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Chalif J, Chambers LM, Yao M, Kuznicki M, DeBernardo R, Rose PG, Michener CM, Vargas R. Extended-duration antibiotics are not associated with a reduction in surgical site infection in patients with ovarian cancer undergoing cytoreductive surgery with large bowel resection. Gynecol Oncol 2024; 186:161-169. [PMID: 38691986 DOI: 10.1016/j.ygyno.2024.04.003] [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: 01/30/2024] [Revised: 03/26/2024] [Accepted: 04/05/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVE(S) To evaluate whether extended dosing of antibiotics (ABX) after cytoreductive surgery (CRS) with large bowel resection for advanced ovarian cancer is associated with reduced incidence of surgical site infection (SSI) compared to standard intra-operative dosing and evaluate predictors of SSI. METHODS A retrospective single-institution cohort study was performed in patients with stage III/IV ovarian cancer who underwent CRS from 2009 to 2017. Patients were divided into two cohorts: 1) standard intra-operative dosing ABX and 2) extended post-operative ABX. All ABX dosing was at the surgeon's discretion. The impact of antibiotic duration on SSI and other postoperative outcomes was assessed using univariate and multivariable Cox regression models. RESULTS In total, 277 patients underwent cytoreductive surgery (CRS) with large bowel resection between 2009 and 2017. Forty-nine percent (n = 137) received standard intra-operative ABX and 50.5% (n = 140) received extended post-operative ABX. Rectosigmoid resection was the most common large bowel resection in the standard ABX (89.9%, n = 124) and extended ABX groups (90.0%, n = 126), respectively. No significant differences existed between age, BMI, hereditary predisposition, or medical comorbidities (p > 0.05). No difference was appreciated in the development of superficial incisional SSI between the standard ABX and extended ABX cohorts (10.9% vs. 12.9%, p = 0.62). Of patients who underwent a transverse colectomy, a larger percentage of patients developed a superficial SSI versus no SSI (21% vs. 6%, p = 0.004). CONCLUSION(S) In this retrospective study of patients with advanced ovarian cancer undergoing CRS with LBR, extended post-operative ABX was not associated with reduced SSI, and prolonged administration of antibiotics should be avoided unless clinically indicated.
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Affiliation(s)
- Julia Chalif
- Division of Gynecologic Oncology, James Cancer Hospital and Solove Research Institute, The Ohio State University Medical Center, Columbus, OH 43210, United States of America.
| | - Laura M Chambers
- Division of Gynecologic Oncology, James Cancer Hospital and Solove Research Institute, The Ohio State University Medical Center, Columbus, OH 43210, United States of America
| | - Meng Yao
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH 44195, United States of America
| | - Michelle Kuznicki
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Robert DeBernardo
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Peter G Rose
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Chad M Michener
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Roberto Vargas
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
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Kelley J, Durmaz A, Kuznicki M, Petty A, Scott J, Vargas R. Abstract 2403: Divergent evolutionary response to multiple fractions of radiation (MF2) therapy in cervical cancer cell lines (CCCL). Cancer Res 2023. [DOI: 10.1158/1538-7445.am2023-2403] [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: 04/07/2023]
Abstract
Abstract
Introduction: Treatment for locally-advanced cervical cancer is not currently tailored based on genomic markers of treatment response. We aim to explore the potential for differential evolutionary trajectories of radiation (RT) resistance throughout treatment using two in vitro models.
Methods: Sixteen cervical cancer cell lines ( CCCL) were exposed to 1.8 Gy fractions of RT radiation for five sequential days and the surviving fraction (MF2) calculated. Differential gene expression (DGE) was performed on pre and post - treatment samples. Partial least squares (PLS) regression was completed with MF2 as the endpoint . Protein-protein interaction (PPI) network and overrepresentation analysis of genes was also performed. Four CCCL (BOKU, SKG II SF, ME180, and HeLa) were serially exposed to 50 Gy of gamma radiation RT given in 2Gy fractions. Five evolutionary replicates and three passage-controls were maintained. The mean integral survival as a function of dose (AUC) was calculated and ANOVA analysis performed.
