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Hughes RW, Marquez JD, Young JB, Garrison JB, Zastrow IS, Evans AM, Sumerlin BS. Selective Electrochemical Modification and Degradation of Polymers. Angew Chem Int Ed Engl 2024; 63:e202403026. [PMID: 38416815 DOI: 10.1002/anie.202403026] [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] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 02/26/2024] [Indexed: 03/01/2024]
Abstract
We demonstrate that electrochemical-induced decarboxylation enables reliable post-polymerization modification and degradation of polymers. Polymers containing N-(acryloxy)phthalimides were subjected to electrochemical decarboxylation under mild conditions, which led to the formation of transient alkyl radicals. By installing these redox-active units, we systematically modified the pendent groups and chain ends of polyacrylates. This approach enabled the production of poly(ethylene-co-methyl acrylate) and poly(propylene-co-methyl acrylate) copolymers, which are difficult to synthesize by direct polymerization. Spectroscopic and chromatographic techniques reveal these transformations are near-quantitative on several polymer systems. Electrochemical decarboxylation also enables the degradation of all-methacrylate poly(N-(methacryloxy)phthalimide-co-methyl methacrylate) copolymers with a degradation efficiency of >95 %. Chain cleavage is achieved through the decarboxylation of the N-hydroxyphthalimide ester and subsequent β-scission of the backbone radical. Electrochemistry is thus shown to be a powerful tool in selective polymer transformations and controlled macromolecular degradation.
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Affiliation(s)
- Rhys W Hughes
- George & Josephine Butler Polymer Research Laboratory, Department of Chemistry, Center for Macromolecular Science & Engineering, University of Florida, Gainesville, FL 32611, United States
| | - Joshua D Marquez
- George & Josephine Butler Polymer Research Laboratory, Department of Chemistry, Center for Macromolecular Science & Engineering, University of Florida, Gainesville, FL 32611, United States
| | - James B Young
- George & Josephine Butler Polymer Research Laboratory, Department of Chemistry, Center for Macromolecular Science & Engineering, University of Florida, Gainesville, FL 32611, United States
| | - John B Garrison
- George & Josephine Butler Polymer Research Laboratory, Department of Chemistry, Center for Macromolecular Science & Engineering, University of Florida, Gainesville, FL 32611, United States
| | - Isabella S Zastrow
- George & Josephine Butler Polymer Research Laboratory, Department of Chemistry, Center for Macromolecular Science & Engineering, University of Florida, Gainesville, FL 32611, United States
| | - Austin M Evans
- George & Josephine Butler Polymer Research Laboratory, Department of Chemistry, Center for Macromolecular Science & Engineering, University of Florida, Gainesville, FL 32611, United States
| | - Brent S Sumerlin
- George & Josephine Butler Polymer Research Laboratory, Department of Chemistry, Center for Macromolecular Science & Engineering, University of Florida, Gainesville, FL 32611, United States
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Pantalone KM, Rogen B, Zirm P, Xiao H, Bena J, Barnard G, Borukh E, Peechakara S, Griebeler ML, Young JB, Burguera B. An Obesity-Centric Approach with and Without Anti-Obesity Medications Compared to the Usual-Care Approach to Management of Patients with Obesity and Type 2 Diabetes in an Employer Setting: A Pragmatic Randomized Controlled Trial (EMPOWER-T2D). Diabetes Ther 2024; 15:1201-1214. [PMID: 38573466 PMCID: PMC11043250 DOI: 10.1007/s13300-024-01563-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/04/2024] [Indexed: 04/05/2024] Open
Abstract
INTRODUCTION This study aimed to compare weight loss and glycated hemoglobin (HbA1c)-reduction effects of two obesity-centric, weight-loss management approaches (with or without anti-obesity medication) versus usual glucose-centric care in patients with obesity and type 2 diabetes. METHODS Single-center, randomized, open-label, 3-armed, parallel-group, pragmatic, noninferiority trial, July 2020 to August 2022. Adults enrolled in the Cleveland Clinic Employee Health Plan (body mass index [BMI] ≥ 30 kg/m2, type 2 diabetes diagnosis, HbA1c > 7.5%) were randomized to usual glucose-centric management ("Usual-Care" group) or one of two obesity-centric management strategies: participation in a weight management program plus anti-obesity medication ("WMP + AOM" group), or WMP participation without anti-obesity medication ("WMP-Only" group). Primary endpoints were changes in weight and HbA1c, baseline to month 12. RESULTS Due to enrollment and retention challenges, largely related to COVID-19, only 74/300 planned participants were randomized and the study was terminated early. Participants were predominantly female (59%), median (interquartile range [IQR]) age 53.5 (47, 60) years, 68% white, with baseline median (IQR) BMI and HbA1c of 37.4 (34.2, 42.7) kg/m2 and 8.8% (7.9%, 10.4%), respectively. At month 12, mean (90% confidence interval [CI]) percentage weight change in the Usual-Care, WMP-Only, and WMP + AOM groups was - 4.5% (- 6.5%, - 2.5%), - 6.7% (- 8.7%, - 4.7%), and - 8.7% (- 10.7%, - 6.8%), respectively; mean (90% CI) HbA1c change was - 1.7% (- 2.1%, - 1.2%), - 2.2% (- 2.7%, - 1.8%), and - 2.2% (- 2.6%, - 1.7%), respectively. WMP + AOM was superior to Usual-Care for weight change (P = 0.02); both WMP + AOM and WMP-Only were noninferior (P ≤ 0.01) to Usual-Care for change in HbA1c. CONCLUSIONS Including anti-obesity medication was associated with superior weight loss with noninferior HbA1c reductions, warranting further evaluation in larger study populations of obesity-focused approaches to type 2 diabetes management. Graphical abstract available for this article. TRIAL REGISTRATION ClinicalTrials.gov NCT03799198.
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Affiliation(s)
- Kevin M Pantalone
- Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, Cleveland, OH, USA
| | - Bruce Rogen
- Employee Health Plan, Cleveland Clinic, Cleveland, OH, USA
| | - Patty Zirm
- Employee Health Plan, Cleveland Clinic, Cleveland, OH, USA
| | - Huijun Xiao
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - James Bena
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Gretchen Barnard
- Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, Cleveland, OH, USA
| | - Elena Borukh
- Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, Cleveland, OH, USA
| | - Seenia Peechakara
- Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, Cleveland, OH, USA
| | - Marcio L Griebeler
- Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, Cleveland, OH, USA
| | - James B Young
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, OH, USA
| | - Bartolome Burguera
- Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, Cleveland, OH, USA.
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Cordova JC, Young JB. When I Am Asked: Lisel Mueller's Beginning in Poetry. Methodist Debakey Cardiovasc J 2024; 20:128-131. [PMID: 38495655 PMCID: PMC10941703 DOI: 10.14797/mdcvj.1335] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 01/03/2024] [Indexed: 03/19/2024] Open
Abstract
Why does anyone write poetry? Lisel Mueller (1924-2020) was a poet, author, and translator with a long and much-decorated career. She and her family fled Nazi Germany in the 1930s and emigrated to the United States, where she would establish herself as a writer. The poem "When I Am Asked" describes the beginning of her journey into poetry, undertaken during a period of grief after the death of her mother. Her writing would come to include nine collections of poetry and myriad accolades, including the 1981 National Book Award and the 1997 Pulitzer Prize for Poetry. Though her ouvre is filled with evocative works, this piece stands out as particularly relevant to physicians and other writers who find solace by expressing themselves through the art of poetry.
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Affiliation(s)
- Justin C. Cordova
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland, US
| | - James B. Young
- Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, US
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Hughes RW, Lott ME, Zastrow IS, Young JB, Maity T, Sumerlin BS. Bulk Depolymerization of Methacrylate Polymers via Pendent Group Activation. J Am Chem Soc 2024; 146:6217-6224. [PMID: 38382047 DOI: 10.1021/jacs.3c14179] [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: 02/23/2024]
Abstract
In this study, we present an efficient approach for the depolymerization of poly(methyl methacrylate) (PMMA) copolymers synthesized via conventional radical polymerization. By incorporating low mol % phthalimide ester-containing monomers during the polymerization process, colorless and transparent polymers closely resembling unfunctionalized PMMA are obtained, which can achieve >95% reversion to methyl methacrylate (MMA). Notably, our catalyst-free bulk depolymerization method exhibits exceptional efficiency, even for high-molecular-weight polymers, including ultrahigh-molecular-weight (106-107 g/mol) PMMA, where near-quantitative depolymerization is achieved. Moreover, this approach yields polymer byproducts of significantly lower molecular weight, distinguishing it from bulk depolymerization methods initiated from chain ends. Furthermore, we extend our investigation to polymethacrylate networks, demonstrating high extents of depolymerization. This innovative depolymerization strategy offers promising opportunities for the development of sustainable polymethacrylate materials, holding great potential for various applications in polymer science.
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Affiliation(s)
- Rhys W Hughes
- George & Josephine Butler Polymer Research Laboratory, Department of Chemistry, Center for Macromolecular Science & Engineering, University of Florida, Gainesville, Florida 32611, United States
| | - Megan E Lott
- George & Josephine Butler Polymer Research Laboratory, Department of Chemistry, Center for Macromolecular Science & Engineering, University of Florida, Gainesville, Florida 32611, United States
| | - Isabella S Zastrow
- George & Josephine Butler Polymer Research Laboratory, Department of Chemistry, Center for Macromolecular Science & Engineering, University of Florida, Gainesville, Florida 32611, United States
| | - James B Young
- George & Josephine Butler Polymer Research Laboratory, Department of Chemistry, Center for Macromolecular Science & Engineering, University of Florida, Gainesville, Florida 32611, United States
| | - Tanmoy Maity
- George & Josephine Butler Polymer Research Laboratory, Department of Chemistry, Center for Macromolecular Science & Engineering, University of Florida, Gainesville, Florida 32611, United States
| | - Brent S Sumerlin
- George & Josephine Butler Polymer Research Laboratory, Department of Chemistry, Center for Macromolecular Science & Engineering, University of Florida, Gainesville, Florida 32611, United States
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Young JB. Truman Capote as a Poet. Methodist Debakey Cardiovasc J 2023; 19:104-106. [PMID: 37547890 PMCID: PMC10402784 DOI: 10.14797/mdcvj.1270] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 06/29/2023] [Indexed: 08/08/2023] Open
Abstract
Truman Capote (1924-1984) was a fascinating, entertaining, and much ballyhooed American character who came of age in the mid-Twentieth Century. Some would say he led a tragic life. Often described as a notable novelist, he was more generally a polymath dabbling in nonfiction between his parties. He also was a screenwriter, playwright, actor, and short-story writer. His literary classics include the novella Breakfast at Tiffany's (1958, movie 1961) and true crime nonfiction "novel" (as Capote described it) In Cold Blood (1965, movie 1967). These two efforts became his most famous. But what about his poetry? Was this one of his creative passions?
