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Ryan PC, Santis A, Vanderkloot E, Bhatti M, Caddle S, Ellis M, Grimes A, Silverman S, Soderstrom E, Stone C, Takoudes A, Tulay P, Wright S. The potential for carbon dioxide removal by enhanced rock weathering in the tropics: An evaluation of Costa Rica. Sci Total Environ 2024; 927:172053. [PMID: 38556010 DOI: 10.1016/j.scitotenv.2024.172053] [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: 08/24/2023] [Revised: 03/20/2024] [Accepted: 03/26/2024] [Indexed: 04/02/2024]
Abstract
Tropical environments show great potential to sequester CO2 by enhanced rock weathering (ERW) of powdered mafic rocks applied to agricultural fields. This study seeks to assess carbon dioxide reduction (CDR) potential in the humid tropics (1) by experimental weathering of mafic rock powders in conditions simulating humid tropical soils, and (2) from weathering rates determined from a Holocene tropical soil chronosequence where parent material is andesitic sediments. Experimentally determined weathering rates by leaching of basaltic andesites from Costa Rica (Arenal and Barva) for 50 t ha-1 applications indicate potential sequestration of 2.4 to 4.5 t CO2 ha-1 yr-1, whereas the USGS basalt standard BHVO-1 yields a rate of 11.9 t ha-1 yr-1 (influenced by more mafic composition and finer particle size). The chronosequence indicates a rate of 1.7 t CO2 ha-1 yr-1. The weathering experiment consisted of 0.6 mm of powdered rock applied atop 12 mm of Ultisol at 35 °C. To simulate a tropical soil solution, 100-mL aliquots of a dilute solution of oxalic acid in carbonated DI water were rained onto soils over a 14-day period to simulate soil moisture in the humid tropics. Solutions were collected and analyzed by ICPMS for concentrations of leached cations. A potential ERW scenario for Costa Rica was assessed assuming that one-half of lowland agricultural kaolinitic soils (mainly Ultisols, common crop and pasture soils, excluding protected areas) were to receive 50 t ha-1 of annual or biennial applications of powdered mafic rock. With an experimentally determined humid tropical CDR rate for basaltic andesite (3.5 t ha-1 yr-1) and allowances for carbon costs (e.g. emissions from processing and delivery) that reduce CDR to a net 3.2 t ha-1 yr-1, potential annual CDR of this tropical nation is ∼2-4 million tons, amounting to ∼25-50 % of annual CO2 emissions (mainly from transportation in Costa Rica).
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Affiliation(s)
- P C Ryan
- Department of Earth and Climate Sciences, Middlebury College, 276 Bicentennial Way, Middlebury, VT 05753, USA.
| | - A Santis
- Department of Earth and Climate Sciences, Middlebury College, 276 Bicentennial Way, Middlebury, VT 05753, USA
| | - E Vanderkloot
- Department of Earth and Climate Sciences, Middlebury College, 276 Bicentennial Way, Middlebury, VT 05753, USA
| | - M Bhatti
- Department of Earth and Climate Sciences, Middlebury College, 276 Bicentennial Way, Middlebury, VT 05753, USA
| | - S Caddle
- Department of Earth and Climate Sciences, Middlebury College, 276 Bicentennial Way, Middlebury, VT 05753, USA
| | - M Ellis
- Department of Earth and Climate Sciences, Middlebury College, 276 Bicentennial Way, Middlebury, VT 05753, USA
| | - A Grimes
- Department of Earth and Climate Sciences, Middlebury College, 276 Bicentennial Way, Middlebury, VT 05753, USA
| | - S Silverman
- Department of Earth and Climate Sciences, Middlebury College, 276 Bicentennial Way, Middlebury, VT 05753, USA
| | - E Soderstrom
- Department of Earth and Climate Sciences, Middlebury College, 276 Bicentennial Way, Middlebury, VT 05753, USA
| | - C Stone
- Department of Earth and Climate Sciences, Middlebury College, 276 Bicentennial Way, Middlebury, VT 05753, USA
| | - A Takoudes
- Department of Earth and Climate Sciences, Middlebury College, 276 Bicentennial Way, Middlebury, VT 05753, USA
| | - P Tulay
- Department of Earth and Climate Sciences, Middlebury College, 276 Bicentennial Way, Middlebury, VT 05753, USA
| | - S Wright
- Department of Earth and Climate Sciences, Middlebury College, 276 Bicentennial Way, Middlebury, VT 05753, USA
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Chandran M, Akesson KE, Javaid MK, Harvey N, Blank RD, Brandi ML, Chevalley T, Cinelli P, Cooper C, Lems W, Lyritis GP, Makras P, Paccou J, Pierroz DD, Sosa M, Thomas T, Silverman S. Impact of osteoporosis and osteoporosis medications on fracture healing: a narrative review. Osteoporos Int 2024:10.1007/s00198-024-07059-8. [PMID: 38587674 DOI: 10.1007/s00198-024-07059-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 03/06/2024] [Indexed: 04/09/2024]
Abstract
Antiresorptive medications do not negatively affect fracture healing in humans. Teriparatide may decrease time to fracture healing. Romosozumab has not shown a beneficial effect on human fracture healing. BACKGROUND Fracture healing is a complex process. Uncertainty exists over the influence of osteoporosis and the medications used to treat it on fracture healing. METHODS Narrative review authored by the members of the Fracture Working Group of the Committee of Scientific Advisors of the International Osteoporosis Foundation (IOF), on behalf of the IOF and the Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT). RESULTS Fracture healing is a multistep process. Most fractures heal through a combination of intramembranous and endochondral ossification. Radiographic imaging is important for evaluating fracture healing and for detecting delayed or non-union. The presence of callus formation, bridging trabeculae, and a decrease in the size of the fracture line over time are indicative of healing. Imaging must be combined with clinical parameters and patient-reported outcomes. Animal data support a negative effect of osteoporosis on fracture healing; however, clinical data do not appear to corroborate with this. Evidence does not support a delay in the initiation of antiresorptive therapy following acute fragility fractures. There is no reason for suspension of osteoporosis medication at the time of fracture if the person is already on treatment. Teriparatide treatment may shorten fracture healing time at certain sites such as distal radius; however, it does not prevent non-union or influence union rate. The positive effect on fracture healing that romosozumab has demonstrated in animals has not been observed in humans. CONCLUSION Overall, there appears to be no deleterious effect of osteoporosis medications on fracture healing. The benefit of treating osteoporosis and the urgent necessity to mitigate imminent refracture risk after a fracture should be given prime consideration. It is imperative that new radiological and biological markers of fracture healing be identified. It is also important to synthesize clinical and basic science methodologies to assess fracture healing, so that a convergence of the two frameworks can be achieved.
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Affiliation(s)
- M Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, DUKE NUS Medical School, Singapore, Singapore.
| | - K E Akesson
- Clinical and Molecular Osteoporosis Research Unit, Department of Clinical Sciences, Lund University, Department of Orthopedics, Skåne University Hospital, Malmö, Sweden
| | - M K Javaid
- NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK
| | - N Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, NIHR Southampton Biomedical Research Centre, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - R D Blank
- Garvan Institute of Medical Research, Medical College of Wisconsin, Darlinghurst, NSW, Australia
- Medical College of Wisconsin, Milwaukee, WI, USA
| | - M L Brandi
- Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Largo Palagi 1, Florence, Italy
| | - T Chevalley
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - P Cinelli
- Department of Trauma Surgery, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - C Cooper
- MRC Lifecourse Epidemiology Centre, University of Southampton, NIHR Southampton Biomedical Research Centre, University of Southampton, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
- NIHR Oxford Biomedical Research Unit, University of Oxford, Oxford, UK
| | - W Lems
- Department of Rheumatology, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - G P Lyritis
- Hellenic Osteoporosis Foundation, Athens, Greece
| | - P Makras
- Department of Medical Research, 251 Hellenic Air Force & VA General Hospital, Athens, Greece
| | - J Paccou
- Department of Rheumatology, MABlab ULR 4490, CHU Lille, Univ. Lille, 59000, Lille, France
| | - D D Pierroz
- International Osteoporosis Foundation, Nyon, Switzerland
| | - M Sosa
- University of Las Palmas de Gran Canaria, Investigation Group on Osteoporosis and Mineral Metabolism, Canary Islands, Spain
| | - T Thomas
- Department of Rheumatology, North Hospital, CHU Saint-Etienne and INSERM U1059, University of Lyon-University Jean Monnet, Saint‑Etienne, France
| | - S Silverman
- Cedars-Sinai Medical Center and Geffen School of Medicine UCLA, Los Angeles, CA, USA
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Roy A, Sreekrishnan A, Camargo Faye E, Silverman S, Zachrison KS, Harriott AM, Matiello M, Manzano GS, Prasanna M, Nedelcu S, Singhal AB. Safety and Feasibility of an Emergency Department-to-Outpatient Pathway for Patients With TIA and Nondisabling Stroke. Neurol Clin Pract 2023; 13:e200209. [PMID: 37829551 PMCID: PMC10567120 DOI: 10.1212/cpj.0000000000200209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 08/28/2023] [Indexed: 10/14/2023]
Abstract
Background and Objectives Evaluation of transient ischemic attack/nondisabling ischemic strokes (TIA/NDS) in the emergency department (ED) contributes to capacity issues and increasing health care expenditures, especially high-cost duplicative imaging. Methods As an institutional quality improvement project, we developed a novel pathway to evaluate patients with TIA/NDS in the ED using a core set of laboratory tests and CT-based neuroimaging. Patients identified as 'low risk' through a safety checklist were discharged and scheduled for prompt outpatient tests and stroke clinic follow-up. In this prespecified analysis designed to assess feasibility and safety, we abstracted data from patients consecutively enrolled in the first 6 months. Results We compared data from 106 patients with TIA/NDS enrolled in the new pathway from April through September 2020 (age 67.9 years, 45% female), against 55 unmatched historical controls with TIA encountered from April 2016 through March 2017 (age 68.3 years, 47% female). Both groups had similar median NIHSS scores (pathway and control 0) and ABCD2 scores (pathway and control 3). Pathway-enrolled patients had a 44% decrease in mean ED length of stay (pathway 13.7 hours, control 24.4 hours, p < 0.001) and decreased utilization of ED MRI-based imaging (pathway 63%, control 91%, p < 0.001) and duplicative ED CT plus MRI-based brain and/or vascular imaging (pathway 35%, control 53%, p = 0.04). Among pathway-enrolled patients, 89% were evaluated in our stroke clinic within a median of 5 business days; only 5.5% were lost to follow-up. Both groups had similar 90-day rates of ED revisits (pathway 21%, control 18%, p = 0.84) and recurrent TIA/ischemic stroke (pathway 1%, control 2%, p = 1.0). Recurrent ischemic events among pathway-enrolled patients were attributed to errors in following the safety checklist before discharge. Discussion Our TIA/NDS pathway, implemented during the initial outbreak of COVID-19, seems feasible and safe, with significant positive impact on ED throughput and ED-based high-cost duplicative imaging. The safety checklist and option of virtual telehealth follow-up are novel features. Broader adoption of such pathways has important implications for value-based health care.
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Affiliation(s)
- Alexis Roy
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Anirudh Sreekrishnan
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Erica Camargo Faye
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Scott Silverman
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kori S Zachrison
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andrea M Harriott
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Marcelo Matiello
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Giovanna S Manzano
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mrinalini Prasanna
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Simona Nedelcu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Moayyeri A, Warden J, Han S, Suh HS, Pinedo-Villanueva R, Harvey NC, Curtis JR, Silverman S, Multani JK, Yeh EJ. Estimating the economic burden of osteoporotic fractures in a multinational study: a real-world data perspective. Osteoporos Int 2023; 34:2121-2132. [PMID: 37653346 PMCID: PMC10651531 DOI: 10.1007/s00198-023-06895-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 08/21/2023] [Indexed: 09/02/2023]
Abstract
Fracture-related costs vary by country. A standardized methodology and presentations were proposed to fairly assess the economic burden of osteoporotic fracture. Results indicated substantial costs of osteoporotic fractures for pharmacy, hospitalization, emergency care, and outpatient visits in women aged ≥ 50 years in Australia, Germany, South Korea, Spain, and the USA. PURPOSE The objective of this multinational, retrospective matched cohort study was to use a standardized methodology across different healthcare systems to estimate the burden of osteoporotic fracture (OF) in women aged ≥ 50 years in Australia, Germany, South Korea, Spain, and the USA. METHODS Within each country, healthcare resource utilization and direct costs of care were compared between patients with newly identified OF and a propensity score-matched cohort without OF during follow-up periods of up to 5 years. RESULTS Across all five countries, the OF cohort had significantly higher rates and length of inpatient admissions compared with the non-OF cohort. In each country, the adjusted total costs of care ratio between OF and non-OF cohorts were significant. The adjusted cost ratios for pharmacy, inpatient care, emergency care, and outpatient visits were similarly higher in the OF cohort across countries. CONCLUSION The current study demonstrates the substantial economic burden of OF across different countries when compared with matched non-OF patients. The findings would assist stakeholders and policymakers in developing appropriate health policies.
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Affiliation(s)
| | | | - S Han
- Health Outcomes Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - H S Suh
- College of Pharmacy, Kyung Hee University, Seoul, South Korea
- Department of Regulatory Science, Graduate School, Kyung Hee University, Seoul, South Korea
| | - R Pinedo-Villanueva
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, NIHR Oxford Biomedical Research Centre, University of Oxford, Windmill Road, Oxford, OX3 7HE, UK
| | - N C Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton General Hospital, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital NHS Foundation Trust, Southampton, UK
| | - J R Curtis
- Division of Clinical Immunology & Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - S Silverman
- Cedars-Sinai Medical Center and School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | | | - E J Yeh
- Amgen Inc., Thousand Oaks, CA, USA.
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Roy AT, Ahmed R, Marquez Loza A, Crowe J, Montes D, Hamam O, Romero JM, Silverman S. Abstract WP134: Long-Term Spontaneous Recanalization Rates Of Symptomatic Cervical Carotid Artery Occlusions. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wp134] [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: 02/05/2023]
Abstract
Background:
Long-term rates of spontaneous recanalization of a previously acutely symptomatic cervical internal carotid artery occlusion (ICAO) have not been well characterized. The purpose of this study was to determine the rate of ICAO recanalization after index transient ischemic attack (TIA)/stroke in patients with serial vessel imaging, and the clinical factors associated with recanalization.
Methods:
This was a single-center, retrospective analysis from 2012-2020 of patients presenting with TIA/stroke due to an acute cervical ICAO. Patients were included if follow-up neck vessel imaging (CTA, MRA or ultrasound) was performed after index TIA/stroke. Recanalization was classified as the presence of continuous flow within the cervical carotid artery on repeat imaging. Patients were excluded if they received catheterization of the occluded artery during index admission or if the occlusion was previously documented (i.e., chronic).
Results:
Fifty-five patients were included in this study (mean age 61 ± 12 years, 27% female). The most common etiology for cervical ICAO was atherosclerosis (71%), followed by dissection (22%). Twelve patients (22%) demonstrated recanalization on follow-up imaging at a median of 125 days from index TIA/stroke (range 2-1072 days). Three patients with recanalization underwent carotid revascularization with endarterectomy or stenting. The administration of intravenous alteplase during index stroke admission was associated with recanalization (p=0.008). However, discharge antithrombotic regimen (antiplatelet or anticoagulation) or the etiology of the occlusion were not associated with recanalization (p=0.48 and p=0.73, respectively). There was no difference in 6-month recurrent TIA/stroke rates between those with recanalization (1 patient, 8.3%) and those without recanalization (4 patients, 9.3%), p=1.0.
Conclusion:
Cervical ICAO recanalization occurred in 12 (22%) patients in our cohort at follow-up and allowed for carotid revascularization procedures in 3 (25%) of these patients. Outpatient follow-up cervical vessel imaging should be considered after symptomatic cervical ICAO, as identifying spontaneous recanalization can alter management.
