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Bikdeli B, Krishnathasan D, Khairani CD, Bejjani A, Davies J, Porio N, Tristani A, Armero A, Assi AA, Nauffal V, Campia U, Almarzooq Z, Wei E, Ortiz-Rios MD, Zuluaga-Sánchez V, Achanta A, Jesudasen SJ, Tiu B, Merli GJ, Leiva O, Fanikos J, Grandone E, Sharma A, Rizzo S, Pfeferman MB, Morrison RB, Vishnevsky A, Hsia J, Nehler MR, Welker J, Bonaca MP, Carroll B, Goldhaber SZ, Lan Z, Piazza G. Low absolute risk of thrombotic and cardiovascular events in outpatient pregnant women with COVID-19. Thromb Res 2024; 237:209-215. [PMID: 38677791 DOI: 10.1016/j.thromres.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/17/2024] [Accepted: 02/20/2024] [Indexed: 04/29/2024]
Abstract
INTRODUCTION Pregnancy may contribute to an excess risk of thrombotic or cardiovascular events. COVID-19 increases the risk of these events, although the risk is relatively limited among outpatients. We sought to determine whether outpatient pregnant women with COVID-19 are at a high risk for cardiovascular or thrombotic events. MATERIALS & METHODS We analyzed pregnant outpatients with COVID-19 from the multicenter CORONA-VTE-Network registry. The main study outcomes were a composite of adjudicated venous or arterial thrombotic events, and a composite of adjudicated cardiovascular events. Events were assessed 90 days after the COVID-19 diagnosis and reported for non-pregnant women ≤45 years, and for men ≤45 years, as points of reference. RESULTS Among 6585 outpatients, 169 were pregnant at diagnosis. By 90-day follow-up, two pregnant women during the third trimester had lower extremity venous thrombosis, one deep and one superficial vein thrombosis. The cumulative incidence of thrombotic events was 1.20 % (95 % confidence interval [CI]: 0.0 to 2.84 %). Respective rates were 0.47 % (95 % CI: 0.14 % to 0.79 %) among non-pregnant women, and 0.49 % (95 % CI: 0.06 % to 0.91 %) among men ≤45 years. No non-thrombotic cardiovascular events occurred in pregnant women. The rates of cardiovascular events were 0.53 % (95 % CI: 0.18 to 0.87) among non-pregnant women, and 0.68 % (95 % CI: 0.18 to 1.18) in men aged ≤45 years. CONCLUSIONS Thrombotic and cardiovascular events are rare among outpatients with COVID-19. Although a higher event rate among outpatient pregnant women cannot be excluded, the absolute event rates are low and do not warrant population-wide cardiovascular interventions to optimize outcomes.
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Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA; YNHH/ Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - Darsiya Krishnathasan
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Candrika D Khairani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Antoine Bejjani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Julia Davies
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Nicole Porio
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Anthony Tristani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Andre Armero
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Ali A Assi
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Victor Nauffal
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Umberto Campia
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Zaid Almarzooq
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Eric Wei
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Marcos D Ortiz-Rios
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Aditya Achanta
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Sirus J Jesudasen
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Bruce Tiu
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Geno J Merli
- Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Orly Leiva
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Elvira Grandone
- Thrombosis and Haemostasis Unit, Fondazione I.R.C.C.S. "Casa Sollievo della Sofferenza", S. Giovanni Rotondo (Foggia), Italy; Department of Obstetrics and Gynecology, First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Aditya Sharma
- Department of Medicine, Cardiovascular Medicine, University of Virginia Health, Charlottesville, VA, USA
| | - Samantha Rizzo
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Mariana B Pfeferman
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Ruth B Morrison
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Alec Vishnevsky
- Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Judith Hsia
- CPC Clinical Research, Aurora, CO, USA; Department of Medicine, University of Colorado, Aurora, CO, USA
| | | | - James Welker
- Anne Arundel Research Institute, Annapolis, MD, USA
| | - Marc P Bonaca
- CPC Clinical Research, Aurora, CO, USA; Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Brett Carroll
- Smith Center for Cardiovascular Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Zhou Lan
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA; Center for Clinical Investigation, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA.
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Achanta A, Belak L, Ritchie CS, Januzzi JL, Wasfy JH. Age-Related Usage of GLP-1 Agonists in Obese Patients With Heart Failure and Preserved Ejection Fraction. J Am Coll Cardiol 2024; 83:1348-1350. [PMID: 38569765 DOI: 10.1016/j.jacc.2024.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/24/2024] [Accepted: 01/30/2024] [Indexed: 04/05/2024]
Affiliation(s)
- Aditya Achanta
- Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA.
| | - Lauren Belak
- Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Christine S Ritchie
- Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - James L Januzzi
- Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Jason H Wasfy
- Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
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Haywood HB, Graham AJ, Chermak D, Achanta A, Butler J, Fonarow GC, Greene SJ. Estimating the Proportion of Heart Failure Admissions Potentially Eligible for Hospital at Home. J Card Fail 2024:S1071-9164(24)00108-8. [PMID: 38588859 DOI: 10.1016/j.cardfail.2024.03.004] [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] [Received: 01/07/2024] [Revised: 02/27/2024] [Accepted: 03/12/2024] [Indexed: 04/10/2024]
Affiliation(s)
- Hubert B Haywood
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC
| | - Aubrey Jolly Graham
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC
| | | | - Aditya Achanta
- Department of Internal Medicine, Massachusetts General Hospital, Boston, MA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX; Department of Medicine, University of Mississippi, Jackson, MI
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles, CA
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Duke University School of Medicine, Durham, NC..