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Affiliation(s)
- James B. Young
- Cleveland Clinic and Professor Emeritus of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, US
- Poet’s Pen, Methodist DeBakey Cardiovascular Journal, US
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Young JB. Old Ironsides. Methodist Debakey Cardiovasc J 2023; 19:103-106. [PMID: 36910547 PMCID: PMC10000333 DOI: 10.14797/mdcvj.1214] [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] [Received: 02/03/2023] [Accepted: 02/08/2023] [Indexed: 03/09/2023] Open
Abstract
Dr. Oliver Wendell Holmes Sr. was a 19th century elite physician, curmudgeon, essayist, and poet. His works were numerous, insightful, entertaining, and characteristic of the pre-Civil War, Civil War, and Gilded age eras. Many of his shorter poems are taught in high school as examples of late 19th century works, as they are relatively easy to memorize and understand. Holmes and the Fireside Poets (Emerson, Longfellow, and Lowell, among others) created works that, in their time, were read aloud by fathers and mothers to their family because the poems often centered around values, morals, and historic events. "Old Ironsides" is characteristic of the type of work for which the Fireside Poets became famous. It is an entertaining poem to read, study, and hear, particularly when linking it to the oldest ship in the world, still afloat and sailing around Boston Bay.
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Affiliation(s)
- James B Young
- Emeritus Executive Director of Academic Affairs, Cleveland Clinic and Professor Emeritus of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, US.,Section Editor, Poet's Pen, Methodist DeBakey Cardiovascular Journal
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Young JB. Up-Hill: An Allegory. Methodist Debakey Cardiovasc J 2023; 19:111-113. [PMID: 37213884 PMCID: PMC10198247 DOI: 10.14797/mdcvj.1236] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 04/06/2023] [Indexed: 05/23/2023] Open
Abstract
The Christina Rossetti poem "Up-Hill" (1862) is an exemplary poem of the Victorian era by one of the rare female poets of the time, including Emily Brontë, Elizabeth Browning, Katherine Tynan, and Alice Meynell. Rossetti, typical of the era and the Victorian genre, wrote allegories about faith and love. She came from a distinguished literary family. "Up-Hill" was one of her better-known works.
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Affiliation(s)
- James B. Young
- Emeritus Executive Director of Academic Affairs, Cleveland Clinic, US
- Professor Emeritus of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, US
- Section Editor, Poet’s Pen, Methodist DeBakey Cardiovascular Journal
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Abstract
Controlled radical polymerization techniques enable the synthesis of polymers with predetermined molecular weights, narrow molecular weight distributions, and controlled architectures. Moreover, these polymerization approaches have been routinely shown to result in retained end-group functionality that can be reactivated to continue polymerization. However, reactivation of these end groups under conditions that instead promote depropagation is a viable route to initiate depolymerization and potentially enable closed-loop recycling from polymer to monomer. In this report, we investigate light as a trigger for thermal depolymerization of polymers prepared by reversible-addition-fragmentation chain-transfer (RAFT) polymerization. We study the role of irradiation wavelength by targeting the n → π* and π → π* electronic transitions of the thiocarbonylthio end-groups of RAFT-generated polymers to enhance depolymerization via terminal bond homolysis. Specifically, we explore depolymerization of polymers with trithiocarbonate, dithiocarbamate, and p-substituted dithiobenzoate end groups with the purpose of increasing depolymerization efficiency with light. As the wavelength decreases from the visible range to the UV range, the rate of depolymerization is dramatically increased. This method of photoassisted depolymerization allows up to 87% depolymerization efficiency within 1 h, results that may further the advancement of recyclable materials and life-cycle circularity.
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Affiliation(s)
- James B Young
- George & Josephine Butler Polymer Research Laboratory, Center for Macromolecular Science and Engineering, Department of Chemistry, University of Florida, Gainesville, Florida 32611, United States
| | - Jared I Bowman
- George & Josephine Butler Polymer Research Laboratory, Center for Macromolecular Science and Engineering, Department of Chemistry, University of Florida, Gainesville, Florida 32611, United States
| | - Cabell B Eades
- George & Josephine Butler Polymer Research Laboratory, Center for Macromolecular Science and Engineering, Department of Chemistry, University of Florida, Gainesville, Florida 32611, United States
| | - Alexander J Wong
- George & Josephine Butler Polymer Research Laboratory, Center for Macromolecular Science and Engineering, Department of Chemistry, University of Florida, Gainesville, Florida 32611, United States
| | - Brent S Sumerlin
- George & Josephine Butler Polymer Research Laboratory, Center for Macromolecular Science and Engineering, Department of Chemistry, University of Florida, Gainesville, Florida 32611, United States
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Young JB. Does Osler's Aequanimitas Inform Our Contemporary Pursuit of Stillness? AMA J Ethics 2022; 24:E1166-1171. [PMID: 36520973 DOI: 10.1001/amajethics.2022.1166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
William Osler (1849-1919) was an academic physician who has been revered by many as an accomplished internist of his time. His contributions to the philosophy and practice of medicine foreground characteristics of a compassionate caregiver, including imperturbability and equanimity. This article defines these qualities, argues that Osler demonstrated both, and suggests how today's clinicians can apply these qualities to their own pursuits of stillness in their practices and relationships with patients.
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Young JB. Gertrude Stein: A Physician Who Wasn't to Be. Methodist Debakey Cardiovasc J 2022; 18:97-100. [PMID: 36132577 PMCID: PMC9461683 DOI: 10.14797/mdcvj.1149] [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: 06/24/2022] [Accepted: 07/27/2022] [Indexed: 11/08/2022] Open
Abstract
After a tumultuous time in the United States, including flunking out of medical school in 1901, Gertrude Stein, an iconic American author, art lover, and critic, moved to Paris in 1903 as an avant garde modernist who became a leading and legendary guru in the Parisian art and literature world.
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Affiliation(s)
- James B Young
- Academic Affairs, Cleveland Clinic, US.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, US.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, US
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Young JB. The Wound Dresser. Methodist Debakey Cardiovasc J 2022; 18:94-97. [PMID: 35734151 PMCID: PMC9165674 DOI: 10.14797/mdcvj.1128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 05/08/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- James B. Young
- Executive Director of Academic Affairs, Cleveland Clinic, Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, US
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Friedman DJ, Al-Khatib SM, Dalgaard F, Fudim M, Abraham WT, Cleland JG, Curtis AB, Gold MR, Kutyifa V, Linde CM, Young JB, Ali-Ahmed F, Olivas-Martinez A, Inoue L, Sanders GD. PO-628-08 RESPONSE TO CRT IS DIFFERENT IN PATIENTS WITH IVCD COMPARED TO RBBB: A PATIENT LEVEL META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Young JB. Do Not Go Gentle Into That Good Night. Methodist Debakey Cardiovasc J 2022; 18:111-113. [PMID: 35414849 PMCID: PMC8932382 DOI: 10.14797/mdcvj.1079] [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: 01/04/2022] [Accepted: 01/17/2022] [Indexed: 11/26/2022] Open
Abstract
Do not go gentle into that good night,Old age should burn and rave at close of day;Rage, rage against the dying of the light.Though wise men at their end know dark is right,Because their works had forked no lightning theyDo not go gentle into that good night.Good men, the last wave by, crying how brightTheir frail deeds might have danced in a green bay,Rage, rage against the dying of the light.Wild men who caught and sang the sun in flight,And learn, too late, they grieved it on its way,Do not go gentle into that good night.Grave men, near death, who see with blinding sightBlind eyes could blaze like meteors and be gay,Rage, rage against the dying of the light.And you, my father, there on the sad height,Curse, bless, me now with your fierce tears, I pray.Do not go gentle into that good night.Rage, rage against the dying of the light.Dylan ThomasThe Poems of Dylan Thomas, New Directions Publishing 1971.This poem is in the public domain.
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Affiliation(s)
- James B. Young
- Executive Director of Academic Affairs, Cleveland Clinic, Professor of Medicine, Cleveland Clinic Lerner College of Medicine, a program of Case Western Reserve University School of Medicine, Cleveland, Ohio, US
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Xanthopoulos A, Wolski K, Wang Q, Blackstone EH, Randhawa VK, Soltesz EG, Young JB, Nissen SE, Estep JD, Triposkiadis F, Starling RC. Postimplant Phosphodiesterase-5 Inhibitor Use in Centrifugal Flow Left Ventricular Assist Devices. JACC Heart Fail 2022; 10:89-100. [PMID: 35115092 DOI: 10.1016/j.jchf.2021.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/24/2021] [Accepted: 09/28/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES This study examined the association between phosphodiesterase-5 inhibitor (PDE-5i) use and outcomes in patients with contemporary centrifugal flow left ventricular assist devices (LVADs). BACKGROUND PDE-5i use may affect outcomes in patients with continuous flow LVADs. METHODS Patients enrolled in INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support), with HeartMate 3 (n = 4,628) or HeartWare Ventricular Assist Device (HVAD) (n = 2,601) implant were included in the analysis. The mean duration of follow-up was 11.94 ± 8.65 months. PDE-5is were used in 2,173 patients. The primary endpoint was the composite of all-cause mortality, ischemic stroke, and pump thrombosis. Propensity matching and stabilized inverse probability of treatment weights were used to adjust for baseline differences between patients receiving and not receiving PDE-5i. Adjusted Cox proportional hazards analysis was performed for each outcome. RESULTS The primary endpoint was lower in the PDE-5i group (adjusted HR: 0.77; 95% CI: 0.69-0.86; P < 0.0001; HeartMate 3: adjusted HR: 0.77; 95% CI: 0.64-0.92; P = 0.0044; HVAD: adjusted HR: 0.76; 95% CI: 0.66-0.88; P = 0.0002). All-cause mortality was lower with PDE-5is (adjusted HR: 0.75; 95% CI: 0.65-0.86; P < 0.0001; HeartMate 3: adjusted HR: 0.70; 95% CI: 0.57-0.86; P = 0.0007; HVAD: adjusted HR: 0.78; 95% CI: 0.65-0.94; P = 0.0098) and fewer ischemic strokes with PDE-5is were observed (adjusted HR: 0.71; 95% CI: 0.56-0.89; P = 0.003; HeartMate 3: adjusted HR: 0.67; 95% CI: 0.45-0.99; P = 0.045; HVAD: adjusted HR: 0.73; 95% CI: 0.56-0.97; P = 0.03). LVAD thrombosis was unchanged with PDE-5is, with overall low event rates observed. CONCLUSIONS Postimplant PDE-5i use was associated with lower mortality and ischemic strokes in patients with centrifugal flow LVADs.
