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Ward MJ, Matheny ME, Rubenstein MD, Bonnet K, Dagostino C, Schlundt DG, Anders S, Reese T, Mixon AS. Determinants of appropriate antibiotic and NSAID prescribing in unscheduled outpatient settings in the veterans health administration. BMC Health Serv Res 2024; 24:640. [PMID: 38760660 PMCID: PMC11102113 DOI: 10.1186/s12913-024-11082-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 05/07/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Despite efforts to enhance the quality of medication prescribing in outpatient settings, potentially inappropriate prescribing remains common, particularly in unscheduled settings where patients can present with infectious and pain-related complaints. Two of the most commonly prescribed medication classes in outpatient settings with frequent rates of potentially inappropriate prescribing include antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs). In the setting of persistent inappropriate prescribing, we sought to understand a diverse set of perspectives on the determinants of inappropriate prescribing of antibiotics and NSAIDs in the Veterans Health Administration. METHODS We conducted a qualitative study guided by the Consolidated Framework for Implementation Research and Theory of Planned Behavior. Semi-structured interviews were conducted with clinicians, stakeholders, and Veterans from March 1, 2021 through December 31, 2021 within the Veteran Affairs Health System in unscheduled outpatient settings at the Tennessee Valley Healthcare System. Stakeholders included clinical operations leadership and methodological experts. Audio-recorded interviews were transcribed and de-identified. Data coding and analysis were conducted by experienced qualitative methodologists adhering to the Consolidated Criteria for Reporting Qualitative Studies guidelines. Analysis was conducted using an iterative inductive/deductive process. RESULTS We conducted semi-structured interviews with 66 participants: clinicians (N = 25), stakeholders (N = 24), and Veterans (N = 17). We identified six themes contributing to potentially inappropriate prescribing of antibiotics and NSAIDs: 1) Perceived versus actual Veterans expectations about prescribing; 2) the influence of a time-pressured clinical environment on prescribing stewardship; 3) Limited clinician knowledge, awareness, and willingness to use evidence-based care; 4) Prescriber uncertainties about the Veteran condition at the time of the clinical encounter; 5) Limited communication; and 6) Technology barriers of the electronic health record and patient portal. CONCLUSIONS The diverse perspectives on prescribing underscore the need for interventions that recognize the detrimental impact of high workload on prescribing stewardship and the need to design interventions with the end-user in mind. This study revealed actionable themes that could be addressed to improve guideline concordant prescribing to enhance the quality of prescribing and to reduce patient harm.
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Affiliation(s)
- Michael J Ward
- Education, and Clinical Center (GRECC), VA , Geriatric Research, Tennessee Valley Healthcare System, 2525 West End Avenue, Ste. 1430, Nashville, TN, 37203, USA.
- Medicine Service, Tennessee Valley Healthcare System, Nashville, TN, USA.
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Michael E Matheny
- Education, and Clinical Center (GRECC), VA , Geriatric Research, Tennessee Valley Healthcare System, 2525 West End Avenue, Ste. 1430, Nashville, TN, 37203, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of General Internal Medicine & Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Melissa D Rubenstein
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kemberlee Bonnet
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Chloe Dagostino
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - David G Schlundt
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Shilo Anders
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Thomas Reese
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amanda S Mixon
- Education, and Clinical Center (GRECC), VA , Geriatric Research, Tennessee Valley Healthcare System, 2525 West End Avenue, Ste. 1430, Nashville, TN, 37203, USA
- Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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van Schaardenburgh M, Sandø AD, Reese T. Mykpreservering og klinisk anatomi. Tidsskr Nor Laegeforen 2022; 142:22-0599. [PMID: 36416657 DOI: 10.4045/tidsskr.22.0599] [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: 11/24/2022] Open
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Shah S, Reese T, Zanussi J, Dickson A, Daniel L, Tao R, Miller-Fleming T, Straub P, Hung A, Nepal P, Wei WQ, Phillips E, Cox N, Stein CM, Feng Q, Chung CP. POS1444 FLT1 AND EPHB2 ARE NOVEL GENETIC MARKERS ASSOCIATED WITH PANCREATITIS IN PATIENTS TAKING AZATHIOPRINE FOR IMMUNE-MEDIATED CONDITIONS: INTEGRATING GENOME- AND TRANSCRIPTOME-WIDE ASSOCIATION STUDIES. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.4265] [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
BackgroundAzathioprine (AZA) is a thiopurine immunosuppressant medication used to treat a variety of immune-mediated diseases. Unfortunately, its use is limited by adverse effects. Pancreatitis, a potentially severe, life-threatening side effect is independent of dose and necessitates AZA discontinuation given the high risk of recurrent pancreatitis with continued use or re-challenge. The mechanisms driving pancreatitis are unclear. While classic thiopurine-induced acute pancreatitis (TIAP) has been associated with HLA haplotypes, most patients taking AZA and presenting with pancreatitis do not fulfill the stringent criteria for TIAP.ObjectivesTo identify genetic risk factors for pancreatitis in patients taking azathioprine for immune-mediated conditions.MethodsUsing a biobank linked to electronic health records (EHR) from a tertiary center, we identified new users of AZA. Patients were excluded if the primary indication for AZA was organ transplant or if there was a history of pancreatitis prior to AZA use. The analysis was restricted to patients with EHR-reported race as White due to insufficient case counts for the non-White group. We then identified patients with amylase or lipase values that exceeded twice the upper limit of normal (“>2x ULN”) or with ICD-9/ICD-10 codes for acute pancreatitis. Each record was manually reviewed to confirm the timing of AZA use in relation to laboratory derangements or ICD coding, as well as to further classify patients into three increasingly strict, but not exclusive categories: 1) pancreatic injury (amylase or lipase >2x ULN); 2) acute pancreatitis1, or 3) TIAP2. We completed genotyping with Illumina Infinium Expanded Multi-Ethnic Genotyping Array plus custom content data, employed Michigan Imputation servers for genetic imputation, and used PrediXcan (GTEx v8) to impute gene expression. We then conducted genome-wide association and transcriptome-wide association studies (GWAS, TWAS). Acknowledging the relatively small overall cohort, and possible imbalance of cases vs controls, we used the Firth logistic regression method, which is a penalized likelihood-based method.ResultsWe studied 2127 AZA users (35.4% male; mean 44.5+/-17.2 years). The median AZA dose was 100mg/day (IQR: 50-125mg/day). Rheumatologic conditions (56.9%) and inflammatory bowel disease (40.4%) comprised the most common primary indications for AZA. Pancreatic injury, pancreatitis, and TIAP were diagnosed in 42 (2.0%), 16 (0.8%), and 9 (0.4%) patients, respectively. GWAS identified several significantly associated genes, many with overlapping TWAS findings in the pancreas and liver (Figure 1). From these, the two protein-encoding genes Fms Related Receptor Tyrosine Kinase-1 (FLT1) and Ephrin type-B receptor-2 (EPHB2) overlapped in two or more pancreatitis phenotypes in the TWAS and GWAS, respectively. EPHB2 was associated with a 8.6-fold (P=1.84 x 10-8) and a 31.4-fold (P=2.87x 10-8) higher likelihood of pancreatic injury and TIAP, respectively.Figure 1.ConclusionFLT1—a gene that encodes a receptor tyrosine kinase and is a member of the vascular endothelial growth factor receptor (VEGFR) family—and EPHB2—a gene that encodes a member of the Eph receptor family, which is the largest subgroup of the receptor tyrosine kinase family—are novel genetic markers associated with pancreatitis in patients taking AZA. VEGF can potentiate inflammation and the pancreas microenvironment is known to promote VEGF expression, which has been linked to pancreatic cancer development; anti-VEGF treatments have been investigated both for mitigating inflammation and also anti-pancreatic cancer treatment. Future studies validating our findings in AZA-induced pancreatitis are warranted.References[1]Crockett et al. Gastroenterology (2018). 154(4):1096-1101.[2]Heap et al. Nature Genetics (2014). 46:1131-1134Disclosure of InterestsShailja Shah Consultant of: ad hoc consultant for Phathom pharmaceuticals, Tyler Reese: None declared, Jacy Zanussi: None declared, Alyson Dickson: None declared, Laura Daniel: None declared, Ran Tao: None declared, Tyne Miller-Fleming: None declared, Peter Straub: None declared, Adriana Hung: None declared, Puran Nepal: None declared, Wei-Qi Wei: None declared, Elizabeth Phillips: None declared, Nancy Cox: None declared, Charles M. Stein: None declared, QiPeng Feng: None declared, Cecilia P. Chung: None declared
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Thiess H, Del Fiol G, Malone DC, Cornia R, Sibilla M, Rhodes B, Boyce RD, Kawamoto K, Reese T. Coordinated use of Health Level 7 standards to support clinical decision support: Case study with shared decision making and drug-drug interactions. Int J Med Inform 2022; 162:104749. [PMID: 35358893 PMCID: PMC9703934 DOI: 10.1016/j.ijmedinf.2022.104749] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 02/22/2022] [Accepted: 03/17/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Despite advances in interoperability standards, it remains challenging and often costly to share clinical decision support (CDS) across healthcare organizations. This is due in part to limited coordination among CDS components. To improve coordination of CDS components, Health Level 7 (HL7) has developed a suite of interoperability standards with Fast Health Interoperability Resources (FHIR) specification as a common information model. Evidence is needed to determine the feasibility of implementing these CDS components; therefore, the objective of this study was to investigate the coordination of emerging HL7 standards with modular CDS architecture components. METHODS We used a modular, standards-based architecture consisting of four components: data, logic, services, and applications. The implementation use-case was an application to support shared decision making in the context of drug-drug interactions (DDInteract). RESULTS DDInteract uses FHIR as the data representation model, Clinical Quality Language for logic representation, CDS Hooks for the services layer, and Substitutable Medical Apps Reusable Technologies for application integration. DDInteract was first implemented in a sandbox environment and then in an electronic health record (Epic®) test environment. DDInteract can be integrated in clinical workflows through on-demand access from a menu or through CDS Hooks upon opening a patient's record or placing a medication order. CONCLUSION In the context of drug interactions, DDInteract is the first application to leverage a full stack of emerging interoperability standards for each component of modular CDS architecture. The demonstrated feasibility of interoperable components can be generalized to other modular CDS applications.
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Affiliation(s)
| | | | | | - Ryan Cornia
- University of Utah, Department of Biomedical Informatics, United States
| | - Max Sibilla
- University of Pittsburgh, Department of Biomedical Informatics, United States
| | - Bryn Rhodes
- Alphora, Chief Technology Officer, United States
| | - Richard D Boyce
- University of Pittsburgh, Department of Biomedical Informatics, United States
| | - Kensaku Kawamoto
- University of Utah, Department of Biomedical Informatics, United States
| | - Thomas Reese
- Vanderbilt University Medical Center, Department of Biomedical Informatics, Nashville, TN.
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Reese T, Wright A, Liu S, Boyce R, Romero A, Del Fiol G, Kawamoto K, Malone D. Improving the specificity of drug-drug interaction alerts: Can it be done? Am J Health Syst Pharm 2022; 79:1086-1095. [PMID: 35136935 PMCID: PMC9218784 DOI: 10.1093/ajhp/zxac045] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE Inaccurate and nonspecific medication alerts contribute to high override rates, alert fatigue, and ultimately patient harm. Drug-drug interaction (DDI) alerts often fail to account for factors that could reduce risk; further, drugs that trigger alerts are often inconsistently grouped into value sets. Toward improving the specificity of DDI alerts, the objectives of this study were to (1) highlight the inconsistency of drug value sets for triggering DDI alerts and (2) demonstrate a method of classifying factors that can be used to modify the risk of harm from a DDI. METHODS This was a proof-of-concept study focused on 15 well-known DDIs. Using 3 drug interaction references, we extracted 2 drug value sets and any available order- and patient-related factors for each DDI. Fleiss' kappa was used to measure the consistency of value sets among references. Risk-modifying factors were classified as order parameters (eg, route and dose) or patient characteristics (eg, comorbidities and laboratory results). RESULTS Seventeen value sets (56%) had nonsignificant agreement. Agreement among the remaining 13 value sets was on average moderate. Thirty-three factors that could reduce risk in 14 of 15 DDIs (93%) were identified. Most risk-modifying factors (67%) were classified as order parameters. CONCLUSION This study demonstrates the importance of increasing the consistency of drug value sets that trigger DDI alerts and how alert specificity and usefulness can be improved with risk-modifying factors obtained from drug references. It may be difficult to operationalize certain factors to reduce unnecessary alerts; however, factors can be used to support decisions by providing contextual information.
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Affiliation(s)
| | - Adam Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Siru Liu
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Richard Boyce
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Andrew Romero
- Department of Pharmacy, Banner University Medical Center, Tucson, AZ, USA
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, USA
| | - Kensaku Kawamoto
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, USA
| | - Daniel Malone
- University of Utah College of Pharmacy, Salt Lake City, UT, USA
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Reese T, Suarez C, Premasiri WR, Shaine ML, Ingraham H, Brodeur AN, Ziegler LD. Surface enhanced Raman scattering specificity for detection and identification of dried bloodstains. Forensic Sci Int 2021; 328:111000. [PMID: 34564021 DOI: 10.1016/j.forsciint.2021.111000] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 08/16/2021] [Accepted: 09/10/2021] [Indexed: 01/20/2023]
Abstract
Surface enhanced Raman spectroscopy (SERS) provides highly specific vibrational signatures identifying dried blood for a variety of forensic applications. SERS spectra on Au nanoparticle substrates excited at 785 nm are found to identify dried stains of human and nonhuman blood from seven animals, and distinguish stains due to menstrual and peripheral blood. In addition, the unique SERS bloodstain spectrum is distinct from the SERS spectra of thirty red-brown stains of potential household substances that could be visually mistaken for bloodstains and from food stains that have been shown to give positive results with presumptive colorimetric blood tests. Finally, a SERS swab procedure has been developed and demonstrates that the substrates that a blood sample dried on does not offer any Raman or fluorescence interference for the SERS identification of dried blood. Such bloodstains on porous and nonporous materials are all identical and exclusively due to the heme moiety of hemoglobin. Optimized selection of the extraction solvent is found to control the chemical composition of molecular components appearing in the SERS spectrum of complex, multicomponent biological mixtures, such as body fluids.