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Schwamm LH, Kamel H, Granger CB, Piccini JP, Katz JM, Sethi PP, Sidorov EV, Kasner SE, Silverman SB, Merriam TT, Franco N, Ziegler PD, Bernstein RA, Abi-Samra F, Acosta I, Al Balushi A, Al-Awwad A, Alimohammad R, Alkahalifah M, Allred J, Alsorogi M, Arias V, Aroor S, Arora R, Asdaghi N, Asi K, Assar M, Badhwar N, Banchs J, Bansal S, Barrett C, Beaver B, Beldner S, Belt G, Bernabei M, Bernard M, Bhatt N, Black J, Bledsoe D, Bonaguidi H, Bonyak K, Boyd C, Cajavilca C, Caprio F, Carter J, Chancellor B, Chang C, Chaudhary G, Chaudhary S, Cheung P, Ching M, Chinitz L, Chiu D, Chokhawala H, Choudhuri I, Choudry S, Clayton S, Cross J, Cucchiara B, Culpepper A, Daniels J, Dash S, Del Brutto V, Deline C, Delpirou Nouh C, Deo R, Dhamoon M, Dillon G, Donsky A, Doshi A, Downey A, Dukkipati S, Epstein L, Etherton M, Fara M, Fayad PB, Felberg R, Flaster M, Frankel D, Furer S, Gadhia R, Gadient P, Garabelli P, Gibson D, Glotzer T, Goltz D, Gordon D, Graner S, Graybeal D, Grimes MR, Guerrero W, Hanna J, Hao Q, Hasabnis S, Hasan R, Heist EK, Horowitz D, Hourihane JM, Hussein H, Ishida K, Ismail H, Jadonath R, Jamal S, Jamnadas P, Jia J, Johnson M, Jung R, Kalafut M, Kalia J, Kandel A, Kasner S, Katz L, Katz J, Kaur G, Kearney M, Khatib S, Kim S, Kim C, Kipta J, Koch S, Koruth J, Kreger H, Krueger K, Kurian C, LaFranchise E, Lambrakos L, Langan MN, Lee R, Libman R, Lillemoe K, Logan W, Lord A, Lubitz S, Luciano J, Lynch J, Maccaro PC, Magadan A, Magun R, Malik M, Malik A, Manda S, Marulanda-Londono E, Matos Diaz I, Mattera B, McCall-Brown A, Mcclelland N, Meisel K, Memon Z, Mendelson S, Mendoza I, Merriam T, Messe S, Miles WM, Miller M, Mir O, Mitrani R, Morin D, Morris K, Moussavi M, Mowla A, Moye S, Mullen M, Mullins S, Neisen K, Nguyen C, Niazi I, Olson N, Olsovsky G, Ortiz G, Ostrander M, Pakala A, Parker B, Parker M, Passman R, Patel A, Patel A, Pickett RA(D, Polin G, Radoslovich G, Ramano J, Rami T, Ramirez D, Rasmussen J, Ray B, Reddy V, Reddy R, Reeves R, Regenhardt R, Rempe D, Rogers P, Rogers J, Rowe S, Rowley C, Ruff I, Sackett M, Sajjad R, Salem R, Saltzman M, Santangeli P, Saucedo S, Sawyer R, Schaller R, Seeger S, Sethi P, Shang T, Sharma J, Sharma R, Sheinart K, Shukla G, Shultz J, Sidorov E, Silverman S, Simonson J, Singh D, Skalabrin E, Sloane K, Smith M, Smith W, Soik D, Stavrakis S, Stein L, Steinberg JS, Sur N, Switzer D, Talpur N, Tansy A, Tempro K, Thavapalan V, Thomas A, Thomas K, Torres J, Torres L, Tuhrim S, Uddin P, Vidal G, Viswanathan A, Volpi J, Ward K, Weinberger J, Whang W, Wilder M, Willner J, Wright P, Yuan Q, Zhang C, Zhu D, Zide K, Zimmerman J, Zweifler R. Predictors of Atrial Fibrillation in Patients With Stroke Attributed to Large- or Small-Vessel Disease: A Prespecified Secondary Analysis of the STROKE AF Randomized Clinical Trial. JAMA Neurol 2023; 80:99-103. [PMID: 36374508 PMCID: PMC9664367 DOI: 10.1001/jamaneurol.2022.4038] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Importance The Stroke of Known Cause and Underlying Atrial Fibrillation (STROKE AF) trial found that approximately 1 in 8 patients with recent ischemic stroke attributed to large- or small-vessel disease had poststroke atrial fibrillation (AF) detected by an insertable cardiac monitor (ICM) at 12 months. Identifying predictors of AF could be useful when considering an ICM in routine poststroke clinical care. Objective To determine the association between commonly assessed risk factors and poststroke detection of new AF in the STROKE AF cohort monitored by ICM. Design, Setting, and Participants This was a prespecified analysis of a randomized (1:1) clinical trial that enrolled patients between April 1, 2016, and July 12, 2019, with primary follow-up through 2020 and mean (SD) duration of 11.0 (3.0) months. Eligible patients were selected from 33 clinical research sites in the US. Patients had an index stroke attributed to large- or small-vessel disease and were 60 years or older or aged 50 to 59 years with at least 1 additional stroke risk factor. A total of 496 patients were enrolled, and 492 were randomly assigned to study groups (3 did not meet inclusion criteria, and 1 withdrew consent). Patients in the ICM group had the index stroke within 10 days before insertion. Data were analyzed from October 8, 2021, to January 28, 2022. Interventions ICM monitoring vs site-specific usual care (short-duration external cardiac monitoring). Main Outcomes and Measures The ICM device automatically detects AF episodes 2 or more minutes in length; episodes were adjudicated by an expert committee. Cox regression multivariable modeling included all parameters identified in the univariate analysis having P values <.10. AF detection rates were calculated using Kaplan-Meier survival estimates. Results The analysis included the 242 participants randomly assigned to the ICM group in the STROKE AF study. Among 242 patients monitored with ICM, 27 developed AF (mean [SD] age, 66.6 [9.3] years; 144 men [60.0%]; 96 [40.0%] women). Two patients had missing baseline data and exited the study early. Univariate predictors of AF detection included age (per 1-year increments: hazard ratio [HR], 1.05; 95% CI, 1.01-1.09; P = .02), CHA2DS2-VASc score (per point: HR, 1.54; 95% CI, 1.15-2.06; P = .004), chronic obstructive pulmonary disease (HR, 2.49; 95% CI, 0.86-7.20; P = .09), congestive heart failure (CHF; with preserved or reduced ejection fraction: HR, 6.64; 95% CI, 2.29-19.24; P < .001), left atrial enlargement (LAE; HR, 3.63; 95% CI, 1.55-8.47; P = .003), QRS duration (HR, 1.02; 95% CI, 1.00-1.04; P = .04), and kidney dysfunction (HR, 3.58; 95% CI, 1.35-9.46; P = .01). In multivariable modeling (n = 197), only CHF (HR, 5.06; 95% CI, 1.45-17.64; P = .05) and LAE (HR, 3.32; 1.34-8.19; P = .009) remained significant predictors of AF. At 12 months, patients with CHF and/or LAE (40 of 142 patients) had an AF detection rate of 23.4% vs 5.0% for patients with neither (HR, 5.1; 95% CI, 2.0-12.8; P < .001). Conclusions and Relevance Among patients with ischemic stroke attributed to large- or small-vessel disease, CHF and LAE were associated with a significantly increased risk of poststroke AF detection. These patients may benefit most from the use of ICMs as part of a secondary stroke prevention strategy. However, the study was not powered for clinical predictors of AF, and therefore, other clinical characteristics may not have reached statistical significance. Trial Registration ClinicalTrials.gov Identifier: NCT02700945.
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Affiliation(s)
- Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, New York,Deputy Editor, JAMA Neurology
| | - Christopher B. Granger
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Jonathan P. Piccini
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey M. Katz
- Department of Neurology and Radiology, North Shore University Hospital, Manhasset, New York
| | - Pramod P. Sethi
- Guilford Neurology Associates, Moses H. Cone Hospital, Greensboro, North Carolina
| | - Evgeny V. Sidorov
- Department of Neurology, The University of Oklahoma Health Sciences Center, Oklahoma City
| | - Scott E. Kasner
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | | | - Noreli Franco
- Clinical Department, Medtronic, Minneapolis, Minnesota
| | | | - Richard A. Bernstein
- Davee Department of Neurology, Feinberg School of Medicine of Northwestern University, Chicago, Illinois
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Sharma R, Silverman S, Patel S, Schwamm LH, Sanborn DY. Frequency, predictors and cardiovascular outcomes associated with transthoracic echocardiographic findings during acute ischaemic stroke hospitalisation. Stroke Vasc Neurol 2022; 7:482-492. [PMID: 35697387 PMCID: PMC9811598 DOI: 10.1136/svn-2021-001170] [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: 06/08/2021] [Accepted: 04/29/2022] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To characterise the clinical utility of transthoracic echocardiography (TTE) at the time of acute ischaemic stroke (AIS). BACKGROUND The utility of obtaining a TTE during AIS hospitalisation is uncertain. METHODS We studied AIS hospitalisations at a single centre (2002-2016). TTE abnormalities were classified as findings associated with: high stroke risk (Category I), cardiac events (Category II) and of unclear significance (Category III). We performed logistic regressions to predict Category I, II and III abnormalities. The odds of 1 year recurrent stroke hospitalisation captured by ICD 9 and 10 codes as a function of Category I, II and III abnormalities were assessed. Improvement in predictive capacity for 1 year recurrent ischaemic stroke hospitalisation beyond stroke risk factors was evaluated by net reclassification improvement. RESULTS There were 5523 AIS hospitalisations. Nearly 81% of admission TTEs were abnormal (18.7% Category I, 32.7% Category II, 72.8% Category III). Older patients with coronary artery disease, atrial fibrillation, hypertension, diabetes, and patent intracranial and extracranial vessels were likely to have an abnormal TTE. Category I finding was associated with lower odds of 1-year recurrent stroke hospitalisation (OR 0.54, 95% CI 0.30 to 0.96). Category I data significantly improved the predictive value for 1-year recurrent ischaemic stroke hospitalisation beyond stroke risk factors (net reclassification improvement 0.1563, 95% CI 0.0465 to 0.2661). CONCLUSIONS TTE abnormalities associated with stroke and cardiac event risk were commonly detected during AIS hospitalisation. Detection of Category I TTE findings reduced the risk of recurrent stroke, potentially due to neutralisation of the cardioembolic source by targeted therapy, indicating the clinical utility of TTE.
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Affiliation(s)
- Richa Sharma
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Scott Silverman
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shaun Patel
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
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8
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Hiligsmann M, Li N, Cooper C, Reginster JY, Silverman S, Carswell C, Husereau D. Improving the reporting of economic evaluation in osteoporosis: the value of CHEERS 2022 statement. Osteoporos Int 2022; 33:1641-1642. [PMID: 35414136 DOI: 10.1007/s00198-022-06400-3] [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: 02/17/2022] [Accepted: 04/04/2022] [Indexed: 10/18/2022]
Affiliation(s)
- M Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Duboisdomein 30, 6229 GT, Maastricht, the Netherlands.
| | - N Li
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Duboisdomein 30, 6229 GT, Maastricht, the Netherlands
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - J-Y Reginster
- WHO Collaborating Center for Public Health Aspects of Musculo-Skeletal Health and Ageing, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - S Silverman
- Cedars-Sinai Medical Center, Los Angeles, USA
| | - C Carswell
- Adis Journals, Springer Nature, Auckland, New Zealand
| | - D Husereau
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Institute of Health Economics, Edmonton, AB, Canada
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9
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Chotiyarnwong P, McCloskey EV, Harvey NC, Lorentzon M, Prieto-Alhambra D, Abrahamsen B, Adachi JD, Borgström F, Bruyere O, Carey JJ, Clark P, Cooper C, Curtis EM, Dennison E, Diaz-Curiel M, Dimai HP, Grigorie D, Hiligsmann M, Khashayar P, Lewiecki EM, Lips P, Lorenc RS, Ortolani S, Papaioannou A, Silverman S, Sosa M, Szulc P, Ward KA, Yoshimura N, Kanis JA. Is it time to consider population screening for fracture risk in postmenopausal women? A position paper from the International Osteoporosis Foundation Epidemiology/Quality of Life Working Group. Arch Osteoporos 2022; 17:87. [PMID: 35763133 PMCID: PMC9239944 DOI: 10.1007/s11657-022-01117-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/03/2022] [Indexed: 02/03/2023]
Abstract
The IOF Epidemiology and Quality of Life Working Group has reviewed the potential role of population screening for high hip fracture risk against well-established criteria. The report concludes that such an approach should strongly be considered in many health care systems to reduce the burden of hip fractures. INTRODUCTION The burden of long-term osteoporosis management falls on primary care in most healthcare systems. However, a wide and stable treatment gap exists in many such settings; most of which appears to be secondary to a lack of awareness of fracture risk. Screening is a public health measure for the purpose of identifying individuals who are likely to benefit from further investigations and/or treatment to reduce the risk of a disease or its complications. The purpose of this report was to review the evidence for a potential screening programme to identify postmenopausal women at increased risk of hip fracture. METHODS The approach took well-established criteria for the development of a screening program, adapted by the UK National Screening Committee, and sought the opinion of 20 members of the International Osteoporosis Foundation's Working Group on Epidemiology and Quality of Life as to whether each criterion was met (yes, partial or no). For each criterion, the evidence base was then reviewed and summarized. RESULTS AND CONCLUSION The report concludes that evidence supports the proposal that screening for high fracture risk in primary care should strongly be considered for incorporation into many health care systems to reduce the burden of fractures, particularly hip fractures. The key remaining hurdles to overcome are engagement with primary care healthcare professionals, and the implementation of systems that facilitate and maintain the screening program.
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Affiliation(s)
- P Chotiyarnwong
- Department of Oncology & Metabolism, Mellanby Centre for Musculoskeletal Research, MRC Versus Arthritis Centre for Integrated Research in Musculoskeletal Ageing, University of Sheffield, Sheffield, UK
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - E V McCloskey
- Department of Oncology & Metabolism, Mellanby Centre for Musculoskeletal Research, MRC Versus Arthritis Centre for Integrated Research in Musculoskeletal Ageing, University of Sheffield, Sheffield, UK.
- Centre for Metabolic Bone Diseases, Northern General Hospital, University of Sheffield, Herries Road, Sheffield, S5 7AU, UK.
| | - N C Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - M Lorentzon
- University of Gothenburg, Gothenburg, Sweden
- Australian Catholic University, Melbourne, Australia
| | - D Prieto-Alhambra
- Oxford NIHR Biomedical Research Centre, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK
- GREMPAL (Grup de Recerca en Malalties Prevalents de L'Aparell Locomotor) Research Group, CIBERFes and Idiap Jordi Gol Primary Care Research Institute, Universitat Autònoma de Barcelona and Instituto de Salud Carlos III, Gran Via de Les Corts Catalanes, 591 Atico, 08007, Barcelona, Spain
| | - B Abrahamsen
- Department of Clinical Research, Odense Patient Data Exploratory Network, University of Southern Denmark, Odense, Denmark
- Department of Medicine, Holbæk Hospital, Holbæk, Denmark
| | - J D Adachi
- Department of Medicine, Michael G DeGroote School of Medicine, St Joseph's Healthcare-McMaster University, Hamilton, ON, Canada
| | - F Borgström
- Quantify Research, Stockholm, Sweden
- Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
| | - O Bruyere
- WHO Collaborating Center for Public Health Aspects of Musculo-Skeletal Health and Ageing, Division of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - J J Carey
- School of Medicine, National University of Ireland Galway, Galway, Ireland
- Department of Rheumatology, Galway University Hospitals, Galway, Ireland
| | - P Clark
- Clinical Epidemiology Unit of Hospital Infantil de México Federico Gómez-Faculty of Medicine, Universidad Nacional Autónoma de México, UNAM, Mexico City, Mexico
| | - C Cooper
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - E M Curtis
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - E Dennison
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - M Diaz-Curiel
- Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - H P Dimai
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - D Grigorie
- Carol Davila University of Medicine, Bucharest, Romania
- Department of Endocrinology & Bone Metabolism, National Institute of Endocrinology, Bucharest, Romania
| | - M Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - P Khashayar
- Center for Microsystems Technology, Imec and Ghent University, 9050, Ghent, Belgium
| | - E M Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA
| | - P Lips
- Department of Internal Medicine, Endocrine Section & Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - R S Lorenc
- Multidisciplinary Osteoporosis Forum, SOMED, Warsaw, Poland
| | - S Ortolani
- IRCCS Istituto Auxologico, UO Endocrinologia E Malattie del Metabolismo, Milano, Italy
| | - A Papaioannou
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- GERAS Centre for Aging Research, Hamilton, ON, Canada
| | - S Silverman
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - M Sosa
- Bone Metabolic Unit, University of Las Palmas de Gran Canaria, Hospital University Insular, Las Palmas, Gran Canaria, Spain
| | - P Szulc
- INSERM UMR 1033, University of Lyon, Hôpital Edouard Herriot, Lyon, France
| | - K A Ward
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - N Yoshimura
- Department of Preventive Medicine for Locomotive Organ Disorders, 22Nd Century Medical and Research Center, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - J A Kanis
- Centre for Metabolic Bone Diseases, Northern General Hospital, University of Sheffield, Herries Road, Sheffield, S5 7AU, UK
- Australian Catholic University, Melbourne, Australia
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10
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He K, Gottumukkala R, Silverman S, Shyn P. Abstract No. 129 Safety and efficacy of PET/CT-guided and CT-guided percutaneous cryoablation of recurrent pleural mesothelioma. J Vasc Interv Radiol 2022. [DOI: 10.1016/j.jvir.2022.03.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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11
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Murphy M, Kashani MA, Saenger J, Levesque V, Silverman S, Shyn P, Fintelmann F. Abstract No. 126 Safety and efficacy of percutaneous thermal ablation of ultra-central lung tumors adjacent to the heart. J Vasc Interv Radiol 2022. [DOI: 10.1016/j.jvir.2022.03.207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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12
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Pinto D, Alshahrani M, Chapurlat R, Chevalley T, Dennison E, Camargos BM, Papaioannou A, Silverman S, Kaux JF, Lane NE, Morales Torres J, Paccou J, Rizzoli R, Bruyere O. The global approach to rehabilitation following an osteoporotic fragility fracture: A review of the rehabilitation working group of the International Osteoporosis Foundation (IOF) committee of scientific advisors. Osteoporos Int 2022; 33:527-540. [PMID: 35048200 DOI: 10.1007/s00198-021-06240-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 11/11/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE To conduct a review of the current state of the evidence for rehabilitation strategies post-fragility fracture. METHODS Narrative review conducted by the Rehabilitation Working Group of the International Osteoporosis Foundation Committee of Scientific Advisors characterizing the range of rehabilitation modalities instrumental for the management of fragility fractures. RESULTS Multi-modal exercise post-fragility fracture to the spine and hip is strongly recommended to reduce pain, improve physical function, and improve quality of life. Outpatient physiotherapy post-hip fracture has a stronger evidence base than outpatient physiotherapy post-vertebral fracture. Appropriate nutritional care after fragility fracture provides a large range of improvement in morbidity and mortality. Education increases understanding of osteoporosis which in turn increases utilization of other rehabilitation services. Education may improve other health outcomes such as pain and increase a patient's ability for self-advocacy. CONCLUSION Rehabilitation interventions are inter-reliant, and research investigating the interaction of exercise, nutrition, and other multi-modal therapies may increase the relevance of rehabilitation research to clinical care.