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Affiliation(s)
- Andrew Xanthopoulos
- Department of Cardiology, University General Hospital of Larissa, Larissa, Greece
| | - Kathy Wolski
- Department of Cardiovascular Medicine, Cleveland Clinic Coordinating Center for Clinical Research, Heart, Vascular, and Thoracic Institute, Cleveland, Ohio, USA
| | - Qiuqing Wang
- Department of Cardiovascular Medicine, Cleveland Clinic Coordinating Center for Clinical Research, Heart, Vascular, and Thoracic Institute, Cleveland, Ohio, USA
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Varinder Kaur Randhawa
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Edward G Soltesz
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - James B Young
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Steven E Nissen
- Department of Cardiovascular Medicine, Cleveland Clinic Coordinating Center for Clinical Research, Heart, Vascular, and Thoracic Institute, Cleveland, Ohio, USA
| | - Jerry D Estep
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Randall C Starling
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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Hendren NS, Segar MW, Zhong L, Michelis KC, Drazner MH, Young JB, Tang WHW, Pandey A, Grodin JL. Phenomapping a Novel Classification System for Patients With Destination Therapy Left Ventricular Assist Devices. Am J Cardiol 2022; 164:93-99. [PMID: 34815060 DOI: 10.1016/j.amjcard.2021.10.028] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 09/30/2021] [Accepted: 10/04/2021] [Indexed: 11/16/2022]
Abstract
Patients with continuous flow destination therapy (DT) left ventricular assist devices (LVAD) comprise a heterogeneous population. We hypothesized that phenotypic clustering of individuals with DT LVADs by their implantation characteristics will be associated with different long-term risk profiles. We analyzed 5,999 patients with continuous flow DT LVADs in Interagency Registry for Mechanically Assisted Circulatory Support using 18 continuous variable baseline characteristics. We Z-transformed the variables and applied a Gaussian finite mixture model to perform unsupervised clustering resulting in identification of 4 phenogroups. Survival analyses considered the competing risk for cumulative incidence of transplant or the composite end point of death or heart transplant where appropriate. Phenogroup 1 (n = 1,163, 19%) was older (71 years) and primarily white (81%). Phenogroups 2 (n = 648, 11%) and 3 (n = 3,671, 61%) were of intermediate age (70 and 62 years), weight (85 and 87 kg), and ventricular size. Phenogroup 4 (n = 517, 9%) was younger (40 years), heavier (108 kg), and more racially diverse. The cumulative incidence of death, heart transplant, bleeding, LVAD malfunction, and LVAD thrombosis differed among phenogroups. The highest incidence of death and the lowest rate of heart transplant was seen in phenogroup 1 (p <0.001). For adverse outcomes, phenogroup 4 had the lowest incidence of bleeding, whereas LVAD device thrombosis and malfunction were lowest in phenogroup 1 (p <0.001 for all). Finally, the incidence of stroke, infection, and renal dysfunction were not statistically different. In conclusion, the present unsupervised machine learning analysis identified 4 phenogroups with different rates of adverse outcomes and these findings underscore the influence of phenotypic heterogeneity on post-LVAD implantation outcomes.
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Affiliation(s)
- Nicholas S Hendren
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Parkland Health and Hospital System, Dallas, Texas
| | - Matthew W Segar
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Parkland Health and Hospital System, Dallas, Texas
| | - Lin Zhong
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Katherine C Michelis
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Division of Cardiology, Department of Internal Medicine, North Texas VA Medical Center, Dallas, Texas
| | - Mark H Drazner
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - James B Young
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Parkland Health and Hospital System, Dallas, Texas
| | - Justin L Grodin
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Parkland Health and Hospital System, Dallas, Texas.
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16
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Nissen SE, Young JB. How a New Understanding of Drug or Drug Class Pharmacology Often Drives Drug Development: A Conversation with Steven E. Nissen, MD. Methodist Debakey Cardiovasc J 2022; 18:54-57. [PMID: 36561089 PMCID: PMC9733186 DOI: 10.14797/mdcvj.1181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022] Open
Abstract
This video interview features Steven Nissen, MD, telling his 2007 story of revealing that the number-1 diabetes drug, rosiglitazone, led to more cardiovascular events than placebo or a variety of competitors. The discovery resulted in new requirements for clinical trials to rule out harm. It focuses on how a new understanding of drug or drug class pharmacology often drives drug development, and includes a discussion of the approval process, which may bring a different result than was originally intended. View the video at https://youtu.be/aFtCfZyd54E.
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Affiliation(s)
- Steven E. Nissen
- Chief Academic Officer of the Cleveland Clinic Heart, Vascular & Thoracic Institute, Cleveland, Ohio, US
| | - James B. Young
- Executive Director of Academic Affairs, Cleveland Clinic, Cleveland, Ohio, US
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17
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Young JB, Raizner AE. Cardiovascular Pharmacology: Contemporary Physiologic and Scientific Approaches to Cardiovascular Disease Prevention and Treatment. Methodist Debakey Cardiovasc J 2022; 18:1-4. [PMID: 36561086 PMCID: PMC9733162 DOI: 10.14797/mdcvj.1184] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 11/12/2022] [Indexed: 12/12/2022] Open
Affiliation(s)
- James B. Young
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, US
| | - Albert E. Raizner
- Houston Methodist DeBakey Heart & Vascular Center, Baylor College of Medicine, and Interventional Cardiology Associates, Houston, Texas, US
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18
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Young JB, Cordova JC. The Noncompliant Patient. Methodist Debakey Cardiovasc J 2022; 18:81-84. [PMID: 36561090 PMCID: PMC9733187 DOI: 10.14797/mdcvj.1166] [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] [Received: 10/01/2022] [Accepted: 10/01/2022] [Indexed: 12/12/2022] Open
Abstract
This issue's Poet's Pen is an experiential work submitted by Captain Justin C. Cordova, MD, from the Department of Anesthesiology at Walter Reed National Military Medical Center in Bethesda, Maryland. The submission was a response to an invitation for our readers to submit poems for consideration of publication. Captain Cordova's work, "Against Medical Advice," is an engaging and provocative poem that focuses on a disturbing healthcare provider challenge-attempting to deliver "best care" to patients who, for countless reasons, choose a pathway we label as noncompliance or against medical advice.
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Affiliation(s)
- James B. Young
- Emeritus Executive Director of Academic Affairs, Cleveland Clinic, Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, US
| | - Justin C. Cordova
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland, US
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19
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Abstract
Single-electron transfer (SET)-induced decarboxylative backbone radical generation was exploited to produce statistical olefin-acrylate copolymers. Quenching of the backbone radical with an H atom donor yielded ethylene or propylene repeat units.
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Affiliation(s)
- John B. Garrison
- George & Josephine Butler Polymer Research Laboratory, Center for Macromolecular Science & Engineering, Department of Chemistry, University of Florida, PO Box 117200, Gainesville, Florida 32611, USA
| | - Rhys W. Hughes
- George & Josephine Butler Polymer Research Laboratory, Center for Macromolecular Science & Engineering, Department of Chemistry, University of Florida, PO Box 117200, Gainesville, Florida 32611, USA
| | - James B. Young
- George & Josephine Butler Polymer Research Laboratory, Center for Macromolecular Science & Engineering, Department of Chemistry, University of Florida, PO Box 117200, Gainesville, Florida 32611, USA
| | - Brent S. Sumerlin
- George & Josephine Butler Polymer Research Laboratory, Center for Macromolecular Science & Engineering, Department of Chemistry, University of Florida, PO Box 117200, Gainesville, Florida 32611, USA
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20
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Raizner AE, Young JB. Constantly Bombarded with New Drugs: What's a Cardiologist to Do? Methodist Debakey Cardiovasc J 2022; 18:74-76. [PMID: 36561079 PMCID: PMC9733149 DOI: 10.14797/mdcvj.1179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 12/12/2022] Open
Abstract
Every physician encounters a barrage of direct-to-consumer and direct-to-physician advertising and is faced with the daunting task of deciding which drugs to add to their clinical armamentarium and how and when to add them. The purpose of this Points to Remember is to present a commonsense approach to incorporating newer drugs, or perhaps new indications for older drugs, into our clinical practice. To illustrate these points, this article focuses on a single drug, empagliflozin, a sodium-glucose cotransporter-2 (SGLT-2) inhibitor that has been highly marketed in lay and medical media and hence has been incorporated into professional society treatment guidelines.
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Affiliation(s)
- Albert E. Raizner
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist, Houston, Texas, US
| | - James B. Young
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, US
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21
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Abstract
Although I can see him still—The freckled man who goesTo a gray place on a hillIn gray Connemara clothesAt dawn to cast his flies—It’s long since I beganTo call up to the eyesThis wise and simple man.All day I’d looked in the faceWhat I had hoped it would beTo write for my own raceAnd the reality:The living men that I hate,The dead man that I loved,The craven man in his seat,The insolent unreproved—And no knave brought to bookWho has won a drunken cheer—The witty man and his jokeAimed at the commonest ear,The clever man who criesThe catch cries of the clown,The beating down of the wiseAnd great Art beaten down.Maybe a twelve-month sinceSuddenly I began,In scorn of this audience,Imagining a man,And his sun-freckled faceAnd gray Connemara cloth,Climbing up to a placeWhere stone is dark with froth,And the down turn of his wristWhen the flies drop in the stream—A man who does not exist,A man who is but a dream;And cried, “Before I am oldI shall have written him onePoem maybe as coldAnd passionate as dawn.” William Butler Yeats Poetry Magazine, Vol.7, No. 5, February 1916 Poetry Foundation https://www.poetryfoundation.org/poetrymagazine/poems/13324/the-fisherman This poem is in the public domain.
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Affiliation(s)
- James B. Young
- Executive Director of Academic Affairs, Cleveland Clinic; Professor of Medicine, Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, US
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22
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Young JB. Ozymandias. Methodist Debakey Cardiovasc J 2021; 17:93-95. [PMID: 34824687 PMCID: PMC8588728 DOI: 10.14797/mdcvj.697] [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] [Received: 06/28/2021] [Accepted: 07/02/2021] [Indexed: 11/11/2022] Open
Abstract
I met a traveler from an antique landWho said: Two vast and trunkless legs of stoneStand in the desert….Near them, on the sand,Half sunk, a visage lies, whose frown,And wrinkled lip, and sneer of cold command,Tell that its sculptor well those passions readWhich yet survive, stamped on these lifeless things,The hand that mocked them, and heart that fed;And on the pedestal these words appear:“My name is Ozymandias, King of Kings;Look on my works, ye Mighty, and despair!”Nothing beside remains. Round the decayOf that colossal wreck, boundless and bareThe lone and level sands stretch far away.Percy Bysshe ShelleyRosalind and Helen, A Modern Eclogue; With Other PoemsLondon: Hollinger. p. 72 (1876) This poem is in the public domain.
