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Kapizioni C, Desoki R, Lam D, Balendran K, Al-Sulais E, Subramanian S, Rimmer JE, De La Revilla Negro J, Pavey H, Pele L, Brooks J, Moran GW, Irving PM, Limdi JK, Lamb CA, Parkes M, Raine T. Biologic therapy for inflammatory bowel disease: Real-world comparative effectiveness and impact of drug sequencing in 13,222 patients within the UK IBD BioResource. J Crohns Colitis 2023:jjad203. [PMID: 38041850 DOI: 10.1093/ecco-jcc/jjad203] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND AND AIMS To compare effectiveness of different biologic therapies and sequences in patients with Inflammatory Bowel Disease (IBD) using real-world data from a large cohort with long exposure. METHODS Demographic, disease, treatment and outcome data were retrieved for patients in the UK IBD BioResource. Effectiveness of treatment was based on persistence free of discontinuation or failure, analysed by Kaplan-Meier survival analysis with inverse probability of treatment weighting to adjust for differences between groups. RESULTS 13,222 evaluable patients received at least one biologic. In ulcerative colitis (UC) first line vedolizumab (VDZ) demonstrated superior effectiveness over five years compared to anti-TNF agents (p=0.006). VDZ was superior to both infliximab (IFX) and adalimumab (ADA) after ADA and IFX failure respectively (p<0.001 and p<0.001). Anti-TNF therapy showed similar effectiveness when used first-line, or after failure of VDZ. In Crohn's disease (CD) we found significant differences between first line treatments over ten years (p=0.045), with superior effectiveness of IFX compared to ADA in perianal CD. Non-anti-TNF biologics were superior to a second anti-TNF after first line anti-TNF failure in CD (p=0.035). Patients with UC or CD experiencing TNF-failure due to delayed loss of response or intolerance had superior outcomes when switching to a non-anti-TNF biologic, rather than a second anti-TNF. CONCLUSIONS We provide real-world evidence to guide biologic selection and sequencing in a range of common scenarios. Our findings challenge current guidelines regarding drug selection after loss of response to first anti-TNF.
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Affiliation(s)
- Christina Kapizioni
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Gastroenterology, Attikon University Hospital, Athens, Greece
| | - Rofaida Desoki
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Genetics, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Danielle Lam
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Gastroenterology, Sir Charles Gairdner Hospital, Perth, Australia
| | - Karthiha Balendran
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Clinical Medicine, University of Jaffna, Sri Lanka
| | - Eman Al-Sulais
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Sreedhar Subramanian
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Joanna E Rimmer
- Academic Department of Military Medicine, Royal Centre for Defence Medicine, Medical Directorate, Joint Medical Command, Birmingham Research Park, Birmingham, UK
| | - Juan De La Revilla Negro
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Holly Pavey
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, UK
- Institute of Health Economics, Medical University Innsbruck, Innsbruck, Austria
| | - Laetitia Pele
- Department of Medicine, University of Cambridge, UK
- IBD BioResource, NIHR BioResource, Cambridge, UK
| | - Johanne Brooks
- Department of Clinical Pharmacology and Biological Sciences, University of Hertfordshire, Hatfield, UK
- Gastroenterology Department, Lister Hospital, Stevenage, UK
| | - Gordon W Moran
- University of Nottingham, NIHR Nottingham Biomedical Research Centre, Nottingham, Nottinghamshire, UK
| | - Peter M Irving
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Jimmy K Limdi
- IBD Section- Northern Care Alliance NHS Foundation Trust, Manchester, UK
- Faculty of Biology, Medicine & Health,University of Manchester
| | - Christopher A Lamb
- Clinical and Translational Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Miles Parkes
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Tim Raine
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Pavey H, Polkey MI, Bolton CE, Cheriyan J, McEniery CM, Wilkinson I, Mohan D, Casaburi R, Miller BE, Tal-Singer R, Fisk M. Circulating testosterone levels and health outcomes in chronic obstructive pulmonary disease: results from ECLIPSE and ERICA. BMJ Open Respir Res 2023; 10:e001601. [PMID: 37316306 PMCID: PMC10277522 DOI: 10.1136/bmjresp-2022-001601] [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: 12/23/2022] [Accepted: 05/30/2023] [Indexed: 06/16/2023] Open
Abstract
The relationship of circulating testosterone levels with health outcomes in people with chronic obstructive pulmonary disease (COPD) is unknown. AIM To determine whether serum testosterone levels predict hospitalised acute exacerbations of COPD (H-AECOPD), cardiovascular disease outcome, and mortality in people with COPD. METHODS Separate analyses were carried out on two observational, multicentre COPD cohorts, Evaluation of COPD Longitudinally to Identify Predictive Surrogate End-points (ECLIPSE) and Evaluation of the Role of Inflammation in Chronic Airways Disease (ERICA), both of which had serum testosterone measured using a validated liquid chromatography assay at the same laboratory. Data from 1296 male participants in ECLIPSE and 386 male, 239 female participants in ERICA were analysed. All analyses were sex-specific. Multivariate logistic regression was used to determine associations with H-AECOPD during follow-up (3 years ECLIPSE, 4.5 years ERICA), a composite endpoint of cardiovascular hospitalisation and cardiovascular death, and all-cause mortality. RESULTS Mean (SD) testosterone levels were consistent across cohorts; 459 (197) and 455 (200) ng/dL for males in ECLIPSE and ERICA, respectively, and in ERICA females: 28 (56) ng/dL. Testosterone was not associated with H-AECOPD (ECLIPSE: OR: 0.76, p=0.329, ERICA males: OR (95% CI): 1.06 (0.73 to 1.56), p=0.779, ERICA females: OR: 0.77 (0.52 to 1.12), p=0.178) or cardiovascular hospitalisation and death. Testosterone was associated with all-cause mortality in Global Initiative for Obstructive Lung Disease (GOLD) stage 2 male patients only, in ECLIPSE (OR: 0.25, p=0.007) and ERICA (OR: (95% CI): 0.56 (0.32 to 0.95), p=0.030). CONCLUSIONS Testosterone levels do not relate to H-AECOPD or cardiovascular outcome in COPD, but are associated with all-cause mortality in GOLD stage 2 COPD male patients, although the clinical significance of this finding is uncertain.