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Affiliation(s)
- T Reese
- Program in Biomedical Forensic Sciences, Boston University School of Medicine, Boston, MA 02118, USA
| | - C Suarez
- Department of Chemistry, Boston University, 590 Commonwealth Ave., Boston, MA 02215, USA
| | - W R Premasiri
- Department of Chemistry, Boston University, 590 Commonwealth Ave., Boston, MA 02215, USA; Photonics Center, Boston University, 15 Saint Mary's St., Boston, MA 02215, USA
| | - M L Shaine
- Program in Biomedical Forensic Sciences, Boston University School of Medicine, Boston, MA 02118, USA
| | - H Ingraham
- Department of Chemistry, Boston University, 590 Commonwealth Ave., Boston, MA 02215, USA; Photonics Center, Boston University, 15 Saint Mary's St., Boston, MA 02215, USA
| | - A N Brodeur
- Program in Biomedical Forensic Sciences, Boston University School of Medicine, Boston, MA 02118, USA
| | - L D Ziegler
- Department of Chemistry, Boston University, 590 Commonwealth Ave., Boston, MA 02215, USA; Photonics Center, Boston University, 15 Saint Mary's St., Boston, MA 02215, USA.
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Maris I, Dölle‐Bierke S, Renaudin J, Lange L, Koehli A, Spindler T, Hourihane J, Scherer K, Nemat K, Kemen C, Neustädter I, Vogelberg C, Reese T, Yildiz I, Szepfalusi Z, Ott H, Straube H, Papadopoulos NG, Hämmerling S, Staden U, Polz M, Mustakov T, Cichocka‐Jarosz E, Cocco R, Fiocchi AG, Fernandez‐Rivas M, Worm M, Grünhagen J, Wittenberg M, Beyer K, Henschel A, Küper S, Möser A, Fuchs T, Ruëff F, Wedi B, Hansen G, Buck T, Büsselberg J, Drägerdt R, Pfeffer L, Dickel H, Körner‐Rettberg C, Merk H, Lehmann S, Bauer A, Nordwig A, Zeil S, Hannapp C, Wagner N, Rietschel E, Hunzelmann N, Huseynow I, Treudler R, Aurich S, Prenzel F, Klimek L, Pfaar O, Reider N, Aberer W, Varga E, Bogatu B, Schmid‐Grendelmeier P, Guggenheim R, Riffelmann F, Kreft B, Kinaciyan K, Hartl L, Ebner C, Horak F, Brehler R, Witte J, Buss M, Hompes S, Bieber T, Gernert S, Bücheler M, Rabe U, Brosi W, Nestoris S, Hawranek T, Lang R, Bruns R, Pföhler C, Eng P, Schweitzer‐Krantz S, Meller S, Rebmann H, Fischer J, Stichtenoth G, Thies S, Gerstlauer M, Utz P, Neustädter I, Klinge J, Volkmuth S, Plank‐Habibi S, Schilling B, Kleinheinz A, Brückner A, Schäkel K, Manolaraki I, Kowalski M, Solarewicz‐Madajek K, Tscheiller S, Seidenberg J, Cardona V, Garcia B, Bilo M, Cabañes Higuero N, Vega Castro A, Poziomkowska‐Gęsicka I, Büsing S, Virchow C, Christoff G, Jappe U, Müller S, Knöpfel F, Correard A, Rogala B, Montoro A, Brandes A, Muraro A, Zimmermann N, Hernandez D, Minale P, Niederwimmer J, Zahel B, Dahdah L, Arasi S, Reissig A, Eitelberger F, Asero R, Hermann F, Zeidler S, Pistauer S, Geißler M, Ensina L, Plaza Martin A, Meister J, Stieglitz S, Hamelmann E. Peanut-induced anaphylaxis in children and adolescents: Data from the European Anaphylaxis Registry. Allergy 2021; 76:1517-1527. [PMID: 33274436 DOI: 10.1111/all.14683] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/26/2020] [Accepted: 11/10/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Peanut allergy has a rising prevalence in high-income countries, affecting 0.5%-1.4% of children. This study aimed to better understand peanut anaphylaxis in comparison to anaphylaxis to other food triggers in European children and adolescents. METHODS Data was sourced from the European Anaphylaxis Registry via an online questionnaire, after in-depth review of food-induced anaphylaxis cases in a tertiary paediatric allergy centre. RESULTS 3514 cases of food anaphylaxis were reported between July 2007 - March 2018, 56% in patients younger than 18 years. Peanut anaphylaxis was recorded in 459 children and adolescents (85% of all peanut anaphylaxis cases). Previous reactions (42% vs. 38%; p = .001), asthma comorbidity (47% vs. 35%; p < .001), relevant cofactors (29% vs. 22%; p = .004) and biphasic reactions (10% vs. 4%; p = .001) were more commonly reported in peanut anaphylaxis. Most cases were labelled as severe anaphylaxis (Ring&Messmer grade III 65% vs. 56% and grade IV 1.1% vs. 0.9%; p = .001). Self-administration of intramuscular adrenaline was low (17% vs. 15%), professional adrenaline administration was higher in non-peanut food anaphylaxis (34% vs. 26%; p = .003). Hospitalization was higher for peanut anaphylaxis (67% vs. 54%; p = .004). CONCLUSIONS The European Anaphylaxis Registry data confirmed peanut as one of the major causes of severe, potentially life-threatening allergic reactions in European children, with some characteristic features e.g., presence of asthma comorbidity and increased rate of biphasic reactions. Usage of intramuscular adrenaline as first-line treatment is low and needs to be improved. The Registry, designed as the largest database on anaphylaxis, allows continuous assessment of this condition.
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Affiliation(s)
- Ioana Maris
- Bon Secours Hospital Cork/Paediatrics and Child HealthUniversity College Cork Cork Ireland
| | - Sabine Dölle‐Bierke
- Division of Allergy and Immunology Department of Dermatology, Venereology and Allergology Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | | | - Lars Lange
- Department of Paediatrics St. Marien‐Hospital Bonn Germany
| | - Alice Koehli
- Division of Allergology University Children’s Hospital Zurich Zürich Switzerland
| | - Thomas Spindler
- Department of Paediatrics Medical Campus Hochgebirgsklinik Davos Davos Switzerland
| | - Jonathan Hourihane
- Paediatrics and Child Health Royal College of Surgeons in Ireland Dublin Ireland
- Children’s Health Ireland Dublin Ireland
| | | | - Katja Nemat
- Practice for paediatric pneumology and allergology Kinderzentrum Dresden‐Friedrichstadt Dresden Germany
| | - C. Kemen
- Department of Paediatrics Children’s Hospital WILHELMSTIFT Hamburg Germany
| | - Irena Neustädter
- Department of Paediatrics Hallerwiese Cnopfsche Kinderklinik Nuremberg Germany
| | - Christian Vogelberg
- Department of Paediatrics Universitätsklinikum Carl Gustav CarusTechnical University Dresden Germany
| | - Thomas Reese
- Department of Paediatrics Mathias‐Spital Rheine Rheine Germany
| | - Ismail Yildiz
- Department of Paediatrics Friedrich‐Ebert‐Krankenhaus Neumuenster Germany
| | - Zsolt Szepfalusi
- Division of Paediatric Pulmonology, Allergology and Endocrinology Department of Paediatrics and Adolescent Medicine Competence Center Paediatrics Medical University of Vienna Vienna Austria
| | - Hagen Ott
- Division of Paediatric Dermatology and Allergology Epidermolysis bullosa‐Centre HannoverChildren’s Hospital AUF DER BULT Hanover Germany
| | - Helen Straube
- Division of Allergology Darmstädter Kinderkliniken Prinzessin Margaret Darmstadt Germany
| | - Nikolaos G. Papadopoulos
- Allergy Department 2nd Paediatric Clinic National and Kapodistrian University of Athens Athens Greece
- Division of Infection Immunity& Respiratory Medicine University of Manchester Manchester UK
| | - Susanne Hämmerling
- Division of Paediatric Pulmonology and Allergology University Children`s Hospital Heidelberg Heidelberg Germany
| | - Ute Staden
- Paediatric Pneumology & Allergology Medical practice Klettke/Staden Berlin Germany
| | - Michael Polz
- Department of Paediatrics GPR Klinikum Rüsselsheim Germany
| | - Tihomir Mustakov
- Chair of Allergy University Hospital Alexandrovska Sofia Bulgaria
| | - Ewa Cichocka‐Jarosz
- Department of Paediatrics Jagiellonian University Medical College Krakow Poland
| | - Renata Cocco
- Division of Allergy Clinical Immunology and Rheumatology Department of Paediatrics Federal University of São Paulo São Paulo Brazil
| | | | | | - Margitta Worm
- Division of Allergy and Immunology Department of Dermatology, Venereology and Allergology Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
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Abstract
OBJECTIVE Increasingly, pharmacists provide team-based care that impacts patient care; however, the extent of recent clinical decision support (CDS), targeted to support the evolving roles of pharmacists, is unknown. Our objective was to evaluate the literature to understand the impact of clinical pharmacists using CDS. METHODS We searched MEDLINE, EMBASE, and Cochrane Central for randomized controlled trials, nonrandomized trials, and quasi-experimental studies which evaluated CDS tools that were developed for inpatient pharmacists as a target user. The primary outcome of our analysis was the impact of CDS on patient safety, quality use of medication, and quality of care. Outcomes were scored as positive, negative, or neutral. The secondary outcome was the proportion of CDS developed for tasks other than medication order verification. Study quality was assessed using the Newcastle-Ottawa Scale. RESULTS Of 4,365 potentially relevant articles, 15 were included. Five studies were randomized controlled trials. All included studies were rated as good quality. Of the studies evaluating inpatient pharmacists using a CDS tool, four showed significantly improved quality use of medications, four showed significantly improved patient safety, and three showed significantly improved quality of care. Six studies (40%) supported expanded roles of clinical pharmacists. CONCLUSION These results suggest that CDS can support clinical inpatient pharmacists in preventing medication errors and optimizing pharmacotherapy. Moreover, an increasing number of CDS tools have been developed for pharmacists' roles outside of order verification, whereby further supporting and establishing pharmacists as leaders in safe and effective pharmacotherapy.
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Affiliation(s)
- Liang Yan
- University of Utah College of Pharmacy, University of Utah Health, Salt Lake City, Utah, United States
| | - Thomas Reese
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Scott D Nelson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
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Hochheiser H, Jing X, Garcia EA, Ayvaz S, Sahay R, Dumontier M, Banda JM, Beyan O, Brochhausen M, Draper E, Habiel S, Hassanzadeh O, Herrero-Zazo M, Hocum B, Horn J, LeBaron B, Malone DC, Nytrø Ø, Reese T, Romagnoli K, Schneider J, Zhang L(Y, Boyce RD. A Minimal Information Model for Potential Drug-Drug Interactions. Front Pharmacol 2021; 11:608068. [PMID: 33762928 PMCID: PMC7982727 DOI: 10.3389/fphar.2020.608068] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 12/29/2020] [Indexed: 01/22/2023] Open
Abstract
Despite the significant health impacts of adverse events associated with drug-drug interactions, no standard models exist for managing and sharing evidence describing potential interactions between medications. Minimal information models have been used in other communities to establish community consensus around simple models capable of communicating useful information. This paper reports on a new minimal information model for describing potential drug-drug interactions. A task force of the Semantic Web in Health Care and Life Sciences Community Group of the World-Wide Web consortium engaged informaticians and drug-drug interaction experts in in-depth examination of recent literature and specific potential interactions. A consensus set of information items was identified, along with example descriptions of selected potential drug-drug interactions (PDDIs). User profiles and use cases were developed to demonstrate the applicability of the model. Ten core information items were identified: drugs involved, clinical consequences, seriousness, operational classification statement, recommended action, mechanism of interaction, contextual information/modifying factors, evidence about a suspected drug-drug interaction, frequency of exposure, and frequency of harm to exposed persons. Eight best practice recommendations suggest how PDDI knowledge artifact creators can best use the 10 information items when synthesizing drug interaction evidence into artifacts intended to aid clinicians. This model has been included in a proposed implementation guide developed by the HL7 Clinical Decision Support Workgroup and in PDDIs published in the CDS Connect repository. The complete description of the model can be found at https://w3id.org/hclscg/pddi.
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Affiliation(s)
- Harry Hochheiser
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States
- Intelligent Systems Program, University of Pittsburgh, Pittsburgh, PA, United States
| | - Xia Jing
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | | | - Serkan Ayvaz
- Department of Software Engineering, Bahçeşehir University, Istanbul, Turkey
| | - Ratnesh Sahay
- Clinical Data Science, AstraZeneca, Cambridge, United Kingdom
| | - Michel Dumontier
- Institute of Data Science, Maastricht University, Maastricht, Netherlands
| | - Juan M. Banda
- Department of Computer Science, Georgia State University, Atlanta, GA, United States
| | - Oya Beyan
- Fraunhofer Institute for Applied Information Technology, RWTH Aachen University, Aachen, Germany
| | - Mathias Brochhausen
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL, United States
| | | | - Sam Habiel
- Open Source Electronic Health Record Alliance, Washington, DC, United States
| | | | - Maria Herrero-Zazo
- The European Bioinformatics Institute, Birney Research Group, London, United Kingdom
| | - Brian Hocum
- Genelex Corporation, Seattle, WA, United States
| | - John Horn
- School of Pharmacy, University of Washington, Seattle, WA, United States
| | - Brian LeBaron
- Southeast Louisiana Veterans Health Care System, New Orleans, LA, United States
| | - Daniel C. Malone
- Department of Pharmacotherapy, University of Utah, Salt Lake City, UT, United States
| | - Øystein Nytrø
- Department of Computer Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Thomas Reese
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States
| | - Katrina Romagnoli
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jodi Schneider
- School of Information Science, University of Illinois, Champaign, IL, United States
| | - Louisa (Yu) Zhang
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States
| | - Richard D. Boyce
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States
- Intelligent Systems Program, University of Pittsburgh, Pittsburgh, PA, United States
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10
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Wright MC, Radcliffe S, Janzen S, Edworthy J, Reese T, Segall N. Organizing Audible Alarm Sounds in the Hospital: A Card-Sorting Study. IEEE Trans Hum Mach Syst 2020; 50:623-627. [PMID: 33777543 PMCID: PMC7996481 DOI: 10.1109/thms.2020.3019363] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
In hospitals, clinicians are presented with varied and disorganized alarm sounds from disparate devices. While there has been attention to reducing inactionable alarms to address alarm overload, little effort has focused on organizing, simplifying, or improving the informativeness of alarms. We sought to elicit nurses' tacit interpretation of alarm events to create an organizational structure to inform the design of advanced alarm sounds or integrated alert systems. We used open card sorting to evaluate nurses' perception of the relatedness of different alarm events. Seventy hospital nurses sorted 89 alarm events into groups they believed could or should be indicated by the same sound. We conducted factor analysis on a similarity matrix of frequency of alarm event pairings to interpret how strongly alarm events loaded on different alarm groups (factors). We interpreted participants' grouping rationale from their group labels and comments. Urgency of response was the most common grouping rationale. Participants also grouped: 1) monitoring-related events, 2) device-related events, and 3) events related to calls and patients. Our findings support standardization and integration of alarm sounds across devices toward a simpler and more informative hospital alarm environment.