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Achanta A, Phadke N, Wasfy JH, Levine D, Weiner RB. Home Hospital Heart Failure Admissions are an Opportunity to Optimize Guideline-Directed Medical Therapy. J Card Fail 2024; 30:115-116. [PMID: 37890656 DOI: 10.1016/j.cardfail.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/04/2023] [Accepted: 09/19/2023] [Indexed: 10/29/2023]
Affiliation(s)
- Aditya Achanta
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
| | - Neelam Phadke
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Allergy and Immunology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Jason H Wasfy
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - David Levine
- Division of General Internal Medicine and Primary Care, Brigham and Woman's Hospital and Harvard Medical School, Boston, MA
| | - Rory B Weiner
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Achanta A, Wasfy JH, Moss CT, Cherukara A, Ho D, Boxer R, Schmieding M, Phadke NA, Thompson R, Levine DM, Weiner RB. Home Hospital Outcomes for Acute Decompensated Heart Failure and Factors Associated With Escalation of Care. Circ Cardiovasc Qual Outcomes 2024; 17:e010031. [PMID: 38054286 DOI: 10.1161/circoutcomes.123.010031] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 10/24/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND Overall outcomes and the escalation rate for home hospital admissions for heart failure (HF) are not known. We report overall outcomes, predict escalation, and describe care provided after escalation among patients admitted to home hospital for HF. METHODS Our retrospective analysis included all patients admitted for HF to 2 home hospital programs in Massachusetts between February 2020 and October 2022. Escalation of care was defined as transfer to an inpatient hospital setting (emergency department, inpatient medical unit) for at least 1 overnight stay. Unexpected mortality was defined as mortality excluding those who desired to pass away at home on admission or transitioned to hospice. We performed the least absolute shrinkage and selection operator logistic regression to predict escalation. RESULTS We included 437 hospitalizations; patients had a median age of 80 (interquartile range, 69-89) years, 58.1% were women, and 64.8% were White. Of the cohort, 29.2% had reduced ejection fraction, 50.9% had chronic kidney disease, and 60.6% had atrial fibrillation. Median admission Get With The Guidelines HF score was 39 (interquartile range, 35-45; 1%-5% predicted inpatient mortality). Escalation occurred in 10.3% of hospitalizations. Thirty-day readmission occurred in 15.1%, 90-day readmission occurred in 33.8%, and 6-month mortality occurred in 11.5%. There was no unexpected mortality during home hospitalization. Patients who experienced escalation had significantly longer median length of stays (19 versus 7.5 days, P<0.001). The most common reason for escalation was progressive renal dysfunction (36.2%). A low mean arterial pressure at the time of admission to home hospital was the most significant predictor of escalation in the least absolute shrinkage and selection operator regression. CONCLUSIONS About 1 in 10 home hospital patients with HF required escalation; none had unexpected mortality. Patients requiring escalation had longer length of stays. A low mean arterial pressure at the time of admission to home hospital was the most important predictor of escalation of care in the least absolute shrinkage and selection operator logistic regression model.
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Affiliation(s)
- Aditya Achanta
- Department of Medicine (A.A., J.H.W., N.P., R.T., R.B.W.), Massachusetts General Hospital and Harvard Medical School, Boston
- Division of General Internal Medicine and Primary Care, Brigham and Woman's Hospital and Harvard Medical School, Boston, MA (A.C., D.H., R.B., M.S., D.L.)
| | - Jason H Wasfy
- Department of Medicine (A.A., J.H.W., N.P., R.T., R.B.W.), Massachusetts General Hospital and Harvard Medical School, Boston
- Cardiology Division (J.H.W., R.B.W.), Massachusetts General Hospital and Harvard Medical School, Boston
| | | | | | - David Ho
- Division of General Internal Medicine and Primary Care, Brigham and Woman's Hospital and Harvard Medical School, Boston, MA (A.C., D.H., R.B., M.S., D.L.)
| | - Robert Boxer
- Division of General Internal Medicine and Primary Care, Brigham and Woman's Hospital and Harvard Medical School, Boston, MA (A.C., D.H., R.B., M.S., D.L.)
| | - Malte Schmieding
- Division of General Internal Medicine and Primary Care, Brigham and Woman's Hospital and Harvard Medical School, Boston, MA (A.C., D.H., R.B., M.S., D.L.)
