEF that was not statistically significant. CONCLUSIONS A common ICAM1 missense variant among Black individuals may be associated with increased risk of HF, which may be HFpEF-specific.
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Affiliation(s)
- Pedro Giro
- From the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jonathan W Cunningham
- Division of Cardiology, Department of Medicine, Brigham and Woman's Hospital, Boston, MA
| | - Laura Rasmussen-Torvik
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Nicholas B Larson
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Laura A Colangelo
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - David R Jacobs
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN
| | - Myron Gross
- Department of Laboratory Medicine and Pathology, University of Minnesota School of Medicine, Minneapolis, MN
| | - Alex P Reiner
- Department of Epidemiology, University of Washington, Seattle, WA
| | - Donald M Lloyd-Jones
- From the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Xiuqing Guo
- The Institute for Translational Genomics and Population Sciences, Department of Pediatrics, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Kent Taylor
- The Institute for Translational Genomics and Population Sciences, Department of Pediatrics, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Muthiah Vaduganathan
- Division of Cardiology, Department of Medicine, Brigham and Woman's Hospital, Boston, MA
| | - Wendy S Post
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Alain Bertoni
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC
| | | | - Amil Shah
- Division of Cardiology, Department of Medicine, Brigham and Woman's Hospital, Boston, MA
| | - Brian Claggett
- Division of Cardiology, Department of Medicine, Brigham and Woman's Hospital, Boston, MA
| | - Eric Boerwinkle
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center, Houston, TX
| | - Bing Yu
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center, Houston, TX
| | - Scott D Solomon
- Division of Cardiology, Department of Medicine, Brigham and Woman's Hospital, Boston, MA
| | - Sanjiv J Shah
- From the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Ravi B Patel
- From the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.
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15
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Patel RB. Cardiovascular Benefits of Sodium-Glucose Cotransporter 2 Inhibitors in Heart Failure-Does the Story Begin and End With the Kidney? JAMA Cardiol 2023:2805337. [PMID: 37223915 DOI: 10.1001/jamacardio.2023.1101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Ravi B Patel
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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16
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Horan MP, Hanson JA, Rakowski DR, Patel RB, Vidal LB, Millett PJ. Outcomes and Survivorship 5 Years After Arthroscopic Rotator Cuff Repair in Active Patients 70 Years and Older. Orthop J Sports Med 2023; 11:23259671231168888. [PMID: 37250743 PMCID: PMC10214071 DOI: 10.1177/23259671231168888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/13/2023] [Indexed: 05/31/2023] Open
Abstract
Background Rotator cuff tears are common in the elderly population and are associated with increased pain, decreased function, and decreased enjoyment of recreational activities. Purpose To evaluate clinical outcomes at a minimum of 5 years after arthroscopic repair of full-thickness rotator cuff tears in recreational athletes aged ≥70 years at the time of surgery. Study Design Case series; Level of evidence, 4. Methods Included were recreational athletes aged ≥70 years who underwent arthroscopic rotator cuff repair (RCR) from December 2005 to January 2016. Patient and surgery characteristics were collected prospectively and retrospectively reviewed. Patient-reported outcome (PRO) scores utilized were the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), the shortened version of Disabilities of the Arm, Shoulder and Hand score (QuickDASH), 12-Item Short Form Health survey (SF-12) questionnaire (Physical Component Summary and Mental Component Summary), and patient satisfaction. Kaplan Meier survivorship analysis was performed, with failure defined as revision RCR or retear on magnetic resonance imaging (MRI). Results Overall, 71 shoulders (n = 67 patients [44 men, 23 women]; mean age, 73.4 years [range, 70.1-81.3 years]) were included in this study. Follow-up data was obtained for 65 of the 69 available shoulders (94%) at a mean of 7.8 years (range, 5-15.3 years). Mean age at follow-up was 81.2 years (range, 75.7-91.0). One RCR was revised after a traumatic accident, and another had a symptomatic, MRI-confirmed retear. One patient had lysis of adhesions for stiffness 3 months postoperatively. All PRO scores improved from pre- to postoperatively-ASES, from 55.3 to 93.6; SANE, from 62 to 89.6; QuickDASH, from 32.9 to 7.3; and SF-12 Physical Component Summary, from 43.3 to 53 (P < .001 for all)-and the median satisfaction score was 10 out of 10. Postoperatively, 63% of the patients returned to their original fitness program and 33% of patients modified their recreational activity. Survivorship analysis showed a 98% survival rate at 5 years and a 92% rate at 10 years. Conclusion Sustained improvement in function, reduced pain, and return to activities was seen after arthroscopic RCR in active patients ≥70 years old. Despite one-third of patients modifying their recreational activity, the cohort reported high levels of satisfaction and general health.
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Affiliation(s)
| | | | | | - Ravi B. Patel
- Steadman Philippon Research Institute,
Vail, Colorado, USA
- The Steadman Clinic, Vail, Colorado,
USA
| | - Leslie B. Vidal
- Steadman Philippon Research Institute,
Vail, Colorado, USA
- The Steadman Clinic, Vail, Colorado,
USA
| | - Peter J. Millett
- Steadman Philippon Research Institute,
Vail, Colorado, USA
- The Steadman Clinic, Vail, Colorado,
USA
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17
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Peigh G, Patel RB. The Left Atrium: A Window into Cardiopulmonary Hemodynamics in Heart Failure with Preserved Ejection Fraction. Eur J Heart Fail 2023. [PMID: 37092327 DOI: 10.1002/ejhf.2872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 04/20/2023] [Indexed: 04/25/2023] Open
Affiliation(s)
- Graham Peigh
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Ravi B Patel
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL
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Mitchell JP, Carter I, Christopher JD, Copley M, Doub WH, Goodey A, Gruenloh CJ, Larson BB, Lyapustina S, Patel RB, Stein SW, Suman JD. Good Practices for the Laboratory Performance Testing of Aqueous Oral Inhaled Products (OIPs): an Assessment from the International Pharmaceutical Aerosol Consortium on Regulation and Science (IPAC-RS). AAPS PharmSciTech 2023; 24:73. [PMID: 36869256 DOI: 10.1208/s12249-023-02528-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 02/06/2023] [Indexed: 03/05/2023] Open
Abstract
Multiple sources must be consulted to determine the most appropriate procedures for the laboratory-based performance evaluation of aqueous oral inhaled products (OIPs) for the primary measures, dose uniformity/delivery, and aerodynamic particle (droplet) size distribution (APSD). These sources have been developed at different times, mainly in Europe and North America, during the past 25 years by diverse organizations, including pharmacopeial chapter/monograph development committees, regulatory agencies, and national and international standards bodies. As a result, there is a lack of consistency across all the recommendations, with the potential to cause confusion to those developing performance test methods. We have reviewed key methodological aspects of source guidance documents identified by a survey of the pertinent literature and evaluated the underlying evidence supporting their recommendations for the evaluation of these performance measures. We have also subsequently developed a consistent series of solutions to guide those faced with the various associated challenges when developing OIP performance testing methods for oral aqueous inhaled products.
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Affiliation(s)
- Jolyon P Mitchell
- Jolyon Mitchell Inhaler Consulting Services Inc., 1154 St. Anthony Road, London, Ontario, N6H2R1, Canada.
| | - I Carter
- PPD Inc., Part of Thermo Fisher Scientific, Athlone, Ireland
| | | | - M Copley
- Copley Scientific Ltd., Nottingham, UK
| | - W H Doub
- OINDP In Vitro Analysis, Kirkwood, Missouri, 63122, USA
| | - A Goodey
- Merck & Co. Inc., Kenilworth, New Jersey, 07033, USA
| | - C J Gruenloh
- PPD Inc., Part of Thermo Fisher Scientific, Middleton, Wisconsin, 53562-466, USA
| | - B B Larson
- PPD Inc., Part of Thermo Fisher Scientific, Middleton, Wisconsin, 53562-466, USA
| | - S Lyapustina
- Faegre Drinker Biddle & Reath LLP, Washington, District of Columbia, 20005, USA
| | - R B Patel
- Intellectual Designs LLC, Brookfield, Connecticut, 06804, USA
| | - S W Stein
- Kindeva Drug Delivery, Woodbury, Minnesota, 55129, USA
| | - J D Suman
- Next Breath LLC, a Division of Aptar Group, Halethorpe, Maryland, 21227, USA
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Patel RB, Giro P, Cunningham J, Rasmussen-Torvik L, Bielinski SJ, Larson N, Colangelo LA, Jacobs DR, Gross M, Reiner A, Lloyd-Jones DM, Guo X, Taylor K, Vaduganathan M, Post WS, Bertoni A, Ballantyne CM, Shah AM, Claggett B, Boerwinkle E, Yu B, Solomon SD, Shah SJ. MISSENSE GENETIC VARIATION OF ICAM1 AND INCIDENT HEART FAILURE: THE MULTI-ETHNIC STUDY OF ATHEROSCLEROSIS. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)00761-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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20
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Mathew D, Peigh G, Lima JA, Bielinski SJ, Larson N, Allison MA, Shah SJ, Patel RB. INTERCELLULAR ADHESION MOLECULE-1, VASCULAR CELL ADHESION MOLECULE-1, AND CARDIAC STRUCTURE AND FUNCTION: THE MULTI-ETHNIC STUDY OF ATHEROSCLEROSIS. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)00890-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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21
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LaPenna KB, Li Z, Doiron JE, Sharp TE, Xia H, Moles K, Koul K, Wang JS, Polhemus DJ, Goodchild TT, Patel RB, Shah SJ, Lefer DJ. Combination Sodium Nitrite and Hydralazine Therapy Attenuates Heart Failure With Preserved Ejection Fraction Severity in a "2-Hit" Murine Model. J Am Heart Assoc 2023; 12:e028480. [PMID: 36752224 PMCID: PMC10111505 DOI: 10.1161/jaha.122.028480] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/04/2023] [Indexed: 02/09/2023]
Abstract
Background Recent studies have suggested that cardiac nitrosative stress mediated by pathological overproduction of nitric oxide (NO) via inducible NO synthase (iNOS) contributes to the pathogenesis of heart failure with preserved ejection fraction (HFpEF). Other studies have suggested that endothelial NO synthase (eNOS) dysfunction and attenuated NO bioavailability contribute to HFpEF morbidity and mortality. We sought to further investigate dysregulated NO signaling and to examine the effects of a NO-based dual therapy (sodium nitrite+hydralazine) following the onset of HFpEF using a "2-hit" murine model. Methods and Results Nine-week-old male C57BL/6 N mice (n=15 per group) were treated concurrently with high-fat diet and N(ω)-nitro-L-arginine methyl ester (L-NAME) (0.5 g/L per day) via drinking water for 10 weeks. At week 5, mice were randomized into either vehicle (normal saline) or combination treatment with sodium nitrite (75 mg/L in the drinking water) and hydralazine (2.0 mg/kg IP, BID). Cardiac structure and function were monitored with echocardiography and invasive hemodynamic measurements. Cardiac mitochondrial respiration, aortic vascular function, and exercise performance were also evaluated. Circulating and myocardial nitrite were measured to determine the bioavailability of NO. Circulating markers of oxidative or nitrosative stress as well as systemic inflammation were also determined. Severe HFpEF was evident by significantly elevated E/E', LVEDP, and Tau in mice treated with L-NAME and HFD, which was associated with impaired NO bioavailability, mitochondrial respiration, aortic vascular function, and exercise capacity. Treatment with sodium nitrite and hydralazine restored NO bioavailability, reduced oxidative and nitrosative stress, preserved endothelial function and mitochondrial respiration, limited the fibrotic response, and improved exercise capacity, ultimately attenuating the severity of "two-hit" HFpEF. Conclusions Our data demonstrate that nitrite, a well-established biomarker of NO bioavailability and a physiological source of NO, is significantly reduced in the heart and circulation in the "2-hit" mouse HFpEF model. Furthermore, sodium nitrite+hydralazine combined therapy significantly attenuated the severity of HFpEF in the "2-hit" cardiometabolic HFpEF. These data suggest that supplementing NO-based therapeutics with a potent antioxidant and vasodilator agent may result in synergistic benefits for the treatment of HFpEF.