Results: MF2 as the phenotypic endpoint identified 19 DE genes. PLS identified histones (H4C8, H2BC18, H2BC4) as positively associated and transcriptional regulators (NR2F1, KALRN) as negatively associated with MF2 (Figure 1AB). PPI and Reactome Pathways also highlighted histone deacetylase pathways, nucleosome assembly and regulation of membrane potentials (Figure 1BC). Longitudinal treatment RT identified differential evolutionary trajectories between CCCL replicates. Two BOKU (p = 0.005 and 0.0090), one SKG II SF (p = 0.0146), and one ME180 (p = 0.0384) replicates became resistant. Four SKG II SF (p < 0.0001), and two HeLa (p = 0.0005 and p = 0.0068) became more sensitive to radiationRT (1C).
Conclusion: Divergent evolutionary trajectories under therapeutic stress can be elicited using in vitro evolutionary experimentation with cervical cancer cell linesCCCL. Genomic correlation with divergent evolutionary trajectories may allow for the identification of real-time markers of resistance or sensitivity and allow for true RT radiotherapy personalization.
Citation Format: Johanna Kelley, Arda Durmaz, Michelle Kuznicki, Aaron Petty, Jacob Scott, Roberto Vargas. Divergent evolutionary response to multiple fractions of radiation (MF2) therapy in cervical cancer cell lines (CCCL) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 2403.
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Chalif J, Yao M, Gruner M, Kuznicki M, Vargas R, Rose PG, Michener C, DeBernardo R, Chambers L. Incidence and prognostic significance of inguinal lymph node metastasis in women with newly diagnosed epithelial ovarian cancer. Gynecol Oncol 2022; 165:90-96. [PMID: 35272875 DOI: 10.1016/j.ygyno.2022.01.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/13/2022] [Accepted: 01/23/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE(S) To assess incidence and oncologic outcomes in women with advanced epithelial ovarian cancer (EOC) with inguinal lymph node metastasis (ILNM) at diagnosis. METHODS An IRB-approved, retrospective single-institution cohort study was performed in women with stage III/IV EOC from 2009 to 2017. Patients with inguinal lymphadenopathy (defined as >1 cm in short axis) clinically or radiographically were identified. The impact of ILNM on progression-free survival (PFS) and overall survival (OS) were assessed. RESULTS Of the 562 women with advanced EOC, 18 (3.2%) had ILNM at diagnosis, accounting for 25.7% of all patients with stage IVB disease (n = 70). Five patients (27.7%) had a known genetic predisposition for EOC, including BRCA1 (11.1%, n = 2), BRCA2 (11.1%, n = 2) and BRIP1 (5.6%, n = 1). The majority of patients underwent optimal primary cytoreductive surgery (CRS), including debulking of inguinal nodal metastasis (83.3%, n = 15), with 50% (n = 9) having no gross residual disease after surgery. There was no difference in PFS (19.9 vs. 19.9 vs. 17.2 months, p = 0.84) or OS (137.2 vs. 52.9 vs. 67.6 months, p = 0.29) in women with stage III/IV with ILNM, stage III/IV without ILNM, and stage IVB disease without ILNM, respectively. Progression-free survival was improved in women with ILNM who underwent an optimal resection to no macroscopic disease vs. non-optimal resection (27.4 vs. 14.3 months, p = 0.019). Median overall survival at the time of analysis did not reach statistical significance (137.2 vs. 57.3 months, p = 0.24). CONCLUSION(S) In this retrospective cohort study, 3.2% of women with advanced EOC presented with ILNM at diagnosis. Although ILNM did not portend worse clinical outcomes compared to all Stage III/IV and Stage IVB patients, respectively, resection to no gross residual disease was associated with improved PFS.
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Affiliation(s)
- Julia Chalif
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH, United States of America.
