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Malin SK, Remchak MME, Heiston EM, Battillo DJ, Gow AJ, Shah AM, Liu Z. Intermediate versus morning chronotype has lower vascular insulin sensitivity in adults with obesity. Diabetes Obes Metab 2024; 26:1582-1592. [PMID: 38246697 PMCID: PMC11001524 DOI: 10.1111/dom.15456] [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: 10/06/2023] [Revised: 12/21/2023] [Accepted: 01/02/2024] [Indexed: 01/23/2024]
Abstract
AIM Chronotype reflects a circadian rhythmicity that regulates endothelial function. While the morning chronotype (MORN) usually has low cardiovascular disease risk, no study has examined insulin action on endothelial function between chronotypes. We hypothesized intermediate chronotypes (INT) would have lower vascular insulin sensitivity than morning chronotype (MORN). MATERIALS AND METHODS Adults with obesity were classified per Morningness-Eveningness Questionnaire (MEQ) as either MORN (n = 27, 22 female, MEQ = 63.7 ± 4.7, 53.8 ± 6.7 years, 35.3 ± 4.9 kg/m2) or INT (n = 29, 23 female, MEQ = 48.8 ± 6.7, 56.6 ± 9.0 years, 35.7 ± 6.1 kg/m2). A 120 min euglycaemic-hyperinsulinaemic clamp (40 mU/m2/min, 90 mg/dl) was conducted to assess macrovascular insulin sensitivity via brachial artery flow-mediated dilation (%FMD; conduit artery), post-ischaemic flow velocity (resistance arteriole), as well as microvascular insulin sensitivity via contrast-enhanced ultrasound [e.g. microvascular blood volume (perfusion)]. Fasting plasma arginine and citrulline, as well as fasting and clamp-derived plasma endothelin-1 and nitrate/nitrite, were assessed as surrogates of vasoconstriction and nitric oxide-mediated vasodilation. Aerobic fitness (VO2max) and body composition (dual-energy X-ray absorptiometry) were also collected. RESULTS MORN had a higher VO2max compared with INT (p < .01), although there was no difference in fat mass. While fasting FMD was similar between groups, insulin lowered FMD corrected to shear stress and microvascular blood volume in INT compared with MORN after co-varying for VO2max (both p ≤ .02). INT also had a lower fasting nitrate (p = .03) and arginine (p = .07). Higher MEQ correlated with elevated FMD (r = 0.33, p = .03) and lower post-ischaemic flow velocity (r = -0.33, p = .03) as well as shear rate (r = -0.36, p = .02) at 120 min. CONCLUSION When measured during the morning, INT had a lower vascular insulin sensitivity than MORN. Additional work is needed to understand endothelial function differences among chronotypes to optimize cardiovascular disease risk reduction.
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Affiliation(s)
- Steven K. Malin
- Rutgers University, New Brunswick, NJ
- Division of Endocrinology, Metabolism & Nutrition; Rutgers University, New Brunswick, NJ
- New Jersey Institute for Food, Nutrition and Health, Rutgers University, New Brunswick, NJ
- Institute of Translational Medicine and Science, Rutgers University, New Brunswick, NJ
| | | | | | | | | | | | - Zhenqi Liu
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia Health System, Charlottesville, VA
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Battillo DJ, Remchak MME, Shah AM, Malin SK. Impact of Insulin-Induced Relative Hypoglycemia on Vascular Insulin Sensitivity and Central Hemodynamics in Prediabetes. J Clin Endocrinol Metab 2024:dgae152. [PMID: 38491968 DOI: 10.1210/clinem/dgae152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 03/05/2024] [Accepted: 03/07/2024] [Indexed: 03/18/2024]
Abstract
CONTEXT Relative hypoglycemia (RH) is linked to sympathetic responses that can alter vascular function in individuals with type 2 diabetes. However, less is known about the role of RH on hemodynamics or metabolic insulin sensitivity in prediabetes. OBJECTIVE Determine if RH alters peripheral endothelial function or central hemodynamics to a greater extent in those with prediabetes (PD) versus normoglycemia (NG). METHODS Seventy adults with obesity were classified using ADA criteria as PD (n=34 (28F); HbA1c=6.02±0.1%) or NG (n=36 (30F); HbA1c=5.4±0.0%). Brachial artery endothelial function, skeletal muscle capillary perfusion, and aortic waveforms were assessed at 0 and 120min of a euglycemic clamp (40 mU/m2/min, 90 mg/dl). Plasma nitrate/nitrite and endothelin-1 (ET-1) were measured as surrogates of nitric oxide-mediated vasodilation and vasoconstriction, respectively. RH was defined as the drop in glucose (%) from fasting to clamp steady state. RESULTS There were no differences in age, weight, or VO2max between groups. PD had higher HbA1c (P<0.01) and a greater drop in glucose in response to insulin (14 vs. 8%; P=0.03). Further, heart rate (HR) increased in NG compared to PD (P<0.01), while forward wave (Pf) decreased in PD (P=0.04). Insulin also tended to reduce arterial stiffness (cfPWV) in NG versus PD (P=0.07), despite similar increases in pre-occlusion diameter (P=0.02), blood flow (P=0.02), and lower augmentation index (AIx75) (P≤0.05). CONCLUSION Compared with NG, insulin-induced RH corresponded with a blunted rise in HR and drop in Pf during insulin infusion in adults with PD, independent of changes in peripheral endothelial function.
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Affiliation(s)
- Daniel J Battillo
- Department of Kinesiology and Health, Rutgers University, New Brunswick, NJ
| | | | - Ankit M Shah
- Division of Endocrinology, Metabolism & Nutrition; Rutgers University, New Brunswick, NJ
| | - Steven K Malin
- Department of Kinesiology and Health, Rutgers University, New Brunswick, NJ
- Division of Endocrinology, Metabolism & Nutrition; Rutgers University, New Brunswick, NJ
- New Jersey Institute for Food, Nutrition and Health, Rutgers University, New Brunswick, NJ
- Institute of Translational Medicine and Science, Rutgers University, New Brunswick, NJ
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Remchak MME, Dosik JK, Pappas G, Gow AJ, Shah AM, Malin SK. Exercise blood pressure and heart rate responses to graded exercise testing in intermediate versus morning chronotypes with obesity. Am J Physiol Heart Circ Physiol 2023; 325:H635-H644. [PMID: 37505468 PMCID: PMC10642995 DOI: 10.1152/ajpheart.00149.2023] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 07/29/2023]
Abstract
Exaggerated exercise blood pressure (BP) is linked to cardiovascular disease (CVD). Although evening chronotypes have greater CVD risk than morning (Morn) types, it is unknown if exercise BP differs in intermediate (Int) types. Adults with obesity were classified as either Morn [n = 23 (18 females), Morning-Eveningness Questionnaire (MEQ) = 63.96 ± 1.0, 54.74 ± 1.4 yr, 33.7 ± 0.6 kg/m2] or Int [n = 23 (19 females), MEQ = 51.36 ± 1.1, 55.96 ± 1.8 yr, 37.2 ± 1.2 kg/m2] chronotype per MEQ. A graded, incremental treadmill test to maximal aerobic capacity (V̇o2max) was conducted. Systolic (SBP) and diastolic (DBP) blood pressure and mean arterial pressure (MAP), rate pressure product (RPP), heart rate (HR), and rate of perceived intensity (RPE) were determined at baseline, 4 min, 6 min, and maximal stages. HR recovery (HRR; maximum postexercise) was determined at 1 and 2 min postexercise. Preexercise fasted aortic waveforms (applanation tonometry), plasma leptin, nitrate/nitrite (nitric oxide bioavailability), and body composition (dual X-ray, DXA) were also collected. Int had lower V̇o2max and plasma nitrate (both P ≤ 0.02) than Morn. No difference in preexercise BP, aortic waveforms, or body composition were noted between groups, although higher plasma leptin was seen in Int compared with Morn (P = 0.04). Although Int had higher brachial DBP and MAP across exercise stages (both P ≤ 0.05) and higher HR, RPE, and RPP at 6 min of exercise (all P ≤ 0.05), covarying for V̇o2max nullified the BP, but not HR or RPE, difference. HRR was greater in Morn independent of V̇o2max (P = 0.046). Fasted leptin correlated with HR at exercise stage 4 (r = 0.421, P = 0.041) and 6 min (r = 0.593, P = 0.002). This observational study suggests that Int has exaggerated BP and HR responses to exercise compared with Morn, although fitness abolished BP differences.NEW & NOTEWORTHY This study compares blood pressure and heart rate responses with graded, incremental exercise between morning and intermediate chronotype adults with obesity. Herein, blood pressure responses to exercise were elevated in intermediate compared with morning chronotype, although V̇o2max abolished this observation. However, heart rate responses to exercise were higher in intermediate vs. morning chronotypes independent of fitness. Collectively, this exercise hemodynamic response among intermediate chronotype may be related to reduced aerobic fitness, altered nitric oxide metabolism, and/or elevated aortic waveforms.
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Affiliation(s)
- Mary-Margaret E Remchak
- Department of Kinesiology and Health, Rutgers University, New Brunswick, New Jersey, United States
| | - Jaclyn K Dosik
- Department of Kinesiology and Health, Rutgers University, New Brunswick, New Jersey, United States
| | - Gregory Pappas
- Department of Kinesiology and Health, Rutgers University, New Brunswick, New Jersey, United States
- Ernest Mario School of Pharmacy, Pharmacology and Toxicology, Rutgers University, New Brunswick, New Jersey, United States
| | - Andrew J Gow
- Ernest Mario School of Pharmacy, Pharmacology and Toxicology, Rutgers University, New Brunswick, New Jersey, United States
| | - Ankit M Shah
- Division of Endocrinology, Metabolism & Nutrition, Rutgers University, New Brunswick, New Jersey, United States
| | - Steven K Malin
- Department of Kinesiology and Health, Rutgers University, New Brunswick, New Jersey, United States
- Division of Endocrinology, Metabolism & Nutrition, Rutgers University, New Brunswick, New Jersey, United States
- New Jersey Institute for Food, Nutrition and Health, Rutgers University, New Brunswick, New Jersey, United States
- Institute of Translational Medicine and Science, Rutgers University, New Brunswick, New Jersey, United States
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4
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Kaura A, Roddick AJ, Samuel NA, Mulla A, Glampson B, Davies J, Woods K, Kharbanda R, Patel RS, Shah AM, Perera D, Channon KM, Mayet J. The association between troponin level and mortality in patients admitted to hospital with acute stroke (NIHR Health Informatics Collaborative TROP-STROKE study). Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1991] [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: 11/13/2022] Open
Abstract
Abstract
Introduction
Acute stroke accounts for significant morbidity and mortality globally. The role of troponin for risk stratification in stroke is unclear.
Purpose
The aims of this study were to assess the relationship between peak troponin and mortality in patients with ischaemic stroke, haemorrhagic stroke, or subarachnoid haemorrhage and to compare this with the predictive value of first troponin or dynamic troponin change.
Methods
A retrospective cohort study was carried out using the National Institute for Health Research Health Informatics Collaborative Cardiovascular dataset of all consecutive patients who had a troponin measured at five hospitals between 2010 and 2017. Patients with at least one troponin measurement and a primary diagnosis of ischaemic stroke, haemorrhagic stroke or subarachnoid haemorrhage during a hospital admission were included. The main exposure variables were first and peak troponin, and dynamic troponin change, and the main outcome was all-cause mortality. Results were analysed using multivariable adjusted restricted cubic spline Cox regression. Survival analyses were adjusted for troponin assay, assay sensitivity (standard or highly sensitive), number of troponin measurements, age, sex, C-reactive protein level, white blood cell count, platelet count, haemoglobin, estimated glomerular filtration rate, angiography during admission, acute coronary syndrome during admission, and cardiovascular history (history of diabetes mellitus, myocardial infarction, heart failure, hypertension, stroke or atrial fibrillation). Receiver Operator Characteristic (ROC) curves were used to assess the predictive value of each exposure variable.
Results
4,712 patients were included in the analysis (ischaemic stroke: 3,346; haemorrhagic stroke: 718; subarachnoid haemorrhage: 648). Peak troponin was above the upper limit of normal in 47.4% of ischaemic stroke patients, 52.8% of haemorrhagic stroke patients, and 57.1% of subarachnoid haemorrhage patients. Patients with elevated peak troponin were older and had more cardiovascular risk factors.
A direct positive relationship was seen between peak troponin level and mortality hazard ratio in all three stroke subtypes (Figure 1). This relationship was consistent when considering dynamic troponin fold change for ischaemic or haemorrhagic stroke. For all three stroke subtypes, there was no added predictive value of peak troponin or dynamic troponin change over first troponin in predicting mortality (Figure 2).