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Affiliation(s)
- Holly Pavey
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Michael I Polkey
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Charlotte E Bolton
- Centre for Respiratory Research, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Joseph Cheriyan
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Carmel M McEniery
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Ian Wilkinson
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Divya Mohan
- Former employee of GSK, Collegeville, Pennsylvania, USA
| | - Richard Casaburi
- Rehabilitation Clinical Trials Center, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, USA
| | | | | | - Marie Fisk
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, UK
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Le E, Rundo L, Tarkin J, Evans N, Chowdhury M, Coughlin P, Pavey H, Wall C, Zaccagna F, Gallagher F, Huang Y, Sriranjan R, Le A, Weir-McCall J, Roberts M, Gilbert F, Warburton E, Schönlieb CB, Sala E, Rudd J. 146 Ct radiomics in carotid artery atherosclerosis: a systematic evaluation of robustness, reproducibility and predictive performance for culprit lesions. IMAGING 2022. [DOI: 10.1136/heartjnl-2022-bcs.146] [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: 11/03/2022] Open
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Raine T, Pavey H, Qian W, Moran GW, Subramanian S, Swaby L, Travis SP, Din S, Irving PM, Lindsay JO, Parkes M, Kennedy NA. Establishment of a validated central reading system for ileocolonoscopy in an academic setting. Gut 2022; 71:661-664. [PMID: 35022265 DOI: 10.1136/gutjnl-2021-325575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 12/23/2021] [Indexed: 12/08/2022]
Affiliation(s)
- Tim Raine
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Holly Pavey
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - Wendi Qian
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - Gordon W Moran
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Sreedhar Subramanian
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Lizzie Swaby
- Clinical Trials Research Unit, ScHARR, The University of Sheffield, Sheffield, Sheffield, UK
| | - Simon Pl Travis
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Shahida Din
- Edinburgh IBD Unit, Western General Hospital, NHS Lothian, Edinburgh, UK
| | - Peter M Irving
- IBD Unit, Guy's and St Thomas' Hospital NHS Trust, London, UK.,School of Immunology & Microbial Sciences, King's College London, London, London, UK
| | - James O Lindsay
- Centre for Immunobiology, Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Miles Parkes
- Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Department of Medicine, University of Cambridge, Cambridge, UK
| | - Nicholas A Kennedy
- Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
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Leong K, Howard L, Lo Giudice F, Pavey H, Davies R, Haji G, Gibbs S, Gopalan D. MRI Feature Tracking Strain in Pulmonary Hypertension: Utility of Combined Left Atrial Volumetric and Deformation Assessment in Distinguishing Post- From Pre-capillary Physiology. Front Cardiovasc Med 2022; 9:787656. [PMID: 35369294 PMCID: PMC8968034 DOI: 10.3389/fcvm.2022.787656] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/09/2022] [Indexed: 11/13/2022] Open
Abstract
AimsPulmonary hypertension (PH) is dichotomized into pre- and post-capillary physiology by invasive catheterization. Imaging, particularly strain assessment, may aid in classification and be helpful with ambiguous hemodynamics. We sought to define cardiac MRI (CMR) feature tracking biatrial peak reservoir and biventricular peak systolic strain in pre- and post-capillary PH and examine the performance of peak left atrial strain in distinguishing the 2 groups compared to TTE.Methods and ResultsRetrospective cross-sectional study from 1 Jan 2015 to 31 Dec 2020; 48 patients (22 pre- and 26 post-capillary) were included with contemporaneous TTE, CMR and catheterization. Mean pulmonary artery pressures were higher in the pre-capillary cohort (55 ± 14 vs. 42 ± 9 mmHg; p < 0.001) as was pulmonary vascular resistance (median 11.7 vs. 3.7 WU; p < 0.001). Post-capillary patients had significantly larger left atria (60 ± 22 vs. 25 ± 9 ml/m2; p < 0.001). There was no difference in right atrial volumes between groups (60 ± 21 vs. 61 ± 29 ml/m2; p = 0.694), however peak RA strain was lower in post-capillary PH patients (8.9 ± 5.5 vs. 18.8 ± 7.0%; p < 0.001). In the post-capillary group, there was commensurately severe peak strain impairment in both atria (LA strain 9.0 ± 5.8%, RA strain 8.9 ± 5.5%). CMR LAVi and peak LA strain had a multivariate AUC of 0.98 (95% CI 0.89–1.00; p < 0.001) for post-capillary PH diagnosis which was superior to TTE.ConclusionCMR volumetric and deformation assessment of the left atrium can highly accurately distinguish post- from pre-capillary PH.