| | - Neelam Ameya Phadke
- Department of Medicine (A.A., J.H.W., N.P., R.T., R.B.W.), Massachusetts General Hospital and Harvard Medical School, Boston
- Allergy and Immunology Division (N.P.), Massachusetts General Hospital and Harvard Medical School, Boston
| | - Ryan Thompson
- Department of Medicine (A.A., J.H.W., N.P., R.T., R.B.W.), Massachusetts General Hospital and Harvard Medical School, Boston
| | - David Michael Levine
- Division of General Internal Medicine and Primary Care, Brigham and Woman's Hospital and Harvard Medical School, Boston, MA (A.C., D.H., R.B., M.S., D.L.)
| | - Rory B Weiner
- Department of Medicine (A.A., J.H.W., N.P., R.T., R.B.W.), Massachusetts General Hospital and Harvard Medical School, Boston
- Cardiology Division (J.H.W., R.B.W.), Massachusetts General Hospital and Harvard Medical School, Boston
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Achanta A, Wasfy JH. More advanced statistical techniques are not yet sufficient to realize the promise of risk prediction to reduce readmission. Cardiovasc Revasc Med 2023; 56:25-26. [PMID: 37394318 DOI: 10.1016/j.carrev.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 07/04/2023]
Affiliation(s)
- Aditya Achanta
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Jason H Wasfy
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America; Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America.
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Wasfy JH, Achanta A, Hidrue MK, Urbut S, Axtell AL, Berman AN, Zhao Y, Chen J, Gustus S, Picard MH. Association between implanted cardioverter-defibrillators and mortality for patients with left ventricular ejection fraction between 30% and 35. Open Heart 2023; 10:e002289. [PMID: 37625819 PMCID: PMC10462974 DOI: 10.1136/openhrt-2023-002289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/30/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Consensus guidelines support the use of implanted cardioverter-defibrillators (ICD) for primary prevention of sudden cardiac death in patients with either non-ischaemic or ischaemic cardiomyopathy with left ventricular ejection fraction (LVEF) ≤35%. However, evidence from trials for efficacy specifically for patients with LVEF near 35% is weak. Past trials are underpowered for this population and future trials are unlikely to be performed. METHODS Patients with lowest LVEF between 30% and 35% without an ICD prior to the lowest-LVEF echo (defined as 'time zero') were identified by querying echocardiography data from 28 November 2001 to 9 July 2020 at the Massachusetts General Hospital linked to ICD treatment status. To assess the association between ICD and mortality, propensity score matching followed by Cox proportional hazards models considering treatment status as a time-dependent covariate was used. A secondary analysis was performed for LVEF 36%-40%. RESULTS Initially, 526 440 echocardiograms representing 266 601 unique patients were identified. After inclusion and exclusion criteria were applied, 6109 patients remained for the analytical cohort. In bivariate unadjusted comparisons, patients who received ICDs were substantially more often male (79.8% vs 65.4%, p<0.0001), more often white (87.5% vs 83.7%, p<0.046) and more often had a history of ventricular tachycardia (74.5% vs 19.1%, p<0.0001) and myocardial infarction (56.1% vs 38.2%, p<0.0001). In the propensity matched sample, after accounting for time-dependence, there was no association between ICD and mortality (HR 0.93, 95% CI 0.75 to 1.15, p=0.482). CONCLUSIONS ICD therapy was not associated with reduced mortality near the conventional LVEF threshold of 35%. Although this treatment design cannot definitively demonstrate lack of efficacy, our results are concordant with available prior trial data. A definitive, well-powered trial is needed to answer the important clinical question of primary prevention ICD efficacy between LVEF 30% and 35%.