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Affiliation(s)
| | | | - Suzanne Janzen
- Saint Alphonsus Regional Medical Center, Boise, ID 83706 USA
| | - Judy Edworthy
- University of Plymouth, Plymouth UK. Dr. Edworthy provides consulting to Masimo
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11
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Waller RG, Wright MC, Segall N, Nesbitt P, Reese T, Borbolla D, Del Fiol G. Novel displays of patient information in critical care settings: a systematic review. J Am Med Inform Assoc 2020; 26:479-489. [PMID: 30865769 DOI: 10.1093/jamia/ocy193] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 09/28/2018] [Accepted: 01/02/2019] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Clinician information overload is prevalent in critical care settings. Improved visualization of patient information may help clinicians cope with information overload, increase efficiency, and improve quality. We compared the effect of information display interventions with usual care on patient care outcomes. MATERIALS AND METHODS We conducted a systematic review including experimental and quasi-experimental studies of information display interventions conducted in critical care and anesthesiology settings. Citations from January 1990 to June 2018 were searched in PubMed and IEEE Xplore. Reviewers worked independently to screen articles, evaluate quality, and abstract primary outcomes and display features. RESULTS Of 6742 studies identified, 22 studies evaluating 17 information displays met the study inclusion criteria. Information display categories included comprehensive integrated displays (3 displays), multipatient dashboards (7 displays), physiologic and laboratory monitoring (5 displays), and expert systems (2 displays). Significant improvement on primary outcomes over usual care was reported in 12 studies for 9 unique displays. Improvement was found mostly with comprehensive integrated displays (4 of 6 studies) and multipatient dashboards (5 of 7 studies). Only 1 of 5 randomized controlled trials had a positive effect in the primary outcome. CONCLUSION We found weak evidence suggesting comprehensive integrated displays improve provider efficiency and process outcomes, and multipatient dashboards improve compliance with care protocols and patient outcomes. Randomized controlled trials of physiologic and laboratory monitoring displays did not show improvement in primary outcomes, despite positive results in simulated settings. Important research translation gaps from laboratory to actual critical care settings exist.
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Affiliation(s)
- Rosalie G Waller
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Melanie C Wright
- Trinity Health and Saint Alphonsus Regional Medical Center, Boise, ID, USA
| | - Noa Segall
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Paige Nesbitt
- Trinity Health and Saint Alphonsus Regional Medical Center, Boise, ID, USA
| | - Thomas Reese
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Damian Borbolla
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
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12
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Reese T, Segall N, Nesbitt P, Del Fiol G, Waller R, Macpherson BC, Tonna JE, Wright MC. Patient information organization in the intensive care setting: expert knowledge elicitation with card sorting methods. J Am Med Inform Assoc 2019; 25:1026-1035. [PMID: 30060091 DOI: 10.1093/jamia/ocy045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 04/11/2018] [Indexed: 11/13/2022] Open
Abstract
Introduction Many electronic health records fail to support information uptake because they impose low-level information organization tasks on users. Clinical concept-oriented views have shown information processing improvements, but the specifics of this organization for critical care are unclear. Objective To determine high-level cognitive processes and patient information organization schema in critical care. Methods We conducted an open card sort of 29 patient data elements and a modified Delphi card sort of 65 patient data elements. Study participants were 39 clinicians with varied critical care training and experience. We analyzed the open sort with a hierarchical cluster analysis (HCA) and factor analysis (FA). The Delphi sort was split into three initiating groups that resulted in three unique solutions. We compared results between open sort analyses (HCA and FA), between card sorting exercises (open and Delphi), and across the Delphi solutions. Results Between the HCA and FA, we observed common constructs including cardiovascular and hemodynamics, infectious disease, medications, neurology, patient overview, respiratory, and vital signs. The more comprehensive Delphi sort solutions also included gastrointestinal, renal, and imaging constructs. Conclusions We identified primarily system-based groupings (e.g., cardiovascular, respiratory). Source-based (e.g., medications, laboratory) groups became apparent when participants were asked to sort a longer list of concepts. These results suggest a hybrid approach to information organization, which may combine systems, source, or problem-based groupings, best supports clinicians' mental models. These results can contribute to the design of information displays to better support clinicians' access and interpretation of information for critical care decisions.
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Affiliation(s)
- Thomas Reese
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Noa Segall
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Paige Nesbitt
- Trinity Health and Saint Alphonsus Regional Medical Center, Boise, ID, USA
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Rosalie Waller
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | - Joseph E Tonna
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Melanie C Wright
- Trinity Health and Saint Alphonsus Regional Medical Center, Boise, ID, USA
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13
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Nguyen BP, Reese T, Decker S, Malone D, Boyce RD, Beyan O. Implementation of Clinical Decision Support Services to Detect Potential Drug-Drug Interaction Using Clinical Quality Language. Stud Health Technol Inform 2019; 264:724-728. [PMID: 31438019 DOI: 10.3233/shti190318] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Potential drug-drug interactions (PDDI) rules are currently represented without any common standard making them difficult to update, maintain, and exchange. The PDDI minimum information model developed by the Semantic Web in the Healthcare and Life Sciences Community Group describes PDDI knowledge in an actionable format. In this paper, we report implementation and evaluation of CDS Services which represent PDDI knowledge with Clinical Quality Language (CQL). The suggested solution is based on emerging standards including CDS Hooks, FHIR, and CQL. Two use cases are selected, implemented with CQL rules and tested at the Connectathon held at the 32nd Annual Plenary & Working Group Meeting of HL7.
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Affiliation(s)
| | - Thomas Reese
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Stefen Decker
- Informatik 5, RWTH Aachen University, Aachen, Germany.,Fraunhofer FIT, Sankt Augustin, Germany
| | - Daniel Malone
- College of Pharmacy, University of Arizona, Tucson, Arizona, USA
| | - Richard D Boyce
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Oya Beyan
- Informatik 5, RWTH Aachen University, Aachen, Germany.,Fraunhofer FIT, Sankt Augustin, Germany
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14
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Wright MC, Borbolla D, Waller RG, Del Fiol G, Reese T, Nesbitt P, Segall N. Critical care information display approaches and design frameworks: A systematic review and meta-analysis. J Biomed Inform 2019; 3:100041. [PMID: 31423485 PMCID: PMC6696941 DOI: 10.1016/j.yjbinx.2019.100041] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 06/10/2019] [Accepted: 06/16/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To systematically review original user evaluations of patient information displays relevant to critical care and understand the impact of design frameworks and information presentation approaches on decision-making, efficiency, workload, and preferences of clinicians. METHODS We included studies that evaluated information displays designed to support real-time care decisions in critical care or anesthesiology using simulated tasks. We searched PubMed and IEEExplore from 1/1/1990 to 6/30/2018. The search strategy was developed iteratively with calibration against known references. Inclusion screening was completed independently by two authors. Extraction of display features, design processes, and evaluation method was completed by one and verified by a second author. RESULTS Fifty-six manuscripts evaluating 32 critical care and 22 anesthesia displays were included. Primary outcome metrics included clinician accuracy and efficiency in recognizing, diagnosing, and treating problems. Implementing user-centered design (UCD) processes, especially iterative evaluation and redesign, resulted in positive impact in outcomes such as accuracy and efficiency. Innovative display approaches that led to improved human-system performance in critical care included: (1) improving the integration and organization of information, (2) improving the representation of trend information, and (3) implementing graphical approaches to make relationships between data visible. CONCLUSION Our review affirms the value of key principles of UCD. Improved information presentation can facilitate faster information interpretation and more accurate diagnoses and treatment. Improvements to information organization and support for rapid interpretation of time-based relationships between related quantitative data is warranted. Designers and developers are encouraged to involve users in formal iterative design and evaluation activities in the design of electronic health records (EHRs), clinical informatics applications, and clinical devices.
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Affiliation(s)
- Melanie C. Wright
- Trinity Health, Livonia, MI, USA
- Saint Alphonsus Regional Medical Center, Boise, ID, USA
| | - Damian Borbolla
- Biomedical Informatics, University of Utah, Salt Lake City, UT, USA
| | | | | | - Thomas Reese
- Biomedical Informatics, University of Utah, Salt Lake City, UT, USA
| | - Paige Nesbitt
- Saint Alphonsus Regional Medical Center, Boise, ID, USA
| | - Noa Segall
- Anesthesiology, Duke University, Durham, NC, USA
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15
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Reese T, Dickson AL, Shuey MM, Gandelman JS, Barnado A, Barker KA, Neal JE, Khan OA, Dupont WD, Stein CM, Chung CP. Increased blood pressure visit-to-visit variability in patients with systemic lupus erythematosus: association with inflammation and comorbidity burden. Lupus 2019; 28:954-960. [PMID: 31221051 DOI: 10.1177/0961203319856988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Blood pressure visit-to-visit variability is a novel risk factor for deleterious long-term cardiac and renal outcomes in the general population. We hypothesized that patients with systemic lupus erythematosus (SLE) have greater blood pressure visit-to-visit variability than control subjects and that blood pressure visit-to-visit variability is associated with a higher comorbidity burden. METHODS We studied 899 patients with SLE and 4172 matched controls using de-identified electronic health records from an academic medical center. We compared blood pressure visit-to-visit variability measures in patients with SLE and control subjects and examined the association between blood pressure visit-to-visit variability and patients' characteristics. RESULTS Patients with SLE had higher systolic blood pressure visit-to-visit variability 9.7% (7.8-11.8%) than the control group 9.2% (7.4-11.2%), P < 0.001 by coefficient of variation. Additional measures of systolic blood pressure visit-to-visit variability (i.e. standard deviation, average real variation, successive variation and maximum measure-to-measure change) were also significantly higher in patients with SLE than in control subjects. In patients with SLE, blood pressure visit-to-visit variability correlated significantly with age, creatinine, CRP, triglyceride concentrations and the Charlson comorbidity score (all P < 0.05). Hydroxychloroquine use was associated with reduced blood pressure visit-to-visit variability (P < 0.001), whereas the use of antihypertensives, cyclophosphamide, mycophenolate mofetil and corticosteroids was associated with increased blood pressure visit-to-visit variability (P < 0.05). CONCLUSION Patients with SLE had higher blood pressure visit-to-visit variability than controls, and this increased blood pressure visit-to-visit variability was associated with greater Charlson comorbidity scores, several clinical characteristics and immunosuppressant medications. In particular, hydroxychloroquine prescription was associated with lower blood pressure visit-to-visit variability.
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Affiliation(s)
- T Reese
- 1 Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - A L Dickson
- 1 Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - M M Shuey
- 1 Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - J S Gandelman
- 2 Vanderbilt University School of Medicine, Nashville, TN, USA
| | - A Barnado
- 1 Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - K A Barker
- 1 Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - J E Neal
- 3 Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - O A Khan
- 3 Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - W D Dupont
- 3 Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - C M Stein
- 1 Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,4 Department of Pharmacology, Vanderbilt University, Nashville, TN, USA
| | - C P Chung
- 1 Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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16
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Bress AP, Dodson JA, King JB, Sauer BC, Reese T, Crook J, Radwanski P, Knippenberg K, Greene T, Nelson RE, Munger MA, Weintraub WS, LaFleur J. Clinical and Economic Outcomes of Ranolazine Versus Conventional Antianginals Users Among Veterans With Chronic Stable Angina Pectoris. Am J Cardiol 2018; 122:1809-1816. [PMID: 30292334 DOI: 10.1016/j.amjcard.2018.08.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 08/14/2018] [Accepted: 08/16/2018] [Indexed: 01/09/2023]
Abstract
Real-world outcomes in patients with chronic stable angina treated with ranolazine and other antianginal medications as second- or third-line therapy are limited. In a historical cohort study of veterans with chronic stable angina, we compared time with coronary revascularization procedures, hospitalizations, and 1-year healthcare costs between new-users of ranolazine versus conventional antianginals (i.e., calcium channel blockers, β blockers, or long-acting nitrates) as second- or third-line. Weighted regression models calculated adjusted hazard ratios (HR) at up to 8-year follow-up, and adjusted incremental costs in the first year. Weighted groups comprised 4,699 ranolazine users and 31,815 conventional antianginal users. Percutaneous coronary intervention (PCI) occurred more often in ranolazine users compared with conventional antianginal users (HR 1.16; 95% confidence intervals [CI] 1.08 to 1.25, p <0.001), and coronary artery bypass grafting occurred less often (HR 0.82; 95% CI 0.68 to 1.00, p <0.046). All-cause and atrial fibrillation (AF) hospitalizations were less common with ranolazine users compared with conventional users (all-cause: HR 0.94; 95% CI 0.90 to 0.99, p <0.010; AF:HR 0.74; 95% CI 0.67 to 0.82, p <0.001), and acute coronary syndrome was more common (HR 1.13; 95% CI 1.00 to 1.27, p <0.042). Adjusted 1-year costs were $24,517 in ranolazine users and $24,798 in conventional users (difference, $-280; 95% CI $-1,742 to $1,181, p = 0.71). In conclusion, ranolazine users had lower rates of coronary artery bypass grafting and all-cause and AF hospitalizations, but higher rates of percutaneous coronary intervention and hospitalizations due to acute coronary syndrome compared with conventional antianginal users. Healthcare costs were similar between ranolazine and conventional antianginal users.