| | - Meng Yao
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, United States of America
| | - Morgan Gruner
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH, United States of America
| | - Michelle Kuznicki
- Division of Gynecologic Oncology; Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH, United States of America
| | - Roberto Vargas
- Division of Gynecologic Oncology; Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH, United States of America
| | - Peter G Rose
- Division of Gynecologic Oncology; Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH, United States of America
| | - Chad Michener
- Division of Gynecologic Oncology; Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH, United States of America
| | - Robert DeBernardo
- Division of Gynecologic Oncology; Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH, United States of America
| | - Laura Chambers
- Division of Gynecologic Oncology; Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH, United States of America; Division of Gynecologic Oncology, The Ohio State University Comprehensive Cancer Center, James Cancer Hospital and Solove Research Institute, Columbus, OH, United States of America
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Rose PG, Chambers LM, Kuznicki M. To PARPI or Not to PARPI BRCA Mutated Ovarian Cancer Following First-line Chemotherapy, That is the Question? Gynecol Obstet (Sunnyvale) 2021; 11:561. [PMID: 34925958 PMCID: PMC8681040] [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] [Grants] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Peter G Rose
- Section of Gynecologic Oncology, Women's Health Institute, Cleveland Clinic, Cleveland Ohio, USA
| | - Laura M Chambers
- Section of Gynecologic Oncology, Women's Health Institute, Cleveland Clinic, Cleveland Ohio, USA
| | - Michelle Kuznicki
- Section of Gynecologic Oncology, Women's Health Institute, Cleveland Clinic, Cleveland Ohio, USA
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Kuznicki M, Mallen A, Eggers E, Lam C, Regis J, Todd S, Tanner J, Anderson M, Rutherford T. Preliminary prospective quality of life and clinical outcomes with an opiate restrictive enhanced recovery protocol in a gynecologic oncology population. Gynecol Oncol 2020. [DOI: 10.1016/j.ygyno.2020.06.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Chambers LM, Kuznicki M, Yao M, Chichura A, Gruner M, Reizes O, Debernardo R, Rose PG, Michener C, Vargas R. Impact of antibiotic treatment during platinum chemotherapy on survival and recurrence in women with advanced epithelial ovarian cancer. Gynecol Oncol 2020; 159:699-705. [PMID: 32950250 DOI: 10.1016/j.ygyno.2020.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 09/06/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE(S) To determine whether antibiotic treatment (ABX) during platinum chemotherapy (PC) for epithelial ovarian cancer (EOC) impacts progression-free survival (PFS) and overall survival (OS). STUDY DESIGN Retrospective single institution cohort study in women with newly diagnosed stage III/IV EOC (n = 424) who underwent cytoreductive surgery (CRS) and PC from 2009 to 2015. ABX for >48 h, including ABX against gram-positive (anti-G + ABX) bacteria were recorded. The impact of ABX on PFS and OS was assessed using univariate and multivariable Cox regression models. RESULTS Of 424 eligible women, 34.7% (n = 147) received ABX, with 11.3% (n = 48) treated with anti-G + ABX. ABX decreased PFS (17.4 vs. 23.1 months, HR 1.50, 95% CI 1.20-1.88, p < 0.001) and OS (45.6 vs. 62.4 months, HR 1.63, 95% CI 1.27-2.08, p < 0.001) compared to no ABX. Similarly, anti-G + ABX worsened PFS (16.5 vs. 23.1 months; HR 1.85, 95% CI 1.33-2.55) and OS (35.0 vs. 62.4 months; HR 2.12, 95% CI 1.50-3.0, p < 0.001). On multivariable analysis, all ABX and anti-G + ABX significantly worsened PFS (HR 1.31, 95% CI 1.04-1.65, p = 0.02), (HR 1.50, 95% CI 1.07-2.10, p = 0.02) and OS (HR 1.52, 95% CI 1.18-1.96, p = 0.001), (HR 1.83, 95% CI 1.27-2.62, p = 0.001) respectively. Increased Clavien Dindo score was associated with worsened PFS (1-2 - HR 1.52, 95% CI 1.14-2.03, p = 0.004; 3-4 - HR 1.86, 95% CI 1.27-2.72, p = 0.001) but not OS (1/2 - HR 1.35, 95% CI 0.97-1.88, p = 0.08; 3/4 - HR 1.53, 95% CI 1.00-2.34, p = 0.05); residual disease (p < 0.05) and neoadjuvant chemotherapy (p < 0.001) were associated with worse PFS and OS. CONCLUSION(S) In this retrospective cohort study of women with advanced EOC undergoing PC, ABX treatment was associated with decreased PFS and OS. Mechanistic studies are needed to investigate the negative impact of ABX upon PC response in EOC.