Conclusions
A positive peak troponin was associated with increased mortality in patients presenting with ischaemic stroke, haemorrhagic stroke, or subarachnoid haemorrhage. Overall, serial troponin measurements may not improve mortality prediction beyond a single measurement. These findings may have implications for risk stratification of patients with acute stroke syndromes.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NIHR Imperial Biomedical Research Centre, as part of the NIHR Health Informatics Collaborative, and 2) British Heart Foundation
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Affiliation(s)
- A Kaura
- Imperial College Hospital NHS Healthcare Trust , London , United Kingdom
| | - A J Roddick
- Oxford University Hospitals NHS Foundation Trust , Oxford , United Kingdom
| | - N A Samuel
- Oxford University Hospitals NHS Foundation Trust , Oxford , United Kingdom
| | - A Mulla
- Imperial College Hospital NHS Healthcare Trust , London , United Kingdom
| | - B Glampson
- Imperial College Hospital NHS Healthcare Trust , London , United Kingdom
| | - J Davies
- Oxford University Hospitals NHS Foundation Trust , Oxford , United Kingdom
| | - K Woods
- Oxford University Hospitals NHS Foundation Trust , Oxford , United Kingdom
| | - R Kharbanda
- Oxford University Hospitals NHS Foundation Trust , Oxford , United Kingdom
| | - R S Patel
- University College London Hospitals , London , United Kingdom
| | - A M Shah
- King's College Hospital NHS Foundation Trust , London , United Kingdom
| | - D Perera
- Guy's & St Thomas' NHS Foundation Trust , London , United Kingdom
| | - K M Channon
- Oxford University Hospitals NHS Foundation Trust , Oxford , United Kingdom
| | - J Mayet
- Imperial College Hospital NHS Healthcare Trust , London , United Kingdom
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Kaura A, Samuel NA, Roddick AJ, Glampson B, Mulla A, Davies J, Woods K, Patel RS, Shah AM, Perera D, Channon KM, Shah ASV, Mayet J. The prognostic significance of troponin level in patients with malignancy (NIHR Health Informatics Collaborative TROP-MALIGNANCY study). Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2588] [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
Background
Cardiac troponin is commonly raised in patients with malignancy and may aid clinicians in risk prediction. The prognostic significance of raised troponin in these patients with known malignancies remains unclear.
Purpose
We sought to investigate the relation between troponin and mortality in a large, well characterised cohort of patients undergoing cardiac troponin testing with a concomitant malignancy.
Methods
A retrospective cohort study was carried out using the National Institute for Health Research Health Informatics Collaborative Cardiovascular dataset of all consecutive patients who had a troponin measured at five hospitals between 2010 and 2017. Patients with a primary inpatient diagnosis of malignancy who had at least one cTn measurement during their hospital stay were identified. Patients were classified into solid tumour or haematological malignancy subgroups. Survival analyses were performed using multivariate Cox regression analyses and Kaplan-Meier plots. Cox regression analyses were adjusted for age, gender, C-reactive protein, haemoglobin, platelet count, white cell count, acute coronary syndrome, diabetes mellitus, heart failure, chronic kidney disease, chronic obstructive pulmonary disease, atrial fibrillation and angiography. The peak cTn level (highest level measured), standardised to the upper limit of normal (ULN), was used for all analyses.
Results
5571 patients undergoing troponin testing had a primary diagnosis of malignancy and comprised of twenty-one different cancer types. 4649 patients were diagnosed with solid tumours and 922 patients were diagnosed with haematological malignancies. Patients with raised troponin had a higher burden of cardiovascular comorbidities compared to patients with a troponin level below the ULN. The median follow-up in the cohort was 14 months (interquartile range 2–39 months). At 1-year follow-up, 2495 (42%) of patients died.
Figure 1 shows Kaplan-Meier plots for patients stratified by troponin level. Patients with a troponin level ≥1xULN had a higher risk of death compared to patients with a troponin level <1xULN (Figure 1A). A similar trend was shown in cancer subtypes (Figure 1B, C). Raised troponin was an independent predictor of mortality in all patients with malignancy (adjusted hazard ratio 1.66, 95% confidence interval [CI] 1.52–1.81), in solid tumours (adjusted hazard ratio 1.63, 95% CI 1.48–1.81) and in haematological malignancy (adjusted hazard ratio 1.75, 95% CI 1.44 to 2.13) when compared to patients with a troponin level <1xULN.
Conclusion
A raised troponin was associated with an increased mortality risk in patients with malignancy regardless of cancer subtype. Stratification of mortality risk using troponin may help guide clinicians in making management decisions for patients with malignancy.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NIHR Imperial Biomedical Research Centre, as part of the NIHR Health Informatics Collaborative, and 2) British Heart Foundation
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Affiliation(s)
- A Kaura
- Imperial College Hospital NHS Healthcare Trust , London , United Kingdom
| | - N A Samuel
- Oxford University Hospitals NHS Foundation Trust , Oxford , United Kingdom
| | - A J Roddick
- Oxford University Hospitals NHS Foundation Trust , Oxford , United Kingdom
| | - B Glampson
- Imperial College Hospital NHS Healthcare Trust , London , United Kingdom
| | - A Mulla
- Imperial College Hospital NHS Healthcare Trust , London , United Kingdom
| | - J Davies
- Oxford University Hospitals NHS Foundation Trust , Oxford , United Kingdom
| | - K Woods
- Oxford University Hospitals NHS Foundation Trust , Oxford , United Kingdom
| | - R S Patel
- University College London Hospitals , London , United Kingdom
| | - A M Shah
- King's College Hospital NHS Foundation Trust , London , United Kingdom
| | - D Perera
- Guy's & St Thomas' NHS Foundation Trust , London , United Kingdom
| | - K M Channon
- Oxford University Hospitals NHS Foundation Trust , Oxford , United Kingdom
| | - A S V Shah
- Imperial College Hospital NHS Healthcare Trust , London , United Kingdom
| | - J Mayet
- Imperial College Hospital NHS Healthcare Trust , London , United Kingdom
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Kaura A, Sterne JAC, Trickey A, Mulla A, Glampson B, Davies J, Woods K, Panoulas V, Shah AD, Patel RS, Kharbanda R, Shah AM, Perera D, Channon KM, Mayet J. Developing informatics infrastructure to curate datasets using electronic health record data from five hospitals for translational cardiovascular research. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2794] [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: 11/12/2022] Open
Abstract
Abstract
Introduction
It has been challenging for researchers to access granular electronic health record (EHR) data at scale. One emerging prospect is to use big data to traverse the translational spectrum from an early discovery phase to a later implementation phase.
Purpose
To create a research-ready dataset to support translational research in cardiovascular medicine, using routinely-collected EHR data from multiple hospitals. As an early discovery phase study, we estimated the effect of invasive versus non-invasive management on the survival of patients with non-ST elevation myocardial infarction (NSTEMI) aged 80 years or older (SENIOR-NSTEMI Study). As a later implementation phase study, we determined the relationship between the full spectrum of troponin level and mortality in patients in whom troponin testing was performed for clinical purposes (TROP-RISK Study).
Methods
Using Microsoft SQL we developed a dataset of 257948 consecutive patients who had a troponin measured between 2010 and 2017 at five hospitals. We extracted phenotypically detailed data, including demographics, blood tests, procedural data, and survival status.
For the SENIOR-NSTEMI Study, eligible patients were 80 years or older who were diagnosed with NSTEMI. We estimated mortality hazard ratios comparing invasive with non-invasive management. For the TROP-RISK Study, we modelled the relation between peak troponin level and all-cause mortality using multivariable adjusted restricted cubic spline Cox regression analyses.
Results
For the SENIOR-NSTEMI Study, 1500 patients with NSTEMI were included who had a median age of 86 (interquartile range (IQR) 82–89) years of whom (845 [56%]) received non-invasive management. During a median follow-up of 3 (IQR 1.2–4.8) years, the adjusted cumulative five-year mortality was 36% in the invasive and 55% in the non-invasive group (hazard ratio 0.68, 95% confidence interval 0.55–0.84).
For the TROP-RISK Study, during a median follow-up of 1198 days (IQR 514–1866 days), 55850 (21.7%) deaths occurred. There was an unexpected inverted U-shaped relation between troponin level and mortality in acute coronary syndrome (ACS) patients (n=120049) (Figure 1A). The paradoxical decline in mortality at very high troponin levels may be driven in part by the changing case mix as troponin levels increase; a higher proportion of patients with very high troponin levels received invasive management (Figure 1B).
Conclusion
Routine EHR data can be aggregated across multiple sites to create highly granular datasets for research. The SENIOR-NSTEMI Study showed a survival advantage of invasive compared with non-invasive management of elderly patients with NSTEMI, who were underrepresented in previous trials. The inverted U-shaped relationship between troponin and mortality in ACS patients in the TROP-RISK Study demonstrates that assembling sufficiently large datasets can cast light on patterns of disease that are impossible to adequately define in single centre studies.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): 1) NIHR Imperial Biomedical Research Centre, as part of the NIHR Health Informatics Collaborative, and 2) British Heart Foundation
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Affiliation(s)
- A Kaura
- Imperial College Hospital NHS Healthcare Trust , London , United Kingdom
| | - J A C Sterne
- University of Bristol , Bristol , United Kingdom
| | - A Trickey
- University of Bristol , Bristol , United Kingdom
| | - A Mulla
- Imperial College Hospital NHS Healthcare Trust , London , United Kingdom
| | - B Glampson
- Imperial College Hospital NHS Healthcare Trust , London , United Kingdom
| | - J Davies
- Oxford University Hospitals NHS Foundation Trust , Oxford , United Kingdom
| | - K Woods
- Oxford University Hospitals NHS Foundation Trust , Oxford , United Kingdom
| | - V Panoulas
- Imperial College Hospital NHS Healthcare Trust , London , United Kingdom
| | - A D Shah
- University College London Hospitals , London , United Kingdom
| | - R S Patel
- University College London Hospitals , London , United Kingdom
| | - R Kharbanda
- Oxford University Hospitals NHS Foundation Trust , Oxford , United Kingdom
| | - A M Shah
- King's College Hospital NHS Foundation Trust , London , United Kingdom
| | - D Perera
- Guy's & St Thomas' NHS Foundation Trust , London , United Kingdom
| | - K M Channon
- Oxford University Hospitals NHS Foundation Trust , Oxford , United Kingdom
| | - J Mayet
- Imperial College Hospital NHS Healthcare Trust , London , United Kingdom
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Kaura A, Goswami S, Mulla A, Glampson B, Davies J, Woods K, Shah AM, Kharbanda R, Patel RS, Perera D, Channon KM, Quint J, Mayet J. The association between age, troponin level, and mortality in patients hospitalised with acute pulmonary embolism (NIHR Health Informatics Collaborative TROP-PE study). Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1873] [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
Background
A positive cardiac troponin (cTn) is an independent predictor of short-term mortality in individuals presenting with acute pulmonary embolism (PE). However, there is limited evidence regarding the impact age has on the association between cTn levels and mortality in patients with PE.
Purpose
The aim of our study was to investigate the relationship between cTn level, age, and all-cause mortality, in hospitalised patients diagnosed with an acute PE.
Methods
A retrospective cohort study using the National Institute for Health Research Health Informatics Collaborative Cardiovascular dataset of all consecutive patients who had a troponin measured at five hospitals between 2010 and 2017. Patients admitted to hospital with a primary diagnosis of PE with at least one cTn measurement were included. We modelled the relation between peak troponin level and all-cause mortality using multivariable adjusted restricted cubic spline Cox regression analyses. Effect estimates were adjusted for age, gender, high-sensitivity troponin assay, C-reactive protein, haemoglobin, platelet count, white cell count, creatinine, sodium, potassium, diabetes, hypertension, hypercholesterolaemia, acute coronary syndrome, atrial fibrillation, heart failure, acute kidney injury, chronic kidney disease, obstructive lung disease, inflammatory disorders, pneumonia and malignancy. The peak cTn level (highest level measured), standardised to the upper limit of normal (ULN), was used for all analyses.
Results
1,477 patients with at least one cTn measurement and a diagnosis of acute PE were included. During a median follow-up of 34.8 months, there were 290 (19.6%) deaths. Elevated cTn (>1xULN) was associated with a hazard ratio (HR) of 3.29 (95% confidence interval [CI] 1.95–5.53) for 30-day mortality and 2.12 (95% CI 1.63–2.75) for 3-year mortality. Higher cTn levels were progressively associated with a higher mortality risk, reaching a maximum HR of 2.59 (95% CI 1.64–4.09) at 141xULN (Figure 1). Younger patients (<55 years), compared with those aged over 55, had the highest 3-year HR associated with a positive cTn of 2.94 (95% CI 1.48–5.82) despite having the lowest troponin levels (mean 7.01xULN) on admission (Figure 2).