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Affiliation(s)
- Adam P Bress
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah; Department of Veterans Affairs Medical Center, Salt Lake City, Utah.
| | - John A Dodson
- Leon. H. Charney Division of Cardiology, Department of Medicine, New York University, New York, New York
| | - Jordan B King
- Department of Pharmacy, Kaiser Permanente Colorado, Aurora, Colorado
| | - Brian C Sauer
- Department of Veterans Affairs Medical Center, Salt Lake City, Utah; Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Thomas Reese
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah
| | - Jacob Crook
- Department of Veterans Affairs Medical Center, Salt Lake City, Utah; Department of Pharmacotherapy, University of Utah, Salt Lake City, Utah
| | - Przemyslaw Radwanski
- Department of Pharmacy Practice and Science, The Ohio State University, Columbus, Ohio
| | | | - Tom Greene
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah; Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Richard E Nelson
- Department of Veterans Affairs Medical Center, Salt Lake City, Utah; Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Mark A Munger
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah; Department of Pharmacotherapy, University of Utah, Salt Lake City, Utah
| | | | - Joanne LaFleur
- Department of Veterans Affairs Medical Center, Salt Lake City, Utah; Department of Pharmacotherapy, University of Utah, Salt Lake City, Utah
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17
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Nelson RE, Jones M, Liu CF, Samore MH, Evans ME, Stevens VW, Reese T, Rubin MA. The Impact of Healthcare-Associated Methicillin-Resistant Staphylococcus aureus Infections on Postdischarge Health Care Costs and Utilization across Multiple Health Care Systems. Health Serv Res 2018; 53 Suppl 3:5419-5437. [PMID: 30298924 DOI: 10.1111/1475-6773.13063] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE To measure how much of the postdischarge cost and utilization attributable to methicillin-resistant Staphylococcus aureus (MRSA) health care-associated infections (HAIs) occur within the US Department of Veterans Affairs (VA) system and how much occurs outside. DATA SOURCES/STUDY SETTING Health care encounters from 3 different settings and payment models: (1) within the VA; (2) outside the VA but paid for by the VA (purchased care); and (3) outside the VA and paid for by Medicare. STUDY DESIGN Historical cohort study using data from admissions to VA hospitals between 2007 and 2012. METHODS We assessed the impact of a positive MRSA test result on costs and utilization during the 365 days following discharge using inverse probability of treatment weights to balance covariates. PRINCIPAL FINDINGS Among a cohort of 152,687 hospitalized Veterans, a positive MRSA test result was associated with an overall increase of 6.6 (95 percent CI: 5.7-7.5) inpatient days and $9,237 (95 percent CI: $8,211-$10,262) during the postdischarge period. VA inpatient admissions, Medicare reimbursements, and purchased care payments accounted for 60.6 percent, 22.5 percent, and 16.9 percent of these inpatient costs. CONCLUSIONS While most of the excess postdischarge health care costs associated with MRSA HAIs occurred in the VA, non-VA costs make up an important subset of the overall burden.
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Affiliation(s)
- Richard E Nelson
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Makoto Jones
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Chuan-Fen Liu
- Veterans Affairs Puget Sound Health Care System, Seattle, WA.,Department of Health Services, University of Washington, Seattle, WA
| | - Matthew H Samore
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Martin E Evans
- Lexington Veterans Affairs Medical Center, Lexington, KY.,MRSA/MDRO Program, National Infectious Diseases Service, Veterans Health Administration, Lexington, KY.,Department of Internal Medicine, University of Kentucky, Lexington, KY
| | - Vanessa W Stevens
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Thomas Reese
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, UT
| | - Michael A Rubin
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
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18
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Bian J, Weir C, Unni P, Borbolla D, Reese T, Wan YKJ, Del Fiol G. Interactive Visual Displays for Interpreting the Results of Clinical Trials: Formative Evaluation With Case Vignettes. J Med Internet Res 2018; 20:e10507. [PMID: 29941416 PMCID: PMC6037946 DOI: 10.2196/10507] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 04/30/2018] [Accepted: 05/03/2018] [Indexed: 11/13/2022] Open
Abstract
Background At the point of care, evidence from randomized controlled trials (RCTs) is underutilized in helping clinicians meet their information needs. Objective To design interactive visual displays to help clinicians interpret and compare the results of relevant RCTs for the management of a specific patient, and to conduct a formative evaluation with physicians comparing interactive visual versus narrative displays. Methods We followed a user-centered and iterative design process succeeded by development of information display prototypes as a Web-based application. We then used a within-subjects design with 20 participants (8 attendings and 12 residents) to evaluate the usability and problem-solving impact of the information displays. We compared subjects’ perceptions of the interactive visual displays versus narrative abstracts. Results The resulting interactive visual displays present RCT results side-by-side according to the Population, Intervention, Comparison, and Outcome (PICO) framework. Study participants completed 19 usability tasks in 3 to 11 seconds with a success rate of 78% to 100%. Participants favored the interactive visual displays over narrative abstracts according to perceived efficiency, effectiveness, effort, user experience and preference (all P values <.001). Conclusions When interpreting and applying RCT findings to case vignettes, physicians preferred interactive graphical and PICO-framework-based information displays that enable direct comparison of the results from multiple RCTs compared to the traditional narrative and study-centered format. Future studies should investigate the use of interactive visual displays to support clinical decision making in care settings and their effect on clinician and patient outcomes.
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Affiliation(s)
- Jiantao Bian
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States
| | - Charlene Weir
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States.,George E. Whalen Veterans Affairs Medical Center, Salt Lake City, UT, United States
| | - Prasad Unni
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States.,Intelligent Medical Objects, Chicago, IL, United States
| | - Damian Borbolla
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States
| | - Thomas Reese
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States
| | - Yik-Ki Jacob Wan
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States
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Ostheimer C, Evers C, Reese T, Bache M, Vordermark D. EP-2307: Prognostic implications of the urokinase plasminogen activator system and osteopontin in NSCLC. Radiother Oncol 2018. [DOI: 10.1016/s0167-8140(18)32616-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Gkika E, Tanadini-Lang S, Kirste S, Holzner PA, Neeff HP, Rischke HC, Reese T, Lohaus F, Duma MN, Dieckmann K, Semrau R, Stockinger M, Imhoff D, Kremers N, Häfner MF, Andratschke N, Nestle U, Grosu AL, Guckenberger M, Brunner TB. Interobserver variability in target volume delineation of hepatocellular carcinoma. Strahlenther Onkol 2017; 193:823-830. [DOI: 10.1007/s00066-017-1177-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 06/22/2017] [Indexed: 12/22/2022]
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Gkika E, Tandini-Lang S, Kirste S, Holzner P, Neeff H, Rischke H, Reese T, Lohaus F, Duma M, Dieckmann K, Semrau R, Stockinger M, Imhoff D, Kremers N, Häfner M, Andratschke N, Nestle U, Grosu A, Guckenberger M, Brunner T. EP-1253: Interobserver variability in the target delineation of hepatocellular carcinoma. Radiother Oncol 2017. [DOI: 10.1016/s0167-8140(17)31688-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Waller R, Segall N, Borbolla D, Nesbitt P, Reese T, Del Fiol G, Wright M. 1148: GRAPHICAL DISPLAY OF PATIENT INFORMATION IMPROVES OUTCOMES IN CRITICAL CARE: A SYSTEMATIC REVIEW. Crit Care Med 2016. [DOI: 10.1097/01.ccm.0000509823.64356.39] [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: 11/25/2022]
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Nelson RE, Reese T, Jones M, Stevens VW, Liu CF, Samore M, Evans M, Rubin M. The Impact of Healthcare-Associated Methicillin-Resistant Staphylococcus aureus Infections Among United States Veterans on Post-Discharge Healthcare Cost and Utilization Outside the Department of Veterans Affairs Healthcare System. Open Forum Infect Dis 2016. [DOI: 10.1093/ofid/ofw172.157] [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: 11/13/2022] Open
Affiliation(s)
- Richard E. Nelson
- Ideas Center, VA Salt Lake City Health Care System, Salt Lake City, Utah
| | - Thomas Reese
- Salt Lake City VA Healthcare System, Salt Lake City, Utah; Pharmacotherapy, University of Utah, Salt Lake City, Utah
| | - Makoto Jones
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | | | | | - Matthew Samore
- University of Utah School of Medicine, Division of Epidemiology, Salt Lake City, Utah
| | - Martin Evans
- Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Michael Rubin
- Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
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Lafleur J, Bress A, Crook J, Esker S, Nyman H, Reese T, Bedimo R, Tebas P, Rosenblatt L. Renal and Bone Outcomes Among HIV-Infected Patients Exposed to EFV/TDF/FTC Compared With Other Tenofovir Disoproxil Fumarate–Containing Antiretroviral Regimens: Findings From the Veterans Health Administration (VHA). Open Forum Infect Dis 2016. [DOI: 10.1093/ofid/ofw172.1730] [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)
- Joanne Lafleur
- Pharmacotherapy, University of Utah, Salt Lake City, Utah
- Salt Lake City US Department of Veterans Affairs Healthcare System, Salt Lake City, Utah
| | - Adam Bress
- Pharmacotherapy, University of Utah, Salt Lake City, Utah
- Salt Lake City US Department of Veterans Affairs Healthcare System, Salt Lake City, Utah
| | - Jacob Crook
- Salt Lake City US Department of Veterans Affairs Healthcare System, Salt Lake City, Utah
- Epidemiology, University of Utah, Salt Lake City, Utah
| | | | - Heather Nyman
- Pharmacotherapy, University of Utah, Salt Lake City, Utah
| | - Thomas Reese
- Pharmacotherapy, University of Utah, Salt Lake City, Utah
- Salt Lake City US Department of Veterans Affairs Healthcare System, Salt Lake City, Utah
| | - Roger Bedimo
- Medicine, US Department of Veterans Affairs N Texas Health Care Systems, University of Texas, Dallas, Texas
| | - Pablo Tebas
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Ostheimer C, Schweyer F, Reese T, Bache M, Vordermark D. The relationship between tumor volume changes and serial plasma osteopontin detection during radical radiotherapy of non-small-cell lung cancer. Oncol Lett 2016; 12:3449-3456. [PMID: 27900019 DOI: 10.3892/ol.2016.5104] [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: 05/18/2016] [Accepted: 07/28/2016] [Indexed: 01/25/2023] Open
Abstract
The prognostic quality of increased osteopontin (OPN) plasma levels has been demonstrated for the chemotherapy and surgery of lung cancer. There is also evidence in the literature that tumor volume impacts prognosis in definitive radiotherapy (RT) of (lung) cancer. We previously demonstrated that elevated plasma levels of OPN before, and increasing OPN plasma levels after RT significantly correlate with survival and outcome after curative-intent RT of non-small-cell lung cancer (NSCLC). Tumor volume was also associated with prognosis. The present prospective clinical study investigated the prognostic interrelation of OPN plasma levels and tumor volume and their changes in the radical RT of NSCLC. We evaluated a subset of patients (n=27) with inoperable, non-metastasized NSCLC of the previously published patient collective. Patients were treated with radical radiochemotherapy (2 Gy ad 66 Gy). OPN plasma concentrations were determined by ELISA before (t0), at the end (t1), and 4 weeks after RT (t2). GTV was delineated PET- and CT-correlated before RT (GTV1) and after 40 Gy (GTV2). The course of OPN during and after RT and the change of GTV during RT was monitored over time and correlated with prognosis. Median GTV2 after 40 Gy (63 ml) was significantly lower than pre-RT GTV1 (90 ml, P<0.0001). Median OPN before (t0), at the end of (t1) and four weeks after RT (t2) was 846, 777 and 624 ng/ml and not significantly different. GTV significantly declined by 39 ml during RT (P<0.0001) and OPN non-significantly decreased by 56 ng/ml during (t0 to t1) and by 54 ng/ml after RT (t1 to t2). No correlations were determined between absolute OPN and GTV values or their relative changes during RT. In univariate analysis, only GTV2 significantly predicted overall survival (OS, P=0.03). In multivariate analysis, both OPN t1 (P<0.001) and GTV2 (P=0.001) remained significant predictors of OS. Relative OPN plasma level changes after (t1 to t2) and GTV changes during RT (GTV 1 to GTV 2) significantly predicted OS (P=0.02). The combination of absolute GTV values before RT (GTV1) and GTV changes during RT (GTV1 to 2) were significantly associated with OS in both uni- and multivariate analysis (P=0.03). The combination of absolute OPN plasma levels and their changes with GTV and its changes did not reach statistical significance. The lack of a significant correlation between OPN and GTV together with the finding that OPN and GTV remained independent predictors of survival outcome but were not associated with OS in combination supports the hypothesis that tumor volume (GTV) and OPN plasma levels (both their changes and absolute values) are not interrelated in terms of prognosis but do possess each parameter separately, a prognostic quality in the radical RT of NSCLC which justifies further prospective studies to validate these results.
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Affiliation(s)
- Christian Ostheimer
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, D-06120 Halle (Saale), Germany
| | - Franziska Schweyer
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, D-06120 Halle (Saale), Germany
| | - Thomas Reese
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, D-06120 Halle (Saale), Germany
| | - Matthias Bache
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, D-06120 Halle (Saale), Germany
| | - Dirk Vordermark
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, D-06120 Halle (Saale), Germany
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Hompes S, Scherer K, Köhli A, Ruëff F, Mahler V, Lange L, Treudler R, Rietschel E, Szépfalusi Z, Lang R, Rabe U, Reese T, Beyer K, Schwerk N, Worm M. Nahrungsmittelanaphylaxie: Daten aus dem Anaphylaxie-Register. Allergo J 2016. [DOI: 10.1007/bf03362320] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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27
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Nelson SD, Poikonen J, Reese T, El Halta D, Weir C. The pharmacist and the EHR. J Am Med Inform Assoc 2016; 24:193-197. [PMID: 27107439 DOI: 10.1093/jamia/ocw044] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 02/10/2016] [Accepted: 02/21/2016] [Indexed: 11/14/2022] Open
Abstract
The adoption of electronic health records (EHRs) across the United States has impacted the methods by which health care professionals care for their patients. It is not always recognized, however, that pharmacists also actively use advanced functionality within the EHR. As critical members of the health care team, pharmacists utilize many different features of the EHR. The literature focuses on 3 main roles: documentation, medication reconciliation, and patient evaluation and monitoring. As health information technology proliferates, it is imperative that pharmacists' workflow and information needs are met within the EHR to optimize medication therapy quality, team communication, and patient outcomes.