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Affiliation(s)
- Kai'En Leong
- Department of Radiology, Imperial College National Health Service Trust/Hammersmith Hospital, London, United Kingdom
- Department of Cardiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Luke Howard
- National Pulmonary Hypertension Service, Imperial College National Health Service Trust, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Francesco Lo Giudice
- National Pulmonary Hypertension Service, Imperial College National Health Service Trust, London, United Kingdom
- Department of Cardiology, Imperial College National Health Service Trust/Hammersmith Hospital, London, United Kingdom
| | - Holly Pavey
- Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, Cambridge, United Kingdom
| | - Rachel Davies
- National Pulmonary Hypertension Service, Imperial College National Health Service Trust, London, United Kingdom
| | - Gulammehdi Haji
- National Pulmonary Hypertension Service, Imperial College National Health Service Trust, London, United Kingdom
| | - Simon Gibbs
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Deepa Gopalan
- Department of Radiology, Imperial College National Health Service Trust/Hammersmith Hospital, London, United Kingdom
- Department of Radiology, Cambridge University Hospitals National Health Service Trust, Cambridge, United Kingdom
- *Correspondence: Deepa Gopalan
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Jha A, Chen F, Mann S, Shah R, Abu-Youssef R, Pavey H, Lin-Jia-Qi H, Cara J, Cunningham D, Fitzpatrick K, Goh C, Ma R, Mookerjee S, Nageshwaran V, Old T, Oxley C, Jordon L, Selvan M, Wood A, Ying A, Zhang C, Wozniak D, Goodhart I, Early F, Fisk M, Fuld J. Physiological effects and subjective tolerability of prone positioning in COVID-19 and healthy hypoxic challenge. ERJ Open Res 2021; 8:00524-2021. [PMID: 35136823 PMCID: PMC8591389 DOI: 10.1183/23120541.00524-2021] [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: 08/25/2021] [Accepted: 10/26/2021] [Indexed: 11/25/2022] Open
Abstract
Background Prone positioning has a beneficial role in coronavirus disease 2019 (COVID-19) patients receiving ventilation but lacks evidence in awake non-ventilated patients, with most studies being retrospective, lacking control populations and information on subjective tolerability. Methods We conducted a prospective, single-centre study of prone positioning in awake non-ventilated patients with COVID-19 and non-COVID-19 pneumonia. The primary outcome was change in peripheral oxygenation in prone versus supine position. Secondary outcomes assessed effects on end-tidal CO2, respiratory rate, heart rate and subjective symptoms. We also recruited healthy volunteers to undergo proning during hypoxic challenge. Results 238 hospitalised patients with pneumonia were screened; 55 were eligible with 25 COVID-19 patients and three non-COVID-19 patients agreeing to undergo proning – the latter insufficient for further analysis. 10 healthy control volunteers underwent hypoxic challenge. Patients with COVID-19 had a median age of 64 years (interquartile range 53–75). Proning led to an increase in oxygen saturation measured by pulse oximetry (SpO2) compared to supine position (difference +1.62%; p=0.003) and occurred within 10 min of proning. There were no effects on end-tidal CO2, respiratory rate or heart rate. There was an increase in subjective discomfort (p=0.003), with no difference in breathlessness. Among healthy controls undergoing hypoxic challenge, proning did not lead to a change in SpO2 or subjective symptom scores. Conclusion Identification of suitable patients with COVID-19 requiring oxygen supplementation from general ward environments for awake proning is challenging. Prone positioning leads to a small increase in SpO2 within 10 min of proning though is associated with increased discomfort. Awake prone positioning in patients with #COVID19 causes a small increase in SpO2 within 10 min of proning but is associated with increased subjective discomfort, and challenges in the identification of hospital patients suitable for the procedurehttps://bit.ly/3wg84BC
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Sun Y, Pavey H, Wilkinson I, Fisk M. Role of the IL-33/ST2 axis in cardiovascular disease: A systematic review and meta-analysis. PLoS One 2021; 16:e0259026. [PMID: 34723980 PMCID: PMC8559957 DOI: 10.1371/journal.pone.0259026] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 10/12/2021] [Indexed: 12/29/2022] Open
Abstract
Interleukin (IL)-33 and its unique receptor, ST2, play a pivotal role in the immune response to infection and stress. However, there have been conflicting reports of the role of IL-33 in cardiovascular disease (CVD) and the potential of this axis in differentiating CVD patients and controls and with CVD disease severity, remains unclear. AIMS 1) To quantify differences in circulating IL-33 and/or sST2 levels between CVD patients versus controls. 2) Determine association of these biomarkers with mortality in CVD and community cohorts. METHODS AND RESULTS Using Pubmed/MEDLINE, Web of Science, Prospero and Cochrane databases, systematic review of studies published on IL-33 and/or sST2 levels in patients with CVD (heart failure, acute coronary syndrome, atrial fibrillation, stroke, coronary artery disease and hypertension) vs controls, and in cohorts of each CVD subtype was performed. Pooled standardised mean difference (SMD) of biomarker levels between CVD-cases versus controls and hazard ratios (HRs) for risk of mortality during follow-up in CVD patients, were assessed by random effects meta-analyses. Heterogeneity was evaluated with random-effects meta-regressions. From 1071 studies screened, 77 were meta-analysed. IL-33 levels were lower in HF and CAD patients vs controls, however levels were higher in stroke patients compared controls [Meta-SMD 1.455, 95% CI 0.372-2.537; p = 0.008, I2 = 97.645]. Soluble ST2 had a stronger association with risk of all-cause mortality in ACS (Meta-multivariate HR 2.207, 95% CI 1.160-4.198; p = 0.016, I2 = 95.661) than risk of all-cause mortality in HF (Meta-multivariate HR 1.425, 95% CI 1.268-1.601; p<0.0001, I2 = 92.276). There were insufficient data to examine the association of IL-33 with clinical outcomes in CVD. CONCLUSIONS IL-33 and sST2 levels differ between CVD patients and controls. Higher levels of sST2 are associated with increased mortality in individuals with CVD. Further study of IL-33/ST2 in cardiovascular studies is essential to progress diagnostic and therapeutic advances related to IL-33/ST2 signalling.
