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Grewal A, Bansal B, Mittal C, Gupta H, Sasi A, Ganesan P, Dabas A, Sahi P, Ramamoorthy L, Lalthanthuami HT, Ramamoorthy J, Sindhu A, Arora S, Bhukya A, Hepzibah M, Devi K, Krishnamurthy K, Rai SK, Mehta N, Antil K, Bakhshi S, Ganguly S. Knowledge and attitude on childhood cancer survivorship among healthcare trainees: a multicentre study from India. Fam Med Community Health 2024; 12:e002618. [PMID: 38575353 PMCID: PMC11002353 DOI: 10.1136/fmch-2023-002618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND The proportion of childhood cancer survivors (CCS) in low/middle-income countries (LMICs) is rising. CCS often develop several physical and psycho-social long-term adverse effects, with unique healthcare needs. Primary healthcare providers (primary care physicians (PCPs)), especially in LMICs, are often not equipped to handle survivorship care. This study aimed to assess knowledge, and attitude among trainee healthcare providers concerning major issues of paediatric survivorship care. METHODS A multi-centre, cross-sectional, questionnaire-based study was conducted among nursing and medical undergraduate students, and postgraduate medical residents across three tertiary-care teaching hospitals in India-All India Institute of Medical Sciences, New Delhi; Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry; and Maulana Azad Medical College, New Delhi. A questionnaire with total of 24 questions (14 knowledge-based and 10 attitude-based) was finalised after validation by expert review and piloting. The major domains covered in the questionnaire included knowledge and attitude regarding long-term adverse effects and psychosocial, employment-related issues faced by the survivors. It was administered to the study participants electronically. The knowledge-based questions had true/false responses (scored as 0 or 1 if incorrect or correct, respectively). Attitude-based questions were scored as 5-point Likert scale. RESULTS Total 898 responses were collected (median age: 21 years, 64% (576/898) female). Among the respondents, 44% were undergraduate medical students, 42% were nursing students and 14% were postgraduate medical residents. The mean (SD) of knowledge score was 8.72 (2.04) (out of 14). On multivariable analysis, only discipline of training predicted knowledge scores regarding survivorship care. Postgraduate medical residents (9.08) as well as undergraduate medical students (8.85), had significantly higher mean knowledge scores than nursing students (8.47) (p=0.004).Two questions were answered incorrectly by the majority; children and siblings of CCS need additional genetic screening (79% incorrectly answered true), and CCS face intimacy issues in relation to normal sexual functioning (59% incorrectly answered false).Nearly half (48%) of respondents believed that their knowledge of cancer survivorship issues was inadequate. Majority of respondents (84%) suggested that oncologists should handle long-term survivorship care rather than PCPs. CONCLUSION Trainee healthcare providers in India reported inadequate knowledge regarding survivorship care. Improving awareness by incorporating survivorship in teaching curriculum is imperative to equip future PCPs to provide survivorship care across the country.
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Affiliation(s)
- Amritesh Grewal
- Medical Student, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Bhavik Bansal
- Medical Student, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Chetanya Mittal
- Medical Student, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Hardik Gupta
- Medical Student, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Archana Sasi
- Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Puducherry, India
| | - Aashima Dabas
- Department of Pediatrics, Lok Nayak Hospital, New Delhi, Delhi, India
- Department of Pediatrics, Maulana Azad Medical College, New Delhi, Delhi, India
| | - Puneet Sahi
- Department of Pediatrics, Lok Nayak Hospital, New Delhi, Delhi, India
- Department of Pediatrics, Maulana Azad Medical College, New Delhi, Delhi, India
| | - Lakshmi Ramamoorthy
- College of Nursing, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Puducherry, India
| | - Hmar Thiak Lalthanthuami
- College of Nursing, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Puducherry, India
| | - Jaikumar Ramamoorthy
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Puducherry, India
| | - Arwachi Sindhu
- Medical Student, Maulana Azad Medical College, New Delhi, Delhi, India
| | - Suyash Arora
- Medical Student, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Anumeha Bhukya
- Medical Student, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Muthumani Hepzibah
- College of Nursing, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Puducherry, India
