1
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Cheung MD, Asiimwe R, Erman EN, Fucile CF, Liu S, Sun CW, Hanumanthu VS, Pal HC, Wright ED, Ghajar-Rahimi G, Epstein D, Orandi BJ, Kumar V, Anderson DJ, Greene ME, Bell M, Yates S, Moore KH, LaFontaine J, Killian JT, Baker G, Perry J, Khan Z, Reed R, Little SC, Rosenberg AF, George JF, Locke JE, Porrett PM. Spatiotemporal immune atlas of a clinical-grade gene-edited pig-to-human kidney xenotransplant. Nat Commun 2024; 15:3140. [PMID: 38605083 PMCID: PMC11009229 DOI: 10.1038/s41467-024-47454-7] [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: 02/12/2023] [Accepted: 04/02/2024] [Indexed: 04/13/2024] Open
Abstract
Pig-to-human xenotransplantation is rapidly approaching the clinical arena; however, it is unclear which immunomodulatory regimens will effectively control human immune responses to pig xenografts. Here, we transplant a gene-edited pig kidney into a brain-dead human recipient on pharmacologic immunosuppression and study the human immune response to the xenograft using spatial transcriptomics and single-cell RNA sequencing. Human immune cells are uncommon in the porcine kidney cortex early after xenotransplantation and consist of primarily myeloid cells. Both the porcine resident macrophages and human infiltrating macrophages express genes consistent with an alternatively activated, anti-inflammatory phenotype. No significant infiltration of human B or T cells into the porcine kidney xenograft is detectable. Altogether, these findings provide proof of concept that conventional pharmacologic immunosuppression may be able to restrict infiltration of human immune cells into the xenograft early after compatible pig-to-human kidney xenotransplantation.
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Affiliation(s)
- Matthew D Cheung
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rebecca Asiimwe
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Elise N Erman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Shanrun Liu
- Department of Biochemistry and Molecular Genetics, University of Alabama at Birmingham, Birmingham, AL, USA
- Flow Cytometry & Single Cell Core Facility, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Chiao-Wang Sun
- Department of Biochemistry and Molecular Genetics, University of Alabama at Birmingham, Birmingham, AL, USA
- Flow Cytometry & Single Cell Core Facility, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Vidya Sagar Hanumanthu
- Flow Cytometry & Single Cell Core Facility, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Harish C Pal
- Flow Cytometry & Single Cell Core Facility, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Emma D Wright
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Daniel Epstein
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Babak J Orandi
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Vineeta Kumar
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Douglas J Anderson
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Morgan E Greene
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Markayla Bell
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Stefani Yates
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kyle H Moore
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jennifer LaFontaine
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John T Killian
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Gavin Baker
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jackson Perry
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Zayd Khan
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rhiannon Reed
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Shawn C Little
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alexander F Rosenberg
- Informatics Institute, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - James F George
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jayme E Locke
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Paige M Porrett
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
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2
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Asiimwe R, Knott B, Greene ME, Wright E, Bell M, Epstein D, Yates SD, Cheung MD, Gonzalez MV, Fry S, Boydston E, Clevenger S, Locke JE, George JF, Burney R, Arora N, Duncan VE, Richter HE, Gunn D, Freud AG, Little SC, Porrett PM. Inhibition of NFAT promotes loss of tissue resident uterine natural killer cells and attendant pregnancy complications in humans. bioRxiv 2024:2024.03.07.583906. [PMID: 38559147 PMCID: PMC10979847 DOI: 10.1101/2024.03.07.583906] [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: 04/04/2024]
Abstract
Uterine natural killer cells (uNKs) are a tissue resident lymphocyte population that are critical for pregnancy success. Although mouse models have demonstrated that NK deficiency results in abnormal placentation and poor pregnancy outcomes, the generalizability of this knowledge to humans remains unclear. Here we identify uterus transplant (UTx) recipients as a human population with reduced endometrial NK cells and altered pregnancy phenotypes. We further show that the NK reduction in UTx is due to impaired transcriptional programming of NK tissue residency due to blockade of the transcription factor nuclear factor of activated T cells (NFAT). NFAT-dependent genes played a role in multiple molecular circuits governing tissue residency in uNKs, including early residency programs involving AP-1 transcription factors as well as TGFβ-mediated upregulation of surface integrins. Collectively, our data identify a previously undescribed role for NFAT in uterine NK tissue residency and provide novel mechanistic insights into the biologic basis of pregnancy complications due to alteration of tissue resident NK subsets in humans. One Sentence Summary Role of NFAT in uterine NK cell tissue residency.
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3
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Simmonds WM, Awuku Y, Barrett C, Brand M, Davidson K, Epstein D, Fredericks E, Gabriel S, Grobler S, Gounden C, Katsidzira L, Louw VJ, Naidoo V, Noel C, Ogutu E, Ramonate N, Seabi N, Setshedi M, Van Zyl J, Watermeyer G, Kassianides C. Guidance for the gastrointestinal evaluation and management of iron deficiency in Sub-Saharan Africa. S Afr Med J 2024; 114:e711. [PMID: 38525666 DOI: 10.7196/samj.2024.v114i1b.711] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND Over 30% of the world's population is anaemic, with a significant proportion of these being iron deficient. As iron deficiency (ID) anaemia in men and post-menopausal women is mostly caused by gastrointestinal blood loss or malabsorption, the initial evaluation of a patient with ID anaemia involves referral to a gastroenterologist. The current drive towards patient blood management in sub-Saharan Africa (SSA)prescribes that we regulate not only the use of blood transfusion but also the management of patients in whom the cause of iron loss or inadequate iron absorption is sought. Recommendations have been developed to: (i) aid clinicians in the evaluation of suspected gastrointestinal iron loss and iron malabsorption, and often a combination of these; (ii) improve clinical outcomes for patients with gastrointestinal causes of ID; (iii) provide current, evidence-based, context-specific recommendations for use in the management of ID; and (iv) conserve resources by ensuring rational utilisation of blood and blood products. METHOD Development of the guidance document was facilitated by the Gastroenterology Foundation of Sub-Saharan Africa and the South African Gastroenterology Society. The consensus recommendations are based on a rigorous process involving 21 experts in gastroenterology and haematology in SSA. Following discussion of the scope and purpose of the guidance document among the experts, an initial review of the literature and existing guidelines was undertaken. Thereafter, draft recommendation statements were produced to fulfil the outlined purpose of the guidance document. These were reviewed in a round-table discussion and were subjected to two rounds of anonymised consensus voting by the full committee in an electronic Delphi exercise during 2022 using the online platform, Research Electronic Data Capture. Recommendations were modified by considering feedback from the previous round, and those reaching a consensus of over 80% were incorporated into the final document. Finally, 44 statements in the document were read and approved by all members of the working group. CONCLUSION The recommendations incorporate six areas, namely: general recommendations and practice, Helicobacter pylori, coeliac disease, suspected small bowel bleeding, inflammatory bowel disease, and preoperative care. Implementation of the recommendations is aimed at various levels from individual practitioners to healthcare institutions, departments and regional, district, provincial and national platforms. It is intended that the recommendations spur the development of centre-specific guidelines and that they are integrated with the relevant patient blood management protocols. Integration of the recommendations is intended to promote optimal evaluation and management of patients with ID, regardless of the presence of anaemia.
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Affiliation(s)
- W M Simmonds
- Gastroenterology Division, Department of Internal Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa.
| | - Y Awuku
- Department of Medicine, University of Health and Allied Sciences, Ho, Ghana.
| | - C Barrett
- School of Clinical Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa.
| | - M Brand
- Department of General Surgery, School of Medicine, University of Pretoria, South Africa.
| | - K Davidson
- Private practice, IBD nurse specialist, Cape Town, South Africa.
| | - D Epstein
- Division of Gastroenterology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.
| | - E Fredericks
- Department of Medicine, Stellenbosch University, South Africa.
| | - S Gabriel
- Gastroenterology Unit, Tygerberg Hospital and Stellenbosch University, South Africa.
| | - S Grobler
- niversitas Netcare Private Hospital, Bloemfontein, South Africa.
| | - C Gounden
- Department of Gastroenterology, School of Clinical Medicine, University of KwaZulu-Natal and Inkosi Albert Luthuli Central Hospital, Durban, South Africa.
| | - L Katsidzira
- Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe.
| | - V J Louw
- Division of Clinical Haematology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.
| | - V Naidoo
- Department of Gastroenterology, School of Clinical Medicine, University of KwaZulu-Natal and Inkosi Albert Luthuli Central Hospital, Durban, South Africa.
| | - C Noel
- Division of Gastrointestinal Surgery, Department of Surgery, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa.
| | - E Ogutu
- Department of Internal Medicine, University of Nairobi and Kenyatta National Hospital, Kenya.
| | - N Ramonate
- Gastroenterology Division, Department of Internal Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa.
| | - N Seabi
- Gastroenterology Division, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa.
| | - M Setshedi
- Division of Gastroenterology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.
| | - J Van Zyl
- Department of Internal Medicine, Faculty of Health Sciences, University of the Free State and Netcare Universitas Private Hospital, Bloemfontein, South Africa.
| | - G Watermeyer
- Division of Gastroenterology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.
| | - C Kassianides
- Department of Medicine, Faculty of Health Sciences, University of Cape Town and Morningside Mediclinic, Johannesburg, South Africa.
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4
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Almog G, Pfeffer RM, Zalmanov-Faermann S, Greenberg V, Lipsky Y, Chernomordikov E, Levin D, Arsenault O, Epstein D, Tamimi Q, Hod K, Limon D, Golan T, Ben-Aharon I, Lawrence Y, Ben-David MA. Pancreatic Cancer Outcome: Local Treatment with Radiation Using MRI-Linac. Int J Radiat Oncol Biol Phys 2023; 117:e285. [PMID: 37785060 DOI: 10.1016/j.ijrobp.2023.06.1271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Stereotactic MR-guided on-table adaptive radiotherapy (SMART) is a surging modality in radiotherapy, delivering high dose radiation to the tumor in great proximity to susceptible organs. The aim of this study is to evaluate the clinical outcome in locally advanced or recurrent pancreatic tumors with or without prior irradiation. MATERIALS/METHODS All consecutive patients were treated in our center for pancreatic cancer (PC) using SMART technology to a prescription of 50Gy (BED10 100 Gy1o) in 5 fractions, with daily on-table adaptation of treatment plan. Endpoints for this retrospective, single center, IRB approved study were local control, overall survival, local disease-free period, acute and late toxicities. RESULTS Fifty-four PC patients were treated between 8.2019-9.2022, with median follow-up of 8.9 months from SMART (0.8-34 months). Forty patients had upfront inoperable PC (45% were metastatic at RT, five treated to liver metastatic lesions concomitantly) and fourteen patients had local recurrence following prior pancreatectomy, six of them had prior adjuvant RT. 87% received at least one round of chemotherapy (Oxaliplatin based- 72%), 25% received ≥2 regimens. Mean age was 68.9 (45-86) years. There was no significant difference in baseline parameters between prior pancreatectomy and inoperable groups. On-table adaptive replanning was performed for 100% of all (269) fractions (one patient received 4 fractions). No patient reported grade ≥2 acute GI toxicity. Six patients reported fatigue at the end of RT, four of them had prior radiation. Forty-eight patients were available for evaluation. Complete local control was achieved in 21.7% (10 patients) for median of 9 months (2.8-28.8 months), three had later local progression. Eight patients had regional or marginal recurrence following treatment. 6-months and 12-months OS was 75% and 52%, respectively. There was no significant difference in toxicity and outcome between post-pancreatectomy and inoperable groups. CONCLUSION Pancreatic cancer local ablative SMART is safe, with minimal treatment-related toxicity, even in previously irradiated patients. Local control with complete response was achieved by 20% of patients. Further studies are needed to evaluate long-term outcome and late toxicity.