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Affiliation(s)
- Yuan Sun
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- * E-mail:
| | - Holly Pavey
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Ian Wilkinson
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Marie Fisk
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
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Cacciottolo PJ, Kostapanos M, Hubsch A, Vamvaka E, Kaloyirou F, Helmy J, Sancho EH, Pavey H, Maki-Petaja K, Wilkinson I, Cheriyan J. THE EFFECTS OF ALIROCUMAB VERSUS EZETIMIBE ON TOP OF STATINS ON VASCULAR INFLAMMATION AND FUNCTION. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)01518-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Cacciottolo PJ, Kostapanos MS, Hernan Sancho E, Pavey H, Kaloyirou F, Vamvaka E, Helmy J, Hubsch A, McEniery CM, Wilkinson IB, Cheriyan J. Investigating the Lowest Threshold of Vascular Benefits from LDL Cholesterol Lowering with a PCSK9 mAb Inhibitor (Alirocumab) in Patients with Stable Cardiovascular Disease (INTENSITY-HIGH): protocol and study rationale for a randomised, open label, parallel group, mechanistic study. BMJ Open 2021; 11:e037457. [PMID: 33849844 PMCID: PMC8051397 DOI: 10.1136/bmjopen-2020-037457] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 01/04/2021] [Accepted: 02/26/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Elevated low-density lipoprotein cholesterol (LDL-C) is a strong independent risk predictor of cardiovascular (CV) events, while interventions to reduce it remain the only evidence-based approach to reduce CV morbidity and mortality. Secondary prevention statin trials in combination with ezetimibe and/or proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors showed that there is no 'J shaped curve' in LDL-C levels with regard to CV outcomes. The lowest threshold beyond which reduction of LDL-C confers no further CV benefits has not been identified.The INTENSITY-HIGH study seeks to explore physiological mechanisms mediating CV benefits of LDL-C lowering by PCSK9 inhibition in patients with established cardiovascular disease (CVD). The study examines the changes in measures of endothelial function and vascular inflammation imaging following intervention with PCSK9 and against standard of care. METHODS AND ANALYSIS This is a single-centre, randomised, open label, parallel group, mechanistic physiological study. It will include approximately 60 subjects with established CVD, with LDL-C of <4.1 mmol/L on high-intensity statins. All eligible participants will undergo 18-fluorodeoxyglucose positron emission tomography/CT (FDG-PET/CT) scanning of the aorta and carotid arteries, as well as baseline endothelial function assessment. Subsequently, they will be randomised on a 1:1 basis to either alirocumab 150 mg or ezetimibe 10 mg/day. Repeat FDG-PET/CT scan and vascular assessments will be undertaken after 8 weeks of treatment. Any changes in these parameters will be correlated with changes in lipid levels and systemic inflammation biomarkers. ETHICS AND DISSEMINATION The study received a favourable opinion from the Wales Research Ethics Committee 4, was registered on clinicaltrials.gov and conformed to International Conference for Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use Good Clinical Practice. The results of this study will be reported through peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER NCT03355027.
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Affiliation(s)
- Paul J Cacciottolo
- Division of Experimental Medicine and Immunotherapeutics (EMIT), University of Cambridge, Cambridge, UK
| | | | - Elena Hernan Sancho
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Holly Pavey
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Fotini Kaloyirou
- Division of Experimental Medicine and Immunotherapeutics (EMIT), University of Cambridge, Cambridge, UK
| | - Evangelia Vamvaka
- Division of Experimental Medicine and Immunotherapeutics (EMIT), University of Cambridge, Cambridge, UK
| | - Joanna Helmy
- Division of Experimental Medicine and Immunotherapeutics (EMIT), University of Cambridge, Cambridge, UK
| | - Annette Hubsch
- Division of Experimental Medicine and Immunotherapeutics (EMIT), University of Cambridge, Cambridge, UK
| | - Carmel M McEniery
- Division of Experimental Medicine and Immunotherapeutics (EMIT), University of Cambridge, Cambridge, UK
| | - Ian B Wilkinson
- Division of Experimental Medicine and Immunotherapeutics (EMIT), University of Cambridge, Cambridge, UK
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Joseph Cheriyan
- Division of Experimental Medicine and Immunotherapeutics (EMIT), University of Cambridge, Cambridge, UK
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Le EPV, Rundo L, Tarkin JM, Evans NR, Chowdhury MM, Coughlin PA, Pavey H, Wall C, Zaccagna F, Gallagher FA, Huang Y, Sriranjan R, Le A, Weir-McCall JR, Roberts M, Gilbert FJ, Warburton EA, Schönlieb CB, Sala E, Rudd JHF. Assessing robustness of carotid artery CT angiography radiomics in the identification of culprit lesions in cerebrovascular events. Sci Rep 2021; 11:3499. [PMID: 33568735 PMCID: PMC7876096 DOI: 10.1038/s41598-021-82760-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/21/2021] [Indexed: 02/02/2023] Open
Abstract
Radiomics, quantitative feature extraction from radiological images, can improve disease diagnosis and prognostication. However, radiomic features are susceptible to image acquisition and segmentation variability. Ideally, only features robust to these variations would be incorporated into predictive models, for good generalisability. We extracted 93 radiomic features from carotid artery computed tomography angiograms of 41 patients with cerebrovascular events. We tested feature robustness to region-of-interest perturbations, image pre-processing settings and quantisation methods using both single- and multi-slice approaches. We assessed the ability of the most robust features to identify culprit and non-culprit arteries using several machine learning algorithms and report the average area under the curve (AUC) from five-fold cross validation. Multi-slice features were superior to single for producing robust radiomic features (67 vs. 61). The optimal image quantisation method used bin widths of 25 or 30. Incorporating our top 10 non-redundant robust radiomics features into ElasticNet achieved an AUC of 0.73 and accuracy of 69% (compared to carotid calcification alone [AUC: 0.44, accuracy: 46%]). Our results provide key information for introducing carotid CT radiomics into clinical practice. If validated prospectively, our robust carotid radiomic set could improve stroke prediction and target therapies to those at highest risk.