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Affiliation(s)
- Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aditya Achanta
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael K Hidrue
- Office of the Chief Medical Officer, Mass General Brigham, Boston, Massachusetts, USA
| | - Sarah Urbut
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrea L Axtell
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Adam N Berman
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yunong Zhao
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julian Chen
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah Gustus
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael H Picard
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Bikdeli B, Khairani CD, Krishnathasan D, Bejjani A, Armero A, Tristani A, Davies J, Porio N, Assi AA, Nauffal V, Campia U, Almarzooq Z, Wei E, Achanta A, Jesudasen SJ, Tiu BC, Merli GJ, Leiva O, Fanikos J, Sharma A, Vishnevsky A, Hsia J, Nehler MR, Welker J, Bonaca MP, Carroll BJ, Lan Z, Goldhaber SZ, Piazza G. Major cardiovascular events after COVID-19, event rates post-vaccination, antiviral or anti-inflammatory therapy, and temporal trends: Rationale and methodology of the CORONA-VTE-Network study. Thromb Res 2023; 228:94-104. [PMID: 37302267 PMCID: PMC10226776 DOI: 10.1016/j.thromres.2023.05.019] [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: 04/23/2023] [Revised: 05/19/2023] [Accepted: 05/24/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is associated with excess risk of cardiovascular and thrombotic events in the early post-infection period and during convalescence. Despite the progress in our understanding of cardiovascular complications, uncertainty persists with respect to more recent event rates, temporal trends, association between vaccination status and outcomes, and findings within vulnerable subgroups such as older adults (aged 65 years or older), or those undergoing hemodialysis. Sex-informed findings, including results among pregnant and breastfeeding women, as well as adjusted comparisons between male and female adults are similarly understudied. METHODS Adult patients, aged ≥18 years, with polymerase chain reaction-confirmed COVID-19 who received inpatient or outpatient care at the participating centers of the registry are eligible for inclusion. A total of 10,000 patients have been included in this multicenter study, with Brigham and Women's Hospital (Boston, MA) serving as the coordinating center. Other sites include Beth Israel Deaconess Medical Center, Anne Arundel Medical Center, University of Virginia Medical Center, University of Colorado Health System, and Thomas Jefferson University Health System. Data elements will be ascertained manually for accuracy. The two main outcomes are 1) a composite of venous or arterial thrombotic events, and 2) a composite of major cardiovascular events, defined as venous or arterial thrombosis, myocarditis or heart failure with inpatient treatment, new atrial fibrillation/flutter, or cardiovascular death. Clinical outcomes are adjudicated by independent physicians. Vaccination status and time of inclusion in the study will be ascertained for subgroup-specific analyses. Outcomes are pre-specified to be reported separately for hospitalized patients versus those who were initially receiving outpatient care. Outcomes will be reported at 30-day and 90-day follow-up. Data cleaning at the sites and the data coordinating center and outcomes adjudication process are in-progress. CONCLUSIONS The CORONA-VTE-Network study will share contemporary information related to rates of cardiovascular and thrombotic events in patients with COVID-19 overall, as well as within key subgroups, including by time of inclusion, vaccination status, patients undergoing hemodialysis, the elderly, and sex-informed analyses such as comparison of women and men, or among pregnant and breastfeeding women.
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Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - Candrika D Khairani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Darsiya Krishnathasan
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Antoine Bejjani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andre Armero
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anthony Tristani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Julia Davies
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicole Porio
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ali A Assi
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Victor Nauffal
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Umberto Campia
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Zaid Almarzooq
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric Wei
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aditya Achanta
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Sirus J Jesudasen
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Bruce C Tiu
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Geno J Merli
- Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Orly Leiva
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aditya Sharma
- Department of Medicine, Cardiovascular Medicine, University of Virginia Health, Charlottesville, VA, USA
| | - Alec Vishnevsky
- Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Judith Hsia
- CPC Clinical Research, Aurora, CO, USA; Department of Medicine, University of Colorado, Aurora, CO, USA
| | | | - James Welker
- Anne Arundel Research Institute, Annapolis, MD, USA
| | - Marc P Bonaca
- CPC Clinical Research, Aurora, CO, USA; Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Brett J Carroll
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Zhou Lan
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Clinical Investigation, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Achanta A, Drezek K, Prario M, Gallandt A, Coglianese E. A Comparison of the LVAD Population 1-Year Clinical Outcomes Before and After the Transplant Allocation System Change. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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10
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Cherukupalli R, Achanta A, Cherukupalli A, Potukuchi S. Machine learning based diagnosis of heart failure with preserved ejection fraction among South Asian patients. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehab849.061] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Diagnosis of Heart Failure with preserved Ejection Fraction (HFpEF) remains challenging even for an astute clinician with the current diagnostic tests, algorithms and scoring systems. The use of Machine Learning (ML) in cardiovascular research has expanded exponentially in recent years.
Purpose
In this study we studied the predictive accuracy of a machine-learning model for the diagnosis of HFpEF in South Asian patients.
Methods
A single centre retrospective data of 1068 admitted patients with a clinical diagnosis of HF were obtained. From this data outliers were removed based on box-and-whisker plot study. This data was then segregated into three: without HF, HF with reduced ejection fraction and HFpEF. Finally, we arrived at 530 patients’ data with left ventricular ejection fraction (LVEF) values of >45%. This data set was randomly divided into two parts: 80% as Training dataset and 20% as Test dataset. Two ML techniques such as Logistic Regression and Neural Networks were chosen to build the prediction models. Orange Data Mining Software version 3.28 was used to build these models. The overall performance of the ML methods has been reported using Precision, Recall and F1 scores of precision and recall; measure that combines precision and recall.
Results
The table summarizes precision, recall and F1 score of both models. The predicted results from the ML models are compared with HFA PEFF score.
Conclusion
ML based diagnosis using two different models showed acceptable predictive accuracy for HFpEF. Limitations of using LVEF as a predictor for the diagnosis of HF by ML and discussion on how the combination of an expert clinician opinion with ML further improves the diagnostic ability will be made. Abstract Figure.