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Affiliation(s)
- Laura M Chambers
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America.
| | - Michelle Kuznicki
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Meng Yao
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH 44195, United States of America
| | - Anna Chichura
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Morgan Gruner
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Ofer Reizes
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, United States of America
| | - Robert Debernardo
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Peter G Rose
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Chad Michener
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Roberto Vargas
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
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Chambers LM, Costales AB, Crean-Tate K, Kuznicki M, Morton M, Horowitz M, Jagielo T, Rose PG, Michener C, Vargas R, Debernardo R. A guide to establishing a hyperthermic intraperitoneal chemotherapy program in gynecologic oncology. Gynecol Oncol 2020; 158:794-802. [DOI: 10.1016/j.ygyno.2020.06.487] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 06/10/2020] [Indexed: 12/11/2022]
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Kuznicki M, Mallen A, McClung EC, Robertson SE, Todd S, Boulware D, Martin S, Quilitz R, Vargas RJ, Apte SM. Dual antibiotic prevention bundle is associated with decreased surgical site infections. Int J Gynecol Cancer 2020; 30:1411-1417. [PMID: 32727930 DOI: 10.1136/ijgc-2020-001515] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/06/2020] [Accepted: 07/08/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Gynecologic oncology surgery is associated with a wide variation in surgical site infection risk. The optimal method for infection prevention in this heterogeneous population remains uncertain. STUDY DESIGN A retrospective cohort study was performed to compare surgical site infection rates for patients undergoing hysterectomy over a 1-year period surrounding the implementation of an institutional infection prevention bundle. The bundle comprised pre-operative, intra-operative, and post-operative interventions including a dual-agent antibiotic surgical prophylaxis with cefazolin and metronidazole. Cohorts consisted of patients undergoing surgery during the 6 months prior to this intervention (pre-bundle) versus those undergoing surgery during the 6 months following the intervention (post-bundle). Secondary outcomes included length of stay, readmission rates, compliance measures, and infection microbiology. Data were compared with pre-specified one-sided exact test, Chi-square test, Fisher's exact test, or Kruskal-Wallis test as appropriate. RESULTS A total of 358 patients were included (178 PRE, 180 POST). Median age was 58 (range 23-90) years. The post-bundle cohort had a 58% reduction in surgical site infection rate, 3.3% POST vs 7.9% PRE (-4.5%, 95% CI -9.3% to -0.2%, p=0.049) as well as reductions in organ space infection, 0.6% POST vs 4.5% PRE (-3.9%, 95% CI -7.2% to -0.7%, p=0.019), and readmission rates, 2.2% POST vs 6.7% PRE (-4.5%, 95% CI -8.7% to -0.2%, p=0.04). Gram-positive, Gram-negative, and anaerobic bacteria were all prevalent in surgical site infection cultures. There were no monomicrobial infections in post-cohort cultures (0% POST vs 58% PRE, p=0.04). No infections contained methicillin-resistant Staphylococcus aureus. CONCLUSION Implementation of a dual antibiotic infection prevention bundle was associated with a 58% reduction in surgical site infection rate after hysterectomy in a surgically diverse gynecologic oncology practice.
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Affiliation(s)
- Michelle Kuznicki
- Gynecologic Oncology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Adrianne Mallen
- Gynecologic Oncology, University of South Florida, Tampa, Florida, USA.,Gynecologic Oncology, H Lee Moffitt Cancer Center and Research Center Inc, Tampa, Florida, USA
| | - Emily Clair McClung
- Gynecologic Oncology, University of Arizona Arizona Health Sciences Center, Tucson, Arizona, USA
| | - Sharon E Robertson
- Gynecologic Oncology, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Gynecologic Oncology, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Indiana, USA
| | - Sarah Todd
- Gynecologic Oncology, University of Louisville, Louisville, Kentucky, USA
| | - David Boulware
- Infection Prevention, H Lee Moffitt Cancer Center and Research Center Inc, Tampa, Florida, USA
| | - Stacy Martin
- Infection Prevention, H Lee Moffitt Cancer Center and Research Center Inc, Tampa, Florida, USA
| | - Rod Quilitz
- Pharmacy, H Lee Moffitt Cancer Center and Research Center Inc, Tampa, Florida, United States
| | - Roberto J Vargas
- Gynecologic Oncology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Sachin M Apte
- Gynecologic Oncology, H Lee Moffitt Cancer Center and Research Center Inc, Tampa, Florida, USA
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Nwabuobi C, Gowda N, Schmitz J, Wood N, Pargas A, Bagiardi L, Odibo L, Camisasca-Lopina H, Kuznicki M, Sinkey R, Odibo A. Risk factors for Cesarean delivery in pregnancy with small-for-gestational-age fetus undergoing induction of labor. Ultrasound Obstet Gynecol 2020; 55:799-805. [PMID: 31441151 DOI: 10.1002/uog.20850] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 08/09/2019] [Accepted: 08/12/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To identify risk factors for Cesarean delivery and non-reassuring fetal heart tracing (NRFHT) in pregnancies with a small-for-gestational-age (SGA) fetus undergoing induction of labor and to design and validate a prediction model, combining antenatal and intrapartum variables known at the time of labor induction, to identify pregnancies at increased risk of Cesarean delivery. METHODS This was a retrospective cohort study