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Affiliation(s)
- Kyle B. LaPenna
- Cardiovascular Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLA
- Department of Pharmacology and Experimental TherapeuticsLouisiana State University Health Sciences CenterNew OrleansLA
| | - Zhen Li
- Department of Cardiac SurgerySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCA
| | - Jake E. Doiron
- Cardiovascular Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLA
- Department of Pharmacology and Experimental TherapeuticsLouisiana State University Health Sciences CenterNew OrleansLA
| | - Thomas E. Sharp
- Cardiovascular Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLA
- Department of Medicine, Section of CardiologyLouisiana State University Health Sciences CenterNew OrleansLA
| | - Huijing Xia
- Cardiovascular Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLA
| | - Karl Moles
- Cardiovascular Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLA
| | - Kashyap Koul
- Cardiovascular Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLA
| | - John S. Wang
- Cardiovascular Center of ExcellenceLouisiana State University Health Sciences CenterNew OrleansLA
| | | | - Traci T. Goodchild
- Department of Cardiac SurgerySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCA
| | - Ravi B. Patel
- Division of Cardiology, Department of Medicine and Bluhm Cardiovascular InstituteNorthwestern University Feinberg School of MedicineChicagoIL
| | - Sanjiv J. Shah
- Division of Cardiology, Department of Medicine and Bluhm Cardiovascular InstituteNorthwestern University Feinberg School of MedicineChicagoIL
| | - David J. Lefer
- Department of Cardiac SurgerySmidt Heart Institute, Cedars‐Sinai Medical CenterLos AngelesCA
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Sawicki KT, Nannini DR, Bielinski SJ, Larson NB, Lloyd-Jones DM, Psaty B, Taylor KD, Shah SJ, Rasmussen-Torvik LJ, Wilkins JT, McNally EM, Patel RB. Secretory leukocyte protease inhibitor and risk of heart failure in the Multi-Ethnic Study of Atherosclerosis. Sci Rep 2023; 13:604. [PMID: 36635319 PMCID: PMC9837113 DOI: 10.1038/s41598-023-27679-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/05/2023] [Indexed: 01/14/2023] Open
Abstract
Circulating protease inhibitors are important regulators of inflammation that are implicated in the pathophysiology of heart failure (HF). Secretory leukocyte protease inhibitor (SLPI) is a serine protease inhibitor which protects pulmonary tissues against inflammatory damage; however, its role in HF is not well understood. We sought to evaluate associations of circulating SLPI and genetically-mediated serum SLPI with incident HF and its subtypes in a multi-ethnic cohort of adults using clinical and genetic epidemiological approaches. Among 2,297 participants in the Multi-Ethnic Study of Atherosclerosis (MESA), each doubling of serum SLPI was independently associated with incident HF (HR 1.77; 95% CI 1.02-3.02; P = 0.04), particularly incident HF with preserved ejection fraction (HFpEF; HR 2.44; 95% CI 1.23-4.84; P = 0.01) but not HF with reduced ejection fraction (HFrEF; HR 0.95; 95% CI 0.36-2.46; P = 0.91). Previously reported circulating SLPI protein quantitative trait loci (pQTLs) were not associated with serum SLPI levels or incident HF among MESA participants. In conclusion, baseline serum SLPI levels, but not genetically-determined serum SLPI, were significantly associated with incident HF and HFpEF over long-term follow-up in a multi-ethnic cohort. Serum circulating SLPI may be a correlate of inflammation that sheds insight on the pathobiology of HFpEF.
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Affiliation(s)
- Konrad Teodor Sawicki
- grid.16753.360000 0001 2299 3507Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL USA ,grid.16753.360000 0001 2299 3507Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL USA ,grid.16753.360000 0001 2299 3507Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Drew R. Nannini
- grid.16753.360000 0001 2299 3507Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Suzette J. Bielinski
- grid.66875.3a0000 0004 0459 167XDepartment of Quantitative Health Sciences, Mayo Clinic, 200 First Street Southwest, Rochester, MN USA
| | - Nicholas B. Larson
- grid.66875.3a0000 0004 0459 167XDepartment of Quantitative Health Sciences, Mayo Clinic, 200 First Street Southwest, Rochester, MN USA
| | - Donald M. Lloyd-Jones
- grid.16753.360000 0001 2299 3507Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL USA ,grid.16753.360000 0001 2299 3507Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Bruce Psaty
- grid.34477.330000000122986657Cardiovascular Health Research Unit, Department of Health Systems and Population Health, University of Washington, Seattle, WA USA
| | - Kent D. Taylor
- grid.513199.6Institute for Translational Genomics, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA USA
| | - Sanjiv J. Shah
- grid.16753.360000 0001 2299 3507Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Laura J. Rasmussen-Torvik
- grid.16753.360000 0001 2299 3507Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - John T. Wilkins
- grid.16753.360000 0001 2299 3507Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL USA ,grid.16753.360000 0001 2299 3507Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Elizabeth M. McNally
- grid.16753.360000 0001 2299 3507Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL USA ,grid.16753.360000 0001 2299 3507Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL USA ,grid.16753.360000 0001 2299 3507Department of Biochemistry and Molecular Genetics, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Ravi B. Patel
- grid.16753.360000 0001 2299 3507Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL USA ,grid.16753.360000 0001 2299 3507Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL USA ,grid.16753.360000 0001 2299 3507Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 N St Clair St, Suite 600, Chicago, IL 60611 USA
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Sinha A, Patel RB. Loop diuretic management after sacubitril/valsartan initiation in heart failure with preserved ejection fraction: deceptively simple or more than meets the eye? Eur J Heart Fail 2023; 25:95-97. [PMID: 36445011 PMCID: PMC9892269 DOI: 10.1002/ejhf.2750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 11/25/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Arjun Sinha
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Ravi B. Patel
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL
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24
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Patel RB, Greene SJ, Xu H, Alhanti B, Peterson P, Yancy CW, Piccini J, Fonarow GC, Vaduganathan M. Intersection of atrial fibrillation and heart failure with mildly reduced and preserved ejection fraction in >400 000 participants in the Get With The Guidelines-Heart Failure Registry. Eur J Heart Fail 2023; 25:63-73. [PMID: 36343200 PMCID: PMC10157723 DOI: 10.1002/ejhf.2729] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 10/29/2022] [Accepted: 10/29/2022] [Indexed: 11/09/2022] Open
Abstract
AIMS Although atrial fibrillation (AF) frequently coexists with heart failure with preserved ejection fraction (HFpEF), few data are available evaluating AF-specific care patterns and post-discharge outcomes in patients hospitalized for HFpEF. We evaluated AF-specific medical therapies and post-discharge outcomes among patients hospitalized for heart failure with mildly reduced ejection fraction (HFmrEF) or HFpEF by AF history. METHODS AND RESULTS Trends in AF prevalence were evaluated among patients hospitalized for HFmrEF or HFpEF in the Get With The Guidelines-Heart Failure Registry from 2014 to 2020. Among those with linked Centers for Medicare & Medicaid Services post-discharge data, we assessed associations of AF with 12-month outcomes and determined trends in post-discharge prescriptions. Among 429 464 patients (median age 76 years [interquartile range 65-85], 57% women), 216 486 (50%) had a history of AF. Over time, the proportion of patients with AF increased slightly. Among the 79 895 patients with post-discharge data, AF was independently associated with higher risk of mortality and all-cause readmissions at 12 months, with stronger associations in HFpEF than in HFmrEF (mortality hazard ratio [HR] 1.13, 95% confidence interval [CI] 1.09-1.16 vs. HR 1.03, 95% CI 0.97-1.10; pinteraction = 0.009). Anti-arrhythmic drug use after heart failure hospitalization was low (18%) and increased modestly over time. Amiodarone accounted for 71% of total anti-arrhythmic drug prescriptions. Overall use of anticoagulants after heart failure hospitalization has significantly increased from 52% in 2014 to 61% in 2019, but remained modest. CONCLUSION Prevalence of AF is rising among patients hospitalized with HFpEF. Those with comorbid AF face elevated post-discharge risks of death and rehospitalization. Current use of pharmacological rhythm control is low.
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Affiliation(s)
- Ravi B Patel
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Haolin Xu
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Pamela Peterson
- Department of Medicine, Denver Health Medical Center, Denver, CO, USA
| | - Clyde W Yancy
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jonathan Piccini
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Gregg C Fonarow
- Department of Medicine, Anschutz Medical Center, Aurora, CO, USA
- Ahmanson-University of California, Los Angeles Cardiomyopathy Center, University of California-Los Angeles, Los Angeles, CA, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Salerno KE, Roy S, Ribaudo C, Fisher T, Patel RB, Mena E, Escorcia FE. A Primer on Radiopharmaceutical Therapy. Int J Radiat Oncol Biol Phys 2023; 115:48-59. [PMID: 35970373 PMCID: PMC9772089 DOI: 10.1016/j.ijrobp.2022.08.010] [Citation(s) in RCA: 3] [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] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/25/2022] [Accepted: 08/03/2022] [Indexed: 12/24/2022]
Abstract
The goal of this article is to serve as a primer for the United States-based radiation oncologist who may be interested in learning more about radiopharmaceutical therapy (RPT). Specifically, we define RPT, review the data behind its current and anticipated indications, and discuss important regulatory considerations for incorporating it into clinical practice. RPT represents an opportunity for radiation oncologists to leverage 2 key areas of expertise, namely therapeutic radiation therapy and oncology, and apply them in a distinct context in collaboration with nuclear medicine and medical oncology colleagues. Although not every radiation oncologist will incorporate RPT into their day-to-day practice, it is important to understand the role for this modality and how it can be appropriately used in select patients.