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Affiliation(s)
| | - A Achanta
- Aster Prime Hospital, Hyderabad, India
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11
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Abstract
On November 25, 2020, CMS announced the creation of an Acute Hospital Care at Home program to reimburse qualifying hospital-at-home models. As we increasingly adopt the Acute Hospital Care at Home program and similar home-based services, it is crucial to better define the value of these programs and their appropriate reimbursement rates. We provide a framework centered around cost, quality, and equity to help accomplish this task. Quality reporting should use both inpatient-specific and home health care-specific metrics, equity-focused process metrics and risk-adjusted outcome metrics, and validated disease-specific tools. Costs should be measured comprehensively and uniformly through the use of time-driven activity-based costing and consider caregiver opportunity costs. It is also worthwhile to consider personal, societal, technical, and allocative value when determining the value and subsequent reimbursement rates of hospital-at-home programs. With careful patient selection, the hospital-at-home model has the potential to significantly benefit a subset of patients. To create sustainable reimbursement mechanisms for hospital-at-home programs, we first need a better definition of the value provided by this model of care.
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Affiliation(s)
- Aditya Achanta
- Harvard Medical School, 4 Greenway Ct, Apt 1, Brookline, MA 02446.
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12
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Antonini MJ, Plana D, Srinivasan S, Atta L, Achanta A, Yang H, Cramer AK, Freake J, Sinha MS, Yu SH, LeBoeuf NR, Linville-Engler B, Sorger PK. A Crisis-Responsive Framework for Medical Device Development Applied to the COVID-19 Pandemic. Front Digit Health 2021; 3:617106. [PMID: 33899045 PMCID: PMC8064560 DOI: 10.3389/fdgth.2021.617106] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 10/14/2020] [Accepted: 02/17/2021] [Indexed: 12/18/2022] Open
Abstract
The disruption of conventional manufacturing, supply, and distribution channels during the COVID-19 pandemic caused widespread shortages in personal protective equipment (PPE) and other medical supplies. These shortages catalyzed local efforts to use nontraditional, rapid manufacturing to meet urgent healthcare needs. Here we present a crisis-responsive design framework designed to assist with product development under pandemic conditions. The framework emphasizes stakeholder engagement, comprehensive but efficient needs assessment, rapid manufacturing, and modified product testing to enable accelerated development of healthcare products. We contrast this framework with traditional medical device manufacturing that proceeds at a more deliberate pace, discuss strengths and weakness of pandemic-responsive fabrication, and consider relevant regulatory policies. We highlight the use of the crisis-responsive framework in a case study of face shield design and production for a large US academic hospital. Finally, we make recommendations aimed at improving future resilience to pandemics and healthcare emergencies. These include continued development of open source designs suitable for rapid manufacturing, education of maker communities and hospital administrators about rapidly-manufactured medical devices, and changes in regulatory policy that help strike a balance between quality and innovation.
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Affiliation(s)
- Marc-Joseph Antonini
- Greater Boston Pandemic Fabrication Team (PanFab) c/o Harvard-MIT Center for Regulatory Science, Harvard Medical School, Boston, MA, United States
- Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, MA, United States
- McGovern Institute for Brain Research, Massachusetts Institute of Technology, Cambridge, MA, United States
- Harvard-MIT Division of Health Sciences and Technology Program, Cambridge, MA, United States
| | - Deborah Plana
- Greater Boston Pandemic Fabrication Team (PanFab) c/o Harvard-MIT Center for Regulatory Science, Harvard Medical School, Boston, MA, United States
- Harvard-MIT Division of Health Sciences and Technology Program, Cambridge, MA, United States
- Department of Systems Biology, Harvard Ludwig Cancer Research Center and Harvard Medical School, Boston, MA, United States
| | - Shriya Srinivasan
- Greater Boston Pandemic Fabrication Team (PanFab) c/o Harvard-MIT Center for Regulatory Science, Harvard Medical School, Boston, MA, United States
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, United States
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, United States
| | - Lyla Atta
- Greater Boston Pandemic Fabrication Team (PanFab) c/o Harvard-MIT Center for Regulatory Science, Harvard Medical School, Boston, MA, United States
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Aditya Achanta
- Greater Boston Pandemic Fabrication Team (PanFab) c/o Harvard-MIT Center for Regulatory Science, Harvard Medical School, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Helen Yang
- Greater Boston Pandemic Fabrication Team (PanFab) c/o Harvard-MIT Center for Regulatory Science, Harvard Medical School, Boston, MA, United States
- Harvard-MIT Center for Regulatory Science, Harvard Medical School, Boston, MA, United States
| | - Avilash K. Cramer
- Greater Boston Pandemic Fabrication Team (PanFab) c/o Harvard-MIT Center for Regulatory Science, Harvard Medical School, Boston, MA, United States
- Harvard-MIT Division of Health Sciences and Technology Program, Cambridge, MA, United States
| | - Jacob Freake
- Greater Boston Pandemic Fabrication Team (PanFab) c/o Harvard-MIT Center for Regulatory Science, Harvard Medical School, Boston, MA, United States
- Fikst Product Development, Woburn, MA, United States
| | - Michael S. Sinha