of non-anomalous, singleton gestations with a SGA fetus that underwent induction of labor, delivered in a single tertiary referral center between January 2011 and December 2016. SGA was defined as estimated fetal weight (EFW) < 10th percentile. The primary outcome was to identify risk factors associated with Cesarean delivery. The secondary outcome was to identify risk factors associated with NRFHT. Univariate and multivariate analyses were used to determine which clinical characteristics, available at the time of admission, had the strongest association with Cesarean delivery and NRFHT during labor induction. The predictive value of the final models was assessed by the area under the receiver-operating-characteristics curve (AUC). Sensitivity and specificity of the models were also assessed. Internal validation of the models was performed using 10 000 bootstrap replicates of the original cohort. The adequacy of the models was evaluated using the Hosmer-Lemeshow goodness-of-fit test. RESULTS A total of 594 pregnancies were included. Cesarean delivery was performed in 243 (40.9%) pregnancies. Significant risk factors associated with Cesarean delivery, and included in the final model, were maternal age, gestational age at delivery and initial method of labor induction. The bootstrap estimate of the AUC of the final prediction model for Cesarean delivery was 0.82 (95% CI, 0.78-0.86). The model had sensitivity of 64.2%, specificity of 86.9%, positive likelihood ratio (LR) of 4.9 and negative LR of 0.41. The model had good fit (P = 0.617). NRFHT complicated 117 (19.7%) pregnancies. Significant risk factors for NRFHT included EFW < 5th percentile, abnormal umbilical artery Doppler studies (pulsatility index > 95th percentile or absent/reversed end-diastolic flow) and gestational age at delivery. The final prediction model for NRFHT had an AUC of 0.69 (95% CI, 0.63-0.75) and specificity of 97.0%. CONCLUSION We identified several significant risk factors for Cesarean delivery and NRFHT among SGA pregnancies undergoing induction of labor. Clinicians may use these risk factors to guide patient counseling and to help anticipate the potential need for operative delivery. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- C Nwabuobi
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - N Gowda
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - J Schmitz
- Department of Obstetrics and Gynecology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - N Wood
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - A Pargas
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - L Bagiardi
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - L Odibo
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - H Camisasca-Lopina
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - M Kuznicki
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - R Sinkey
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - A Odibo
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
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Kuznicki M, Joehlin-Price A, Rose PG, Mahdi H. Efficacy and toxicity of immunotherapy with immune checkpoint inhibitors in gynecologic cancers. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e18092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18092 Background: There is limited data on outcomes for gynecologic cancer patients treated with immune checkpoint inhibitors (ICI) outside the scope of clinical trials. Here we present our Institutional experience with a cohort of endometrial (EC) and ovarian cancer (OC) treated with ICI. Methods: 59 patients who received ICI were included (23 OC and 36 EC). Progression-free (PFS) and Overall survivals (OS) were determined by Kaplan-Meier (KM) curve and log rank test. Comparison of duration of response (DOR) and stable disease (DOSD) was done with unpaired t-test or one-way ANOVA. Rates of objective response (ORR) including partial response (PR) and complete response (CR), and stable disease (SD) were compared by Fischer’s exact test. Results: Median age was 66 years. 23 patients were microsatellite stable (MSS), 23 microsatellite instability high (MSI-H). Median number of prior lines was 2 (0-11). PFS and OS for EC and OC were overlapping; therefore outcomes for both were combined [(PFS 6.4m OC vs 7.3 m EC, p = 0.61), (OS 15.9 m OC vs 14.2 m EC, p = 0.78)]. Response rates consisted of 20.3% PR, 8.5% CR, 37.3% SD. Differences in responses were noted for clear cell carcinoma (CC) (33.3% PR, 11.1% CR, 33.3% SD) and MSI-H (36.4% PR, 18.2% CR, 22.7% SD) compared to MSS (11.8% PR, 0% CR, 47% SD). MSI-H had higher ORR vs. MSS (54.1% vs 11.8%, p = 0.0078). CC trended toward improved ORR vs. MSS (44.4% vs 11.8%, p = 0.14). PFS was improved for MSI-H vs. MSS (10m v 5.0m, p = 0.03). OS for CC compared to any other histology was improved (NR vs 12.8m respectively, p = 0.009). 5 recurrent MSI-H EC patients received ICI as first line monotherapy. Responses included 4 PR and 1 SD (80% ORR, 100% clinical benefit). PFS was 9.2m (3.3-13.3). 80% remained progression-free at last follow up. Overall, 38.9% experienced toxicity: hypothyroidism (15%), dermatitis (5%), pneumonitis (10%), LFT elevation (2%), amylase/lipase elevation (3%), colitis or diarrhea (5%), uveitis (2%) or nephritis (5%). 10% of patients required discontinuation of ICI secondary to toxicity. Trends for PFS and OS favored improved outcomes in patients with toxicity vs. no toxicity [(PFS 12.9m vs 5.6m, p = 0.07), (OS 22.9m vs 13.1m, p = NS)] respectively. Conclusions: In this study, immunotherapy with ICI outcomes favor MSI-H and CC compared to MSS disease. CC had promising OS compared to other histology types. ICI showed promising efficacy in MSI-H EC with 100% clinical benefit rate in chemonaive patients. First line ICI should be investigated in these patients. Positive correlation between toxicity and outcome is noted and will be further investigated.
