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Bansal S, Fleming T, Canez J, Maine GN, Bharat A, Walia R, Tokman S, Smith MA, Tiffany B, Bremner RM, Mohanakumar T. Immune responses of lung transplant recipients against SARS-CoV-2 and common respiratory coronaviruses: Evidence for pre-existing cross-reactive immunity. Transpl Immunol 2023; 81:101940. [PMID: 37866672 PMCID: PMC11019873 DOI: 10.1016/j.trim.2023.101940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/09/2023] [Accepted: 10/19/2023] [Indexed: 10/24/2023]
Abstract
Humoral and cellular immune responses to SARS-CoV-2 and other coronaviruses in lung transplant recipients are unknown. We measured antibodies and T cell responses against the SARS-CoV-2 spike S2 and nucleocapsid antigens and spike antigens from common respiratory coronaviruses (229E, NL63, OC43, and HKU1) after vaccination or infection of LTxRs. 148 LTxRs from single center were included in this study: 98 after vaccination and 50 following SARS-CoV-2 infection. Antibodies were quantified by enzyme-linked immunosorbent assay. The frequency of T cells secreting IL2, IL4, IL10, IL17, TNFα, and IFNγ were enumerated by enzyme-linked immunospot assay. Our results have shown the development of antibodies to SARS-CoV-2 spike protein in infected LTxRs (39/50) and vaccinated LTxRs (52/98). Vaccinated LTxRs had higher number of T cells producing TNFα but less cells producing IFNγ than infected LTxRs in response to the nucleocapsid antigen and other coronavirus spike antigens. We didn't find correlation between the development of antibodies and cellular immune responses against the SARS-CoV-2 spike protein after vaccination. Instead, LTxRs have pre-existing cellular immunity to common respiratory coronaviruses, leading to cross-reactive immunity against SARS-CoV-2 which likely will provide protection against SARS-Cov-2 infection.
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Affiliation(s)
- Sandhya Bansal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Timothy Fleming
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Jesse Canez
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Gabriel N Maine
- Department of Pathology and Laboratory Medicine, Royal Oak, Beaumont Health, MI, USA
| | | | - Rajat Walia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Sofya Tokman
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Michael A Smith
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Brian Tiffany
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - T Mohanakumar
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.
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Self WH, Shotwell MS, Gibbs KW, de Wit M, Files DC, Harkins M, Hudock KM, Merck LH, Moskowitz A, Apodaca KD, Barksdale A, Safdar B, Javaheri A, Sturek JM, Schrager H, Iovine N, Tiffany B, Douglas IS, Levitt J, Busse LW, Ginde AA, Brown SM, Hager DN, Boyle K, Duggal A, Khan A, Lanspa M, Chen P, Puskarich M, Vonderhaar D, Venkateshaiah L, Gentile N, Rosenberg Y, Troendle J, Bistran-Hall AJ, DeClercq J, Lavieri R, Joly MM, Orr M, Pulley J, Rice TW, Schildcrout JS, Semler MW, Wang L, Bernard GR, Collins SP. Renin-Angiotensin System Modulation With Synthetic Angiotensin (1-7) and Angiotensin II Type 1 Receptor-Biased Ligand in Adults With COVID-19: Two Randomized Clinical Trials. JAMA 2023; 329:1170-1182. [PMID: 37039791 PMCID: PMC10091180 DOI: 10.1001/jama.2023.3546] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/24/2023] [Indexed: 04/12/2023]
Abstract
Importance Preclinical models suggest dysregulation of the renin-angiotensin system (RAS) caused by SARS-CoV-2 infection may increase the relative activity of angiotensin II compared with angiotensin (1-7) and may be an important contributor to COVID-19 pathophysiology. Objective To evaluate the efficacy and safety of RAS modulation using 2 investigational RAS agents, TXA-127 (synthetic angiotensin [1-7]) and TRV-027 (an angiotensin II type 1 receptor-biased ligand), that are hypothesized to potentiate the action of angiotensin (1-7) and mitigate the action of the angiotensin II. Design, Setting, and Participants Two randomized clinical trials including adults hospitalized with acute COVID-19 and new-onset hypoxemia were conducted at 35 sites in the US between July 22, 2021, and April 20, 2022; last follow-up visit: July 26, 2022. Interventions A 0.5-mg/kg intravenous infusion of TXA-127 once daily for 5 days or placebo. A 12-mg/h continuous intravenous infusion of TRV-027 for 5 days or placebo. Main Outcomes and Measures The primary outcome was oxygen-free days, an ordinal outcome that classifies a patient's status at day 28 based on mortality and duration of supplemental oxygen use; an adjusted odds ratio (OR) greater