Conclusion
Elevated cTn, at all ages, is associated with an increased mortality risk in patients presenting with PE, with increasing cTn levels conferring a progressively worse long-term prognosis. Elevated cTn, no matter how small, needs to be taken seriously, particularly in young patients with an acute PE.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): 1) NIHR Imperial Biomedical Research Centre, as part of the NIHR Health Informatics Collaborative, and 2) British Heart Foundation
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Affiliation(s)
- A Kaura
- Imperial College Hospital NHS Healthcare Trust , London , United Kingdom
| | - S Goswami
- Barts and The London School of Medicine and Dentistry , London , United Kingdom
| | - A Mulla
- Imperial College Hospital NHS Healthcare Trust , London , United Kingdom
| | - B Glampson
- Imperial College Hospital NHS Healthcare Trust , London , United Kingdom
| | - J Davies
- Oxford University Hospitals NHS Foundation Trust , Oxford , United Kingdom
| | - K Woods
- Oxford University Hospitals NHS Foundation Trust , Oxford , United Kingdom
| | - A M Shah
- King's College Hospital NHS Foundation Trust , London , United Kingdom
| | - R Kharbanda
- Oxford University Hospitals NHS Foundation Trust , Oxford , United Kingdom
| | - R S Patel
- University College London Hospitals , London , United Kingdom
| | - D Perera
- Guy's & St Thomas' NHS Foundation Trust , London , United Kingdom
| | - K M Channon
- Oxford University Hospitals NHS Foundation Trust , Oxford , United Kingdom
| | - J Quint
- Imperial College Hospital NHS Healthcare Trust , London , United Kingdom
| | - J Mayet
- Imperial College Hospital NHS Healthcare Trust , London , United Kingdom
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8
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Evans RA, Leavy OC, Richardson M, Elneima O, McAuley HJC, Shikotra A, Singapuri A, Sereno M, Saunders RM, Harris VC, Houchen-Wolloff L, Aul R, Beirne P, Bolton CE, Brown JS, Choudhury G, Diar-Bakerly N, Easom N, Echevarria C, Fuld J, Hart N, Hurst J, Jones MG, Parekh D, Pfeffer P, Rahman NM, Rowland-Jones SL, Shah AM, Wootton DG, Chalder T, Davies MJ, De Soyza A, Geddes JR, Greenhalf W, Greening NJ, Heaney LG, Heller S, Howard LS, Jacob J, Jenkins RG, Lord JM, Man WDC, McCann GP, Neubauer S, Openshaw PJM, Porter JC, Rowland MJ, Scott JT, Semple MG, Singh SJ, Thomas DC, Toshner M, Lewis KE, Thwaites RS, Briggs A, Docherty AB, Kerr S, Lone NI, Quint J, Sheikh A, Thorpe M, Zheng B, Chalmers JD, Ho LP, Horsley A, Marks M, Poinasamy K, Raman B, Harrison EM, Wain LV, Brightling CE, Abel K, Adamali H, Adeloye D, Adeyemi O, Adrego R, Aguilar Jimenez LA, Ahmad S, Ahmad Haider N, Ahmed R, Ahwireng N, Ainsworth M, Al-Sheklly B, Alamoudi A, Ali M, Aljaroof M, All AM, Allan L, Allen RJ, Allerton L, Allsop L, Almeida P, Altmann D, Alvarez Corral M, Amoils S, Anderson D, Antoniades C, Arbane G, Arias A, Armour C, Armstrong L, Armstrong N, Arnold D, Arnold H, Ashish A, Ashworth A, Ashworth M, Aslani S, Assefa-Kebede H, Atkin C, Atkin P, Aung H, Austin L, Avram C, Ayoub A, Babores M, Baggott R, Bagshaw J, Baguley D, Bailey L, Baillie JK, Bain S, Bakali M, Bakau M, Baldry E, Baldwin D, Ballard C, Banerjee A, Bang B, Barker RE, Barman L, Barratt S, Barrett F, Basire D, Basu N, Bates M, Bates A, Batterham R, Baxendale H, Bayes H, Beadsworth M, Beckett P, Beggs M, Begum M, Bell D, Bell R, Bennett K, Beranova E, Bermperi A, Berridge A, Berry C, Betts S, Bevan E, Bhui K, Bingham M, Birchall K, Bishop L, Bisnauthsing K, Blaikely J, Bloss A, Bolger A, Bonnington J, Botkai A, Bourne C, Bourne M, Bramham K, Brear L, Breen G, Breeze J, Bright E, Brill S, Brindle K, Broad L, Broadley A, Brookes C, Broome M, Brown A, Brown A, Brown J, Brown J, Brown M, Brown M, Brown V, Brugha T, Brunskill N, Buch M, Buckley P, Bularga A, Bullmore E, Burden L, Burdett T, Burn D, Burns G, Burns A, Busby J, Butcher R, Butt A, Byrne S, Cairns P, Calder PC, Calvelo E, Carborn H, Card B, Carr C, Carr L, Carson G, Carter P, Casey A, Cassar M, Cavanagh J, Chablani M, Chambers RC, Chan F, Channon KM, Chapman K, Charalambou A, Chaudhuri N, Checkley A, Chen J, Cheng Y, Chetham L, Childs C, Chilvers ER, Chinoy H, Chiribiri A, Chong-James K, Choudhury N, Chowienczyk P, Christie C, Chrystal M, Clark D, Clark C, Clarke J, Clohisey S, Coakley G, Coburn Z, Coetzee S, Cole J, Coleman C, Conneh F, Connell D, Connolly B, Connor L, Cook A, Cooper B, Cooper J, Cooper S, Copeland D, Cosier T, Coulding M, Coupland C, Cox E, Craig T, Crisp P, Cristiano D, Crooks MG, Cross A, Cruz I, Cullinan P, Cuthbertson D, Daines L, Dalton M, Daly P, Daniels A, Dark P, Dasgin J, David A, David C, Davies E, Davies F, Davies G, Davies GA, Davies K, Dawson J, Daynes E, Deakin B, Deans A, Deas C, Deery J, Defres S, Dell A, Dempsey K, Denneny E, Dennis J, Dewar A, Dharmagunawardena R, Dickens C, Dipper A, Diver S, Diwanji SN, Dixon M, Djukanovic R, Dobson H, Dobson SL, Donaldson A, Dong T, Dormand N, Dougherty A, Dowling R, Drain S, Draxlbauer K, Drury K, Dulawan P, Dunleavy A, Dunn S, Earley J, Edwards S, Edwardson C, El-Taweel H, Elliott A, Elliott K, Ellis Y, Elmer A, Evans D, Evans H, Evans J, Evans R, Evans RI, Evans T, Evenden C, Evison L, Fabbri L, Fairbairn S, Fairman A, Fallon K, Faluyi D, Favager C, Fayzan T, Featherstone J, Felton T, Finch J, Finney S, Finnigan J, Finnigan L, Fisher H, Fletcher S, Flockton R, Flynn M, Foot H, Foote D, Ford A, Forton D, Fraile E, Francis C, Francis R, Francis S, Frankel A, Fraser E, Free R, French N, Fu X, Furniss J, Garner L, Gautam N, George J, George P, Gibbons M, Gill M, Gilmour L, Gleeson F, Glossop J, Glover S, Goodman N, Goodwin C, Gooptu B, Gordon H, Gorsuch T, Greatorex M, Greenhaff PL, Greenhalgh A, Greenwood J, Gregory H, Gregory R, Grieve D, Griffin D, Griffiths L, Guerdette AM, Guillen Guio B, Gummadi M, Gupta A, Gurram S, Guthrie E, Guy Z, H Henson H, Hadley K, Haggar A, Hainey K, Hairsine B, Haldar P, Hall I, Hall L, Halling-Brown M, Hamil R, Hancock A, Hancock K, Hanley NA, Haq S, Hardwick HE, Hardy E, Hardy T, Hargadon B, Harrington K, Harris E, Harrison P, Harvey A, Harvey M, Harvie M, Haslam L, Havinden-Williams M, Hawkes J, Hawkings N, Haworth J, Hayday A, Haynes M, Hazeldine J, Hazelton T, Heeley C, Heeney JL, Heightman M, Henderson M, Hesselden L, Hewitt M, Highett V, Hillman T, Hiwot T, Hoare A, Hoare M, Hockridge J, Hogarth P, Holbourn A, Holden S, Holdsworth L, Holgate D, Holland M, Holloway L, Holmes K, Holmes M, Holroyd-Hind B, Holt L, Hormis A, Hosseini A, Hotopf M, Howard K, Howell A, Hufton E, Hughes AD, Hughes J, Hughes R, Humphries A, Huneke N, Hurditch E, Husain M, Hussell T, Hutchinson J, Ibrahim W, Ilyas F, Ingham J, Ingram L, Ionita D, Isaacs K, Ismail K, Jackson T, James WY, Jarman C, Jarrold I, Jarvis H, Jastrub R, Jayaraman B, Jezzard P, Jiwa K, Johnson C, Johnson S, Johnston D, Jolley CJ, Jones D, Jones G, Jones H, Jones H, Jones I, Jones L, Jones S, Jose S, Kabir T, Kaltsakas G, Kamwa V, Kanellakis N, Kaprowska S, Kausar Z, Keenan N, Kelly S, Kemp G, Kerslake H, Key AL, Khan F, Khunti K, Kilroy S, King B, King C, Kingham L, Kirk J, Kitterick P, Klenerman P, Knibbs L, Knight S, Knighton A, Kon O, Kon S, Kon SS, Koprowska S, Korszun A, Koychev I, Kurasz C, Kurupati P, Laing C, Lamlum H, Landers G, Langenberg C, Lasserson D, Lavelle-Langham L, Lawrie A, Lawson C, Lawson C, Layton A, Lea A, Lee D, Lee JH, Lee E, Leitch K, Lenagh R, Lewis D, Lewis J, Lewis V, Lewis-Burke N, Li X, Light T, Lightstone L, Lilaonitkul W, Lim L, Linford S, Lingford-Hughes A, Lipman M, Liyanage K, Lloyd A, Logan S, Lomas D, Loosley R, Lota H, Lovegrove W, Lucey A, Lukaschuk E, Lye A, Lynch C, MacDonald S, MacGowan G, Macharia I, Mackie J, Macliver L, Madathil S, Madzamba G, Magee N, Magtoto MM, Mairs N, Majeed N, Major E, Malein F, Malim M, Mallison G, Mandal S, Mangion K, Manisty C, Manley R, March K, Marciniak S, Marino P, Mariveles M, Marouzet E, Marsh S, Marshall B, Marshall M, Martin J, Martineau A, Martinez LM, Maskell N, Matila D, Matimba-Mupaya W, Matthews L, Mbuyisa A, McAdoo S, Weir McCall J, McAllister-Williams H, McArdle A, McArdle P, McAulay D, McCormick J, McCormick W, McCourt P, McGarvey L, McGee C, Mcgee K, McGinness J, McGlynn K, McGovern A, McGuinness H, McInnes IB, McIntosh J, McIvor E, McIvor K, McLeavey L, McMahon A, McMahon MJ, McMorrow L, Mcnally T, McNarry M, McNeill J, McQueen A, McShane H, Mears C, Megson C, Megson S, Mehta P, Meiring J, Melling L, Mencias M, Menzies D, Merida Morillas M, Michael A, Milligan L, Miller C, Mills C, Mills NL, Milner L, Misra S, Mitchell J, Mohamed A, Mohamed N, Mohammed S, Molyneaux PL, Monteiro W, Moriera S, Morley A, Morrison L, Morriss R, Morrow A, Moss AJ, Moss P, Motohashi K, Msimanga N, Mukaetova-Ladinska E, Munawar U, Murira J, Nanda U, Nassa H, Nasseri M, Neal A, Needham R, Neill P, Newell H, Newman T, Newton-Cox A, Nicholson T, Nicoll D, Nolan CM, Noonan MJ, Norman C, Novotny P, Nunag J, Nwafor L, Nwanguma U, Nyaboko J, O'Donnell K, O'Brien C, O'Brien L, O'Regan D, Odell N, Ogg G, Olaosebikan O, Oliver C, Omar Z, Orriss-Dib L, Osborne L, Osbourne R, Ostermann M, Overton C, Owen J, Oxton J, Pack J, Pacpaco E, Paddick S, Painter S, Pakzad A, Palmer S, Papineni P, Paques K, Paradowski K, Pareek M, Parfrey H, Pariante C, Parker S, Parkes M, Parmar J, Patale S, Patel B, Patel M, Patel S, Pattenadk D, Pavlides M, Payne S, Pearce L, Pearl JE, Peckham D, Pendlebury J, Peng Y, Pennington C, Peralta I, Perkins E, Peterkin Z, Peto T, Petousi N, Petrie J, Phipps J, Pimm J, Piper Hanley K, Pius R, Plant H, Plein S, Plekhanova T, Plowright M, Polgar O, Poll L, Porter J, Portukhay S, Powell N, Prabhu A, Pratt J, Price A, Price C, Price C, Price D, Price L, Price L, Prickett A, Propescu J, Pugmire S, Quaid S, Quigley J, Qureshi H, Qureshi IN, Radhakrishnan K, Ralser M, Ramos A, Ramos H, Rangeley J, Rangelov B, Ratcliffe L, Ravencroft P, Reddington A, Reddy R, Redfearn H, Redwood D, Reed A, Rees M, Rees T, Regan K, Reynolds W, Ribeiro C, Richards A, Richardson E, Rivera-Ortega P, Roberts K, Robertson E, Robinson E, Robinson L, Roche L, Roddis C, Rodger J, Ross A, Ross G, Rossdale J, Rostron A, Rowe A, Rowland A, Rowland J, Roy K, Roy M, Rudan I, Russell R, Russell E, Saalmink G, Sabit R, Sage EK, Samakomva T, Samani N, Sampson C, Samuel K, Samuel R, Sanderson A, Sapey E, Saralaya D, Sargant J, Sarginson C, Sass T, Sattar N, Saunders K, Saunders P, Saunders LC, Savill H, Saxon W, Sayer A, Schronce J, Schwaeble W, Scott K, Selby N, Sewell TA, Shah K, Shah P, Shankar-Hari M, Sharma M, Sharpe C, Sharpe M, Shashaa S, Shaw A, Shaw K, Shaw V, Shelton S, Shenton L, Shevket K, Short J, Siddique S, Siddiqui S, Sidebottom J, Sigfrid L, Simons G, Simpson J, Simpson N, Singh C, Singh S, Sissons D, Skeemer J, Slack K, Smith A, Smith D, Smith S, Smith J, Smith L, Soares M, Solano TS, Solly R, Solstice AR, Soulsby T, Southern D, Sowter D, Spears M, Spencer LG, Speranza F, Stadon L, Stanel S, Steele N, Steiner M, Stensel D, Stephens G, Stephenson L, Stern M, Stewart I, Stimpson R, Stockdale S, Stockley J, Stoker W, Stone R, Storrar W, Storrie A, Storton K, Stringer E, Strong-Sheldrake S, Stroud N, Subbe C, Sudlow CL, Suleiman Z, Summers C, Summersgill C, Sutherland D, Sykes DL, Sykes R, Talbot N, Tan AL, Tarusan L, Tavoukjian V, Taylor A, Taylor C, Taylor J, Te A, Tedd H, Tee CJ, Teixeira J, Tench H, Terry S, Thackray-Nocera S, Thaivalappil F, Thamu B, Thickett D, Thomas C, Thomas S, Thomas AK, Thomas-Woods T, Thompson T, Thompson AAR, Thornton T, Tilley J, Tinker N, Tiongson GF, Tobin M, Tomlinson J, Tong C, Touyz R, Tripp KA, Tunnicliffe E, Turnbull A, Turner E, Turner S, Turner V, Turner K, Turney S, Turtle L, Turton H, Ugoji J, Ugwuoke R, Upthegrove R, Valabhji J, Ventura M, Vere J, Vickers C, Vinson B, Wade E, Wade P, Wainwright T, Wajero LO, Walder S, Walker S, Walker S, Wall E, Wallis T, Walmsley S, Walsh JA, Walsh S, Warburton L, Ward TJC, Warwick K, Wassall H, Waterson S, Watson E, Watson L, Watson J, Welch C, Welch H, Welsh B, Wessely S, West S, Weston H, Wheeler H, White S, Whitehead V, Whitney J, Whittaker S, Whittam B, Whitworth V, Wight A, Wild J, Wilkins M, Wilkinson D, Williams N, Williams N, Williams J, Williams-Howard SA, Willicombe M, Willis G, Willoughby J, Wilson A, Wilson D, Wilson I, Window N, Witham M, Wolf-Roberts R, Wood C, Woodhead F, Woods J, Wormleighton J, Worsley J, Wraith D, Wrey Brown C, Wright C, Wright L, Wright S, Wyles J, Wynter I, Xu M, Yasmin N, Yasmin S, Yates T, Yip KP, Young B, Young S, Young A, Yousuf AJ, Zawia A, Zeidan L, Zhao B, Zongo O. Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study. Lancet Respir Med 2022; 10:761-775. [PMID: 35472304 PMCID: PMC9034855 DOI: 10.1016/s2213-2600(22)00127-8] [Citation(s) in RCA: 144] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/23/2022] [Accepted: 03/31/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge. METHODS The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing. FINDINGS 2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters. INTERPRETATION The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials. FUNDING UK Research and Innovation and National Institute for Health Research.