| | - Kanchana Devi
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Puducherry, India
| | - Karthick Krishnamurthy
- College of Nursing, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Puducherry, India
| | - Sanjeet K Rai
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Nikhil Mehta
- Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Komal Antil
- College of Nursing, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Sameer Bakhshi
- Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Shuvadeep Ganguly
- Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, Delhi, India
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Rappel WJ, Baykaner T, Zaman J, Ganesan P, Rogers AJ, Narayan SM. Spatially Conserved Spiral Wave Activity During Human Atrial Fibrillation. Circ Arrhythm Electrophysiol 2024; 17:e012041. [PMID: 38348685 PMCID: PMC10950516 DOI: 10.1161/circep.123.012041] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 01/17/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Atrial fibrillation is the most common cardiac arrhythmia in the world and increases the risk for stroke and morbidity. During atrial fibrillation, the electric activation fronts are no longer coherently propagating through the tissue and, instead, show rotational activity, consistent with spiral wave activation, focal activity, collision, or partial versions of these spatial patterns. An unexplained phenomenon is that although simulations of cardiac models abundantly demonstrate spiral waves, clinical recordings often show only intermittent spiral wave activity. METHODS In silico data were generated using simulations in which spiral waves were continuously created and annihilated and in simulations in which a spiral wave was intermittently trapped at a heterogeneity. Clinically, spatio-temporal activation maps were constructed using 60 s recordings from a 64 electrode catheter within the atrium of N=34 patients (n=24 persistent atrial fibrillation). The location of clockwise and counterclockwise rotating spiral waves was quantified and all intervals during which these spiral waves were present were determined. For each interval, the angle of rotation as a function of time was computed and used to determine whether the spiral wave returned in step or changed phase at the start of each interval. RESULTS In both simulations, spiral waves did not come back in phase and were out of step." In contrast, spiral waves returned in step in the majority (68%; P=0.05) of patients. Thus, the intermittently observed rotational activity in these patients is due to a temporally and spatially conserved spiral wave and not due to ones that are newly created at the onset of each interval. CONCLUSIONS Intermittency of spiral wave activity represents conserved spiral wave activity of long, but interrupted duration or transient spiral activity, in the majority of patients. This finding could have important ramifications for identifying clinically important forms of atrial fibrillation and in guiding treatment.
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Affiliation(s)
| | - Tina Baykaner
- Department of Medicine, Stanford University, Palo Alto
| | - Junaid Zaman
- Department of Cardiovascular Medicine, University of Southern California, Los Angeles, CA
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Kumar L, Melinkeri S, Ganesan P, Kumar J, Biswas G, Kilara N, Pathalingappa H, Prasad S, Jain M, Mishra SK, Prasad S, Boyella PK, Sahoo RK, Bondarde S, Shah S, Rege M, Deb U, Korde T, Dixit J. Daratumumab in Indian patients with relapsed and refractory multiple myeloma: a prospective, multicenter, phase IV study. Future Oncol 2024; 20:191-205. [PMID: 38116642 DOI: 10.2217/fon-2023-0842] [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] [Indexed: 12/21/2023] Open
Abstract
Aim: To assess the safety and effectiveness of daratumumab monotherapy in Indian patients with relapsed/refractory multiple myeloma. Methods: In this prospective, multicenter, phase IV study, patients (aged ≥18 years) received intravenous daratumumab (16 mg/kg) in six cycles. Safety was the primary end point. Results: Of the 139 patients included, 121 (87.1%) experienced ≥1 treatment-emergent adverse events (TEAEs; 53 [38.1%] drug-related), 32 (23%) had ≥1 serious TEAEs (five [3.6%] drug-related) and 16 (11.5%) deaths were reported (one death [0.7%] was drug-related). Overall response rate was 26.3%; 62.7% of patients had stable disease. Median time to first response and median progression-free survival were 5.2 and 5.9 months, respectively. Functional status and well-being were improved. Conclusion: Daratumumab showed an acceptable and expected safety profile with consistent efficacy, providing a novel therapeutic option for relapsed/refractory multiple myeloma management in India.