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Affiliation(s)
- Kilian E Salerno
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Soumyajit Roy
- Radiation Oncology Department, Rush Medical Center, Chicago, Illinois
| | - Cathy Ribaudo
- Division of Radiation Safety, National Institutes of Health, Bethesda, Maryland
| | - Teresa Fisher
- Division of Radiation Safety, National Institutes of Health, Bethesda, Maryland
| | - Ravi B Patel
- Radiation Oncology Department, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Esther Mena
- Molecular Imaging Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Freddy E Escorcia
- Radiation Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Molecular Imaging Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
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26
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Carlson PM, Patel RB, Birstler J, Rodriquez M, Sun C, Erbe AK, Bates AM, Marsh I, Grudzinski J, Hernandez R, Pieper AA, Feils AS, Rakhmilevich AL, Weichert JP, Bednarz BP, Sondel PM, Morris ZS. Radiation to all macroscopic sites of tumor permits greater systemic antitumor response to in situ vaccination. J Immunother Cancer 2023; 11:e005463. [PMID: 36639155 PMCID: PMC9843201 DOI: 10.1136/jitc-2022-005463] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The antitumor effects of external beam radiation therapy (EBRT) are mediated, in part, by an immune response. We have reported that a single fraction of 12 Gy EBRT combined with intratumoral anti-GD2 hu14.18-IL2 immunocytokine (IC) generates an effective in situ vaccine (ISV) against GD2-positive murine tumors. This ISV is effective in eradicating single tumors with sustained immune memory; however, it does not generate an adequate abscopal response against macroscopic distant tumors. Given the immune-stimulatory capacity of radiation therapy (RT), we hypothesized that delivering RT to all sites of disease would augment systemic antitumor responses to ISV. METHODS We used a syngeneic B78 murine melanoma model consisting of a 'primary' flank tumor and a contralateral smaller 'secondary' flank tumor, treated with 12 Gy EBRT and intratumoral IC immunotherapy to the primary and additional EBRT to the secondary tumor. As a means of delivering RT to all sites of disease, both known and occult, we also used a novel alkylphosphocholine analog, NM600, conjugated to 90Y as a targeted radionuclide therapy (TRT). Tumor growth, overall survival, and cause of death were measured. Flow cytometry was used to evaluate immune population changes in both tumors. RESULTS Abscopal effects of local ISV were amplified by delivering as little as 2-6 Gy of EBRT to the secondary tumor. When the primary tumor ISV regimen was delivered in mice receiving 12 Gy EBRT to the secondary tumor, we observed improved overall survival and more disease-free mice with immune memory compared with either ISV or 12 Gy EBRT alone. Similarly, TRT combined with ISV resulted in improved overall survival and a trend towards reduced tumor growth rates when compared with either treatment alone. Using flow cytometry, we identified an influx of CD8+ T cells with a less exhausted phenotype in both the ISV-targeted primary and the distant secondary tumor following the combination of secondary tumor EBRT or TRT with primary tumor ISV. CONCLUSIONS We report a novel use for low-dose RT, not as a direct antitumor modality but as an immunomodulator capable of driving and expanding antitumor immunity against metastatic tumor sites following ISV.
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Affiliation(s)
- Peter M Carlson
- Human Oncology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Ravi B Patel
- Radiation Oncology, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Jen Birstler
- Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Matthew Rodriquez
- Human Oncology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Claire Sun
- Human Oncology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Amy K Erbe
- Pediatrics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Amber M Bates
- Human Oncology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Ian Marsh
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Joseph Grudzinski
- Medical Physics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | | | - Alexander A Pieper
- Human Oncology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Arika S Feils
- Human Oncology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Alexander L Rakhmilevich
- Human Oncology, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Pediatrics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Jamey P Weichert
- Radiology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Bryan P Bednarz
- Medical Physics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Paul M Sondel
- Human Oncology, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Pediatrics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Zachary S Morris
- Human Oncology, University of Wisconsin-Madison, Madison, Wisconsin, USA
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27
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Huber MP, Pandit JA, Jensen PN, Wiggins KL, Patel RB, Freed BH, Bertoni AG, Shah SJ, Heckbert SR, Floyd JS. Left Atrial Strain and the Risk of Atrial Arrhythmias From Extended Ambulatory Cardiac Monitoring: MESA. J Am Heart Assoc 2022; 11:e026875. [PMID: 36314499 PMCID: PMC9673638 DOI: 10.1161/jaha.122.026875] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Background Abnormalities in left atrial (LA) function often occur before LA structural changes and clinically identified atrial fibrillation (AF). Little is known about the relationship between LA strain and the risk of subclinical atrial arrhythmias detected from extended ambulatory cardiac monitoring. Methods and Results A total of 1441 participants of MESA (Multi-Ethnic Study of Atherosclerosis) completed speckle-tracking echocardiography and cardiac monitoring during 2016 to 2018 (mean age, 73 years); participants in AF during echocardiography or during the entire cardiac monitoring period were excluded. Absolute values of LA reservoir, booster pump, and conduit strains were measured. We evaluated associations of LA strain with monitor-detected AF, premature atrial contractions, and supraventricular tachycardia. Primary analyses adjusted for demographic variables, blood pressure, diabetes, smoking, and clinical cardiovascular disease. Cardiac monitoring (median, 14 days) detected AF in 3%. Each SD (4.0%) lower (worse) LA booster pump strain was associated with 84% higher risk of monitor-detected AF (95% CI, 30%-162%), 39% higher premature atrial contraction frequency (95% CI, 27%-53%), and 19% higher supraventricular tachycardia frequency (95% CI, 10%-29%). Additional adjustment for NT-proBNP (N-terminal pro-B-type natriuretic peptide), LA volume index, tissue Doppler a' peak velocity, left ventricular ejection fraction, and global longitudinal strain had little impact on associations. Findings were similar for LA reservoir strain and null for LA conduit strain. Conclusions In a multiethnic community-based cohort, impaired LA strain was an important correlate of subclinical atrial arrhythmias, even after adjustment for conventional measures of LA structure and function.
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Affiliation(s)
- Matthew P. Huber
- Division of Cardiology, Department of MedicineUniversity of Washington School of MedicineSeattleWA,Cardiovascular Health Research UnitUniversity of WashingtonSeattleWA
| | - Jay A. Pandit
- Division of Digital MedicineScripps Research and Translational InstituteLa JollaCA
| | - Paul N. Jensen
- Cardiovascular Health Research UnitUniversity of WashingtonSeattleWA,Division of General Internal Medicine, Department of MedicineUniversity of Washington School of MedicineSeattleWA
| | - Kerri L. Wiggins
- Cardiovascular Health Research UnitUniversity of WashingtonSeattleWA,Division of General Internal Medicine, Department of MedicineUniversity of Washington School of MedicineSeattleWA
| | - Ravi B. Patel
- Division of Cardiology, Department of MedicineNorthwestern University Feinberg School of MedicineChicagoIL
| | - Benjamin H. Freed
- Division of Cardiology, Department of MedicineNorthwestern University Feinberg School of MedicineChicagoIL
| | - Alain G. Bertoni
- Division of Public Health SciencesWake Forest University School of MedicineWinston‐SalemNC
| | - Sanjiv J. Shah
- Division of Cardiology, Department of MedicineNorthwestern University Feinberg School of MedicineChicagoIL
| | - Susan R. Heckbert
- Cardiovascular Health Research UnitUniversity of WashingtonSeattleWA,Department of EpidemiologyUniversity of Washington School of Public HealthSeattleWA
| | - James S. Floyd
- Cardiovascular Health Research UnitUniversity of WashingtonSeattleWA,Division of General Internal Medicine, Department of MedicineUniversity of Washington School of MedicineSeattleWA,Department of EpidemiologyUniversity of Washington School of Public HealthSeattleWA
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28
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Bellavia MC, Patel RB, Anderson CJ. Combined Targeted Radiopharmaceutical Therapy and Immune Checkpoint Blockade: From Preclinical Advances to the Clinic. J Nucl Med 2022; 63:1636-1641. [DOI: 10.2967/jnumed.122.264373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 08/13/2022] [Indexed: 11/16/2022] Open
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Bellavia MC, Nyiranshuti L, Latoche JD, Ho KV, Fecek RJ, Taylor JL, Day KE, Nigam S, Pun M, Gallazzi F, Edinger RS, Storkus WJ, Patel RB, Anderson CJ. PET Imaging of VLA-4 in a New BRAF V600E Mouse Model of Melanoma. Mol Imaging Biol 2022; 24:425-433. [PMID: 34694528 PMCID: PMC9183947 DOI: 10.1007/s11307-021-01666-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/28/2021] [Accepted: 10/05/2021] [Indexed: 01/05/2023]
Abstract
PURPOSE Despite unprecedented responses to immune checkpoint inhibitors and targeted therapy in melanoma, a major subset of patients progresses and have few effective salvage options. We have previously demonstrated robust, selective uptake of the peptidomimetic LLP2A labeled with Cu-64 ([64Cu]-LLP2A) for positron emission tomography (PET) imaging in subcutaneous and metastatic models of B16F10 murine melanoma. LLP2A binds with high affinity to very late antigen-4 (VLA-4, integrin α4β1), a transmembrane protein overexpressed in melanoma and other cancers that facilitates tumor growth and metastasis. Yet B16F10 fails to faithfully reflect human melanoma biology, as it lacks certain oncogenic driver mutations, including BRAF mutations found in ≥ 50 % of clinical specimens. Here, we evaluated the PET tracer [64Cu]-CB-TE1A1P-PEG4-LLP2A ([64Cu]-LLP2A) in novel, translational BRAFV600E mutant melanoma models differing in VLA-4 expression-BPR (VLA-4-) and BPRα (VLA-4+). PROCEDURES BPR cells were transduced with α4 (CD49d) to overexpress intact cell surface VLA-4 (BPRα). The binding affinity of [64Cu]-LLP2A to BPR and BPRα cells was determined by saturation binding assays. [64Cu]-LLP2A internalization into B16F10, BPR, and BPRα cells was quantified via a plate-based assay. Tracer biodistribution and PET/CT imaging were evaluated in mice bearing subcutaneous BPR and BPRα tumors. RESULTS [64Cu]-LLP2A demonstrated high binding affinity to BPRα (Kd = 1.4 nM) but indeterminate binding to BPR cells. VLA-4+ BPRα and B16F10 displayed comparable time-dependent [64Cu]-LLP2A internalization, whereas BPR internalization was undetectable. PET/CT showed increased tracer uptake in BPRα tumors vs. BPR tumors in vivo, which was validated by significantly greater (p < 0.0001) BPRα tumor uptake in biodistribution analyses. CONCLUSIONS [64Cu]-LLP2A discriminates BPRα (VLA-4+) vs. BPR (VLA-4-) melanomas in vivo, supporting translation of these BRAF-mutated melanoma models via prospective imaging and theranostic studies. These results extend the utility of LLP2A to selectively target clinically relevant and therapy-resistant tumor variants toward its use for therapeutic patient care.