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Shah AM, Wang TP, Mones K, Jean P, Ravipati A, Galor A. Conjunctival Inflammation and Dry Eye Symptoms at Day 100 Post-Transplantation Do Not Predict Risk for Chronic Graft Versus Host Disease. Transplant Cell Ther 2022. [DOI: 10.1016/s2666-6367(22)00559-0] [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: 11/29/2022]
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Kang X, Amevor FK, Zhang L, Shah AM, Zhu Q, Tian Y, Shu G, Wang Y, Zhao X. Study on the Major Genes Related with Fat Deposition in Liver and Abdominal Fat of Different Breeds of Chicken. Braz J Poult Sci 2022. [DOI: 10.1590/1806-9061-2020-1373] [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] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- X Kang
- Sichuan Agricultural University, China
| | - FK Amevor
- Sichuan Agricultural University, China
| | - L Zhang
- Sichuan Agricultural University, China
| | - AM Shah
- Sichuan Agricultural University, China
| | - Q Zhu
- Sichuan Agricultural University, China
| | - Y Tian
- Sichuan Agricultural University, China
| | - G Shu
- Sichuan Agricultural University, China
| | - Y Wang
- Sichuan Agricultural University, China
| | - X Zhao
- Sichuan Agricultural University, China
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Kronenfeld JP, Collier AL, Choi S, Perez-Sanchez D, Shah AM, Lee C, Goel N. Surgical oncology operative experience at a high-volume safety-net hospital during the COVID-19 pandemic. J Surg Oncol 2021; 124:983-988. [PMID: 34291824 PMCID: PMC8426825 DOI: 10.1002/jso.26616] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/08/2021] [Accepted: 07/10/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND The coronavirus (COVID-19) pandemic led to disruptions in operative and hospital capabilities as the country triaged resources and canceled elective procedures. This study details the operative experience of a safety-net hospital for cancer-related operations during a 3-month period at the height of the pandemic. METHODS Patients operated on for or diagnosed with malignancies of the abdomen, breast, skin, or soft-tissue (September 3, 2020-September 6, 2020) were identified from operative/clinic schedules. Sociodemographics, tumor and treatment characteristics, and COVID-19 information was identified through retrospective chart review of a prospectively maintained database. Descriptive statistics were calculated. RESULTS Fifty patients evaluated within this window underwent oncologic surgery. Median age was 61 (interquartile range: 53-68), 56% were female, 86% were White, and 66% were Hispanic. The majority (28%) were for colon cancer. Only two patients tested positive for COVID-19 preoperatively or within 30 days of their operation. There were no mortalities during the 1-year study period. CONCLUSION During the COVID-19 pandemic, many hospitals and operative centers limited interventions to preserve resources, but oncologic procedures continued at many large-volume academic cancer centers. This study underscores the importance of continuing to offer surgery during the pandemic for surgical oncology cases at safety-net hospitals to minimize delays in time-sensitive oncologic treatment.
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Affiliation(s)
- Joshua P Kronenfeld
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Amber L Collier
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Seraphina Choi
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Dayana Perez-Sanchez
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ankit M Shah
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Christina Lee
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Neha Goel
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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Shah AM, Wondisford FE. Reply to Hernández-Glycolysis and gluconeogenesis: A teaching view. J Biol Chem 2021; 296:100021. [PMID: 33450696 PMCID: PMC7948971 DOI: 10.1016/j.jbc.2020.100021] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 10/30/2020] [Accepted: 11/03/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Ankit M Shah
- Department of Medicine, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
| | - Fredric E Wondisford
- Department of Medicine, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA.
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Shah AM, Galor A. Impact of Ocular Surface Temperature on Tear Characteristics: Current Insights. Clin Optom (Auckl) 2021; 13:51-62. [PMID: 33623465 PMCID: PMC7894805 DOI: 10.2147/opto.s281601] [Citation(s) in RCA: 11] [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] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 01/20/2021] [Indexed: 05/12/2023]
Abstract
Infrared (IR) thermographic assessment of ocular surface temperature (OST) is gaining interest as an adjuvant method to evaluate the ocular surface. It is a quick, non-invasive test that causes minimal, if any, discomfort to patients. The purpose of this article was to summarize research on how OST relates to tear film parameters and dry eye disease (DED). PubMed, Google Scholar, and Scopus searches for specific terms were carried out and eligible articles reviewed. OST of the central cornea is ~34-35°C when measured as a single time-point (typically right after a blink). Dynamically, OST values decrease over time at a rate of ~ -0.01 °C/s in healthy eyes. Single time-point OST values are impacted by temperature, with positive correlations noted with both ambient (1°C↓ results in ~0.16°C↓ in OST) and body (1°C↑ results in ~0.98°C↑ in OST) temperature. Single time-point OST values are also impacted by tear parameters, with negative correlations noted with tear break-up time (TBUT; r=-0.61) and positive correlations with lipid layer thickness (~r=0.50). Dynamically, the rate of OST cooling over the interblink period correlates with various tear parameters including Schirmer's test scores (r=-0.39), tear meniscus height (r=-0.52) and the rate of tear film break-up (r=-0.74). These data imply that OST decreases more rapidly in individuals with greater tear production, larger tear volumes, and shorter tear break-up times (faster rates of tear film break-up). There are discrepancies in relationships between OST and DED across studies, which is not surprising given that DED encompasses a number of different phenotypic presentations. However, most studies found that OST decreases at a more rapid rate in DED vs. control groups. As such, cooling rate may have utility as a screening tool in DED in combination with established point-of-care tests.
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Affiliation(s)
- Ankit M Shah
- Bascom Palmer Eye Institute, University of Miami, Miami, FL, USA
| | - Anat Galor
- Bascom Palmer Eye Institute, University of Miami, Miami, FL, USA
- Surgical Services, Miami Veterans Affairs (VA) Medical Center, Miami, FL, USA
- Correspondence: Anat Galor Bascom Palmer Eye Institute, 900 NW 17th St, Miami, FL, 33136, USA Email
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Abstract
As the burden of type 2 diabetes mellitus (T2DM) grows in the 21st century, the need to understand glucose metabolism heightens. Increased gluconeogenesis is a major contributor to the hyperglycemia seen in T2DM. Isotope tracer experiments in humans and animals over several decades have offered insights into gluconeogenesis under euglycemic and diabetic conditions. This review focuses on the current understanding of carbon flux in gluconeogenesis, including substrate contribution of various gluconeogenic precursors to glucose production. Alterations of gluconeogenic metabolites and fluxes in T2DM are discussed. We also highlight ongoing knowledge gaps in the literature that require further investigation. A comprehensive analysis of gluconeogenesis may enable a better understanding of T2DM pathophysiology and identification of novel targets for treating hyperglycemia.
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Affiliation(s)
- Ankit M Shah
- Department of Medicine, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
| | - Fredric E Wondisford
- Department of Medicine, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
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Gori M, Claggett B, Shah AM, Senni M, Goldenberg I, Kutyifa V, Solomon SD. 4301Diastolic dysfunction is an independent predictor of adverse events in patients with systolic dysfunction. Insights from the MADIT-CRT trial. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0146] [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: 11/13/2022] Open
Abstract
Abstract
Background
Diastolic dysfunction (DD) is common in patients with heart failure with reduced ejection fraction (HFrEF). However, its prognostic relevance in HFrEF, on top of conventional risk factors including natriuretic peptides, is unknown
Purpose
To show the prognostic contribution of DD in HFrEF
Methods
We analyzed 1155 baseline echocardiograms (63% of all available exams) in the MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy) study, comprising HFrEF patients with LVEF≤30%, QRS duration ≥130 ms, and NYHA class I/II. We classified DD according to ASE 2016 classification, based on transmitral Doppler velocities, mitral annular Tissue Doppler velocities, pulmonary venous flow velocities, and left atrial volumes. Using Cox regression and C-statistics we assessed the independent prognostic value of DD for nonfatal HF or death. We also evaluated CART (Classification And Regression Tree) analysis
Results
Patients were 64±11 years-old, 24% females, and mean LVEF was 24±5%. While 45% had impaired relaxation, 33% had pseudo-normal filling, 12% restrictive patter, 6% had indeterminate diastolic function, and 4% were not classifiable due to missing data. During a mean follow-up of 2.1±1.0 years, there were 233 adverse events. After multiple adjustment, compared to patients with impaired relaxation, those with pseudo-normal and restrictive filling had greater risk of HF/death (respectively HR 1.76, 95% CI 1.16–2.66, p=0.007; HR 2.70, 95% CI 1.58–4.60, p<0.001), independently of assigned treatment (p-interaction 0.34). Adding DD to conventional markers of risk improved prediction (C-statistic 0.733, 95% CI 0.689–0.776 versus 0.708, 95% CI 0.663–0.753, p=0.024). Finally, at CART analysis DD was the first parameter to be considered to risk stratify patients (Figure)
Risk stratification tree
Conclusions
DD is a strong independent predictor of death or heart failure in HFrEF patients with mild symptoms and should be considered in assessment of risk in this population
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Affiliation(s)
- M Gori
- Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - B Claggett
- Brigham and Womens Hospital, Boston, United States of America
| | - A M Shah
- Brigham and Womens Hospital, Boston, United States of America
| | - M Senni
- Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - I Goldenberg
- University of Rochester, Rochester, United States of America
| | - V Kutyifa
- University of Rochester, Rochester, United States of America
| | - S D Solomon
- Brigham and Womens Hospital, Boston, United States of America
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Kaura A, Sterne J, Mulla A, Panoulas V, Glampson B, Davies J, Woods K, Omigie J, Melikian N, Francis DP, Kharbanda R, Shah AM, Perera D, Patel RS, Mayet J. 6029Invasive versus medical management for non-ST elevation myocardial infarction in the elderly (SENIOR-NSTEMI study). Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0113] [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: 11/13/2022] Open
Abstract
Abstract
Background
Trials and registry studies suggest lower long-term mortality after invasive than medical management among patients with non-ST elevated myocardial infarction (NSTEMI), but elderly patients were underrepresented.