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Affiliation(s)
- Lalit Kumar
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, 110608, India
| | - Sameer Melinkeri
- Department of Hematology, Deenanath Mangeshkar Hospital & Research Center, Pune, Maharashtra, 411004, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, 605006, India
| | - Jeevan Kumar
- Department of Clinical Hematology & HCT, Tata Medical Center, Kolkata, West Bengal, 700156, India
| | - Ghanashyam Biswas
- Department of Oncology, Sparsh Superspeciality Hospital & Critical Care, Bhubaneswar, 751007, Odisha, India
| | - Nalini Kilara
- Department of Medical Oncology, MS Ramaiah Medical College, Bengaluru, Karnataka, 560054, India
| | - Harish Pathalingappa
- Department of Medical Oncology, Cytecare Cancer Hospitals, Bangalore, Karnataka, 560063, India
| | - Svss Prasad
- Division of Medical Oncology, Apollo Cancer Hospitals, Hyderabad, Telangana,500033, India
| | - Minish Jain
- Department of Oncology, Noble Hospital, Pune, Maharashtra, 411013, India
| | - Sourav Kumar Mishra
- Department of Medical Oncology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Saurabh Prasad
- Department of Cancer & Immunotherapy & Research, Kims Kingsway Hospitals, Nagpur, Maharashtra, 440001, India
| | - Pavan Kumar Boyella
- Department of Medical Oncology, Basavatarakam Indo-American Cancer Hospital & Research Institute, Hyderabad, Telangana, 500034, India
| | - Ranjit Kumar Sahoo
- Department of Medical Oncology, IRCH, All India Institute of Medical Sciences, New Delhi, 110608, India
| | - Shailesh Bondarde
- Department of Oncology, Apex Wellness's Rishikesh Hospital, Nashik, Maharashtra, 422009, India
| | - Sandip Shah
- Department of Hemato-Oncology, Avron Hospitals Private Limited, Ahmedabad, Gujarat, 380014, India
| | - Milind Rege
- Medical Affairs Operations, Johnson & Johnson Private Limited, Mumbai, Maharashtra, 400080, India
| | - Uttiya Deb
- Medical Affairs, Johnson & Johnson Private Limited, Mumbai, Maharashtra, 400080, India
| | - Tanuja Korde
- Medical Affairs Operations, Johnson & Johnson Private Limited, Mumbai, Maharashtra, 400080, India
| | - Jitendra Dixit
- Medical Affairs, Johnson & Johnson Private Limited, Mumbai, Maharashtra, 400080, India
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Gopal V, Nisha Y, Ganesan P, Kayal S, Bobby Z, Adithan S, Penumadu P, Ramakrishnalay VP, Bandlamudi BP, Bahttacharjee A, Dahagama S, Dubashi B. Role of CYFRA 21-1 and CEA as prognostic and predictive markers in locally advanced and metastatic gastric carcinoma. J Cancer Res Ther 2024:01363817-990000000-00060. [PMID: 38261458 DOI: 10.4103/jcrt.jcrt_746_22] [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: 04/06/2022] [Accepted: 02/07/2023] [Indexed: 01/25/2024]
Abstract
PURPOSE Tumor-associated serum markers have demonstrated predictive and prognostic value in patients being treated for malignancies. However, the clinical importance of tumor markers in gastric cancers (GC) is poorly standardized. OBJECTIVES The objective is to assess the clinical utility of cytokeratin-19 fragment (CYFRA 21-1) and carcinoembryonic antigen (CEA) as serum tumor markers in advanced GC. METHODS In this prospective study, CYFRA 21-1 and CEA levels were measured at baseline and after three cycles of chemotherapy in patients with advanced GC. The association of tumor marker levels with prognosis and decline of tumor markers with radiological overall response rates (ORR) and survival were analyzed. RESULTS In the 105 patients, the proportion of patients with elevated baseline CYFRA 21-1 and CEA levels was 55% (N = 58) and 37% (N = 39) based on predefined cutoffs. Response assessment was done for 61 patients who received a minimum of three cycles of chemotherapy. A 15% and 13% reduction of serum levels from baseline for CYFRA 21-1 and CEA were selected for defining "CYFRA 21-1 response" and "CEA-response," respectively. Both responses were significant predictors of radiological ORR. The median overall survival (OS) was 9.6 months in the entire cohort and 13 months for patients who received at least three cycles of chemotherapy. In multivariate analysis, baseline CEA levels and ECOG status were significant predictors of OS. In a subset analysis of patients receiving palliative chemotherapy, any of the tumor marker responses predicted improved 1-year OS. CONCLUSION In advanced GC, CYFRA 21-1 and CEA decline from baseline appeared to be reliable surrogate markers of chemotherapy efficacy and improved survival.