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Affiliation(s)
- G Almog
- Goldman School of Medicine, Ben Gurion University of the Negev, Beer Sheva, Israel, Beer Sheva, Israel
| | | | | | | | - Y Lipsky
- Assuta Medical Centers, Tel Aviv, Israel
| | - E Chernomordikov
- Radiation Oncology Department, Assuta Medical Center, Tel Aviv, Israel, Tel Aviv, Israel
| | - D Levin
- Assuta Medical Centers, Tel Aviv, Israel
| | | | - D Epstein
- Assuta Medical Centers, Tel Aviv, Israel
| | - Q Tamimi
- Assuta Medical Centers, Tel Aviv, Israel
| | - K Hod
- Assuta Medical Center, Tel Aviv, Israel
| | - D Limon
- Tel Aviv University Medical Center, Tel Aviv, Israel
| | - T Golan
- Department Medical Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - I Ben-Aharon
- Fishman Oncology Center, Rambam Health Care Campus, Haifa, Israel, Haifa, Israel
| | - Y Lawrence
- Radiation Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - M A Ben-David
- Department of Radiation Oncology, Assuta Medical Center, Tel Aviv, Israel
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5
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Umfress A, Chakraborti A, Priya Sudarsana Devi S, Adams R, Epstein D, Massicano A, Sorace A, Singh S, Iqbal Hossian M, Andrabi SA, Crossman DK, Kumar N, Shahid Mukhtar M, Luo H, Simpson C, Abell K, Stokes M, Wiederhold T, Rosen C, Lu H, Natarajan A, Bibb JA. Cdk5 mediates rotational force-induced brain injury. Sci Rep 2023; 13:3394. [PMID: 36854738 PMCID: PMC9974974 DOI: 10.1038/s41598-023-29322-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 02/02/2023] [Indexed: 03/02/2023] Open
Abstract
Millions of traumatic brain injuries (TBIs) occur annually. TBIs commonly result from falls, traffic accidents, and sports-related injuries, all of which involve rotational acceleration/deceleration of the brain. During these injuries, the brain endures a multitude of primary insults including compression of brain tissue, damaged vasculature, and diffuse axonal injury. All of these deleterious effects can contribute to secondary brain ischemia, cellular death, and neuroinflammation that progress for weeks, months, and lifetime after injury. While the linear effects of head trauma have been extensively modeled, less is known about how rotational injuries mediate neuronal damage following injury. Here, we developed a new model of repetitive rotational head trauma in rodents and demonstrated acute and prolonged pathological, behavioral, and electrophysiological effects of rotational TBI (rTBI). We identify aberrant Cyclin-dependent kinase 5 (Cdk5) activity as a principal mediator of rTBI. We utilized Cdk5-enriched phosphoproteomics to uncover potential downstream mediators of rTBI and show pharmacological inhibition of Cdk5 reduces the cognitive and pathological consequences of injury. These studies contribute meaningfully to our understanding of the mechanisms of rTBI and how they may be effectively treated.
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Affiliation(s)
- Alan Umfress
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ayanabha Chakraborti
- Department of Translational Neuroscience, University of Arizona College of Medicine in Phoeni, Biomedical Sciences Partnership Bldg, Phoenix, AZ, 85004 , USA
| | | | - Raegan Adams
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Daniel Epstein
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Adriana Massicano
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Anna Sorace
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sarbjit Singh
- Eppley Institute for Research in Cancer and Allied Diseases University of Nebraska Medical Center, Omaha, NE, USA
| | - M Iqbal Hossian
- Department of Pharmacology and Toxicology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Shaida A Andrabi
- Department of Pharmacology and Toxicology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David K Crossman
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nilesh Kumar
- Department of Biology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - M Shahid Mukhtar
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Biology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | | | | | | | - Charles Rosen
- OSF Healthcare Illinois Neurological Institute, Peoria, IL, USA
| | - Hongbing Lu
- Department of Mechanical Engineering, University of Texas at Dallas, Dallas, TX, USA
| | - Amarnath Natarajan
- Eppley Institute for Research in Cancer and Allied Diseases University of Nebraska Medical Center, Omaha, NE, USA
| | - James A Bibb
- Department of Translational Neuroscience, University of Arizona College of Medicine in Phoeni, Biomedical Sciences Partnership Bldg, Phoenix, AZ, 85004 , USA.
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6
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Cheung MD, Asiimwe R, Erman EN, Fucile CF, Liu S, Sun CW, Hanumanthu VS, Pal HC, Wright ED, Ghajar-Rahimi G, Epstein D, Orandi BJ, Kumar V, Anderson DJ, Greene ME, Bell M, Yates S, Moore KH, LaFontaine J, Killian JT, Baker G, Perry J, Reed R, Little SC, Rosenberg AF, George JF, Locke JE, Porrett PM. Spatiotemporal immune atlas of the first clinical-grade, gene-edited pig-to-human kidney xenotransplant. Res Sq 2023:rs.3.rs-2382345. [PMID: 36711785 PMCID: PMC9882594 DOI: 10.21203/rs.3.rs-2382345/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Pig-to-human xenotransplantation is rapidly approaching the clinical arena; however, it is unclear which immunomodulatory regimens will effectively control human immune responses to pig xenografts. We transplanted a gene-edited pig kidney into a brain-dead human recipient on pharmacologic immunosuppression and studied the human immune response to the xenograft using spatial transcriptomics and single-cell RNA sequencing. Human immune cells were uncommon in the porcine kidney cortex early after xenotransplantation and consisted of primarily myeloid cells. Both the porcine resident macrophages and human infiltrating macrophages expressed genes consistent with an alternatively activated, anti-inflammatory phenotype. No significant infiltration of human B or T cells into the porcine kidney xenograft was detected. Altogether, these findings provide proof of concept that conventional pharmacologic immunosuppression is sufficient to restrict infiltration of human immune cells into the xenograft early after compatible pig-to-human kidney xenotransplantation.
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Affiliation(s)
- Matthew D. Cheung
- Department of Surgery, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Rebecca Asiimwe
- Department of Surgery, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Elise N. Erman
- Department of Surgery, University of Alabama at Birmingham; Birmingham, AL, USA
| | | | - Shanrun Liu
- Department of Biochemistry and Molecular Genetics, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Chiao-Wang Sun
- Department of Biochemistry and Molecular Genetics, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Vidya Sagar Hanumanthu
- Flow Cytometry & Single Cell Core Facility, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Harish C. Pal
- Flow Cytometry & Single Cell Core Facility, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Emma D. Wright
- Department of Surgery, University of Alabama at Birmingham; Birmingham, AL, USA
| | | | - Daniel Epstein
- Department of Surgery, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Babak J. Orandi
- Department of Surgery, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Vineeta Kumar
- Department of Medicine, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Douglas J. Anderson
- Department of Surgery, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Morgan E. Greene
- Department of Surgery, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Markayla Bell
- Department of Surgery, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Stefani Yates
- Department of Surgery, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Kyle H. Moore
- Department of Medicine, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Jennifer LaFontaine
- Department of Surgery, University of Alabama at Birmingham; Birmingham, AL, USA
| | - John T. Killian
- Department of Surgery, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Gavin Baker
- Department of Surgery, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Jackson Perry
- Department of Surgery, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Rhiannon Reed
- Department of Surgery, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Shawn C. Little
- Department of Surgery, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Alexander F. Rosenberg
- Informatics Institute, University of Alabama at Birmingham; Birmingham, AL, USA
- Department of Microbiology, University of Alabama at Birmingham; Birmingham, AL, USA
| | - James F. George
- Department of Surgery, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Jayme E. Locke
- Department of Surgery, University of Alabama at Birmingham; Birmingham, AL, USA
| | - Paige M. Porrett
- Department of Surgery, University of Alabama at Birmingham; Birmingham, AL, USA
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7
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Abidi A, Demiraj F, Berdichevskiy G, Gupta K, Epstein D, Kurian S, Aranyos A, Gerstenfeld A, Assadi N, Penales CH. The Effects of COVID-19 on Physicians’ Perceived Ability to Provide Care for Patients With Type II Diabetes Mellitus. Cureus 2022; 14:e29135. [PMID: 36258937 PMCID: PMC9560814 DOI: 10.7759/cureus.29135] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/13/2022] [Indexed: 11/05/2022] Open
Abstract
Background and objective The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), presents multiple, diverse challenges to providing appropriate medical care, especially in terms of medication and treatment adherence for chronic diseases such as type 2 diabetes mellitus (T2DM). The COVID-19 pandemic has exacerbated these barriers by potentially forcing physicians to modify their treatment plans due to limitations on in-person visits and changes to patients' financial and social support systems. It remains uncertain whether physicians believe they can provide the same standard of care using telehealth technology or other means to their patients during the pandemic. The goal of this study was to explore physician perceptions about their ability to provide care to patients with T2DM during the COVID-19 pandemic. Methodology This cross-sectional study collected data between January 25, 2021, and February 2, 2021, using an anonymous, self-administered online survey involving DO and MD physicians including residents treating patients with T2DM. The survey was administered via REDCap and collected data on participant demographics, attitudes, perceptions, knowledge, and prior and current (COVID-19-era) experience with care for T2DM patients. Physicians registered with the Florida Department of Health with publicly available emails were invited to participate. Results The survey showed that during the COVID-19 pandemic, 57.9% of physicians (n=48) believed that their patients have a weaker social support system; 68.7% (n=57) modified their patient care plans due to patients' financial difficulties; 78.4% (n=65) believed a regular physical exam is necessary to properly treat patients; 48.2% (n=40) did not believe they had a more complete picture of the case with remote consultations; 47.0% (n=39) were not as satisfied with remote consultations as with face-to-face patient visits; 68.7% (n=57) believed telehealth is necessary to adequately treat patients; 38.5% (n=32) have been less likely to refer their patients to other providers or specialists; 45.8% (n=38) reported concerns over admitting their patients to the hospital for acute medical care; 61.5% (n=51) reported having more patients delay scheduling their routine follow-up care; 61.5% (n=51) believed their patients have been less compliant with the healthcare plans recommended to them. Conclusions The study showed that COVID-19 has significantly impacted physicians’ perceptions and abilities to provide care for patients with T2DM. COVID-19 has negatively impacted several crucial aspects of diabetes management, including consistent in-person examinations, social support, and referral to other required services, which could result in long-term consequences for these patients. Furthermore, our study suggests that physicians may not be as satisfied with the care they are able to provide via remote consultations as they are with in-person visits, which has significant implications as we move toward a more telehealth-driven healthcare delivery system.
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8
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Aviv O, Epstein L, Fried Y, Spitz HB, Shonkor S, Epstein D, Naim A, Yungrais Z, Datz H. A METHOD TO IDENTIFY AND LOCALIZE A SINGLE HOT PARTICLE IN THE LUNGS USING AN ARRAY OF HIGH-PURITY GERMANIUM DETECTORS FOR IMPROVED ESTIMATE OF THE DEPOSITED ACTIVITY. Radiat Prot Dosimetry 2022; 198:62-73. [PMID: 35043200 DOI: 10.1093/rpd/ncab187] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 06/14/2023]
Abstract
A new method has been developed to identify and localize a single hot particle in the lungs using an array of four high-purity germanium detectors. The method is based upon calculating a set of three count rate ratios (generated by each individual detector in the array) that are evaluated in sequence to designate whether the measured deposition can be associated with a hot particle rather than the default assumption of a uniform activity distribution. Identification and localization of the hot particle are determined from a single in vivo measurement in which detectors are positioned above and below the thorax. The method was tested using an anthropomorphic thorax phantom in which point sources of 241Am, 137Cs and 60Co were individually inserted in the lungs at 15 different locations and were measured using a scanning bed whole-body counter. Depending upon source location and photon energy, a bias of -35% up to +76% could be introduced by falsely assuming a uniform activity distribution in the lungs. This bias would directly translate to an erroneous dose estimate to the lungs. It was demonstrated that by using the appropriate detector efficiencies for the single hot particle, the bias associated with the activity determination is reduced to <10% and ~2% in average.