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Affiliation(s)
- Michael C Bellavia
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Lea Nyiranshuti
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Department of Molecular and Medical Pharmacology, University of California Los Angeles, Los Angeles, CA, 90095, USA
- RayzeBio Inc., San Diego, CA, 92121, USA
| | - Joseph D Latoche
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Khanh-Van Ho
- Department of Chemistry, University of Missouri, Columbia, MO, 65211, USA
| | - Ronald J Fecek
- Department of Dermatology, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Department of Microbiology and Immunology, Lake Erie College of Osteopathic Medicine at Seton Hill, Greensburg, PA, 15601, USA
| | - Jennifer L Taylor
- Department of Dermatology, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Kathryn E Day
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Shubhanchi Nigam
- Department of Radiology, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Eurofins Scientific, Philadelphia, PA, 19355, USA
| | - Michael Pun
- Department of Chemistry, University of Missouri, Columbia, MO, 65211, USA
| | - Fabio Gallazzi
- Department of Chemistry, University of Missouri, Columbia, MO, 65211, USA
| | - Robert S Edinger
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Department of Radiation Oncology, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Walter J Storkus
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Department of Dermatology, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Ravi B Patel
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
- Department of Radiation Oncology, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
| | - Carolyn J Anderson
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
- Department of Chemistry, University of Missouri, Columbia, MO, 65211, USA.
- Department of Radiology, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
- Department of Radiology, University of Missouri, Columbia, MO, 65211, USA.
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Fudim M, Fail PS, Litwin SE, Shaburishvili T, Goyal P, Hummel S, Borlaug BA, Mohan RC, Patel RB, Mitter SS, Klein L, Rocha-Singh K, Patel MR, Reddy VY, Burkhoff D, Shah SJ. Endovascular Ablation of the Right Greater Splanchnic Nerve in Heart Failure with Preserved Ejection Fraction: Early Results of the REBALANCE-HF Trial Roll-in Cohort. Eur J Heart Fail 2022; 24:1410-1414. [PMID: 35598154 PMCID: PMC9388552 DOI: 10.1002/ejhf.2559] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 05/12/2022] [Accepted: 05/15/2022] [Indexed: 11/25/2022] Open
Abstract
Aims In heart failure (HF) with preserved ejection fraction (HFpEF), excessive redistribution of blood volume into the central circulation leads to elevations of intracardiac pressures with exercise limitations. Splanchnic ablation for volume management (SAVM) has been proposed as a therapeutic intervention. Here we present preliminary safety and efficacy data from the initial roll‐in cohort of the REBALANCE‐HF trial. Methods and results The open‐label (roll‐in) arm of REBALANCE‐HF will enrol up to 30 patients, followed by the randomized, sham‐controlled portion of the trial (up to 80 additional patients). Patients with HF, left ventricular ejection fraction (LVEF) ≥50%, and invasive peak exercise pulmonary capillary wedge pressure (PCWP) ≥25 mmHg underwent SAVM. Baseline and follow‐up assessments included resting and exercise PCWP, New York Heart Association (NYHA) class, Kansas City Cardiomyopathy Questionnaire (KCCQ), 6‐min walk test, and N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP). Efficacy and safety were assessed at 1 and 3 months. Here we report on the first 18 patients with HFpEF that have been enrolled into the roll‐in, open‐label arm of the study across nine centres; 14 (78%) female; 16 (89%) in NYHA class III; and median (interquartile range) age 75.2 (68.4–81) years, LVEF 61.0 (56.0–63.2)%, and average (standard deviation) 20 W exercise PCWP 36.4 (±8.6) mmHg. All 18 patients were successfully treated. Three non‐serious moderate device/procedure‐related adverse events were reported. At 1‐month, the mean PCWP at 20 W exercise decreased from 36.4 (±8.6) to 28.9 (±7.8) mmHg (p < 0.01), NYHA class improved by at least one class in 33% of patients (p = 0.02) and KCCQ score improved by 22.1 points (95% confidence interval 9.4–34.2) (p < 0.01). Conclusion The preliminary open‐label results from the multicentre REBALANCE‐HF roll‐in cohort support the safety and efficacy of SAVM in HFpEF. The findings require confirmation in the ongoing randomized, sham‐controlled portion of the trial.
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Affiliation(s)
| | - Peter S Fail
- Cardiovascular Institute of the South, Houma, LA
| | | | | | | | - Scott Hummel
- Michigan School of Medicine, University of Michigan, Ann Arbor, MI
| | | | | | - Ravi B Patel
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sumeet S Mitter
- Mount Sinai Hospital - Icahn School of Medicine at Mount Sinai, New York, NY
| | - Liviu Klein
- University of California San Francisco, San Francisco, CA
| | | | | | - Vivek Y Reddy
- Mount Sinai Hospital - Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL
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Espinal A, Epperly MW, Mukherjee A, Fisher R, Shields D, Wang H, Huq MS, Hamade DF, Vlad AM, Coffman L, Buckanovich R, Yu J, Leibowitz BJ, van Pijkeren JP, Patel RB, Stolz D, Watkins S, Ejaz A, Greenberger JS. Intestinal Radiation Protection and Mitigation by Second-Generation Probiotic Lactobacillus-reuteri Engineered to Deliver Interleukin-22. Int J Mol Sci 2022; 23:5616. [PMID: 35628427 PMCID: PMC9145862 DOI: 10.3390/ijms23105616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/10/2022] [Accepted: 05/12/2022] [Indexed: 12/13/2022] Open
Abstract
(1) Background: The systemic administration of therapeutic agents to the intestine including cytokines, such as Interleukin-22 (IL-22), is compromised by damage to the microvasculature 24 hrs after total body irradiation (TBI). At that time, there is significant death of intestinal microvascular endothelial cells and destruction of the lamina propria, which limits drug delivery through the circulation, thus reducing the capacity of therapeutics to stabilize the numbers of Lgr5+ intestinal crypt stem cells and their progeny, and improve survival. By its direct action on intestinal stem cells and their villus regeneration capacity, IL-22 is both an ionizing irradiation protector and mitigator. (2) Methods: To improve delivery of IL-22 to the irradiated intestine, we gavaged Lactobacillus-reuteri as a platform for the second-generation probiotic Lactobacillus-reuteri-Interleukin-22 (LR-IL-22). (3) Results: There was effective radiation mitigation by gavage of LR-IL-22 at 24 h after intestinal irradiation. Multiple biomarkers of radiation damage to the intestine, immune system and bone marrow were improved by LR-IL-22 compared to the gavage of control LR or intraperitoneal injection of IL-22 protein. (4) Conclusions: Oral administration of LR-IL-22 is an effective protector and mitigator of intestinal irradiation damage.
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Affiliation(s)
- Alexis Espinal
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA 15232, USA; (A.E.); (M.W.E.); (A.M.); (R.F.); shieldsd+@pitt.edu (D.S.); (M.S.H.); (D.F.H.); (R.B.P.)
| | - Michael W. Epperly
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA 15232, USA; (A.E.); (M.W.E.); (A.M.); (R.F.); shieldsd+@pitt.edu (D.S.); (M.S.H.); (D.F.H.); (R.B.P.)
| | - Amitava Mukherjee
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA 15232, USA; (A.E.); (M.W.E.); (A.M.); (R.F.); shieldsd+@pitt.edu (D.S.); (M.S.H.); (D.F.H.); (R.B.P.)
| | - Renee Fisher
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA 15232, USA; (A.E.); (M.W.E.); (A.M.); (R.F.); shieldsd+@pitt.edu (D.S.); (M.S.H.); (D.F.H.); (R.B.P.)
| | - Donna Shields
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA 15232, USA; (A.E.); (M.W.E.); (A.M.); (R.F.); shieldsd+@pitt.edu (D.S.); (M.S.H.); (D.F.H.); (R.B.P.)
| | - Hong Wang
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA 15232, USA;
| | - M. Saiful Huq
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA 15232, USA; (A.E.); (M.W.E.); (A.M.); (R.F.); shieldsd+@pitt.edu (D.S.); (M.S.H.); (D.F.H.); (R.B.P.)
| | - Diala Fatima Hamade
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA 15232, USA; (A.E.); (M.W.E.); (A.M.); (R.F.); shieldsd+@pitt.edu (D.S.); (M.S.H.); (D.F.H.); (R.B.P.)
| | - Anda M. Vlad
- Department of Obstetrics and Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA 15232, USA;
| | - Lan Coffman
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15232, USA; (L.C.); (R.B.)
| | - Ronald Buckanovich
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15232, USA; (L.C.); (R.B.)
| | - Jian Yu
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA 15232, USA; (J.Y.); (B.J.L.)
| | - Brian J. Leibowitz
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA 15232, USA; (J.Y.); (B.J.L.)
| | | | - Ravi B. Patel
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA 15232, USA; (A.E.); (M.W.E.); (A.M.); (R.F.); shieldsd+@pitt.edu (D.S.); (M.S.H.); (D.F.H.); (R.B.P.)
| | - Donna Stolz
- Department of Cell Biology, University of Pittsburgh, Pittsburgh, PA 15232, USA; (D.S.); (S.W.)
| | - Simon Watkins
- Department of Cell Biology, University of Pittsburgh, Pittsburgh, PA 15232, USA; (D.S.); (S.W.)
| | - Asim Ejaz
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, PA 15232, USA;
| | - Joel S. Greenberger
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA 15232, USA; (A.E.); (M.W.E.); (A.M.); (R.F.); shieldsd+@pitt.edu (D.S.); (M.S.H.); (D.F.H.); (R.B.P.)
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Patel RB, Shah SJ. Inclusion Criteria for Heart Failure With Preserved Ejection Fraction Clinical Trials: Making the Case for Precision Diagnosis and Greater Inclusivity. J Card Fail 2022; 28:732-735. [PMID: 35331890 PMCID: PMC9106892 DOI: 10.1016/j.cardfail.2022.03.345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/01/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Ravi B Patel
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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Sinha A, Yancy CW, Patel RB. Tipping the Scale Toward a More Accurate and Equitable Assessment of HFrEF Pharmacotherapy Eligibility: A Call to Incorporate Cystatin C in Estimating Glomerular Filtration Rate. Eur J Heart Fail 2022; 24:867-870. [PMID: 35415943 PMCID: PMC9133180 DOI: 10.1002/ejhf.2505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/10/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Arjun Sinha
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Clyde W Yancy
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Ravi B Patel
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
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Bavishi A, Colangelo LA, Rasmussen-Torvik LJ, Lima JAC, Nannini DR, Vaduganathan M, Pandey A, Lloyd-Jones DM, Shah SJ, Patel RB. Genetic variation in sodium glucose co-transporter 1 and cardiac structure and function at middle age. ESC Heart Fail 2022; 9:1496-1501. [PMID: 35166069 PMCID: PMC8934939 DOI: 10.1002/ehf2.13841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/14/2022] [Accepted: 01/31/2022] [Indexed: 11/12/2022] Open
Abstract
Aims The effects of inhibition of sodium glucose cotransporter (SGLT)‐1, as opposed to SGLT2, on cardiovascular structure and function are not well known. We assessed the associations of a missense genetic variant of SGLT1 with cardiac structure and function. Methods and results We evaluated associations of a functionally modifying variant of SLC5A1 (rs17683011 [p.Asn51Ser]), the gene that encodes SGLT1, with cardiac structure and function on echocardiography among middle‐aged adults in the Coronary Artery Risk Development in Young Adults Study. Of 1904 participants (55.3 ± 3.5 years, 57% female, 34% Black), 166 (13%) White participants and 18 (3%) Black participants had at least one copy of rs17683011. There were no significant differences in age, sex, body mass index, glucose, or diabetes status by the presence of the rs17683011 variant. In Black participants, the presence of at least one copy of the rs17683011 variant was significantly associated with better GLS compared with those without a copy of the variant after covariate adjustment (−15.8 ± 0.7% vs. −14.0 ± 0.1%, P = 0.02). Although the direction of effect was consistent, the association between the presence of at least one copy of rs17683011 and GLS was not statistically significant in White participants (−15.1 ± 0.2% vs. −14.8 ± 0.1%, P = 0.16). There were no significant associations between rs17683011 and other measures of LV structure, systolic function, or diastolic function. Conclusions The rs17683011 variant, a functionally modifying variant of the SGLT1 gene, was associated with higher GLS among middle‐age adults. These exploratory findings require further validation and suggest that SGLT1 inhibition may have beneficial effects upon LV systolic function.