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Affiliation(s)
- D Pinto
- Department of Physical Therapy, Marquette University, P.O. Box 1881, Wisconsin, 53201, Milwaukee, USA.
- Department of Public Health, Epidemiology and Health Economics, WHO Collaborating Centre for Public Health Aspects of Musculo-Skeletal Health and Ageing, University of Liège, 4000, Liège, Belgium.
| | - M Alshahrani
- Department of Physical Therapy, Marquette University, P.O. Box 1881, Wisconsin, 53201, Milwaukee, USA
- Department of Medical Rehabilitation Science, King Khalid University, Abha, Kingdom of Saudi Arabia
| | - R Chapurlat
- INSERM UMR 1033, Université de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - T Chevalley
- Division of Bone Diseases, Department of Medicine, University Hospitals and Faculty of Medicine of Geneva, Geneva, Switzerland
| | - E Dennison
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - B M Camargos
- Densitometry Diagnostic Unit - Rede Materdei de Saúde, Belo Horizonte, Mina Gerais, Brazil
| | - A Papaioannou
- Department of Medicine, Division of Geriatrics, McMaster University, Hamilton, Canada
| | - S Silverman
- Cedars-Sinai Medical Center and University of California, Los Angeles, CA, USA
| | - J-F Kaux
- Department of Physical and Rehabilitation Medicine, University Hospital of Liège, University of Liège, Liège, Belgium
| | - N E Lane
- Department of Medicine and Rheumatology, Davis School of Medicine, University of California, Sacramento, CA, USA
| | - J Morales Torres
- University of Guanajuato at León, Osteoporosis Unit, Hospital Aranda de La Parra, León, Mexico
| | - J Paccou
- Département Universitaire de Rhumatologie, Centre Hospitalier Et Universitaire, Hôpital Roger Salengro, Lille, France
| | - R Rizzoli
- Division of Bone Diseases, Department of Medicine, University Hospitals and Faculty of Medicine of Geneva, Geneva, Switzerland
| | - O Bruyere
- Department of Public Health, Epidemiology and Health Economics, WHO Collaborating Centre for Public Health Aspects of Musculo-Skeletal Health and Ageing, University of Liège, 4000, Liège, Belgium
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13
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Roy AT, Sreekrishnan A, Faye EC, Silverman S, Harriott A, Matiello M, Nedelcu S, Manzano GS, Singhal AB. Abstract 150: Safety And Feasibility Of An ED-To-Outpatient Pathway For Transient Ischemic Attack Or Non-Disabling Stroke. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.150] [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
Introduction:
The evaluation and risk stratification of patients with TIA/non-disabling ischemic stroke (TIA/NDS) arriving to the Emergency Department (ED) incurs high-cost imaging and increases ED length of stay (EDLOS). We evaluated the safety and feasibility of an ED-to-Outpatient Pathway for TIA/NDS.
Methods:
In April 2020, we developed a risk stratification algorithm for TIA/NDS in the ED using features of the clincal presentation, limited blood tests, telemetry, and head-neck CT/CTA. Patients deemed low risk based on a “safety checklist” were discharged with plans for expedited outpatient testing as warranted (e.g., brain MRI, echocardiogram) followed by rapid outpatient follow-up. To assess safety/feasibility of this pathway, we analyzed data of the first 101 patients prospectively enrolled through October 2020.
Results:
Mean age 68 years (range, 33-99); 53% men; median NIHSS score 0 (range 0-3). Symptom duration was classified as <10 min (24%), 10-59 min (23%), >60 min (49%), unclear (4%). Deficits included isolated weakness (16%), isolated aphasia (15%), amaurosis fugax (6%), numbness/combined deficits/other (63%). Median ABCD2 score 3 (range 1-7). Outpatient follow-up included stroke clinic (82%), primary care (4%), not required or patient declined (6%), other hospital (1%); 7% were lost to follow-up; 43% had follow-up within 7 days. Imaging performed in the ED included CT/CTA only (39%), MRI/MRA only (27%), both (33%), or no imaging (1%). EDLOS was significantly less for patients when CT/CTA only was performed, as per pathway (12.8 versus 16.8 hours, p<0.05). The safety checklist was followed in 69% of patients. When the checklist was used properly, there were 0 recurrent strokes or TIAs within 90-days (versus 2 when not used correctly, p<0.05). Return rates to the ED were 8% with use of checklist and 6% without use (p=0.76).
Conclusion:
Our TIA/NDS pathway, implemented shortly after the outbreak of Covid-19 in the USA, significantly decreased EDLOS, and still allowed for TIA/NDS patients to be safely discharged from the ED. Acceptable risk stratification and safety is suggested by the low rates of recurrent events when the pathway was followed properly. More education is needed to ensure consistent and proper use of the pathway.
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Affiliation(s)
- Alexis T Roy
- Neurology, Massachusetts General Hosp, Boston, MA
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14
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Hagino H, Tanaka K, Silverman S, McClung M, Gandra SR, Charokopou M, Adachi K, Johnson B, Stollenwerk B. Cost effectiveness of romosozumab versus teriparatide for severe postmenopausal osteoporosis in Japan. Osteoporos Int 2021; 32:2011-2021. [PMID: 33772328 DOI: 10.1007/s00198-021-05927-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/15/2021] [Indexed: 12/19/2022]
Abstract
UNLABELLED This study assessed the cost effectiveness of romosozumab versus teriparatide, both sequenced to alendronate, for the treatment of severe postmenopausal osteoporosis in Japan, using bone mineral density (BMD) efficacy data. Results show that romosozumab/alendronate produces greater health benefits at a lower cost than teriparatide/alendronate. INTRODUCTION This study aims to assess the cost effectiveness of romosozumab versus teriparatide, both sequenced to alendronate, for the treatment of severe postmenopausal osteoporosis in Japanese women previously treated with bisphosphonates. METHODS A Markov model was used to assess the relative cost effectiveness of 1 year of romosozumab versus 2 years of teriparatide, both sequenced to alendronate for a total treatment duration of 5 years. Outcomes for a cohort of women with a mean age of 78 years, a T-score ≤-2.5 and a previous fragility fracture were simulated over a lifetime horizon. The analysis was conducted from the perspective of the Japanese healthcare system and used a discount rate of 2% per annum. To inform relative fracture incidence, the bone mineral density (BMD) advantage of romosozumab over teriparatide was translated into relative risks of fracture, using relationships provided by a meta-regression of osteoporosis therapy trials. Outcomes were assessed in terms of lifetime costs (2020 US dollars) and quality-adjusted life years (QALYs). RESULTS Base case results showed that, compared with teriparatide/alendronate, romosozumab/alendronate reduced costs by $5134 per patient and yielded 0.045 additional QALYs. Scenario analyses and probabilistic sensitivity analysis confirmed that results are robust to uncertainty in model assumptions and inputs. CONCLUSION Results show that romosozumab/alendronate produces greater health benefits at a lower total cost than teriparatide/alendronate.
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Affiliation(s)
- H Hagino
- Tottori University, Tottori, Japan
| | - K Tanaka
- Kobe Gakuin University, Kobe, Japan
| | | | - M McClung
- Oregon Osteoporosis Center, Portland, OR, USA
- Mary McKillop Center for Health Research, Australian Catholic University, Melbourne, Australia
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Punjabi A, Barrett E, Cheng A, Mulla A, Walls G, Johnston D, McAleese J, Moore K, Hicks J, Blyth K, Denholm M, Magee L, Gilligan D, Silverman S, Qureshi M, Clinch H, Hatton M, Philipps L, Brown S, O'Brien M, McDonald F, Faivre-Finn C, Hiley C, Evison M. Neutrophil-Lymphocyte Ratio and Absolute Lymphocyte Count as Prognostic Markers in Patients Treated with Curative-intent Radiotherapy for Non-small Cell Lung Cancer. Clin Oncol (R Coll Radiol) 2021; 33:e331-e338. [PMID: 33863615 DOI: 10.1016/j.clon.2021.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 02/27/2021] [Accepted: 03/24/2021] [Indexed: 12/21/2022]
Abstract
AIMS The neutrophil-lymphocyte ratio (NLR) and the absolute lymphocyte count (ALC) have been proposed as prognostic markers in non-small cell lung cancer (NSCLC). The objective of this study was to examine the association of NLR/ALC before and after curative-intent radiotherapy for NSCLC on disease recurrence and overall survival. MATERIALS AND METHODS A retrospective study of consecutive patients who underwent curative-intent radiotherapy for NSCLC across nine sites in the UK from 1 October 2014 to 1 October 2016. A multivariate analysis was carried out to assess the ability of pre-treatment NLR/ALC, post-treatment NLR/ALC and change in NLR/ALC, adjusted for confounding factors using the Cox proportional hazards model, to predict disease recurrence and overall survival within 2 years of treatment. RESULTS In total, 425 patients were identified with complete blood parameter values. None of the NLR/ALC parameters were independent predictors of disease recurrence. Higher pre-NLR, post-NLR and change in NLR plus lower post-ALC were all independent predictors of worse survival. Receiver operator curve analysis found a pre-NLR > 2.5 (odds ratio 1.71, 95% confidence interval 1.06-2.79, P < 0.05), a post-NLR > 5.5 (odds ratio 2.36, 95% confidence interval 1.49-3.76, P < 0.001), a change in NLR >3.6 (odds ratio 2.41, 95% confidence interval 1.5-3.91, P < 0.001) and a post-ALC < 0.8 (odds ratio 2.86, 95% confidence interval 1.76-4.69, P < 0.001) optimally predicted poor overall survival on both univariate and multivariate analysis when adjusted for confounding factors. Median overall survival for the high-versus low-risk groups were: pre-NLR 770 versus 1009 days (P = 0.34), post-NLR 596 versus 1287 days (P ≤ 0.001), change in NLR 553 versus 1214 days (P ≤ 0.001) and post-ALC 594 versus 1287 days (P ≤ 0.001). CONCLUSION NLR and ALC, surrogate markers for systemic inflammation, have prognostic value in NSCLC patients treated with curative-intent radiotherapy. These simple and readily available parameters may have a future role in risk stratification post-treatment to inform the intensity of surveillance protocols.
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Affiliation(s)
- A Punjabi
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - E Barrett
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - A Cheng
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - A Mulla
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - G Walls
- Queen's University Belfast, Belfast, UK
| | - D Johnston
- Northern Ireland Cancer Centre, Belfast, UK
| | - J McAleese
- Northern Ireland Cancer Centre, Belfast, UK
| | - K Moore
- NHS Greater Glasgow & Clyde, Glasgow, UK
| | - J Hicks
- NHS Greater Glasgow & Clyde, Glasgow, UK
| | - K Blyth
- NHS Greater Glasgow & Clyde, Glasgow, UK
| | - M Denholm
- Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - L Magee
- Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - D Gilligan
- Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - S Silverman
- University College London Hospital, London, UK
| | - M Qureshi
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - H Clinch
- The University of Sheffield Medical School, Sheffield, UK
| | - M Hatton
- Weston Park Hospital, Sheffield, UK
| | | | - S Brown
- The University of Manchester, Manchester, UK
| | | | | | - C Faivre-Finn
- The University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK
| | - C Hiley
- CRUK Lung Cancer Centre of Excellence, UCL Cancer Institute, London, UK
| | - M Evison
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.