than 1.0 indicated superiority of the RAS agent vs placebo. A key secondary outcome was 28-day all-cause mortality. Safety outcomes included allergic reaction, new kidney replacement therapy, and hypotension. Results Both trials met prespecified early stopping criteria for a low probability of efficacy. Of 343 patients in the TXA-127 trial (226 [65.9%] aged 31-64 years, 200 [58.3%] men, 225 [65.6%] White, and 274 [79.9%] not Hispanic), 170 received TXA-127 and 173 received placebo. Of 290 patients in the TRV-027 trial (199 [68.6%] aged 31-64 years, 168 [57.9%] men, 195 [67.2%] White, and 225 [77.6%] not Hispanic), 145 received TRV-027 and 145 received placebo. Compared with placebo, both TXA-127 (unadjusted mean difference, -2.3 [95% CrI, -4.8 to 0.2]; adjusted OR, 0.88 [95% CrI, 0.59 to 1.30]) and TRV-027 (unadjusted mean difference, -2.4 [95% CrI, -5.1 to 0.3]; adjusted OR, 0.74 [95% CrI, 0.48 to 1.13]) resulted in no difference in oxygen-free days. In the TXA-127 trial, 28-day all-cause mortality occurred in 22 of 163 patients (13.5%) in the TXA-127 group vs 22 of 166 patients (13.3%) in the placebo group (adjusted OR, 0.83 [95% CrI, 0.41 to 1.66]). In the TRV-027 trial, 28-day all-cause mortality occurred in 29 of 141 patients (20.6%) in the TRV-027 group vs 18 of 140 patients (12.9%) in the placebo group (adjusted OR, 1.52 [95% CrI, 0.75 to 3.08]). The frequency of the safety outcomes was similar with either TXA-127 or TRV-027 vs placebo. Conclusions and Relevance In adults with severe COVID-19, RAS modulation (TXA-127 or TRV-027) did not improve oxygen-free days vs placebo. These results do not support the hypotheses that pharmacological interventions that selectively block the angiotensin II type 1 receptor or increase angiotensin (1-7) improve outcomes for patients with severe COVID-19. Trial Registration ClinicalTrials.gov Identifier: NCT04924660.
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Affiliation(s)
- Wesley H. Self
- Vanderbilt Institute for Clinical and Translational Research, Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew S. Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kevin W. Gibbs
- Department of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Marjolein de Wit
- Department of Medicine, Virginia Commonwealth University, Richmond
| | - D. Clark Files
- Department of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Michelle Harkins
- Department of Internal Medicine, University of New Mexico, Albuquerque
| | | | - Lisa H. Merck
- Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond
| | - Ari Moskowitz
- Department of Medicine, Montefiore Medical Center, Bronx, New York
| | | | - Aaron Barksdale
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha
| | - Basmah Safdar
- Department of Emergency Medicine, Yale University, New Haven, Connecticut
| | - Ali Javaheri
- Department of Medicine, Washington University, St Louis, Missouri
| | | | - Harry Schrager
- Department of Medicine, Tufts School of Medicine, Newton-Wellesley Hospital, Newton, Massachusetts
| | - Nicole Iovine
- Department of Medicine, University of Florida, Gainesville
| | | | - Ivor S. Douglas
- Department of Medicine, Denver Health Medical Center, Denver, Colorado
| | - Joseph Levitt
- Department of Medicine, Stanford University, Stanford, California
| | | | - Adit A. Ginde
- Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora
| | - Samuel M. Brown
- Department of Pulmonary/Critical Care Medicine, Intermountain Medical Center, Murray, Utah
| | - David N. Hager
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Katherine Boyle
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Abhijit Duggal
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Akram Khan
- Department of Medicine, Oregon Health & Science University, Portland
| | - Michael Lanspa
- Department of Pulmonary/Critical Care Medicine, Intermountain Medical Center, Murray, Utah
| | - Peter Chen
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis
| | - Derek Vonderhaar
- Department of Medicine, Ochsner Medical Center, New Orleans, Louisiana
| | | | - Nina Gentile
- Department of Emergency Medicine, Temple University, Philadelphia, Pennsylvania
| | - Yves Rosenberg
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - James Troendle
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Amanda J. Bistran-Hall
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Josh DeClercq
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert Lavieri
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Meghan Morrison Joly
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael Orr
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jill Pulley
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd W. Rice