Purpose
To estimate the effect of invasive compared with medical management on survival in patients with NSTEMI aged ≥80 years, using routine clinical data.
Methods
We used National Institute for Health Research Health Informatics Collaborative data to identify eligible patients admitted during 2010–2017 at five tertiary centres. We compared patients who did and did not have invasive management within 3 days of their peak troponin level. To limit the effect of immortal time bias, follow-up started 3 days after peak troponin: deaths within three days were excluded. We conducted intention-to-treat analyses.
Propensity scores were derived from a logistic regression model based on pre-treatment variables: patient demographics, blood test results, cardiovascular risk factors, history of cardiovascular disease and other comorbidities. We modelled non-linear relationships using splines. Patients with high probability (based on propensity score) of medical or invasive intervention were excluded. We used Cox models to estimate hazard ratios (HR) comparing invasive with medical management. Three methods were used to control confounding; multivariable-adjusted, multivariable-adjusted additionally for continuous propensity score (primary analysis), and inverse-probability-of-treatment (IPT) weighting. Kaplan-Meier survival curves were plotted. The robustness of the results to unmeasured confounding was assessed in sensitivity analyses.
Results
The 2,239 patients (61.3% medical management) included in analyses had a median age of 85 (IQR 82–89) years. During a median follow-up of 32.1 (IQR 11.1–54.3) months, there were 1,015 (45.3%) deaths. At 3-years, cumulative survival was 78.9% and 50.3% in the invasive and medical management groups, respectively (Figure 1).
The crude HR comparing invasive with medical management was 0.34 (95% CI 0.29–0.40). The multivariable-adjusted HR was 0.44 (95% CI 0.36–0.53), was unchanged with additional adjustment for propensity score, and was 0.46 (95% CI 0.39–0.56) in the IPT-weighted model (all p<0.0001). The E-value for the point estimate was 2.91: this implies that residual confounding could explain the association if there is an unmeasured covariate with a relative risk of at least 2.91 for both mortality and undergoing invasive management. The highest mortality HR for comorbidities included in our model were aortic stenosis 1.66 (95% CI 1.28–2.14) and obstructive lung disease 1.50 (95% CI 1.16–1.94).
Figure 1. Kaplan-Meier survival curves
Conclusion
This study provides evidence that the survival advantage from invasive management may extend to elderly patients with NSTEMI. Future research should address the possibility of unmeasured confounding, including by post-admission prognostic factors that affect choice of invasive or medical management.
Acknowledgement/Funding
Funded by NIHR Imperial Biomedical Research Centre (BRC) using NIHR Health Informatics Collaborative data service, supported by OUH, GSTT & UCLH BRCs
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Affiliation(s)
- A Kaura
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - J Sterne
- Bristol Heart Institute, NIHR Bristol Biomedical Research Centre, University of Bristol, Bristol, United Kingdom
| | - A Mulla
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - V Panoulas
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - B Glampson
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - J Davies
- Oxford University Hospitals NHS Trust, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - K Woods
- Oxford University Hospitals NHS Trust, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - J Omigie
- Kings College Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - N Melikian
- Kings College Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - D P Francis
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - R Kharbanda
- Oxford University Hospitals NHS Trust, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - A M Shah
- Kings College Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - D Perera
- St Thomas' Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - R S Patel
- University College London Hospitals NHS Foundation Trust, NIHR University College London Biomedical Research Centre, University College London, London, United Kingdom
| | - J Mayet
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
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17
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Kaura A, Davies J, Panoulas V, Glampson B, Mulla A, Woods K, Omigie J, Shah AD, Melikian N, Francis DP, Kharbanda R, Perera D, Shah AM, Patel RS, Mayet J. P4345Supporting big data research in cardiovascular medicine using routinely-collected data. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0753] [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
Background
Many of the data points required to support translational research are collected as a matter of routine, and should be available within electronic patient records. Variations in clinical and data recording practice can mean that the extraction and standardisation of this data, with the aim of producing a large-scale, research-ready dataset, presents a number of challenges.
Purpose
We set out to create a large-scale, research-ready dataset to support translational research in cardiovascular medicine, using routinely-collected data from five large university-hospital partnerships. As an initial focus, we selected those data points that would support an investigation of the relationship between test results and outcomes in acute coronary syndrome (ACS).
Methods
The National Institute of Health Research (NIHR) Health Informatics Collaborative (HIC) is a programme of infrastructure development aimed at increasing the quality and availability of routinely-collected data for collaborative, translational research. Eighteen university-hospital partnerships signed the data sharing agreement, and are working to facilitate the sharing and re-use of data across centres, for approved research purposes.
With support from the Directors of the NIHR Biomedical Research Centres (BRCs) within five of the largest partnerships, we established a clinical data collaboration, specifying a dataset and selecting an initial research question (Figure 1). The NIHR HIC team worked to extract data against this specification. With approval from an ethics committee, and from the information governance teams at each contributing centre, data was processed by one of the centres for standardisation and analysis.
Results
The specified dataset represented a longitudinal record for patients presenting with a suspected ACS, characterised by a request for a troponin test (Figure 1). The dataset included 156 data points, grouped into demographics, cardiovascular risk factor profile, emergency department attendance and inpatient episodes, blood tests, echocardiography and mortality. Data was extracted from the records of patients for whom a troponin test was requested between 2010 and 2017. A total of 257,948 records were standardised and analysed.
The collaboration has been successful, and an initial version of the combined dataset has been created. The size of the dataset has yielded new insights into the relationship between test results and outcomes, and publications are in preparation. An expanded dataset of over 800 data points has been agreed for the next phase of the collaboration, and three other centres have joined.
Figure 1. NIHR HIC dataset generation
Conclusion
It is perfectly feasible – in terms of governance and technology – to re-use routinely-collected data for collaborative, translational research in cardiovascular medicine. The resulting dataset will be large and complex enough to require big data tools and techniques, and will yield the kind of insights afforded only by big data in medicine.
Acknowledgement/Funding
Funded by NIHR Imperial Biomedical Research Centre (BRC) using NIHR Health Informatics Collaborative data service, supported by OUH, GSTT & UCLH BRCs
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Affiliation(s)
- A Kaura
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - J Davies
- Oxford University Hospitals NHS Trust, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - V Panoulas
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - B Glampson
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - A Mulla
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - K Woods
- Oxford University Hospitals NHS Trust, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - J Omigie
- Kings College Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - A D Shah
- University College London Hospitals NHS Foundation Trust, NIHR University College London Biomedical Research Centre, University College London, London, United Kingdom
| | - N Melikian
- Kings College Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - D P Francis
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - R Kharbanda
- Oxford University Hospitals NHS Trust, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - D Perera
- St Thomas' Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - A M Shah
- Kings College Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - R S Patel
- University College London Hospitals NHS Foundation Trust, NIHR University College London Biomedical Research Centre, University College London, London, United Kingdom
| | - J Mayet
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
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18
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Kaura A, Hartley A, Panoulas V, Glampson B, Davies J, Mulla A, Woods K, Francis DP, Koenig W, Shah AM, Kharbanda R, Perera D, Patel RS, Mayet J, Khamis R. 2231HsCRP predicts mortality beyond troponin in 102,337 patients with suspected acute coronary syndrome (CRP-RISK study). Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0127] [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: 11/12/2022] Open
Abstract
Abstract
Background
The incremental long-term prognostic value of high-sensitivity C-reactive protein (hsCRP) above troponin in a large real-world cohort of unselected patients presenting with suspected acute coronary syndromes (ACS) is unknown.
Purpose
We hypothesised that a mildly elevated hsCRP is associated with mortality risk in patients with suspected ACS, independent of troponin level.
Methods
We used the National Institute for Health Research Health Informatics Collaborative data of 257,948 patients who had a troponin measured at 5 cardiac centres. We excluded patients with clinically abnormal white cell counts and hsCRP >15 mg/L to try limiting the population to those without overt infections, malignancies or systemic inflammatory conditions that may confound our analyses. Patients were divided into four hsCRP groups (<2, 2–4.9, 5–9.9 and 10–15 mg/L) and the association between hsCRP levels and all-cause mortality assessed.
Results
There were 102,337 patients included in the analysis (hsCRP <2 mg/L (n=38,390), 2–4.9 mg/L (n=27,397), 5–9.9 mg/L (n=26,957) and 10–15 mg/L (n=9,593)). Figure 1A displays cumulative mortality per hsCRP group, revealing increasing mortality with each consecutive group. Figure 1B further stratifies the groups according to dichotomised peak troponin level as positive or negative. This shows the greatest mortality for patients in the highest hsCRP group who also had a positive troponin assay (36.0% at 3 years).
In Cox regression analysis with time-dependent covariates, even mildly raised hsCRP was an independent predictor of mortality over time, after adjusting for age, gender, haemoglobin, white cell count, platelet count, creatinine and troponin positivity. There was a positive and graded relationship between hsCRP level and mortality at baseline, which remained at 3-years (hazard ratio (95% CI) of 1.32 (1.18–1.48) for those with hsCRP 2.0–4.9mg/L, and 1.40 (1.26–1.57), and 2.00 (1.75–2.28) for those with hsCRP 5–9.9 mg/L and 10–15 mg/L, respectively.
We explored whether inclusion of hsCRP could better reclassify the population into at-risk mortality groups. The association with 30-day, 1-year and 3-year mortality was assessed using three different risk models (model 1: age, gender, haemoglobin, creatinine; model 2: model 1 plus troponin (positivity versus negativity); model 3: model 2 plus hsCRP groups. For cumulative mortality at each time point, each successive model was better able to discriminate risk than its precursor (p<0.0001); such that inclusion of troponin and hsCRP gave the most robust risk discrimination. Model 3 achieved an AUROC >0.8 at 30 days, 1-year and 3-year mortality, surpassing the use of troponin on its own.
Figure 1. Kaplan-Meier mortality curves
Conclusions
These multi-centre, real-world data from a large cohort of patients with suspected ACS identify hsCRP as a clinically meaningful prognostic marker in addition to troponin levels and point to its potential utility in selecting patients for novel treatments targeting inflammation.
Acknowledgement/Funding
Funded by NIHR Imperial Biomedical Research Centre (BRC) using NIHR Health Informatics Collaborative data service, supported by OUH, GSTT & UCLH BRCs
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Affiliation(s)
- A Kaura
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - A Hartley
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - V Panoulas
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - B Glampson
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - J Davies
- Oxford University Hospitals NHS Trust, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - A Mulla
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - K Woods
- Oxford University Hospitals NHS Trust, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - D P Francis
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - W Koenig
- Deutsches Herzzentrum Technische Universitat, German Centre for Cardiovascular Research, Munich, Germany
| | - A M Shah
- Kings College Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - R Kharbanda
- Oxford University Hospitals NHS Trust, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - D Perera
- St Thomas' Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - R S Patel
- University College London Hospitals NHS Foundation Trust, NIHR University College London Biomedical Research Centre, University College London, London, United Kingdom
| | - J Mayet
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - R Khamis
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
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19
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Kaura A, Panoulas V, Glampson B, Davies J, Mulla A, Woods K, Omigie J, Shah AD, Melikian N, Kharbanda R, Perera D, Shah AM, Patel RS, Francis DP, Mayet J. P3592Troponin level and mortality risk in an unselected population of over 250,000 patients (TROP-RISK study). Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0452] [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: 11/13/2022] Open
Abstract
Abstract
Background
Current evidence suggests a direct relationship between the magnitude of troponin elevation and mortality, albeit over a limited range of troponin levels, and clinicians generally work under the impression that higher troponins signify higher mortality in all age groups.
Purpose
The objective was to use big data to determine the relationship between the full spectrum of troponin level and mortality in patients in whom troponin testing has been performed for clinical purposes.
Methods
As part of the National Institute for Health Research Health Informatics Collaborative project, all troponin values measured during the study period (2010 to 2017) were assembled from five cardiovascular centres. Troponin concentrations were standardised as a multiple of each laboratory's 99th-percentile of the upper limit of normal (ULN). All patients were followed up until death or censoring on 1st April 2017. To model the relation between peak troponin level and all-cause mortality we used restricted cubic spline Cox regression analysis. Splines were adjusted for patient age, gender, haemoglobin, creatinine, white cell count and C-reactive protein.
Results
257,948 patients underwent troponin assessment. During a median follow-up of 1,198 (IQR, 514–1,866) days, there were 55,850 (21.7%) deaths. Using multivariable-adjusted restricted cubic spline Cox regression analysis, an inverted-U shaped relationship was observed between peak troponin level and mortality in all patients (Figure 1A). Among patients who were admitted to hospital, the recorded diagnostic code was acute coronary syndrome (ACS) in 14,468 patients and non-ACS in 120,049 patients.
The revascularisation rate within 3 months was 61.0% (n=8,820) in ACS versus 4.0% (n=4,793) in non-ACS patients. There was a very different rate of revascularisation across the spectrum of troponin. The rate was only 1.4% for troponins below 1 xULN, and 6.1% between 1 and 10 xULN. Beyond 10 xULN, rate of revascularisation rose rapidly to over 85% for greater than 10,000 xULN (Figure 1B). Stratifying patients by revascularisation, the restricted cubic spline Cox regression curve showed a progressive increase in mortality within both the revascularised and non-revascularised strata, even to very high peak troponin levels (Figure 1C). Overall, revascularisation was associated with lower hazard ratios across all troponin levels. A similar pattern was seen when patients were stratified by the presence or absence of ACS diagnosis.