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Mills KA, Joshi TV, West L, Kuznicki M, Kent L, Hokenstad AN, Cripe JC, Woolfolk C, Senter L, Bakkum-Gamez JN, Wenham RM, Cohn DE, Bae-Jump V, Thaker PH. Is hormonal therapy after risk-reducing salpingo-oophorectomy associated with an increased risk of malignancy in pathogenic variant carriers? Gynecol Oncol 2020; 157:706-710. [PMID: 32143914 DOI: 10.1016/j.ygyno.2020.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/22/2020] [Accepted: 02/24/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES This study aimed to assess the association between hormone replacement therapy and the incidence of subsequent malignancies in patients who underwent risk-reducing salpingo-oophorectomy and had mutations predisposing them to Müllerian cancers. METHODS This Institutional Review Board-approved retrospective study was performed at five academic institutions. Women were included if they were age 18-51 years, had one or more confirmed germline highly penetrant pathogenic variants, and underwent risk-reducing salpingo-oophorectomy. Patients with a prior malignancy were excluded. Clinicodemographic data were collected by chart review. Patients with no documented contact for one year prior to study termination were called to confirm duration of hormone use and occurrence of secondary outcomes. Hormone replacement therapy included any combination of estrogen or progesterone. RESULTS Data were analyzed for 159 women, of which 82 received hormone replacement therapy and 77 did not. In both groups an average of 6 years since risk reduction had passed. The patients treated with hormone replacement therapy did not have a higher risk of subsequent malignancy than those not treated with hormone replacement therapy (6 out of 82 vs. 7 out of 77, P = .68). Patients who received hormone replacement therapy were younger than those who did not receive hormone replacement therapy (39.0 vs. 43.9 years, P < .01) and were more likely to have undergone other risk reductive procedures including mastectomy and/or hysterectomy, though this difference was not statistically significant (69.5% vs. 55.8%, P = .07). CONCLUSIONS In this multi-institution retrospective study of data from patients with high-risk variant carriers who underwent risk-reducing salpingo-oophorectomy, there was no statistically significant difference in the incidence of malignancy between women who did and did not receive hormone replacement therapy.
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Affiliation(s)
- Kathryn A Mills
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University, St. Louis, MO, United States of America.