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Affiliation(s)
- Scott D Nelson
- Principal Domain Specialist, EHR Portfolio, Vanderbilt University Medical Center, Nashville, TN, USA
| | - John Poikonen
- Director of Informatics, Avhana Health, Cambridge, MA, USA
| | - Thomas Reese
- Research Associate, Department of Pharmacotherapy, University of Utah, Salt Lake City, UT, USA
| | - David El Halta
- Informatics Pharmacist, University of Utah Hospital and Clinics, Salt Lake City, UT, USA
| | - Charlene Weir
- Research Professor, Department of Biomedical Informatics, Research Associate Professor, College of Nursing, University of Utah, Salt Lake City, UT, USA
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Grabenhenrich LB, Dölle S, Moneret-Vautrin A, Köhli A, Lange L, Spindler T, Ruëff F, Nemat K, Maris I, Roumpedaki E, Scherer K, Ott H, Reese T, Mustakov T, Lang R, Fernandez-Rivas M, Kowalski ML, Bilò MB, Hourihane JO, Papadopoulos NG, Beyer K, Muraro A, Worm M. Anaphylaxis in children and adolescents: The European Anaphylaxis Registry. J Allergy Clin Immunol 2016; 137:1128-1137.e1. [PMID: 26806049 DOI: 10.1016/j.jaci.2015.11.015] [Citation(s) in RCA: 324] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 10/09/2015] [Accepted: 11/10/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Anaphylaxis in children and adolescents is a potentially life-threatening condition. Its heterogeneous clinical presentation and sudden occurrence in virtually any setting without warning have impeded a comprehensive description. OBJECTIVE We sought to characterize severe allergic reactions in terms of elicitors, symptoms, emergency treatment, and long-term management in European children and adolescents. METHODS The European Anaphylaxis Registry recorded details of anaphylaxis after referral for in-depth diagnosis and counseling to 1 of 90 tertiary allergy centers in 10 European countries, aiming to oversample the most severe reactions. Data were retrieved from medical records by using a multilanguage online form. RESULTS Between July 2007 and March 2015, anaphylaxis was identified in 1970 patients younger than 18 years. Most incidents occurred in private homes (46%) and outdoors (19%). One third of the patients had experienced anaphylaxis previously. Food items were the most frequent trigger (66%), followed by insect venom (19%). Cow's milk and hen's egg were prevalent elicitors in the first 2 years, hazelnut and cashew in preschool-aged children, and peanut at all ages. There was a continuous shift from food- to insect venom- and drug-induced anaphylaxis up to age 10 years, and there were few changes thereafter. Vomiting and cough were prevalent symptoms in the first decade of life, and subjective symptoms (nausea, throat tightness, and dizziness) were prevalent later in life. Thirty percent of cases were lay treated, of which 10% were treated with an epinephrine autoinjector. The fraction of intramuscular epinephrine in professional emergency treatment increased from 12% in 2011 to 25% in 2014. Twenty-six (1.3%) patients were either admitted to the intensive care unit or had grade IV/fatal reactions. CONCLUSIONS The European Anaphylaxis Registry confirmed food as the major elicitor of anaphylaxis in children, specifically hen's egg, cow's milk, and nuts. Reactions to insect venom were seen more in young adulthood. Intensive care unit admissions and grade IV/fatal reactions were rare. The registry will serve as a systematic foundation for a continuous description of this multiform condition.
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Affiliation(s)
- Linus B Grabenhenrich
- Institute for Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sabine Dölle
- Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Alice Köhli
- Division of Allergology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Lars Lange
- Department of Pediatrics, St Marien-Hospital, Bonn, Germany
| | - Thomas Spindler
- Pediatric Pneumology and Allergology, Lungenzentrum Süd-West, Wangen, Germany
| | - Franziska Ruëff
- Department of Dermatology and Allergology, Ludwig-Maximilian-Universität, Munich, Germany
| | - Katja Nemat
- Pediatric Pneumology and Allergology, Kinderzentrum Dresden-Friedrichstadt, Dresden, Germany
| | - Ioana Maris
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | | | - Kathrin Scherer
- Department of Dermatology, University Hospital Basel, Basel, Switzerland
| | - Hagen Ott
- Pediatric Dermatology and Allergology, Children's Hospital Auf der Bult, Hannover, Germany
| | - Thomas Reese
- Rheine Kinderklinik, Mathias-Spital, Rheine, Germany
| | - Tihomir Mustakov
- Clinical Centre of Allergology, University Hospital Alexandrovska/Medical University Sofia, Sofia, Bulgaria
| | - Roland Lang
- Department of Dermatology, Paracelsus Medizinische Privatuniversität Salzburg, Salzburg, Austria
| | | | - Marek L Kowalski
- Department of Immunology, Rheumatology and Allergy, Medical University of Lodz, Lodz, Poland
| | - Maria B Bilò
- Department of Internal Medicine/Allergy Unit, University Hospital Ospedali Riuniti, Ancona, Italy
| | | | | | - Kirsten Beyer
- Department of Pediatric Pneumology and Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Icahn School of Medicine at Mount Sinai, New York, NY
| | - Antonella Muraro
- Department of Mother and Child Health, Padua General University Hospital, Padua, Italy
| | - Margitta Worm
- Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany.
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Rosenberger I, Strauss A, Dobiasch S, Weis C, Szanyi S, Gil-Iceta L, Alonso E, González Esparza M, Gómez-Vallejo V, Szczupak B, Plaza-García S, Mirzaei S, Israel LL, Bianchessi S, Scanziani E, Lellouche JP, Knoll P, Werner J, Felix K, Grenacher L, Reese T, Kreuter J, Jiménez-González M. Targeted diagnostic magnetic nanoparticles for medical imaging of pancreatic cancer. J Control Release 2015; 214:76-84. [PMID: 26192099 DOI: 10.1016/j.jconrel.2015.07.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 07/14/2015] [Accepted: 07/15/2015] [Indexed: 01/15/2023]
Abstract
Highly aggressive cancer types such as pancreatic cancer possess a mortality rate of up to 80% within the first 6months after diagnosis. To reduce this high mortality rate, more sensitive diagnostic tools allowing an early stage medical imaging of even very small tumours are needed. For this purpose, magnetic, biodegradable nanoparticles prepared using recombinant human serum albumin (rHSA) and incorporated iron oxide (maghemite, γ-Fe2O3) nanoparticles were developed. Galectin-1 has been chosen as target receptor as this protein is upregulated in pancreatic cancer and its precursor lesions but not in healthy pancreatic tissue nor in pancreatitis. Tissue plasminogen activator derived peptides (t-PA-ligands), that have a high affinity to galectin-1 have been chosen as target moieties and were covalently attached onto the nanoparticle surface. Improved targeting and imaging properties were shown in mice using single photon emission computed tomography-computer tomography (SPECT-CT), a handheld gamma camera, and magnetic resonance imaging (MRI).
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Affiliation(s)
- I Rosenberger
- Institute of Pharmaceutical Technology, Biocenter Niederursel, Goethe University, Max-von-Laue-Str. 9, 60438 Frankfurt/Main, Germany; Wilhelimnenspital, Institute of Nuclear Medicine, Montleartstr. 37, 1160 Wien, Austria
| | - A Strauss
- Department of Diagnostic Radiology, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - S Dobiasch
- Department of General and Visceral Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - C Weis
- Department of Diagnostic Radiology, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - S Szanyi
- Department of General and Visceral Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - L Gil-Iceta
- CIC biomaGUNE, Molecular Imaging Unit, Paseo Miramón No 182, Parque Tecnológico de San Sebastián, 20009 San Sebastián, Guipúzcoa, Spain
| | - E Alonso
- CIC biomaGUNE, Molecular Imaging Unit, Paseo Miramón No 182, Parque Tecnológico de San Sebastián, 20009 San Sebastián, Guipúzcoa, Spain
| | - M González Esparza
- CIC biomaGUNE, Molecular Imaging Unit, Paseo Miramón No 182, Parque Tecnológico de San Sebastián, 20009 San Sebastián, Guipúzcoa, Spain
| | - V Gómez-Vallejo
- CIC biomaGUNE, Molecular Imaging Unit, Paseo Miramón No 182, Parque Tecnológico de San Sebastián, 20009 San Sebastián, Guipúzcoa, Spain
| | - B Szczupak
- CIC biomaGUNE, Molecular Imaging Unit, Paseo Miramón No 182, Parque Tecnológico de San Sebastián, 20009 San Sebastián, Guipúzcoa, Spain
| | - S Plaza-García
- CIC biomaGUNE, Molecular Imaging Unit, Paseo Miramón No 182, Parque Tecnológico de San Sebastián, 20009 San Sebastián, Guipúzcoa, Spain
| | - S Mirzaei
- Wilhelimnenspital, Institute of Nuclear Medicine, Montleartstr. 37, 1160 Wien, Austria
| | - L L Israel
- Department of Chemistry & Institute of Nanotechnology & Advanced Materials, Bar-Ilan University, Ramat-Gan 5290002, Israel
| | - S Bianchessi
- Fondazione Filarete, Viale Ortles 22/4, 20139 Milano, Italy
| | - E Scanziani
- Fondazione Filarete, Viale Ortles 22/4, 20139 Milano, Italy
| | - J-P Lellouche
- Department of Chemistry & Institute of Nanotechnology & Advanced Materials, Bar-Ilan University, Ramat-Gan 5290002, Israel
| | - P Knoll
- Wilhelimnenspital, Institute of Nuclear Medicine, Montleartstr. 37, 1160 Wien, Austria
| | - J Werner
- Department of General and Visceral Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany; Department of General-, Visceral-, Transplantation-, Vascular- and Thorax-Surgery LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - K Felix
- Department of General and Visceral Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - L Grenacher
- Department of Diagnostic Radiology, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - T Reese
- CIC biomaGUNE, Molecular Imaging Unit, Paseo Miramón No 182, Parque Tecnológico de San Sebastián, 20009 San Sebastián, Guipúzcoa, Spain
| | - J Kreuter
- Institute of Pharmaceutical Technology, Biocenter Niederursel, Goethe University, Max-von-Laue-Str. 9, 60438 Frankfurt/Main, Germany.
| | - M Jiménez-González
- CIC biomaGUNE, Molecular Imaging Unit, Paseo Miramón No 182, Parque Tecnológico de San Sebastián, 20009 San Sebastián, Guipúzcoa, Spain
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Ostheimer C, Meyer F, Kornhuber C, Reese T, Vordermark D. [What does the general and abdominal surgeon need to know about radiotherapy? - aspects of radiotherapy in general and abdominal surgery]. Zentralbl Chir 2015; 140:83-93. [PMID: 25723755 DOI: 10.1055/s-0034-1383338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Radiooncological therapies are an integral part of the multimodal oncological treatment concepts in general and abdominal surgery. These include therapeutic approaches with a curative intention such as the neoadjuvant (pre-operative) radiotherapy of locoregionally advanced and/or N+ oesophageal and rectal cancer, definitive combined chemoradiotherapy of locally advanced, unresectable oesophageal cancer or oesophageal tumour lesions of the upper third, definitive radiotherapy of anal cancer (sphincter sparing) and pre- or post-operative radiotherapy of soft tissue sarcoma on the one hand. A yT0 stage achieved as characteristic of a curative effect by radiation in oesophageal and rectal cancer (omitting subsequent surgical intervention, naturally under clinical and imaging-based controls within short-term follow-up intervals) can be considered as a very interesting set-up with regard to its reasonable integration in daily clinical practice, which needs to be further and critically discussed. By integrating radiotherapy in interdisciplinary therapy concepts, improved tumour control and survival rates with clinically acceptable toxicity can be achieved. On the other hand, non-invasive, locally ablative radiooncological therapies such as extracranial stereotactic body radiotherapy constitute an effective and feasible treatment method for liver metastases in oligometastatic colorectal cancer or other tumour entities according to the decisions by the institutional tumour board, offering high local tumour control rates which can be part of multistep, multimodal procedures with curative intention. This review aims at providing an overview for the general and abdominal surgeon, outlining relevant radiooncological treatment aspects in the multimodal cancer therapy with a focus on the treatment of rectal, oesophageal and anal cancer as well as soft tissue sarcoma and hepatic metastases in oligometastatic colorectal cancer.
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Affiliation(s)
- C Ostheimer
- Klinik und Poliklinik für Strahlentherapie, Universitätsklinikum Halle, Deutschland
| | - F Meyer
- Universitätsklinik für Allgemein-, Viszeral- & Gefäßchirurgie, Universitätsklinikum Magdeburg A. ö. R., Deutschland
| | - C Kornhuber
- Klinik und Poliklinik für Strahlentherapie, Universitätsklinikum Halle, Deutschland
| | - T Reese
- Klinik und Poliklinik für Strahlentherapie, Universitätsklinikum Halle, Deutschland
| | - D Vordermark
- Klinik und Poliklinik für Strahlentherapie, Universitätsklinikum Halle, Deutschland
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Ostheimer C, Bache M, Güttler A, Reese T, Vordermark D. Prognostic information of serial plasma osteopontin measurement in radiotherapy of non-small-cell lung cancer. BMC Cancer 2014; 14:858. [PMID: 25416631 PMCID: PMC4251866 DOI: 10.1186/1471-2407-14-858] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 10/24/2014] [Indexed: 12/24/2022] Open
Abstract
Background Circulating baseline levels of the plasma-protein osteopontin (OPN) have been suggested as a prognostic indicator in chemotherapy and surgery for lung cancer. However, the role of this hypoxia-related protein in radiotherapy of lung cancer is unclear. We previously demonstrated the prognostic effect of baseline OPN plasma levels which was increased by co-detection with other hypoxia-related proteins in the radical radiotherapy of non-small-cell lung cancer (NSCLC). This prospective clinical study investigated whether serial OPN measurements during and after curative-intent radiotherapy for NSCLC provide additional or superior prognostic information. Methods Sixty-nine patients with inoperable NSCLC were prospectively enrolled (55 M0, 14 M1). OPN plasma levels were measured before (t0), at the end (t1) and four weeks after radiotherapy (t2) by ELISA, compared between M0 and M1 patients and correlated with clinicopathological parameters. OPN levels were monitored over time and correlated with prognosis in M0-stage patients treated by radical 66-Gy radiotherapy ± chemotherapy. Results Pre-treatment OPN levels were associated with T stage (p = .03), lung function (p = .002), weight loss (p = .01), tumor volume (p = .02) and hemoglobin concentration (p = 04). M1 patients had significantly elevated OPN levels at all time points (p < .001). Patients with increasing OPN levels after radiotherapy had inferior freedom from relapse (p = .008), overall survival (p = .004) and disease-free survival (p = .001) compared to patients with stable or decreasing OPN levels. The risk of relapse in patients with increasing or stable OPN levels after radiotherapy was increased by a factor of 2.9 (p = .01). Patients with increasing post-treatment OPN levels had a 3.1-fold increased risk of death (p = .003). In an exploratory multivariate model, post-treatment OPN level changes but not absolute baseline OPN levels remained an independent prognostic factor for overall survival (p = .002) with a 3.6-fold increased risk of death, as well as N stage (p = .006). Conclusions Our results suggest that OPN level changes over time, particularly post-treatment, may yield additional prognostic information in curative-intent radiotherapy of NSCLC.