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Hiley C, Punjabi A, Barrett E, Cheng A, Mulla A, Walls G, Johnston D, McAleese J, Moore K, Hicks J, Blyth K, Denholm M, Magee L, Gilligan D, Silverman S, Qureshi M, Clinch H, Hatton M, Philips L, Brown S, O’Brien M, Macdonald F, Faivre-Finn C, Evison M. PH-0274 NLR & ALC as prognostic markers in patients treated with curative intent radiotherapy for NSCLC. Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)07289-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Silverman S, Schepman P, Rice JB, Beck C, White A, Thakkar S, Johnson M, Robinson R, Emir B. POS0283 TREATMENT PATTERNS AND CLINICAL CHARACTERISTICS OF PATIENTS WITH OSTEOARTHRITIS OF THE HIP AND/OR KNEE TREATED WITH TRADITIONAL NSAIDS VS COX-2S: A REAL-WORLD STUDY OF COMMERCIALLY-INSURED PATIENTS. Ann Rheum Dis 2021. [DOI: 10.1136/annrheumdis-2021-eular.2175] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background:The 2019 American College of Rheumatology (ACR) guidelines strongly recommend oral nonsteroidal anti-inflammatory drugs (NSAIDs) for management of hip and knee osteoarthritis (OA) and strongly recommend topical NSAIDs for knee OA. There are, however, important safety considerations with NSAIDs in terms of increased rates of gastrointestinal, cardiovascular, and renal events. Given these risks, it is important to understand the characteristics and drug utilization of the patients who start treatment on these different treatments (i.e., traditional NSAIDs [tNSAIDs] and cyclooxygenase-2 inhibitors [COX-2s]).Objectives:The goal of this research was to describe and compare baseline characteristics of commercially-insured patients diagnosed with OA of the hip and/or knee who started treatment on different types of NSAIDs (i.e., oral tNSAIDs, topical tNSAIDs, and COX-2s).Methods:The Optum Healthcare Solutions, Inc. claims database (1/2012-3/2017) was used to identify patients ≥18 years old, with ≥2 diagnoses of hip and/or knee OA, and ≥90 days supply of oral tNSAIDs, topical tNSAIDs, or COX-2s during the one-year follow up period. The index date was defined as the first prescription after the first OA diagnosis. Patients were assigned to cohorts based on the type of NSAID prescribed on index date. Patients were required to be continuously-enrolled six months before (baseline period) and 36 months after (follow-up period) the index date. Demographic and clinical characteristics including age, sex, comorbidities, and healthcare resource use (HRU) were summarized during baseline. Drug utilization characteristics including days supply and number of prescriptions for the different NSAIDs types were summarized during follow-up period.Results:Data for 23,796 patients were analyzed: 18,100 patients received oral tNSAIDs, 4,825 received COX-2s, and 871 topical tNSAIDs. Patients who initiated treatment on oral tNSAIDs were the youngest (mean age of 60.6 vs. 64.6 for COX-2s and 65.0 for topical tNSAIDs) and topical tNSAIDs had the highest proportion of female patients (71% vs. 62% for oral tNSAIDs and 63% for COX-2s). The topical tNSAIDs cohort had the highest presence of chronic kidney disease (2.6% vs. 1.0% and 1.5% for oral tNSAIDs and COX-2s, respectively) and congestive heart failure (2.5% vs. 0.8% and 1.7% for oral tNSAIDs and COX-2s, respectively) at baseline. In terms of HRU during baseline, topical tNSAIDs had the most patients with emergency department visits (20.8% vs. 16.7% in both COX-2s and oral tNSAIDs), and COX-2 had the most patients with inpatient visits (18.1% vs. 15.4% for topical tNSAIDs and 11.8% for oral tNSAIDs). Oral tNSAIDs had the lowest total all-cause cost ($6,504), and the topical tNSAIDs cohort had the highest costs ($8,455), but fairly comparable with COX-2s ($8,289). During follow-up, oral tNSAIDs patients stayed mostly on oral tNSAIDs as less than 15% of oral tNSAIDs patients later had a prescription for COX-2s or topical tNSAIDs. 37% of COX-2 patients and 56% of topical tNSAIDs patients later took oral tNSAIDs. Topical tNSAIDs patients had an average of 184.4 days of supply for topical tNSAIDs yet also extensively used oral NSAIDs during follow-up (average days of supply for oral tNSAIDs was 315.5 days and for COX-2s was 383.5 days).Conclusion:This study suggests that patients with more complex comorbidity profiles, including higher rates of adverse effects, often start pharmacological treatment with topical tNSAIDs. However, patients who start treatment with topical tNSAIDs switch to other types of NSAIDs; oral tNSAIDs were the most frequently prescribed treatment across the cohorts. Thus, despite the safety concerns with oral tNSAIDs and COX-2s, patients are still placed on these treatments to manage their OA pain. There is a need for new innovative treatments as there is currently a lack of other options.Disclosure of Interests:Stuart Silverman Consultant of: Stuart Silverman is a paid consultant to Pfizer and Eli Lilly and Company in connection with this study, Patricia Schepman Shareholder of: Patricia Schepman is an employee of Pfizer with stock and/or stock options, Employee of: Pfizer, James B Rice Consultant of: Brad Rice is an employee of Analysis Group, who were paid consultants to Pfizer and Eli Lilly and Company for this study, Craig Beck Shareholder of: Craig Beck is an employee of Pfizer with stock and/or stock options, Employee of: Pfizer, Alan White Consultant of: Alan White is an employee of Analysis Group, who were paid consultants to Pfizer and Eli Lilly and Company for this study, Sheena Thakkar Shareholder of: Sheena Thakkar is an employee of Pfizer with stock and/or stock options, Employee of: Pfizer, Michaela Johnson Consultant of: Michaela Johnson is an employee of Analysis Group, who were paid consultants to Pfizer and Eli Lilly and Company for this study, Rebecca Robinson Shareholder of: Rebecca Robinson is an employee and minor stockholder of Eli Lilly and Company, Employee of: Eli Lilly and Company, Birol Emir Shareholder of: Birol Emir is an employee of Pfizer with stock and/or stock options, Employee of: Pfizer
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Evison M, Barrett E, Cheng A, Mulla A, Walls G, Johnston D, McAleese J, Moore K, Hicks J, Blyth K, Denholm M, Magee L, Gilligan D, Silverman S, Hiley C, Qureshi M, Clinch H, Hatton M, Philipps L, Brown S, O'Brien M, McDonald F, Faivre-Finn C. Predicting the Risk of Disease Recurrence and Death Following Curative-intent Radiotherapy for Non-small Cell Lung Cancer: The Development and Validation of Two Scoring Systems From a Large Multicentre UK Cohort. Clin Oncol (R Coll Radiol) 2021; 33:145-154. [PMID: 32978027 DOI: 10.1016/j.clon.2020.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/30/2020] [Accepted: 09/02/2020] [Indexed: 12/26/2022]
Abstract
AIMS There is a paucity of evidence on which to produce recommendations on neither the clinical nor the imaging follow-up of lung cancer patients after curative-intent radiotherapy. In the 2019 National Institute for Health and Care Excellence lung cancer guidelines, further research into risk-stratification models to inform follow-up protocols was recommended. MATERIALS AND METHODS A retrospective study of consecutive patients undergoing curative-intent radiotherapy for non-small cell lung cancer from 1 October 2014 to 1 October 2016 across nine UK trusts was carried out. Twenty-two demographic, clinical and treatment-related variables were collected and multivariable logistic regression was used to develop and validate two risk-stratification models to determine the risk of disease recurrence and death. RESULTS In total, 898 patients were included in the study. The mean age was 72 years, 63% (562/898) had a good performance status (0-1) and 43% (388/898), 15% (134/898) and 42% (376/898) were clinical stage I, II and III, respectively. Thirty-six per cent (322/898) suffered disease recurrence and 41% (369/898) died in the first 2 years after radiotherapy. The ASSENT score (age, performance status, smoking status, staging endobronchial ultrasound, N-stage, T-stage) was developed, which stratifies the risk for disease recurrence within 2 years, with an area under the receiver operating characteristic curve (AUROC) for the total score of 0.712 (0.671-0.753) and 0.72 (0.65-0.789) in the derivation and validation sets, respectively. The STEPS score (sex, performance status, staging endobronchial ultrasound, T-stage, N-stage) was developed, which stratifies the risk of death within 2 years, with an AUROC for the total score of 0.625 (0.581-0.669) and 0.607 (0.53-0.684) in the derivation and validation sets, respectively. CONCLUSIONS These validated risk-stratification models could be used to inform follow-up protocols after curative-intent radiotherapy for lung cancer. The modest performance highlights the need for more advanced risk prediction tools.
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Affiliation(s)
- M Evison
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.
| | - E Barrett
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - A Cheng
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - A Mulla
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - G Walls
- Northern Ireland Cancer Centre, Belfast, UK
| | - D Johnston
- Cancer Centre Belfast City Hospital, Belfast, UK
| | - J McAleese
- Cancer Centre Belfast City Hospital, Belfast, UK
| | - K Moore
- NHS Greater Glasgow & Clyde, Glasgow, UK
| | - J Hicks
- NHS Greater Glasgow & Clyde, Glasgow, UK
| | - K Blyth
- NHS Greater Glasgow & Clyde, Glasgow, UK
| | - M Denholm
- Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - L Magee
- Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - D Gilligan
- Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - S Silverman
- University College London Hospital, London, UK
| | - C Hiley
- CRUK Lung Cancer Centre of Excellence, UCL Cancer Institute, London, UK
| | | | - H Clinch
- The University of Sheffield Medical School, Sheffield, UK
| | - M Hatton
- Weston Park Hospital, Sheffield, UK
| | | | - S Brown
- The Christie NHS Foundation Trust, Manchester, UK
| | | | | | - C Faivre-Finn
- The Christie NHS Foundation Trust, Manchester, UK; The University of Manchester, Manchester, UK
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Silverman S, Rice J, White A, Le N, Somma M, Beck C, Robinson R, Schepman P. FRI0423 CLINICAL BURDEN OF TREATING COMMERCIALLY-INSURED OSTEOARTHRITIS PATIENTS WITH PRESCRIPTION NSAIDS. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.3716] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Prescription NSAIDs/Cox-2s (“NSAIDs”) are commonly prescribed by physicians to treat patients with chronic pain, and much is known about the potential negative outcomes associated with their use1. Such negative outcomes include gastrointestinal (“GI”) issues and hepatorenal toxicity.1In addition, CV risk of Cox-2s has not been completely clarified.1,2However, less is known about the extent to which these outcomes are pervasive and problematic in specific patient populations such as those diagnosed with osteoarthritis (“OA”).Objectives:The goal of this research is to assess the clinical burden of commercially-insured patients diagnosed with OA of the hip and/or knee before and after treatment with prescription NSAIDs, in a large, national database in recent years.Methods:The Optum Healthcare Solutions, Inc. data (1/2012-3/2017) were used to identify patients ≥18 years old with ≥2 diagnoses of hip and/or knee OA, and ≥90 days supply of NSAIDs during the three-year period from first prescription (index date) after their first OA diagnosis. Patients were required to be continuously-enrolled during the six months before (baseline period) and 36 months after (follow-up period) the index date. Selected clinical outcomes such as GI issues, CV events, and renal toxicity were compared between the baseline and follow-up periods. Costs and resource use were normalized to account for differential duration in analytic time periods.Results:Data for 22,435 patients (60.8% as female, with an average age of 62) with hip and/or knee OA were analyzed. On average, patients were prescribed NSAIDs for 489 days during the follow-up period. From the baseline period to follow-up period, negative clinical outcomes associated with GI issues increased by 393% (1.5% v 7.5%), driven by a 667% (0.3% v 2.3%) increase in acute GI hemorrhages. Additionally, negative clinical outcomes associated with CV events increased by 73% (40.7% v 70.6%), largely due to a 600% (0.3% v 2.1%) increase in acute myocardial infarction. Lastly, negative clinical outcomes associated with renal toxicity increased by 433% (1.5% v 8.0%), with a 740% (0.5% v 4.2%) increase in acute renal failure being the most substantial.Conclusion:These findings suggest that prescribing of NSAIDs among OA patients is associated with an increase in negative clinical outcomes. This suggests that new treatment options other than NSAIDs should be evaluated.References:[1]van Laar M, et al. Pain treatment in arthritis-related pain: beyond NSAIDs.Open Rheumatol J. 2012;6:320–330.[2]Nissen SE, et al. Cardiovascular safety of celecoxib, naproxen, or ibuprofen for arthritis.NEJM2016;2519-2529.Disclosure of Interests:Stuart Silverman Consultant of: Pfizer and Eli Lilly for this project., Speakers bureau: Amgen, Radius, James Rice Consultant of: Pfizer and Eli Lilly have funded this project., Alan White Consultant of: Pfizer and Eli Lilly have funded this project., Nguyen Le Consultant of: Pfizer and Eli Lilly have funded this project., Michael Somma Consultant of: Eli Lilly and Pfizer have funded this project., Craig Beck Shareholder of: Pfizer, Employee of: Pfizer, Rebecca Robinson Shareholder of: Eli Lilly, Employee of: Eli Lilly, Patricia Schepman Shareholder of: Pfizer, Employee of: Pfizer
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Sharma R, Zachrison KS, Viswanathan A, Matiello M, Estrada J, Anderson CD, Etherton M, Silverman S, Rost NS, Feske SK, Schwamm LH. Trends in Telestroke Care Delivery: A 15-Year Experience of an Academic Hub and Its Network of Spokes. Circ Cardiovasc Qual Outcomes 2020; 13:e005903. [PMID: 32126805 PMCID: PMC7374496 DOI: 10.1161/circoutcomes.119.005903] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [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] [Indexed: 01/01/2023]
Abstract
BACKGROUND Telestroke provides access to vascular neurology expertise for hospitals lacking stroke coverage, and its use has risen rapidly in the past decade. We aim to characterize consultations, spoke behavior, and the relationship between spoke telestroke utilization (number of telestroke consults per year) and spoke alteplase treatment metrics in an academic telestroke network. METHODS AND RESULTS We analyzed prospectively collected data on all telestroke consults from 2003 to 2018. Trends in network performance and spoke characteristics were analyzed using generalized estimating equations and Kendall τβ nonparametric tests as appropriate. Unadjusted and adjusted linear regression models determined associations between telestroke utilization and treatment metrics. The network included 2 hubs and 43 spokes with 12 803 consults performed during the study period. Network growth overall was +1.8 spokes per year, and median duration of spoke participation was 7.9 years. The numbers of consults and alteplase-treated patients increased annually, even after adjusting for the number of spokes in the network (P<0.01 for both). Although times from last seen well to spoke emergency department arrival and to consult request increased, door-to-needle time, time from teleconsult request to callback, and time from teleconsult to alteplase administration all decreased (all P<0.01). With time, the network included more spokes without a Primary Stroke Center designation. In adjusted analyses, for every 10 telestroke consults requested by a spoke, the spoke door-to-needle decreased by 1.8 minutes (P=0.02), number of patients treated with alteplase was an additional 1.7 (P<0.01), and the percent of eligible patients treated with alteplase increased by 8% (P=0.03). CONCLUSIONS Telestroke network size and utilization increased over time. Increased use of teleconsults was associated with increased and timely use of alteplase. Over time, the delivery of timely emergency care has improved significantly among emergency departments participating in this telestroke network. Replication of these findings in other networks is warranted.
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Affiliation(s)
- Richa Sharma
- Dept of Neurology, Yale University School of Medicine
| | | | - Anand Viswanathan
- Dept of Neurology, Comprehensive Stroke Center, Fireman Vascular Center, Massachusetts General Hospital
| | - Marcelo Matiello
- Dept of Neurology, Comprehensive Stroke Center, Fireman Vascular Center, Massachusetts General Hospital
| | - Juan Estrada
- Dept of Neurology, Comprehensive Stroke Center, Fireman Vascular Center, Massachusetts General Hospital
| | - Christopher D. Anderson
- Dept of Neurology, Comprehensive Stroke Center, Fireman Vascular Center, Massachusetts General Hospital
| | - Mark Etherton
- Dept of Neurology, Comprehensive Stroke Center, Fireman Vascular Center, Massachusetts General Hospital
| | - Scott Silverman
- Dept of Neurology, Comprehensive Stroke Center, Fireman Vascular Center, Massachusetts General Hospital
| | - Natalia S. Rost
- Dept of Neurology, Comprehensive Stroke Center, Fireman Vascular Center, Massachusetts General Hospital
| | | | - Lee H. Schwamm
- Dept of Neurology, Comprehensive Stroke Center, Fireman Vascular Center, Massachusetts General Hospital
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Vasikaran SD, Bhattoa HP, Eastell R, Heijboer AC, Jørgensen NR, Makris K, Ulmer C, Kanis JA, Cooper C, Silverman S, Cavalier E. Harmonization of commercial assays for PINP; the way forward. Osteoporos Int 2020; 31:409-412. [PMID: 31975180 PMCID: PMC7080559 DOI: 10.1007/s00198-020-05310-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 01/20/2020] [Indexed: 12/31/2022]
Abstract
UNLABELLED International Federation of Clinical Chemistry and Laboratory Medicine and The International Osteoporosis Foundation Joint Committee on Bone Metabolism believes that the harmonization of PINP assays is an achievable and practical goal. INTRODUCTION In order to examine the agreement between current commercial assays, a multi-center study was performed for PINP in serum and plasma. METHODS The automated methods for PINP (Roche Cobas and IDS iSYS) gave similar results. A significant proportional bias was observed between the two automated assays and the Orion radioimmunoassay (RIA) for PINP. RESULTS Results from other published studies comparing PINP values among these three assays broadly support our findings. Taken together, these results confirm that harmonized PINP measurements exist between the two automated assays (Roche Cobas and IDS iSYS) when the eGFR is > 30 mL/min/1.73m2, but a significant bias exists between the Orion RIA and the two automated assays. CONCLUSION Therefore, in subjects with normal renal function, PINP results reported by the Roche Cobas and IDS iSYS assays are similar and may be used interchangeably, and similar reference intervals and treatment targets could be applied for the two automated assays. Harmonization between the automated assays and the RIA is potentially possible with the use of common calibrators and the development of a reference method for PINP. This should also help ensure that any new commercial assay developed in the future will attain similar results. IOF and IFCC are committed to working together towards this goal with the cooperation of the reagent manufacturing industry.
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Affiliation(s)
- S D Vasikaran
- PathWest Laboratory Medicine, Fiona Stanley Hospital, Murdoch, WA, Australia.
| | - H P Bhattoa
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - R Eastell
- Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| | - A C Heijboer
- Department of Clinical Chemistry, Endocrine Laboratory, Amsterdam Gastroenterology & Metabolism, Vrije Universiteit Amsterdam and University of Amsterdam, Amsterdam UMC, Amsterdam, Netherlands
| | - N R Jørgensen
- Department of Clinical Biochemistry, Rigshospitalet, DK-2600, Glostrup, Denmark
- OPEN, Odense Patient data Explorative Network, Odense University Hospital/Institute of Clinical Research, University of Southern Denmark, DK-8000, Odense, Denmark
| | - K Makris
- Clinical Biochemistry Department, KAT General Hospital, 14561, Athens, Greece
- Laboratory for Research of the Musculoskeletal System "Th. Garofalidis", Medical School, University of Athens, Athens, Greece
| | - C Ulmer
- Clinical Chemistry Branch, Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Buford, Atlanta, GA, USA
| | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - C Cooper
- The MRC Epidemiology Resource Centre, Southampton General Hospital, University of Southampton, Southampton, UK
| | - S Silverman
- Cedars-Sinai Medical Center and UCLA School of Medicine, Beverly Hills, CA, USA
| | - E Cavalier
- Department of Clinical Chemistry, University of Liège, CHU Sart-Tilman, Domaine du Sart-Tilman, B-4000, Liège, Belgium
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Abstract
PURPOSE OF REVIEW The goal of this paper is to provide the reader with a review of the evidence supporting the surgical and medical management of patients with asymptomatic internal carotid artery (ICA) stenosis. RECENT FINDINGS Based on the results of earlier clinical trials, surgical intervention with carotid endarterectomy (CEA) has long been the preferred method of management for patients with asymptomatic severe carotid stenosis. Carotid artery stenting (CAS) is another less invasive surgical option that has similar outcomes over the long-term. However, more recent improvements in medical management have reduced the risk of stroke in this population to comparable rates seen with CEA. As a result, medical management alone is advocated as well for patients with asymptomatic carotid stenosis. In addition to stenosis severity, there are a number of features of plaque morphology associated with vulnerable plaque that predict future stroke risk. Rates of stroke in patients with asymptomatic severe carotid stenosis with modern surgical techniques, CEA and CAS, are similar to modern medical therapy alone. Both surgery and medical therapy are good treatment options but it is not known which treatment is superior. The Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2), an NIH-sponsored, multicenter, randomized trial that aims to answer this important management decision.