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Affiliation(s)
| | - Leonardo Rundo
- Department of Radiology, University of Cambridge, Cambridge, UK
- Cancer Research UK Cambridge Centre, University of Cambridge, Cambridge, UK
| | - Jason M Tarkin
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Nicholas R Evans
- Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Mohammed M Chowdhury
- Division of Vascular Surgery, Department of Surgery, University of Cambridge, Cambridge, UK
| | - Patrick A Coughlin
- Division of Vascular Surgery, Department of Surgery, University of Cambridge, Cambridge, UK
| | - Holly Pavey
- Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, Cambridge, UK
| | - Chris Wall
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Fulvio Zaccagna
- Department of Radiology, University of Cambridge, Cambridge, UK
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | | | - Yuan Huang
- Department of Radiology, University of Cambridge, Cambridge, UK
- EPSRC Centre for Mathematical Imaging in Healthcare, University of Cambridge, Cambridge, UK
| | | | - Anthony Le
- School of Medicine, University of Leeds, Leeds, UK
| | | | - Michael Roberts
- EPSRC Centre for Mathematical Imaging in Healthcare, University of Cambridge, Cambridge, UK
- Oncology R&D, AstraZeneca, Cambridge, UK
- Department of Applied Mathematics and Theoretical Physics, University of Cambridge, Cambridge, UK
| | - Fiona J Gilbert
- Department of Radiology, University of Cambridge, Cambridge, UK
| | | | - Carola-Bibiane Schönlieb
- EPSRC Centre for Mathematical Imaging in Healthcare, University of Cambridge, Cambridge, UK
- Department of Applied Mathematics and Theoretical Physics, University of Cambridge, Cambridge, UK
| | - Evis Sala
- Department of Radiology, University of Cambridge, Cambridge, UK
- Cancer Research UK Cambridge Centre, University of Cambridge, Cambridge, UK
| | - James H F Rudd
- Department of Medicine, University of Cambridge, Cambridge, UK.
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11
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Le E, Evans N, Tarkin J, Chowdhury M, Zaccagna F, Pavey H, Ganeshan B, Wall C, Huang Y, Weir-Mccall J, Warburton E, Schonlieb C, Sala E, Rudd J. Radiomics applied to carotid CT angiograms can identify significant differences between culprit and non-culprit lesions in patients with stroke and transient ischaemic attack. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Carotid artery atherosclerosis is an important cause of ischaemic stroke. In oncology, textural analysis (“radiomics”) of computed tomography (CT) images can predict the metastatic potential and prognosis of several types of malignant tumours. We investigated whether this quantitative approach could be applied in carotid artery disease.
Purpose
(1) To evaluate the feasibility of computed tomography angiography (CTA) texture analysis in differentiating symptomatic from asymptomatic patients. (2) To investigate whether CTA carotid texture analysis can identify culprit lesions in patients with stroke and transient ischaemic attack (TIA).
Methods
Carotid CTAs of consented research subjects were included in the study. Symptomatic patients had confirmed carotid artery-related ischaemic stroke or TIA in the 7 days before CTA imaging. Asymptomatic (ASX) patients had no prior stroke/TIA. Both TexRAD, a research texture analysis software, and PyRadiomics, a Python package for radiomics studies, were used to extract 99 first-order and higher-order texture features from regions-of-interest (ROI) drawn around the outer wall of the carotid artery. Single-slice analysis compared the carotid bifurcations of symptomatic and asymptomatic patients, and of culprit (CC) and non-culprit (NC) arteries in symptomatic patients. Multi-slice analysis was conducted using a 3D volume defined by ROIs drawn on 14 consecutive CT slices of 3mm thickness, covering 3cm of carotid artery. The Mann-Whitney U test was used for inter-subject comparisons (ASX vs CC; ASX vs NC) and the Wilcoxon signed-rank test was used for intra-subject comparisons (CC vs NC). A p value <0.0005 was deemed statistically significant after Bonferroni correction for multiple comparisons. Non-normally distributed variables are reported as median (interquartile range).
Results
The dataset comprised 82 carotid arteries from 41 symptomatic patients (41 culprit; 41 non-culprit) and 50 carotid arteries from 25 asymptomatic patients. Single-slice analysis revealed greater homogeneity in asymptomatic carotids versus symptomatic culprit carotids (Uniformity: ASX 0.11 (0.05); CC 0.08 (0.05), p<0.0005) and non-culprit carotids (NC 0.08 (0.18), p<0.0005). In multi-slice analysis, culprit and non-culprit carotid arteries displayed greater heterogeneity than asymptomatic carotids (GLSZM zone entropy: CC 6.57 (0.59); NC 6.76 (0.65); ASX 6.21 (0.32), p<0.0005). Multi-slice analysis of symptomatic culprit versus non-culprit carotids revealed greater heterogeneity in culprit carotids than non-culprit carotids (GLRLM run entropy CC 6.57 (0.59); NC 5.05 (0.70), p<0.0001).
Conclusion
Textural analysis of carotid CTAs reveal significant differences between symptomatic and asymptomatic patients and between culprit and non-culprit carotid arteries within symptomatic patients. This approach could be used to identify patients at high risk of further stroke for aggressive medical therapy and surveillance.