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Affiliation(s)
- Christian Ostheimer
- Department of Radiation Oncology, Martin Luther University Halle-Wittenberg, Klinik und Poliklinik für Strahlentherapie, Martin Luther Universitaet Halle-Wittenberg, Ernst-Grube-Strasse 40, 06097 Halle (Saale), Germany.
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Dellas K, Höhler T, Reese T, Würschmidt F, Engel E, Rödel C, Wagner W, Richter M, Arnold D, Dunst J. Phase II trial of preoperative radiochemotherapy with concurrent bevacizumab, capecitabine and oxaliplatin in patients with locally advanced rectal cancer. Radiat Oncol 2013; 8:90. [PMID: 23587311 PMCID: PMC3679876 DOI: 10.1186/1748-717x-8-90] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2012] [Accepted: 04/01/2013] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Preoperative radiochemotherapy (RCT) with 5-FU or capecitabine is the standard of care for patients with locally advanced rectal cancer (LARC). Preoperative RCT achieves pathological complete response rates (pCR) of 10-15%. We conducted a single arm phase II study to investigate the feasibility and efficacy of addition of bevacizumab and oxaliplatin to preoperative standard RCT with capecitabine. METHODS Eligible patients had LARC (cT3-4; N0/1/2, M0/1) and were treated with preoperative RCT prior to planned surgery. Patients received conventionally fractionated radiotherapy (50.4 Gy in 1.8 Gy fractions) and simultaneous chemotherapy with capecitabine 825 mg/m2 bid (d1-14, d22-35) and oxaliplatin 50 mg/m2 (d1, d8, d22, d29). Bevacizumab 5 mg/kg was added on days 1, 15, and 29. The primary study objective was the pCR rate. RESULTS 70 patients with LARC (cT3-4; N0/1, M0/1), ECOG < 2, were enrolled at 6 sites from 07/2008 through 02/2010 (median age 61 years [range 39-89], 68% male). At initial diagnosis, 84% of patients had clinical stage T3, 62% of patients had nodal involvement and 83% of patients were M0. Mean tumor distance from anal verge was 5.92 cm (± 3.68). 58 patients received the complete RCT (full dose RT and full dose of all chemotherapy). During preoperative treatment, grade 3 or 4 toxicities were experienced by 6 and 2 patients, respectively: grade 4 diarrhea and nausea in one patient (1.4%), respectively, grade 3 diarrhea in 2 patients (3%), grade 3 obstipation, anal abscess, anaphylactic reaction, leucopenia and neutropenia in one patient (1.4%), respectively. In total, 30 patients (46%) developed postoperative complications of any grade including one gastrointestinal perforation in one patient (2%), wound-healing problems in 7 patients (11%) and bleedings in 2 patients (3%). pCR was observed in 12/69 (17.4%) patients. Pathological downstaging (ypT < cT and ypN ≤ cN) was achieved in 31 of 69 patients (44.9%). All of the 66 operated patients had a R0 resection. 47 patients (68.1%) underwent sphincter preserving surgery. CONCLUSIONS The addition of bevacizumab and oxaliplatin to RCT with capecitabine was well tolerated and did not increase perioperative morbidity or mortality. However, the pCR rate was not improved in comparison to other trials that used capecitabine or capecitabine/oxaliplatin in preoperative radiochemotherapy.
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Dellas K, Reese T, Richter M, Arnold D, Dunst J. Concurrent chemoradiation of metastases with capecitabine and oxaliplatin and 3D-CRT in patients with oligometastatic colorectal cancer: results of a phase I study. Radiat Oncol 2012; 7:83. [PMID: 22681700 PMCID: PMC3403841 DOI: 10.1186/1748-717x-7-83] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 06/09/2012] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Local control appears to be an important treatment aim in patients with limited metastases (oligometastases) of colorectal cancer (CRC). Those patients show a favourable prognosis, if--in addition to the local effective treatment--an occurrence of new metastases may also be postponed by effective systemic therapy. The purpose of this dose escalation phase I study was to establish the efficacy of local radiotherapy (RT) of oligometastatic CRC with a concurrent standard chemotherapy regimen. METHODS Patients with first-, second- or third-line therapy of oligometastatic CRC (1-3 metastases or local recurrence plus max. 2 metastases) received capecitabine (825 mg/m²/d BID d 1-14; 22-35) and oxaliplatin (50 mg/m² d 1, 8, 22, 29). 3D-conformal RT of all metastatic lesions was delivered in 2.0 Gy up to 36 Gy to 50 Gy (3 dose levels). Primary endpoint was the maximal tolerable dose (MTD) of RT defined as the level at which two or more of six patients experienced dose-limiting toxicity (DLT). RESULTS Between 09/2004 and 08/2007, 9 patients (7 male, 2 female, 50-74 years) were enrolled, 6 patients treated at dose level 1 (36 Gy), 3 patients at dose level 2 (44 Gy). 1 patient from the first cohort experienced DLT (oxaliplatin-related hypersensitivity reaction). No radiation-induced DLT occurred. 6/9 patients achieved objective response (partial remission). One year after initiation, all patients were alive, 6 patients survived (16 to 54 months) patients died of tumor progression (14 to 23 months). The phase II part of the trial had to be closed due to recruitment failure. CONCLUSIONS Local 3D-CRT to metastatic lesions in addition to standard chemotherapy was feasible, DLT was not documented. 3/9 patients survived for a period of 3.5 to 4.4 years (time at the last evaluation). Radiotherapy of metastatic lesions should be incorporated into subsequent trials.
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Affiliation(s)
- Kathrin Dellas
- North European Radiooncological Center Kiel (NRoCK), Kiel, Germany
- Department of Radiooncology, University of Lübeck, Lübeck, Germany
| | - Thomas Reese
- Department of Radiotherapy, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Michael Richter
- Coordination Center for Clinical Trials, Halle (Saale), Germany
| | - Dirk Arnold
- Hubertus Wald Tumor Center, University Comprehensive Cancer Center Hamburg-Eppendorf (UCCH), Hamburg, Germany
| | - Jürgen Dunst
- North European Radiooncological Center Kiel (NRoCK), Kiel, Germany
- Department of Radiooncology, University of Lübeck, Lübeck, Germany
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Hompes S, Köhli A, Nemat K, Scherer K, Lange L, Rueff F, Rietschel E, Reese T, Szepfalusi Z, Schwerk N, Beyer K, Hawranek T, Niggemann B, Worm M. Provoking allergens and treatment of anaphylaxis in children and adolescents--data from the anaphylaxis registry of German-speaking countries. Pediatr Allergy Immunol 2011; 22:568-74. [PMID: 21435004 DOI: 10.1111/j.1399-3038.2011.01154.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Anaphylaxis is the most severe reaction of an IgE-mediated hypersensitivity. Data about affected patients may help to improve our knowledge of anaphylaxis and its medical care. We analysed data from the anaphylaxis registry of German speaking countries with regard to the provoking allergens and treatment modalities of anaphylaxis in children and adolescents. Inclusion criteria were severe systemic allergic reactions with concomitant pulmonary and/or cardiovascular symptoms. The data are collected by a password-controlled online-questionnaire. For this analysis, data of 197 reported anaphylactic reactions from children and adolescents registered between 2006 and 2009 were included. The data show that within the registered cases the most frequently affected organ systems for children and adolescents were the skin (89%) and the respiratory tract (87%) followed by symptoms of the cardiovascular system (47%) and the gastrointestinal tract (43%). The most frequent elicitors were food allergens accounting for 58% of cases, followed by insect venom (24%) and drugs (8%). The most frequent food allergens were peanuts followed by tree nuts and animal related food products. In 18% aggravating factors such as physical exercise were noted by the clinicians. 26% of the analysed patients had experienced more than one reaction. The data regarding the emergency treatment show that antihistamines (87%) and corticosteroids (85%) were often used but that adrenaline was rarely used (22% of the registered cases). Taken together these data show that the analysis of anaphylaxis by registration of affected individuals can provide data about provoking allergens and treatment measures but also suggest the impact of aggravating factors on anaphylactic reactions. The under-represented usage of adrenaline indicates the need of educational measures for patients and their physicians.
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Affiliation(s)
- Stephanie Hompes
- Department of Dermatology and Allergy, University Hospital Charité Berlin, Germany
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Guérin B, Cho S, Chun SY, Zhu X, Alpert NM, El Fakhri G, Reese T, Catana C. Nonrigid PET motion compensation in the lower abdomen using simultaneous tagged-MRI and PET imaging. Med Phys 2011; 38:3025-38. [PMID: 21815376 DOI: 10.1118/1.3589136] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE We propose a novel approach for PET respiratory motion correction using tagged-MRI and simultaneous PET-MRI acquisitions. METHODS We use a tagged-MRI acquisition followed by motion tracking in the phase domain to estimate the nonrigid deformation of biological tissues during breathing. In order to accurately estimate motion even in the presence of noise and susceptibility artifacts, we regularize the traditional HARP tracking strategy using a quadratic roughness penalty on neighboring displacement vectors (R-HARP). We then incorporate the motion fields estimated with R-HARP in the system matrix of an MLEM PET reconstruction algorithm formulated both for sinogram and list-mode data representations. This approach allows reconstruction of all detected coincidences in a single image while modeling the effect of motion both in the emission and the attenuation maps. At present, tagged-MRI does not allow estimation of motion in the lungs and our approach is therefore limited to motion correction in soft tissues. Since it is difficult to assess the accuracy of motion correction approaches in vivo, we evaluated the proposed approach in numerical simulations of simultaneous PET-MRI acquisitions using the NCAT phantom. We also assessed its practical feasibility in PET-MRI acquisitions of a small deformable phantom that mimics the complex deformation pattern of a lung that we imaged on a combined PET-MRI brain scanner. RESULTS Simulations showed that the R-HARP tracking strategy accurately estimated realistic respiratory motion fields for different levels of noise in the tagged-MRI simulation. In simulations of tumors exhibiting increased uptake, contrast estimation was 20% more accurate with motion correction than without. Signal-to-noise ratio (SNR) was more than 100% greater when performing motion-corrected reconstruction which included all counts, compared to when reconstructing only coincidences detected in the first of eight gated frames. These results were confirmed in our proof-of-principle PET-MRI acquisitions, indicating that our motion correction strategy is accurate, practically feasible, and is therefore ready to be tested in vivo. CONCLUSIONS This work shows that PET motion correction using motion fields measured with tagged-MRI in simultaneous PET-MRI acquisitions can be made practical for clinical application and that doing so has the potential to remove motion blur in whole-body PET studies of the torso.
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Affiliation(s)
- B Guérin
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114, USA
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Hoehler T, Dellas K, Riesenbeck D, Reese T, Wuerschmidt F, Roedel C, Wagner W, Zuehlke H, Richter M, Dunst J. Preoperative chemoradiation (CRT) with concurrent capecitabine (Cap), oxaliplatin (Ox), and bevacizumab (Bev) in patients with locally advanced rectal cancer (RC): Effects on pathological complete response (pCR) and surgical complications. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.3630] [Citation(s) in RCA: 3] [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: 11/20/2022] Open
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Dunst J, Debus J, Rudat V, Wulf J, Budach W, Hoelscher T, Reese T, Mose S, Roedel C, Zuehlke H, Hinke A. Neoadjuvant capecitabine combined with standard radiotherapy in patients with locally advanced rectal cancer: mature results of a phase II trial. Strahlenther Onkol 2008; 184:450-6. [PMID: 19016023 DOI: 10.1007/s00066-008-1751-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2007] [Accepted: 06/13/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE The objective of this expanded phase II trial was to confirm the safety results of the preceding phase I study and establish the efficacy of neoadjuvant radiochemotherapy with capecitabine in rectal cancer in a multicenter setting. PATIENTS AND METHODS 96 patients (63% male, age 34-81 years) with advanced rectal cancer (cT3-4 or cN+) from seven university centers in Germany were recruited. All were to receive a total irradiation dose of 50.4-55.8 Gy with conventional fractions. Capecitabine was given at an oral dosage of 825 mg/m(2)bid on each day of the radiotherapy period with the first daily dose applied 2 h before irradiation, followed by surgery 6 weeks later. RESULTS Most of the patients suffered from an advanced primary tumor (cT3: 57%, cT4: 40%) with lymph node involvement in 60%. After neoadjuvant treatment, with a mean of 99% of the scheduled radiation dose actually delivered, a clinical response rate of 68% (95% confidence interval: 57-78%) was observed. Out of 87 evaluable patients undergoing surgery, a sphincter-preserving procedure could be performed in 51% and R0 resection in 94%. A pathologically complete response was achieved in six patients (7%, 95% confidence interval: 3-14%). The comparison of initial diagnosis and pathologic findings showed a downstaging in 61%. Acute toxicity with > 5% incidence of NCI (National Cancer Institute) grade >/= 3 included lymphopenia (12%), leukopenia (6%), and diarrhea (7%). Mild to moderate hand-foot syndrome occurred in 12% only. After a median follow-up of 48 months, the 5-year overall survival and tumor control data were, with regard to patient selection, in the expected range with an overall survival of 65%, a relapse-free survival of 47%, and a local recurrence rate after 5 years of 17%. CONCLUSION The data clearly confirm that capecitabine is an adequate substitute for 5-fluorouracil in preoperative chemoradiation of rectal cancer with a favorable safety profile.
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Affiliation(s)
- Juergen Dunst
- Department of Radiotherapy, University of Lübeck, Lübeck, Germany.