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Affiliation(s)
- Vishnu Gopal
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Yadav Nisha
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Smita Kayal
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Zachariah Bobby
- Department of Biochemistry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Subathra Adithan
- Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Prasanth Penumadu
- Department of Surgical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Vishnu P Ramakrishnalay
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Bhanu P Bandlamudi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Arnab Bahttacharjee
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Sindhu Dahagama
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Biswajit Dubashi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Goenka L, Kumar SM, Essakky S, Rajasulochana SR, Sivanantham P, Ayiraveetil R, Kar SS, Ganesan P. Cost-effectiveness of response-adapted therapy (RAT) for advanced Hodgkin's Lymphoma compared with conventional treatment in India: a Markov-model based analysis. Leuk Lymphoma 2023; 64:2188-2194. [PMID: 37667967 DOI: 10.1080/10428194.2023.2249154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 04/16/2023] [Accepted: 04/22/2023] [Indexed: 09/06/2023]
Abstract
Cost effectiveness analysis of interim positron emission tomography (PET-2, done after 2 cycles of chemotherapy) based response adaptive therapy (RAT) approaches in advanced Hodgkin lymphoma (aHL) are not available from an Indian perspective. We used a five-year decision analytics model to assess the cost-effectiveness of the two RAT approaches [(escalation (RAT-1) or de-escalation (RAT-2)] compared with standard care (SOC) in aHL (mean age:35 years). Modelling data was derived from secondary sources and sensitivity analyses were performed to assess the robustness of the model. Net monetary benefit (NMB) gained from RAT2 in Indian rupees (INR) (INR 2,26,896) was higher than the RAT1 (INR 1,83,138) when compared with SOC. Proportion achieving the complete response after initial treatment (CR1) was the key determining factor for the RAT1/2 dominance over SOC. Despite higher initial input costs, response-adapted therapy of aHL was cost-effective by minimizing the cost incurred and disutility experienced during relapse and salvage.
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Affiliation(s)
- Luxitaa Goenka
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - S Mathan Kumar
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Saravanan Essakky
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Subramania Raju Rajasulochana
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Parthibane Sivanantham
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Reshma Ayiraveetil
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Sitanshu Sekhar Kar
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Charles L, Elangovan A, Nisha Y, Jafa E, Kate V, Selvarajan S, Kayal S, Ganesh RN, Dubashi B, Penumadu P, Ganesan P. Clinicopathological features and survival outcomes for gastric adenocarcinoma: Real-world single-center data. Indian J Gastroenterol 2023:10.1007/s12664-023-01455-4. [PMID: 37948007 DOI: 10.1007/s12664-023-01455-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 08/22/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION Gastric cancer is the fifth most-common cancer and fourth common cause for cancer-related deaths globally. Surgery preceded or followed by chemotherapy or chemoradiotherapy is considered an optimal treatment for locally advanced gastric cancer. This study is a real-world data from a tertiary referral institute in southern India, in its experience with treating gastric adenocarcinoma over a period of four years with a minimum of two-year follow-up. METHODS This was a retrospective analysis of data of patients with histologically proven gastric adenocarcinoma enrolled in the Department of Medical Oncology from 2015 to 2018. The demographic details, presentation, staging, treatment received and outcomes of patients with gastric adenocarcinoma were collected and analyzed in this study. RESULTS Total 488 patients with gastric adenocarcinoma were included for the study. The stage-wise distribution of patients revealed early and locally advanced (45%) and metastatic (55%). The peritoneum and liver were the common sites of metastasis. The treatment distribution of these patients included perioperative chemotherapy followed by surgery (25 [5%]), surgery followed by adjuvant chemotherapy (65 [13%]), surgery alone (16 [3%]), perioperative chemotherapy alone (23 [4%]), palliative chemotherapy (274 [56%]) and supportive care (85 [17%]). The median overall survival for curative, palliative and supportive treatment was 23 (18-28), nine (7.6-10.4) and four (2.7-5.3) months, respectively. The two-year overall survival in the intention to treat population in the primary surgery (n = 81) and perioperative chemotherapy groups (n = 66) was 67.4% vs. 29.9% (p < 0.0001), respectively. CONCLUSION This study highlights the advanced nature of the presentation of gastric cancer patients and the poor rate of treatment completion. The median survival rates in curative patients remain to be dismally poor. The treatment sequence in curable gastric cancer of surgery followed by adjuvant chemotherapy vs. perioperative chemotherapy followed by surgery needs to be explored in our country.
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Affiliation(s)
- L Charles
- Department of Medical Oncology, Regional Cancer Centre, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantari Nagar, Pondicherry, 605 006, India
| | - Archana Elangovan
- Department of Surgical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantari Nagar, Pondicherry, 605 006, India
| | - Yadav Nisha
- Department of Medical Oncology, Regional Cancer Centre, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantari Nagar, Pondicherry, 605 006, India
| | - Esha Jafa
- Department of Medical Oncology, Regional Cancer Centre, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantari Nagar, Pondicherry, 605 006, India
| | - Vikram Kate
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantari Nagar, Pondicherry, 605 006, India
| | - Sandhiya Selvarajan
- Department of Clinical Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantari Nagar, Pondicherry, 605 006, India
| | - Smita Kayal
- Department of Medical Oncology, Regional Cancer Centre, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantari Nagar, Pondicherry, 605 006, India
| | - Rajesh Nachiappa Ganesh
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantari Nagar, Pondicherry, 605 006, India
| | - Biswajit Dubashi
- Department of Medical Oncology, Regional Cancer Centre, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantari Nagar, Pondicherry, 605 006, India.