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Affiliation(s)
- O Aviv
- Radiation Safety Department, Soreq Nuclear Research Center, Yavne 81800, Israel
| | - L Epstein
- Radiation Safety Department, Soreq Nuclear Research Center, Yavne 81800, Israel
| | - Y Fried
- Radiation Safety Department, Soreq Nuclear Research Center, Yavne 81800, Israel
| | - H B Spitz
- Department of Mechanical and Materials Engineering, University of Cincinnati, Cincinnati, OH 45221-0072, USA
| | - S Shonkor
- Radiation Safety Department, Soreq Nuclear Research Center, Yavne 81800, Israel
| | - D Epstein
- Department of Radiotherapy, Assuta Medical Center, Tel Aviv 6971028, Israel
| | - A Naim
- Radiation Safety Department, Soreq Nuclear Research Center, Yavne 81800, Israel
| | - Z Yungrais
- Radiation Safety Department, Soreq Nuclear Research Center, Yavne 81800, Israel
| | - H Datz
- Radiation Safety Department, Soreq Nuclear Research Center, Yavne 81800, Israel
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King CA, Eisenberg D, Pistorello J, Coryell W, Albucher RC, Favorite T, Horwitz A, Bonar EE, Epstein D, Zheng K. Electronic bridge to mental health for college students: A randomized controlled intervention trial. J Consult Clin Psychol 2022; 90:172-183. [PMID: 35099205 DOI: 10.1037/ccp0000709] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Suicide is the second leading cause of death among college students in the United States, and the percentage of students reporting suicidal thoughts is increasing. Nevertheless, many students at risk do not seek mental health (MH) services. This randomized controlled trial (RCT) examined the efficacy of Electronic Bridge to Mental Health for College Students (eBridge) for increasing at-risk students' linkage to MH services. METHOD Students from four universities were recruited via email; 40,347 (22.6%) completed the online suicide risk screen; and 3,363 (8.3%) met criteria for randomization based on suicide risk factors and lack of current treatment (62.2% female, 35.0% male, 2.8% transgender/nonbinary; 73.2% White, 7.0% Black, 19.9% Asian, 11.7% other; 12.4% Hispanic, 76.2% undergraduate). These students were randomized to eBridge [personalized feedback (PF) with option of online counseling] or Control (PF). The primary outcome was linkage to MH services within 6 months. RESULTS Among students assigned to eBridge, 355 students (21.0%) posted ≥1 message, and 168 (10.0%) posted ≥2 messages to the counselor. In intent-to-treat analyses, there was no eBridge effect on obtaining MH services. However, within the eBridge group, students who posted ≥1 message were significantly more likely to link to MH services. CONCLUSIONS eBridge shows promise for reaching a relatively small subset of college students at risk for suicide; however, engagement in eBridge was low. This study underscores the urgent need for more effective strategies to engage young adults in online mental health interventions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Radus R, Epstein D, Levin D. Verifying Plan QA for Online Adaptive Treatment in MR Linac. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.1421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Diop M, Epstein D, Ruiz-Adame M. Personality traits associated with Healthy Diet and Obesity: A systematic review. Eur J Public Health 2021. [DOI: 10.1093/eurpub/ckab164.446] [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: 11/13/2022] Open
Abstract
Abstract
Objective
This study aimed to examine the association between personality traits and either dietary behaviour or weight-related outcomes.
Methods
A systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement was conducted through Scopus, PubMed and PsychInfo databases. Studies were included if they used a facet of personality that we were confidently able to map to a Big Five dimension.
Results
A total of 21 studies were eligible for inclusion. Most studies that reported a measure of association found a result that was statistically insignificant at the 5% level. In studies where the result was statistically significant, Extraversion, Openness, Agreeableness and Conscientiousness were almost always positively associated with healthy dietary behaviour and negatively associated with fat consumption, eating problems, obesity and measures of unhealthy weight across all the populations. Four studies found statistically significant results in the opposite direction. Neuroticism was associated with unhealthy behaviours or weight problems.
Conclusions and Implications
The Big-Five-model is an adequate instrument to measure the relationship between personality and diet. Healthy dietary behaviour tends to be associated with more pro-social personality characteristics, whereas poor weight control could be linked with Neuroticism. These results suggest there may be some benefit from using psychological traits to personalise interventions aimed at improving nutrition.
Key messages
There may be some benefit from using psychological traits to personalise interventions aimed at improving nutrition. Another interesting line of research may take account of the role of peer-effects and role-models in promoting healthy or unhealthy behaviour across social networks.
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Affiliation(s)
- M Diop
- Applied Economic, University of Granada, Granada, Spain
| | - D Epstein
- Applied Economic, University of Granada, Granada, Spain
| | - M Ruiz-Adame
- Applied Economic, University of Granada, Granada, Spain
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Abstract
Abstract
Objective
To systematically reviews the costs, resource uses, clinical complication and quality of life among patients with spinal cord injury.
Methods
A systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement was conducted through Scopus, PubMed and Embase databases.
Results
A total of 52 studies were eligible for inclusion. The estimated lifetime economic burden per individual with SCI ranges from $1.5 million to $3.0 million. Among studies which reported clinical outcomes, the mortality rates were estimated less than 4%, the most medical complication reported are spasticity, pain, pressures score and neurological deteriorations. Overall health status is negatively associated with QoL. People with a higher severity the of injury, a longer duration of injury, ambulatory mode, and with depression are more likely to report score low values of QoL. Employment and salary are consistently positively associated with better QoL. Age is negatively correlated with QoL.
Conclusions
Although spinal cord injury is related with high costs, no studies were found with detailed resources use. Also, A variety of instrument were used to examine how different factors have a role in predicting quality of life in spinal cord injury population. However, it is important to consider that differences found in those studies may at least be part in function of the instruments used. Therefore, standardized instruments should be used as part of these process.
Key messages
Paraplegia or the severity of SCI impact negatively quality of life and positively on healthcare and social costs. Promoting the employment of subjects with SCI generates a positive impact on their quality of life.
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Affiliation(s)
- M Diop
- Applied Economic, University of Granada, Granada, Spain
| | - D Epstein
- Applied Economic, University of Granada, Granada, Spain
| | - A Gaggero
- Applied Economic, University of Granada, Granada, Spain
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Borreda I, Zukermann R, Epstein D, Marcusohn E. IV sodium ferric gluconate complex in patients admitted due to acute decompansated heart failure and iron deficiency. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0896] [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
Patients suffering from heart failure (HF) and iron deficiency (ID) have worse outcomes. Intra-venous (IV) ferric carboxymaltose has been shown to reduce HF readmissions and improve symptoms in patients with HF with reduced ejection fraction. However, IV ferric carboxymaltose is significantly more expensive than IV Sodium Ferric Gluconate Complex limiting its availability to most HF failure patients around the globe.
Methods
This is a retrospective analysis comparing patients admitted due to acute decompensated HF (ADHF) and treated with or without IV sodium ferric gluconate complex on top of standard medical therapy. The study included all patients admitted due to ADHF, with either reduced or preserved EF between January 2013 to December 2018.
Results
During the study period, a total of 1856 patients were admitted due to ADHF. Among them 840 patients had an indication for IV iron therapy. Among them 122 (14.5%) patients were treated with IV Sodium Ferric Gluconate during hospitalisation. When comparing the group that was treated with IV iron compared to standard HF treatment no difference was found at one year after the hospitalization regarding reduction in readmissions due to ADHF (27.9% vs 24.8% respectively P=0.54), nor in all-cause mortality (25.4% vs. 25.6% respectively, P=0.99).
Conclusion
Treatment with IV Sodium ferric gluconate complex during hospitalization due to ADHF did not show any advantage in reduction of readmission due to heart failure after 1 year follow up.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- I Borreda
- Rambam Health Care Campus, Cardiology, Haifa, Israel
| | - R Zukermann
- Rambam Health Care Campus, Cardiology, Haifa, Israel
| | - D Epstein
- Rambam Health Care Campus, Intensive care unit, Haifa, Israel
| | - E Marcusohn
- Rambam Health Care Campus, Cardiology, Haifa, Israel
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Al-Shahi Salman R, Keerie C, Stephen J, Lewis S, Norrie J, Dennis MS, Newby DE, Wardlaw JM, Lip GY, Parry-Jones A, White PM, Baigent C, Lasserson D, Oliver C, O'Mahony F, Amoils S, Bamford J, Armitage J, Emberson J, Rinkel GJ, Lowe G, Innes K, Adamczuk K, Dinsmore L, Drever J, Milne G, Walker A, Hutchison A, Williams C, Fraser R, Anderson R, Covil K, Stewart K, Rees J, Hall P, Bullen A, Stoddart A, Moullaali TJ, Palmer J, Sakka E, Perthen J, Lyttle N, Samarasekera N, MacRaild A, Burgess S, Teasdale J, Coakley M, Taylor P, Blair G, Whiteley W, Shenkin S, Clancy U, Macleod M, Sutherland R, Moullaali T, Barugh A, Lerpiniere C, Moreton F, Fethers N, Anjum T, Krishnan M, Slade P, Storton S, Williams M, Davies C, Connor L, Gainard G, Murphy C, Barber M, Esson D, Choulerton J, Shaw L, Lucas S, Hierons S, Avis J, Stone A, Gbadamoshi L, Costa T, Pearce L, Harkness K, Richards E, Howe J, Kamara C, Lindert R, Ali A, Rehan J, Chapman S, Edwards M, Bathula R, Cohen D, Devine J, Mpelembue M, Yesupatham P, Chhabra S, Adewetan G, Ballantine R, Brooks D, Smith G, Rogers G, Marsden S, Clark S, Wilkinson A, Brown E, Stephenson L, Nyo K, Abraham A, Pai Y, Shim G, Baliga V, Nair A, Robinson M, Hawksworth C, Greig J, Alam I, Nortcliffe T, Ramiz R, Shaw R, Parry-Jones A, Lee S, Marsden T, Perez J, Birleson E, Yadava R, Sangombe M, Stafford S, Hughes T, Knibbs L, Morse B, Schwarz S, Jelley B, White S, Richard B, Lawson H, Moseley S, Tayler M, Edwards M, Triscott C, Wallace R, Hall A, Dell A, Rashed K, Board S, Buckley C, Tanate A, Pitt-Kerby T, Beesley K, Perry J, Hellyer C, Guyler P, Menon N, Tysoe S, Prabakaran R, Cooper M, Rajapakse A, Wynter I, Smith S, Weir N, Boxall C, Yates H, Smith S, Crawford P, Marigold J, Smith F, Harvey J, Evans S, Baldwin L, Hammond S, Mudd P, Bowring A, Keenan S, Thorpe K, Haque M, Taaffe J, Temple N, Peachey T, Wells K, Haines F, Butterworth-Cowin N, Horne Z, Licenik R, Boughton H, England T, Hedstrom A, Menezes B, Davies R, Johnson V, Whittingham-Jones S, Werring D, Obarey S, Watchurst C, Ashton A, Feerick S, Francia N, Banaras A, Epstein D, Marinescu M, Williams A, Robinson A, Humphries