- Vanderbilt Institute for Clinical and Translational Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Matthew W. Semler
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gordon R. Bernard
- Vanderbilt Institute for Clinical and Translational Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sean P. Collins
- Vanderbilt Institute for Clinical and Translational Research, Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville
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Peacock WF, Soto‐Ruiz KM, House SL, Cannon CM, Headden G, Tiffany B, Motov S, Merchant‐Borna K, Chang AM, Pearson C, Patterson BW, Jones AE, Miller J, Varon J, Bastani A, Clark C, Rafique Z, Kea B, Eppensteiner J, Williams JM, Mahler SA, Driver BE, Hendry P, Quackenbush E, Robinson D, Schrock JW, D'Etienne JP, Hogan CJ, Osborne A, Riviello R, Young S. Utility of COVID-19 antigen testing in the emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12605. [PMID: 35072154 PMCID: PMC8760952 DOI: 10.1002/emp2.12605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/28/2021] [Accepted: 11/02/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The BinaxNOW coronavirus disease 2019 (COVID-19) Ag Card test (Abbott Diagnostics Scarborough, Inc.) is a lateral flow immunochromatographic point-of-care test for the qualitative detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleocapsid protein antigen. It provides results from nasal swabs in 15 minutes. Our purpose was to determine its sensitivity and specificity for a COVID-19 diagnosis. METHODS Eligible patients had symptoms of COVID-19 or suspected exposure. After consent, 2 nasal swabs were collected; 1 was tested using the Abbott RealTime SARS-CoV-2 (ie, the gold standard polymerase chain reaction test) and the second run on the BinaxNOW point of care platform by emergency department staff. RESULTS From July 20 to October 28, 2020, 767 patients were enrolled, of which 735 had evaluable samples. Their mean (SD) age was 46.8 (16.6) years, and 422 (57.4%) were women. A total of 623 (84.8%) patients had COVID-19 symptoms, most commonly shortness of breath (n = 404; 55.0%), cough (n = 314; 42.7%), and fever (n = 253; 34.4%). Although 460 (62.6%) had symptoms ≤7 days, the mean (SD) time since symptom onset was 8.1 (14.0) days. Positive tests occurred in 173 (23.5%) and 141 (19.2%) with the gold standard versus BinaxNOW test, respectively. Those with symptoms >2 weeks had a positive test rate roughly half of those with earlier presentations. In patients with symptoms ≤7 days, the sensitivity, specificity, and negative and positive predictive values for the BinaxNOW test were 84.6%, 98.5%, 94.9%, and 95.2%, respectively. CONCLUSIONS The BinaxNOW point-of-care test has good sensitivity and excellent specificity for the detection of COVID-19. We recommend using the BinasNOW for patients with symptoms up to 2 weeks.
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Affiliation(s)
- W. Frank Peacock
- Department of Emergency MedicineBaylor College of MedicineHoustonTexasUSA
| | | | - Stacey L. House
- Department of Emergency MedicineWashington University School of MedicineSt. LouisMissouriUSA
| | - Chad M. Cannon
- Department of Emergency MedicineUniversity of Kansas Medical CenterKansas CityKansasUSA
| | - Gary Headden
- Department of Emergency MedicineMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | | | - Sergey Motov
- Department of Emergency MedicineMaimonides Medical CenterBrooklynNew YorkUSA
| | - Kian Merchant‐Borna
- Department of Emergency MedicineUniversity of Rochester Medical CenterUniversity of Rochester School of Medicine and DentistryRochesterNew YorkUSA
| | - Anna Marie Chang
- Department of Emergency MedicineThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Claire Pearson
- Department of Emergency Medicine, Wayne State UniversityAscension St. JohnDetroitMichiganUSA
| | - Brian W. Patterson
- Department of Emergency MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Alan E. Jones
- Department of Emergency MedicineUniversity of Mississippi Medical CenterJacksonMississippiUSA
| | - Joseph Miller
- Department of Emergency MedicineHenry Ford HospitalDetroitMichiganUSA
| | - Joseph Varon
- Department of Intensive Care MedicineUnited Memorial Medical CenterThe University of Houston School of MedicineHoustonTexasUSA
| | - Aveh Bastani
- Department of Emergency MedicineWilliam Beaumont Health SystemTroyMichiganUSA
| | - Carol Clark
- Department of Emergency MedicineWilliam Beaumont Health SystemRoyal OakMichiganUSA
| | - Zubaid Rafique
- Department of Emergency MedicineBaylor College of MedicineHoustonTexasUSA
| | - Bory Kea
- Department of Emergency MedicineOregon Health & Sciences UniversityPortlandOregonUSA