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Affiliation(s)
- Scott Silverman
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
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Dennison EM, Cooper C, Kanis JA, Bruyère O, Silverman S, McCloskey E, Abrahamsen B, Prieto-Alhambra D, Ferrari S. Fracture risk following intermission of osteoporosis therapy. Osteoporos Int 2019; 30:1733-1743. [PMID: 31175404 DOI: 10.1007/s00198-019-05002-w] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [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: 02/06/2019] [Accepted: 03/26/2019] [Indexed: 11/27/2022]
Abstract
Given the widespread practice of recommending drug holidays, we reviewed the impact of medication discontinuation of two common anti-osteoporosis therapies (bisphosphonates and denosumab). Trial evidence suggests the risk of new clinical fractures, and vertebral fracture increases when osteoporosis treatment with bisphosphonates or denosumab is stopped. INTRODUCTION The aim of this paper was to review the available literature to assess what evidence exists to inform clinical decision-making with regard to drug holidays following treatment with bisphosphonates (BiP) or denosumab. METHODS Systematic review. RESULTS Differing pharmacokinetics lead to varying outcomes on stopping therapy. Prospective and retrospective analyses report that the risk of new clinical fractures was 20-40% higher in subjects who stopped BiP treatment, and vertebral fracture risk was approximately doubled. Rapid bone loss has been well described following denosumab discontinuation with an incidence of multiple vertebral fractures around 5%. Studies have not identified risk factors for fracture after stopping treatment other than those that provide an indication for treatment (e.g. prior fracture and low BMD). Studies that considered long-term continuation did not identify increased fracture risk, and reported only very low rates of adverse skeletal events such as atypical femoral fracture. CONCLUSIONS The view that patients on long-term treatment with bisphosphonates or denosumab should always be offered a drug holiday is not supported by the existing evidence. Different pharmacokinetic properties for different therapies require different strategies to manage drug intermission. In contrast, long-term treatment with anti-resorptives is not associated with increased risk of fragility fractures and skeletal adverse events remain rare.
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Affiliation(s)
- E M Dennison
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK.
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, University of Sheffield, Sheffield, UK
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
| | - O Bruyère
- World Health Organization Collaborating Center for Public Health Aspects of Musculoskeletal Health and Ageing, Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - S Silverman
- Cedars-Sinai/UCLA Medical Center and OMC Clinical Research Center, Beverly Hills, CA, USA
| | - E McCloskey
- Academic Unit of Bone Metabolism, Department of Oncology and Metabolism, The Mellanby Centre For Bone Research, University of Sheffield, Sheffield, UK
| | - B Abrahamsen
- Department of Medicine, Holbaek Hospital, Holbaek, Denmark
- OPEN, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - D Prieto-Alhambra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- GREMPAL Research Group, Idiap Jordi Gol and CIBERFes, Universitat Autonoma de Barcelona and Instituto de Salud Carlos III, Barcelona, Spain
| | - S Ferrari
- Division of Bone Disease, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland
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Bhagavatula S, Upadhyaya K, Miller B, Bursch P, Lammers A, Silverman S, Jonas O. 04:21 PM Abstract No. 430 Novel method of implantation and retrieval of a miniature microdevice for in vivo cancer drug evaluation. J Vasc Interv Radiol 2019. [DOI: 10.1016/j.jvir.2018.12.509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Sharma R, Sanborn D, Silverman S, Schwamm L. Abstract WP254: Predictors of Atrial Fibrillation Detection by Mobile Cardiac Output Telemetry After Hospital Discharge for Acute Ischemic Stroke. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp254] [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
Background:
Patients with cryptogenic stroke without atrial fibrillation (AF) detected in the hospital often undergo 30-day mobile cardiac outpatient telemetry (MCOT) to increase the AF detection rate. We sought to determine the clinical and transthoracic echocardiogram (TTE) characteristics associated with AF detection by MCOT.
Methods:
We analyzed a cohort of admissions from 2005 to 2016 with an acute ischemic stroke diagnosis, an inpatient TTE, and an MCOT performed upon discharge. Each admission was treated as a unique observation. Cases with subsequent AF vs. no AF on MCOT were compared by Chi-squared tests if variables were categorical and t-tests if continuous. A multivariable stepwise logistic regression model was created to determine the predictors of AF detection as a function of variables which were significant in univariate analysis and not significantly collinear.
Results:
Of the 4,880 inpatient hospitalizations for acute ischemic stroke with an TTE performed during admission, there were 283 cases which underwent MCOT (10.4 cases/year in 2005-2014, 90 cases/year in 2015-2016). There were 23 (8.10%) cases of AF on MCOT, and they were more likely to be older, white, admitted earlier during the study, and have larger left atrial anterior-posterior and medial-lateral dimensions (Table). A multivariable model demonstrated that age greater than the median of 66 yr (OR 3.25, 1.21-8.74) and left atrial anterior-posterior dimension greater than the median of 40cm (OR 5.86, 2.38-14. 43) were strong predictors of AF detection by MCOT (c-statistic 0.78).
Conclusions:
We observed low rates of AF on 30-day MCOT post-discharge. Left atrial anatomic dimension is predictive of a higher rate of early AF detection after adjusting for age. This TTE feature, coupled with clinical information, may improve patient selection for MCOTs and potentially avoid the need for more expensive implantable loop monitors in those for whom MOCT does not yield an answer.
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Hiligsmann M, Reginster JY, Tosteson ANA, Bukata SV, Saag KG, Gold DT, Halbout P, Jiwa F, Lewiecki EM, Pinto D, Adachi JD, Al-Daghri N, Bruyère O, Chandran M, Cooper C, Harvey NC, Einhorn TA, Kanis JA, Kendler DL, Messina OD, Rizzoli R, Si L, Silverman S. Recommendations for the conduct of economic evaluations in osteoporosis: outcomes of an experts' consensus meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) and the US branch of the International Osteoporosis Foundation. Osteoporos Int 2019; 30:45-57. [PMID: 30382319 PMCID: PMC6331734 DOI: 10.1007/s00198-018-4744-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 10/16/2018] [Indexed: 01/31/2023]
Abstract
Economic evaluations are increasingly used to assess the value of health interventions, but variable quality and heterogeneity limit the use of these evaluations by decision-makers. These recommendations provide guidance for the design, conduct, and reporting of economic evaluations in osteoporosis to improve their transparency, comparability, and methodologic standards. INTRODUCTION This paper aims to provide recommendations for the conduct of economic evaluations in osteoporosis in order to improve their transparency, comparability, and methodologic standards. METHODS A working group was convened by the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis to make recommendations for the design, conduct, and reporting of economic evaluations in osteoporosis, to define an osteoporosis-specific reference case to serve a minimum standard for all economic analyses in osteoporosis, to discuss methodologic challenges and initiate a call for research. A literature review, a face-to-face meeting in New York City (including 11 experts), and a review/approval by a larger group of experts worldwide (including 23 experts in total) were conducted. RESULTS Recommendations on the type of economic evaluation, methods for economic evaluation, modeling aspects, base-case analysis and population, excess mortality, fracture costs and disutility, treatment characteristics, and model validation were provided. Recommendations for reporting economic evaluations in osteoporosis were also made and an osteoporosis-specific checklist was designed that includes items to report when performing an economic evaluation in osteoporosis. Further, 12 minimum criteria for economic evaluations in osteoporosis were identified and 12 methodologic challenges and need for further research were discussed. CONCLUSION While the working group acknowledges challenges and the need for further research, these recommendations are intended to supplement general and national guidelines for economic evaluations, improve transparency, quality, and comparability of economic evaluations in osteoporosis, and maintain methodologic standards to increase their use by decision-makers.
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Affiliation(s)
- M Hiligsmann
- Department of Health Services Research, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands.
| | - J-Y Reginster
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
- Chair for Biomarkers of Chronic Diseases, Biochemistry Department, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - A N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - S V Bukata
- UCLA Orthopaedic Center, Santa Monica, CA, USA
| | - K G Saag
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - D T Gold
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - P Halbout
- International Osteoporosis Foundation, Nyon, Switzerland
| | - F Jiwa
- Patients Societies at the International Osteoporosis Foundation, Osteoporosis Canada, Toronto, Canada
| | - E M Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA
| | - D Pinto
- Department of Physical Therapy, Marquette University, Milwaukee, USA
- Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - J D Adachi
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - N Al-Daghri
- Chair for Biomarkers of Chronic Diseases, Biochemistry Department, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - O Bruyère
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - M Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- UKNIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - N C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - T A Einhorn
- New York University Langone Health, New York, USA
| | - J A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK
- University of Sheffield Medical School, Sheffield, UK
- Mary McKillop Health Institute, Australian Catholic University, Melbourne, Australia
| | - D L Kendler
- University of British Columbia, Vancouver, Canada
| | - O D Messina
- Cosme Argerich Hospital and IRO medical research centre, Buenos Aires, Argentina
| | - R Rizzoli
- Service of Bone Diseases, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - L Si
- The George Institute for Global Health, University of New South Wales, Kensington, NH, Australia
- Centre for the Health Economy, Macquarie University, Sydney, NSW, Australia
| | - S Silverman
- Cedars-Sinai Medical Center, UCLA School of Medicine and the OMC Clinical Research Center, Los Angeles, CA, USA
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Affiliation(s)
- G H Saunders
- VA RR&D National Center for Rehabilitative Auditory Research, Portland, Oregon,United States
| | - M Frederick
- VA RR&D National Center for Rehabilitative Auditory Research, Portland, OR, USA
| | - S Silverman
- VA RR&D National Center for Rehabilitative Auditory Research, Portland, OR, USA
| | - M Arnold
- University of South Florida - Sarasota-Manatee, Sarasota, FL, USA
| | - T Chisolm
- University of South Florida, Tampa, FL, USA
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Frederick M, Silverman S, Laplante-Levesque A, Nielsen C, Saunders G. PROMOTING HEARING HEALTH BEHAVIOR CHANGE IN ADULTS. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.1335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- M Frederick
- VA RR&D National Center for Rehabilitative Auditory Research, Portland, Oregon, United States
| | - S Silverman
- VA RR&D National Center for Rehabilitative Auditory Research, Portland, OR, USA
| | | | - C Nielsen
- Eriksholm Research Center, Snekkersten, Denmark
| | - G Saunders
- VA RR&D National Center for Rehabilitative Auditory Research, Portland, OR, USA
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Scott E, Silverman S, Ah-See ML. Audit of Bone-modifying Treatment in Metastatic Breast Cancer at a Single Breast Unit. Clin Oncol (R Coll Radiol) 2018. [DOI: 10.1016/j.clon.2018.02.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Svedbom A, Borgstöm F, Hernlund E, Ström O, Alekna V, Bianchi ML, Clark P, Curiel MD, Dimai HP, Jürisson M, Kallikorm R, Lember M, Lesnyak O, McCloskey E, Sanders KM, Silverman S, Solodovnikov A, Tamulaitiene M, Thomas T, Toroptsova N, Uusküla A, Tosteson ANA, Jönsson B, Kanis JA. Quality of life for up to 18 months after low-energy hip, vertebral, and distal forearm fractures-results from the ICUROS. Osteoporos Int 2018; 29:557-566. [PMID: 29230511 DOI: 10.1007/s00198-017-4317-4] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 11/13/2017] [Indexed: 11/25/2022]
Abstract
UNLABELLED This study used data from the International Costs and Utilities Related to Osteoporotic fractures Study (ICUROS) to estimate the quality of life (QoL) impact of fracture. Hip, vertebral, and distal forearm fractures incur substantial QoL losses. Hip and vertebral fracture results in markedly impaired QoL for at least 18 months. INTRODUCTION The International Costs and Utilities Related to Osteoporotic fractures Study (ICUROS) is a multinational observational study that aims to describe costs and quality of life (QoL) consequences of osteoporotic fractures. To date, 11 countries have participated in the study: Australia, Austria, Estonia, France, Italy, Lithuania, Mexico, Russia, Spain, the UK, and the USA. The objective of this paper is to describe the QoL impact of hip, vertebral, and distal forearm fracture. METHODS Data were collected at four time-points for five QoL point estimates: within 2 weeks after fracture (including pre-fracture recall) and at 4, 12, and 18 months after fracture. Quality of life was measured as health state utility values (HSUVs) derived from the EQ-5D-3L. Complete case analysis was conducted as the base case with available case and multiple imputation performed as sensitivity analyses. Multivariate analysis was performed to explore predictors of QoL impact of fracture. RESULTS Among 5456 patients enrolled using convenience sampling, 3021 patients were eligible for the base case analysis (1415 hip, 1047 distal forearm, and 559 vertebral fractures). The mean (SD) difference between HSUV before and after fracture for hip, vertebral, and distal forearm fracture was estimated at 0.89 (0.40), 0.67 (0.45), and 0.48 (0.34), respectively (p < 0.001 for all fracture types). Eighteen months after fracture, mean HSUVs were lower than before the fracture in patients with hip fracture (0.66 vs. 0.77 p < 0.001) and vertebral fracture (0.70 vs. 0.83 p < 0.001). Hospitalization and higher recalled pre-fracture QoL were associated with increased QoL impact for all fracture types. CONCLUSIONS Hip, vertebral, and distal forearm fractures incur substantial loss in QoL and for patients with hip or vertebral fracture, QoL is markedly impaired for at least 18 months.
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Affiliation(s)
| | - F Borgstöm
- LIME/MMC, Karolinska Institutet, Stockholm, Sweden
| | | | - O Ström
- LIME/MMC, Karolinska Institutet, Stockholm, Sweden
| | - V Alekna
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - M L Bianchi
- Bone Metabolism Unit, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - P Clark
- Clinical Epidemiology Unit, Hospital Infantil Federico Gómez and Faculty of Medicine UNAM, Mexico City, Mexico
| | - M D Curiel
- Servicio de Medicina Interna/Enfermedades Metabolicas Oseas, Fundacion Jimenez Diaz, Madrid, Spain
- Catedra de Enfermedades Metabolicas Óseas, Universidad Autonoma, Madrid, Spain
| | - H P Dimai
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - M Jürisson
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - R Kallikorm
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - M Lember
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - O Lesnyak
- Ural State Medical University, Yekaterinburg, Russia
- North West Mechnikov State Medical University, St. Petersburg, Russia
| | - E McCloskey
- Academic Unit of Bone Metabolism, Centre for Integrated Research in Musculoskeletal Ageing, Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| | - K M Sanders
- Institute for Health and Ageing, Australian Catholic University, Melbourne, 3000, Australia
| | - S Silverman
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - M Tamulaitiene
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - T Thomas
- INSERM U1059, Lab Biologie Intégrée du Tissu Osseux, Service de Rhumatologie, CHU de Saint-Etienne, Université de Lyon, Saint-Etienne, France
| | - N Toroptsova
- FSBSI "Scientific Research Institute of Rheumatology named after V.A.Nasonova, Moscow, Russia
| | - A Uusküla
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - A N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, PA, USA
| | - B Jönsson
- Stockholm School of Economics, Stockholm, Sweden
| | - J A Kanis
- Institute for Health and Ageing, Australian Catholic University, Melbourne, 3000, Australia
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
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Song B, Deng W, Fisher L, Chou IY, McMullin D, Silverman S, Wang X, Lo EH, Xu Y, Buonanno FS, Ning M. Abstract WP207: Could White Matter Lesion Predict the Risk of Paroxysmal Atrial Fibrillation in Cryptogenic Stroke? Stroke 2018. [DOI: 10.1161/str.49.suppl_1.wp207] [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
Background:
Stroke caused by paroxysmal atrial fibrillation (PAF) can be more severe than other cryptogenic stroke (CS), with higher recurrence rates and requiring different prevention strategies. Therefore, it is important to identify PAF early. Studies showed that age and PR-interval predict PAF, but with only moderate reliability. Additional PAF risk predictors are direly needed to triage cost-effective workup in real time clinical care. Since studies show strong association between white matter lesions (WML) and AFib, we explore whether chronic WML found during acute stroke hospitalization can prospectively predict the risk of PAF after discharge in CS patients.