- Greater Boston Pandemic Fabrication Team (PanFab) c/o Harvard-MIT Center for Regulatory Science, Harvard Medical School, Boston, MA, United States
- Harvard-MIT Center for Regulatory Science, Harvard Medical School, Boston, MA, United States
| | - Sherry H. Yu
- Greater Boston Pandemic Fabrication Team (PanFab) c/o Harvard-MIT Center for Regulatory Science, Harvard Medical School, Boston, MA, United States
- Department of Dermatology, Yale University School of Medicine, New Haven, CT, United States
| | - Nicole R. LeBoeuf
- Greater Boston Pandemic Fabrication Team (PanFab) c/o Harvard-MIT Center for Regulatory Science, Harvard Medical School, Boston, MA, United States
- Department of Dermatology, Center for Cutaneous Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Ben Linville-Engler
- Greater Boston Pandemic Fabrication Team (PanFab) c/o Harvard-MIT Center for Regulatory Science, Harvard Medical School, Boston, MA, United States
- System Design and Management, Massachusetts Institute of Technology, Cambridge, MA, United States
- Massachusetts Manufacturing Emergency Response Team (MA M-ERT), Massachusetts Technology Collaborative, Westborough, MA, United States
| | - Peter K. Sorger
- Greater Boston Pandemic Fabrication Team (PanFab) c/o Harvard-MIT Center for Regulatory Science, Harvard Medical School, Boston, MA, United States
- Department of Systems Biology, Harvard Ludwig Cancer Research Center and Harvard Medical School, Boston, MA, United States
- Harvard-MIT Center for Regulatory Science, Harvard Medical School, Boston, MA, United States
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13
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Abstract
Cardiovascular complications have been reported in patients with COVID-19. We sought to examine the association of ABO blood group type with cardiovascular complications in COVID-19. We examined 409 individuals enrolled in the COVID-19 Registry to Assess Frequency, Management, and Outcomes of Arterial and Venous Thromboembolic Complications (CORONA-VTE) who had ABO blood group data available. Multiple logistic regression was used to assess the association of ABO blood group types with three primary outcomes: major adverse cardiovascular events (MACE), major arterial and venous thrombosis and all-cause mortality. 201, 121, 61 and 26 individuals had blood group O, A, B and AB, respectively. In multivariable analysis, blood group A was associated with a 2.5-fold higher odds of MACE than blood group O (OR 2.47[1.18–5.18]). There was an effect suggesting a 2-fold higher odds of major thrombotic events in blood group A vs. O that did not reach statistical significance (OR 2.15 [0.89–5.20]). No association between blood group type and all-cause mortality was found. Compared with the other blood group types, blood group A was associated with an increased odds of MACE(ORA/non−A 2.18[1.11–4.29]), while blood group O was associated with lower odds of MACE(ORO/non−O 0.50[0.26–0.97]). In conclusion, blood group A was associated with an increased odds of MACE, whereas blood group O was associated with a reduction in the odds of MACE in patients with COVID-19. These findings may inform risk stratification of COVID-19 patients for cardiovascular complications. Additional studies are needed to validate our findings.
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Affiliation(s)
- Victor Nauffal
- Division of Cardiovascular Medicine, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA
| | - Aditya Achanta
- Division of Cardiovascular Medicine, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA.
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14
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Achanta A, Hayden D, Thompson BT. Fluid Management in Patients with Acute Respiratory Distress Syndrome and Diabetes Mellitus: A propensity score matched analysis of the fluid and catheter treatment trial. Medicine (Baltimore) 2020; 99:e22311. [PMID: 32957394 PMCID: PMC7505338 DOI: 10.1097/md.0000000000022311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Diabetes mellitus results in an attenuated inflammatory response, reduces pulmonary microvascular permeability, and may decrease the risk of developing acute respiratory distress syndrome (ARDS). Studies have shown that patients with ARDS are better managed by a conservative as compared to liberal fluid management strategy. However, it is not known if the same fluid management principles hold true for patients with comorbid diabetes mellitus and ARDS.As diabetes mellitus results in reduced pulmonary microvascular permeability and an attenuated inflammatory response, we hypothesize that in the setting of ARDS, diabetic patients will be able to tolerate a positive fluid balance better than patients without diabetes.The Fluid and Catheter Treatment Trial (FACTT) randomized patients with ARDS to conservative versus liberal fluid management strategies. In a secondary analysis of this trial, we calculated the interaction of diabetic status and differing fluid strategies on outcomes. Propensity score subclassification matching was used to control for the differing baseline characteristics between patients with and without diabetes.Nine hundred fifty-six patients were analyzed. In a propensity score matched analysis, the difference in the effect of a conservative as compared to liberal fluid management strategy on ventilator free days was 2.23 days (95% CI: -0.97 to 5.43 days) in diabetic patients, and 2.37 days (95% CI: -0.21 to 4.95 days) in non-diabetic patients. The difference in the effect of a conservative as compared to liberal fluid management on 60 day mortality was 2% (95% CI: -11.8% to 15.8%) in diabetic patients, and -7.9% (95% CI: -21.7% to 5.9%) in non-diabetic patients.When comparing a conservative fluid management strategy to a liberal fluid management strategy, diabetic patients with ARDS did not have a statistically significant difference in outcomes than non-diabetic patients.