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Affiliation(s)
- Aakash Bavishi
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 N. St Clair St, Suite 600, Chicago, IL, 60611, USA
| | - Laura A Colangelo
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Laura J Rasmussen-Torvik
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joao A C Lima
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Drew R Nannini
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Muthiah Vaduganathan
- Division of Cardiology, Department of Medicine, Brigham and Woman''s Hospital, Boston, MA, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - Donald M Lloyd-Jones
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 N. St Clair St, Suite 600, Chicago, IL, 60611, USA.,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 N. St Clair St, Suite 600, Chicago, IL, 60611, USA
| | - Ravi B Patel
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 N. St Clair St, Suite 600, Chicago, IL, 60611, USA.,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Patel RB, Shah SJ, Inciardi RM. Collagen homeostasis of the left atrium: an emerging treatment target to prevent heart failure? Eur J Heart Fail 2022; 24:332-334. [PMID: 34989102 PMCID: PMC8900253 DOI: 10.1002/ejhf.2422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 01/03/2022] [Indexed: 02/03/2023] Open
Affiliation(s)
- Ravi B. Patel
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sanjiv J. Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Riccardo M. Inciardi
- Division of Cardiology, Civil Hospitals of Brescia; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy,Corresponding author. Civil Hospitals of Brescia; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25123 Brescia, Italy. Tel: +39 3281526343,
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Sempere-Llagostera S, Thekkadath GS, Patel RB, Kolthammer WS, Walmsley IA. Reducing g (2)(0) of a parametric down-conversion source via photon-number resolution with superconducting nanowire detectors. Opt Express 2022; 30:3138-3147. [PMID: 35209439 DOI: 10.1364/oe.450172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/06/2022] [Indexed: 06/14/2023]
Abstract
Multiphoton contributions pose a significant challenge for the realisation of heralded single-photon sources (HSPS) based on nonlinear processes. In this work, we improve the quality of single photons generated in this way by harnessing the photon-number resolving (PNR) capabilities of commercial superconducting nanowire single-photon detectors (SNSPDs). We report a 13 ± 0.4% reduction of g(2)(τ = 0), even with a collection efficiency in the photon source of only 29.6%. Our work demonstrates the first application of the PNR capabilities of SNSPDs and shows improvement in the quality of an HSPS with widely available technology.
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Thekkadath GS, Bell BA, Patel RB, Kim MS, Walmsley IA. Measuring the Joint Spectral Mode of Photon Pairs Using Intensity Interferometry. Phys Rev Lett 2022; 128:023601. [PMID: 35089759 DOI: 10.1103/physrevlett.128.023601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/12/2021] [Accepted: 12/22/2021] [Indexed: 05/14/2023]
Abstract
The ability to manipulate and measure the time-frequency structure of quantum light is useful for information processing and metrology. Measuring this structure is also important when developing quantum light sources with high modal purity that can interfere with other independent sources. Here, we present and experimentally demonstrate a scheme based on intensity interferometry to measure the joint spectral mode of photon pairs produced by spontaneous parametric down-conversion. We observe correlations in the spectral phase of the photons due to chirp in the pump. We show that our scheme can be combined with stimulated emission tomography to quickly measure their mode using bright classical light. Our scheme does not require phase stability, nonlinearities, or spectral shaping and thus is an experimentally simple way of measuring the modal structure of quantum light.
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Affiliation(s)
- G S Thekkadath
- Department of Physics, Imperial College London, Prince Consort Road, London SW7 2AZ, United Kingdom
- National Research Council of Canada, 100 Sussex Drive, Ottawa, K1A 0R6, Canada
| | - B A Bell
- Department of Physics, Imperial College London, Prince Consort Road, London SW7 2AZ, United Kingdom
| | - R B Patel
- Department of Physics, Imperial College London, Prince Consort Road, London SW7 2AZ, United Kingdom
- Clarendon Laboratory, University of Oxford, Parks Road, Oxford, OX1 3PU, United Kingdom
| | - M S Kim
- Department of Physics, Imperial College London, Prince Consort Road, London SW7 2AZ, United Kingdom
| | - I A Walmsley
- Department of Physics, Imperial College London, Prince Consort Road, London SW7 2AZ, United Kingdom
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Min J, Putt ME, Yang W, Bertoni A, Ding J, Lima JA, Allison MA, Barr RG, Al-Naamani N, Patel RB, Beussink-Nelson L, Kawut S, Shah SJ, Freed BH. Association of Pericardial Fat with Cardiac Structure, Function and Mechanics: the Multi-Ethnic Study of Atherosclerosis. J Am Soc Echocardiogr 2022; 35:579-587.e5. [DOI: 10.1016/j.echo.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/18/2021] [Accepted: 01/06/2022] [Indexed: 11/24/2022]
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Pieper AA, Zangl LM, Speigelman DV, Feils AS, Hoefges A, Jagodinsky JC, Felder MA, Tsarovsky NW, Arthur IS, Brown RJ, Birstler J, Le T, Carlson PM, Bates AM, Hank JA, Rakhmilevich AL, Erbe AK, Sondel PM, Patel RB, Morris ZS. Radiation Augments the Local Anti-Tumor Effect of In Situ Vaccine With CpG-Oligodeoxynucleotides and Anti-OX40 in Immunologically Cold Tumor Models. Front Immunol 2021; 12:763888. [PMID: 34868010 PMCID: PMC8634717 DOI: 10.3389/fimmu.2021.763888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/13/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction Combining CpG oligodeoxynucleotides with anti-OX40 agonist antibody (CpG+OX40) is able to generate an effective in situ vaccine in some tumor models, including the A20 lymphoma model. Immunologically "cold" tumors, which are typically less responsive to immunotherapy, are characterized by few tumor infiltrating lymphocytes (TILs), low mutation burden, and limited neoantigen expression. Radiation therapy (RT) can change the tumor microenvironment (TME) of an immunologically "cold" tumor. This study investigated the effect of combining RT with the in situ vaccine CpG+OX40 in immunologically "cold" tumor models. Methods Mice bearing flank tumors (A20 lymphoma, B78 melanoma or 4T1 breast cancer) were treated with combinations of local RT, CpG, and/or OX40, and response to treatment was monitored. Flow cytometry and quantitative polymerase chain reaction (qPCR) experiments were conducted to study differences in the TME, secondary lymphoid organs, and immune activation after treatment. Results An in situ vaccine regimen of CpG+OX40, which was effective in the A20 model, did not significantly improve tumor response or survival in the "cold" B78 and 4T1 models, as tested here. In both models, treatment with RT prior to CpG+OX40 enabled a local response to this in situ vaccine, significantly improving the anti-tumor response and survival compared to RT alone or CpG+OX40 alone. RT increased OX40 expression on tumor infiltrating CD4+ non-regulatory T cells. RT+CpG+OX40 increased the ratio of tumor-infiltrating effector T cells to T regulatory cells and significantly increased CD4+ and CD8+ T cell activation in the tumor draining lymph node (TDLN) and spleen. Conclusion RT significantly improves the local anti-tumor effect of the in situ vaccine CpG+OX40 in immunologically "cold", solid, murine tumor models where RT or CpG+OX40 alone fail to stimulate tumor regression.
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Affiliation(s)
- Alexander A. Pieper
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Luke M. Zangl
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Dan V. Speigelman
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Arika S. Feils
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Anna Hoefges
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Justin C. Jagodinsky
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Mildred A. Felder
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Noah W. Tsarovsky
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Ian S. Arthur
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Ryan J. Brown
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Jen Birstler
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Trang Le
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Peter M. Carlson
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Amber M. Bates
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Jacquelyn A. Hank
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Alexander L. Rakhmilevich
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Amy K. Erbe
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Paul M. Sondel
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Ravi B. Patel
- Department of Radiation Oncology and Bioengineering, University of Pittsburgh Hillman Cancer Center, Pittsburgh, PA, United States
| | - Zachary S. Morris
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
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Patel RB, Hernandez R, Carlson P, Grudzinski J, Bates AM, Jagodinsky JC, Erbe A, Marsh IR, Arthur I, Aluicio-Sarduy E, Sriramaneni RN, Jin WJ, Massey C, Rakhmilevich AL, Vail D, Engle JW, Le T, Kim K, Bednarz B, Sondel PM, Weichert J, Morris ZS. Low-dose targeted radionuclide therapy renders immunologically cold tumors responsive to immune checkpoint blockade. Sci Transl Med 2021; 13:13/602/eabb3631. [PMID: 34261797 DOI: 10.1126/scitranslmed.abb3631] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 02/10/2021] [Accepted: 06/24/2021] [Indexed: 12/12/2022]
Abstract
Molecular and cellular effects of radiotherapy on tumor microenvironment (TME) can help prime and propagate antitumor immunity. We hypothesized that delivering radiation to all tumor sites could augment response to immunotherapies. We tested an approach to enhance response to immune checkpoint inhibitors (ICIs) by using targeted radionuclide therapy (TRT) to deliver radiation semiselectively to tumors. NM600, an alkylphosphocholine analog that preferentially accumulates in most tumor types, chelates a radioisotope and semiselectively delivers it to the TME for therapeutic or diagnostic applications. Using serial 86Y-NM600 positron emission tomography (PET) imaging, we estimated the dosimetry of 90Y-NM600 in immunologically cold syngeneic murine models that do not respond to ICIs alone. We observed strong therapeutic efficacy and reported optimal dose (2.5 to 5 gray) and sequence for 90Y-NM600 in combination with ICIs. After combined treatment, 45 to 66% of mice exhibited complete response and tumor-specific T cell memory, compared to 0% with 90Y-NM600 or ICI alone. This required expression of STING in tumor cells. Combined TRT and ICI activated production of proinflammatory cytokines in the TME, promoted tumor infiltration by and clonal expansion of CD8+ T cells, and reduced metastases. In mice bearing multiple tumors, combining TRT with moderate-dose (12 gray) external beam radiotherapy (EBRT) targeting a single tumor augmented response to ICIs compared to combination of ICIs with either TRT or EBRT alone. The safety of TRT was confirmed in a companion canine study. Low-dose TRT represents a translatable approach to promote response to ICIs for many tumor types, regardless of location.