| | - Prasanth Penumadu
- Department of Surgical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantari Nagar, Pondicherry, 605 006, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Regional Cancer Centre, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantari Nagar, Pondicherry, 605 006, India
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Feng R, Deb B, Ganesan P, Tjong FVY, Rogers AJ, Ruipérez-Campillo S, Somani S, Clopton P, Baykaner T, Rodrigo M, Zou J, Haddad F, Zahari M, Narayan SM. Segmenting computed tomograms for cardiac ablation using machine learning leveraged by domain knowledge encoding. Front Cardiovasc Med 2023; 10:1189293. [PMID: 37849936 PMCID: PMC10577270 DOI: 10.3389/fcvm.2023.1189293] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 09/18/2023] [Indexed: 10/19/2023] Open
Abstract
Background Segmentation of computed tomography (CT) is important for many clinical procedures including personalized cardiac ablation for the management of cardiac arrhythmias. While segmentation can be automated by machine learning (ML), it is limited by the need for large, labeled training data that may be difficult to obtain. We set out to combine ML of cardiac CT with domain knowledge, which reduces the need for large training datasets by encoding cardiac geometry, which we then tested in independent datasets and in a prospective study of atrial fibrillation (AF) ablation. Methods We mathematically represented atrial anatomy with simple geometric shapes and derived a model to parse cardiac structures in a small set of N = 6 digital hearts. The model, termed "virtual dissection," was used to train ML to segment cardiac CT in N = 20 patients, then tested in independent datasets and in a prospective study. Results In independent test cohorts (N = 160) from 2 Institutions with different CT scanners, atrial structures were accurately segmented with Dice scores of 96.7% in internal (IQR: 95.3%-97.7%) and 93.5% in external (IQR: 91.9%-94.7%) test data, with good agreement with experts (r = 0.99; p < 0.0001). In a prospective study of 42 patients at ablation, this approach reduced segmentation time by 85% (2.3 ± 0.8 vs. 15.0 ± 6.9 min, p < 0.0001), yet provided similar Dice scores to experts (93.9% (IQR: 93.0%-94.6%) vs. 94.4% (IQR: 92.8%-95.7%), p = NS). Conclusions Encoding cardiac geometry using mathematical models greatly accelerated training of ML to segment CT, reducing the need for large training sets while retaining accuracy in independent test data. Combining ML with domain knowledge may have broad applications.
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Affiliation(s)
- Ruibin Feng
- Department of Medicine and Cardiovascular Institute, Stanford University, Stanford, CA, United States
| | - Brototo Deb
- Department of Medicine and Cardiovascular Institute, Stanford University, Stanford, CA, United States
| | - Prasanth Ganesan
- Department of Medicine and Cardiovascular Institute, Stanford University, Stanford, CA, United States
| | - Fleur V. Y. Tjong
- Department of Medicine and Cardiovascular Institute, Stanford University, Stanford, CA, United States
- Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Albert J. Rogers
- Department of Medicine and Cardiovascular Institute, Stanford University, Stanford, CA, United States
| | - Samuel Ruipérez-Campillo
- Department of Medicine and Cardiovascular Institute, Stanford University, Stanford, CA, United States
- Bioengineering Department, University of California, Berkeley, Berkeley, CA, United States
| | - Sulaiman Somani
- Department of Medicine and Cardiovascular Institute, Stanford University, Stanford, CA, United States
| | - Paul Clopton
- Department of Medicine and Cardiovascular Institute, Stanford University, Stanford, CA, United States
| | - Tina Baykaner
- Department of Medicine and Cardiovascular Institute, Stanford University, Stanford, CA, United States
| | - Miguel Rodrigo
- Department of Medicine and Cardiovascular Institute, Stanford University, Stanford, CA, United States
- CoMMLab, Universitat Politècnica de València, Valencia, Spain
| | - James Zou
- Department of Biomedical Data Science, Stanford University, Stanford, CA, United States
| | - Francois Haddad
- Department of Medicine and Cardiovascular Institute, Stanford University, Stanford, CA, United States
| | - Matei Zahari
- Department of Computer Science, Stanford University, Stanford, CA, United States
| | - Sanjiv M. Narayan
- Department of Medicine and Cardiovascular Institute, Stanford University, Stanford, CA, United States
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Krishnamoorthi N, Charles L, Nisha Y, Dubashi B, Ganesan P, Kayal S, Penumadu P, Nelamangala Ramakrishnaiah VP, Ganesh RN. Aggressive Histology and Extensive Metastasis Characteristic of Very Young Gastric Cancer (Less Than 30 Years): A Retrospective Clinical Audit. South Asian J Cancer 2023; 12:326-333. [PMID: 38130279 PMCID: PMC10733067 DOI: 10.1055/s-0043-1761284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