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Affiliation(s)
- James B Young
- Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, US
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23
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Ueland T, Gullestad L, Kou L, Young JB, Pfeffer MA, van Veldhuisen DJ, Swedberg K, Mcmurray JJV, Desai AS, Anand IS, Aukrust P. Growth differentiation factor 15 predicts poor prognosis in patients with heart failure and reduced ejection fraction and anemia: results from RED-HF. Clin Res Cardiol 2021; 111:440-450. [PMID: 34611778 PMCID: PMC8971146 DOI: 10.1007/s00392-021-01944-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 09/15/2021] [Indexed: 11/24/2022]
Abstract
Aims We aimed to assess the value of GDF-15, a stress-responsive cytokine, in predicting clinical outcomes in patients with heart failure (HF) with reduced ejection fraction (HFrEF) and anemia Methods and results Serum GDF-15 was assessed in 1582 HFrEF and mild-to-moderate anemia patients who where followed for 28 months in the Reduction of Events by Darbepoetin alfa in Heart Failure (RED-HF) trial, an overall neutral RCT evaluating the effect darbepoetin alfa on clinical outcomes in patients with systolic heart failure and mild-to-moderate anemia. Association between baseline and change in GDF-15 during 6 months follow-up and the primary composite outcome of all-cause death or HF hospitalization were evaluated in multivariable Cox-models adjusted for conventional clinical and biochemical risk factors. The adjusted risk for the primary outcome increased with (i) successive tertiles of baseline GDF-15 (tertile 3 HR 1.56 [1.23–1.98] p < 0.001) as well as with (ii) a 15% increase in GDF-15 levels over 6 months of follow-up (HR 1.68 [1.38–2.06] p < 0.001). Addition of change in GDF-15 to the fully adjusted model improved the C-statistics (p < 0.001). No interaction between treatment and baseline or change in GDF-15 on outcome was observed. GDF-15 was inversely associated with several indices of anemia and correlated positively with ferritin. Conclusions In patients with HF and anemia, both higher baseline serum GDF-15 levels and an increase in GDF-15 during follow-up, were associated with worse clinical outcomes. GDF-15 did not identify subgroups of patients who might benefit from correction of anemia but was associated with several indices of anemia and iron status in the HF patients. Graphic abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s00392-021-01944-6.
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Affiliation(s)
- Thor Ueland
- Research Institute of Internal Medicine, Oslo University Hospital, Rikshospitalet, Nydalen, P. B. 4950, 0424, Oslo, Norway. .,Faculty of Medicine, University of Oslo, Oslo, Norway. .,K. G. Jebsen Thrombosis Research and Expertise Center, University of Tromsø, Tromsö, Norway.
| | - Lars Gullestad
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway.,Center for Heart Failure Research, University of Oslo, Oslo, Norway.,K.G. Jebsen Cardiac Research Center, University of Oslo, Oslo, Norway
| | - Lei Kou
- Cleveland Clinic, Cleveland, OH, USA
| | | | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Karl Swedberg
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,National Heart and Lung Institute, Imperial College, London, UK
| | - John J V Mcmurray
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Inderjit S Anand
- VA Medical Center, Minneapolis, MN, USA.,University of Minnesota, Minneapolis, MN, USA
| | - Pål Aukrust
- Research Institute of Internal Medicine, Oslo University Hospital, Rikshospitalet, Nydalen, P. B. 4950, 0424, Oslo, Norway.,Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway.,K. G. Jebsen Inflammation Research Center, University of Oslo, Oslo, Norway.,K. G. Jebsen Thrombosis Research and Expertise Center, University of Tromsø, Tromsö, Norway
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24
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Ferlinghetti L, Young JB. Pity the Nation (After Khalil Gibran). Methodist Debakey Cardiovasc J 2021; 17:162-163. [PMID: 34326938 PMCID: PMC8298127 DOI: 10.14797/mcci6003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
| | - James B Young
- Executive Director of Academic Affairs, Cleveland Clinic, Professor of Medicine, Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University, Section Editor, Poet's Pen, Methodist DeBakey Cardiovascular Journal
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25
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Pantalone KM, Smolarz BG, Ramasamy A, Baz Hecht M, Harty BJ, Rogen B, Griebeler ML, Borukh E, Young JB, Burguera B. Effectiveness of Combining Antiobesity Medication With an Employer-Based Weight Management Program for Treatment of Obesity: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2116595. [PMID: 34255049 PMCID: PMC8278271 DOI: 10.1001/jamanetworkopen.2021.16595] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE The clinical efficacy of antiobesity medications (AOMs) as adjuncts to lifestyle intervention is well characterized, but data regarding their use in conjunction with workplace wellness plans are lacking, and coverage of AOMs by US private employers is limited. OBJECTIVE To determine the effect of combining AOMs with a comprehensive, interdisciplinary, employer-based weight management program (WMP) compared with the WMP alone on weight loss, treatment adherence, and work productivity and limitations. DESIGN, SETTING, AND PARTICIPANTS This 1-year, single-center, open-label, parallel-group, real-world, randomized clinical trial was conducted at the Cleveland Clinic's Endocrinology and Metabolism Institute in Cleveland, Ohio, from January 7, 2019, to May 22, 2020. Participants were adults with obesity (body mass index [BMI; calculated as weight in kilograms divided by height in meters squared] ≥30) enrolled in the Cleveland Clinic Employee Health Plan. INTERVENTIONS In total, 200 participants were randomized 1:1, 100 participants to WMP combined with an AOM (WMP+Rx), and 100 participants to WMP alone. The WMP was the Cleveland Clinic Endocrinology and Metabolism Institute's employer-based integrated medical WMP implemented through monthly multidisciplinary shared medical appointments. Participants in the WMP+Rx group initiated treatment with 1 of 5 US Food and Drug Administration-approved medications for chronic weight management (orlistat, lorcaserin, phentermine/topiramate, naltrexone/bupropion, and liraglutide, 3.0 mg) according to standard clinical practice. MAIN OUTCOMES AND MEASURES The primary end point was the percentage change in body weight from baseline to month 12. RESULTS The 200 participants were predominately (177 of 200 [88.5%]) women, had a mean (SD) age of 50.0 (10.3) years, and a mean (SD) baseline weight of 105.0 (19.0) kg. For the primary intention-to-treat estimand, the estimated mean (SE) weight loss was -7.7% (0.7%) for the WMP+Rx group vs -4.2% (0.7%) for the WMP group, with an estimated treatment difference of -3.5% (95% CI, -5.5% to -1.5%) (P < .001). The estimated percentage of participants achieving at least 5% weight loss was 62.5% for WMP+Rx vs 44.8% for WMP (P = .02). The rate of attendance at shared medical appointments was higher for the WMP+Rx group than for the WMP group. No meaningful differences in patient-reported work productivity or limitation measures were observed. CONCLUSIONS AND RELEVANCE Clinically meaningful superior mean weight loss was achieved when access to AOMs was provided in the real-world setting of an employer-based WMP, compared with the WMP alone. Such results may inform employer decisions regarding AOM coverage and guide best practices for comprehensive, interdisciplinary employer-based WMPs. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03799198.
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Affiliation(s)
- Kevin M. Pantalone
- Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | | | | | - Bruce Rogen
- Cleveland Clinic Employee Health Plan, Cleveland, Ohio
| | | | - Elena Borukh
- Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, Ohio
| | - James B. Young
- Cleveland Clinic Executive Administration, Cleveland, Ohio
| | - Bartolome Burguera
- Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, Ohio
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26
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Misra-Hebert AD, Ji X, Jehi L, Milinovich A, Pfoh ER, Kattan MW, Young JB. COVID-19 Home Monitoring After Diagnosis and Health Care Utilization in an Integrated Health System. JAMA Health Forum 2021; 2:e210333. [PMID: 35977306 PMCID: PMC8796892 DOI: 10.1001/jamahealthforum.2021.0333] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/03/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Anita D. Misra-Hebert
- Healthcare Delivery and Implementation Science Center, Cleveland Clinic, Cleveland, Ohio
| | - Xinge Ji
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Lara Jehi
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alex Milinovich
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Elizabeth R. Pfoh
- Center for Value-Based Care Research, Cleveland Clinic Community Care, Cleveland, Ohio
| | - Michael W. Kattan
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - James B. Young
- Healthcare Delivery and Implementation Science Center, Cleveland Clinic, Cleveland, Ohio
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27
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Young JB, Frost R. The Gift Outright. Methodist Debakey Cardiovasc J 2021; 17:73-74. [PMID: 34104327 DOI: 10.14797/kenw7739] [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] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- James B Young
- Executive Director of Academic Affairs, Cleveland Clinic Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Section Editor, Poet's Pen, Methodist DeBakey Cardiovascular Journal
| | - Robert Frost
- The Witness Tree (1942), copyright Henry Holt & Co., New York
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28
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Michelis KC, Zhong L, Tang WW, Young JB, Peltz M, Drazner MH, Pandey A, Griffin J, Maurer MS, Grodin JL. Durable Mechanical Circulatory Support in Patients With Amyloid Cardiomyopathy. Circ Heart Fail 2020; 13:e007931. [DOI: 10.1161/circheartfailure.120.007931] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 11/16/2022]
Abstract
Background:
Many patients with amyloid cardiomyopathy (ACM) develop advanced heart failure, and durable mechanical circulatory support (MCS) may be a consideration. However, data describing clinical outcomes after MCS in this population are limited.
Methods:
Adult patients in the Interagency Registry for Mechanically Assisted Circulatory Support with dilated cardiomyopathy (DCM, n=19 921), nonamyloid restrictive cardiomyopathy (RCM, n=248), or ACM (n=46) between 2005 and 2017 were included. Patient and device characteristics were compared between cardiomyopathy groups. The primary end point was the cumulative incidence of death with heart transplantation as a competing risk.
Results:
Patients with ACM (n=46) were older (61 years [interquartile range, 55–69 years] versus 58 years [interquartile range, 49–66 years] for DCM and 55 years [interquartile range, 46–62 years] for nonamyloid RCM,
P
<0.001) and were more commonly Interagency Registry for Mechanically Assisted Circulatory Support profile 1 (30.4% versus 17.9% for DCM and 21.0% for nonamyloid RCM,
P
=0.04) at device implantation. Use of biventricular support (biventricular assist device or total artificial heart) was the highest for patients with ACM (41.3% versus 6.7% and 19.4% for patients with DCM and nonamyloid RCM, respectively,
P
=0.014). The cumulative incidence of death was highest for patients with ACM relative to those with DCM or nonamyloid RCM (
P
<0.001) but did not differ significantly between groups for those who required biventricular MCS.