F, Anwar I, Annamalai A, Crawford S, Collins V, Shepherd L, Siddle E, Penge J, Epstein D, Qureshi S, Krishnamurthy V, Papavasileiou V, Waugh D, Veraque E, Douglas N, Khan N, Ramachandran S, Sommerville P, Rudd A, Kullane S, Bhalla A, Birns J, Ahmed R, Gibbons M, Klamerus E, Cendreda B, Muir K, Day N, Welch A, Smith W, Elliot J, Eltawil S, Mahmood A, Hatherley K, Mitchell S, Bains H, Quinn L, Teal R, Gbinigie I, Harston G, Mathieson P, Ford G, Schulz U, Kennedy J, Nagaratnam K, Bangalore K, Bhupathiraju N, Wharton C, Fotherby K, Nasar A, Stevens A, Willberry A, Evans R, Rai B, Blake C, Thavanesan K, Hann G, Changuion T, Nix S, Whiting A, Dharmasiri M, Mallon L, Keltos M, Smyth N, Eglinton C, Duffy J, Tone E, Sykes L, Porter E, Fitton C, Kirkineziadis N, Cluckie G, Kennedy K, Trippier S, Williams R, Hayter E, Rackie J, Patel B, Rita G, Blight A, Jones V, Zhang L, Choy L, Pereira A, Clarke B, Al-Hussayni S, Dixon L, Young A, Bergin A, Broughton D, Raghunathan S, Jackson B, Appleton J, Wilkes G, Buck A, Richardson C, Clarke J, Fleming L, Squires G, Law Z, Hutchinson C, Cvoro V, Couser M, McGregor A, McAuley S, Pound S, Cochrane P, Holmes C, Murphy P, Devitt N, Osborn M, Steele A, Guthrie LB, Smith E, Hewitt J, Chaston N, Myint M, Smith A, Fairlie L, Davis M, Atkinson B, Woodward S, Hogg V, Fawcett M, Finlay L, Dixit A, Cameron E, Keegan B, Kelly J, Concannon D, Dutta D, Ward D, Glass J, O'Connell S, Ngeh J, O'Kelly A, Williams E, Ragab S, Jenkinson D, Dube J, Gleave L, Leggett J, Kissoon N, Southern L, Naghotra U, Bokhari M, McClelland B, Adie K, Mate A, Harrington F, James A, Swanson E, Chant T, Naccache M, Coutts A, Courtauld G, Whurr S, Webber S, Shead E, Luder R, Bhargava M, Murali E, Cuenoud L, Pasco K, Speirs O, Chapman L, Inskip L, Kavanagh L, Srinivasan M, Motherwell N, Mukherjee I, Tonks L, Donaldson D, Button H, Wilcox R, Hurford F, Logan R, Taylor A, Arden T, Carpenter M, Datta P, Zahoor T, Jackson L, Needle A, Stanners A, Ghouri I, Exley D, Akhtar S, Brooke H, Beadle S, O'Brien E, Francis J, McGee J, Amis E, Mitchell J, Finlay S, Sinha D, Manoczki C, King S, Tarka J, Choudhary S, Premaruban J, Sutton D, Kumar P, Culmsee C, Winckley C, Davies H, Thatcher H, Vasileiadis E, Aweid B, Holden M, Mason C, Hlaing T, Madzamba G, Ingram T, Linforth M, Cullen C, Thomas N, France J, Saulat A, Bhaskaran B, Fitzell P, Horan K, Manyoni C, Garfield-Smith J, Griffin H, Atkins S, Redome J, Muddegowda G, Maguire H, Barry A, Abano N, Varquez R, Hiden J, Lyjko S, Remegoso A, Finney K, Butler A, Strecker M, MaCleod MJ, Irvine J, Nelson S, Guzmangutierrez G, Furnace J, Taylor V, Ramadan H, Storton K, Hassan S, Abdus Sami E, Bellfield R, Stewart K, Quinn O, Patterson C, Emsley H, Gregary B, Ahmed S, Patel S, Raj S, Sultan S, Wright F, Langhorne P, Graham R, Quinn T, McArthur K. Effects of oral anticoagulation for atrial fibrillation after spontaneous intracranial haemorrhage in the UK: a randomised, open-label, assessor-masked, pilot-phase, non-inferiority trial. Lancet Neurol 2021; 20:842-853. [PMID: 34487722 DOI: 10.1016/s1474-4422(21)00264-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Oral anticoagulation reduces the rate of systemic embolism for patients with atrial fibrillation by two-thirds, but its benefits for patients with previous intracranial haemorrhage are uncertain. In the Start or STop Anticoagulants Randomised Trial (SoSTART), we aimed to establish whether starting is non-inferior to avoiding oral anticoagulation for survivors of intracranial haemorrhage who have atrial fibrillation. METHODS SoSTART was a prospective, randomised, open-label, assessor-masked, parallel-group, pilot phase trial done at 67 hospitals in the UK. We recruited adults (aged ≥18 years) who had survived at least 24 h after symptomatic spontaneous intracranial haemorrhage, had atrial fibrillation, and had a CHA2DS2-VASc score of at least 2. Web-based computerised randomisation incorporating a minimisation algorithm allocated participants (1:1) to start or avoid long-term (≥1 year) full treatment dose open-label oral anticoagulation. The participants assigned to start oral anticoagulation received either a direct oral anticoagulant or vitamin K antagonist, and the group assigned to avoid oral anticoagulation received standard clinical practice (antiplatelet agent or no antithrombotic agent). The primary outcome was recurrent symptomatic spontaneous intracranial haemorrhage, and was adjudicated by an individual masked to treatment allocation. All outcomes were ascertained for at least 1 year after randomisation and assessed in the intention-to-treat population of all randomly assigned participants, using Cox proportional hazards regression adjusted for minimisation covariates. We planned a sample size of 190 participants (one-sided p=0·025, power 90%, allowing for non-adherence) based on a non-inferiority margin of 12% (or adjusted hazard ratio [HR] of 3·2). This trial is registered with ClinicalTrials.gov (NCT03153150) and is complete. FINDINGS Between March 29, 2018, and Feb 27, 2020, consent was obtained at 61 sites for 218 participants, of whom 203 were randomly assigned at a median of 115 days (IQR 49-265) after intracranial haemorrhage onset. 101 were assigned to start and 102 to avoid oral anticoagulation. Participants were followed up for median of 1·2 years (IQR 0·97-1·95; completeness 97·2%). Starting oral anticoagulation was not non-inferior to avoiding oral anticoagulation: eight (8%) of 101 in the start group versus four (4%) of 102 in the avoid group had intracranial haemorrhage recurrences (adjusted HR 2·42 [95% CI 0·72-8·09]; p=0·152). Serious adverse events occurred in 17 (17%) participants in the start group and 15 (15%) in the avoid group. 22 (22%) patients in the start group and 11 (11%) patients in the avoid group died during the study. INTERPRETATION Whether starting oral anticoagulation was non-inferior to avoiding it for people with atrial fibrillation after intracranial haemorrhage was inconclusive, although rates of recurrent intracranial haemorrhage were lower than expected. In view of weak evidence from analyses of three composite secondary outcomes, the possibility that oral anticoagulation might be superior for preventing symptomatic major vascular events should be investigated in adequately powered randomised trials. FUNDING British Heart Foundation, Medical Research Council, Chest Heart & Stroke Scotland.
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Epstein D, Enticott J, Larson H, Barton C. Pragmatic cluster randomised control trial using Vaxcards as an age-appropriate tool to incentivise and educate school students about vaccination. BMJ Open 2021; 11:e049562. [PMID: 34475171 PMCID: PMC8413930 DOI: 10.1136/bmjopen-2021-049562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE This trial aimed to determine if return rates of consent forms for vaccination could be improved when Vaxcards were offered as an incentive to school children. SETTING Nineteen schools in South East Melbourne participated. INTERVENTIONS Students in the experimental arm received a pack of Vaxcards when they returned their government consent form. OUTCOME MEASURES Return of 'yes' consent forms for vaccination as part of a local government council vaccine programme was the primary outcome of this trial. Return rates were compared between the intervention and control schools and with historical return rates. RESULTS Secondary school students (N=3087) from 19 schools participated. Compared with historical returns, a small global reduction in 'yes' responses to consent forms of -4.21% in human papilloma virus consent 'yes' responses and -4.69% for diphtheria, tetanus and pertussis was observed across all schools. No difference between the experimental and control groups was observed. CONCLUSIONS Low 'yes' consent rates and reduction in consent rates between 2018 and 2019 for all groups are concerning. This finding highlights the need for behaviour change interventions across all groups to increase vaccine confidence. Lack of effect of incentivisation with Vaxcards in this study may have been due to the timing of receiving the cards (after the decision to vaccinate had been made, not before) and the limited intensity of the intervention. Optimising the timing and the intensity of exposure to Vaxcards could improve the outcome. TRIAL REGISTRATION NUMBER ACTRN12618001753246.
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Affiliation(s)
- Daniel Epstein
- Department of General Practice, Monash University, Clayton, Victoria, Australia
| | - Joanne Enticott
- Department of General Practice, Monash University, Notting Hill, Victoria, Australia
- Southern Synergy, Victoria, Australia
| | - Heidi Larson
- Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Christopher Barton
- Department of General Practice, Monash University, Clayton, Victoria, Australia
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Hickmott L, Jeyarajah C, Logarajah S, Webber A, Epstein D, Qureshi S, Penge J. 133 Incidence of Imaging Confirmed Stroke and Thrombotic Events in Older Adults with Severe COVID-19 Infection. Age Ageing 2021. [PMCID: PMC7989647 DOI: 10.1093/ageing/afab030.94] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
During the initial phase of the response to COVID-19, concern was raised regarding a potential link with increased risk of stroke. We aimed to explore the incidence of stroke and thrombotic events within our local population with COVID-19 infection who required admission to the Intensive Care Unit (ICU). Methods Retrospective analysis of 57 consecutive patients with a diagnosis of COVID-19 infection admitted to Barnet General Hospital ICU between 6th March and 26th April 2020. Cases were reviewed to establish whether there had been imaging (CT or MRI) confirmed ischaemic stroke, intra-cerebral haemorrhage (ICH), venous sinus thrombosis (VST) or other thrombotic event, including pulmonary embolism (PE). Data was collected on baseline characteristics and blood tests including D-Dimer levels. Statistical analysis was performed using two-tailed t-test and Fischer’s exact test (FET). Findings: Nineteen patients (33%) were age 65 years or older (mean age 69, range 65 to 74 years) and of these 2 patients (10.5%) had imaging confirmed acute ischaemic stroke. In those under 65 (mean age 54, range 29–64 years) there was one confirmed ICH and one VST. The incidence of PE was 21% in both groups. Survival was significantly lower in the age 65 or older group (26.3% versus 63.2%, p = 0.0119 (FET)). Peak recorded D-Dimer levels also appeared to be significantly higher in the age 65 or older group (p = 0.0003, 95% CI 13068.89 to 39858.68). Conclusions and limitations These findings highlight the importance of awareness of risk of thrombotic events, including acute stroke, in older adults with severe Covid-19 infection. It is possible that the incidence of stroke was underestimated, including due to challenges identifying clinical signs of acute stroke and safely obtaining imaging in this population. Further, ideally prospective, studies are required to more clearly elucidate the degree of association between COVID-19 infection and stroke and VST.
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Sweeney A, Bellenberg H, Butt H, Badat S, Epstein D. 80 Improving Documentation of DNAR Decisions on the Acute Medical Take. Age Ageing 2021. [DOI: 10.1093/ageing/afab030.41] [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: 11/12/2022] Open
Abstract
Abstract
Introduction
The BMA, Resuscitation Council and Royal College of Nursing have set out clear guidelines on documentation of Resuscitation discussions and decisions.1 On the acute medical take documentation of these discussions and decisions can be unclear despite use of an electronic patient record (EPR). The aim of this audit was to improve documentation of Do Not Attempt Resuscitation (DNAR) decisions in EPR.