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Crisponi L, Crisponi G, Meloni A, Toliat MR, Nurnberg G, Usala G, Uda M, Masala M, Hohne W, Becker C, Marongiu M, Chiappe F, Kleta R, Rauch A, Wollnik B, Strasser F, Reese T, Jakobs C, Kurlemann G, Cao A, Nurnberg P, Rutsch F. Crisponi syndrome is caused by mutations in the CRLF1 gene and is allelic to cold-induced sweating syndrome type 1. Am J Hum Genet 2007; 80:971-81. [PMID: 17436252 PMCID: PMC1852730 DOI: 10.1086/516843] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2007] [Accepted: 03/01/2007] [Indexed: 02/01/2023] Open
Abstract
Crisponi syndrome is a severe autosomal recessive condition that is phenotypically characterized by abnormal, paroxysmal muscular contractions resembling neonatal tetanus, large face, broad nose, anteverted nares, camptodactyly, hyperthermia, and sudden death in most cases. We performed homozygosity mapping in five Sardinian and three Turkish families with Crisponi syndrome, using high-density single-nucleotide polymorphism arrays, and identified a critical region on chromosome 19p12-13.1. The most prominent candidate gene was CRLF1, recently found to be involved in the pathogenesis of cold-induced sweating syndrome type 1 (CISS1). CISS1 belongs to a group of conditions with overlapping phenotypes, also including cold-induced sweating syndrome type 2 and Stuve-Wiedemann syndrome. All these syndromes are caused by mutations of genes of the ciliary neurotrophic factor (CNTF)-receptor pathway. Here, we describe the identification of four different CRLF1 mutations in eight different Crisponi-affected families, including a missense mutation, a single-nucleotide insertion, and a nonsense and an insertion/deletion (indel) mutation, all segregating with the disease trait in the families. Comparison of the mutation spectra of Crisponi syndrome and CISS1 suggests that neither the type nor the location of the CRLF1 mutations points to a phenotype/genotype correlation that would account for the most severe phenotype in Crisponi syndrome. Other, still-unknown molecular factors may be responsible for the variable phenotypic expression of the CRLF1 mutations. We suggest that the syndromes can comprise a family of "CNTF-receptor-related disorders," of which Crisponi syndrome would be the newest member and allelic to CISS1.
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Affiliation(s)
- Laura Crisponi
- Istituto di Neurogenetica e Neurofarmacologia-Consiglio Nazionale delle Ricerche, Cittadella Universitaria di Monserrato, Monserrato, Italy.
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Rödel C, Liersch T, Hermann RM, Arnold D, Reese T, Hipp M, Fürst A, Schwella N, Bieker M, Hellmich G, Ewald H, Haier J, Lordick F, Flentje M, Sülberg H, Hohenberger W, Sauer R. Multicenter phase II trial of chemoradiation with oxaliplatin for rectal cancer. J Clin Oncol 2007; 25:110-7. [PMID: 17194912 DOI: 10.1200/jco.2006.08.3675] [Citation(s) in RCA: 163] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE To evaluate the activity and safety of preoperative radiotherapy (RT) and concurrent capecitabine and oxaliplatin (XELOX-RT) plus four cycles of adjuvant XELOX in patients with rectal cancer. PATIENTS AND METHODS One hundred ten patients with T3/T4 or N+ rectal cancer were entered onto the trial in 11 investigator sites and received preoperative RT (50.4 Gy in 28 fractions). Capecitabine was administered concurrently at 1,650 mg/m2 on days 1 to 14 and 22 to 35, and oxaliplatin was administered at 50 mg/m2 on days 1, 8, 22, and 29. Surgery was scheduled 4 to 6 weeks after completion of XELOX-RT. Four cycles of adjuvant XELOX (capecitabine 1,000 mg/m2 bid on days 1 to 14; oxaliplatin 130 mg/m2 on day 1) were administered. The main end points were activity as assessed by the pathologic complete response (pCR) rate and the feasibility of postoperative XELOX chemotherapy. RESULTS After XELOX-RT, 103 of 104 eligible patients underwent surgery; pCR was achieved in 17 patients (16%), one patient had ypT0N1 disease, and 53 patients showed tumor regression of more than 50% of the tumor mass. R0 resections were achieved in 95% of patients, and sphincter preservation was accomplished in 77%. Full-dose preoperative XELOX-RT was administered in 96%. Grade 3 or 4 diarrhea occurred in 12% of patients. Postoperative complication occurred in 43% of patients. Sixty percent of patients received all four cycles of adjuvant XELOX, with sensory neuropathy (18%) and diarrhea (12%) being the main grade 3 or 4 toxicities. CONCLUSION Preoperative XELOX-RT plus four cycles of adjuvant XELOX is an active and feasible treatment. This regimen is proposed for phase III evaluation comparing standard fluorouracil-based treatment with XELOX- based multimodality treatment.
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Affiliation(s)
- Claus Rödel
- Department of Radiotherapy, University of Erlangen-Nürnberg, Erlangen, Germany.
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Arnold D, Hipp M, Reese T, Hohenberger W, Liersch T, Lordick F, Sülberg H, Sauer R, Rödel C. Phase I/II study of cetuximab, capecitabine and oxaliplatin (CAPOX) combined with standard radiotherapy (RTX) as neoadjuvant treatment of advanced rectal cancer (RC). J Clin Oncol 2006. [DOI: 10.1200/jco.2006.24.18_suppl.3574] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
3574 Background: CAPOX given concurrently to neoadjuvant RTX in RC is well tolerated and yielded high rates of pathologic complete responses in phase II trials. Cetuximab, a monoclonal antibody targeted against the EGF receptor, is active in metastatic colorectal cancer. Furthermore, synergy of cetuximab with RTX was shown in improved survival vs. RTX alone in head and neck cancer. This trial was to evaluate maximal tolerated dose (MTD), feasibility and efficacy of CAPOX + RTX with cetuximab in RC. Method: Patients (pts) had to have unpretreated T3–4 and/or N+ disease, with distant metastases allowed. During a conventionally fractionated RTX (1.8 Gy for 28 days [d]), cetuximab was given in standard dosage (400mg/m2 on d-7, then 6 weekly doses of 250 mg/m2, to d35). CAPOX was given on the basis of a previously examined schedule with oxaliplatin (50 mg/m2 d 1,8,22 and 29) in combination with capecitabine (d1–14 and d22–35) at 3 dose levels: 1000, 1300 and 1650mg/m2 bid. In phase I, a standard 3+3 design was used, allowing for dose escalation in 0/3 or 1/6 pt with dose-limiting toxicity (DLT). Results: 13 pts were enrolled: Median age 58 [35–75] yrs., m/f 7/6 pts. T3 85%, T4 15%; N+ 92%, M1 46%; G2 92%, G3 8%. As on dose level 1 one DLT (diarrhea grade 3) occurred, it was extended to 7 pts. No further DLT was observed as it was on levels 2 and 3 with 3 pts each. Full RTX course was administered in all pts, while CAPOX-cetuximab was stopped in the DLT case and cetuximab in 1 pt with hypersensitivity reaction. Toxicities are displayed in the table . Conclusion: CAPOX can safely be combined with cetuximab without requiring chemotherapy dose reduction. The multicenter phase II part of the trial with 31 pts. included so far is ongoing and updated results (including resectability) will be presented. [Table: see text] [Table: see text]
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Affiliation(s)
- D. Arnold
- Martin Luther University, Halle, Germany; University Clinic, Regensburg, Germany; Friedrich Alexander University, Erlangen, Germany; George August University, Goettingen, Germany; Klinikum Rechts der Isar, Technical University, Munich, Germany; WiSP, Langenfeld, Germany
| | - M. Hipp
- Martin Luther University, Halle, Germany; University Clinic, Regensburg, Germany; Friedrich Alexander University, Erlangen, Germany; George August University, Goettingen, Germany; Klinikum Rechts der Isar, Technical University, Munich, Germany; WiSP, Langenfeld, Germany
| | - T. Reese
- Martin Luther University, Halle, Germany; University Clinic, Regensburg, Germany; Friedrich Alexander University, Erlangen, Germany; George August University, Goettingen, Germany; Klinikum Rechts der Isar, Technical University, Munich, Germany; WiSP, Langenfeld, Germany
| | - W. Hohenberger
- Martin Luther University, Halle, Germany; University Clinic, Regensburg, Germany; Friedrich Alexander University, Erlangen, Germany; George August University, Goettingen, Germany; Klinikum Rechts der Isar, Technical University, Munich, Germany; WiSP, Langenfeld, Germany
| | - T. Liersch
- Martin Luther University, Halle, Germany; University Clinic, Regensburg, Germany; Friedrich Alexander University, Erlangen, Germany; George August University, Goettingen, Germany; Klinikum Rechts der Isar, Technical University, Munich, Germany; WiSP, Langenfeld, Germany
| | - F. Lordick
- Martin Luther University, Halle, Germany; University Clinic, Regensburg, Germany; Friedrich Alexander University, Erlangen, Germany; George August University, Goettingen, Germany; Klinikum Rechts der Isar, Technical University, Munich, Germany; WiSP, Langenfeld, Germany
| | - H. Sülberg
- Martin Luther University, Halle, Germany; University Clinic, Regensburg, Germany; Friedrich Alexander University, Erlangen, Germany; George August University, Goettingen, Germany; Klinikum Rechts der Isar, Technical University, Munich, Germany; WiSP, Langenfeld, Germany
| | - R. Sauer
- Martin Luther University, Halle, Germany; University Clinic, Regensburg, Germany; Friedrich Alexander University, Erlangen, Germany; George August University, Goettingen, Germany; Klinikum Rechts der Isar, Technical University, Munich, Germany; WiSP, Langenfeld, Germany
| | - C. Rödel
- Martin Luther University, Halle, Germany; University Clinic, Regensburg, Germany; Friedrich Alexander University, Erlangen, Germany; George August University, Goettingen, Germany; Klinikum Rechts der Isar, Technical University, Munich, Germany; WiSP, Langenfeld, Germany
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Schwarz AJ, Zocchi A, Reese T, Gozzi A, Garzotti M, Varnier G, Curcuruto O, Sartori I, Girlanda E, Biscaro B, Crestan V, Bertani S, Heidbreder C, Bifone A. Concurrent pharmacological MRI and in situ microdialysis of cocaine reveal a complex relationship between the central hemodynamic response and local dopamine concentration. Neuroimage 2004; 23:296-304. [PMID: 15325377 DOI: 10.1016/j.neuroimage.2004.05.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2004] [Revised: 04/08/2004] [Accepted: 05/03/2004] [Indexed: 12/22/2022] Open
Abstract
The mechanisms underlying the signal changes observed with pharmacological magnetic resonance imaging (phMRI) remain to be fully elucidated. In this study, we obtained microdialysis samples in situ at 5-min intervals during phMRI experiments using a blood pool contrast agent to correlate relative cerebral blood volume (rCBV) changes with changes in dopamine and cocaine concentrations following acute cocaine challenge (0.5 mg/kg iv) in the rat over a duration of 30 min. Three brain areas were investigated: the dorsal striatum (n = 8), the medial prefrontal cortex (mPFC; n = 5), and the primary motor cortex (n = 8). In the striatum and mPFC groups, cocaine and dopamine temporal profiles were tightly correlated, peaking during the first 5-min period postinjection, then rapidly decreasing. However, the local rCBV changes were uncorrelated and exhibited broader temporal profiles than those of cocaine and dopamine, attaining maximal response 5-10 min later. This demonstrates that direct vasoactivity of dopamine is not the dominant component of the hemodynamic response in these regions. In the motor cortex group, microdialysis revealed no local change in dopamine in any of the animals, despite large local cocaine increase and strong rCBV response, indicating that the central hemodynamic response following acute iv cocaine challenge is not driven directly by local dopamine changes in the motor cortex. The combination of phMRI and in situ microdialysis promises to be of great value in elucidating the relationship between the phMRI response to psychoactive drugs and underlying neurochemical changes.
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Affiliation(s)
- A J Schwarz
- Department of Neuroimaging, Psychiatry Centre of Excellence in Drug Discovery, GlaxoSmithKline Medicines Research Centre, 37135 Verona, Italy
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Dunst J, Reese T, Debus J, Hoelscher T, Budach W, Rudat V, Wulf J, Mose S, Hinke A. Phase-II-study of preoperative chemoradiation with capecitabine in rectal cancer. J Clin Oncol 2004. [DOI: 10.1200/jco.2004.22.90140.3559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- J. Dunst
- Martin-Luther-University, Halle, Germany; University of Heidelberg, Heidelberg, Germany; Technical University, Dresden, Germany; University of Tuebingen, Tuebingen, Germany; University of Hamburg, Hamburg, Germany; University of Wuerzburg, Wuerzburg, Germany; University of Frankfurt, Frankfurt, Germany; WiSP GmbH, Langenfeld, Germany
| | - T. Reese
- Martin-Luther-University, Halle, Germany; University of Heidelberg, Heidelberg, Germany; Technical University, Dresden, Germany; University of Tuebingen, Tuebingen, Germany; University of Hamburg, Hamburg, Germany; University of Wuerzburg, Wuerzburg, Germany; University of Frankfurt, Frankfurt, Germany; WiSP GmbH, Langenfeld, Germany
| | - J. Debus
- Martin-Luther-University, Halle, Germany; University of Heidelberg, Heidelberg, Germany; Technical University, Dresden, Germany; University of Tuebingen, Tuebingen, Germany; University of Hamburg, Hamburg, Germany; University of Wuerzburg, Wuerzburg, Germany; University of Frankfurt, Frankfurt, Germany; WiSP GmbH, Langenfeld, Germany
| | - T. Hoelscher
- Martin-Luther-University, Halle, Germany; University of Heidelberg, Heidelberg, Germany; Technical University, Dresden, Germany; University of Tuebingen, Tuebingen, Germany; University of Hamburg, Hamburg, Germany; University of Wuerzburg, Wuerzburg, Germany; University of Frankfurt, Frankfurt, Germany; WiSP GmbH, Langenfeld, Germany
| | - W. Budach
- Martin-Luther-University, Halle, Germany; University of Heidelberg, Heidelberg, Germany; Technical University, Dresden, Germany; University of Tuebingen, Tuebingen, Germany; University of Hamburg, Hamburg, Germany; University of Wuerzburg, Wuerzburg, Germany; University of Frankfurt, Frankfurt, Germany; WiSP GmbH, Langenfeld, Germany
| | - V. Rudat
- Martin-Luther-University, Halle, Germany; University of Heidelberg, Heidelberg, Germany; Technical University, Dresden, Germany; University of Tuebingen, Tuebingen, Germany; University of Hamburg, Hamburg, Germany; University of Wuerzburg, Wuerzburg, Germany; University of Frankfurt, Frankfurt, Germany; WiSP GmbH, Langenfeld, Germany
| | - J. Wulf
- Martin-Luther-University, Halle, Germany; University of Heidelberg, Heidelberg, Germany; Technical University, Dresden, Germany; University of Tuebingen, Tuebingen, Germany; University of Hamburg, Hamburg, Germany; University of Wuerzburg, Wuerzburg, Germany; University of Frankfurt, Frankfurt, Germany; WiSP GmbH, Langenfeld, Germany
| | - S. Mose
- Martin-Luther-University, Halle, Germany; University of Heidelberg, Heidelberg, Germany; Technical University, Dresden, Germany; University of Tuebingen, Tuebingen, Germany; University of Hamburg, Hamburg, Germany; University of Wuerzburg, Wuerzburg, Germany; University of Frankfurt, Frankfurt, Germany; WiSP GmbH, Langenfeld, Germany
| | - A. Hinke
- Martin-Luther-University, Halle, Germany; University of Heidelberg, Heidelberg, Germany; Technical University, Dresden, Germany; University of Tuebingen, Tuebingen, Germany; University of Hamburg, Hamburg, Germany; University of Wuerzburg, Wuerzburg, Germany; University of Frankfurt, Frankfurt, Germany; WiSP GmbH, Langenfeld, Germany
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Schiebe ME, Reese T, Wenz F, Schmidberger H, Engenhart-Cabillic R, Dunst J, Hess CF, Hoffmann W. Phase I study of oral uracil and Tegafur plus leucovorin and pelvic radiation in patients with recurrent rectal cancer. Anticancer Drugs 2002; 13:1005-9. [PMID: 12439334 DOI: 10.1097/00001813-200211000-00004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Continuous 5-fluorouracil (5-FU) infusion during radiation therapy is superior to the application of bolus 5-FU schedules. As an oral therapy, that provides prolonged fluoropyrimidine exposure, uracil and Tegafur (UFT) plus leucovorin (LV) has shown favorable activity with only moderate toxicity in colorectal cancer. The present study was designed to evaluate the safety of UFT+LV combined with pelvic radiation to determine the maximum-tolerated dose (MTD) in recurrent rectal cancer. Patients with recurrent rectal cancer received escalating doses of UFT (starting at 250 mg/m /day with 50 mg/m /day increments between consecutive cohorts) and fixed doses of LV (90 mg). The UFT+LV combination was given 5 days per week simultaneously to a 5-week course of irradiation up to a total dose of 50.4 Gy, 1.8 Gy daily fractions followed by a boost of 5.4 or 9.0 Gy to the gross tumor volume. Nineteen patients were treated and 14 received the full chemotherapy with delivery of all planned radiotherapy. The MTD of UFT was 400 mg/m /day due to the occurrence of dose-limiting diarrhea and emesis. Toxicities were mild and manageable on the lower dose levels. Treatment was feasible mainly on an outpatient base. We conclude that combined chemoradiation with oral UFT+LV is feasible and well tolerated for recurrent rectal cancer patients undergoing pelvic radiation. The safety profile appears comparable to that of i.v. dosing without requiring any i.v. port systems. The recommended doses for further phase II chemoradiation trials are 350 mg/m /day UFT+90 mg LV.