Funding Acknowledgement
Type of funding source: Public grant(s) – National budget only. Main funding source(s): EPVL is undertaking a PhD funded by the Cambridge School of Clinical Medicine and the Medical Research Council's Doctoral Training Partnership
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Affiliation(s)
- E Le
- University of Cambridge, Cambridge, United Kingdom
| | - N.R Evans
- University of Cambridge, Cambridge, United Kingdom
| | - J.M Tarkin
- University of Cambridge, Cambridge, United Kingdom
| | | | - F Zaccagna
- University of Cambridge, Cambridge, United Kingdom
| | - H Pavey
- University of Cambridge, Cambridge, United Kingdom
| | - B Ganeshan
- University College London, London, United Kingdom
| | - C Wall
- University of Cambridge, Cambridge, United Kingdom
| | - Y Huang
- University of Cambridge, Cambridge, United Kingdom
| | | | | | | | - E Sala
- University of Cambridge, Cambridge, United Kingdom
| | - J.H.F Rudd
- University of Cambridge, Cambridge, United Kingdom
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12
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Gopalan D, Nordgren-Rogberg A, Le EPV, Pavey H, Tarkin J, Nyrén S, Auger W, Lindholm P. Abnormal Pulmonary Venous Filling: An Adjunct Feature in the Computed Tomography Pulmonary Angiogram Assessment of Chronic Thromboembolic Pulmonary Hypertension. J Am Heart Assoc 2020; 9:e018075. [PMID: 33115320 PMCID: PMC7763423 DOI: 10.1161/jaha.120.018075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Hypodense filling defects within the pulmonary veins on computed tomography described as pulmonary vein sign (PVS) have been noted in acute pulmonary embolism and shown to be associated with poor prognosis. We evaluated venous flow abnormalities in chronic thromboembolic pulmonary hypertension (CTEPH) to determine its usefulness in the computed tomography assessment of CTEPH. Methods and Results Blinded retrospective computed tomography analysis of 50 proximal CTEPH cases and 3 control groups—50 acute pulmonary embolism, 50 nonthromboembolic cohort, and 50 pulmonary arterial hypertension. Venous flow reduction was assessed by the following: (1) presence of a filling defect of at least 2 cm in a pulmonary vein draining into the left atrium, and (2) left atrium attenuation (>160 Hounsfield units). PVS was most prevalent in CTEPH. Compared with all controls, sensitivity and specificity of PVS for CTEPH is 78.0% and 85.3% (95% CI, 64.0–88.5 and 78.6–90.6, respectively) versus 34.0% and 70.7% (95% CI, 21.2−48.8 and 62.7–77.8) in acute pulmonary embolism, 8.0% and 62% (95% CI, 2.2–19.2 and 53.7–69.8) in nonthromboembolic and 2.0% and 60% (95% CI, 0.1−10.7 and 51.7−67.9) in pulmonary arterial hypertension. In CTEPH, lobar and segmental arterial occlusive disease was most commonly associated with corresponding absent venous flow. PVS detection was highly reproducible (Kappa=0.96, 95% CI, 0.90–1.01, P<0.001). Conclusions PVS is easy to detect with higher sensitivity and specificity in CTEPH compared with acute pulmonary embolism and is not a feature of pulmonary arterial hypertension. Asymmetric enhancement of pulmonary veins may serve as an additional parameter in the computed tomography assessment of CTEPH and can be used to differentiate CTEPH from pulmonary arterial hypertension.
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Affiliation(s)
- Deepa Gopalan
- Department of Physiology and Pharmacology Karolinska Institutet Stockholm Sweden.,Imperial College Healthcare NHS Trust London United Kingdom
| | - Anna Nordgren-Rogberg
- Department of Physiology and Pharmacology Karolinska Institutet Stockholm Sweden.,Department of Radiology Solna Karolinska University Hospital Stockholm Sweden
| | | | - Holly Pavey
- Division of Experimental Medicine and Immunotherapeutics University of Cambridge United Kingdom
| | - Jason Tarkin
- Department of Medicine University of Cambridge United Kingdom
| | - Sven Nyrén
- Department of Radiology Solna Karolinska University Hospital Stockholm Sweden.,Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
| | | | - Peter Lindholm
- Department of Physiology and Pharmacology Karolinska Institutet Stockholm Sweden.,Department of Emergency Medicine University of California San Diego San Diego CA
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13
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Le EPV, Evans N, Tarkin J, Chowdhury M, Zaccagna F, Pavey H, Wall C, Huang Y, Weir-McCall J, Warburton E, Rundo L, Schönlieb CB, Sala E, Rudd JHF. 105 Machine learning and carotid artery CT radiomics identify significant differences between culprit and non-culprit lesions in patients with stroke and transient ischaemic attack. Imaging 2020. [DOI: 10.1136/heartjnl-2020-bcs.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
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14
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El-Damanawi R, Lee M, Harris T, Cowley LB, Bond S, Pavey H, Sandford RN, Wilkinson IB, Karet Frankl FE, Hiemstra TF. High water vs. ad libitum water intake for autosomal dominant polycystic kidney disease: a randomized controlled feasibility trial. QJM 2020; 113:258-265. [PMID: 31665476 PMCID: PMC7133783 DOI: 10.1093/qjmed/hcz278] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 10/02/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Vasopressin stimulates cyst growth in autosomal dominant polycystic kidney disease (ADPKD) and is a key therapeutic target. Evaluation of high water intake as an alternative to pharmacological vasopressin blockade is supported by patients. However feasibility, safety and adherence-promoting strategies required to deliver this remain unknown. AIMS Assess the feasibility of a definitive randomized high water intake trial in ADPKD. METHODS In this prospective open-label randomized trial, adult ADPKD patients with eGFR ≥ 20 ml/min/1.73 m2 were randomized to prescribed high water (HW) intake targeting urine osmolality (UOsm) ≤270 mOsm/kg, or ad libitum (AW) intake (UOsm >300 mOsm/kg). Self-management strategies including home-monitoring of urine-specific gravity (USG) were employed to promote adherence. RESULTS We enrolled 42 participants, baseline median eGFR (HW 68.4 [interquartile range (IQR) 35.9-107.2] vs. AW 75.8 [IQR 59.0-111.0 ml/min/1.73 m2, P = 0.22) and UOsm (HW 353 [IQR 190-438] vs. AW 350 [IQR 240-452] mOsm/kg, P = 0.71) were similar between groups. After 8 weeks, 67% in the HW vs. 24% in AW group achieved UOsm ≤270 mOsm/kg, P = 0.001. HW group achieved lower UOsm (194 [IQR 190-438] vs. 379 [IQR 235-503] mOsm/kg, P = 0.01) and higher urine volumes (3155 [IQR 2270-4295] vs. 1920 [IQR 1670-2960] ml/day, P = 0.02). Two cases of hyponatraemia occurred in HW group. No acute GFR effects were detected. In total 79% (519/672) of USG were submitted and 90% (468/519) were within target. Overall, 17% withdrew during the study. CONCLUSION DRINK demonstrated successful recruitment and adherence leading to separation between treatment arms in primary outcomes. These findings suggest a definitive trial assessing the impact of high water on kidney disease progression in ADPKD is feasible.