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Affiliation(s)
- Ravi B Patel
- Department of Radiation Oncology, University of Pittsburgh Hillman Cancer Center, Pittsburgh, PA 15213, USA.
| | - Reinier Hernandez
- Department of Radiology, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Peter Carlson
- Department of Human Oncology, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Joseph Grudzinski
- Department of Radiology, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Amber M Bates
- Department of Human Oncology, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Justin C Jagodinsky
- Department of Human Oncology, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Amy Erbe
- Department of Human Oncology, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Ian R Marsh
- Department of Medical Physics, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Ian Arthur
- Department of Human Oncology, University of Wisconsin-Madison, Madison, WI 53792, USA
| | | | - Raghava N Sriramaneni
- Department of Human Oncology, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Won Jong Jin
- Department of Human Oncology, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Christopher Massey
- Department of Radiology, University of Wisconsin-Madison, Madison, WI 53792, USA
| | | | - David Vail
- Department of Medical Sciences, School of Veterinary Medicine, University of Wisconsin-Madison, Madison, WI 53792, USA.,Barbara A. Suran Comparative Oncology Institute, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Johnathan W Engle
- Department of Radiology, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Trang Le
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - KyungMann Kim
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Bryan Bednarz
- Department of Radiology, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Paul M Sondel
- Department of Human Oncology, University of Wisconsin-Madison, Madison, WI 53792, USA.,Department of Pediatrics, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Jamey Weichert
- Department of Radiology, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Zachary S Morris
- Department of Human Oncology, University of Wisconsin-Madison, Madison, WI 53792, USA.
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Patel RB, Freed BH, Beussink-Nelson L, Allen NB, Konety SH, Post WS, Yeboah J, Kitzman DW, Bertoni AG, Shah SJ. Associations of Cardiac Mechanics With Exercise Capacity: The Multi-Ethnic Study of Atherosclerosis. J Am Coll Cardiol 2021; 78:245-257. [PMID: 33992746 PMCID: PMC8299435 DOI: 10.1016/j.jacc.2021.04.082] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/15/2021] [Accepted: 04/30/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Lower exercise capacity, as measured by 6-minute walk distance (6MWD), is associated with incident heart failure (HF). Among those without HF, the associations of measures of cardiac function with 6MWD are unclear, and may provide insight regarding the risk of incident HF. OBJECTIVES The purpose of this study was to understand the relationships between cardiac function and exercise capacity. METHODS This study evaluated the associations of cardiac mechanics with 6MWD in the sixth examination of the Multi-Ethnic Study of Atherosclerosis. Echocardiography (2-dimensional, Doppler, and speckle-tracking) was performed at rest and after passive leg raise to evaluate functional reserve after intravascular volume challenge. RESULTS Of 2,096 participants without HF (mean age 73 years, 48% men, 58% non-White), individuals with lower (worse) left atrial (LA) reservoir strain were older and had higher blood pressure. Lower resting LA reservoir strain (β coefficient per SD decrease: -5.0; 95% confidence interval [CI]: -8.8 to -1.3 m; p = 0.009), inability to augment LA reservoir strain after passive leg raise (β coefficient per SD decrease: -5.8; 95% CI: -9.1 to -2.5 m; p < 0.001), and lower right atrial reservoir strain (β coefficient per SD decrease: -4.4; 95% CI: -7.8 to -1.1 m; p = 0.01) were associated with shorter 6MWD. Worse left ventricular (LV) diastolic function was also associated with lower 6MWD. There were no independent associations of measures of LV systolic function (global longitudinal strain, circumferential strain, ejection fraction) with 6MWD. CONCLUSIONS Among individuals without HF, worse biatrial function, lack of LA functional reserve, and worse LV diastolic function were associated with reduced submaximal exercise capacity. Therapies aimed to improve these functional domains may increase exercise capacity and prevent HF.
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Affiliation(s)
- Ravi B Patel
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA. https://twitter.com/RBPatelMD
| | - Benjamin H Freed
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lauren Beussink-Nelson
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Norrina B Allen
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Suma H Konety
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Wendy S Post
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Joseph Yeboah
- Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Dalane W Kitzman
- Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Alain G Bertoni
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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Patel RB, Shah SJ. The splanchnic reservoir: an oasis for blood volume in heart failure with preserved ejection fraction? Eur J Heart Fail 2021; 23:1144-1146. [PMID: 34118181 DOI: 10.1002/ejhf.2268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 06/10/2021] [Indexed: 11/09/2022] Open
Affiliation(s)
- Ravi B Patel
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sanjiv J Shah
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Carlson PM, Mohan M, Patel RB, Birstler J, Nettenstrom L, Sheerar D, Fox K, Rodriguez M, Hoefges A, Hernandez R, Zahm C, Kim K, McNeel DG, Weichert J, Morris ZS, Sondel PM. Optimizing Flow Cytometric Analysis of Immune Cells in Samples Requiring Cryopreservation from Tumor-Bearing Mice. J Immunol 2021; 207:720-734. [PMID: 34261667 DOI: 10.4049/jimmunol.2000656] [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] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 05/17/2021] [Indexed: 11/19/2022]
Abstract
Most shared resource flow cytometry facilities do not permit analysis of radioactive samples. We are investigating low-dose molecular targeted radionuclide therapy (MTRT) as an immunomodulator in combination with in situ tumor vaccines and need to analyze radioactive samples from MTRT-treated mice using flow cytometry. Further, the sudden shutdown of core facilities in response to the COVID-19 pandemic has created an unprecedented work stoppage. In these and other research settings, a robust and reliable means of cryopreservation of immune samples is required. We evaluated different fixation and cryopreservation protocols of disaggregated tumor cells with the aim of identifying a protocol for subsequent flow cytometry of the thawed sample, which most accurately reflects the flow cytometric analysis of the tumor immune microenvironment of a freshly disaggregated and analyzed sample. Cohorts of C57BL/6 mice bearing B78 melanoma tumors were evaluated using dual lymphoid and myeloid immunophenotyping panels involving fixation and cryopreservation at three distinct points during the workflow. Results demonstrate that freezing samples after all staining and fixation are completed most accurately matches the results from noncryopreserved equivalent samples. We observed that cryopreservation of living, unfixed cells introduces a nonuniform alteration to PD1 expression. We confirm the utility of our cryopreservation protocol by comparing tumors treated with in situ tumor vaccines, analyzing both fresh and cryopreserved tumor samples with similar results. Last, we use this cryopreservation protocol with radioactive specimens to demonstrate potentially beneficial effector cell changes to the tumor immune microenvironment following administration of a novel MTRT in a dose- and time-dependent manner.
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Affiliation(s)
- Peter M Carlson
- Department of Human Oncology, Wisconsin Institutes for Medical Research, Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI.,Cellular and Molecular Biology Graduate Program, Bock Laboratories, University of Wisconsin-Madison, Madison, WI.,Medical Scientist Training Program, Health Sciences Learning Center, University of Wisconsin-Madison, Madison, WI
| | - Manasi Mohan
- Department of Human Oncology, Wisconsin Institutes for Medical Research, Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI
| | - Ravi B Patel
- Department of Radiation Oncology, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, PA
| | - Jen Birstler
- Department of Biostatistics and Medical Informatics, Wisconsin Alumni Research Foundation, Madison, WI
| | - Lauren Nettenstrom
- Flow Cytometry Laboratory, Wisconsin Institutes for Medical Research, Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI
| | - Dagna Sheerar
- Flow Cytometry Laboratory, Wisconsin Institutes for Medical Research, Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI
| | - Kathryn Fox
- Flow Cytometry Laboratory, Wisconsin Institutes for Medical Research, Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI
| | - Matthew Rodriguez
- Department of Human Oncology, Wisconsin Institutes for Medical Research, Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI
| | - Anna Hoefges
- Department of Human Oncology, Wisconsin Institutes for Medical Research, Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI.,Cellular and Molecular Pathology Graduate Program, University of Wisconsin-Madison, Madison, WI
| | - Reinier Hernandez
- Department of Radiology, Wisconsin Institutes for Medical Research, Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI
| | - Chris Zahm
- Department of Medicine, Wisconsin Institutes for Medical Research, Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI
| | - KyungMann Kim
- Department of Biostatistics and Medical Informatics, Wisconsin Alumni Research Foundation, Madison, WI
| | - Douglas G McNeel
- Department of Medicine, Wisconsin Institutes for Medical Research, Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI
| | - Jamey Weichert
- Department of Radiology, Wisconsin Institutes for Medical Research, Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI.,Department of Medical Physics, Wisconsin Institutes for Medical Research, Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI; and
| | - Zachary S Morris
- Department of Human Oncology, Wisconsin Institutes for Medical Research, Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI
| | - Paul M Sondel
- Department of Human Oncology, Wisconsin Institutes for Medical Research, Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI; .,Department of Pediatrics, Wisconsin Institutes for Medical Research, Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI
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Sumiec EG, Bates AM, Hernandez R, Grudzinski JJ, Marsh IR, Emma SE, Nystuen EJ, Jagodinsky JC, Pieper AA, Sosa GA, Bednarz BP, Patel RB, Weichert J, Morris ZS. Abstract 679: In vivo synergy of 90Y-NM600 and Bempegaldesleukin improves anti-tumor efficacy of immune checkpoint inhibitors in syngeneic murine cancer models. Cancer Res 2021. [DOI: 10.1158/1538-7445.am2021-679] [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
We have observed in preclinical studies that the delivery of low dose targeted radionuclide therapy (TRT) therapy to sites of primary and metastatic cancer can improve the anti-tumor immune response to immune checkpoint inhibition (ICI) with anti-CTLA4 or anti-PDL1. NM600, an alkylphosphocholine that can be radiolabeled with 90Y, is taken up and retained in most cancer cells following intravenous injection. Bempegaldesleukin (BEMPEG) is a first in class, CD122-preferential IL2 pathway agonist that can selectively stimulate an immune response. We hypothesized that combining low dose TRT with BEMPEG would increase immune activation to enhance the response to ICIs in immunologically “cold” murine cancer models. C57Bl/6 female mice were subcutaneously engrafted in the flank with the murine head and neck squamous cell carcinoma (HNSCC) cell line, MOC2. In vivo dosimetry performed using the Monte Carlo based RAPID platform following serial 86Y-NM600 PET/CT imaging demonstrated that 100 µCi of 90Y-NM600 would deliver ~8 Gy to the MOC2 tumor. Mice bearing MOC2 tumors (mean volume ~100 mm3) received combinations of 90Y-NM600 (100 µCi, day 1 IV), BEMPEG (16 µg, days 6, 15, and 24 IV), and anti-CTLA4 (200 µg, days 4, 7, and 10 IP) using a 2x2x2 study design. Tumor growth and survival were monitored. Blood was collected weekly and analyzed on the Abaxis VetScan HM5 to evaluate for toxicity. In a parallel 2x2x2 survival study, an orthotopic model generated by engrafting MOC2 tumors in the cheek was used, and mice were treated with combinations of BEMPEG, 90Y-NM600, and anti-PDL1 (200 µg, days 4, 7, and 10, IP). Mice were euthanized when >25% weight loss was observed. Similar experiments using 90Y-NM600 and BEMPEG were performed in additional syngeneic mouse cancer models including SCC7 (HNSCC), 4T1 (breast), LLC (lung), and Panc02 (pancreatic). In the immunologically “cold” MOC2 HNSCC model, 62.5% of mice treated with 90Y-NM600 (TRT), BEMPEG, and anti-CTLA4; and 44.4% of mice treated with 90Y-NM600, BEMPEG, and anti-PDL1 experienced complete tumor response with no observable primary or metastatic disease at day 60. In mice treated with 90Y-NM600 and BEMPEG, tumor regression followed by escape was seen without ICI. By day 60, no mice receiving single or dual treatment combinations exhibited a complete tumor response. Comprehensive whole blood analysis did not show any major hematologic toxicities. This treatment was explored in mice bearing SCC7, 4T1, Panc02, and LLC tumors, and similar trends were seen. Combination of 90Y-NM600, BEMPEG, and ICI displays robust anti-tumor activity that prevents metastatic disease progression and prolongs survival in spontaneously metastatic, immunologically “cold” tumor models. Clinical studies are warranted to test the safety and efficacy of this promising combined modality treatment regimen.