Method:
Eligible patients were prospectively recruited in accordance with IRB. All patients underwent full cryptogenic stroke workup including MRI/MRA, outpatient cardiac monitor (>30 days), cardiac echo, and hypercoagulable testing.
Results:
Of 1,131 acute ischemic stroke patients enrolled, 126 (11.1%) were diagnosed with first ever CS at discharge. 18 pts were diagnosed with PAF at 1 year after discharge. PAF pts were older, with more incidence of cancer and diabetes, and more severe WML burden (table ). Total Scheltens score independently predicts post-discharge PAF in CS with cut-off value >=6 (sensitivity 76.47%, specificity 62%, p=0.013).
Conclusion:
We found chronic WML burden can prospectively predict later PAF risk in CS stroke patients at acute hospital discharge. To better triage cost-effective outpatient PAF workup, readily available imaging characteristics from acute hospitalization may be an important adjunct for future PAF risk prediction. A larger cohort with additional risk factors is needed to improve prospective prognostic value of WML in the prediction of PAF.
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Affiliation(s)
- Bo Song
- Massachusetts General Hosp and Harvard Med Sch, Boston, MA
| | - Wenjun Deng
- Massachusetts General Hosp and Harvard Med Sch, Boston, MA
| | - Lindsay Fisher
- Massachusetts General Hosp and Harvard Med Sch, Boston, MA
| | - I-ying Chou
- Massachusetts General Hosp and Harvard Med Sch, Boston, MA
| | - David McMullin
- Massachusetts General Hosp and Harvard Med Sch, Boston, MA
| | | | - Xiaoying Wang
- Massachusetts General Hosp and Harvard Med Sch, Boston, MA
| | - Eng H. Lo
- Massachusetts General Hosp and Harvard Med Sch, Boston, MA
| | - Yuming Xu
- Neurology, The First Affiliated Hosp of Zhengzhou Univ, Zhengzhou, China
| | | | - Mingming Ning
- Massachusetts General Hosp and Harvard Med Sch, Boston, MA
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Song B, Chou IY, Deng W, Inglessis I, Elmariah S, Palacios I, Camargo-Faye E, Silverman S, McMullin D, Lo EH, Wang X, Xu Y, Buonanno FS, Ning M. Abstract TP160: May-Thurner Syndrome is Associated With Stroke Due to Paradoxical Embolism. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.tp160] [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
Background:
May-Thurner Syndrome (MTS) is a potential risk factor for cryptogenic stroke (CS). While retrospective reports have found important association with MTS in CS, prospective data has been lacking. In this study, we prospectively explored the epidemiology and clinical correlates of MTS patients with cryptogenic stroke.
Method:
Eligible patients were prospectively recruited in accordance with an IRB-approved protocol. All patients underwent full evaluation of etiopathogenesis of stroke such as MRI/MRA, long-term cardiac telemetry (>30 days), echocardiography, and extensive thrombophilia screen (AT3, FV Leiden, Proteins C and S; prothrombin gene mutations, APLAbs, lipoprotein(a), homocysteine) and 1.5T pelvic MRV.
Results:
We prospectively recruited 1,131 acute ischemic stroke patients, with 59 patients with PFO-related CS; 15 (40.5%) had May-Thurner anatomy (MTA), and 6 (16.2%) had MTS. MTS pts are younger (36.33±9.95 vs. 53.35±14.78, p=0.011), with a lower trend for BMI (24.40±4.87 V.S. 31.13±8.75, p=0.051, table 1). Lower BMI is predictive of MTS in CS (<=22) with high specificity 93.3% (AUC=0.756, p=0.007).
Conclusion:
In this prospective study, we found MTA and MTS to be very common in PFO CS patients - especially in younger patients with lower BMI and without traditional stroke risk factors. MTS is a novel risk factor that may aide in the diagnosis of PFO CS, and needs further study.
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Affiliation(s)
- Bo Song
- Neurology, Massachusetts General Hosp and Harvard Med Sch, Boston, MA
| | - I-ying Chou
- Neurology, Massachusetts General Hosp and Harvard Med Sch, Boston, MA
| | - Wenjun Deng
- Neurology, Massachusetts General Hosp and Harvard Med Sch, Boston, MA
| | - Ignacio Inglessis
- Neurology, Massachusetts General Hosp and Harvard Med Sch, Boston, MA
| | - Sammy Elmariah
- Neurology, Massachusetts General Hosp and Harvard Med Sch, Boston, MA
| | - Igor Palacios
- Neurology, Massachusetts General Hosp and Harvard Med Sch, Boston, MA
| | | | - Scott Silverman
- Neurology, Massachusetts General Hosp and Harvard Med Sch, Boston, MA
| | - David McMullin
- Neurology, Massachusetts General Hosp and Harvard Med Sch, Boston, MA
| | - Eng H. Lo
- Neurology, Massachusetts General Hosp and Harvard Med Sch, Boston, MA
| | - Xiaoying Wang
- Neurology, Massachusetts General Hosp and Harvard Med Sch, Boston, MA
| | - Yuming Xu
- Neurology, Massachusetts General Hosp and Harvard Med Sch, Boston, MA
| | | | - Mingming Ning
- Neurology, Massachusetts General Hosp and Harvard Med Sch, Boston, MA
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Litwic AE, Compston JE, Wyman A, Siris ES, Gehlbach SH, Adachi JD, Chapurlat R, Díez-Pérez A, LaCroix AZ, Nieves JW, Netelenbos JC, Pfeilschifter J, Rossini M, Roux C, Saag KG, Silverman S, Watts NB, Greenspan SL, March L, Gregson CL, Cooper C, Dennison EM. Self-perception of fracture risk: what can it tell us? Osteoporos Int 2017; 28:3495-3500. [PMID: 28861636 PMCID: PMC5759929 DOI: 10.1007/s00198-017-4200-3] [Citation(s) in RCA: 7] [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: 03/16/2017] [Accepted: 08/16/2017] [Indexed: 11/28/2022]
Abstract
UNLABELLED In this study, we report that self-perception of fracture risk captures some aspect of fracture risk not currently measured using conventional fracture prediction tools and is associated with improved medication uptake. It suggests that adequate appreciation of fracture risk may be beneficial and lead to greater healthcare engagement and treatment. INTRODUCTION This study aimed to assess how well self-perception of fracture risk, and fracture risk as estimated by the fracture prediction tool FRAX, related to fracture incidence and uptake and persistence of anti-osteoporosis medication among women participating in the Global Longitudinal study of Osteoporosis in Women (GLOW). METHODS GLOW is an international cohort study involving 723 physician practices across 10 countries in Europe, North America and Australia. Aged ≥ 55 years, 60,393 women completed baseline questionnaires detailing medical history, including co-morbidities, fractures and self-perceived fracture risk (SPR). Annual follow-up included self-reported incident fractures and anti-osteoporosis medication (AOM) use. We calculated FRAX risk without bone mineral density measurement. RESULTS Of the 39,241 women with at least 1 year of follow-up data, 2132 (5.4%) sustained an incident major osteoporotic fracture over 5 years of follow-up. Within each SPR category, risk of fracture increased as the FRAX categorisation of risk increased. In GLOW, only 11% of women with a lower baseline SPR were taking AOM at baseline, compared with 46% of women with a higher SPR. AOM use tended to increase in the years after a reported fracture. However, women with a lower SPR who were fractured still reported lower AOM rates than women with or without a fracture but had a higher SPR. CONCLUSIONS These results suggest that SPR captures some aspect of fracture risk not currently measured using conventional fracture prediction tools and is also associated with improved medication uptake.
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Affiliation(s)
- A E Litwic
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK
| | | | - A Wyman
- Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA, USA
| | - E S Siris
- Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - S H Gehlbach
- Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA, USA
| | - J D Adachi
- St. Joseph's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - R Chapurlat
- INSERM U831, Division of Rheumatology, Hôpital E. Herriot, Université de Lyon, Lyon, France
| | - A Díez-Pérez
- Hospital del Mar-IMIM-Autonomous, University of Barcelona, Barcelona, Spain
| | - A Z LaCroix
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - J W Nieves
- Helen Hayes Hospital and Columbia University, West Haverstraw, NY, USA
| | - J C Netelenbos
- Department of Endocrinology, VU University Medical Center, Amsterdam, The Netherlands
| | - J Pfeilschifter
- Department of Internal Medicine III, Alfried Krupp Krankenhaus, Essen, Germany
| | - M Rossini
- Department of Rheumatology, University of Verona, Verona, Italy
| | - C Roux
- Cochin Hospital, Paris Descartes University, Paris, France
| | - K G Saag
- University of Alabama-Birmingham, Birmingham, AL, USA
| | - S Silverman
- Department of Rheumatology, Cedars-Sinai/UCLA, Los Angeles, CA, USA
| | - N B Watts
- Bone Health and Osteoporosis Center, University of Cincinnati, Cincinnati, OH, USA
| | | | - L March
- Faculty of Medicine and Department of Public Health, University of Sydney, Sydney, Australia
| | - C L Gregson
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK
- Musculoskeletal Research Unit, Learning and Research Building, Southmead Hospital, University of Bristol, Bristol, UK
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK
- Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - E M Dennison
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK.
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Tharmalingam H, Tsang Y, Duong J, Silverman S, Brooks C, Harrison M. Clinical Experience of Stereotactic Ablative Body Radiation Therapy for the Treatment of Oligometastases Originating from Lower Gastrointestinal Primary Malignancies. Int J Radiat Oncol Biol Phys 2017. [DOI: 10.1016/j.ijrobp.2017.06.1060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Diez-Perez A, Naylor KE, Abrahamsen B, Agnusdei D, Brandi ML, Cooper C, Dennison E, Eriksen EF, Gold DT, Guañabens N, Hadji P, Hiligsmann M, Horne R, Josse R, Kanis JA, Obermayer-Pietsch B, Prieto-Alhambra D, Reginster JY, Rizzoli R, Silverman S, Zillikens MC, Eastell R. International Osteoporosis Foundation and European Calcified Tissue Society Working Group. Recommendations for the screening of adherence to oral bisphosphonates. Osteoporos Int 2017; 28:767-774. [PMID: 28093634 PMCID: PMC5302161 DOI: 10.1007/s00198-017-3906-6] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 01/02/2017] [Indexed: 11/29/2022]
Abstract
Adherence to oral bisphosphonates is low. A screening strategy is proposed based on the response of biochemical markers of bone turnover after 3 months of therapy. If no change is observed, the clinician should reassess the adherence to the treatment and also other potential issues with the drug. INTRODUCTION Low adherence to oral bisphosphonates is a common problem that jeopardizes the efficacy of treatment of osteoporosis. No clear screening strategy for the assessment of compliance is widely accepted in these patients. METHODS The International Osteoporosis Foundation and the European Calcified Tissue Society have convened a working group to propose a screening strategy to detect a lack of adherence to these drugs. The question to answer was whether the bone turnover markers (BTMs) PINP and CTX can be used to identify low adherence in patients with postmenopausal osteoporosis initiating oral bisphosphonates for osteoporosis. The findings of the TRIO study specifically address this question and were used as the basis for testing the hypothesis. RESULTS Based on the findings of the TRIO study, specifically addressing this question, the working group recommends measuring PINP and CTX at baseline and 3 months after starting therapy to check for a decrease above the least significant change (decrease of more than 38% for PINP and 56% for CTX). Detection rate for the measurement of PINP is 84%, for CTX 87% and, if variation in at least one is considered when measuring both, the level of detection is 94.5%. CONCLUSIONS If a significant decrease is observed, the treatment can continue, but if no decrease occurs, the clinician should reassess to identify problems with the treatment, mainly low adherence.
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Affiliation(s)
- A Diez-Perez
- Department of Internal Medicine, Hospital del Mar-IMIM-Universitat Autònoma and CIBERFES-ISCIII, P Maritim 25-29, 08003, Barcelona, Spain.
| | - K E Naylor
- Academic Unit of Bone Metabolism, Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| | - B Abrahamsen
- Institute of Clinical Research, Odense Patient Data Explorative Network, University of Southern Denmark, Odense, Denmark
- Department of Medicine, Holbæk Hospital, Holbæk, Denmark
| | - D Agnusdei
- Independent Scientific Consultant, Florence, Italy
| | - M L Brandi
- Mineral and Bone Metabolic Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, UK
- NIHR Musculoskeletal Biomedical Research Unit, Institute of Musculoskeletal Sciences, University of Oxford, and CIBERFES-ISCIII, Oxford, UK
| | - E Dennison
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, UK
| | - E F Eriksen
- Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - D T Gold
- Duke University Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, USA
| | - N Guañabens
- Rheumatology Department, Hospital Clínic, University of Barcelona, CIBERehd, Barcelona, Spain
| | - P Hadji
- Department of Bone Oncology, Endocrinology and Reproductive Medicine, Nordwest Hospital, Frankfurt, Germany
| | - M Hiligsmann
- Department of Health Services Research, School for Public Health & Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - R Horne
- Centre for Behavioural Medicine, UCL School of Pharmacy, University College London, London, UK
| | - R Josse
- Department of Nutritional Sciences and Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - J A Kanis
- Centre for Metabolic Bone Diseases, Centre for Integrated Research in Musculoskeletal Ageing, University of Sheffield, Sheffield, UK
| | - B Obermayer-Pietsch
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - D Prieto-Alhambra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - J-Y Reginster
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
| | - R Rizzoli
- Service of Bone Diseases, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - S Silverman
- Cedars-Sinai/University of California, Los Angeles, USA
| | - M C Zillikens
- Department of Internal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - R Eastell
- Academic Unit of Bone Metabolism, Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
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Deng W, Wickham T, Fisher L, Oyer M, Chou IYR, Song B, Silverman S, McMullin D, Inglessis-Azuaje I, Palacios I, Buonanno FS, Lo EH, Ning M. Abstract 111: Plasma Levels of Oxidative Stress Marker ADMA (Asymmetric Dimethylarginine) is Reduced by Successful PFO Closure. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.111] [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
Background:
Patent foramen ovale (PFO) is an independent risk factor of ischemic stroke. It enables the mixing of venous and arterial blood and therefore serves as a conduit for venous clots and vasoactive factors to enter into arterial circulation and contribute to a prothrombotic status. Asymmetric dimethylarginine (ADMA), an endogenous competitive inhibitor of nitric oxide synthase, contributes to vascular disease and has been linked with increased levels of homocysteine, which creates additional oxidative stress by decreasing the production of dimethylarginine dimethlyaminohydrolase (DDAH) and further inhibiting the clearance of ADMA. We previously identified a significant reduction of homocysteine by PFO closure. Here we study the influence of PFO on ADMA levels, a marker of oxidative stress.
Method:
97 PFO-related stroke patients were prospectively recruited in accordance with IRB, of which 61 received PFO closure and 36 underwent medical therapy alone. Peripheral venous blood was collected at baseline (BL) and 1 year follow-up (FU) post treatments. Plasma ADMA was quantified by mass spectrometry.
Result:
Compared to baseline, plasma ADMA levels were statistically significantly reduced post PFO closure (p = 0.0026), while no changes were observed for the patients treated with medications alone (p = 0.5500) (Figure 1A). Moreover, among the patients receiving PFO closure, the reduction of ADMA was only pronounced for those without residual shunting (p = 0.0009) but not for those with residual shunting (p = 0.4557) (Figure 1B, C).
Conclusion:
PFO closure reduced oxidative stress marker ADMA in the circulation, but no changes were observed in patients on medical treatment only or those with residual shunting post PFO closure. Our results support the hypothesis that PFO-related right-to-left interatrial blood shunting may causally contribute to the high level of vasoactive factors in circulation. Further studies on an expanded cohort of PFO patients are ongoing.