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Affiliation(s)
- Aditya Achanta
- Biostatistics Center, Massachusetts General Hospital
- Harvard Medical School, Boston, MA
| | - Douglas Hayden
- Biostatistics Center, Massachusetts General Hospital
- Harvard Medical School, Boston, MA
| | - Boyd Taylor Thompson
- Biostatistics Center, Massachusetts General Hospital
- Harvard Medical School, Boston, MA
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15
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Oberfeld B, Achanta A, Carpenter K, Chen P, Gilette NM, Langat P, Said JT, Schiff AE, Zhou AS, Barczak AK, Pillai S. SnapShot: COVID-19. Cell 2020; 181:954-954.e1. [PMID: 32413300 PMCID: PMC7190493 DOI: 10.1016/j.cell.2020.04.013] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Coronavirus disease 2019 (COVID-19) is a novel respiratory illness caused by SARS-CoV-2. Viral entry is mediated through viral spike protein and host ACE2 enzyme interaction. Most cases are mild; severe disease often involves cytokine storm and organ failure. Therapeutics including antivirals, immunomodulators, and vaccines are in development. To view this SnapShot, open or download the PDF.
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Affiliation(s)
| | | | | | - Pamela Chen
- Harvard Medical School, Boston, MA 02115, USA
| | | | | | | | - Abigail E Schiff
- Harvard Medical School, Boston, MA 02115, USA; Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA.
| | | | - Amy K Barczak
- Harvard Medical School, Boston, MA 02115, USA; Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA
| | - Shiv Pillai
- Harvard Medical School, Boston, MA 02115, USA; Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA
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16
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Guragai M, Achanta A, Gopez AY, Niyotwambaza J, Cardoso LG, Estavillo NL, Dykstra M. Medical Students' Response to the COVID-19 Pandemic: Experience and Recommendations from Five Countries. Perspect Biol Med 2020; 63:623-631. [PMID: 33416801 DOI: 10.1353/pbm.2020.0051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The COVID-19 pandemic has provided medical students around the globe with unique challenges and opportunities. With formal medical school education and training interrupted, medical students sought innovative ways to contribute to their health-care systems and communities. Their responses could be organized into three categories: clinical (remote clinical care and triage, helping in COVID testing or treatment centers, and contact tracing), nonclinical (PPE acquisition, COVID-related policy and research, and supporting vulnerable groups in the community), and educational (creating materials to educate peers, the community, or community health workers). We present examples of responses developed by students from five countries: Brazil, Nepal, the Philippines, Rwanda, and the United States. We discuss the challenges, outcomes, and recommendations for each case. One critical opportunity for growth is strengthening international collaborations. We hope that these examples provide a framework for medical students to plan coordinated and effective responses to the next pandemic, and further medical student engagement in international collaboration.
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17
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Achanta A, Nordestgaard AT, Kongkaewpaisan N, Han KR, Mendoza A, Saillant N, Rosenthal MG, Fagenholz PJ, Velmahos GC, Kaafarani HM. Most of the Variation in Length of Stay in Emergency Surgery Is Not Patient-Related: A National Analysis of 226,632 Procedures. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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18
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Han K, Lee JM, Achanta A, Kongkaewpaisan N, Kongwibulwut M, Eid AI, Kokoroskos N, van Wijck S, Meier K, Nordestgaard A, Rodriguez G, Jia Z, Lee J, King D, Fagenholz P, Saillant N, Mendoza A, Rosenthal M, Velmahos G, Kaafarani HMA. Emergency Surgery Score Accurately Predicts the Risk of Post-Operative Infection in Emergency General Surgery. Surg Infect (Larchmt) 2018; 20:4-9. [PMID: 30272533 DOI: 10.1089/sur.2018.101] [Citation(s) in RCA: 27] [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] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The Emergency Surgery Score (ESS) was validated recently as an accurate and user-friendly post-operative mortality risk calculator specific for Emergency General Surgery (EGS). ESS is calculated by adding one to three integer points for each of 22 pre-operative variables (demographics, co-morbidities, and pre-operative laboratory values); increasing scores accurately and gradually predict higher mortality rates. We sought to evaluate whether ESS can predict the occurrence of post-operative infectious complications in EGS patients. PATIENTS AND METHODS Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2007-2015, all EGS patients were identified by using the "emergent" ACS-NSQIP variable and a concomitant surgery Current Procedural Terminology code for "digestive system." Patients with any missing ESS variables or those who died within 72 hours from the surgical procedure were excluded. A composite variable, post-operative infection, was created and defined as the post-operative occurrence of one or more of the following: superficial, deep incisional or organ/space surgical site infection, surgical site disruption, pneumonia, sepsis, septic shock, or urinary tract infection. ESS was calculated for all included patients, and the correlation between ESS and post-operative infection was examined using c-statistics. RESULTS Of a total of 4,456,809 patients, 90,412 patients were included. The mean age of the population was 56 years, 51% were female, and 70% were white; 22% developed one or more post-operative infections, most commonly sepsis/septic shock (12.2%), surgical site infection (9%), and pneumonia (5.7%). The ESS gradually and consistently predicted infectious complications; post-operative infections developed in 7%, 24%, and 49% of patients with an ESS of 1, 5, and 10, respectively. The c-statistics for overall post-operative infection, post-operative sepsis/septic shock, and pneumonia were 0.73, 0.75, and 0.80, respectively. CONCLUSION The ESS accurately predicts the occurrence of post-operative infectious complications in EGS patients and could be used for pre-operative clinical decision-making as well as quality benchmarking of infection rates in EGS.