| | - John Eppensteiner
- Department of Emergency MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - James M. Williams
- Department of Emergency MedicineSchool of MedicineMeritus Medical Center, Texas Tech University Health Science CenterLubbockTexasUSA
| | - Simon A. Mahler
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Brian E. Driver
- Department of Emergency MedicineHennepin County Medical CenterMinneapolisMinnesotaUSA
| | - Phyllis Hendry
- Department of Emergency MedicineUniversity of Florida College of MedicineJacksonvilleFloridaUSA
| | - Eugenia Quackenbush
- Department of Emergency MedicineUniversity of North Carolina School of MedicineChapel HillNorth CarolinaUSA
| | - David Robinson
- Department of Emergency Medicine at McGovern Medical SchoolThe University of TexasHoustonTexasUSA
| | - Jon W. Schrock
- Department of Emergency MedicineMetroHealth Medical CenterCase Western Reserve University School of MedicineClevelandOhioUSA
| | - James P. D'Etienne
- John Peter Smith Health Network/Integrative Emergency ServicesFort WorthTexasUSA
| | - Christopher J. Hogan
- Virginia Commonwealth University Medical CenterDepartments of Emergency Medicine and SurgeryRichmondVirginiaUSA
| | - Anwar Osborne
- Department of Emergency MedicineEmory University School of MedicineAtlantaGeorgia
| | - Ralph Riviello
- Department of Emergency MedicineUniversity of Texas Health San AntonioSan AntonioTexasUSA
| | - Stephen Young
- TriCore Reference LaboratoriesAlbuquerqueNew MexicoUSA
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Bansal S, Perincheri S, Fleming T, Poulson C, Tiffany B, Bremner RM, Mohanakumar T. Cutting Edge: Circulating Exosomes with COVID Spike Protein Are Induced by BNT162b2 (Pfizer-BioNTech) Vaccination prior to Development of Antibodies: A Novel Mechanism for Immune Activation by mRNA Vaccines. J Immunol 2021; 207:2405-2410. [PMID: 34654691 PMCID: PMC11073804 DOI: 10.4049/jimmunol.2100637] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/15/2021] [Indexed: 01/15/2023]
Abstract
Severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) causes severe acute respiratory syndrome. mRNA vaccines directed at the SARS-CoV-2 spike protein resulted in development of Abs and protective immunity. To determine the mechanism, we analyzed the kinetics of induction of circulating exosomes with SARS-CoV-2 spike protein and Ab following vaccination of healthy individuals. Results demonstrated induction of circulating exosomes expressing spike protein on day 14 after vaccination followed by Abs 14 d after the second dose. Exosomes with spike protein, Abs to SARS-CoV-2 spike, and T cells secreting IFN-γ and TNF-α increased following the booster dose. Transmission electron microscopy of exosomes also demonstrated spike protein Ags on their surface. Exosomes with spike protein and Abs decreased in parallel after four months. These results demonstrate an important role of circulating exosomes with spike protein for effective immunization following mRNA-based vaccination. This is further documented by induction of humoral and cellular immune responses in mice immunized with exosomes carrying spike protein.
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Affiliation(s)
- Sandhya Bansal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ; and
| | - Sudhir Perincheri
- Department of Pathology and Laboratory Medicine Yale School of Medicine, New Haven, CT
| | - Timothy Fleming
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ; and
| | - Christin Poulson
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ; and
| | - Brian Tiffany
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ; and
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ; and
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The CONSERVE-HCW Research Group, Tiffany B, Bremner R, Cogo J, Zumbuhl J, Wood L, Arriola B, Wiley N, Sanders S. 209 Seroprevalence of Anti-SARS CoV-2 Nucleocapsid IgG in a Cohort of Healthcare Workers Over Nine Months. Ann Emerg Med 2021. [PMCID: PMC8536272 DOI: 10.1016/j.annemergmed.2021.09.221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Tiffany B, Cogo J, Bremner R, Zumbuhl J, Wood L, Sanders S. 32 Decay of Anti-SARS-CoV-2 Nucleocapsid IgG in Seropositive Health Care Workers Over Time. Ann Emerg Med 2021. [PMCID: PMC8335426 DOI: 10.1016/j.annemergmed.2021.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tiffany K, Arnholt A, Arzumanyan D, Arzumanyan L, Barber M, Copes E, Crow T, Esser E, Kuborn A, Reinhardt K, Tiffany B, Woods A, Sahoo D. In with the Good and out with the Bad – The Role of SR‐B1 in Lowering Blood Cholesterol Levels. FASEB J 2018. [DOI: 10.1096/fasebj.2018.32.1_supplement.lb208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | | | | | - E. Copes