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Affiliation(s)
| | | | | | | | | | - Bo Song
- Massachusetts General Hosp, Boston, MA
| | | | | | | | | | | | - Eng H Lo
- Massachusetts General Hosp, Boston, MA
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Frenk N, Fintelmann F, Daye D, Shyn P, Arellano R, Silverman S, Uppot R. Local tumor control and survival after image-guided thermal ablation of adrenal gland metastases. J Vasc Interv Radiol 2017. [DOI: 10.1016/j.jvir.2016.12.791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Adams AL, Xue F, Chantra JQ, Dell RM, Ott SM, Silverman S, Giaconi JC, Critchlow C. Sensitivity and specificity of radiographic characteristics in atypical femoral fractures. Osteoporos Int 2017; 28:413-417. [PMID: 27766369 DOI: 10.1007/s00198-016-3809-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/11/2016] [Indexed: 12/30/2022]
Abstract
UNLABELLED Using the American Society for Bone and Mineral Research Task Force case definition for atypical femoral fractures, sensitivity and specificity of radiographic fracture characteristics were calculated. Fracture pattern was the most sensitive and specific characteristic. This suggests that some characteristics should be weighted more heavily when identifying these fractures. INTRODUCTION To estimate the sensitivity and specificity of each radiographic criterion in the 2013 ASBMR atypical femoral fracture (AFF) case definition for distinguishing AFF from other subtrochanteric/diaphyseal fractures (non-AFF) among women enrolled in a large integrated health care organization. METHODS Radiographs from 55 physician-confirmed AFFs and a sample of 39 non-AFFs were reviewed by four independent expert reviewers representing four medical specialties. One image per fracture was selected for review. Using a standardized data collection tool, based on the 2013 AFF case definition, reviewers indicated the presence or absence of the following characteristics viewable on radiograph: fracture pattern, comminution, periosteal and/or endosteal thickening, and cortical thickening. Sensitivity and specificity for each characteristic was calculated for each reviewer and summarized across reviewers with the mean and range. Agreement across reviewers was quantified using Fleiss's kappa (FK) statistic. RESULTS The most sensitive factors distinguishing AFF from non-AFF were lateral cortex transverse fracture pattern (mean 93.6 %, range 85.5-98.2 %), medial cortex transverse or oblique fracture pattern (mean 84.1 %, range 72.7-98.2 %), and minimal/non-comminution (mean 93.2 %, range 89.1-98.2 %). Specificity was the greatest for lateral cortex transverse fracture pattern (mean 95.5 %, range 92.3-97.4 %). Agreement across reviewers was the highest for lateral cortex transverse fracture pattern (FK 0.83) and incomplete fracture through the lateral cortex only (FK 0.80). CONCLUSION Lateral cortex transverse fracture pattern was the most sensitive and specific characteristic and the most highly agreed upon across reviewers. Other characteristics were less readily agreed upon across reviewers. Measurement of discrete combinations of individual characteristics may enhance sensitivity and/or specificity.
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Affiliation(s)
- A L Adams
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, 2nd Floor, Pasadena, CA, 91101, USA.
| | - F Xue
- Center for Observational Research, Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA, 91320, USA
| | - J Q Chantra
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave, 2nd Floor, Pasadena, CA, 91101, USA
| | - R M Dell
- Department of Orthopedic Surgery, Kaiser Permanente Southern California, 9333 Imperial Hwy, Downey, CA, 90242, USA
| | - S M Ott
- Department of Medicine, University of Washington, 1959 NE Pacific Street, UW Mailbox 356426, Seattle, WA, 98195, USA
| | - S Silverman
- Department of Rheumatology, Cedars-Sinai/UCLA, 200 UCLA Medical Plaza, Los Angeles, CA, 90095, USA
| | - J C Giaconi
- Cedars Sinai Imaging Medical Group, Cedars Sinai Medical Center, 8700 Beverly Blvd.,, Los Angeles, CA, 90048, USA
| | - C Critchlow
- Center for Observational Research, Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA, 91320, USA
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Blain H, Masud T, Dargent-Molina P, Martin F, Rosendahl E, van der Velde N, Bousquet J, Benetos A, Cooper C, Kanis J, Reginster J, Rizzoli R, Cortet B, Barbagallo M, Dreinhöfer K, Vellas B, Maggi S, Strandberg T, Alvarez M, Annweiler C, Bernard PL, Beswetherick N, Bischoff-Ferrari H, Bloch F, Boddaert J, Bonnefoy M, Bousson V, Bourdel-Marchasson I, Capisizu A, Che H, Clara J, Combe B, Delignieres D, Eklund P, Emmelot-Vonk M, Freiberger E, Gauvain JB, Goswami N, Guldemond N, Herrero Á, Joël ME, Jónsdóttir A, Kemoun G, Kiss I, Kolk H, Kowalski M, Krajcík Š, Kutsal Y, Lauretani F, Macijauskienė J, Mellingsæter M, Morel J, Mourey F, Nourashemi F, Nyakas C, Puisieux F, Rambourg P, Ramírez A, Rapp K, Rolland Y, Ryg J, Sahota O, Snoeijs S, Stephan Y, Thomas E, Todd C, Treml J, Adachi R, Agnusdei D, Body JJ, Breuil V, Bruyère O, Burckardt P, Cannata-Andia J, Carey J, Chan DC, Chapuis L, Chevalley T, Cohen-Solal M, Dawson-Hughes B, Dennison E, Devogelaer JP, Fardellone P, Féron JM, Perez A, Felsenberg D, Glueer C, Harvey N, Hiligsman M, Javaid M, Jörgensen N, Kendler D, Kraenzlin M, Laroche M, Legrand E, Leslie W, Lespessailles E, Lewiecki E, Nakamura T, Papaioannou A, Roux C, Silverman S, Henriquez M, Thomas T, Vasikaran S, Watts N, Weryha G. A comprehensive fracture prevention strategy in older adults: The European union geriatric medicine society (EUGMS) statement. Eur Geriatr Med 2016. [DOI: 10.1016/j.eurger.2016.04.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Ali SF, Siddiqui K, Ay H, Silverman S, Singhal A, Viswanathan A, Rost N, Lev M, Schwamm LH. Baseline Predictors of Poor Outcome in Patients Too Good to Treat With Intravenous Thrombolysis. Stroke 2016; 47:2986-2992. [PMID: 27834750 DOI: 10.1161/strokeaha.116.014871] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [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: 07/22/2016] [Revised: 09/13/2016] [Accepted: 10/05/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Several studies have reported poor outcomes in patients too good to treat with intravenous thrombolysis because of mild or rapidly improving symptoms. We sought to determine baseline clinical and imaging predictors of poor outcome in these patients. METHODS Among 3950 consecutive stroke admissions (2009-2015) in our local Get With the Guidelines-Stroke database, 632 patients presented ≤4.5 hours and did not receive tissue-type plasminogen activator, with 380 of 632 (60.1%) being too good to treat. Univariate and multivariable analyses explored the clinical and imaging features associated with poor outcome (defined as not being discharged to home) in these 380 cases. RESULTS Among these 380 cases, only 68% were discharged home; the other 25% to inpatient rehabilitation, 4% to a skilled nursing facility, and 3% expired or were discharged to hospice. Patients with poor outcome were older, were more often Hispanic, had more vascular risk factors, and had higher median National Institutes of Health Stroke Scale. Imaging characteristics associated with poor outcomes included large or multifocal infarction and poor collaterals. In multivariable analysis, only age, initial National Institutes of Health Stroke Scale, and infarct location were independently associated with poor outcome. CONCLUSIONS Approximately one third of patients deemed too good for intravenous tissue-type plasminogen activator are unable to be discharged directly to home. Given the current safety profile of intravenous tissue-type plasminogen activator, our results suggest that the concept of being too good to treat should be re-examined with an emphasis on the features associated with poor outcome identified in our study. If replicated, these findings could be incorporated into tissue-type plasminogen activator decision-making algorithms.
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Affiliation(s)
- Syed F Ali
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Khawja Siddiqui
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Hakan Ay
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Scott Silverman
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Aneesh Singhal
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Anand Viswanathan
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Natalia Rost
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Michael Lev
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Lee H Schwamm
- From the Department of Neurology, Massachusetts General Hospital, Boston.
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Abstract
In this preliminary study we explored the possibility of an immunologic component in oral lichen planus by assessment of serum immunoglobulins and complement levels, by skin tests for cellular immunity, and by fluorescent antibody techniques to detect immunoglobulins in the lesions. Although certain abnormalities were noted, none was consistent or of significant magnitude to clarify the cause of this disease.
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Affiliation(s)
- M. Griffith
- Departments of Oral Biology and Dermatology, Schools of Dentistry and Medicine, University of California, San Francsico, California 94143, USA
| | - H.S. Kaufman
- Departments of Oral Biology and Dermatology, Schools of Dentistry and Medicine, University of California, San Francsico, California 94143, USA
| | - S. Silverman
- Departments of Oral Biology and Dermatology, Schools of Dentistry and Medicine, University of California, San Francsico, California 94143, USA
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Abstract
A method for measuring the modu lus of elasticity of fibers and films by sonic means is described, and the results of an exploratory study of this modulus in various nat ural and synthetic fib ers and films are given. The method is based on the equation for the prop agation of longitudinal (sound) waves in elastic materials, which expresses the velocity of propa gation in terms of the elastic modulus and density of the me dium. The procedure involves measuring the sound velocity and calculating the modulus, using the proper density value. The modu lus so calculated is characteristic of a dynamic, essentially adiabatic, high-loading rate, short period measurement, since a sound fre quency of approximately 10,000 cycles per second was used. The range of moduli for common textile materials was from 1 X 1010 to 50 X 1010 dynes per square centi meter.
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Affiliation(s)
- J.W. Ballou
- E.I. duPont de Nemours and Company, Buffalo, N. Y
| | - S. Silverman
- E.I. duPont de Nemours and Company, Buffalo, N. Y
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Rost NS, Giugliano RP, Ruff CT, Murphy SA, Crompton AE, Norden AD, Silverman S, Singhal AB, Nicolau JC, SomaRaju B, Mercuri MF, Antman EM, Braunwald E. Outcomes With Edoxaban Versus Warfarin in Patients With Previous Cerebrovascular Events. Stroke 2016; 47:2075-82. [DOI: 10.1161/strokeaha.116.013540] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 05/24/2016] [Indexed: 02/01/2023]
Abstract
Background and Purpose—
Patients with atrial fibrillation and previous ischemic stroke (IS)/transient ischemic attack (TIA) are at high risk of recurrent cerebrovascular events despite anticoagulation. In this prespecified subgroup analysis, we compared warfarin with edoxaban in patients with versus without previous IS/TIA.
Methods—
ENGAGE AF-TIMI 48 (Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction 48) was a double-blind trial of 21 105 patients with atrial fibrillation randomized to warfarin (international normalized ratio, 2.0–3.0; median time-in-therapeutic range, 68.4%) versus once-daily edoxaban (higher-dose edoxaban regimen [HDER], 60/30 mg; lower-dose edoxaban regimen, 30/15 mg) with 2.8-year median follow-up. Primary end points included all stroke/systemic embolic events (efficacy) and major bleeding (safety). Because only HDER is approved, we focused on the comparison of HDER versus warfarin.
Results—
Of 5973 (28.3%) patients with previous IS/TIA, 67% had CHADS
2
(congestive heart failure, hypertension, age, diabetes, prior stroke/transient ischemic attack) >3 and 36% were ≥75 years. Compared with 15 132 without previous IS/TIA, patients with previous IS/TIA were at higher risk of both thromboembolism and bleeding (stroke/systemic embolic events 2.83% versus 1.42% per year;
P
<0.001; major bleeding 3.03% versus 2.64% per year;
P
<0.001; intracranial hemorrhage, 0.70% versus 0.40% per year;
P
<0.001). Among patients with previous IS/TIA, annualized intracranial hemorrhage rates were lower with HDER than with warfarin (0.62% versus 1.09%; absolute risk difference, 47 [8–85] per 10 000 patient-years; hazard ratio, 0.57; 95% confidence interval, 0.36–0.92;
P
=0.02). No treatment subgroup interactions were found for primary efficacy (
P
=0.86) or for intracranial hemorrhage (
P
=0.28).
Conclusions—
Patients with atrial fibrillation with previous IS/TIA are at high risk of recurrent thromboembolism and bleeding. HDER is at least as effective and is safer than warfarin, regardless of the presence or the absence of previous IS or TIA.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00781391.
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Affiliation(s)
- Natalia S. Rost
- From the Massachusetts General Hospital, Boston (N.S.R., S.S., A.B.S.); TIMI Study Group, Cardiovascular Medicine, Brigham and Women’s Hospital, Boston MA (R.P.G., C.T.R., S.A.M., A.E.C., A.D.N., E.M.A., E.B.); Heart Institute (InCor), University of São Paulo Medical School, Brazil (J.C.N.); CARE Musheerabad, Hyderabad, India (B.S.); and Daiichi-Sankyo Pharma Development, Edison, NJ (M.F.M.)
| | - Robert P. Giugliano
- From the Massachusetts General Hospital, Boston (N.S.R., S.S., A.B.S.); TIMI Study Group, Cardiovascular Medicine, Brigham and Women’s Hospital, Boston MA (R.P.G., C.T.R., S.A.M., A.E.C., A.D.N., E.M.A., E.B.); Heart Institute (InCor), University of São Paulo Medical School, Brazil (J.C.N.); CARE Musheerabad, Hyderabad, India (B.S.); and Daiichi-Sankyo Pharma Development, Edison, NJ (M.F.M.)
| | - Christian T. Ruff
- From the Massachusetts General Hospital, Boston (N.S.R., S.S., A.B.S.); TIMI Study Group, Cardiovascular Medicine, Brigham and Women’s Hospital, Boston MA (R.P.G., C.T.R., S.A.M., A.E.C., A.D.N., E.M.A., E.B.); Heart Institute (InCor), University of São Paulo Medical School, Brazil (J.C.N.); CARE Musheerabad, Hyderabad, India (B.S.); and Daiichi-Sankyo Pharma Development, Edison, NJ (M.F.M.)
| | - Sabina A. Murphy
- From the Massachusetts General Hospital, Boston (N.S.R., S.S., A.B.S.); TIMI Study Group, Cardiovascular Medicine, Brigham and Women’s Hospital, Boston MA (R.P.G., C.T.R., S.A.M., A.E.C., A.D.N., E.M.A., E.B.); Heart Institute (InCor), University of São Paulo Medical School, Brazil (J.C.N.); CARE Musheerabad, Hyderabad, India (B.S.); and Daiichi-Sankyo Pharma Development, Edison, NJ (M.F.M.)
| | - Andrea E. Crompton
- From the Massachusetts General Hospital, Boston (N.S.R., S.S., A.B.S.); TIMI Study Group, Cardiovascular Medicine, Brigham and Women’s Hospital, Boston MA (R.P.G., C.T.R., S.A.M., A.E.C., A.D.N., E.M.A., E.B.); Heart Institute (InCor), University of São Paulo Medical School, Brazil (J.C.N.); CARE Musheerabad, Hyderabad, India (B.S.); and Daiichi-Sankyo Pharma Development, Edison, NJ (M.F.M.)
| | - Andrew D. Norden
- From the Massachusetts General Hospital, Boston (N.S.R., S.S., A.B.S.); TIMI Study Group, Cardiovascular Medicine, Brigham and Women’s Hospital, Boston MA (R.P.G., C.T.R., S.A.M., A.E.C., A.D.N., E.M.A., E.B.); Heart Institute (InCor), University of São Paulo Medical School, Brazil (J.C.N.); CARE Musheerabad, Hyderabad, India (B.S.); and Daiichi-Sankyo Pharma Development, Edison, NJ (M.F.M.)
| | - Scott Silverman
- From the Massachusetts General Hospital, Boston (N.S.R., S.S., A.B.S.); TIMI Study Group, Cardiovascular Medicine, Brigham and Women’s Hospital, Boston MA (R.P.G., C.T.R., S.A.M., A.E.C., A.D.N., E.M.A., E.B.); Heart Institute (InCor), University of São Paulo Medical School, Brazil (J.C.N.); CARE Musheerabad, Hyderabad, India (B.S.); and Daiichi-Sankyo Pharma Development, Edison, NJ (M.F.M.)
| | - Aneesh B. Singhal
- From the Massachusetts General Hospital, Boston (N.S.R., S.S., A.B.S.); TIMI Study Group, Cardiovascular Medicine, Brigham and Women’s Hospital, Boston MA (R.P.G., C.T.R., S.A.M., A.E.C., A.D.N., E.M.A., E.B.); Heart Institute (InCor), University of São Paulo Medical School, Brazil (J.C.N.); CARE Musheerabad, Hyderabad, India (B.S.); and Daiichi-Sankyo Pharma Development, Edison, NJ (M.F.M.)
| | - José C. Nicolau
- From the Massachusetts General Hospital, Boston (N.S.R., S.S., A.B.S.); TIMI Study Group, Cardiovascular Medicine, Brigham and Women’s Hospital, Boston MA (R.P.G., C.T.R., S.A.M., A.E.C., A.D.N., E.M.A., E.B.); Heart Institute (InCor), University of São Paulo Medical School, Brazil (J.C.N.); CARE Musheerabad, Hyderabad, India (B.S.); and Daiichi-Sankyo Pharma Development, Edison, NJ (M.F.M.)
| | - Bhupathi SomaRaju
- From the Massachusetts General Hospital, Boston (N.S.R., S.S., A.B.S.); TIMI Study Group, Cardiovascular Medicine, Brigham and Women’s Hospital, Boston MA (R.P.G., C.T.R., S.A.M., A.E.C., A.D.N., E.M.A., E.B.); Heart Institute (InCor), University of São Paulo Medical School, Brazil (J.C.N.); CARE Musheerabad, Hyderabad, India (B.S.); and Daiichi-Sankyo Pharma Development, Edison, NJ (M.F.M.)
| | - Michele F. Mercuri
- From the Massachusetts General Hospital, Boston (N.S.R., S.S., A.B.S.); TIMI Study Group, Cardiovascular Medicine, Brigham and Women’s Hospital, Boston MA (R.P.G., C.T.R., S.A.M., A.E.C., A.D.N., E.M.A., E.B.); Heart Institute (InCor), University of São Paulo Medical School, Brazil (J.C.N.); CARE Musheerabad, Hyderabad, India (B.S.); and Daiichi-Sankyo Pharma Development, Edison, NJ (M.F.M.)
| | - Elliott M. Antman
- From the Massachusetts General Hospital, Boston (N.S.R., S.S., A.B.S.); TIMI Study Group, Cardiovascular Medicine, Brigham and Women’s Hospital, Boston MA (R.P.G., C.T.R., S.A.M., A.E.C., A.D.N., E.M.A., E.B.); Heart Institute (InCor), University of São Paulo Medical School, Brazil (J.C.N.); CARE Musheerabad, Hyderabad, India (B.S.); and Daiichi-Sankyo Pharma Development, Edison, NJ (M.F.M.)
| | - Eugene Braunwald
- From the Massachusetts General Hospital, Boston (N.S.R., S.S., A.B.S.); TIMI Study Group, Cardiovascular Medicine, Brigham and Women’s Hospital, Boston MA (R.P.G., C.T.R., S.A.M., A.E.C., A.D.N., E.M.A., E.B.); Heart Institute (InCor), University of São Paulo Medical School, Brazil (J.C.N.); CARE Musheerabad, Hyderabad, India (B.S.); and Daiichi-Sankyo Pharma Development, Edison, NJ (M.F.M.)