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Affiliation(s)
- R El-Damanawi
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge
| | - M Lee
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge
| | - T Harris
- PKD Charity, 91 Royal College, London
| | - L B Cowley
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge
- Patient Led Research Hub, Cambridge NIHR Biomedical Research Centre, Cambridge
| | - S Bond
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge
| | - H Pavey
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge
| | - R N Sandford
- Department of Medical Genetics, University of Cambridge, Hills Road, Cambridge, UK
| | - I B Wilkinson
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge
| | - F E Karet Frankl
- Department of Medical Genetics, University of Cambridge, Hills Road, Cambridge, UK
| | - T F Hiemstra
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge
- Address correspondence to Dr T.F. Hiemstra, Cambridge Clinical Trials Unit, Box 401 Cambridge Biomedical Camp us, Hills Road, Cambridge CB2 0QQ, UK.
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15
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El-Damanawi R, Lee M, Harris T, Cowley LB, Bond S, Pavey H, Sandford RN, Wilkinson IB, Karet Frankl FE, Hiemstra TF. High water vs. ad libitum water intake for autosomal dominant polycystic kidney disease: a randomized controlled feasibility trial. QJM 2020; 113:306. [PMID: 31956915 PMCID: PMC7133781 DOI: 10.1093/qjmed/hcz326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- R El-Damanawi
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge
| | - M Lee
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge
| | - T Harris
- PKD Charity, 91 Royal College, London
| | - L B Cowley
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge
- Patient Led Research Hub, Cambridge NIHR Biomedical Research Centre, Cambridge
| | - S Bond
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge
| | - H Pavey
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge
| | - R N Sandford
- Department of Medical Genetics, University of Cambridge, Hills Road, Cambridge, UK
| | - I B Wilkinson
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge
| | - F E Karet Frankl
- Department of Medical Genetics, University of Cambridge, Hills Road, Cambridge, UK
| | - T F Hiemstra
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge
- Address correspondence to Dr T.F. Hiemstra, Cambridge Clinical Trials Unit, Box 401 Cambridge Biomedical Camp us, Hills Road, Cambridge CB2 0QQ, UK.
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16
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Kostapanos MS, Cacciottolo PJ, Hubsch A, Pavey H, Hurlock J, Maki-Petaja K, Wilkinson IB, Cheriyan J. Investigating the lowest threshold of vascular benefits from LDL cholesterol lowering with a PCSK9 mAb inhibitor (alirocumab) in healthy volunteers - a mechanistic physiological study (INTENSITY-LOW): protocol and study rationale. J Drug Assess 2019; 8:167-174. [PMID: 31692938 PMCID: PMC6818119 DOI: 10.1080/21556660.2019.1677673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/25/2019] [Indexed: 11/15/2022] Open
Abstract
Objective: Whether reducing low density lipoprotein cholesterol (LDL-C) is associated with cardiovascular benefits in low risk normocholesterolaemic subjects is unknown. The INTENSITY LOW [Investigating the lowest threshold of vascular benefits from LDL-cholesterol lowering with a PCSK9 mAb inhibitor (alirocumab) in healthy volunteers] study aims to assess whether lowering LDL-C by alirocumab monotherapy can improve endothelial-dependent vascular function compared with placebo (primary objective) in low-risk normocholesterolaemic healthy individuals. Changes in endothelial-dependent or endothelial-independent vascular function, arterial stiffness and biomarkers of systemic inflammation by alirocumab, atorvastatin or their combination are secondary objectives. Study design and methods: This is a single-center, randomized, two-period, single-blind, placebo-controlled clinical trial. The study was registered on clinicaltrials.gov (N03273972). It will include 30 healthy low-risk subjects with LDL-C < 4.1 mmol/l. After passing the screening visit (Visit 1), eligible participants will be randomized 1:1 to either subcutaneous alirocumab 150 mg or placebo. These will be administered as single doses in 2 visits 14 days apart (Visits 2 and 3). Atorvastatin 20 mg once nightly will be prescribed for 14 days at Visit 3 in both groups through to Visit 4. At baseline (Visit 2) and during all post-dose visits (Visits 3–4), endothelial function will be assessed using venous occlusion plethysmography. Specifically, changes in forearm blood flow responses to intra-arterial infusions of acetylcholine, sodium nitroprusside and L-NG-monomethyl-arginine acetate will be assessed as surrogates of endothelial-dependent and -independent vasodilatation. Additionally, arterial stiffness and carotid intima-media thickness will be evaluated at the same timepoints. The above-mentioned changes will be correlated with changes in lipid and systemic inflammation biomarkers.