- Cedarburg High SchoolCedarburgWI
| | - T. Crow
- Cedarburg High SchoolCedarburgWI
| | - E. Esser
- Cedarburg High SchoolCedarburgWI
| | | | | | | | - A. Woods
- Cedarburg High SchoolCedarburgWI
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Singer AJ, Birkhahn RH, Guss D, Chandra A, Miller CD, Tiffany B, Levy P, Dunne R, Bastani A, Thode HC, Hollander JE. Rapid Emergency Department Heart Failure Outpatients Trial (REDHOT II). Circ Heart Fail 2009; 2:287-93. [DOI: 10.1161/circheartfailure.108.826685] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [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: 11/16/2022]
Affiliation(s)
- Adam J. Singer
- From the Department of Emergency Medicine (J.E.H.), University of Pennsylvania, Philadelphia, Pa; Department of Emergency Medicine (A.J.S., H.C.T.), Stony Brook University, Stony Brook, NY; Department of Emergency Medicine (R.H.B.), New York Methodist Hospital, New York, NY; Department of Emergency Medicine (D.G.), University of California at San Diego, Calif; Department of Emergency Medicine (A.C.), Duke University, Durham, NC; Department of Emergency Medicine (C.D.M.), School of Medicine, Wake
| | - Robert H. Birkhahn
- From the Department of Emergency Medicine (J.E.H.), University of Pennsylvania, Philadelphia, Pa; Department of Emergency Medicine (A.J.S., H.C.T.), Stony Brook University, Stony Brook, NY; Department of Emergency Medicine (R.H.B.), New York Methodist Hospital, New York, NY; Department of Emergency Medicine (D.G.), University of California at San Diego, Calif; Department of Emergency Medicine (A.C.), Duke University, Durham, NC; Department of Emergency Medicine (C.D.M.), School of Medicine, Wake
| | - David Guss
- From the Department of Emergency Medicine (J.E.H.), University of Pennsylvania, Philadelphia, Pa; Department of Emergency Medicine (A.J.S., H.C.T.), Stony Brook University, Stony Brook, NY; Department of Emergency Medicine (R.H.B.), New York Methodist Hospital, New York, NY; Department of Emergency Medicine (D.G.), University of California at San Diego, Calif; Department of Emergency Medicine (A.C.), Duke University, Durham, NC; Department of Emergency Medicine (C.D.M.), School of Medicine, Wake
| | - Abhinav Chandra
- From the Department of Emergency Medicine (J.E.H.), University of Pennsylvania, Philadelphia, Pa; Department of Emergency Medicine (A.J.S., H.C.T.), Stony Brook University, Stony Brook, NY; Department of Emergency Medicine (R.H.B.), New York Methodist Hospital, New York, NY; Department of Emergency Medicine (D.G.), University of California at San Diego, Calif; Department of Emergency Medicine (A.C.), Duke University, Durham, NC; Department of Emergency Medicine (C.D.M.), School of Medicine, Wake
| | - Chadwick D. Miller
- From the Department of Emergency Medicine (J.E.H.), University of Pennsylvania, Philadelphia, Pa; Department of Emergency Medicine (A.J.S., H.C.T.), Stony Brook University, Stony Brook, NY; Department of Emergency Medicine (R.H.B.), New York Methodist Hospital, New York, NY; Department of Emergency Medicine (D.G.), University of California at San Diego, Calif; Department of Emergency Medicine (A.C.), Duke University, Durham, NC; Department of Emergency Medicine (C.D.M.), School of Medicine, Wake
| | - Brian Tiffany
- From the Department of Emergency Medicine (J.E.H.), University of Pennsylvania, Philadelphia, Pa; Department of Emergency Medicine (A.J.S., H.C.T.), Stony Brook University, Stony Brook, NY; Department of Emergency Medicine (R.H.B.), New York Methodist Hospital, New York, NY; Department of Emergency Medicine (D.G.), University of California at San Diego, Calif; Department of Emergency Medicine (A.C.), Duke University, Durham, NC; Department of Emergency Medicine (C.D.M.), School of Medicine, Wake
| | - Phillip Levy
- From the Department of Emergency Medicine (J.E.H.), University of Pennsylvania, Philadelphia, Pa; Department of Emergency Medicine (A.J.S., H.C.T.), Stony Brook University, Stony Brook, NY; Department of Emergency Medicine (R.H.B.), New York Methodist Hospital, New York, NY; Department of Emergency Medicine (D.G.), University of California at San Diego, Calif; Department of Emergency Medicine (A.C.), Duke University, Durham, NC; Department of Emergency Medicine (C.D.M.), School of Medicine, Wake
| | - Robert Dunne
- From the Department of Emergency Medicine (J.E.H.), University of Pennsylvania, Philadelphia, Pa; Department of Emergency Medicine (A.J.S., H.C.T.), Stony Brook University, Stony Brook, NY; Department of Emergency Medicine (R.H.B.), New York Methodist Hospital, New York, NY; Department of Emergency Medicine (D.G.), University of California at San Diego, Calif; Department of Emergency Medicine (A.C.), Duke University, Durham, NC; Department of Emergency Medicine (C.D.M.), School of Medicine, Wake