Methods
We listed patients admitted on the medical take over 1-week, looking at resuscitation status and the documentation of the DNAR decision. We then implemented a change to the format of the EPR treatment escalation plan (TEP) form. Prior to the change the DNAR form was behind the TEP form which had to be clicked on separately and was not mandatory to complete. After the intervention the DNAR decision was placed in a box on the front page of the TEP form to ensure that it was clear and accessible.
Results
Pre-intervention we reviewed 114 patients notes of which 94 were DNAR. Of these 94 only 17 (18%) had correctly documented DNAR decisions in EPR. Following the intervention we again looked at all admissions to the medical take over a 1-week period, out of 151 patients 75 were DNAR and of these 75 patients 29 had correctly documented DNAR forms. This shows an increase in the percentage of the DNAR decisions filled in from 18% to 39%.
Conclusion
The results show that although there has been an improvement in the number of DNAR decisions being documented there are still a large percentage of patients who do not have this correctly documented. We are designing further interventions to ensure that the DNAR documentation is marked as a mandatory part of the TEP form as well as educating around the importance of this documentation.
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Affiliation(s)
- A Sweeney
- Barnet Hospital, Royal Free NHS Trust
| | | | - H Butt
- Barnet Hospital, Royal Free NHS Trust
| | - S Badat
- Barnet Hospital, Royal Free NHS Trust
| | - D Epstein
- Barnet Hospital, Royal Free NHS Trust
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Shekel E, Rosenfeld H, Epstein D, Grinfeld G, Elinger G, Tova Y, Ben-David M, Greenberg V, Sapir E, Zalmanov-Faermann S, Pfeffer R, Levin D. Comparing Different Psychoeducational Interventions to Decrease Treatment Related Anxiety in Breast Cancer Patients Undergoing Radiotherapy. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.1427] [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: 11/25/2022]
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Marcusohn E, Epstein D, Roguin A, Zukermann R. P2679Normal high sensitive troponin I and suspected myocardial infarction, is the rapid rule out algorythm for all? Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0997] [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
Introduction
Since the introduction of High sensitive troponin assays, many studies showed that patients presenting to the ED with cardiac chest pain and HsTnI under 5 ng/dl have very good prognosis and extremely low risk for major cardiovascular events at follow up. These studies led to a few rapid rule out algorythms for MI according to undetectable HsTnI in first hours following admission.
Purpose
The aim of the study was to examine whether a maximal HsTnI under 5 ng/dl, in a hemodynamicaly stable patient, is sufficient to discharge a patient without further testing.
Methods
Retrospective analysis of patients admitted to the emergency depatment due to suspected myocardial infarction between February 2016 and December 2018. All patients had a HsTnI under 5 ng/dl and were either discharged home or admitted for further observation and testing. The collection of data was performed by the MDCLONE software from the electronic medical records in our medical center.
Results
Between February 2016 and December 2018, 10,936 patients were admitted to the emergency department due to chest pain or suspected MI. In 7925 (72%) the maximal HsTnI value was under 5 ng/dl. Group 1 included 6699 (85%) patients who did not undergo any further test and group 2 included 1226 (15%) who were admitted for further testing. Further testing included Coronary CT in 999 (81%) and Stress myocardial perfusion imaging (MPI) in 227 (19%). 11 patients underwent both tests. Out of the 999 patients examined with coronary CT, 114 (11%) needed further evaluation with coronary angiogiography and 41 required angioplasty and stening. 18 (7%) patients that were evaluated using stress MPI needed angio and 7 (3%) required stenting.
Comparing the group 1 and 2, patients who went through further testing were more likely to be older, with higher prevalence of diabetes, hypertenstion, smoking history and after CABG in the past. Group 1 had 0.07%, 0.16% and 0.33% all cause mortality in 30, 90 and 360 days respectivly. Group 2 had no mortality in 30 and 90 days, and 0.25% all cause mortality in 360 days. No statistical significance was reached in all time points.
There was no difference in re-admissions in the first 90 days after discharge between the groups.
Conclusions
Based on our data, patients admitted to the emergency department due to suspected myocardial infarction and known cardiovascular risk factors but with HsTnI under the 5 ng/dl, the use of rapid rule out algorithms may be questionable.
Acknowledgement/Funding
None
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Affiliation(s)
- E Marcusohn
- Rambam Health Care Campus, Cardiology, Haifa, Israel
| | - D Epstein
- Rambam Health Care Campus, Cardiology, Haifa, Israel
| | - A Roguin
- Hillel Yaffe Medical Center, Hadera, Israel
| | - R Zukermann
- Rambam Health Care Campus, Cardiology, Haifa, Israel
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Cardullo S, Perez LG, Epstein D, Cellini N, Monteanni T, Terraneo A, Bonci A, Gallimberti L, Madeo G. Sleep quality in patients with cocaine use disorder undergoing repetitive Transcranial Magnetic Stimulation (rTMS). Brain Stimul 2019. [DOI: 10.1016/j.brs.2018.12.621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Abstract
BACKGROUND The aim of this study is to determine the effectiveness of non-pharmacological interventions for prevention of cardiovascular disease (CVD) events and mortality in healthy adults or those at high risk of CVD. METHODS An umbrella review about primary prevention of non-pharmacological interventions was undertaken in key databases as PubMed Health, Effective Health Care Program AHRQ, McMaster University and the Cochrane Plus until July 2017. The primary outcomes were the relative risk of fatal and non-fatal CVD events, and mortality. Secondary outcomes were adverse events. RESULTS Twenty-four reviews were included of which thirteen reported outcomes of interest. Four of these found a pooled statistically significant risk reduction: dietary supplements of vitamin D, increased consumption of omega 3 fatty acids, Qigong, and counselling or education to modify more than one cardiovascular risk factor. Seven studies reported adverse events but minor or insignificant with respect to the control group. CONCLUSIONS Four non-pharmacological interventions have been shown to provide a statistically significant reduction in risk of CVD events or overall mortality, with minor adverse events if any. Further research should aim for higher methodological quality and longer follow-up of interventions to establish if these interventions, alone or in combination, translate into definite long-term health benefits.
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Van Heertum K, Epstein D, Libby V, Segal T, Bouchelion A, Goldfarb J, Weinerman R. Body mass index (BMI) is not correlated with blastulation rate. Fertil Steril 2018. [DOI: 10.1016/j.fertnstert.2018.07.368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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23
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Epstein D, Gohel M, Heatley F, Davies AH. Cost-effectiveness of treatments for superficial venous reflux in patients with chronic venous ulceration. BJS Open 2018; 2:203-212. [PMID: 30079389 PMCID: PMC6069357 DOI: 10.1002/bjs5.56] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 01/19/2018] [Indexed: 12/04/2022] Open
Abstract
Background Venous leg ulcers impair quality of life significantly, with substantial costs to health services. The aim of this study was to estimate the cost‐effectiveness of interventional procedures alongside compression therapy versus compression therapy alone for the treatment of chronic venous leg ulceration. Methods A Markov decision analytical model was developed. The main outcome measures were quality‐adjusted life‐years (QALYs) and lifetime costs per patient, from the perspective of the UK National Health Service at 2015 prices. Resource use included the initial procedures, compression therapy, primary care and outpatient consultations. The interventional procedures included superficial venous surgery, endothermal ablation and ultrasound‐guided foam sclerotherapy (UGFS). The study population was patients with a chronic venous ulcer who were eligible for either compression therapy or an interventional procedure. Data were obtained from systematic review and meta‐analysis of RCTs. Results Surgery gained 0·112 (95 per cent c.i. −0·011 to 0·213) QALYs compared with compression therapy alone, with a difference in lifetime costs of €−1330 (−3570 to 1262). Given the expected savings in community care, the procedure would pay for itself within 4 years. There was insufficient evidence regarding endothermal ablation and UGFS to draw conclusions. Discussion This modelling study found surgery to be more effective and less costly than compression therapy alone. Further RCT evidence is required for both endothermal ablation and UGFS.
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Affiliation(s)
- D Epstein
- Department of Applied Economics University of Granada Campus de Cartuja, 18071 Granada Spain
| | - M Gohel
- Department of Vascular Surgery Addenbrooke's Hospital Cambridge UK
| | - F Heatley
- Section of Vascular Surgery, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine Imperial College School of Medicine London UK
| | - A H Davies
- Section of Vascular Surgery, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine Imperial College School of Medicine London UK
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Jin EJ, Kiral FR, Ozel MN, Burchardt LS, Osterland M, Epstein D, Wolfenberg H, Prohaska S, Hiesinger PR. Live Observation of Two Parallel Membrane Degradation Pathways at Axon Terminals. Curr Biol 2018; 28:1027-1038.e4. [PMID: 29551411 PMCID: PMC5944365 DOI: 10.1016/j.cub.2018.02.032] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [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: 10/03/2017] [Revised: 01/24/2018] [Accepted: 02/14/2018] [Indexed: 01/04/2023]
Abstract
Neurons are highly polarized cells that require continuous turnover of membrane proteins at axon terminals to develop, function, and survive. Yet, it is still unclear whether membrane protein degradation requires transport back to the cell body or whether degradation also occurs locally at the axon terminal, where live observation of sorting and degradation has remained a challenge. Here, we report direct observation of two cargo-specific membrane protein degradation mechanisms at axon terminals based on a live-imaging approach in intact Drosophila brains. We show that different acidification-sensing cargo probes are sorted into distinct classes of degradative “hub” compartments for synaptic vesicle proteins and plasma membrane proteins at axon terminals. Sorting and degradation of the two cargoes in the separate hubs are molecularly distinct. Local sorting of synaptic vesicle proteins for degradation at the axon terminal is, surprisingly, Rab7 independent, whereas sorting of plasma membrane proteins is Rab7 dependent. The cathepsin-like protease CP1 is specific to synaptic vesicle hubs, and its delivery requires the vesicle SNARE neuronal synaptobrevin. Cargo separation only occurs at the axon terminal, whereas degradative compartments at the cell body are mixed. These data show that at least two local, molecularly distinct pathways sort membrane cargo for degradation specifically at the axon terminal, whereas degradation can occur both at the terminal and en route to the cell body.
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Affiliation(s)
- Eugene Jennifer Jin
- Division of Neurobiology, Freie Universität Berlin, Königin Luise Straße 1-3, 14195 Berlin, Germany; Graduate School of Biomedical Sciences, UT Southwestern Medical Center, Dallas, TX 75390, USA
| | - Ferdi Ridvan Kiral
- Division of Neurobiology, Freie Universität Berlin, Königin Luise Straße 1-3, 14195 Berlin, Germany
| | - Mehmet Neset Ozel
- Division of Neurobiology, Freie Universität Berlin, Königin Luise Straße 1-3, 14195 Berlin, Germany; Graduate School of Biomedical Sciences, UT Southwestern Medical Center, Dallas, TX 75390, USA
| | - Lara Sophie Burchardt
- Division of Neurobiology, Freie Universität Berlin, Königin Luise Straße 1-3, 14195 Berlin, Germany
| | - Marc Osterland
- Zuse Institute Berlin, Takustraße 7, 14195 Berlin, Germany
| | - Daniel Epstein
- Division of Neurobiology, Freie Universität Berlin, Königin Luise Straße 1-3, 14195 Berlin, Germany
| | - Heike Wolfenberg
- Division of Neurobiology, Freie Universität Berlin, Königin Luise Straße 1-3, 14195 Berlin, Germany
| | | | - Peter Robin Hiesinger
- Division of Neurobiology, Freie Universität Berlin, Königin Luise Straße 1-3, 14195 Berlin, Germany.