Narendran KrishnamoorthiObjectives Gastric cancer (GC) is an aggressive disease and remains one of the most common causes of cancer-related mortality worldwide. Incidence of gastric cancer in young (GCY) varies between 2 and 8%. GCY faces unique challenges such as biological variation, diagnosis at an advanced stage, issues related to fertility preservation, and psychosocial considerations. This study aimed to find the differences in clinical characteristics and treatment outcomes of GCY compared to gastric cancer in older adults (GCO). Material and Methods This is a retrospective study from a tertiary care center. We screened records from 2015 to 2020, identified 33 records of GCY (less than 30 years), and compared the data with GCO (greater than 30 years) during 2015 and 2018. Results We identified 33 patients with GCY with a median age of 28 years (21-30) and a female to male ratio of 2:1. In GCY, 60% of patients presented with metastatic disease. Diffuse-type histology was more common in the GCY than in GCO (66.7% vs. 41.7%, p = 0.001). In patients with metastasis, multiple metastases were common in GCY compared to GCO (45% vs. 15%, p = 0.003). The median duration of follow-up for all patients was 27 (24-29) months. In GCY, the median OS was not reached for patients treated with curative intent, and it was 13 months for those treated with palliative intent. Conclusion The incidence of GCY in our study was like the western literature. Female patients with aggressive diffuse histology and multiple extensive metastases were characteristic of GCY. The survival outcomes were identical to GCO.
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Affiliation(s)
- Narendran Krishnamoorthi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantari Nagar, Pondicherry, India
| | - Lourdhusamy Charles
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantari Nagar, Pondicherry, India
| | - Yadav Nisha
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantari Nagar, Pondicherry, India
| | - Biswajit Dubashi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantari Nagar, Pondicherry, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantari Nagar, Pondicherry, India
| | - Smita Kayal
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantari Nagar, Pondicherry, India
| | - Prasanth Penumadu
- Department of Surgical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantari Nagar, Pondicherry, India
| | | | - Rajesh Nachiappa Ganesh
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantari Nagar, Pondicherry, India
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Nisha Y, Dubashi B, Bobby Z, Sahoo JP, Kayal S, Ananthakrishnan R, Reddy VB, L C, Ganesan P. Negative impact on bone homeostasis in postmenopausal women with non-metastatic breast cancer during cytotoxic chemotherapy. J Bone Miner Metab 2023; 41:682-692. [PMID: 37410202 DOI: 10.1007/s00774-023-01444-9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/29/2023] [Indexed: 07/07/2023]
Abstract
INTRODUCTION The burden and mechanisms of endocrine therapy-related bone loss are well known, while there are limited data on chemotherapy-induced bone resorption. The study aimed to evaluate the effect of cytotoxic chemotherapy on bone homeostasis among postmenopausal women with non-metastatic breast cancer. MATERIALS AND METHODS Early and locally advanced postmenopausal non-metastatic breast cancer patients aged 45 to 65 planned for three cycles of anthracycline and four cycles of taxane chemotherapy administered along with dexamethasone (cumulative dose-256 mg) as an antiemetic from June 2018 to December 2021 were included. Bone mineral density (BMD), bone turnover markers, calciotropic hormones, pro-inflammatory cytokines, oxidative stress, and total antioxidant levels (TAS) were measured. RESULTS We recruited 109 patients, with early 34 (31.2%) and locally advanced breast cancer 75 (68.8%) with median age 53 (45-65) years. There was a significant decrease in the % BMD at the lumbar spine, neck of the femur, and total hip post-chemotherapy. There was a significant increase in serum C-terminal telopeptide of type I collagen (CTX) and procollagen type I N-terminal propeptide (PINP) levels post-chemotherapy. PINP/CTX ratio significantly decreased post-chemotherapy. Serum 25-OH vitamin D was significantly reduced with a compensatory increase in plasma iPTH levels. The change in CTX, PINP/CTX ratio, 25-OH vitamin D, iPTH, and oxidative stress index was more pronounced during anthracycline as taxane chemotherapy. There were no significant changes in pro-inflammatory cytokine levels. CONCLUSION Chemotherapy and dexamethasone as antiemetic resulted in significant bone loss, as evidenced by bone turnover markers. Further studies are required to understand the mechanism of chemotherapy-induced bone loss and the need for bone-strengthening agents during chemotherapy.