Citation Format: Elizabeth G. Sumiec, Amber M. Bates, Reinier Hernandez, Joseph J. Grudzinski, Ian R. Marsh, Sarah E. Emma, Erin J. Nystuen, Justin C. Jagodinsky, Alexander A. Pieper, Gustavo A. Sosa, Bryan P. Bednarz, Ravi B. Patel, Jamey Weichert, Zachary S. Morris. In vivo synergy of 90Y-NM600 and Bempegaldesleukin improves anti-tumor efficacy of immune checkpoint inhibitors in syngeneic murine cancer models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 679.
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Affiliation(s)
| | - Amber M. Bates
- 1University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Reinier Hernandez
- 1University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Ian R. Marsh
- 1University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Sarah E. Emma
- 1University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Erin J. Nystuen
- 1University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | - Gustavo A. Sosa
- 1University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Bryan P. Bednarz
- 1University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ravi B. Patel
- 2University of Pittsburgh Hillman Cancer Center, Pittsburgh, PA
| | - Jamey Weichert
- 1University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Zachary S. Morris
- 1University of Wisconsin School of Medicine and Public Health, Madison, WI
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Jagodinsky JC, Bates AM, Hernandez R, Grudzinski JJ, Marsh IR, Chakravarty I, Arthur IS, Zangl LM, Brown RJ, Nystuen EJ, Emma SE, Kerr C, Jin WJ, Carlson PM, Engle JW, Aluicio-Sarduy E, Barnhart TE, Le T, Kim K, Bednarz BP, Weichert JP, Patel RB, Morris ZS. Abstract 3060: Temporal analysis of type 1 interferon activation in tumor cells following external beam radiotherapy or targeted radionuclide therapy. Cancer Res 2021. [DOI: 10.1158/1538-7445.am2021-3060] [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: Radiation (RT) activates a type 1 interferon (IFN1) response and this is critical to the effect of RT in priming a response to immune checkpoint blockade (ie anti-CTLA4). However, little is known about the time course of this effect. Clinical interest in utilizing systemically administered targeted radionuclide therapy agents (TRT) is growing as these agents can be used to target multiple sites of disease including micro-metastases. It is unclear how IFN1 activation induced by continuous delivery of RT during exponential decay of a TRT source will compare to that induced following instantaneous external beam RT (EBRT). Here we report the time course of IFN1 response following RT in vitro and in vivo.
Methods: For in vitro studies, we utilized murine models of melanoma (B16, B16 STING knockout, B78), and head and neck squamous cell carcinoma (MOC2). EBRT was prescribed to 2.5 Gy, 12 Gy, or 3 fractions of 8 Gy. For in vivo studies, syngeneic C57BL/6 mice were engrafted with either B78 or MOC2 cells on the flank and RT was delivered when mean tumor size was 100-150 mm3. EBRT was prescribed to 2.5 Gy or 12 Gy. For TRT, we used 90Y conjugated to NM600, an alkylphosphocholine analog that exhibits selective uptake and retention in tumor cells of nearly any type, including B78 and MOC2. Tumor-specific dosimetry for 90Y-NM600 was determined using sequential 86Y-NM600 PET/CT imaging (3h, 24h, 48h, 72h) and a Monte Carlo based dose calculation platform. TRT was prescribed to a cumulative absorbed dose of 2.5 Gy or 12 Gy. Following delivery of RT, cells or tumors were harvested at 1d, 7d, and 14d post RT and RNA was isolated. Gene expression of Ifn-β and IFN response elements was quantified by qPCR and normalized to untreated controls.
Results: We observed significant IFN1 activation in all cell lines, with peak activation in B78, B16, and MOC2 cell lines occurring 7, 7, and 1 days, respectively, following RT for all doses. This effect was STING-dependent. Select IFN response genes remained upregulated at 14 days following RT. IFN1 activation following STING agonist treatment in vitro was identical to RT suggesting time course differences between cell lines were mediated by STING pathway kinetics and not DNA damage susceptibility. In vivo delivery of EBRT and TRT to B78 and MOC2 tumors resulted in a comparable time course and magnitude of IFN1 activation. In the MOC2 model, the combination of 90Y-NM600 and anti-CTLA-4 therapy reduced tumor growth and prolonged survival compared to single agent therapy.
Conclusions: We report the time course of the STING-dependent IFN1 response following RT in multiple murine tumor models. We show the potential of TRT to stimulate IFN1 activation that is comparable to that observed with EBRT of equivalent cumulative dose. Further evaluation of the timing and magnitude of IFN1 response following EBRT and TRT may be critical to the optimal integration with immunotherapies.
Citation Format: Justin C. Jagodinsky, Amber M. Bates, Reinier Hernandez, Joseph J. Grudzinski, Ian R. Marsh, Ishan Chakravarty, Ian S. Arthur, Luke M. Zangl, Ryan J. Brown, Erin J. Nystuen, Sarah E. Emma, Caroline Kerr, Won Jong Jin, Peter M. Carlson, Jonathan W. Engle, Eduardo Aluicio-Sarduy, Todd E. Barnhart, Trang Le, KyungMann Kim, Bryan P. Bednarz, Jamey P. Weichert, Ravi B. Patel, Zachary S. Morris. Temporal analysis of type 1 interferon activation in tumor cells following external beam radiotherapy or targeted radionuclide therapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 3060.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Trang Le
- 1University of Wisconsin-Madison, Madison, WI
| | | | | | | | - Ravi B. Patel
- 2University of Pittsburgh School Hillman Cancer Center, Pittsburgh, PA
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Emma SE, Bates AM, Hernandez R, Grudzinski JJ, Marsh IR, Jagodinsky JC, Bednarz BP, Pieper AA, Sumiec EG, Nystuen EJ, Sosa GA, Patel RB, Weichert J, Morris ZS. Abstract 508: Mechanisms of cooperative response to bempegaldesleukin (BEMPEG) and 90Y-NM600 targeted radionuclide therapy in the treatment of a syngeneic murine model of head and neck squamous cell carcinoma. Cancer Res 2021. [DOI: 10.1158/1538-7445.am2021-508] [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
The purpose of this study was to evaluate mechanisms of cooperative therapeutic effects of bempegaldesleukin (BEMPEG; NKTR-214) and 90Y-NM600 in head and neck squamous cell carcinoma (HNSCC). BEMPEG is a first in class, CD122-preferential interleukin-2 (IL2) pathway agonist tailored to stimulate antitumor immunity through promoting activation and proliferation of CD8+ T and NK cells. We have observed that targeted radionuclide therapy (TRT) delivered at low doses to sites of metastatic cancer can enhance immune susceptibility in immunologically “cold” tumors such as the MOC2 syngeneic mouse HNSCC model. NM600 is an alkylphosphocholine analog that is selectively sequestered and retained by most human and murine cancer cells. We hypothesized that combining BEMPEG and 90Y-NM600 would cooperate to increase immunosusceptibility and immune cell tumor infiltration and create an overall more favorable immune microenvironment in MOC2 HNSCC tumors. MOC2 tumors were engrafted in the flank of C57BL/6 female mice. Once tumors reached ~100 mm³, mice were randomized into one of eight groups for a survival study utilizing varying combinations of BEMPEG (16 µg, days 6, 15, 24 IV), 90Y-NM600 (100 µCi, day 1 IV), and anti-CTLA4 (200 µg, days 4, 7, 10 IP). In vivo dosimetry was performed prior to day 1 using the Monte Carlo based RAPID platform. Serial 86Y-NM600 PET/CT imaging indicated the dose delivered to the tumor was ~8 Gy. Cohorts of mice in a parallel study were treated with PBS (control), BEMPEG, 90Y-NM600, or BEMPEG and 90Y-NM600. Flow cytometry, qPCR analysis, multiplex cytokine analyses were used to evaluate tumors collected at day 14. In this immunologically “cold” murine HNSCC model, a complete tumor response was observed in 62.5% of mice treated with the triple combination therapy of BEMPEG, 90Y-NM600, and anti-CTLA4. Compared to single therapy groups, mice treated with BEMPEG and 90Y-NM600 had increased CD8+ T cell tumor infiltrate, and 90Y-NM600 induced increased expression of the IL2βγ receptor, CD122, on the surface of CD8 T cells. Tumors from mice treated with BEMPEG and 90Y-NM600 had increased expression of genes associated with tumor cell immune susceptibility (Pdl1, Mhc1, Fas), a type 1 interferon response (Mx1, Trex1, Oas2, Oas3), tumor immune cell recruitment (MIP1α , Tnfα, Mac1, Csf1, Cxcl11) activation of cytotoxic T lymphocytes (Ifny, Cxcl10), and production of immune stimulatory cytokines (IFNy, IL3, IL4, IL5, IL17, RANTES, TNFα, MIP1β, MIP1α, CXCL10, CXCL9). These results suggest a synergistic interaction between BEMPEG and 90Y-NM600 that improves the immune microenvironment in this difficult to treat murine model of HNSCC, which may thereby enhance the response to immune checkpoint blockade. Further studies are warranted to examine the therapeutic implications of this combination in patients.