| | - Tanvi V Joshi
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH, United States of America
| | - Lindsay West
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, The University of North Carolina, Chapel Hill, NC, United States of America
| | - Michelle Kuznicki
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, FL, United States of America
| | - Laura Kent
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, FL, United States of America
| | - Alexis N Hokenstad
- Division of Gynecologic Oncology, The Mayo Clinic, Rochester, MN, United States of America
| | - James C Cripe
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University, St. Louis, MO, United States of America
| | - Candice Woolfolk
- Division of Oncologic Biostatistics, Washington University, St. Louis, MO, United States of America
| | - Leigha Senter
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH, United States of America
| | - Jamie N Bakkum-Gamez
- Division of Gynecologic Oncology, The Mayo Clinic, Rochester, MN, United States of America
| | - Robert M Wenham
- Department of Gynecologic Oncology, Moffitt Cancer Center, Tampa, FL, United States of America
| | - David E Cohn
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH, United States of America
| | - Victoria Bae-Jump
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, The University of North Carolina, Chapel Hill, NC, United States of America
| | - Premal H Thaker
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University, St. Louis, MO, United States of America
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Mallen AR, Conley CC, Townsend MK, Wells A, Boac BM, Todd S, Gandhi A, Kuznicki M, Augusto BM, McIntyre M, Fridley BL, Tworoger SS, Wenham RM, Vadaparampil ST. Patterns and predictors of genetic referral among ovarian cancer patients at a National Cancer Institute-Comprehensive Cancer Center. Clin Genet 2020; 97:370-375. [PMID: 31600840 PMCID: PMC7322721 DOI: 10.1111/cge.13654] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 08/26/2019] [Accepted: 09/18/2019] [Indexed: 12/23/2022]
Abstract
Germline mutations (eg, BRCA1/2) have prognostic and treatment implications for ovarian cancer (OVCA) patients. Thus, national guidelines recommend genetic testing for OVCA patients. The present study examines patterns and predictors of genetics referral in OVCA patients. Electronic medical record data were abstracted retrospectively from 557 OVCA patients treated from 1 January 2001 to 31 December 2015. Logistic regression models identified sociodemographic characteristics, disease/treatment characteristics, family history data, provider characteristics, and survival data that predicted genetics referral. Overall, 27.5% of patients received referral. Eleven variables predicting referral were selected during stepwise regression: younger age, White race, not having private insurance, professional school education, year of OVCA diagnosis, platinum sensitivity, female gynecologic oncologist, chemotherapy administered by a gynecologic oncologist, clinical trial enrollment, longer overall survival, and family history of OVCA. Genetics referral among OVCA patients was similar to rates reported nationwide. Unique predictive factors will contribute to quality improvement and should be validated at a multi-institutional level to ensure guideline concordant care is provided to all OVCA patients. Future research should identify both patient-level and provider-level factors associated with genetics referral.
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Affiliation(s)
- Adrianne R Mallen
- Department of Gynecologic Oncology, Moffitt Cancer Center, Tampa, Florida
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida
| | - Claire C Conley
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Mary K Townsend
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, Florida
| | - Ali Wells
- University of South Florida, Morsani School of Medicine, Tampa, Florida
| | - Bernadette M Boac
- Department of Pathology, University of South Florida & Moffitt Cancer Center, Tampa, Florida
| | - Sarah Todd
- Department of Gynecologic Oncology, Moffitt Cancer Center, Tampa, Florida
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida
| | - Anjalika Gandhi
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida
| | - Michelle Kuznicki
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida
| | - Bianca M Augusto
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - McKenzie McIntyre
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
| | - Brooke L Fridley
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, Florida
| | - Shelley S Tworoger
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, Florida
| | - Robert M Wenham
- Department of Gynecologic Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Susan T Vadaparampil
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida
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Mallen A, Townsend M, Boac B, Todd S, Gandhi A, Kuznicki M, Magliocco A, Fridley B, Tworoger S, Vadaparampil S, Wenham R. Predictive factors of genetic referral for advanced, epithelial ovarian cancer patients at a Single-Institution Cancer Center. Gynecol Oncol 2019. [DOI: 10.1016/j.ygyno.2019.03.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Mills K, Kuznicki M, Kent L, Hokenstad A, Cripe J, Woolfolk C, Senter L, Bakkum-Gamez J, Wenham R, Cohn D, Thaker P, Joshi T. Does using hormonal therapy after risk reducing salpingo-oophorectomy increase the incidence of malignancy in women with high risk genetic predisposition to cancer? Gynecol Oncol 2019. [DOI: 10.1016/j.ygyno.2019.04.394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Kuznicki M, Mallen A, Robertson S, Todd S, Boulware D, Martin S, McClung E, Apte S. Prevention of surgical site infection after hysterectomy at a cancer center. Gynecol Oncol 2018. [DOI: 10.1016/j.ygyno.2018.04.358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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16