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Levin D, Shekel E, Epstein D, Pfeffer R, Lipsky Y, Zalmanov-Faermann S, Spiegelmann R. Determining the Optimal Technique for Treating Multiple Brain Metastases With a Single Isocenter Plan. Int J Radiat Oncol Biol Phys 2017. [DOI: 10.1016/j.ijrobp.2017.06.2254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Gómez-García F, Epstein D, Isla-Tejera B, Lorente A, Vélez García-Nieto A, Ruano J. Short-term efficacy and safety of new biological agents targeting the interleukin-23-T helper 17 pathway for moderate-to-severe plaque psoriasis: a systematic review and network meta-analysis. Br J Dermatol 2016; 176:594-603. [PMID: 27292159 DOI: 10.1111/bjd.14814] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2016] [Indexed: 12/26/2022]
Abstract
A new generation of biologics targeting the interleukin-23-T helper 17 pathway has been developed. This study aimed to assess the short-term effectiveness and safety of these new agents using a network meta-analysis. Twenty-seven randomized clinical trials (10 629 patients) were identified by a comprehensive systematic literature review (PROSPERO 2015: CRD42015025472). Quality of evidence was assessed following Cochrane-compliant rules and the Grading of Recommendations, Assessment, Development and Evaluations approach. Efficacy and safety outcomes at weeks 10-16 were compared using a random-effects network meta-analysis within a frequentist framework to estimate pooled odds ratios (ORs) of direct and indirect comparisons among the therapeutic options. There were six direct drug-to-drug comparisons in the network, with a high degree of consistency between the direct and indirect evidence. From the available evidence, infliximab 5 mg kg-1 every 8 weeks [OR 118·89, 95% confidence interval (CI) 60·91-232·04] and secukinumab 300 mg every 4 weeks (OR 87·07, 95% CI 55·01-137·82) are shown to be among the most effective short-term treatments, but are ranked as the biologics most likely to produce any adverse event or an infectious adverse event, respectively. Ustekinumab 90 mg every 12 weeks, the third most efficacious treatment (OR 73·67, 95% CI 46·97-115·56), was the only agent that did not show increased risk of adverse events compared with placebo. Treatment recommendations should also consider long-term outcomes and costs.
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Affiliation(s)
- F Gómez-García
- Department of Dermatology, Hospital Universitario Reina Sofía, Menendez Pidal Ave, 14004, Córdoba, Spain.,Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Universitario Reina Sofía/Universidad de Córdoba, Córdoba, Spain
| | - D Epstein
- Department of Applied Economics, School of Economics, University of Granada, Granada, Spain
| | - B Isla-Tejera
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Universitario Reina Sofía/Universidad de Córdoba, Córdoba, Spain.,Department of Pharmacy, Hospital Universitario Reina Sofía, Menendez Pidal Ave, 14004, Córdoba, Spain
| | - A Lorente
- Department of Dermatology, Hospital Universitario Reina Sofía, Menendez Pidal Ave, 14004, Córdoba, Spain.,Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Universitario Reina Sofía/Universidad de Córdoba, Córdoba, Spain
| | - A Vélez García-Nieto
- Department of Dermatology, Hospital Universitario Reina Sofía, Menendez Pidal Ave, 14004, Córdoba, Spain.,Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Universitario Reina Sofía/Universidad de Córdoba, Córdoba, Spain
| | - J Ruano
- Department of Dermatology, Hospital Universitario Reina Sofía, Menendez Pidal Ave, 14004, Córdoba, Spain.,Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Universitario Reina Sofía/Universidad de Córdoba, Córdoba, Spain
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Levin D, Shekel E, Epstein D, Spiegelmann R, Pfeffer R. SU-G-BRC-06: Evaluation of a Novel Radiosurgery Software for Treating Multiple Brain Metastases Simultaneously in a Single Fraction. Med Phys 2016. [DOI: 10.1118/1.4956896] [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: 11/07/2022] Open
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28
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Shekel E, Epstein D, Levin D. SU-F-T-517: Determining the Tissue Equivalence of a Brass Mesh Bolus in a Reconstructed Chest Wall Irradiation. Med Phys 2016. [DOI: 10.1118/1.4956702] [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: 11/07/2022] Open
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29
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Bueler E, Epstein D, Hicks-Little C, Fuller A, DiMuzio J, McGlade E, Yurgelun-Todd D. Aggression and Quality Of Life in Collegiate Football Players at Pre-season and One-year Follow Up. Med Sci Sports Exerc 2016. [DOI: 10.1249/01.mss.0000487525.37568.96] [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: 11/21/2022]
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30
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Shekel E, Epstein D, Spiegelmann R, Pfeffer R, Levin D. A Novel Radiosurgery Software for Treating Multiple Brain Metastases Simultaneously in a Single Fraction: First Clinical Experience. Int J Radiat Oncol Biol Phys 2015. [DOI: 10.1016/j.ijrobp.2015.07.1976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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31
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Epstein D, Shekel E, Levin D. SU-E-T-377: Evaluation of a Novel Transmission Detector as a Reference Chamber for Use in Beam Measurements. Med Phys 2015. [DOI: 10.1118/1.4924738] [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: 11/07/2022] Open
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32
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Simpson K, Miller J, Lancaster T, Henn M, Epstein D, Schuessler R, Balzer D, Shahanavaz S, Murphy J, Eghtesady P, Boston U, Canter C. Improved Transplant Survival in Failed Fontan Patients With Preserved Ventricular Function in the Current Era. J Heart Lung Transplant 2015. [DOI: 10.1016/j.healun.2015.01.086] [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: 12/01/2022] Open
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Faria R, Liu S, Epstein D, Manca A. Real-World Verse Randomised Controlled Trial Data: A Case Study On The Cost-Effectiveness Of Laparoscopic Surgery For Chronic Reflux. Value Health 2014; 17:A576. [PMID: 27201936 DOI: 10.1016/j.jval.2014.08.1939] [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: 06/05/2023]
Affiliation(s)
- R Faria
- University of York, York, UK
| | - S Liu
- University of York, York, UK
| | | | - A Manca
- University of York, York, UK
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Shekel E, Levin D, Epstein D, Tova Y, Zalmanov-Faermann S, Pfeffer R. Is Contouring the Left Anterior Descending (LAD) Artery Necessary for Left-Breast Patients?: A Retrospective Comparison Between Treated and Revised Plans. Int J Radiat Oncol Biol Phys 2014. [DOI: 10.1016/j.ijrobp.2014.05.916] [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: 10/24/2022]
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35
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Epstein D, Shekel E, Levin D. SU-E-T-426: Dose Delivery Accuracy in Breast Field Junction for Free Breath and Deep Inspiration Breath Hold Techniques. Med Phys 2014. [DOI: 10.1118/1.4888759] [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: 11/07/2022] Open
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36
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Wang D, Epstein D, Khalaf O, Srinivasan S, Williamson WR, Fayyazuddin A, Quiocho FA, Hiesinger PR. Ca2+-Calmodulin regulates SNARE assembly and spontaneous neurotransmitter release via v-ATPase subunit V0a1. ACTA ACUST UNITED AC 2014; 205:21-31. [PMID: 24733584 PMCID: PMC3987144 DOI: 10.1083/jcb.201312109] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Ca2+–Calmodulin binding to neuronal v-ATPase V0 subunit a1 (V100) regulates SNARE complex assembly for a putative subset of synaptic vesicles that sustain spontaneous release in Drosophila. Most chemical neurotransmission occurs through Ca2+-dependent evoked or spontaneous vesicle exocytosis. In both cases, Ca2+ sensing is thought to occur shortly before exocytosis. In this paper, we provide evidence that the Ca2+ dependence of spontaneous vesicle release may partly result from an earlier requirement of Ca2+ for the assembly of soluble N-ethylmaleimide–sensitive fusion attachment protein receptor (SNARE) complexes. We show that the neuronal vacuolar-type H+-adenosine triphosphatase V0 subunit a1 (V100) can regulate the formation of SNARE complexes in a Ca2+–Calmodulin (CaM)-dependent manner. Ca2+–CaM regulation of V100 is not required for vesicle acidification. Specific disruption of the Ca2+-dependent regulation of V100 by CaM led to a >90% loss of spontaneous release but only had a mild effect on evoked release at Drosophila melanogaster embryo neuromuscular junctions. Our data suggest that Ca2+–CaM regulation of V100 may control SNARE complex assembly for a subset of synaptic vesicles that sustain spontaneous release.
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Affiliation(s)
- Dong Wang
- Department of Physiology and 2 Green Center Division for Systems Biology, University of Texas Southwestern Medical Center, Dallas, TX 75390
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37
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Wang D, Epstein D, Khalaf O, Srinivasan S, Williamson WR, Fayyazuddin A, Quiocho FA, Hiesinger PR. Ca2+–Calmodulin regulates SNARE assembly and spontaneous neurotransmitter release via v-ATPase subunit V0a1. J Gen Physiol 2014. [DOI: 10.1085/jgp.1435oia16] [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: 11/20/2022] Open
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38
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Epstein D, Sculpher MJ, Powell JT, Thompson SG, Brown LC, Greenhalgh RM. Long-term cost-effectiveness analysis of endovascular versus open repair for abdominal aortic aneurysm based on four randomized clinical trials. Br J Surg 2014; 101:623-31. [DOI: 10.1002/bjs.9464] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2014] [Indexed: 11/08/2022]
Abstract
Abstract
Background
A number of published economic evaluations of elective endovascular aneurysm repair (EVAR) versus open repair for abdominal aortic aneurysm (AAA) have come to differing conclusions about whether EVAR is cost-effective. This paper reviews the current evidence base and presents up-to-date cost-effectiveness analyses in the light of results of four randomized clinical trials: EVAR-1, DREAM, OVER and ACE.
Methods
Markov models were used to estimate lifetime costs from a UK perspective and quality-adjusted life-years (QALYs) based on the results of each of the four trials. The outcomes included in the model were: procedure costs, surveillance costs, reintervention costs, health-related quality of life, aneurysm-related mortality and other-cause mortality. Alternative scenarios about complications, reinterventions and deaths beyond the trial were explored.
Results
Models based on the results of the EVAR-1, DREAM or ACE trials did not find EVAR to be cost-effective at thresholds used in the UK (up to £30 000 per QALY). EVAR seemed cost-effective according to models based on the OVER trial. These results seemed robust to alternative model scenarios about events beyond the trial intervals.
Conclusion
These analyses did not find that EVAR is cost-effective compared with open repair in the long term in trials conducted in European centres. EVAR did appear to be cost-effective based on the OVER trial, conducted in the USA. Caution must be exercised when transferring the results of economic evaluations from one country to another.