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Affiliation(s)
- Yadav Nisha
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| | - Biswajit Dubashi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India.
| | - Zachariah Bobby
- Department of Biochemistry, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| | - Jaya Prakash Sahoo
- Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| | - Smita Kayal
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| | - Ramesh Ananthakrishnan
- Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| | - Vijay Bhaskar Reddy
- Department of Endocrinology, Vijay Diabetes, Thyroid and Endocrine Clinic, Saradambal Nagar, Puducherry, India
| | - Charles L
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
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Pramesh CS, Sengar M, Patankar S, Chinnaswamy G, Gupta S, Vijayakumar M, Sood S, Sathe AN, Radhakrishnan V, Ganesan P, Mallavarapu KM, Badwe RA. A National Cancer Grid pooled procurement initiative, India. Bull World Health Organ 2023; 101:587-594. [PMID: 37638358 PMCID: PMC10452934 DOI: 10.2471/blt.23.289714] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 05/17/2023] [Accepted: 05/19/2023] [Indexed: 08/29/2023] Open
Abstract
In health systems with little public funding and decentralized procurement processes, the pricing and quality of anti-cancer medicines directly affects access to effective anti-cancer therapy. Factors such as differential pricing, volume-dependent negotiation and reliance on low-priced generics without any evaluation of their quality can lead to supply and demand lags, high out-of-pocket expenditures for patients and poor treatment outcomes. While pooled procurement of medicines can help address some of these challenges, monitoring of the procurement process requires considerable administrative investment. Group negotiation to fix prices, issuing of uniform contracts with standardized terms and conditions, and procurement by individual hospitals also reduce costs and improve quality without significant investment. The National Cancer Grid, a network of more than 250 cancer centres in India, piloted pooled procurement to improve negotiability of high-value oncology and supportive care medicines. A total of 40 drugs were included in this pilot. The pooled demand for the drugs from 23 centres was equivalent to 15.6 billion Indian rupees (197 million United States dollars (US$)) based on maximum retail prices. The process included technical and financial evaluation followed by contracts between individual centres and the selected vendors. Savings of 13.2 billion Indian Rupees (US$ 166.7million) were made compared to the maximum retail prices. The savings ranged from 23% to 99% (median: 82%) and were more with generics than innovator and newly patented medicines. This study reveals the advantages of group negotiation in pooled procurement for high-value medicines, an approach that can be applied to other health systems.
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Affiliation(s)
- C S Pramesh
- Tata Memorial Hospital, Tata Memorial Centre, affiliated with the Homi Bhabha National Institute, Dr Ernest Borges Road, Parel, Mumbai400012, India
| | - Manju Sengar
- Tata Memorial Centre, affiliated with the Homi Bhabha National Institute, Mumbai, India
| | - Sumedha Patankar
- Tata Memorial Centre, affiliated with the Homi Bhabha National Institute, Mumbai, India
| | - Girish Chinnaswamy
- Tata Memorial Centre, affiliated with the Homi Bhabha National Institute, Mumbai, India
| | - Sudeep Gupta
- Tata Memorial Centre, affiliated with the Homi Bhabha National Institute, Mumbai, India
| | - M Vijayakumar
- Zulekha Yenepoya Institute of Oncology, Yenepoya (Deemed to be university), Mangalore, India
| | - Sanjeev Sood
- Tata Memorial Centre, affiliated with the Homi Bhabha National Institute, Mumbai, India
| | - Anil N Sathe
- Tata Memorial Centre, affiliated with the Homi Bhabha National Institute, Mumbai, India
| | | | - Prasanth Ganesan
- Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | | | - Rajendra A Badwe
- Tata Memorial Centre, affiliated with the Homi Bhabha National Institute, Mumbai, India
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Sandhya L, Ganesan P. Reply to H. Onishi et al. J Clin Oncol 2023; 41:4185-4186. [PMID: 37352487 DOI: 10.1200/jco.23.01090] [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] [Received: 05/21/2023] [Accepted: 05/23/2023] [Indexed: 06/25/2023] Open
Affiliation(s)
- Lakshmi Sandhya
- Lakshmi Sandhya, MD and Prasanth Ganesan, MD, Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Prasanth Ganesan
- Lakshmi Sandhya, MD and Prasanth Ganesan, MD, Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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12