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Affiliation(s)
- Michael S Kostapanos
- Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, Cambridge, UK.,Lipid Clinic, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Paul J Cacciottolo
- Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, Cambridge, UK
| | - Annette Hubsch
- Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, Cambridge, UK
| | - Holly Pavey
- Cardiovascular Trials Office, Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - James Hurlock
- Cardiovascular Trials Office, Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Kaisa Maki-Petaja
- Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, Cambridge, UK
| | - Ian B Wilkinson
- Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, Cambridge, UK.,Cardiovascular Trials Office, Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Joseph Cheriyan
- Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, Cambridge, UK.,Cardiovascular Trials Office, Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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17
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Wang X, Le EPV, Rajani NK, Hudson-Peacock NJ, Pavey H, Tarkin JM, Babar J, Williams MC, Gopalan D, Rudd JHF. A zero coronary artery calcium score in patients with stable chest pain is associated with a good prognosis, despite risk of non-calcified plaques. Open Heart 2019; 6:e000945. [PMID: 31168373 PMCID: PMC6519430 DOI: 10.1136/openhrt-2018-000945] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 03/07/2019] [Accepted: 03/18/2019] [Indexed: 11/03/2022] Open
Abstract
Objectives To estimate the prevalence of non-calcified coronary artery disease (CAD) in patients with suspected stable angina and a zero coronary artery calcification (CAC) score, and to assess the prognostic significance of a zero CAC in these symptomatic patients. Methods In this prospective cohort study, consecutive patients with stable chest pain underwent CAC scoring ± CT coronary angiography (CTCA) as part of routine clinical care at a single tertiary centre over 7 years. Major adverse cardiac event (MACE) was defined as cardiac death, non-fatal myocardial infarction and/or non-elective revascularisation. Results A total of 915 of 1753 (52.2%) patients (mean age 56.8 ± 12.0 years; 46.2% male) had a zero CAC score. Of the 751 (82.1%) patients with a zero CAC in whom CTCA was performed, 674 (89.7%) had normal coronary arteries, 63 (8.4%) had non-calcified CAD with < 50% stenosis and 14 (1.9%) had ≥ 50% stenosis in at least one coronary artery. The negative predictive value of a zero CAC for excluding a ≥ 50% CTCA stenosis was 98.1%. Over a median follow-up period of 2.2 years (range 1.0-7.0 years), the absolute annualised rates of MACE were as follows: zero CAC 1.9 per 1000 person-years and non-zero CAC 7.4 per 1000 person-years (HR 3.8, p = 0.009). However, after adjusting for age, gender and cardiovascular risk factors using a multivariable Cox proportional hazards model, there was no statistically significant difference in the risk of MACE between the two patient cohorts (p = 0.19). After adjusting for age, gender and cardiovascular risk factors, the HR for all-cause mortality among the zero CAC cohort vers non-zero CAC was 2.1 (p = 0.27). Conclusion A zero CAC score in patients undergoing CT scanning for suspected stable angina has a high negative predictive value for the exclusion of obstructive CAD and is associated with a good medium-term prognosis.
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Affiliation(s)
- Xue Wang
- Division of Cardiovascular Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Elizabeth Phuong Vi Le
- Division of Cardiovascular Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Nikil K Rajani
- Department of Clinical Radiology, Imperial College Hospitals NHS Trust, St Mary's Hospital, London, UK
| | - NJ Hudson-Peacock
- Division of Cardiovascular Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Holly Pavey
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Jason M Tarkin
- Division of Cardiovascular Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Judith Babar
- Department of Radiology, Addenbrooke's Hospital, Cambridge, UK
| | | | - Deepa Gopalan
- Department of Radiology, Addenbrooke's Hospital, Cambridge, UK
| | - James H F Rudd
- Division of Cardiovascular Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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18
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El-Damanawi R, Lee M, Harris T, Mader LB, Bond S, Pavey H, Sandford RN, Wilkinson IB, Burrows A, Woznowski P, Ben-Shlomo Y, Karet Frankl FE, Hiemstra TF. Randomised controlled trial of high versus ad libitum water intake in patients with autosomal dominant polycystic kidney disease: rationale and design of the DRINK feasibility trial. BMJ Open 2018; 8:e022859. [PMID: 29743334 PMCID: PMC5942404 DOI: 10.1136/bmjopen-2018-022859] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Vasopressin stimulates cyst growth in autosomal dominant polycystic kidney disease (ADPKD) leading to enlarged kidneys, hypertension and renal failure. Vasopressin receptor blockade slows disease progression. Physiological suppression of vasopressin secretion through high water (HW) intake could achieve a similar effect, necessitating a definitive large-scale trial of HW intake in ADPKD. The objective of the DRINK trial is to answer the key design and feasibility questions required to deliver a successful definitive water intake trial. METHODS AND ANALYSIS We describe the design of a single-centre, open-label, prospective, randomised controlled trial. The "Determining feasibility of R andomisation to high vs. ad libitum water In take in Polycystic K idney Disease" (DRINK) trial aims to enrol 50 patients with ADPKD, over the age of 16 years with an estimated glomerular filtration rate (eGFR) ≥20 mL/min/1.73 m2. Participants will be randomised 1:1 to HW intake based on an individualised water intake prescription, or to ad libitum (AW) water intake. The HW group will aim for a dilute urine (urine osmolality ≤270 mOsm/kg) as a surrogate marker of vasopressin suppression, and those in the AW group will target more concentrated urine. Participants will have an 8-week treatment period, and will be seen at weeks 0, 2, 4 and 8, undergoing assessments of fluid status, renal function and serum and urine osmolalities. They will receive dietary advice, and self-monitor urine specific gravity and fluid intake. The trial employs smartphone technology to permit home monitoring and remote direct data capture. The primary feasibility end points are recruitment rate and separation between arms in measured urinary osmolality. Key secondary assessments include acceptability, adherence, health-related quality of life, acute effects of HW intake on measured (51Cr-EDTA) and eGFR and ADPKD-related pain. ETHICS AND DISSEMINATION Ethical approval was awarded by the East of England Essex Research Ethics Committee (16/EE/0026). The results of DRINK will be submitted to peer-reviewed journals, and presented to patients via the PKD Charity. TRIAL REGISTRATION NUMBER NCT02933268 and ISCRTN16794957.
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Affiliation(s)
- Ragada El-Damanawi
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, UK
- Cambridge Clinical Trials Unit, Cambridge, UK
| | - Michael Lee
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | | | - Laura B Mader
- Cambridge Clinical Trials Unit, Cambridge, UK
- Patient Led Research Hub, Cambridge, UK
| | - Simon Bond
- Cambridge Clinical Trials Unit, Cambridge, UK
| | - Holly Pavey
- Cambridge Clinical Trials Unit, Cambridge, UK
| | | | - Ian B Wilkinson
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, UK
- Cambridge Clinical Trials Unit, Cambridge, UK
| | | | | | | | | | - Thomas F Hiemstra
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, UK
- Cambridge Clinical Trials Unit, Cambridge, UK
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