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Affiliation(s)
- D Epstein
- Department of Applied Economics, University of Granada, Granada, Spain
| | - M J Sculpher
- Centre for Health Economics, University of York, York, UK
| | - J T Powell
- Vascular Surgery Research Group, Imperial College London, UK
| | - S G Thompson
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - L C Brown
- Medical Research Council Clinical Trials Unit, London, UK
| | - R M Greenhalgh
- Vascular Surgery Research Group, Imperial College London, UK
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Cherry S, Jin EJ, Ozel MN, Lu Z, Agi E, Wang D, Jung WH, Epstein D, Meinertzhagen IA, Chan CC, Hiesinger PR. Charcot-Marie-Tooth 2B mutations in rab7 cause dosage-dependent neurodegeneration due to partial loss of function. eLife 2013; 2:e01064. [PMID: 24327558 PMCID: PMC3857549 DOI: 10.7554/elife.01064] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The small GTPase Rab7 is a key regulator of endosomal maturation in eukaryotic cells. Mutations in rab7 are thought to cause the dominant neuropathy Charcot-Marie-Tooth 2B (CMT2B) by a gain-of-function mechanism. Here we show that loss of rab7, but not overexpression of rab7 CMT2B mutants, causes adult-onset neurodegeneration in a Drosophila model. All CMT2B mutant proteins retain 10–50% function based on quantitative imaging, electrophysiology, and rescue experiments in sensory and motor neurons in vivo. Consequently, expression of CMT2B mutants at levels between 0.5 and 10-fold their endogenous levels fully rescues the neuropathy-like phenotypes of the rab7 mutant. Live imaging reveals that CMT2B proteins are inefficiently recruited to endosomes, but do not impair endosomal maturation. These findings are not consistent with a gain-of-function mechanism. Instead, they indicate a dosage-dependent sensitivity of neurons to rab7-dependent degradation. Our results suggest a therapeutic approach opposite to the currently proposed reduction of mutant protein function. DOI:http://dx.doi.org/10.7554/eLife.01064.001 Charcot-Marie-Tooth disease is an inherited disorder of the nervous system with symptoms that typically begin in adolescence or early adulthood. The sensory and motor nerves gradually degenerate, causing muscles to waste away and leading to the loss of touch sensation across the body. One subtype of the disease—Charcot-Marie-Tooth 2B—is caused by mutations in a gene called rab7, which codes for a protein that helps to regulate the breakdown of waste proteins inside cells. Charcot-Marie-Tooth 2B is described as a genetically dominant disorder because all patients have one wild type copy and one mutant copy of the rab7 gene. Overexpression of the mutant gene in cells grown in culture alters many of the signaling pathways inside the cells, but it is unclear whether these alterations cause the pathology seen in the disease. Now, Cherry et al. have obtained new insights into the genetics of Charcot-Marie-Tooth 2B by creating the first animal model of the disorder. Fruit flies that did not have the rab7 gene in the light-sensitive sensory neurons in their eyes were used to compare normal and mutant cells. While the two cell types were initially similar, the mutant cells gradually degenerated in the adult animal. By contrast, cells that overexpressed a mutant form of the rab7 gene continued to function normally throughout adulthood. Moreover, when mutant Rab7 proteins were introduced into the cells that lacked the rab7 gene, the proteins restored the cells’ sensitivity to light. These results suggest that mutant Rab7 proteins do not cause degeneration; instead, it is the loss of normal Rab7 function that causes problems. At present, most research into treatment is aimed at finding ways to reduce the activity of mutant Rab7 proteins. However, the work of Cherry et al. suggests that increasing the activity of normal Rab7 proteins—or increasing the activity of alternative pathways that degrade waste proteins—may help to restore nerve function in this, and possibly other, neurodegenerative diseases. DOI:http://dx.doi.org/10.7554/eLife.01064.002
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Affiliation(s)
- Smita Cherry
- Department of Physiology, University of Texas Southwestern Medical Center, Dallas, United States
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Levin D, Shekel E, Epstein D, Tova Y, Zalmanov-Faermann S, Pfeffer R. TH-A-116-10: A Dosimetric Comparison Between Volumetric Modulated Arc and 3D Treatment Plans for Synchronous Bilateral Breast Patients Treated with Simultaneous Integrated Boost. Med Phys 2013. [DOI: 10.1118/1.4815739] [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: 11/07/2022] Open
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Power A, Epstein D, Cohen D, Bathula R, Devine J, Kar A, Taube D, Duncan N, Ames D. Renal Impairment Reduces the Efficacy of Thrombolytic Therapy in Acute Ischemic Stroke. Cerebrovasc Dis 2013; 35:45-52. [DOI: 10.1159/000345071] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Accepted: 10/11/2012] [Indexed: 11/19/2022] Open
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Thapar A, Garcia Mochon L, Epstein D, Shalhoub J, Davies AH. Modelling the cost-effectiveness of carotid endarterectomy for asymptomatic stenosis5. Br J Surg 2012. [DOI: 10.1002/bjs.8960] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Background
The aim of this study was to model the cost-effectiveness of carotid endarterectomy for asymptomatic stenosis versus medical therapy based on 10-year data from the Asymptomatic Carotid Surgery Trial (ACST).
Methods
This was a cost–utility analysis based on clinical effectiveness data from the ACST with UK-specific costs and stroke outcomes. A Markov model was used to calculate the incremental cost-effectiveness ratio (ICER, or cost per additional quality-of-life year) for a strategy of early endarterectomy versus medical therapy for the average patient and published subgroups. An exploratory analysis considered contemporary event rates.
Results
The ICER was £ 7584 per additional quality-adjusted life-year (QALY) for the average patient in the ACST. At thresholds of £ 20 000 and £ 30 000 there was a 74 and 84 per cent chance respectively of early endarterectomy being cost-effective. The ICER for men below 75 years of age was £ 3254, and that for men aged 75 years or above was £ 71 699. For women aged under 75 years endarterectomy was less costly and more effective than medical therapy; for women aged 75 years or more endarterectomy was less effective and more costly than medical therapy. At contemporary perioperative event rates of 2·7 per cent and background any-territory stroke rates of 1·6 per cent, early endarterectomy remained cost-effective.
Conclusion
In the ACST, early endarterectomy was predicted to be cost-effective in those below 75 years of age, using a threshold of £ 20 000 per QALY. If background any-territory stroke rates fell below 1 per cent per annum, early endarterectomy would cease to be cost-effective.
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Affiliation(s)
- A Thapar
- Academic Section of Vascular Surgery, Imperial College London, London, UK
| | - L Garcia Mochon
- Department of Health Management, Andalusian School of Public Health, Granada, Spain
| | - D Epstein
- Centre for Health Economics, University of York, York, UK
- Department of Health Management, Andalusian School of Public Health, Granada, Spain
| | - J Shalhoub
- Academic Section of Vascular Surgery, Imperial College London, London, UK
| | - A H Davies
- Academic Section of Vascular Surgery, Imperial College London, London, UK
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Vinciguerra P, Albé E, Frueh BE, Trazza S, Epstein D. Two-year corneal cross-linking results in patients younger than 18 years with documented progressive keratoconus. Am J Ophthalmol 2012; 154:520-6. [PMID: 22633357 DOI: 10.1016/j.ajo.2012.03.020] [Citation(s) in RCA: 155] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Revised: 03/06/2012] [Accepted: 03/06/2012] [Indexed: 11/18/2022]
Abstract
PURPOSE To report refractive, topographic, aberrometric, and tomographic outcomes 24 months after corneal cross-linking (CXL) in patients up to 18 years of age with progressive keratoconus. DESIGN Prospective, interventional case series. METHODS Forty eyes underwent riboflavin-ultraviolet A-induced CXL. Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), sphere and cylinder, topography, aberrometry, tomography, and endothelial cell counts were evaluated at baseline and at 1, 3, 6, 12, and 24 months. RESULTS Mean logarithm of the minimum angle of resolution baseline UCVA and BSCVA were 0.79 ± 0.21 and 0.39 ± 0.10, respectively. Mean UCVA and BSCVA at 2 years were 0.58 ± 0.18 and 0.20 ± 0.09, respectively. The improvement in UCVA and BSCVA was significant throughout the postoperative follow-up (P < .05). Mean spherical equivalent refraction showed a significant decrease of 1.57 diopters (D) at 24 months (P = .02). Mean baseline simulated keratometry was 46.32 D in the flattest meridian and 51.48 D in the steepest meridian; at 2 years, the values were 45.30 D (P = .04) and 50.21 D (P = .07), respectively. For a 3-mm pupil, there was a significant reduction (P < .05) in whole eye (total), corneal, higher-order, and astigmatic wavefront aberrations at 24 months. A significant difference (P < .05) in total coma and total spherical aberration 2 years after CXL also was observed. Mean baseline pupil center pachymetry decreased significantly (P = .04) at 6 months, but recovered by 12 months and remained stable thereafter through the 2-year follow-up. Endothelial cell counts did not change significantly (P = .32). CONCLUSIONS CXL improved UCVA and BSCVA in the study patients, most likely by significantly reducing corneal asymmetry and corneal as well as total wavefront aberrations.
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Affiliation(s)
- Paolo Vinciguerra
- Department of Ophthalmology, Istituto Clinico Humanitas, Rozzano-Milano, Italy
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Ghia D, Thomas P, Cordato D, Epstein D, Beran RG, Cappelen-Smith C, Griffith N, Hanna I, McDougall A, Hodgkinson SJ, Worthington JM. Low positive predictive value of the ABCD2 score in emergency department transient ischaemic attack diagnoses: the South Western Sydney transient ischaemic attack study. Intern Med J 2012; 42:913-8. [PMID: 21790923 DOI: 10.1111/j.1445-5994.2011.02564.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [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: 02/05/2023]
Abstract
BACKGROUND The ABCD(2) stroke risk score is recommended in national guidelines for stratifying care in transient ischaemic attack (TIA) patients, based on its prediction of early stroke risk. We had become concerned about the score accuracy and its clinical value in modern TIA cohorts. METHODS We identified emergency department-diagnosed TIA at two hospitals over 3 years (2004-2006). Cases were followed for stroke occurrence and ABCD(2) scores were determined from expert record review. Sensitivity, specificity and positive predictive values (PPV) of moderate-high ABCD(2) scores were determined. RESULTS There were 827 indexed TIA diagnoses and record review was possible in 95.4%. Admitted patients had lower 30-day stroke risk (n = 0) than discharged patients (n = 7; 3.1%) (P < 0.0001). There was no significant difference in proportion of strokes between those with a low or moderate-high ABCD(2) score at 30 (1.2 vs 0.8%), 90 (2.0 vs 1.9%) and 365 days (2.4 vs 2.4%) respectively. At 30 days the sensitivity, specificity and PPV of a moderate-high score were 57% (95% confidence interval (CI) 25.0-84.2), 32.2% (95% CI 29.1-35.6) and 0.75% (95% CI 0.29-1.91) respectively. CONCLUSIONS Early stroke risk was low after an emergency diagnosis of TIA and significantly lower in admitted patients. Moderate-high ABCD(2) scores did not predict early stroke risk. We suggest local validation of ABCD(2) before its clinical use and a review of its place in national guidelines.