Conclusions:
Compared with patients with DCM or nonamyloid RCM who received durable MCS, those with ACM experienced the highest use of biventricular support and the worst survival. These data highlight concerns with the use of durable MCS for patients with ACM.
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Affiliation(s)
- Katherine C. Michelis
- Division of Cardiology, Department of Internal Medicine (K.C.M., M.H.D., A.P., J.L.G.), University of Texas Southwestern Medical Center, Dallas
- Division of Cardiology, Department of Internal Medicine, North Texas VA Medical Center, Dallas (K.C.M.)
| | - Lin Zhong
- Division of Bioinformatics, Department of Clinical Sciences (L.Z.), University of Texas Southwestern Medical Center, Dallas
| | - W.H. Wilson Tang
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, OH (W.H.W.T., J.B.Y.)
| | - James B. Young
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, OH (W.H.W.T., J.B.Y.)
| | - Matthias Peltz
- Department of Cardiovascular and Thoracic Surgery (M.P.), University of Texas Southwestern Medical Center, Dallas
| | - Mark H. Drazner
- Division of Cardiology, Department of Internal Medicine (K.C.M., M.H.D., A.P., J.L.G.), University of Texas Southwestern Medical Center, Dallas
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine (K.C.M., M.H.D., A.P., J.L.G.), University of Texas Southwestern Medical Center, Dallas
| | - Jan Griffin
- Division of Cardiovascular Disease, Department of Internal Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center (J.G., M.S.M.)
| | - Mathew S. Maurer
- Division of Cardiovascular Disease, Department of Internal Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center (J.G., M.S.M.)
| | - Justin L. Grodin
- Division of Cardiology, Department of Internal Medicine (K.C.M., M.H.D., A.P., J.L.G.), University of Texas Southwestern Medical Center, Dallas
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29
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Misra-Hebert AD, Jehi L, Ji X, Nowacki AS, Gordon S, Terpeluk P, Chung MK, Mehra R, Dell KM, Pennell N, Hamilton A, Milinovich A, Kattan MW, Young JB. Impact of the COVID-19 Pandemic on Healthcare Workers' Risk of Infection and Outcomes in a Large, Integrated Health System. J Gen Intern Med 2020; 35:3293-3301. [PMID: 32875500 PMCID: PMC7462108 DOI: 10.1007/s11606-020-06171-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [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: 08/01/2020] [Accepted: 08/17/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Understanding the impact of the COVID-19 pandemic on healthcare workers (HCW) is crucial. OBJECTIVE Utilizing a health system COVID-19 research registry, we assessed HCW risk for COVID-19 infection, hospitalization, and intensive care unit (ICU) admission. DESIGN Retrospective cohort study with overlap propensity score weighting. PARTICIPANTS Individuals tested for SARS-CoV-2 infection in a large academic healthcare system (N = 72,909) from March 8-June 9, 2020, stratified by HCW and patient-facing status. MAIN MEASURES SARS-CoV-2 test result, hospitalization, and ICU admission for COVID-19 infection. KEY RESULTS Of 72,909 individuals tested, 9.0% (551) of 6145 HCW tested positive for SARS-CoV-2 compared to 6.5% (4353) of 66,764 non-HCW. The HCW were younger than the non-HCW (median age 39.7 vs. 57.5, p < 0.001) with more females (proportion of males 21.5 vs. 44.9%, p < 0.001), higher reporting of COVID-19 exposure (72 vs. 17%, p < 0.001), and fewer comorbidities. However, the overlap propensity score weighted proportions were 8.9 vs. 7.7 for HCW vs. non-HCW having a positive test with weighted odds ratio (OR) 1.17, 95% confidence interval (CI) 0.99-1.38. Among those testing positive, weighted proportions for hospitalization were 7.4 vs. 15.9 for HCW vs. non-HCW with OR of 0.42 (CI 0.26-0.66) and for ICU admission: 2.2 vs. 4.5 for HCW vs. non-HCW with OR of 0.48 (CI 0.20-1.04). Those HCW identified as patient facing compared to not had increased odds of a positive SARS-CoV-2 test (OR 1.60, CI 1.08-2.39, proportions 8.6 vs. 5.5), but no statistically significant increase in hospitalization (OR 0.88, CI 0.20-3.66, proportions 10.2 vs. 11.4) and ICU admission (OR 0.34, CI 0.01-3.97, proportions 1.8 vs. 5.2). CONCLUSIONS In a large healthcare system, HCW had similar odds for testing SARS-CoV-2 positive, but lower odds of hospitalization compared to non-HCW. Patient-facing HCW had higher odds of a positive test. These results are key to understanding HCW risk mitigation during the COVID-19 pandemic.
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Affiliation(s)
- Anita D Misra-Hebert
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA.
- Healthcare Delivery and Implementation Science Center, Cleveland Clinic, Cleveland, OH, USA.
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA.
| | - Lara Jehi
- Department of Neurology, Cleveland Clinic, Cleveland, OH, USA
- Information Technology Division Administration, Cleveland Clinic, Cleveland, OH, USA
| | - Xinge Ji
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Amy S Nowacki
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Steven Gordon
- Department of Infectious Disease, Cleveland Clinic, Cleveland, OH, USA
| | - Paul Terpeluk
- Department of Occupational Health, Cleveland Clinic, Cleveland, OH, USA
| | - Mina K Chung
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Reena Mehra
- Sleep Disorders Center, Cleveland Clinic, Cleveland, OH, USA
| | - Katherine M Dell
- Center for Pediatric Nephrology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Nathan Pennell
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Aaron Hamilton
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Alex Milinovich
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Michael W Kattan
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - James B Young
- Healthcare Delivery and Implementation Science Center, Cleveland Clinic, Cleveland, OH, USA
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
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Young JB. Poet's Pen: Two Sonnets by John Keats (1795-1821). Methodist Debakey Cardiovasc J 2020; 16:326-327. [PMID: 33500765 DOI: 10.14797/mdcj-16-4-326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- James B Young
- Chief Academic Officer, Cleveland Clinic, Professor of Medicine and Vice-Dean for Cleveland Clinic Academic Affairs, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Section Editor, Poet's Pen, Methodist DeBakey Cardiovascular Journal
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Mehta N, Kalra A, Nowacki AS, Anjewierden S, Han Z, Bhat P, Carmona-Rubio AE, Jacob M, Procop GW, Harrington S, Milinovich A, Svensson LG, Jehi L, Young JB, Chung MK. Association of Use of Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers With Testing Positive for Coronavirus Disease 2019 (COVID-19). JAMA Cardiol 2020; 5:1020-1026. [PMID: 32936273 DOI: 10.1001/jamacardio.2020.1855] [Citation(s) in RCA: 308] [Impact Index Per Article: 77.0] [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: 12/11/2022]
Abstract
Importance The role of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) in the setting of the coronavirus disease 2019 (COVID-19) pandemic is hotly debated. There have been recommendations to discontinue these medications, which are essential in the treatment of several chronic disease conditions, while, in the absence of clinical evidence, professional societies have advocated their continued use. Objective To study the association between use of ACEIs/ARBs with the likelihood of testing positive for COVID-19 and to study outcome data in subsets of patients taking ACEIs/ARBs who tested positive with severity of clinical outcomes of COVID-19 (eg, hospitalization, intensive care unit admission, and requirement for mechanical ventilation). Design, Setting, and Participants Retrospective cohort study with overlap propensity score weighting was conducted at the Cleveland Clinic Health System in Ohio and Florida. All patients tested for COVID-19 between March 8 and April 12, 2020, were included. Exposures History of taking ACEIs or ARBs at the time of COVID-19 testing. Main Outcomes and Measures Results of COVID-19 testing in the entire cohort, number of patients requiring hospitalizations, intensive care unit admissions, and mechanical ventilation among those who tested positive. Results A total of 18 472 patients tested for COVID-19. The mean (SD) age was 49 (21) years, 7384 (40%) were male, and 12 725 (69%) were white. Of 18 472 patients who underwent COVID-19 testing, 2285 (12.4%) were taking either ACEIs or ARBs. A positive COVID-19 test result was observed in 1735 of 18 472 patients (9.4%). Among patients who tested positive, 421 (24.3%) were admitted to the hospital, 161 (9.3%) were admitted to an intensive care unit, and 111 (6.4%) required mechanical ventilation. Overlap propensity score weighting showed no significant association of ACEI and/or ARB use with COVID-19 test positivity (overlap propensity score-weighted odds ratio, 0.97; 95% CI, 0.81-1.15). Conclusions and Relevance This study found no association between ACEI or ARB use and COVID-19 test positivity. These clinical data support current professional society guidelines to not discontinue ACEIs or ARBs in the setting of the COVID-19 pandemic. However, further study in larger numbers of hospitalized patients receiving ACEI and ARB therapy is needed to determine the association with clinical measures of COVID-19 severity.
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Affiliation(s)
- Neil Mehta
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio
| | - Ankur Kalra
- Heart, Vascular and Thoracic Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.,Section of Cardiovascular Research, Heart, Vascular and Thoracic Department, Cleveland Clinic Akron General, Akron, Ohio
| | - Amy S Nowacki
- Lerner Research Institute, Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Scott Anjewierden
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio
| | - Zheyi Han
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio
| | - Pavan Bhat
- Heart, Vascular and Thoracic Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Andres E Carmona-Rubio
- Heart, Vascular and Thoracic Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Miriam Jacob
- Heart, Vascular and Thoracic Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Gary W Procop
- Pathology and Laboratory Medicine Institute, Department of Laboratory Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Susan Harrington
- Pathology and Laboratory Medicine Institute, Department of Laboratory Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Alex Milinovich
- Lerner Research Institute, Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Heart, Vascular and Thoracic Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - James B Young
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio.,Heart, Vascular and Thoracic Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Mina K Chung
- Heart, Vascular and Thoracic Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.,Lerner Research Institute, Department of Cardiovascular and Metabolic Sciences, Cleveland Clinic, Cleveland, Ohio
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Kalra A, Hawkins ES, Nowacki AS, Jain V, Milinovich A, Saef J, Thomas G, Gebreselassie SK, Karnik SS, Jehi L, Young JB, Svensson LG, Chung MK, Mehta N. Angiotensin-Converting Enzyme Inhibitors Versus Angiotensin II Receptor Blockers: A Comparison of Outcomes in Patients With COVID-19. Circ Cardiovasc Qual Outcomes 2020; 13:e007115. [PMID: 32856462 DOI: 10.1161/circoutcomes.120.007115] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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] [Indexed: 12/17/2022]
Affiliation(s)
- Ankur Kalra
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute (A.K., J.S., M.K.C.), Cleveland Clinic, OH.,Section of Cardiovascular Research, Heart, Vascular and Thoracic Department, Cleveland Clinic Akron General, OH (A.K.)