Figure 1. Troponin level and mortality
Conclusions
An elevated troponin, even slightly above the ULN should be taken seriously. The inverted-U shaped mortality relationship with troponin occurred because patients with the highest troponin formed a different clinical subgroup who underwent different clinical management with a high revascularisation rate. These data on troponin level and mortality may help to inform clinical practice decisions and guide future risk stratification algorithms for patients with elevated troponin.
Acknowledgement/Funding
Funded by NIHR Imperial Biomedical Research Centre (BRC) using NIHR Health Informatics Collaborative data service, supported by OUH, GSTT & UCLH BRCs
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Affiliation(s)
- A Kaura
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - V Panoulas
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - B Glampson
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - J Davies
- Oxford University Hospitals NHS Trust, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - A Mulla
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - K Woods
- Oxford University Hospitals NHS Trust, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - J Omigie
- Kings College Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - A D Shah
- University College London Hospitals NHS Foundation Trust, NIHR University College London Biomedical Research Centre, University College London, London, United Kingdom
| | - N Melikian
- Kings College Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - R Kharbanda
- Oxford University Hospitals NHS Trust, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - D Perera
- St Thomas' Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - A M Shah
- Kings College Hospital, NIHR King's Biomedical Research Centre, King's College London, London, United Kingdom
| | - R S Patel
- University College London Hospitals NHS Foundation Trust, NIHR University College London Biomedical Research Centre, University College London, London, United Kingdom
| | - D P Francis
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
| | - J Mayet
- Imperial College Healthcare NHS Trust, NIHR Imperial Biomedical Research Centre, Imperial College London, London, United Kingdom
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20
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Shah AM, Hayes L, Weston P, Lowe A, Liu C, Watkins L, Greenwood R. WP1-6 The syndrome of the trephined. J Neurol Neurosurg Psychiatry 2019. [DOI: 10.1136/jnnp-2019-abn.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
ObjectivesSyndrome of the Trephined (SoT) or sinking skin flap syndrome is characterised by neurological deterioration occurring after a delay post-craniectomy, with or without a significant postural component, that may improve with cranioplasty. The symptoms and signs seen are heterogeneous and can be readily missed. With increasing numbers of patients surviving after decompressive craniectomies, and often a long delay before cranioplasty, we think it important that awareness of this potentially lethal but reversible condition is raised.DesignCase Series.SubjectsCases with suspected SoT were identified retrospectively from all admissions to a Level 1 Neurorehabilitation Unit over 2 years.MethodsCases were identified by their treating clinicians. Their clinical features are described, and outcomes after cranioplasty are discussed.ResultsFrom 36 patients admitted after craniectomy over 2 years, 4 patients with suspected SoT were identified, with a latency of 4–12 months post-injury. Late neurological deterioriation included reduced alertness and mobility, cognitive decline and headache. Two patients had a clear postural component to their symptoms. Coexisting hydrocephalus was sometimes seen, and complicated neurosurgical management. All cases improved after cranioplasty.ConclusionsSoT is an under-reported and under-recognised complication of craniectomy. It is a potentially reversible cause of significant late deterioration following craniectomy. Further research into the optimal timing for cranioplasty is needed.
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21
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Bromage DI, Santos CX, Shah AM. Developing potential biomarkers through bedside-to-bench translation. J Mol Cell Cardiol 2018; 133:209-210. [PMID: 30472252 DOI: 10.1016/j.yjmcc.2018.07.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 07/25/2018] [Indexed: 10/27/2022]
Affiliation(s)
- D I Bromage
- King's College London British Heart Foundation Centre of Excellence, London, UK
| | - C X Santos
- King's College London British Heart Foundation Centre of Excellence, London, UK
| | - A M Shah
- King's College London British Heart Foundation Centre of Excellence, London, UK.
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22
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Starr JF, Bandeira LC, Agarwal S, Shah AM, Nishiyama KK, Hu Y, McMahon DJ, Guo XE, Silverberg SJ, Rubin MR. Robust Trabecular Microstructure in Type 2 Diabetes Revealed by Individual Trabecula Segmentation Analysis of HR-pQCT Images. J Bone Miner Res 2018; 33:1665-1675. [PMID: 29750829 PMCID: PMC6119094 DOI: 10.1002/jbmr.3465] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 04/05/2018] [Accepted: 04/20/2018] [Indexed: 01/27/2023]
Abstract
Type 2 diabetes (T2D) patients have an increased fracture risk, which may be partly explained by compromised bone microarchitecture within the cortical bone compartment. Data on trabecular bone parameters in T2D are contradictory. By high-resolution peripheral quantitative computed tomography (HR-pQCT), trabecular microarchitecture is preserved, yet larger trabecular holes are detected in T2D by MRI and DXA-based trabecular bone scores are abnormal. To determine if there are differences in trabecular microstructure, connectivity, and alignment in postmenopausal women with T2D as compared with controls, we performed an individual trabecula segmentation (ITS) analysis on HR-pQCT scans of the distal radius and tibia in 92 women with (n = 42) and without (n = 50) T2D. Unadjusted analyses showed that T2D subjects had greater total trabecular bone volume, trabecular plate volume fraction, plate number density, plate junction density, and axial alignment at the radius and tibia, and increased plate tissue fraction, but decreased rod tissue fraction and rod length at the radius (p < 0.05 for all). After adjustments for clinical covariates, plate number density and plate junction density remained higher at the radius and tibia, whereas total trabecular bone volume was increased and trabecular rod length was decreased at the radius. These differences remained significant after adjustment for hip BMD and trabecular volumetric bone density. Notably, the increased plate-like ITS qualities were seen in those with T2D duration of <10 years, whereas ITS parameters in subjects with T2D duration ≥10 years did not differ from those of control subjects. In conclusion, postmenopausal women with early T2D had a greater plate-like and less rod-like trabecular network. This early advantage in trabecular plate quality does not explain the well-established increased fracture risk in these patients and does not persist in the later stage of T2D. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Jessica F Starr
- Department of Medicine, Metabolic Bone Diseases Unit, Division of Endocrinology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Leonardo C Bandeira
- Department of Medicine, Metabolic Bone Diseases Unit, Division of Endocrinology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Sanchita Agarwal
- Department of Medicine, Metabolic Bone Diseases Unit, Division of Endocrinology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Ankit M Shah
- Department of Medicine, Metabolic Bone Diseases Unit, Division of Endocrinology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Kyle K Nishiyama
- Department of Medicine, Metabolic Bone Diseases Unit, Division of Endocrinology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Yizhong Hu
- Bone Bioengineering Laboratory, Department of Biomedical Engineering, Columbia University, New York, NY, USA
| | - Donald J McMahon
- Department of Medicine, Metabolic Bone Diseases Unit, Division of Endocrinology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - X Edward Guo
- Bone Bioengineering Laboratory, Department of Biomedical Engineering, Columbia University, New York, NY, USA
| | - Shonni J Silverberg
- Department of Medicine, Metabolic Bone Diseases Unit, Division of Endocrinology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Mishaela R Rubin
- Department of Medicine, Metabolic Bone Diseases Unit, Division of Endocrinology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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Reimer Jensen AM, Skali H, Matsushita K, Konety S, Butler K, Kitzman DW, Solomon SD, Claggett B, Shah AM. P1532Contemporary assessment of left ventricular ejection fraction in older adults: the atherosclerosis risk in communities study. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p1532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- A M Reimer Jensen
- Brigham and Women's Hospital, Cardiovascular Medicine Division, Boston, United States of America
| | - H Skali
- Brigham and Women's Hospital, Cardiovascular Medicine Division, Boston, United States of America
| | - K Matsushita
- Johns Hopkins University of Baltimore, Bloomberg School of Public Health, Baltimore, United States of America
| | - S Konety
- University of Minnesota, Cardiovascular Division, Minneapolis, United States of America
| | - K Butler
- The University of Mississippi Medical Center, Department of Medicine–Geriatrics/Gerontology, Jackson, United States of America
| | - D W Kitzman
- Wake Forest University, Wake Forest School of Medicine, Winston-Salem, United States of America
| | - S D Solomon
- Brigham and Women's Hospital, Cardiovascular Medicine Division, Boston, United States of America
| | - B Claggett
- Brigham and Women's Hospital, Cardiovascular Medicine Division, Boston, United States of America
| | - A M Shah
- Brigham and Women's Hospital, Cardiovascular Medicine Division, Boston, United States of America
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Reimer Jensen AM, Ramalho SHR, Claggett B, Biering-Sorensen T, Shah AM. P5419Influence of HIV infection on cardiac structure and function in the era of HAART: a systematic review and meta-analysis of case-control studies. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p5419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- A M Reimer Jensen
- Brigham and Women's Hospital, Cardiovascular Medicine Division, Boston, United States of America
| | - S H R Ramalho
- University of Brasilia, Health Sciences and Technologies Post-Graduation Program, Brasilia, Brazil
| | - B Claggett
- Brigham and Women's Hospital, Cardiovascular Medicine Division, Boston, United States of America
| | - T Biering-Sorensen
- University of Copenhagen, Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - A M Shah
- Brigham and Women's Hospital, Cardiovascular Medicine Division, Boston, United States of America
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25
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Shah A, Rather MA, Hassan QP, Aga MA, Mushtaq S, Shah AM, Hussain A, Baba SA, Ahmad Z. Discovery of anti-microbial and anti-tubercular molecules from Fusarium solani: an endophyte of Glycyrrhiza glabra. J Appl Microbiol 2017; 122:1168-1176. [PMID: 28150900 DOI: 10.1111/jam.13410] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [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: 10/06/2016] [Revised: 12/09/2016] [Accepted: 01/24/2017] [Indexed: 12/30/2022]
Abstract
AIMS Glycyrrhiza glabra is a high-value medicinal plant thriving in biodiversity rich Kashmir Himalaya. The present study was designed to explore the fungal endophytes from G. glabra as a source of bioactive molecules. METHODS AND RESULTS The extracts prepared from the isolated endophytes were evaluated for anti-microbial activities using broth micro-dilution assay. The endophytic strain coded as A2 exhibiting promising anti-bacterial as well as anti-tuberculosis activity was identified as Fusarium solani by ITS-5.8S ribosomal gene sequencing technique. This strain was subjected to large-scale fermentation followed by isolation of its bioactive compounds using column chromatography. From the results of spectral data analysis and comparison with literature, the molecules were identified as 3,6,9-trihydroxy-7-methoxy-4,4-dimethyl-3,4-dihydro-1H-benzo[g]isochromene-5,10-dione (1), fusarubin (2), 3-O-methylfusarubin (3) and javanicin (4). Compound 1 is reported for the first time from this strain. All the four compounds inhibited the growth of various tested bacterial strains with MIC values in the range of <1 to 256 μg ml-1 . Fusarubin showed good activity against Mycobacterium tuberculosis strain H37Rv with MIC value of 8 μg ml-1 , whereas compounds 1, 3 and 4 exhibited moderate activity with MIC values of 256, 64, 32 μg ml-1 , respectively. CONCLUSIONS To the best of our knowledge, this is the first study that reports significant anti-tuberculosis potential of bioactive molecules from endophytic F. solani evaluated against the virulent strain of M. tuberculosis. This study sets background towards their synthetic intervention for activity enhancement experiments in anti-microbial drug discovery programme. SIGNIFICANCE AND IMPACT OF THE STUDY Due to the chemoprofile variation of same endophyte with respect to source plant and ecoregions, further studies are required to explore endophytes of medicinal plants of all unusual biodiversity rich ecoregions for important and or novel bioactive molecules.