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Affiliation(s)
- D Ghia
- Neurology Department, Liverpool Hospital, Sydney, New South Wales, Australia
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Rodgers M, Soares M, Epstein D, Yang H, Fox D, Eastwood A. Bevacizumab in combination with a taxane for the first-line treatment of HER2-negative metastatic breast cancer. Health Technol Assess 2012; 15 Suppl 1:1-12. [PMID: 21609648 DOI: 10.3310/hta15suppl1/01] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This paper presents a summary of the evidence review group (ERG) report into the use of bevacizumab (Avastin®, Roche) in combination with a taxane for the treatment of untreated metastatic breast cancer (mBC). The main clinical effectiveness data were derived from a single, open-label randomised controlled trial (RCT) (E2100) that evaluated the addition of bevacizumab to weekly (q.w.) paclitaxel in patients with human epidermal growth factor receptor 2-negative mBC who had not previously received chemotherapy for advanced disease. This trial reported statistically significant increases in median progression-free survival (PFS) for the addition of bevacizumab (5.8-11.3 months). Median overall survival was not significantly different between the two groups; whether this is a true null finding or due to crossover between treatment arms cannot be established, as relevant data were not collected. The manufacturer reported that the addition of bevacizumab to paclitaxel q.w. therapy was associated with a significant improvement in quality of life, as measured by FACT-B (functional assessment of cancer therapy for breast cancer) scores. However, the ERG noted that these results were based on extreme imputed values, the removal of which led to non-significant differences in quality of life. The manufacturer conducted an indirect comparison. However, owing to methodological limitations and concerns about the validity and exchangeability of the included trials, the ERG did not consider the findings to be reliable. One additional relevant RCT [AVADO (Avastin and Docetaxel); BO17708] evaluating the addition of bevacizumab to docetaxel was excluded from the manufacturer's submission. This was summarised by the ERG. In terms of response rate and PFS, AVADO reported a markedly smaller benefit of adding bevacizumab to docetaxel than that reported for adding bevacizumab to q.w. paclitaxel in E2100. AVADO also reported no statistically significant effect of combination therapy versus docetaxel in terms of overall survival. The manufacturer developed a de novo economic model that considered patients with the same baseline characteristics as women in the E2100 trial. The model assessed BEV + PAC - bevacizumab 10 mg/kg every 2 weeks in combination with paclitaxel 90 mg/m2 weekly for 3 weeks followed by 1 week of rest; PAC q.w. - paclitaxel (monotherapy) 90 mg/m2 weekly for 3 weeks followed by 1 week of rest; DOC - docetaxel (monotherapy) 75 mg/m2 on day 1 every 21 days (considered current UK NHS clinical practice in the submission); and GEM + PAC - gemcitabine 1250 mg/m2 on days 1 and 8 plus paclitaxel 175 mg/m2 on day 1 every 21 days. Pairwise comparisons were made between BEV + PAC and PAC (using the E2100 trial), BEV + PAC and DOC, and BEV + PAC and GEM + PAC. Based on NHS list prices, the manufacturer's model estimated incremental cost-effectiveness ratios (ICERs) for BEV + PAC of £ 117,803, £ 115,059 and £ 105,777 per QALY gained, relative to PAC, DOC and GEM + PAC regimens, respectively. If the NHS Purchasing and Supply Agency prices for PAC with a 10-g cap on the cost per patient of BEV were used instead, the ICERs for BEV + PAC were estimated at £ 77,314, £ 57,753 and £ 60,101 per QALY, respectively. The submission suggested that the regimen of BEV + DOC is not cost-effective because it is considered less effective and more costly than BEV + PAC. Analysis by the ERG suggested that alternative assumptions can increase the ICERs further and, based on current prices, no plausible changes to the model assumptions will bring the ICERs for BEV + PAC lower.
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Affiliation(s)
- M Rodgers
- Centre for Reviews and Dissemination, University of York, York, UK.
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Yang H, Epstein D, Bojke L, Craig D, Light K, Bruce I, Sculpher M, Woolacott N. Golimumab for the treatment of psoriatic arthritis. Health Technol Assess 2012; 15 Suppl 1:87-95. [PMID: 21609657 DOI: 10.3310/hta15suppl1/10] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This paper presents a summary of the evidence review group (ERG) report into the use of golimumab for the treatment of psoriatic arthritis (PsA). The main clinical effectiveness data were derived from a single phase III randomised controlled trial (RCT: GO-REVEAL) that compared golimumab with placebo for treating patients with active and progressive PsA who were symptomatic despite the use of previous disease-modifying antirheumatic drugs or non-steroidal anti-inflammatory drugs. The 14-week data showed that, compared with placebo, golimumab 50 mg significantly improved joint disease response as measured by American College of Rheumatology (ACR) 20 [relative risk (RR) 5.73, 95% confidence interval (CI) 3.24 to 10.56] and Psoriatic Arthritis Response Criteria (PsARC) (RR 3.45, 95% CI 2.49 to 4.87), and skin disease response as measured by the Psoriasis Area and Severity Index (PASI) 75 (RR 15.95, 95% CI 4.62 to 59.11). The 24-week absolute data showed that these treatment benefits were maintained. There was a significant improvement in patients' functional status as measured by the Health Assessment Questionnaire (HAQ) change from baseline at 24 weeks (-0.33, p < 0.001). The open-label extension data showed that these beneficial effects were also maintained at 52 and 104 weeks. However, PASI 50 and PASI 90 at 14 weeks, and all of the PASI outcomes at 24 weeks, were not performed on the basis of intention-to-treat analysis. Furthermore, analyses of the 24-week data were less robust, failing to adjust for treatment contamination due to patient crossover at week 16. The manufacturer conducted a mixed treatment comparison (MTC) analysis. The ERG considered the assumption of exchangeability between the trials for the purpose of the MTC analysis to be acceptable, and the statistical approach in the MTC analysis to be reliable. Regarding the safety evaluation of golimumab, the manufacturer failed to provide longer-term data or to consider adverse event data of golimumab from controlled studies in other conditions, such as rheumatoid arthritis and ankylosing spondylitis. Although the adverse effect profile of golimumab appears similar to other anti-tumour necrosis factor (TNF) agents, the longer-term safety profile of golimumab remains uncertain. The manufacturer's submission presented a decision model to compare etanercept, infliximab, golimumab and adalimumab versus palliative care for patients with PsA. In the base-case model, 73% of the cohort of patients were assumed to have significant psoriasis (> 3% of body surface area). Estimates of the effectiveness of anti-TNF agents in terms of PsARC, HAQ change and PASI change were obtained from an MTC analysis of RCT data. The manufacturer failed to calculate incremental cost-effectiveness ratios (ICERs) correctly by comparing golimumab with palliative care instead of the most cost-effective alternative (etanercept). Despite the manufacturer's claim that golimumab is a cost-effective treatment option, the manufacturer's own model showed that golimumab is not cost-effective compared with other biologics when the ICERs are correctly calculated. None of the sensitivity analyses carried out by the manufacturer or the ERG regarding uncertainty in the estimates of clinical effectiveness, the acquisition and administration cost of drugs, the cost of treating psoriasis and the utility functions estimated to generate health outcomes changed this conclusion. However, a key area in determining the cost-effectiveness of anti-TNF agents is whether they should be treated as a class. If all anti-TNF agents are considered equally effective then etanercept, adalimumab and golimumab have very nearly equal costs and equal quality-adjusted life-years (QALYs), and all have an ICER of about £ 15,000 per QALY versus palliative care, whereas infliximab with a higher acquisition cost is dominated by the other biologics.
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Affiliation(s)
- H Yang
- Centre for Reviews and Dissemination (CRD), University of York, York, UK.
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Tsilimbaris M, Diakonis VF, Kymionis GD, Eleftheriadou MI, Fragkiskou S, Moschandreas J, Frueh BE, Epstein D, Pallikaris AI. Prospective study of foveal thickness alterations after cataract surgery assessed by optical coherence tomography. ACTA ACUST UNITED AC 2012; 228:53-8. [PMID: 22488127 DOI: 10.1159/000336908] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Accepted: 01/17/2012] [Indexed: 01/20/2023]
Abstract
BACKGROUND/AIMS To evaluate the alterations of mean foveal thickness (MFT) and visual acuity (VA) outcomes after uncomplicated cataract surgery in different groups of patients. METHODS This study included eyes of consecutive patients who underwent cataract surgery between November 2007 and June 2009. The patients included in the study were divided into 4 groups, as follows: history-free patients, patients with diabetes mellitus without macular involvement at baseline, patients with glaucoma, and patients with epiretinal membrane (ERM). Preoperatively and at 1, 3 and 6 months postoperatively, patients were evaluated for MFT by optical coherence tomography at the central 1-mm macular zone and for logarithm of the minimum angle of resolution best spectacle-corrected VA (BSCVA). RESULTS A total of 202 eyes were included in the study. MFT values demonstrated a statistically significant increase (p < 0.01) after cataract surgery in all groups at the first and third postoperative month. The history-free (p = 0.09) and glaucoma (p = 0.19) groups did not demonstrate a statistically significant difference in MFT values between the preoperative and 6-month measurements. MFT values 6 months after cataract surgery in the diabetes and ERM groups remained significantly higher (p < 0.01). Despite these findings, VA increased significantly (p < 0.01) in all groups at all postoperative follow-ups. CONCLUSIONS MFT values increased significantly in all groups at the first and third months after cataract surgery. At 6 months, MFT values returned to preoperative levels in the history-free and glaucoma patients, while they remained significantly higher in the diabetic and ERM patients. Despite these macular alterations, BSCVA improved significantly after cataract surgery in all groups at all postoperative follow-ups.
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Haberman A, Williamson WR, Epstein D, Wang D, Rina S, Meinertzhagen IA, Hiesinger PR. The synaptic vesicle SNARE neuronal Synaptobrevin promotes endolysosomal degradation and prevents neurodegeneration. ACTA ACUST UNITED AC 2012; 196:261-76. [PMID: 22270918 PMCID: PMC3265959 DOI: 10.1083/jcb.201108088] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The synaptic v-SNARE n-Syb functions not only in synaptic vesicle exocytosis but also in delivery of protein-degrading enzymes to endosomes that are necessary to prevent protein aggregation and neurodegeneration. Soluble NSF attachment protein receptors (SNAREs) are the core proteins in membrane fusion. The neuron-specific synaptic v-SNARE n-syb (neuronal Synaptobrevin) plays a key role during synaptic vesicle exocytosis. In this paper, we report that loss of n-syb caused slow neurodegeneration independent of its role in neurotransmitter release in adult Drosophila melanogaster photoreceptor neurons. In addition to synaptic vesicles, n-Syb localized to endosomal vesicles. Loss of n-syb lead to endosomal accumulations, transmembrane protein degradation defects, and a secondary increase in autophagy. Our evidence suggests a primary defect of impaired delivery of vesicles that contain degradation proteins, including the acidification-activated Cathepsin proteases and the neuron-specific proton pump and V0 adenosine triphosphatase component V100. Overexpressing V100 partially rescued n-syb–dependent degeneration through an acidification-independent endosomal sorting mechanism. Collectively, these findings reveal a role for n-Syb in a neuron-specific sort-and-degrade mechanism that protects neurons from degeneration. Our findings further shed light on which intraneuronal compartments exhibit increased or decreased neurotoxicity.
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Affiliation(s)
- Adam Haberman
- Department of Physiology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
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Chan CC, Epstein D, Hiesinger PR. Intracellular trafficking in Drosophila visual system development: a basis for pattern formation through simple mechanisms. Dev Neurobiol 2012; 71:1227-45. [PMID: 21714102 DOI: 10.1002/dneu.20940] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Intracellular trafficking underlies cellular functions ranging from membrane remodeling to receptor activation. During multicellular organ development, these basic cell biological functions are required as both passive machinery and active signaling regulators. Exocytosis, endocytosis, and recycling of several key signaling receptors have long been known to actively regulate morphogenesis and pattern formation during Drosophila eye development. Hence, intracellular membrane trafficking not only sets the cell biological stage for receptor-mediated signaling but also actively controls signaling through spatiotemporally regulated receptor localization. In contrast to eye development, the role of intracellular trafficking for the establishment of the eye-to-brain connectivity map has only recently received more attention. It is still poorly understood how guidance receptors are spatiotemporally regulated to serve as meaningful synapse formation signals. Yet, the Drosophila visual system provides some of the most striking examples for the regulatory role of intracellular trafficking during multicellular organ development. In this review we will first highlight the experimental and conceptual advances that motivate the study of intracellular trafficking during Drosophila visual system development. We will then illuminate the development of the eye, the eye-to-brain connectivity map and the optic lobe from the perspective of cell biological dynamics. Finally, we provide a conceptual framework that seeks to explain how the interplay of simple genetically encoded intracellular trafficking events governs the seemingly complex cellular behaviors, which in turn determine the developmental product.
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Affiliation(s)
- Chih-Chiang Chan
- Department of Physiology and Green Center for Systems Biology, UT Southwestern Medical Center, Dallas, Texas, USA
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