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Deng W, Wickham T, McMullin D, Feeney K, Silverman S, Inglessis I, Palacios I, Lo EH, Buonanno FS, Ning M. MP6: HOMOCYSTEINE LEVEL IN PFO RELATED STROKE PATIENTS WITH RESPECT TO MEDICAL THERAPY VS PFO CLOSURE. J Investig Med 2016. [DOI: 10.1136/jim-2016-000080.18] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Purpose of StudyHomocysteine is an independent risk factor of ischemic stroke by promoting vascular endothelial dysfunction and thrombotic process through oxidative stress. We previously found that PFO closure may reduce total homocysteine level (tHcy) in plasma. Here, we compare the effect of PFO closure and medical treatment in reducing mild homocysteinemia in PFO-related stroke patients.Methods Used28 PFO-related stroke patients with mildly elevated tHcy (>12 µmol/l) were prospectively recruited in accordance with IRB. 14 received PFO closure and 14 were treated by medical therapy (antiplatelet/anticoagulant) alone. None of the patients were on folate or vitamin B supplementation. Plasma was collected at baseline and 1 year follow-up after treatment. tHcy level was determined by selected reaction monitoring using mass spectrometry.Summary of ResultsCompared to medical therapy, PFO closure resulted in a lower tHcy level during follow-up (PFO closure: 11.13±3.94 µmol/L, medical therapy: 15.48±3.55 µmol/L, p=0.006), with no difference at baseline (PFO closure: 17.77±4.39 µmol/L, medical therapy: 16.47±7.50 µmol/L, p=0.575). Mild hyperhomocysteinemia patients post PFO closure had a significant reduction of tHcy by 37.34% (p=0.0005), with 71.43% of the patients (10 of 14) having tHcy levels back to normal (<12 µmol/l), while most of medically treated patients (13 of 14) stayed abnormal (p=0.4820) (χ2-test, adjusted p=0.002).ConclusionsWe found that compared with routine medical therapy, PFO closure reduced tHcy level in patients with mild hyperhomocysteinemia. Since PFO stroke patients tend to be younger, the life-time risk of even mildly elevated tHcy may be important for future thrombotic risk. Understanding the mechanism of PFO-related tHcy changes is important in optimizing medical treatment (e.g, folate replacement); studies are ongoing.Abstract MP6 Figure 1
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Deng W, Wickham T, McMullin D, Feeney K, Silverman S, Inglessis I, Palacios I, Lo EH, Buonanno F, Ning M. Abstract TP443: Homocysteine Level in PFO Related Stroke Patients With Respect to Medical Therapy vs PFO Closure. Stroke 2016. [DOI: 10.1161/str.47.suppl_1.tp443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Homocysteine is an independent risk factor of ischemic stroke by promoting vascular endothelial dysfunction and thrombotic process through oxidative stress. We previously found that PFO closure may reduce total homocysteine level (tHcy) in plasma. Here, we compare the effect of PFO closure and medical treatment in reducing mild homocysteinemia in PFO-related stroke patients.
Method:
28 PFO-related stroke patients with mildly elevated tHcy (>12 μmol/l) were prospectively recruited in accordance with IRB. 14 received PFO closure and 14 were treated by medical therapy (antiplatelet/anticoagulant) alone. None of the patients were on folate or vitamin B supplementation. Plasma was collected at baseline and 1 year follow-up after treatment. tHcy level was determined by selected reaction monitoring using mass spectrometry.
Result:
Compared to medical therapy, PFO closure resulted in a lower tHcy level during follow-up (PFO closure: 11.13 ± 3.94 μmol/L, medical therapy: 15.48 ± 3.55 μmol/L, p = 0.006), with no difference at baseline (PFO closure: 17.77 ± 4.39 μmol/L, medical therapy: 16.47 ± 7.50 μmol/L, p = 0.575). Mild hyperhomocysteinemia patients post PFO closure had a significant reduction of tHcy by 37.34% (p = 0.0005), with 71.43% of the patients (10 of 14) having tHcy levels back to normal (<12 μmol/l), while most of medically treated patients (13 of 14) stayed abnormal (p = 0.4820) (χ2-test, adjusted p = 0.002).
Conclusion:
We found that compared with routine medical therapy, PFO closure reduced tHcy level in patients with mild hyperhomocysteinemia. Since PFO stroke patients tend to be younger, the life-time risk of even mildly elevated tHcy may be relevant for future thrombotic risk. Understanding the mechanism of PFO-related tHcy changes is important in optimizing medical treatment (e.g. folate replacement); studies are ongoing.
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Affiliation(s)
| | | | | | | | | | | | | | - Eng H Lo
- Massachusetts General Hosp, Boston, MA
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46
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Ali SF, Siddiqui K, Shinohara Y, Ay H, Singhal A, Viswanathan A, Silverman S, Rost N, Lev M, Schwamm L. Abstract 176: Clinical and Imaging Characteristics Associated With Poor Outcomes in Patients Not Thrombolysed Due to Mild or Rapidly Improving Symptoms. Stroke 2016. [DOI: 10.1161/str.47.suppl_1.176] [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
Introduction:
Several studies have reported poor outcomes in patients “too good to treat” with tPA (TGTT) due to mild or rapidly improving symptoms. We sought to evaluate clinical and imaging factors associated with poor outcomes in these patients
Methods:
Using our institutional GWTG stroke registry, we analyzed 4,745 consecutive stroke admissions (2009-2015). Univariate and multivariable analysis determined factors associated with poor outcome (i.e., not being discharged home).
Results:
Of the total 4,745 patients, there were 380 TGTT patients’ symptoms. Of these, 67.8% were discharged home, 25.1% to inpatient rehabilitation, 4.2% to a skilled nursing facility and 2.9% expired/hospice. Patients with poor outcome were older, more often Hispanic had more vascular risk factors and higher median NIHSS. Imaging characteristics associated with poor outcomes included large, multifocal or insular infarcts and proximal occlusion or poor collaterals. In multivariable analysis, age, Hispanic ethnicity, diabetes, NIHSS, and infarct distribution (posterior/anterior+posterior) remained significant.
Conclusion:
A substantial percentage of patients deemed “too good” for IV tPA were unable to be discharged home. Factors such as advanced age, stroke risk factors, higher NIHSS and infarct location independently predicted poor outcome in patients who are considered TGTT and could be considered in tPA decision-making to optimize outcomes.
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Affiliation(s)
- Syed F Ali
- Dept of Neurology, Massachusetts General Hosp, Boston, MA
| | | | | | - Hakan Ay
- Dept of Neurology, Massachusetts General Hosp, Boston, MA
| | - Aneesh Singhal
- Dept of Neurology, Massachusetts General Hosp, Boston, MA
| | | | | | - Natalia Rost
- Dept of Neurology, Massachusetts General Hosp, Boston, MA
| | | | - Lee Schwamm
- Dept of Neurology, Massachusetts General Hosp, Boston, MA
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47
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Harriott A, Faye EC, Abreu N, Silverman S, Rordorf G. Aneurysmal Subarachnoid and Spinal Hemorrhage Associated With Systemic Lupus Erythematosus. Stroke 2016; 47:e42-5. [PMID: 26797667 DOI: 10.1161/strokeaha.115.012373] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 12/09/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Andrea Harriott
- From the Department of Neurology, Massachusetts General Hospital, Boston.
| | - Erica Camargo Faye
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Nicholas Abreu
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Scott Silverman
- From the Department of Neurology, Massachusetts General Hospital, Boston
| | - Guy Rordorf
- From the Department of Neurology, Massachusetts General Hospital, Boston
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48
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Silverman S, Sanchez-Migallon Guzman D, Stern J, Gustavsen KA, Griffiths LG. Standardization of the two-dimensional transcoelomic echocardiographic examination in the central bearded dragon (Pogona vitticeps). J Vet Cardiol 2016; 18:168-78. [PMID: 26810489 DOI: 10.1016/j.jvc.2015.10.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 10/08/2015] [Accepted: 10/22/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To objectively and subjectively describe the normal spectrum of two-dimensional echocardiographic findings in the central bearded dragon (Pogona vitticeps). ANIMALS Sixteen central bearded dragons. METHODS Central bearded dragons were prospectively evaluated under manual restraint in right and left lateral recumbency to identify imaging planes for reproducible measurements of cardiac chambers, subjective two-dimensional analysis and color Doppler assessment. RESULTS Echocardiography can be performed through windows in the left and right axillae. The window in the left axilla allows for a subjective and objective assessment of cardiac structure and function. The right axillary window allows for evaluation of pulmonary artery flow. Both views provide data for the presence of pericardial effusion or valvular insufficiency. With optimized imaging planes, cardiac chambers and fractional area change along with fractional shortening in the longitudinal and transverse planes can be calculated. Body weight and cardiac chamber dimensions of males were significantly larger than females. Ventricular fractional area change was the most consistent functional assessment. The majority of animals were found to have no evidence of valvular insufficiency, while approximately half had evidence of pericardial fluid. Pulmonary artery flow was assessed in all patients. Left and right aortic velocities cannot be reliably obtained. CONCLUSIONS This study is the first to generate reference values for cardiac structure and function in clinically healthy central bearded dragons. Valvular insufficiency is not a normal finding in central bearded dragons, while mild pericardial effusion may be.
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Affiliation(s)
- S Silverman
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California-Davis, One Shields Avenue, Davis, CA 95616, USA
| | - D Sanchez-Migallon Guzman
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California-Davis, One Shields Avenue, Davis, CA 95616, USA
| | - J Stern
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California-Davis, One Shields Avenue, Davis, CA 95616, USA.
| | - K A Gustavsen
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California-Davis, One Shields Avenue, Davis, CA 95616, USA
| | - L G Griffiths
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California-Davis, One Shields Avenue, Davis, CA 95616, USA
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49
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John S, Walsh KM, Hui FK, Sundararajan S, Silverman S, Bain M. Dynamic Angiographic Nature of Cerebral Mycotic Aneurysms in Patients With Infective Endocarditis. Stroke 2016; 47:e8-e10. [DOI: 10.1161/strokeaha.115.011198] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 10/09/2015] [Indexed: 01/24/2023]
Affiliation(s)
- Seby John
- From the Department of Radiology (S.J., F.K.H.) and Department of Neurological Surgery (K.M.W., M.B.), Cleveland Clinic, OH; Department of Neurology, University Hospitals Case Medical Center, Cleveland, OH (S. Sundararajan); and Department of Neurology, Massachusetts General Hospital, Boston (S. Silverman)
| | - Kevin M. Walsh
- From the Department of Radiology (S.J., F.K.H.) and Department of Neurological Surgery (K.M.W., M.B.), Cleveland Clinic, OH; Department of Neurology, University Hospitals Case Medical Center, Cleveland, OH (S. Sundararajan); and Department of Neurology, Massachusetts General Hospital, Boston (S. Silverman)
| | - Ferdinand K. Hui
- From the Department of Radiology (S.J., F.K.H.) and Department of Neurological Surgery (K.M.W., M.B.), Cleveland Clinic, OH; Department of Neurology, University Hospitals Case Medical Center, Cleveland, OH (S. Sundararajan); and Department of Neurology, Massachusetts General Hospital, Boston (S. Silverman)
| | - Sophia Sundararajan
- From the Department of Radiology (S.J., F.K.H.) and Department of Neurological Surgery (K.M.W., M.B.), Cleveland Clinic, OH; Department of Neurology, University Hospitals Case Medical Center, Cleveland, OH (S. Sundararajan); and Department of Neurology, Massachusetts General Hospital, Boston (S. Silverman)
| | - Scott Silverman
- From the Department of Radiology (S.J., F.K.H.) and Department of Neurological Surgery (K.M.W., M.B.), Cleveland Clinic, OH; Department of Neurology, University Hospitals Case Medical Center, Cleveland, OH (S. Sundararajan); and Department of Neurology, Massachusetts General Hospital, Boston (S. Silverman)
| | - Mark Bain
- From the Department of Radiology (S.J., F.K.H.) and Department of Neurological Surgery (K.M.W., M.B.), Cleveland Clinic, OH; Department of Neurology, University Hospitals Case Medical Center, Cleveland, OH (S. Sundararajan); and Department of Neurology, Massachusetts General Hospital, Boston (S. Silverman)
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50
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Mijalski C, Lovett A, Mahajan R, Sundararajan S, Silverman S, Feske S. Cerebral Fat Embolism: A Case of Rapid-Onset Coma. Stroke 2015; 46:e251-3. [PMID: 26493673 DOI: 10.1161/strokeaha.115.011440] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 09/09/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Christina Mijalski
- From the Department of Neurology, Massachusetts General Hospital, Boston (C.M., A.L., R.M., S.S.); Department of Neurology, Brigham and Women's Hospital, Boston, MA (C.M., A.L., R.M., S.F.); and Department of Neurology, University Hospitals Case Medical Center, Cleveland, OH (S.S.).
| | - Alexandra Lovett
- From the Department of Neurology, Massachusetts General Hospital, Boston (C.M., A.L., R.M., S.S.); Department of Neurology, Brigham and Women's Hospital, Boston, MA (C.M., A.L., R.M., S.F.); and Department of Neurology, University Hospitals Case Medical Center, Cleveland, OH (S.S.)
| | - Rahul Mahajan
- From the Department of Neurology, Massachusetts General Hospital, Boston (C.M., A.L., R.M., S.S.); Department of Neurology, Brigham and Women's Hospital, Boston, MA (C.M., A.L., R.M., S.F.); and Department of Neurology, University Hospitals Case Medical Center, Cleveland, OH (S.S.)
| | - Sophia Sundararajan
- From the Department of Neurology, Massachusetts General Hospital, Boston (C.M., A.L., R.M., S.S.); Department of Neurology, Brigham and Women's Hospital, Boston, MA (C.M., A.L., R.M., S.F.); and Department of Neurology, University Hospitals Case Medical Center, Cleveland, OH (S.S.)
| | - Scott Silverman
- From the Department of Neurology, Massachusetts General Hospital, Boston (C.M., A.L., R.M., S.S.); Department of Neurology, Brigham and Women's Hospital, Boston, MA (C.M., A.L., R.M., S.F.); and Department of Neurology, University Hospitals Case Medical Center, Cleveland, OH (S.S.)
| | - Steven Feske
- From the Department of Neurology, Massachusetts General Hospital, Boston (C.M., A.L., R.M., S.S.); Department of Neurology, Brigham and Women's Hospital, Boston, MA (C.M., A.L., R.M., S.F.); and Department of Neurology, University Hospitals Case Medical Center, Cleveland, OH (S.S.)
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