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Affiliation(s)
- A Shah
- Microbial Biotechnology Division, CSIR-Indian Institute of Integrative Medicine, Sanatnagar, Srinagar, Jammu & Kashmir, India.,Academy of Scientific and Innovative Research, CSIR-Indian Institute of Integrative Medicine, Canal Road, Jammu Tawi, India
| | - M A Rather
- Clinical Microbiology and PK-PD Division, CSIR-Indian Institute of Integrative Medicine, Sanatnagar, Srinagar, Jammu & Kashmir, India.,Department of Biochemistry, University of Kashmir, Srinagar, India
| | - Q P Hassan
- Microbial Biotechnology Division, CSIR-Indian Institute of Integrative Medicine, Sanatnagar, Srinagar, Jammu & Kashmir, India.,Academy of Scientific and Innovative Research, CSIR-Indian Institute of Integrative Medicine, Canal Road, Jammu Tawi, India
| | - M A Aga
- Bioorganic Chemistry Division, CSIR-Indian Institute of Integrative Medicine, Sanatnagar, Srinagar, Jammu & Kashmir, India
| | - S Mushtaq
- Microbial Biotechnology Division, CSIR-Indian Institute of Integrative Medicine, Sanatnagar, Srinagar, Jammu & Kashmir, India
| | - A M Shah
- Microbial Biotechnology Division, CSIR-Indian Institute of Integrative Medicine, Sanatnagar, Srinagar, Jammu & Kashmir, India.,Academy of Scientific and Innovative Research, CSIR-Indian Institute of Integrative Medicine, Canal Road, Jammu Tawi, India
| | - A Hussain
- Microbial Biotechnology Division, CSIR-Indian Institute of Integrative Medicine, Sanatnagar, Srinagar, Jammu & Kashmir, India.,Academy of Scientific and Innovative Research, CSIR-Indian Institute of Integrative Medicine, Canal Road, Jammu Tawi, India
| | - S A Baba
- Academy of Scientific and Innovative Research, CSIR-Indian Institute of Integrative Medicine, Canal Road, Jammu Tawi, India
| | - Z Ahmad
- Academy of Scientific and Innovative Research, CSIR-Indian Institute of Integrative Medicine, Canal Road, Jammu Tawi, India.,Clinical Microbiology and PK-PD Division, CSIR-Indian Institute of Integrative Medicine, Sanatnagar, Srinagar, Jammu & Kashmir, India
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26
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Patel MH, Patel AM, Shah AM. Seroprevalence of HIV, HBV, HCV & RPR among cornea donor in the regional institute of ophthalmology. ACTA ACUST UNITED AC 2017. [DOI: 10.4103/2347-6486.240223] [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: 11/04/2022]
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27
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Jayavelu AK, Müller JP, Bauer R, Böhmer SA, Lässig J, Cerny-Reiterer S, Sperr WR, Valent P, Maurer B, Moriggl R, Schröder K, Shah AM, Fischer M, Scholl S, Barth J, Oellerich T, Berg T, Serve H, Frey S, Fischer T, Heidel FH, Böhmer FD. NOX4-driven ROS formation mediates PTP inactivation and cell transformation in FLT3ITD-positive AML cells. Leukemia 2015; 30:473-83. [DOI: 10.1038/leu.2015.234] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 08/04/2015] [Accepted: 08/14/2015] [Indexed: 12/21/2022]
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28
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Trevelin SC, Santos CX, Zhang M, Sag C, Cunha TM, Alves-Filho JC, Lopes LR, Cunha FQ, Ivetic A, Shah AM. P600Endothelial Nox2 is protective against sepsis-induced severe hypotension and systemic inflammatory response. Cardiovasc Res 2014. [DOI: 10.1093/cvr/cvu098.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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29
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Cuello F, Shankar-Hari M, Mayr U, Yin X, Marshall M, Willeit P, Langley SR, Terblanche M, Shah AM, Mayr M. P258Redox-state of pentraxin 3 as a novel biomarker for resolution of inflammation and survival in sepsis. Cardiovasc Res 2014. [DOI: 10.1093/cvr/cvu082.189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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30
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Sukumar P, Viswambharan H, Imrie H, Cubbon R, Yuldasheva N, Gage M, Galloway S, Skromna A, Kandavelu P, Santos CX, Gatenby K, Smith J, Beech DJ, Wheatcroft SB, Channon KM, Shah AM, Kearney MT. 195 TARGETING NOX2 NADPH OXIDASE IN INSULIN RESISTANCE RELATED ENDOTHELIAL DYSFUNCTION. Heart 2013. [DOI: 10.1136/heartjnl-2013-304019.195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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31
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Sukumar P, Viswambharan H, Imrie H, Cubbon RM, Yuldasheva N, Gage M, Galloway S, Skromna A, Kandavelu P, Santos CX, Gatenby VK, Smith J, Beech DJ, Wheatcroft SB, Channon KM, Shah AM, Kearney MT. E: TARGETING NOX2 NADPH OXIDASE IN INSULIN RESISTANCE RELATED ENDOTHELIAL DYSFUNCTION. Heart 2013. [DOI: 10.1136/heartjnl-2013-304019.278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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32
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Brayson D, Shah AM, Shanahan C. 218 A TRANSGENIC MODEL OF PRELAMIN A ACCUMULATION LEADS TO CARDIAC DYSFUNCTION IN MICE. Heart 2013. [DOI: 10.1136/heartjnl-2013-304019.218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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33
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Al-Salahi OSA, Zaki AH, Chan KL, Shah AM, Al-Hassan F, Abdullah WZ, Yusoff NM. <i>In vitro</i> Anti-proliferative and Apoptotic Activities of <i>Eurycoma longifolia</i> Jack (Simaroubaceae) on HL-60 Cell Line. TROP J PHARM RES 2013. [DOI: 10.4314/tjpr.v12i1.10] [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: 11/17/2022] Open
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34
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Yu M, Bardia A, Wittner BS, Stott SL, Smas ME, Ting DT, Isakoff SJ, Ciciliano JC, Wells MN, Shah AM, Concannon KF, Sequist LV, Brachtel E, Sgroi D, Baselga J, Ramaswamy S, Toner M, Haber DA, Maheswaran S. Abstract P2-01-14: circulating tumor cells in breast cancer exhibit dynamic changes in epithelial and mesenchymal cell composition. Cancer Res 2012. [DOI: 10.1158/0008-5472.sabcs12-p2-01-14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Epithelial to mesenchymal transition (EMT) has been postulated to contribute to the migration and dissemination of cancer cells, but supporting histopathological evidence is limited. We used a microfluidic device to isolate circulating tumor cells (CTCs), combined with multiplex fluorescent RNA-in-situ hybridization (ISH) and RNA sequencing, to quantify and characterize EMT in breast cancer cells within the bloodstream. Whereas only rare (0.1–10%) cells in the primary tumor expressed both mesenchymal and epithelial markers, such biphenotypic as well as purely mesenchymal cells were enriched among CTCs, across all histological subtypes of breast cancer. Analysis of the therapy response in 8 patients suggest an association of mesenchymal CTCs with disease progression. In an index patient followed longitudinally, fluctuation in epithelial and mesenchymal states was observed as a function of initial response and subsequent resistance to therapy. Mesenchymal markers were predominant in clusters of tumor cells, many of which had adherent platelets. Finally, RNA sequencing of mesenchymal CTC clusters identified TGF-B and other EMT-related signatures, which were absent from more epithelial CTCs. FOXC1, a known regulator of EMT, was abundantly expressed in mesenchymal CTCs and was detectable within localized regions of the primary breast tumor. Together, these data support a role for EMT in the blood-borne dissemination of breast cancer and point to the dynamic nature of this cell fate change.
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-01-14.
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Affiliation(s)
- M Yu
- Massachusetts General Hospital, Harvard Medical School; Howard Hughes Medical Institute
| | - A Bardia
- Massachusetts General Hospital, Harvard Medical School; Howard Hughes Medical Institute
| | - BS Wittner
- Massachusetts General Hospital, Harvard Medical School; Howard Hughes Medical Institute
| | - SL Stott
- Massachusetts General Hospital, Harvard Medical School; Howard Hughes Medical Institute
| | - ME Smas
- Massachusetts General Hospital, Harvard Medical School; Howard Hughes Medical Institute
| | - DT Ting
- Massachusetts General Hospital, Harvard Medical School; Howard Hughes Medical Institute
| | - SJ Isakoff
- Massachusetts General Hospital, Harvard Medical School; Howard Hughes Medical Institute
| | - JC Ciciliano
- Massachusetts General Hospital, Harvard Medical School; Howard Hughes Medical Institute
| | - MN Wells
- Massachusetts General Hospital, Harvard Medical School; Howard Hughes Medical Institute
| | - AM Shah
- Massachusetts General Hospital, Harvard Medical School; Howard Hughes Medical Institute
| | - KF Concannon
- Massachusetts General Hospital, Harvard Medical School; Howard Hughes Medical Institute
| | - LV Sequist
- Massachusetts General Hospital, Harvard Medical School; Howard Hughes Medical Institute
| | - E Brachtel
- Massachusetts General Hospital, Harvard Medical School; Howard Hughes Medical Institute
| | - D Sgroi
- Massachusetts General Hospital, Harvard Medical School; Howard Hughes Medical Institute
| | - J Baselga
- Massachusetts General Hospital, Harvard Medical School; Howard Hughes Medical Institute
| | - S Ramaswamy
- Massachusetts General Hospital, Harvard Medical School; Howard Hughes Medical Institute
| | - M Toner
- Massachusetts General Hospital, Harvard Medical School; Howard Hughes Medical Institute
| | - DA Haber
- Massachusetts General Hospital, Harvard Medical School; Howard Hughes Medical Institute
| | - S Maheswaran
- Massachusetts General Hospital, Harvard Medical School; Howard Hughes Medical Institute
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Sukumar P, Viswambharan H, Imrie H, Cubbon RM, Yuldasheva N, Gage M, Galloway S, Skromna A, Smith J, Gatenby K, Beech DJ, Wheatcroft SB, Channon KM, Shah AM, Kearney MT. 105 NOX2 NADPH—oxidase a novel target to prevent insulin resistance related endothelial cell dysfunction. Heart 2012. [DOI: 10.1136/heartjnl-2012-301877b.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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36
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Shabeeh H, Melikian N, Dworakowski R, Casadei B, Chowienczyk P, Shah AM. 106 Role of neuronal vs endothelial nitric oxide synthase in the coronary blood flow response to pacing. Heart 2012. [DOI: 10.1136/heartjnl-2012-301877b.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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37
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Shah AM, Malhotra A, Patel B, Spira R, DePasquale JR, Baddoura W. Acute diverticulitis in the young: a 5-year retrospective study of risk factors, clinical presentation and complications. Colorectal Dis 2011; 13:1158-61. [PMID: 20646011 DOI: 10.1111/j.1463-1318.2010.02372.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [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: 02/08/2023]
Abstract
AIM Acute diverticulitis in the young is considered to follow an aggressive course, but there is a paucity of data on factors that could determine a complicated course. METHOD All patients of 18-40 years of age diagnosed with acute diverticulitis from 1 January 2003 to 31 December 2008 were identified. Patients were included if they had computed tomography (CT) evidence of acute diverticulitis and at least one clinical feature. Demographics, body mass index, presenting symptoms/signs, CT location of diverticulitis and complications were noted. Fisher's exact test and a multivariate logistic regression analysis model were used to detect possible associations between clinical variables and complications. RESULTS There were 76 patients, of whom 23 (30.2%) had fever (>38°C) and 52 (68.4%) had leucocytosis (≥11000/mm(3)). The majority [48 (63.1%)] were obese. A total of 29 (38.1%) patients had complications, with perforation [18 (62%)] being the most common. Twelve (15.7%) required surgical or radiological intervention. Fever of ≥38.0°C and a body mass index of ≥25 were independently associated with complications (P=0.04 and P=0.03, respectively). CONCLUSION Fever (≥38°C) at presentation and a body mass index of ≥25 may help to predict a complicated course of acute diverticulitis in patients under 40 years of age.
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Affiliation(s)
- A M Shah
- Department of Internal Medicine, St. Joseph's Regional Medical Center, Paterson, New Jersey 07503, USA.
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38
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Abstract
Despite recent advances in medical treatment, pulmonary arterial hypertension (PAH) continues to be associated with high morbidity and mortality. While the diagnosis is established via a right heart catheterisation, current non-invasive measures of disease severity and response to treatment used in clinical practice are the 6-min walk distance and the World Health Organization functional class. Although both parameters correlate with disease severity and prognosis, they have significant limitations. A major shortcoming in assessing PAH is lack of standardised, non-invasive, objective parameters that function as biomarkers to help assess the severity and prognosis of disease and to follow patients' response to treatment. In this article, we will review current knowledge on potential biomarkers associated with diagnosis, prognosis and response to treatment of PAH. Most biomarkers are either being evaluated for potential use in clinical practice, or being used as research tools.
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Affiliation(s)
- S Rafeq
- Pulmonary, Critical Care and Sleep Division, Tufts University School of Medicine, Tufts Medical Center, Boston, MA 02111, USA
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39
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Ameer OZ, Salman IM, Siddiqui MJA, Yam MF, Sriramaneni RN, Sadikun A, Ismail Z, Shah AM, Asmawi MZ. Cardiovascular activity of the n-butanol fraction of the methanol extract of Loranthus ferrugineus Roxb. ACTA ACUST UNITED AC 2010; 43:186-94. [PMID: 20084331 DOI: 10.1590/s0100-879x2010005000002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Accepted: 11/13/2009] [Indexed: 11/21/2022]
Abstract
We investigated the vascular responses and the blood pressure reducing effects of different fractions obtained from the methanol extract of Loranthus ferrugineus Roxb. (F. Loranthaceae). By means of solvent-solvent extraction, L. ferrugineus methanol extract (LFME) was successively fractionated with chloroform, ethyl acetate and n-butanol. The ability of these LFME fractions to relax vascular smooth muscle against phenylephrine (PE)- and KCl-induced contractions in isolated rat aortic rings was determined. In another set of experiments, LFME fractions were tested for blood pressure lowering activity in anesthetized adult male Sprague-Dawley rats (250-300 g, 14-18 weeks). The n-butanol fraction of LFME (NBF-LFME) produced a significant concentration-dependent inhibition of PE- and KCl-induced aortic ring contractions compared to other fractions. Moreover, NBF-LFME had a significantly higher relaxant effect against PE- than against high K+-induced contractions. In anesthetized Sprague-Dawley rats, NBF-LFME significantly lowered blood pressure in a dose-dependent manner and with a relatively longer duration of action compared to the other fractions. HPLC, UV and IR spectra suggested the presence of terpenoid constituents in both LFME and NBF-LFME. Accordingly, we conclude that NBF-LFME is the most potent fraction producing a concentration-dependent relaxation in vascular smooth muscle in vitro and a dose-dependent blood pressure lowering activity in vivo. The cardiovascular effects of NBF-LFME are most likely attributable to its terpenoid content.