| | - Edward S Hawkins
- Center for Emergency Medicine-West, Cleveland Clinic Medina Hospital, Medina, OH (E.S.H.)
| | - Amy S Nowacki
- Department of Quantitative Health Sciences, Lerner Research Institute (A.S.N., A.M.), Cleveland Clinic, OH
| | - Vardhmaan Jain
- Department of Internal Medicine, Cleveland Clinic Foundation, OH (V.J.)
| | - Alex Milinovich
- Department of Quantitative Health Sciences, Lerner Research Institute (A.S.N., A.M.), Cleveland Clinic, OH
| | - Joshua Saef
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute (A.K., J.S., M.K.C.), Cleveland Clinic, OH
| | - George Thomas
- Department of Nephrology and Hypertension (G.T.), Cleveland Clinic, OH
| | | | - Sadashiva S Karnik
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute (S.S.K., M.K.C.), Cleveland Clinic, OH
| | - Lara Jehi
- Cleveland Clinic Foundation, OH (L.J.)
| | - James B Young
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (J.B.Y., N.M.), Cleveland Clinic, OH
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute (L.G.S.), Cleveland Clinic, OH
| | - Mina K Chung
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute (A.K., J.S., M.K.C.), Cleveland Clinic, OH.,Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute (S.S.K., M.K.C.), Cleveland Clinic, OH
| | - Neil Mehta
- Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (J.B.Y., N.M.), Cleveland Clinic, OH
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Misra-Hebert AD, Jehi L, Ji X, Nowacki AS, Gordon S, Terpeluk P, Chung MK, Mehra R, Dell KM, Pennell N, Hamilton A, Milinovich A, Kattan MW, Young JB. Impact of the COVID-19 pandemic on healthcare workers risk of infection and outcomes in a large, integrated health system. Res Sq 2020:rs.3.rs-61235. [PMID: 32839766 PMCID: PMC7444292 DOI: 10.21203/rs.3.rs-61235/v1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background: Understanding the impact of the COVID-19 pandemic on healthcare workers (HCW) is crucial. Objective: Utilizing a health system COVID-19 research registry, we assessed HCW risk for COVID-19 infection, hospitalization and intensive care unit (ICU) admission. Design: Retrospective cohort study with overlap propensity score weighting. Participants: Individuals tested for SARS-CoV-2 infection in a large academic healthcare system (N=72,909) from March 8-June 9 2020 stratified by HCW and patient-facing status. Main Measures: SARS-CoV-2 test result, hospitalization, and ICU admission for COVID-19 infection. Key Results: Of 72,909 individuals tested, 9.0% (551) of 6,145 HCW tested positive for SARS-CoV-2 compared to 6.5% (4353) of 66,764 non-HCW. The HCW were younger than non-HCW (median age 39.7 vs. 57.5, p<0.001) with more females (proportion of males 21.5 vs. 44.9%, p<0.001), higher reporting of COVID-19 exposure (72 vs. 17 %, p<0.001) and fewer comorbidities. However, the overlap propensity score weighted proportions were 8.9 vs. 7.7 for HCW vs. non-HCW having a positive test with weighted odds ratio (OR) 1.17, 95% confidence interval (CI) 0.99-1.38. Among those testing positive, weighted proportions for hospitalization were 7.4 vs.15.9 for HCW vs. non-HCW with OR of 0.42 (CI 0.26-0.66) and for ICU admission: 2.2 vs.4.5 for HCW vs. non-HCW with OR of 0.48 (CI 0.20 -1.04). Those HCW identified as patient-facing compared to not had increased odds of a positive SARS-CoV-2 test (OR 1.60, CI 1.08-2.39, proportions 8.6 vs. 5.5), but no statistically significant increase in hospitalization (OR 0.88, CI 0.20-3.66, proportions 10.2 vs. 11.4) and ICU admission (OR 0.34, CI 0.01-3.97, proportions 1.8 vs. 5.2). Conclusions: In a large healthcare system, HCW had similar odds for testing SARS-CoV-2 positive, but lower odds of hospitalization compared to non-HCW. Patient-facing HCW had higher odds of a positive test. These results are key to understanding HCW risk mitigation during the COVID-19 pandemic.
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Jehi L, Ji X, Milinovich A, Erzurum S, Merlino A, Gordon S, Young JB, Kattan MW. Development and validation of a model for individualized prediction of hospitalization risk in 4,536 patients with COVID-19. PLoS One 2020; 15:e0237419. [PMID: 32780765 PMCID: PMC7418996 DOI: 10.1371/journal.pone.0237419] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [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: 04/24/2020] [Accepted: 07/27/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Coronavirus Disease 2019 is a pandemic that is straining healthcare resources, mainly hospital beds. Multiple risk factors of disease progression requiring hospitalization have been identified, but medical decision-making remains complex. OBJECTIVE To characterize a large cohort of patients hospitalized with COVID-19, their outcomes, develop and validate a statistical model that allows individualized prediction of future hospitalization risk for a patient newly diagnosed with COVID-19. DESIGN Retrospective cohort study of patients with COVID-19 applying a least absolute shrinkage and selection operator (LASSO) logistic regression algorithm to retain the most predictive features for hospitalization risk, followed by validation in a temporally distinct patient cohort. The final model was displayed as a nomogram and programmed into an online risk calculator. SETTING One healthcare system in Ohio and Florida. PARTICIPANTS All patients infected with SARS-CoV-2 between March 8, 2020 and June 5, 2020. Those tested before May 1 were included in the development cohort, while those tested May 1 and later comprised the validation cohort. MEASUREMENTS Demographic, clinical, social influencers of health, exposure risk, medical co-morbidities, vaccination history, presenting symptoms, medications, and laboratory values were collected on all patients, and considered in our model development. RESULTS 4,536 patients tested positive for SARS-CoV-2 during the study period. Of those, 958 (21.1%) required hospitalization. By day 3 of hospitalization, 24% of patients were transferred to the intensive care unit, and around half of the remaining patients were discharged home. Ten patients died. Hospitalization risk was increased with older age, black race, male sex, former smoking history, diabetes, hypertension, chronic lung disease, poor socioeconomic status, shortness of breath, diarrhea, and certain medications (NSAIDs, immunosuppressive treatment). Hospitalization risk was reduced with prior flu vaccination. Model discrimination was excellent with an area under the curve of 0.900 (95% confidence interval of 0.886-0.914) in the development cohort, and 0.813 (0.786, 0.839) in the validation cohort. The scaled Brier score was 42.6% (95% CI 37.8%, 47.4%) in the development cohort and 25.6% (19.9%, 31.3%) in the validation cohort. Calibration was very good. The online risk calculator is freely available and found at https://riskcalc.org/COVID19Hospitalization/. LIMITATION Retrospective cohort design. CONCLUSION Our study crystallizes published risk factors of COVID-19 progression, but also provides new data on the role of social influencers of health, race, and influenza vaccination. In a context of a pandemic and limited healthcare resources, individualized outcome prediction through this nomogram or online risk calculator can facilitate complex medical decision-making.
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Affiliation(s)
- Lara Jehi
- Neurological Institute, Chief Research Information Officer, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Xinge Ji
- Quantitative Health Science Department, Lerner Research Institute Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Alex Milinovich
- Quantitative Health Science Department, Lerner Research Institute Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Serpil Erzurum
- Respiratory Institute, Chair of the Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Amy Merlino
- Obstetrics and gynecology, Chief Medical Information Ofc., Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Steve Gordon
- Infectious Disease Department, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - James B. Young
- Cardiology, Chief Academic Officer, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Michael W. Kattan
- Quantitative Health Science Department, Lerner Research Institute Cleveland Clinic, Cleveland, Ohio, United States of America
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Gorodeski EZ, Moennich LA, Riaz H, Jehi L, Young JB, Tang WW. Virtual Versus In-Person Visits and Appointment No-Show Rates in Heart Failure Care Transitions. Circ Heart Fail 2020; 13:e007119. [DOI: 10.1161/circheartfailure.120.007119] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Eiran Z. Gorodeski
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH (E.Z.G.)
| | - Laurie Ann Moennich
- Heart, Vascular, and Thoracic Institute Research and Registries, Cleveland Clinic, OH (L.A.M.)
| | - Haris Riaz
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, OH (H.R., J.B.Y., W.H.W.T.)
| | - Lara Jehi
- Epilepsy Center, Neurological Institute, Cleveland Clinic, OH (L.J.)
| | - James B. Young
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, OH (H.R., J.B.Y., W.H.W.T.)
| | - W.H. Wilson Tang
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, OH (H.R., J.B.Y., W.H.W.T.)
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Chung MK, Karnik S, Saef J, Bergmann C, Barnard J, Lederman MM, Tilton J, Cheng F, Harding CV, Young JB, Mehta N, Cameron SJ, McCrae KR, Schmaier AH, Smith JD, Kalra A, Gebreselassie SK, Thomas G, Hawkins ES, Svensson LG. SARS-CoV-2 and ACE2: The biology and clinical data settling the ARB and ACEI controversy. EBioMedicine 2020; 58:102907. [PMID: 32771682 PMCID: PMC7415847 DOI: 10.1016/j.ebiom.2020.102907] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [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: 05/15/2020] [Revised: 06/20/2020] [Accepted: 07/07/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND SARS-CoV-2 enters cells by binding of its spike protein to angiotensin-converting enzyme 2 (ACE2). Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) have been reported to increase ACE2 expression in animal models, and worse outcomes are reported in patients with co-morbidities commonly treated with these agents, leading to controversy during the COVID-19 pandemic over whether these drugs might be helpful or harmful. METHODS Animal, in vitro and clinical data relevant to the biology of the renin-angiotensin system (RAS), its interaction with the kallikrein-kinin system (KKS) and SARS-CoV-2, and clinical studies were reviewed. FINDINGS AND INTERPRETATION SARS-CoV-2 hijacks ACE2to invade and damage cells, downregulating ACE2, reducing its protective effects and exacerbating injurious Ang II effects. However, retrospective observational studies do not show higher risk of infection with ACEI or ARB use. Nevertheless, study of the RAS and KKS in the setting of coronaviral infection may yield therapeutic targets.