| | - Aveh Bastani
- From the Department of Emergency Medicine (J.E.H.), University of Pennsylvania, Philadelphia, Pa; Department of Emergency Medicine (A.J.S., H.C.T.), Stony Brook University, Stony Brook, NY; Department of Emergency Medicine (R.H.B.), New York Methodist Hospital, New York, NY; Department of Emergency Medicine (D.G.), University of California at San Diego, Calif; Department of Emergency Medicine (A.C.), Duke University, Durham, NC; Department of Emergency Medicine (C.D.M.), School of Medicine, Wake
| | - Henry C. Thode
- From the Department of Emergency Medicine (J.E.H.), University of Pennsylvania, Philadelphia, Pa; Department of Emergency Medicine (A.J.S., H.C.T.), Stony Brook University, Stony Brook, NY; Department of Emergency Medicine (R.H.B.), New York Methodist Hospital, New York, NY; Department of Emergency Medicine (D.G.), University of California at San Diego, Calif; Department of Emergency Medicine (A.C.), Duke University, Durham, NC; Department of Emergency Medicine (C.D.M.), School of Medicine, Wake
| | - Judd E. Hollander
- From the Department of Emergency Medicine (J.E.H.), University of Pennsylvania, Philadelphia, Pa; Department of Emergency Medicine (A.J.S., H.C.T.), Stony Brook University, Stony Brook, NY; Department of Emergency Medicine (R.H.B.), New York Methodist Hospital, New York, NY; Department of Emergency Medicine (D.G.), University of California at San Diego, Calif; Department of Emergency Medicine (A.C.), Duke University, Durham, NC; Department of Emergency Medicine (C.D.M.), School of Medicine, Wake
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9
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Lindsell CJ, Anantharaman V, Diercks D, Han JH, Hoekstra JW, Hollander JE, Kirk JD, Lim SH, Peacock WF, Tiffany B, Wilke EK, Gibler WB, Pollack CV. The Internet Tracking Registry of Acute Coronary Syndromes (i*trACS): A Multicenter Registry of Patients With Suspicion of Acute Coronary Syndromes Reported Using the Standardized Reporting Guidelines for Emergency Department Chest Pain Studies. Ann Emerg Med 2006; 48:666-77, 677.e1-9. [PMID: 17014928 DOI: 10.1016/j.annemergmed.2006.08.005] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2005] [Revised: 04/04/2006] [Accepted: 04/24/2006] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE Observational studies of well-described patient populations presenting to emergency departments (EDs) with suspicion of acute coronary syndrome are necessary to understand the relationships between patients' signs and symptoms, cardiac risk profile, test results, practice patterns, and outcomes. We describe the methods for data collection and the ED population enrolled in a multicenter registry of patients with chest pain. METHODS Patients older than 18 years, presenting to one of 8 EDs in the United States or 1 ED in Singapore, and with possible acute coronary syndrome were enrolled in the Internet Tracking Registry of Acute Coronary Syndromes between June 1999 and August 2001. Prospective data, including presenting signs and symptoms, ECG findings, and the ED physician's initial impression of risk, were systematically collected. Medical record review or daily follow-up was used to obtain cardiac biomarker results, invasive and noninvasive testing, treatments, procedures, and inhospital outcomes. Thirty-day outcomes were determined by telephone follow-up and medical record review. RESULTS The registry includes 15,608 patients, with 17,713 visits. Chest pain was the chief complaint in 71% of visits. The ECG was diagnostic of ischemia or infarction in 10.1% and positive cardiac biomarkers were observed in 10% of visits. Forty-three percent of patients were sent home directly from the ED. Of admitted patients, 5% died by 30 days, and 3% had documented coronary artery disease or had undergone percutaneous coronary intervention or coronary artery bypass grafting within 30 days. For patients discharged directly from the ED, 0.4% died or had a documented myocardial infarction within 30 days. Coronary artery bypass graft surgery, percutaneous coronary intervention, or a diagnosis of coronary artery disease was found in 0.5% of discharged patients. CONCLUSION A unique description of undifferentiated ED chest pain patients with suspected acute coronary syndrome is provided. The data set can be used to generate and explore hypotheses to improve understanding of the complex relationships between presentation, treatment, testing, intervention and outcomes.
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Affiliation(s)
- Christopher J Lindsell
- Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH 45267-0769, USA.