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Affiliation(s)
- O Z Ameer
- Department of Physiology and Pharmacology, Universiti Sains Malaysia, Penang, Malaysia.
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40
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Fabre JW, Grehan A, Whitehorne M, Sawyer GJ, Dong X, Salehi S, Eckley L, Zhang X, Seddon M, Shah AM, Davenport M, Rela M. Hydrodynamic gene delivery to the pig liver via an isolated segment of the inferior vena cava. Gene Ther 2007; 15:452-62. [PMID: 18004400 DOI: 10.1038/sj.gt.3303079] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Hydrodynamic gene delivery is an attractive option for non-viral liver gene therapy, but requires evaluation of efficacy, safety and clinically applicable techniques in large animal models. We have evaluated retrograde delivery of DNA to the whole liver via the isolated segment of inferior vena cava (IVC) draining the hepatic veins. Pigs (18-20 kg weight) were given the pGL3 plasmid via two programmable syringe pumps in parallel. Volumes corresponding to 2% of body weight (360-400 ml) were delivered at 100 ml s(-1) via a Y connector. The IVC segment pressure, portal venous pressure, arterial pressure, electrocardiogram (ECG) and pulse were monitored. Concurrent studies were performed in rats for interspecies comparisons. The hydrodynamic procedure generated intrahepatic vascular pressures of 101-126 mm Hg, which is approximately 4 times higher than in rodents, but levels of gene delivery were approximately 200-fold lower. Suprahepatic IVC clamping caused a fall in arterial pressure, with the development of ECG signs of myocardial ischaemia, but these abnormalities resolved rapidly. The IVC segment approach is a clinically acceptable approach to liver gene therapy. However, it is less effective in pigs than in rodents, possibly because of larger liver size or a less compliant connective tissue framework.
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Affiliation(s)
- J W Fabre
- Department of Hepatology and Transplantation, King's College London School of Medicine, James Black Centre, London, UK.
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Sawyer GJ, Dong X, Whitehorne M, Grehan A, Seddon M, Shah AM, Zhang X, Fabre JW. Cardiovascular function following acute volume overload for hydrodynamic gene delivery to the liver. Gene Ther 2007; 14:1208-17. [PMID: 17568768 DOI: 10.1038/sj.gt.3302976] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [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: 11/09/2022]
Abstract
Hydrodynamic gene delivery to the liver is a valuable experimental tool and an attractive option for nonviral gene therapy of liver disease. However, little attention has been paid to the major obstacle to clinical application: acute volume overload of the cardiovascular system. We delivered volumes of DNA solution (pGL3 plasmid) corresponding to 1, 2, 4, 6 and 8% of the body weight at 100 ml/min to the inferior vena cava (IVC) of DA strain rats. Central venous pressure (CVP), arterial pressure, pulse and electrocardiogram (ECG) were continuously recorded for subsequent analysis. Each volume produced a characteristic response, but all (including the 1% volume) caused severe falls in blood pressure and pulse within 1-2 s of the infusion, with ectopic beats and widening of the QRS complex in the ECG. The response to volumes of 4% and higher suggested that the liver acted as a volume sink, mitigating the immediate effects of volume overload. The 6 and 8% volumes caused profound and protracted falls in blood pressure and pulse, with a multitude of severe electrical abnormalities in the heart, including electromechanical dissociation. Vagal blockade with atropine, and the use of Ringer's solution to prevent electrolyte disturbances, did not ameliorate this picture.
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Affiliation(s)
- G J Sawyer
- Department of Hepatology and Transplantation, King's College London School of Medicine, The Rayne Institute, and Department of Clinical Perfusion Sciences, King's College Hospital, London, UK
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Abstract
Increased oxidative stress plays an important role in the pathophysiology of many diseases such as atherosclerosis, diabetes mellitus, myocardial infarction and heart failure. In addition to the well-known damaging effects of oxygen-free radicals, ROS (reactive oxygen species) also have signalling roles, acting as second messengers that modulate the activity of diverse intracellular signalling pathways and transcription factors, thereby inducing changes in cell phenotype. NADPH oxidases appear to be especially important sources of ROS involved in redox signalling. Seven NADPH oxidase isoforms, known as Noxs (NAPDH oxidases), are expressed in a cell- and tissue-specific fashion. These oxidases are thought to subserve distinct functions as a result of their tightly regulated activation (e.g. by neurohormonal and growth factors and mechanical stimuli) and their specific coupling with distinct downstream signalling pathways. In the present paper, we review the structure and mechanisms of activation of NADPH oxidases and consider their involvement in redox signalling, focusing mainly on the cardiovascular system.
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Affiliation(s)
- R Dworakowski
- Cardiovascular Division, Department of Cardiology, King's College London School of Medicine, Bessemer Road, London SE5 9PJ, UK
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Williams IL, Chowienczyk PJ, Wheatcroft SB, Patel A, Sherwood R, Momin A, Shah AM, Kearney MT. Effect of fat distribution on endothelial-dependent and endothelial-independent vasodilatation in healthy humans. Diabetes Obes Metab 2006; 8:296-301. [PMID: 16634989 DOI: 10.1111/j.1463-1326.2005.00505.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [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] [Indexed: 11/26/2022]
Abstract
AIM The present study aims to explore the relationship between inflammatory cytokines, plasma lipids, insulin, blood pressure (BP), total adiposity/markers of fat distribution and endothelial function in healthy people across a wide range of body fatness. METHODS Seventy-three healthy people (44 women; age range: 24-64 years) with body mass index (BMI) range of 18.6-73.1 kg/m2 were recruited. All participants underwent assessment of conduit artery endothelial-dependent vasodilatation by using flow-mediated vasodilatation (FMD) of the brachial artery and endothelial-independent vasodilatation to sublingual GTN. They had blood taken for measurement of plasma markers of glucose homeostasis (fasting insulin and glucose), systemic inflammation (interleukin-6 (IL-6), C-reactive protein (CRP) and tumour necrosis factor-alpha receptor 2 (TNF-alpha R2)) and lipids (low-density lipoprotein (LDL), high-density lipoprotein (HDL) and triglycerides). Morphometric assessment (waist circumference, BMI and waist-to-hip ratio (WHR)) and systolic and diastolic arterial pressure were also measured. RESULTS Markers of total body fat/fat distribution (waist circumference, BMI and WHR), inflammation (IL-6, CRP and TNF-alpha R2), metabolism (fasting insulin, HDL, LDL and triglycerides) and BP (systolic and diastolic) correlated with FMD. Among these measurements, WHR was the only independent predictor of FMD (r2 = 0.30; p = 0.0001). CONCLUSIONS WHR is an important marker of endothelial dysfunction in healthy people across a wide range of body fatness.
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Affiliation(s)
- I L Williams
- Cardiovascular Division, King's College, London, UK
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Abstract
A case of asymptomatic, newly diagnosed, moderate mitral stenosis in a 27 year old pregnant woman is described. A conservative management strategy with regular cardiac assessment was adopted and the patient remained well. Routine transthoracic echocardiography at 36 weeks' gestation showed the development of severe pulmonary hypertension with right ventricular pressure overload, which was successfully treated with oral diuretics resulting in rapid normalisation of pulmonary pressure. Mitral stenosis in pregnancy and its management in pregnancy are briefly discussed.
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Affiliation(s)
- A Siva
- Department of Cardiology, Kings College Hospital, London SE5 9PJ, UK.
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Kearney MT, Fox KAA, Lee AJ, Brooksby WP, Shah AM, Flapan A, Prescott RJ, Andrews R, Batin PD, Eckberg DL, Gall N, Zaman AG, Lindsay HS, Nolan J. Predicting sudden death in patients with mild to moderate chronic heart failure. Heart 2004; 90:1137-43. [PMID: 15367507 PMCID: PMC1768484 DOI: 10.1136/hrt.2003.021733] [Citation(s) in RCA: 41] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES To explore the relation between non-invasive measures of cardiac function and sudden cardiac death, as well as the development and utility of an index integrating these variables to identify patients at increased risk of this mode of death. DESIGN UK-HEART (United Kingdom-heart failure evaluation and assessment of risk trial) was a prospective study conducted between December 1993 and April 2000. The study was specifically designed to identify non-invasive markers of death and mode of death among patients with chronic heart failure. SETTING 8 UK general hospitals. MAIN OUTCOME MEASURES Death and mode of death. RESULTS 553 patients aged a mean (SD) of 63 (10) years, in New York Heart Association functional class 2.3 (0.02), recruited prospectively. After 2365 patient-years' follow up, 201 patients had died (67 suddenly). Predictors of sudden death were greater cardiothoracic ratio, QRS dispersion, QT dispersion corrected for rate (QTc) across leads V1-V6 on the 12 lead ECG, and the presence of non-sustained ventricular tachycardia. The hazard ratio and 95% confidence intervals (CI) of sudden death for a 10% increase in cardiothoracic ratio was 1.43 (95% CI 1.20 to 1.71), for a 10% increase in QRS dispersion 1.11 (95% CI 1.04 to 1.19), for the presence of non-sustained ventricular tachycardia 2.03 (95% CI 1.27 to 3.25), and for a 10% increase in QTc dispersion across leads V1-V6 1.03 (95% CI 1.00 to 1.07) (all p < 0.04). An index derived from these four factors performed well in identifying patients specifically at increased risk of sudden death. CONCLUSIONS Results show that an index derived from three widely available non-invasive investigations has the potential to identify ambulant patients with chronic heart failure at increased risk of sudden death. This predictive tool could be used to target more sophisticated investigations or interventions aimed at preventing sudden death.
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Affiliation(s)
- M T Kearney
- Department of Cardiology, King's College, Bessemer Road, London SE5 9PJ, UK.
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Abstract
BACKGROUND Although breathlessness is common in chronic heart failure (CHF), the role of inspiratory muscle dysfunction remains unclear. We hypothesised that inspiratory muscle endurance, expressed as a function of endurance time (Tlim) adjusted for inspiratory muscle load and inspiratory muscle capacity, would be reduced in CHF. METHODS Endurance was measured in 10 healthy controls and 10 patients with CHF using threshold loading at 40% maximal oesophageal pressure (Poes(max)). Oesophageal pressure-time product (PTPoes per cycle) and Poes(max) were used as indices of inspiratory muscle load and capacity, respectively. RESULTS Although Poes(max) was slightly less in the CHF group (-117.7 (23.6) v -100.0 (18.3) cm H(2)O; 95% CI -37.5 to 2.2 cm H(2)O, p = 0.1), Tlim was greatly reduced (1800 v 306 (190) s; 95% CI 1368 to 1620 s, p<0.0001) and the observed PTPoes per cycle/Poes(max) was increased (0.13 (0.05) v 0.21 (0.04); 95% CI -0.11 to -0.03, p = 0.001). Most of this increased inspiratory muscle load was due to a maladaptive breathing pattern, with a reduction in expiratory time (3.0 (5.8) v 1.1 (0.3) s; 95% CI 0.3 to 3.5 s, p = 0.03) accompanied by an increased inspiratory time relative to total respiratory cycle (Ti/Ttot) (0.43 (0.14) v 0.62 (0.07); 95% CI -0.3 to -0.1, p = 0.001). However, log Tlim, which incorporates the higher inspiratory muscle load to capacity ratio caused by this altered breathing pattern, was >/=85% predicted in seven of 10 patients. CONCLUSIONS Although a marked reduction in endurance time was observed in CHF, much of this reduction was explained by the increased inspiratory muscle load to capacity ratio, suggesting that the major contributor to task failure was a maladaptive breathing pattern rather than impaired inspiratory muscle endurance.
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Affiliation(s)
- N Hart
- Respiratory Muscle Laboratory, Royal Brompton Hospital, London, UK.
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Shah AM, Singhal P, Chhajed PN, Athavale A, Krishnan R, Shah AC. Bronchoscopic closure of bronchopleural fistula using gelfoam. J Assoc Physicians India 2004; 52:508-9. [PMID: 15645968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Management of a persistent bronchopleural fistula (BPF) can be a therapeutic challenge. The etiological factors responsible for BPF include pulmonary tuberculosis, post-thoracic resection surgeries, trauma, malignancy, necrotising infections and rupture of lung abscess. The immediate management of BPF is drainage of the pleural cavity with insertion of an intercostal drainage tube. Patients with BPF may also require surgical intervention in the form of a wedge resection or lobectomy or muscle flap surgery. We report a case of a peripheral BPF secondary to a bacterial infection, which was successfully managed by the instillation of gelfoam via flexible bronchoscopy.
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Affiliation(s)
- A M Shah
- Department of Respiratory Diseases, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai
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Affiliation(s)
- A M Shah
- Department of Cardiology, Guy's King's & St Thomas's School of Medicine, King's College London, UK.
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