Citation Format: Sarah E. Emma, Amber M. Bates, Reinier Hernandez, Joseph J. Grudzinski, Ian R. Marsh, Justin C. Jagodinsky, Bryan P. Bednarz, Alexander A. Pieper, Elizabeth G. Sumiec, Erin J. Nystuen, Gustavo A. Sosa, Ravi B. Patel, Jamey Weichert, Zachary S. Morris. Mechanisms of cooperative response to bempegaldesleukin (BEMPEG) and 90Y-NM600 targeted radionuclide therapy in the treatment of a syngeneic murine model of head and neck squamous cell carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 508.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Ravi B. Patel
- 2University of Pittsburgh Hillman Cancer Center, Pittsburgh, PA
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Pieper AA, Rakhmilevich AL, Spiegelman DV, Patel RB, Birstler J, Jin WJ, Carlson PM, Charych DH, Hank JA, Erbe AK, Overwijk WW, Morris ZS, Sondel PM. Combination of radiation therapy, bempegaldesleukin, and checkpoint blockade eradicates advanced solid tumors and metastases in mice. J Immunother Cancer 2021; 9:jitc-2021-002715. [PMID: 34172518 PMCID: PMC8237721 DOI: 10.1136/jitc-2021-002715] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2021] [Indexed: 01/11/2023] Open
Abstract
Background Current clinical trials are using radiation therapy (RT) to enhance an antitumor response elicited by high-dose interleukin (IL)-2 therapy or immune checkpoint blockade (ICB). Bempegaldesleukin (BEMPEG) is an investigational CD122-preferential IL-2 pathway agonist with prolonged in vivo half-life and preferential intratumoral expansion of T effector cells over T regulatory cells. BEMPEG has shown encouraging safety and efficacy in clinical trials when used in combination with PD-1 checkpoint blockade. In this study, we investigated the antitumor effect of local RT combined with BEMPEG in multiple immunologically ‘cold’ tumor models. Additionally, we asked if ICB could further enhance the local and distant antitumor effect of RT+BEMPEG in the setting of advanced solid tumors or metastatic disease. Methods Mice bearing flank tumors (B78 melanoma, 4T1 breast cancer, or MOC2 head and neck squamous cell carcinoma) were treated with combinations of RT and immunotherapy (including BEMPEG, high-dose IL-2, anti(α)-CTLA-4, and α-PD-L1). Mice bearing B78 flank tumors were injected intravenously with B16 melanoma cells to mimic metastatic disease and were subsequently treated with RT and/or immunotherapy. Tumor growth and survival were monitored. Peripheral T cells and tumor-infiltrating lymphocytes were assessed via flow cytometry. Results A cooperative antitumor effect was observed in all models when RT was combined with BEMPEG, and RT increased IL-2 receptor expression on peripheral T cells. This cooperative interaction was associated with increased IL-2 receptor expression on peripheral T cells following RT. In the B78 melanoma model, RT+BEMPEG resulted in complete tumor regression in the majority of mice with a single ~400 mm3 tumor. This antitumor response was T-cell dependent and supported by long-lasting immune memory. Adding ICB to RT+BEMPEG strengthened the antitumor response and cured the majority of mice with a single ~1000 mm3 B78 tumor. In models with disseminated metastasis (B78 primary with B16 metastasis, 4T1, and MOC2), the triple combination of RT, BEMPEG, and ICB significantly improved primary tumor response and survival. Conclusion The combination of local RT, BEMPEG, and ICB cured mice with advanced, immunologically cold tumors and distant metastasis in a T cell-dependent manner, suggesting this triple combination warrants clinical testing.
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Affiliation(s)
- Alexander A Pieper
- Department of Human Oncology, University of Wisconsin Madison, Madison, Wisconsin, USA
| | | | - Daniel V Spiegelman
- Department of Human Oncology, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Ravi B Patel
- Department of Radiation Oncology, University of Pittsburgh Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - Jen Birstler
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Won Jong Jin
- Department of Human Oncology, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Peter M Carlson
- Department of Human Oncology, University of Wisconsin Madison, Madison, Wisconsin, USA
| | | | - Jacquelyn A Hank
- Department of Human Oncology, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Amy K Erbe
- Department of Human Oncology, University of Wisconsin Madison, Madison, Wisconsin, USA
| | | | - Zachary S Morris
- Department of Human Oncology, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Paul M Sondel
- Department of Human Oncology, University of Wisconsin Madison, Madison, Wisconsin, USA .,Department of Pediatrics, University of Wisconsin Madison, Madison, Wisconsin, USA
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Thekkadath GS, Sempere-Llagostera S, Bell BA, Patel RB, Kim MS, Walmsley IA. Single-shot discrimination of coherent states beyond the standard quantum limit. Opt Lett 2021; 46:2565-2568. [PMID: 34061057 DOI: 10.1364/ol.421646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/13/2021] [Indexed: 06/12/2023]
Abstract
The discrimination of coherent states is a key task in optical communication and quantum key distribution protocols. In this work, we use a photon-number-resolving detector, the transition-edge sensor, to discriminate binary-phase-shifted coherent states at a telecom wavelength. Owing to its dynamic range and high efficiency, we achieve a bit error probability that unconditionally exceeds the standard quantum limit (SQL) by up to 7.7 dB. The improvement to the SQL persists for signals containing up to approximately seven photons on average and is achieved in a single shot (i.e., without measurement feedback), thus making our approach compatible with larger bandwidths.
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Baman JR, Cox JL, McCarthy PM, Kim D, Patel RB, Passman RS, Wilcox JE. Atrial fibrillation and atrial cardiomyopathies. J Cardiovasc Electrophysiol 2021; 32:2845-2853. [PMID: 33993617 DOI: 10.1111/jce.15083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/13/2021] [Accepted: 05/03/2021] [Indexed: 12/12/2022]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia among adults. While there have been incredible advances in the management of AF and its clinical sequelae, investigation of atrial cardiomyopathies (ACMs) is becoming increasingly more prominent. ACM refers to the electromechanical changes-appreciated subclinically and/or clinically-that underlie atrial dysfunction and create an environment ripe for the development of clinically apparent AF. There are several subtypes of ACM, distinguished by histologic features. Recent progress in cardiovascular imaging, including echocardiography with speckle-tracking (e.g., strain analysis), cardiovascular magnetic resonance imaging (CMR), and atrial 4-D flow CMR, has enabled increased recognition of ACM. Identification of ACM and its features carry clinical implications, including elevating a patient's risk for development of AF, as well as associations with outcomes related to catheter-based and surgical AF ablation. In this review, we explore the definition and classifications of ACM, its complex relationship with clinical AF, imaging modalities, and clinical implications. We propose next steps for a more unified approach to ACM recognition that can direct further research into this complex field.
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Affiliation(s)
- Jayson R Baman
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - James L Cox
- Department of Cardiac Surgery, Bluhm Cardiovascular Institute of Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Patrick M McCarthy
- Department of Cardiac Surgery, Bluhm Cardiovascular Institute of Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Daniel Kim
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ravi B Patel
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rod S Passman
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Center for Arrhythmia Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jane E Wilcox
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Patel RB, Fonarow GC, Greene SJ, Zhang S, Alhanti B, DeVore AD, Butler J, Heidenreich PA, Huang JC, Kittleson MM, Joynt Maddox KE, McDermott JJ, Owens AT, Peterson PN, Solomon SD, Vardeny O, Yancy CW, Vaduganathan M. Kidney Function and Outcomes in Patients Hospitalized With Heart Failure. J Am Coll Cardiol 2021; 78:330-343. [PMID: 33989713 DOI: 10.1016/j.jacc.2021.05.002] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 04/28/2021] [Accepted: 05/03/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Few contemporary data exist evaluating care patterns and outcomes in heart failure (HF) across the spectrum of kidney function. OBJECTIVES This study sought to characterize differences in quality of care and outcomes in patients hospitalized for HF by degree of kidney dysfunction. METHODS Guideline-directed medical therapies were evaluated among patients hospitalized with HF at 418 sites in the GWTG-HF (Get With The Guidelines-Heart Failure) registry from 2014 to 2019 by discharge CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration)-derived estimated glomerular filtration rate (eGFR). We additionally evaluated the risk-adjusted association of admission eGFR with in-hospital mortality. RESULTS Among 365,494 hospitalizations (age 72 ± 15 years, left ventricular ejection fraction [EF]: 43 ± 17%), median discharge eGFR was 51 ml/min/1.73 m2 (interquartile range: 34 to 72 ml/min/1.73 m2), 234,332 (64%) had eGFR <60 ml/min/1.73 m2, and 18,869 (5%) were on dialysis. eGFR distribution remained stable from 2014 to 2019. Among 157,439 patients with HF with reduced EF (≤40%), discharge guideline-directed medical therapies, including beta-blockers, were lowest in discharge eGFR <30 mL/min/1.73 m2 or dialysis (p < 0.001). "Triple therapy" with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor + beta-blocker + mineralocorticoid receptor antagonist was used in 38%, 33%, 25%, 15%, 5%, and 3% for eGFR ≥90, 60 to 89, 45 to 59, 30 to 44, <30 ml/min/1.73 m2, and dialysis, respectively; p < 0.001. Mortality was higher in a graded fashion at lower admission eGFR groups (1.1%, 1.5%, 2.0%, 3.0%, 5.0%, and 4.2%, respectively; p < 0.001). Steep covariate-adjusted associations between admission eGFR and mortality were observed across EF subgroups, but was slightly stronger for HF with reduced EF compared with HF with mid-range or preserved EF (pinteraction = 0.045). CONCLUSIONS Despite facing elevated risks of mortality, patients with comorbid HF with reduced EF and kidney disease are not optimally treated with evidence-based medical therapies, even at levels of eGFR where such therapies would not be contraindicated by kidney dysfunction. Further efforts are required to mitigate risk in comorbid HF and kidney disease.
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Affiliation(s)
- Ravi B Patel
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA. https://twitter.com/RBPatelMD
| | - Gregg C Fonarow
- Ahmanson-University of California, Los Angeles Cardiomyopathy Center, University of California-Los Angeles, Los Angeles, California, USA.
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA. https://twitter.com/SJGreene_md
| | - Shuaiqi Zhang
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Brooke Alhanti
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Adam D DeVore
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA. https://twitter.com/_adevore
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA. https://twitter.com/JavedButler1
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | | | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai, Los Angeles, California, USA. https://twitter.com/MKIttlesonMD
| | - Karen E Joynt Maddox
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri, USA. https://twitter.com/kejoynt
| | | | - Anjali Tiku Owens
- Heart and Vascular Center, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA. https://twitter.com/tikuowens
| | - Pamela N Peterson
- Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA; Department of Medicine, Anschutz Medical Center, Aurora, Colorado, USA
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/scottdsolomon
| | - Orly Vardeny
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, University of Minnesota, Minnesota, USA. https://twitter.com/orlyvardeny
| | - Clyde W Yancy
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/mvaduganathan
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