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Venkat A, Hoekstra J, Lindsell C, Prall D, Hollander JE, Pollack CV, Diercks D, Kirk JD, Tiffany B, Peacock F, Storrow AB, Gibler WB. The impact of race on the acute management of chest pain. Acad Emerg Med 2004; 10:1199-208. [PMID: 14597496 DOI: 10.1111/j.1553-2712.2003.tb00604.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES African Americans with acute coronary syndromes receive cardiac catheterization less frequently than whites. The objective was to determine if such disparities extend to acute evaluation and non interventional treatment. METHODS Data on adults with chest pain (N = 7,935) presenting to eight emergency departments (EDs) were evaluated from the Internet Tracking Registry of Acute Coronary Syndromes. Groups were selected from final ED diagnosis: 1) acute myocardial infarction (AMI), n = 400; 2) unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI), n = 1,153; and 3) nonacute coronary syndrome chest pain (non-ACS CP), n = 6,382. American College of Cardiology/American Heart Association guidelines for AMI and UA/NSTEMI were used to evaluate racial disparities with logistic regression models. Odds ratios (ORs) were adjusted for age, gender, guideline publication, and insurance status. Non-ACS CP patients were assessed by comparing electrocardiographic (ECG)/laboratory evaluation, medical treatment, admission rates, and invasive and noninvasive testing for coronary artery disease (CAD). RESULTS African Americans with UA/NSTEMI received glycoprotein IIb/IIIa receptor inhibitors less often than whites (OR, 0.41; 95% CI = 0.19 to 0.91). African Americans with non-ACS CP underwent ECG/laboratory evaluation, medical treatment, and invasive and noninvasive testing for CAD less often than whites (p < 0.05). Other nonwhites with non-ACS CP were admitted and received invasive testing for CAD less often than whites (p < 0.01). African Americans and other nonwhites with AMI underwent catheterization less frequently than whites (OR, 0.45; 95% CI = 0.29 to 0.71 and OR, 0.40; 95% CI = 0.17 to 0.92, respectively). A similar disparity in catheterization was noted in UA/NSTEMI therapy (OR, 0.53; 95% CI = 0.40 to 0.68 and OR, 0.68; 95% CI = 0.47 to 0.99). CONCLUSIONS Racial disparities in acute chest pain management extend beyond cardiac catheterization. Poor compliance with recommended treatments for ACS may be an explanation.
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Affiliation(s)
- Arvind Venkat
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
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Capellan O, Hollander JE, Pollack C, Hoekstra JW, Wilke E, Tiffany B, Sites FD, Shofer FS, Gibler WB. Prospective evaluation of emergency department patients with potential coronary syndromes using initial absolute CK-MB vs. CK-MB relative index. J Emerg Med 2003; 24:361-7. [PMID: 12745035 DOI: 10.1016/s0736-4679(03)00030-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [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: 10/27/2022]
Abstract
We compared the predictive properties of an initial absolute creatine kinase-MB (CK-MB) to creatine kinase-MB relative index (CK-MB RI) for detecting acute myocardial infarction (AMI), acute coronary syndromes (ACS), and serious cardiac events (SCE). Consecutive patients > 24 years of age with chest pain who received an electrocardiogram (EKG) as part of their Emergency Department (ED) evaluation had CK and CK-MB drawn at presentation. Patients were followed prospectively during their hospital course. The main outcome was AMI, ACS or SCE (death, AMI, dysrhythmias, CHF, PTCA/stent, CABG) within 30 days. The sensitivity, specificity, PPV and NPV of CK-MB and CK-MB RI to predict AMI, ACS, and SCE were calculated with 95% CIs. We enrolled 2028 patients. There were 105 patients (5.2%) with AMI, 266 (13.1%) with ACS, and 150 with SCE (7.4%). Absolute CK-MB had a higher sensitivity than CK-MB RI for AMI (52.0 vs. 46.9, respectively), ACS (23.5 vs. 20.8, respectively), and SCE (39.6 vs. 36.0, respectively), but a lower specificity than CK-MB RI for AMI (93.2 vs. 96.1, respectively), ACS (93.1 vs. 96.1, respectively) and SCE (93.3 vs. 96.3, respectively); and lower PPV for AMI (35.7 vs. 46.5, respectively), ACS (42.0 vs. 53.4, respectively) and SCE (38.5 vs. 50.5, respectively). The negative predictive values were similar for all outcomes. We conclude that the risk stratification of ED chest pain patients by absolute CK-MB has higher sensitivity, similar NPV, but a lower specificity and PPV than CK-MB relative index for detection of AMI, ACS, and SCE. The optimal test depends upon the relative importance of the sensitivity or specificity for clinical decision-making in an individual patient.