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Affiliation(s)
- Martina E Schiebe
- Department of Radio-Oncology and Radiotherapy, Klinikum Braunschweig, 38114 Braunschweig, Germany.
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Dunst J, Reese T, Sutter T, Zühlke H, Hinke A, Kölling-Schlebusch K, Frings S. Phase I trial evaluating the concurrent combination of radiotherapy and capecitabine in rectal cancer. J Clin Oncol 2002; 20:3983-91. [PMID: 12351595 DOI: 10.1200/jco.2002.02.049] [Citation(s) in RCA: 185] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To establish the feasibility of concurrent radiotherapy and capecitabine and define the maximum-tolerated dose (MTD) in patients with rectal cancer. PATIENTS AND METHODS Thirty-six patients with rectal cancer received treatment in the adjuvant, neoadjuvant, or palliative setting with a total irradiation dose of 50.4 Gy with 1.8 Gy/d in approximately 6 weeks. Capecitabine was administered at escalating doses from 250 to 1,250 mg/m(2) bid (including weekends) for the duration of radiotherapy. The MTD was defined when two or more patients in a cohort of three or six patients experienced dose-limiting toxicities. RESULTS Dose-limiting grade 3 hand-foot syndrome was observed in two of six patients treated at a capecitabine dose of 1,000 mg/m(2) bid. Other toxicities were generally rare and/or mild, with only one case of non-dose-limiting grade 3 diarrhea and a single patient with grade 3 skin toxicity. Myelosuppression consisted mainly of leukocytopenia, with a maximum severity of grade 2. Thus, a dosage of 825 mg/m(2) bid is the recommended dose level for further evaluation. One pathologic complete remission of a T3N1 tumor and nine partial remissions were observed in 10 patients treated in the neoadjuvant setting. CONCLUSION The recommended dose for phase II evaluation is capecitabine 825 mg/m(2) bid, administered without break during a conventional radiotherapy period of about 6 weeks. This combined-modality approach proved to be a feasible and well-tolerated treatment option with promising preliminary efficacy results in rectal cancer.
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Affiliation(s)
- Jürgen Dunst
- Clinic of Radiotherapy and Clinic of General Surgery, Martin-Luther-Universität, Halle, Germany.
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Abstract
Behavioral recovery takes place even after permanent damage to the entire brain region normally controlling sensorimotor hind limb function in the rat. In our study, 2 weeks after full behavioral recovery from an experimental unilateral permanent brain damage, the topographic representation of the previous paretic hindlimb was investigated by fMRI. The analysis showed that during electrical stimulation of the previously paretic hindlimb, two normally inactive brain regions were now being activated. One region was the non-damaged contralateral sensori-motor cortex and the other region was located lateral to the lesion. These results suggest that behavioral recovery can be explained by functional reorganization and neuromodulation of the brain.
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Affiliation(s)
- M Abo
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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46
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Reese T, Pórszász R, Baumann D, Bochelen D, Boumezbeur F, McAllister KH, Sauter A, Bjelke B, Rudin M. Cytoprotection does not preserve brain functionality in rats during the acute post-stroke phase despite evidence of non-infarction provided by MRI. NMR Biomed 2000; 13:361-370. [PMID: 11002315 DOI: 10.1002/1099-1492(200010)13:6<361::aid-nbm654>3.0.co;2-c] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
In animal models of stroke the promise of a therapy is commonly judged from infarct size measurements, assuming that a reduction in infarct size results in reduction of the functional deficits. We have evaluated the validity of the concept that structural integrity translates into functional integrity during the acute post-stroke period (24 h). Unilateral permanent middle cerebral artery occlusion (pMCAO) in Fischer F344 rats leads to infarcts comprising the ipsilateral striatum and cortical structures, including the somatosensory cortex. Infarct volumes were assessed using magnetic resonance imaging (MRI) methods (T(2), diffusion, perfusion MRI). The functional integrity of the somatosensory cortex was assessed by functional MRI (fMRI) measuring changes in local cerebral blood volume, and by assessing the forelimb grip strength and the beam-walking performance of the animals. Treatment with the calcium antagonist isradipine (2.5 mg/kg injected s.c. immediately after pMCAO) reduced the total infarct size by more than 40% compared to vehicle-injected controls. In particular, the ipsilateral somatosensory cortex appeared normal in diffusion- and T(2)-weighted MRI images. In sham-operated rats simultaneous electrical stimulation of both forepaws led to similar activation of both somatosensory cortices, while in pMCAO animals given vehicle only the contralateral cortex showed an fMRI response. Similarly, in pMCAO rats treated with isradipine, functional activation following bilateral electrical stimulation was only detected in the contralateral somatosensory cortex despite the normal appearance of the ipsilateral cortex in MRI images. Furthermore, fMRI responses to pharmacological stimulation with bicuculline were virtually absent in the ipsilateral somatosensory cortices both in vehicle- and isradipine-treated rats. Finally there was no significant difference between vehicle- and isradipine-treated animals upon the performance of beam-walking test or in forelimb grip strength. It is concluded that during the acute (24 h) post-occlusion period, structural integrity in the somatosensory cortex revealed by MRI does not translate into preservation of function.
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Affiliation(s)
- T Reese
- Core Technology, Novartis Pharma Ltd, CH-4002 Basel, Switzerland
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Dunst J, Semlin S, Pigorsch S, Müller AC, Reese T. Intermittent use of amifostine during postoperative radiochemotherapy and acute toxicity in rectal cancer patients. Strahlenther Onkol 2000; 176:416-21. [PMID: 11050915 DOI: 10.1007/pl00002350] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE Amifostine has been shown to be able to reduce acute radiation toxicity if administered daily prior to radiation during a course of a conventionally fractionated radiotherapy. A disadvantage is the necessity of daily intravenous injection. We have used amifostin in patients undergoing adjuvant radiochemotherapy for rectal cancer. Amifostine was administered only in the first and fifth week of radiotherapy together with 5-FU chemotherapy. The objective was to determine whether the intermittent use of amifostine may be effective in reducing acute radiation toxicity. PATIENTS AND METHODS From September 1997 through October 1998, 30 patients with stage II/III rectal cancer underwent postoperative radiochemotherapy at our department. All patients had undergone curative (R0) resection and received 50.4 Gy to the pelvis with a 3-field technique using a belly board followed by a boost of 5.4 Gy to the presacral space in conventional fractionation with 1.8 Gy per fraction. 5-FU chemotherapy was administered as 120-hours continuous infusion in the first and fifth radiation week via a central venous catheter in a daily dosage of 1,000 mg/m2. All patients were offered to participate in a phase-II study using additional amifostine. Fifteen patients participated and received 500 mg amifostine daily on chemotherapy days (days 1 to 5 and 29 to 33) immediately prior to the daily radiation fraction. Fifteen patients did not participate and served as non-randomized control. The study was approved by the ethical committee of the Martin-Luther-University and informed consent was obtained from all patients. RESULTS The distribution of patients' characteristics and prognostic parameters was comparable in both groups. Side effects of amifostine were mild and included hypotension (53% grade I, 7% grade II) and nausea (47% grade I, 13% grade II). Antiemetics were not routinely used. All patients completed radiochemotherapy plus amifostine without unplanned breaks or dose reductions. One patient developed a cerebral infarction which was considered to be not related to the use of amifostine. As compared to the non-randomized control group, patients with additional amifostine had less acute skin and bowel toxicity (maximum erythema score 1.47 +/- 0.64 without vs 0.87 +/- 0.52 with amifostine, p = 0.009 and maximum diarrhea score 1.07 +/- 1.03 vs 0.40 +/- 0.63, p = 0.044). Oral 5-FU-related mucositis and hematological toxicity were not significantly different. CONCLUSIONS In this phase-II study, amifostine significantly reduced acute skin and bowel toxicity of adjuvant chemoradiation in patients with rectal cancer even if the drug was administered only intermittently and not during the whole course of radiotherapy. This finding might be important with regard to intense combined regimes and should be further investigated.
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Affiliation(s)
- J Dunst
- Department of Radiotherapy, Martin-Luther-University Halle-Wittenberg, Germany.
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Abstract
Numerous methods exist for HER-2/neu assessment; however, technical and interpretive standardization is virtually absent. We evaluated 2 commercially available antibodies on routinely fixed paraffin-embedded tissue sections to establish our own guidelines. Thirty-three cases of infiltrating breast carcinoma were evaluated simultaneously with monoclonal and polyclonal antibodies. Only membranous staining, no matter how focal, was considered positive. An additional 32 tumors were studied subsequently using only the polyclonal antibody. Of all carcinomas, 13.0% showed immunohistochemical evidence of HER-2/neu overexpression. High-grade tumors were more often positive. There was no HER-2/neu gene expression in the benign epithelium that generally was present in the tissue section or in any of the well-differentiated tumors tested. The polyclonal antibody proved more sensitive than the monoclonal antibody. While true cytoplasmic staining was present occasionally, it did not create substantial difficulty in interpretation. The polyclonal antibody cost substantially less than the monoclonal antibody. Fluorescence in situ hybridization assay for HER-2/neu gene amplification performed on 32 of 65 cases showed concordant results in 31 cases. The immunohistochemical assay for HER-2/neu gene overexpression, using our methods, is accurate, economic, and easily integrated into the laboratory.
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Affiliation(s)
- R Vang
- University of Texas Medical School, USA
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Reese T, Bjelke B, Porszasz R, Baumann D, Bochelen D, Sauter A, Rudin M. Regional brain activation by bicuculline visualized by functional magnetic resonance imaging. Time-resolved assessment of bicuculline-induced changes in local cerebral blood volume using an intravascular contrast agent. NMR Biomed 2000; 13:43-49. [PMID: 10668053 DOI: 10.1002/(sici)1099-1492(200002)13:1<43::aid-nbm608>3.0.co;2-s] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Functional magnetic resonance imaging (fMRI) has been applied to study rat focal brain activation induced by intravenous administration of the GABA(A) antagonist bicuculline. Using magnetite nanoparticles as a blood pool contrast agent, local changes in cerebral blood volume (CBV) were assessed with high temporal (10 s) and spatial (0.35 x 0.6 mm(2)) resolutions. Upon infusion of the bicuculline region-specific increases in CBV have been observed, suggesting CBV to reflect brain activity. During the first 2 min, the signal increases were predominant in the cortex, followed by increases in other brain areas, such as the caudate putamen, thalamus and cerebellum. Ten minutes after the start of infusion, a dominant response was observed in the thalamus, while in the caudate putamen a biphasic response pattern was seen. The magnitude of the signal responses in all brain regions was dependent on the dose of bicuculline and, in general, matched the known distribution of GABA(A) binding sites. This study suggests that pharmacological fMRI, displaying brain function at the highly specific level of drug-receptor interaction, should foster our understanding of normal and pathological brain function.
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Affiliation(s)
- T Reese
- Core Technologies Area, Novartis Pharma Ltd, CH-4002 Basel, Switzerland
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Abstract
We describe and discuss the application of three-dimensional (3D) time-of-flight (TOF) magnetic resonance angiography (MRA) to visualize non-invasively the cerebral vasculature of the rat. MR angiograms of healthy spontaneously hypertensive rats were obtained without the use of contrast agents. Total imaging time ranged from 1 to 50 min for a 3D data set. The influences of the data matrix and the inflow delay on the image quality and the total imaging time are assessed and discussed. Varying the inflow delay yielded in addition semiquantitative information on hemodynamics. The method was applied to obtain angiograms in rat models of permanent and temporal middle cerebral artery occlusion. Occlusion and reopening of the vessel could easily be verified by MRA. However, after reperfusion a slight reduction in blood flow was observed.
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Affiliation(s)
- T Reese
- Core Technology, Novartis Pharma Ltd, Basel, Switzerland.
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