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Affiliation(s)
- Kelsey Han
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Jae Moo Lee
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Aditya Achanta
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Napaporn Kongkaewpaisan
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Manasnun Kongwibulwut
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Ahmed I Eid
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Nikolaos Kokoroskos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Suzanne van Wijck
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Karien Meier
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Ask Nordestgaard
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Gabriel Rodriguez
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Zhenyi Jia
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Jarone Lee
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - David King
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Peter Fagenholz
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Noelle Saillant
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - April Mendoza
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Martin Rosenthal
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - George Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital , Boston, Massachusetts
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Zhao X, Suryawanshi S, Hruska M, Feng Y, Wang X, Shen J, Vezina HE, McHenry MB, Waxman IM, Achanta A, Bello A, Roy A, Agrawal S. Assessment of nivolumab benefit-risk profile of a 240-mg flat dose relative to a 3-mg/kg dosing regimen in patients with advanced tumors. Ann Oncol 2018; 28:2002-2008. [PMID: 28520840 PMCID: PMC5834087 DOI: 10.1093/annonc/mdx235] [Citation(s) in RCA: 134] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background Nivolumab 3 mg/kg every 2 weeks (Q2W) has shown benefit versus the standard of care in melanoma, non-small cell lung cancer (NSCLC), and renal cell carcinoma (RCC). However, flat dosing is expected to shorten preparation time and improve ease of administration. With knowledge of nivolumab safety, efficacy, and pharmacokinetics across a wide dose range in body weight (BW) dosing, assessment of the benefit–risk profile of a 240-mg flat dose relative to the approved 3-mg/kg dose was approached by quantitative clinical pharmacology. Patients and methods A flat dose of 240 mg was selected based on its equivalence to the 3-mg/kg dose at the median BW of ∼80 kg in patients in the nivolumab program. The benefit–risk profile of nivolumab 240 mg was evaluated by comparing exposures at 3 mg/kg Q2W and 240 mg Q2W across BW and tumor types; clinical safety at 3 mg/kg Q2W by BW and exposure quartiles in melanoma, NSCLC, and RCC; and safety and efficacy at 240 mg Q2W relative to 3 mg/kg Q2W in melanoma, NSCLC, and RCC. Results The median nivolumab exposure and its distribution at 240 mg Q2W were similar to 3 mg/kg Q2W in the simulated population. Safety analyses did not demonstrate a clinically meaningful relationship between BW or nivolumab exposure quartiles and frequency or severity of adverse events. The predicted safety and efficacy were similar across nivolumab exposure ranges achieved with 3 mg/kg Q2W or 240 mg Q2W flat dose. Conclusion Based on population pharmacokinetic modeling, established flat exposure–response relationships for efficacy and safety, and clinical safety, the benefit–risk profile of nivolumab 240 mg Q2W was comparable to 3 mg/kg Q2W. The quantitative clinical pharmacology approach provided evidence for regulatory decision-making on dose modification, obviating the need for an independent clinical study.
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Affiliation(s)
- X Zhao
- Clinical Pharmacology & Pharmacometrics
| | | | - M Hruska
- Clinical Pharmacology & Pharmacometrics
| | - Y Feng
- Clinical Pharmacology & Pharmacometrics
| | - X Wang
- Clinical Pharmacology & Pharmacometrics
| | - J Shen
- Clinical Pharmacology & Pharmacometrics
| | | | | | | | - A Achanta
- Global Regulatory Sciences, Global Biometric Sciences, Bristol-Myers Squibb, Princeton, NJ, USA
| | - A Bello
- Clinical Pharmacology & Pharmacometrics
| | - A Roy
- Clinical Pharmacology & Pharmacometrics
| | - S Agrawal
- Clinical Pharmacology & Pharmacometrics
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20
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Zhao X, Suryawanshi S, Hruska M, Feng Y, Wang X, Shen J, McHenry B, Waxman I, Achanta A, Bello A, Roy A, Agrawal S. Assessment of nivolumab (Nivo) benefit-risk profile from a 240-mg flat dose versus a 3-mg/kg dosing regimen in patients (Pts) with solid tumors. Ann Oncol 2016. [DOI: 10.1093/annonc/mdw378.52] [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: 11/15/2022] Open
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