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Affiliation(s)
- Mina K Chung
- Heart, Vascular and Thoracic Institute, United States; Lerner Research Institute, Cleveland Clinic, United States; Cleveland Clinic Lerner College of Medicine, United States; Case Western Reserve University, United States.
| | - Sadashiva Karnik
- Lerner Research Institute, Cleveland Clinic, United States; Cleveland Clinic Lerner College of Medicine, United States; Case Western Reserve University, United States
| | - Joshua Saef
- Heart, Vascular and Thoracic Institute, United States
| | - Cornelia Bergmann
- Lerner Research Institute, Cleveland Clinic, United States; Cleveland Clinic Lerner College of Medicine, United States; Case Western Reserve University, United States
| | - John Barnard
- Lerner Research Institute, Cleveland Clinic, United States
| | - Michael M Lederman
- Case Western Reserve University, United States; University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - John Tilton
- Case Western Reserve University, United States
| | - Feixiong Cheng
- Lerner Research Institute, Cleveland Clinic, United States
| | - Clifford V Harding
- Case Western Reserve University, United States; University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - James B Young
- Heart, Vascular and Thoracic Institute, United States; Cleveland Clinic Lerner College of Medicine, United States; Case Western Reserve University, United States
| | - Neil Mehta
- Cleveland Clinic Lerner College of Medicine, United States; Case Western Reserve University, United States
| | - Scott J Cameron
- Heart, Vascular and Thoracic Institute, United States; Lerner Research Institute, Cleveland Clinic, United States; Cleveland Clinic Lerner College of Medicine, United States
| | - Keith R McCrae
- Lerner Research Institute, Cleveland Clinic, United States; Cleveland Clinic Lerner College of Medicine, United States
| | - Alvin H Schmaier
- Case Western Reserve University, United States; University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Jonathan D Smith
- Lerner Research Institute, Cleveland Clinic, United States; Cleveland Clinic Lerner College of Medicine, United States; Case Western Reserve University, United States
| | - Ankur Kalra
- Heart, Vascular and Thoracic Institute, United States
| | - Surafel K Gebreselassie
- Cleveland Clinic Lerner College of Medicine, United States; Case Western Reserve University, United States
| | - George Thomas
- Cleveland Clinic Lerner College of Medicine, United States; Case Western Reserve University, United States
| | - Edward S Hawkins
- Cleveland Clinic Lerner College of Medicine, United States; Case Western Reserve University, United States
| | - Lars G Svensson
- Heart, Vascular and Thoracic Institute, United States; Cleveland Clinic Lerner College of Medicine, United States; Case Western Reserve University, United States
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Xanthopoulos A, Tryposkiadis K, Triposkiadis F, Fukamachi K, Soltesz EG, Young JB, Wolski K, Blackstone EH, Starling RC. Postimplant Phosphodiesterase Type 5 Inhibitors Use Is Associated With Lower Rates of Thrombotic Events After Left Ventricular Assist Device Implantation. J Am Heart Assoc 2020; 9:e015897. [PMID: 32648508 PMCID: PMC7660717 DOI: 10.1161/jaha.119.015897] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background Left ventricular assist device (LVAD) thrombosis is clinically devastating and impacts the cost effectiveness of LVAD therapy for advanced heart failure. Anticoagulation and antiplatelet therapies represent the standard of care to mitigate LVAD thrombosis. Phosphodiesterase type 5 inhibitors (PDE-5is) exhibit hemodynamic, antiplatelet, and antithrombotic effects. Using a national registry, we examined the relationship of PDE-5i use on thrombotic events in patients with continuous-flow LVADs. Methods and Results We obtained data from 13 772 patients with continuous flow LVADs participating in a national registry. Patients implanted with primary LVADs from 2012 to 2017 were included in the analysis. The primary end point was a composite of LVAD thrombosis and ischemic stroke. Patients were analyzed according to any use of PDE-5i after LVAD implantation (PDE-5i group) versus no use after LVAD implantation (no PDE-5i group). The primary end point was significantly lower in the PDE-5i group compared with the no PDE-5i group (hazard ratio [HR], 0.84; 95% CI, 0.77-0.91; P<0.001) at 48 months. The components of the primary end point (LVAD thrombosis: HR, 0.82; 95% CI, 0.74-0.90; P<0.001; and ischemic stroke: HR, 0.85; 95% CI, 0.75-0.97; P=0.019), as well as the secondary end point all-cause mortality (HR, 0.86; 95% CI, 0.79-0.93; P<0.001) were lower in the PDE-5i group versus the no PDE-5i at 48 months post LVAD. The favorable results observed with postimplant PDE-5i use were consistent with both axial and centrifugal flow devices. Conclusions The postimplant use of PDE-5i was associated with fewer thrombotic events and improved survival in LVAD patients. A randomized clinical trial is warranted to confirm these findings.
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Affiliation(s)
- Andrew Xanthopoulos
- Kaufman Center for Heart Failure, Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | | | | | - Kiyotaka Fukamachi
- Kaufman Center for Heart Failure, Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Edward G Soltesz
- Kaufman Center for Heart Failure, Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - James B Young
- Kaufman Center for Heart Failure, Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Kathy Wolski
- Kaufman Center for Heart Failure, Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Eugene H Blackstone
- Kaufman Center for Heart Failure, Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Randall C Starling
- Kaufman Center for Heart Failure, Heart and Vascular Institute Cleveland Clinic Cleveland OH
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Michelis KC, Zhong L, Peltz M, Pandey A, Tang WHW, Rohatgi A, Young JB, Drazner MH, Grodin JL. Dynamic Forecasts of Survival for Patients Living With Destination Left Ventricular Assist Devices: Insights From INTERMACS. J Am Heart Assoc 2020; 9:e016203. [PMID: 32648531 PMCID: PMC7660737 DOI: 10.1161/jaha.119.016203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background Left ventricular assist devices (LVADs) improve outcomes in patients with end-stage heart failure and are increasingly implanted for destination therapy. We describe dynamic estimates of event-free survival with conditional survival probabilities in a destination therapy LVAD population. Methods and Results We studied 8245 adult patients in INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) implanted with a continuous-flow destination therapy LVAD. The composite primary end point was death, device exchange or removal, or heart transplantation. Conditional survival probabilities were calculated and stratified by implantation characteristics and nonfatal adverse events experienced within the first year after implant. Probabilities of surviving an additional 1 to 3 years were numerically higher after longer prior event-free survival. INTERMACS profile 1, extracorporeal membrane oxygenation support, prior or concomitant surgery, and dialysis within 48 hours of implantation were associated with significantly lower event-free survival in the first year but did not impact event-free survival beyond then. For patients who experienced a nonfatal adverse event within the first year, subsequent 1-year conditional survival was lower than in the absence of that event for stroke (65% [95% CI, 57%-73%] versus 75% [95% CI, 73%-77%]; P<0.001), device-related infection (64% [95% CI 57%-71%] versus 76% [95% CI, 74%-78%]; P<0.001), and pump thrombosis or malfunction (64% [95% CI, 57%-70%] versus 76% [95% CI, 74%-78%]; P<0.001). Conclusions Conditional survival in patients with destination therapy LVADs improves over time, even for patients with unfavorable implantation characteristics. However, LVAD-related complications including stroke, device-related infection, and pump thrombosis or malfunction have an enduring negative influence on dynamic estimates of long-term prognosis.
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Affiliation(s)
- Katherine C Michelis
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
| | - Lin Zhong
- Division of Bioinformatics Department of Clinical Sciences University of Texas Southwestern Medical Center Dallas TX
| | - Matthias Peltz
- Department of Cardiovascular and Thoracic Surgery University of Texas Southwestern Medical Center Dallas TX
| | - Ambarish Pandey
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
| | - W H Wilson Tang
- Department of Cardiovascular Medicine Cleveland Clinic Cleveland OH
| | - Anand Rohatgi
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
| | - James B Young
- Department of Cardiovascular Medicine Cleveland Clinic Cleveland OH
| | - Mark H Drazner
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
| | - Justin L Grodin
- Division of Cardiology Department of Internal Medicine University of Texas Southwestern Medical Center Dallas TX
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Young JB. Two "Plague" Poems. Methodist Debakey Cardiovasc J 2020; 16:252-253. [DOI: 10.14797/mdcj-16-3-252] [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: 11/08/2022] Open
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Jehi L, Ji X, Milinovich A, Erzurum S, Rubin BP, Gordon S, Young JB, Kattan MW. Individualizing Risk Prediction for Positive Coronavirus Disease 2019 Testing: Results From 11,672 Patients. Chest 2020; 158:1364-1375. [PMID: 32533957 PMCID: PMC7286244 DOI: 10.1016/j.chest.2020.05.580] [Citation(s) in RCA: 127] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/20/2020] [Accepted: 05/24/2020] [Indexed: 01/08/2023] Open
Abstract
Background Coronavirus disease 2019 (COVID-19) is sweeping the globe. Despite multiple case-series, actionable knowledge to tailor decision-making proactively is missing. Research Question Can a statistical model accurately predict infection with COVID-19? Study Design and Methods We developed a prospective registry of all patients tested for COVID-19 in Cleveland Clinic to create individualized risk prediction models. We focus here on the likelihood of a positive nasal or oropharyngeal COVID-19 test. A least absolute shrinkage and selection operator logistic regression algorithm was constructed that removed variables that were not contributing to the model’s cross-validated concordance index. After external validation in a temporally and geographically distinct cohort, the statistical prediction model was illustrated as a nomogram and deployed in an online risk calculator. Results In the development cohort, 11,672 patients fulfilled study criteria, including 818 patients (7.0%) who tested positive for COVID-19; in the validation cohort, 2295 patients fulfilled criteria, including 290 patients who tested positive for COVID-19. Male, African American, older patients, and those with known COVID-19 exposure were at higher risk of being positive for COVID-19. Risk was reduced in those who had pneumococcal polysaccharide or influenza vaccine or who were on melatonin, paroxetine, or carvedilol. Our model had favorable discrimination (c-statistic = 0.863 in the development cohort and 0.840 in the validation cohort) and calibration. We present sensitivity, specificity, negative predictive value, and positive predictive value at different prediction cutoff points. The calculator is freely available at https://riskcalc.org/COVID19. Interpretation Prediction of a COVID-19 positive test is possible and could help direct health-care resources. We demonstrate relevance of age, race, sex, and socioeconomic characteristics in COVID-19 susceptibility and suggest a potential modifying role of certain common vaccinations and drugs that have been identified in drug-repurposing studies.