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Affiliation(s)
- Otilia Capellan
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104-4283, USA
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Limkakeng A, Gibler WB, Pollack C, Hoekstra JW, Sites F, Shofer FS, Tiffany B, Wilke E, Hollander JE. Combination of Goldman risk and initial cardiac troponin I for emergency department chest pain patient risk stratification. Acad Emerg Med 2001; 8:696-702. [PMID: 11435183 DOI: 10.1111/j.1553-2712.2001.tb00187.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.7] [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: 11/28/2022]
Abstract
BACKGROUND Accurate identification of low-risk emergency department (ED) chest pain patients who may be safe for discharge has not been well defined. Goldman criteria have reliably risk-stratified patients but have not identified any subset safe for ED release. Cardiac troponin I (cTnI) values have also been shown to risk-stratify patients but have not identified a subset safe for ED release. OBJECTIVE To test the hypothesis that ED chest pain patients with a Goldman risk of < or =4% and a single negative cTnI (< or =0.3 ng/mL) at the time of ED presentation would be safe for discharge [<1% risk for death, acute myocardial infarction (AMI), revascularization]. METHODS A prospective cohort study was performed in which consecutive ED chest pain patients were enrolled from July 1999 to November 2000. Data collected included patient demographics, medical and cardiac history, electrocardiogram, and creatine kinase-MB and cTnI. Goldman risk stratification score was calculated while patients were still in the ED. Hospital course was followed daily. Telephone follow-up occurred at 30 days. The main outcome was death, AMI, or revascularization (percutaneous transluminal coronary angioplasty/stents/coronary artery bypass grafting) within 30 days. RESULTS Of 2,322 patients evaluated, 998 had both a Goldman risk < or =4% and a cTnI < or =0.3 ng/mL. During the initial hospitalization, 37 patients met the composite endpoint (3.7%): 6 deaths (0.7%), 17 AMIs (1.7%), 18 revascularizations (1.8%). Between the time of hospital discharge and 30-day follow-up, 15 patients met the composite endpoint: 4 deaths (0.4%), 6 AMIs (0.6%), and 5 revascularizations (0.5%). Overall, 49 patients met the composite endpoint (4.9%; 95% CI = 3.6% to 6.2%): 10 deaths (1.0%; 95% CI = 0.4% to 1.6%); 23 AMIs (2.3%; 95% CI = 1.4% to 3.2%), and 23 revascularizations (2.3%; 95% CI = 1.4% to 3.2%) within 30 days of presentation. CONCLUSIONS The combination of two risk stratification modalities for ED chest pain patients (Goldman risk < or =4% and cTnI < or =0.3 ng/mL) did not identify a subgroup of chest pain patients at <1% risk for death, AMI, or revascularization within 30 days.
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Affiliation(s)
- A Limkakeng
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104-4283, USA
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Macnab A, Christenson J, Findlay J, Horwood B, Johnson D, Jones L, Phillips K, Pollack C, Robinson DJ, Rumball C, Stair T, Tiffany B, Whelan M. A new system for sternal intraosseous infusion in adults. PREHOSP EMERG CARE 2000; 4:173-7. [PMID: 10782608 DOI: 10.1080/10903120090941461] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.9] [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: 10/23/2022]
Abstract
BACKGROUND Intraosseous (IO) infusion provides an alternative route for the administration of fluids and medications when difficulty with peripheral or central lines is encountered during resuscitation of critically ill and injured patients. OBJECTIVE To report the first 50 uses of a new system for emergency IO infusion into the sternum in adults, the Pyng F.A.S.T.1 IO infusion system. METHODS Six emergency departments and five prehospital emergency medical services (EMS) sites in Canada and the United States provided clinical and/or research data on their use of the IO system in a pilot study of success rates, insertion times, and complications. Indications for use included adult patient, urgent need for fluids or medications, and unacceptable delay or inability to achieve standard vascular access. A basic data set was standardized for all sites, and some sites collected additional data. RESULTS The overall success rate for achieving vascular access with the system was 84%. Success rates were 74% for first-time users, and 95% for experienced users. Failure to achieve vascular access occurred most frequently in patients (5 of 9) described subjectively by the user as "very obese," in whom there was a thick layer of tissue overlying the sternum. Mean time to achieve vascular access was 77 seconds. Flow rates of up to 80 mL/min were reported for gravity drip, and more than 150 mL/min by syringe bolus. Pressure cuffs were also used successfully, although fluid rate was controlled by clamping the line. Further research on flow rates is needed. No complications or complaints were reported at two-month follow-up. CONCLUSION These early data indicate that sternal IO infusion using the new F.A.S.T.1 IO system may provide rapid, safe vascular access and may be a useful technique for reducing unacceptable delays in the provision of emergency treatment.
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Affiliation(s)
- A Macnab
- University of British Columbia, Vancouver, Canada.
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Tiffany B. Cancer carer. Interview by Caroline Howie. Nurs Times 1988; 84:18. [PMID: 3174464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Tiffany B. The splinter effect. Nurs Times 1984; 80:33. [PMID: 6563566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
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Quinn S, Tiffany B, Parrish A, Hancock C, Clark G, Clark J, Rye D, Newson K. Issues in nursing: singing for their supper. Interview by M Allen. Nurs Mirror 1982; 154:19-23. [PMID: 6919054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Tiffany B. Childhood cancer: introduction. Nurs Mirror 1980; 151:i. [PMID: 6902348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Tiffany B. The honest art of cancer nursing. Nurs Times 1978; 74:1551-2. [PMID: 249996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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