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Kuznicki M, Castaneda A, Mostofizadeh S, McClung E, Matsuo K, Shahzad M. Central nervous system metastasis from endometrial carcinoma: A multi-institution retrospective study. Gynecol Oncol 2018. [DOI: 10.1016/j.ygyno.2018.04.445] [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: 11/16/2022]
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Mallen AR, Boac BM, Todd S, Robertson SE, Gandhi A, Kuznicki M, Cao B, Magliocco AM, Wenham RM, Fridley B, Chon HS. Patient predictive factors for clinical trial participation. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.6530] [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: 11/20/2022] Open
Affiliation(s)
- Adrianne Rose Mallen
- University of South Florida/Moffitt Cancer Center Gynecologic Oncology Fellowshi, Tampa, FL
| | | | - Sarah Todd
- University of South Florida/Moffitt Cancer Center, Tampa, FL
| | | | - Anjalika Gandhi
- University of South Florida Department of Obstetrics and Gynecology, Tampa, FL
| | - Michelle Kuznicki
- University of South Florida Department of Obstetrics and Gynecology, Tampa, FL
| | - Biwei Cao
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
| | | | | | - Brooke Fridley
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
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Liu Z, Chen JM, Huang H, Kuznicki M, Zheng S, Sun W, Quan N, Wang L, Yang H, Guo HM, Li J, Zhuang J, Zhu P. The protective effect of trimetazidine on myocardial ischemia/reperfusion injury through activating AMPK and ERK signaling pathway. Metabolism 2016; 65:122-30. [PMID: 26892523 PMCID: PMC4967934 DOI: 10.1016/j.metabol.2015.10.022] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 10/02/2015] [Accepted: 10/12/2015] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Trimetazidine (TMZ) is an anti-anginal drug that has been widely used in Europe and Asia. The TMZ can optimize energy metabolism via inhibition of long-chain 3-ketoacyl CoA thiolase (3-KAT) in the heart, with subsequent decrease in fatty acid oxidation and stimulation of glucose oxidation. However, the mechanism by which TMZ aids in cardioprotection against ischemic injury has not been characterized. AMP-activated protein kinase (AMPK) is an energy sensor that controls ATP supply from substrate metabolism and protects heart from energy stress. TMZ changes the cardiac AMP/ATP ratio by modulating fatty acid oxidation, thereby triggering AMPK signaling cascade that contributes to the protection of the heart from ischemia/reperfusion (I/R) injury. METHODS The mouse model of in vivo regional ischemia and reperfusion by the ligation of the left anterior descending coronary artery (LAD) was used for determination of myocardial infarction. The infarct size was compared between C57BL/6J WT mice and AMPK kinase dead (KD) transgenic mice with or without TMZ treatment. The ex vivo working heart perfusion system was used to monitor the effect of TMZ on glucose oxidation and fatty acid oxidation in the heart. RESULTS TMZ treatment significantly stimulates cardiac AMPK and extracellular signal-regulated kinase (ERK) signaling pathways (p<0.05 vs. vehicle group). The administration of TMZ reduces myocardial infarction size in WT C57BL/6J hearts, the reduction of myocardial infarction size by TMZ in AMPK KD hearts was significantly impaired versus WT hearts (p<0.05). Intriguingly, the administration of ERK inhibitor, PD98059, to AMPK KD mice abolished the cardioprotection of TMZ against I/R injury. The ex vivo working heart perfusion data demonstrated that TMZ treatment significantly activates AMPK signaling and modulating the substrate metabolism by shifting fatty acid oxidation to glucose oxidation during reperfusion, leading to reduction of oxidative stress in the I/R hearts. Therefore, both AMPK and ERK signaling pathways mediate the cardioprotection of TMZ against ischemic injury. The metabolic benefits of TMZ for angina patients could be due to the activation of energy sensor AMPK in the heart by TMZ administration.
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Affiliation(s)
- Zhenling Liu
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510080, China; State University of New York at Buffalo, Buffalo, NY 14214, USA
| | - Ji-Mei Chen
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510080, China
| | - Huanlei Huang
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510080, China
| | | | - Shaoyi Zheng
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510080, China
| | - Wanqing Sun
- State University of New York at Buffalo, Buffalo, NY 14214, USA; Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Nanhu Quan
- State University of New York at Buffalo, Buffalo, NY 14214, USA; Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Lin Wang
- State University of New York at Buffalo, Buffalo, NY 14214, USA; Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Hui Yang
- State University of New York at Buffalo, Buffalo, NY 14214, USA
| | - Hui-Ming Guo
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510080, China.
| | - Ji Li
- State University of New York at Buffalo, Buffalo, NY 14214, USA; Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Jian Zhuang
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510080, China.
| | - Ping Zhu
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510080, China.
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