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Affiliation(s)
- Lara Jehi
- Neurological Institute, Cleveland Clinic, Cleveland, OH.
| | - Xinge Ji
- Quantitative Health Science Department, Cleveland Clinic, Cleveland, OH
| | - Alex Milinovich
- Quantitative Health Science Department, Cleveland Clinic, Cleveland, OH
| | - Serpil Erzurum
- Lerner Research Institute, the Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Brian P Rubin
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH
| | - Steve Gordon
- Infectious Disease Department, Cleveland Clinic, Cleveland, OH
| | | | - Michael W Kattan
- Quantitative Health Science Department, Cleveland Clinic, Cleveland, OH
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Masefield J, Young JB. Sea Fever. Methodist Debakey Cardiovasc J 2020; 16:175. [DOI: 10.14797/mdcj-16-2-175] [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: 11/08/2022] Open
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Wysham CH, Gauthier-Loiselle M, Bailey RA, Manceur AM, Lefebvre P, Greenberg M, Duh MS, Young JB. Development of risk models for major adverse chronic renal outcomes among patients with type 2 diabetes mellitus using insurance claims: a retrospective observational study. Curr Med Res Opin 2020; 36:219-227. [PMID: 31625766 DOI: 10.1080/03007995.2019.1682981] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: To develop and validate models allowing the prediction of major adverse chronic renal outcomes (MACRO) in patients with type 2 diabetes mellitus (T2DM) using insurance claims data.Methods: The Optum Integrated Real World Evidence Electronic Health Records and Claims de-identified database (10/01/2006-09/30/2016) was used to identify T2DM patients ≥50 years old. Risk factors were assessed over a 12-month baseline period, and MACRO were subsequently assessed until the end of data availability, continuous enrollment, or death. Separate models were built for moderate-to-severe diabetic kidney disease (DKD), end-stage renal disease (ESRD), and renal death. A random split-sample approach was employed, where 70% of the sample served for model development (training set) and the remaining 30% served for validation (testing set). C-statistics were used to assess model performance.Results: A total of 160,031 patients were included. Risk factors associated with MACRO for all models included adapted diabetes complications severity index, heart failure, anemia, diabetic nephropathy, and CKD. C-statistics ranged between 0.70 (moderate-to-severe DKD) and 0.84 (renal death) in the testing set. A substantial proportion (e.g. 88.7% for moderate-to-severe DKD) of patients predicted to be at high-risk of MACRO did not have diabetic nephropathy, proteinuria, or CKD at baseline.Conclusions: The models developed using insurance claims data could reliably predict the risk of MACRO in patients with T2DM and enabled patients at higher-risk of DKD to be identified in the absence of baseline diabetic nephropathy, CKD, or proteinuria. These models could help establish strategies to reduce the risk of MACRO in T2DM patients.
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Affiliation(s)
| | | | | | | | | | | | | | - James B Young
- Cleveland Clinic Foundation Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
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Young JB. Grief Chariots. Methodist Debakey Cardiovasc J 2020. [DOI: 10.14797/mdcj-16-1-69] [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: 11/08/2022] Open
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Young JB. Shiloh: a Requiem (April, 1862). Methodist Debakey Cardiovasc J 2019. [DOI: 10.14797/mdcj-15-4-308] [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: 11/08/2022] Open
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van der Meer P, Grote Beverborg N, Pfeffer MA, Olson K, Anand IS, Westenbrink BD, McMurray JJV, Swedberg K, Young JB, Solomon SD, van Veldhuisen DJ. Hyporesponsiveness to Darbepoetin Alfa in Patients With Heart Failure and Anemia in the RED-HF Study (Reduction of Events by Darbepoetin Alfa in Heart Failure): Clinical and Prognostic Associations. Circ Heart Fail 2019; 11:e004431. [PMID: 29367268 DOI: 10.1161/circheartfailure.117.004431] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 11/30/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND A poor response to erythropoiesis-stimulating agents such as darbepoetin alfa has been associated with adverse outcomes in patients with diabetes mellitus, chronic kidney disease, and anemia; whether this is also true in heart failure is unclear. METHODS AND RESULTS We performed a post hoc analysis of the RED-HF trial (Reduction of Events by Darbepoetin Alfa in Heart Failure), in which 1008 patients with systolic heart failure and anemia (hemoglobin level, 9.0-12.0 g/dL) were randomized to darbepoetin alfa. We examined the relationship between the hematopoietic response to darbepoetin alfa and the incidence of all-cause death or first heart failure hospitalization during a follow-up of 28 months. For the purposes of the present study, patients in the lowest quartile of hemoglobin change after 4 weeks were considered nonresponders. The median initial hemoglobin change in nonresponders (n=252) was -0.25 g/dL and +1.00 g/dL in the remainder of patients (n=756). Worse renal function, lower sodium levels, and less use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers were independently associated with nonresponse. Although a low endogenous erythropoietin level helped to differentiate responders from nonresponders, its predictive value in a multivariable model was poor (C statistic=0.69). Nonresponders had a higher rate of all-cause death or first heart failure hospitalization (hazard ratio, 1.25; 95% confidence interval, 1.02-1.54) and a higher risk of all-cause mortality (hazard ratio, 1.30; 95% confidence interval, 1.04-1.63) than responders. CONCLUSIONS A poor response to darbepoetin alfa was associated with worse outcomes in heart failure patients with anemia. Patients with a poor response were difficult to identify using clinical and biochemical biomarkers. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT00358215.
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Affiliation(s)
- Peter van der Meer
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, the Netherlands (P.v.d.M., N.G.B., B.D.W., D.J.v.V.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., S.D.S.), Amgen, Thousand Oaks, CA (K.O.); Department of Medicine, University of Minnesota Medical School and VA Medical Center, Minneapolis (I.S.A.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Department of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden (K.S.); and Department of Medicine, Cleveland Clinic, OH (J.B.Y.).
| | - Niels Grote Beverborg
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, the Netherlands (P.v.d.M., N.G.B., B.D.W., D.J.v.V.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., S.D.S.), Amgen, Thousand Oaks, CA (K.O.); Department of Medicine, University of Minnesota Medical School and VA Medical Center, Minneapolis (I.S.A.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Department of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden (K.S.); and Department of Medicine, Cleveland Clinic, OH (J.B.Y.)
| | - Marc A Pfeffer
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, the Netherlands (P.v.d.M., N.G.B., B.D.W., D.J.v.V.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., S.D.S.), Amgen, Thousand Oaks, CA (K.O.); Department of Medicine, University of Minnesota Medical School and VA Medical Center, Minneapolis (I.S.A.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Department of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden (K.S.); and Department of Medicine, Cleveland Clinic, OH (J.B.Y.)
| | - Kurt Olson
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, the Netherlands (P.v.d.M., N.G.B., B.D.W., D.J.v.V.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., S.D.S.), Amgen, Thousand Oaks, CA (K.O.); Department of Medicine, University of Minnesota Medical School and VA Medical Center, Minneapolis (I.S.A.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Department of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden (K.S.); and Department of Medicine, Cleveland Clinic, OH (J.B.Y.)
| | - Inder S Anand
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, the Netherlands (P.v.d.M., N.G.B., B.D.W., D.J.v.V.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., S.D.S.), Amgen, Thousand Oaks, CA (K.O.); Department of Medicine, University of Minnesota Medical School and VA Medical Center, Minneapolis (I.S.A.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Department of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden (K.S.); and Department of Medicine, Cleveland Clinic, OH (J.B.Y.)
| | - B Daan Westenbrink
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, the Netherlands (P.v.d.M., N.G.B., B.D.W., D.J.v.V.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., S.D.S.), Amgen, Thousand Oaks, CA (K.O.); Department of Medicine, University of Minnesota Medical School and VA Medical Center, Minneapolis (I.S.A.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Department of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden (K.S.); and Department of Medicine, Cleveland Clinic, OH (J.B.Y.)
| | - John J V McMurray
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, the Netherlands (P.v.d.M., N.G.B., B.D.W., D.J.v.V.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., S.D.S.), Amgen, Thousand Oaks, CA (K.O.); Department of Medicine, University of Minnesota Medical School and VA Medical Center, Minneapolis (I.S.A.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Department of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden (K.S.); and Department of Medicine, Cleveland Clinic, OH (J.B.Y.)
| | - Karl Swedberg
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, the Netherlands (P.v.d.M., N.G.B., B.D.W., D.J.v.V.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., S.D.S.), Amgen, Thousand Oaks, CA (K.O.); Department of Medicine, University of Minnesota Medical School and VA Medical Center, Minneapolis (I.S.A.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Department of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden (K.S.); and Department of Medicine, Cleveland Clinic, OH (J.B.Y.)
| | - James B Young
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, the Netherlands (P.v.d.M., N.G.B., B.D.W., D.J.v.V.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., S.D.S.), Amgen, Thousand Oaks, CA (K.O.); Department of Medicine, University of Minnesota Medical School and VA Medical Center, Minneapolis (I.S.A.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Department of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden (K.S.); and Department of Medicine, Cleveland Clinic, OH (J.B.Y.)
| | - Scott D Solomon
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, the Netherlands (P.v.d.M., N.G.B., B.D.W., D.J.v.V.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., S.D.S.), Amgen, Thousand Oaks, CA (K.O.); Department of Medicine, University of Minnesota Medical School and VA Medical Center, Minneapolis (I.S.A.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Department of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden (K.S.); and Department of Medicine, Cleveland Clinic, OH (J.B.Y.)
| | - Dirk J van Veldhuisen
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, the Netherlands (P.v.d.M., N.G.B., B.D.W., D.J.v.V.); Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.A.P., S.D.S.), Amgen, Thousand Oaks, CA (K.O.); Department of Medicine, University of Minnesota Medical School and VA Medical Center, Minneapolis (I.S.A.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Department of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden (K.S.); and Department of Medicine, Cleveland Clinic, OH (J.B.Y.)
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Young JB. Danse Russe. Methodist Debakey Cardiovasc J 2019. [DOI: 10.14797/mdcj-15-2-160] [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: 11/08/2022] Open
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Affiliation(s)
- James B Young
- From the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, the Kaufman Center for Heart Failure, and the Endocrinology and Metabolism and Heart and Vascular Institutes of the Cleveland Clinic, OH (J.B.Y.); and the Division of Cardiology, The CardioVascular Center, Tufts Medical Center, Boston, MA (A.V.).
| | - Amanda R Vest
- From the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, the Kaufman Center for Heart Failure, and the Endocrinology and Metabolism and Heart and Vascular Institutes of the Cleveland Clinic, OH (J.B.Y.); and the Division of Cardiology, The CardioVascular Center, Tufts Medical Center, Boston, MA (A.V.)
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Young JB. The Wait. Methodist Debakey Cardiovasc J 2019. [DOI: 10.14797/mdcj-15-1-90] [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: 11/08/2022] Open
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Young JB. “<i>No man is an island entirely of itself</i>”. Methodist Debakey Cardiovasc J 2018; 14:308. [DOI: 10.14797/mdcj-14-4-308] [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: 11/08/2022] Open
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