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Jafa E, L C, Nisha Y, Kate V, Kayal S, Ganesh RN, V C S, Ganesan P, Penumadu P, Dubashi B. Comparison of Efficacy of Aspirin Plus EOX vs. EOX Alone in Patients with Locally Advanced and Metastatic Gastric Cancer: a Randomized Clinical Trial. J Gastrointest Cancer 2023; 54:642-650. [PMID: 35842566 DOI: 10.1007/s12029-022-00845-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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] [Accepted: 06/18/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE The role of aspirin in cancer prevention has been well defined; the last decade revealed its therapeutic role with improved efficacy when aspirin was added to capecitabine in heavily pre-treated metastatic colorectal cancer. Aspirin affects tumour growth through the PI3K pathway, which regulates apoptosis and autophagy. The objective was to compare the efficacy of aspirin plus epirubicin, oxaliplatin, capecitabine (EOX) chemotherapy versus EOX alone in locally advanced and metastatic gastric cancer. METHODS All patients with advanced gastric cancer reporting to the Department of Medical oncology between March 2017 and May 2019 were screened for study eligibility. They were randomly assigned to standard EOX with or without aspirin at a daily dose of 150 mg. Tumour measurements were assessed at baseline and after 3-4 cycles by an independent blinded radiologist according to RECIST criteria 1.1. Toxicity profiles were recorded as per CTCAE v 4.03. Per-protocol group was identified as 70 patients. The primary endpoint was overall response rates in the per-protocol group (defined as patients who received a minimum of 3 cycles and had an evaluable response after randomization). The secondary endpoints included toxicity analysis, progression-free survival, and overall survival. RESULTS Ninety-five patients who fulfilled the study inclusion and exclusion criteria were randomized to group 1 EOX (50) or group 2 EOX plus aspirin (45). Seventy patients were included for the per-protocol analysis. The overall response rate in group 1 was 27% compared to group 2, which was 42%, P = 0.176. The median duration of follow was 29 (18.56-39.45) months. The median overall survival (n = 95) of group 1 versus group 2 was 11 (8.58-13.42) months and 10 (6.86-13.14) months, respectively, P = 0.90. There was no statistical significance in the overall survival per-protocol analysis (n = 70) between group one 12 (8.75-15.25) months versus group two 12 (6.21-17.79) months, P = 0.50. CONCLUSIONS There was no improvement in the response rates, progression-free survival, and overall survival on adding aspirin to EOX chemotherapy in locally advanced and metastatic gastric cancer in an unselected population. A further role of PI3K mutation as a biomarker needs to be evaluated in this setting.
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Affiliation(s)
- Esha Jafa
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Charles L
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Yadav Nisha
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Vikram Kate
- Department of General Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Smita Kayal
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Rajesh Nachiappa Ganesh
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Sunitha V C
- Department of Radio-Diagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Prasanth Penumadu
- Department of Surgical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Biswajit Dubashi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.
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Ganesan P, Narayan SM, Giles WR. Increases in dietary phosphate levels can augment atrial arrhythmias. Acta Physiol (Oxf) 2023; 238:e13978. [PMID: 37062019 PMCID: PMC11042787 DOI: 10.1111/apha.13978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 04/13/2023] [Indexed: 04/17/2023]
Affiliation(s)
- P. Ganesan
- Department of Medicine, Stanford University, Palo Alto, California, USA
| | - S. M. Narayan
- Department of Medicine, Stanford University, Palo Alto, California, USA
| | - W. R. Giles
- Department of Physiology and Pharmacology, University of Calgary, Calgary, Alberta, Canada
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14
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Ganesan P, El Cheikh J, Isidori A, Kuo SH, Saleh M, Nair R. Editorial: The management of hematologic malignancies in lower-income countries. Front Oncol 2023; 13:1218718. [PMID: 37284195 PMCID: PMC10240044 DOI: 10.3389/fonc.2023.1218718] [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] [Received: 05/08/2023] [Accepted: 05/15/2023] [Indexed: 06/08/2023] Open
Affiliation(s)
- Prasanth Ganesan
- Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Jean El Cheikh
- Department of Hematology-Oncology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Alessandro Isidori
- Hematology and Stem Cell Transplant Center, Marche Norde Hospital, Pesaro, Italy
| | - Sung-Hsin Kuo
- Graduate Institute of Oncology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Mustafa Saleh
- Department of Hematology-Oncology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Reena Nair
- Clinical Haematology Oncology and Hematopoietic Cell Transplantation (HCT), Tata Medical Centre, Kolkata, India
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15
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Ganesan P, Deb B, Feng R, Rodrigo M, Ruiperez-Campillo S, Rogers AJ, Clopton P, Wang PJ, Zeemering S, Schotten U, Rappel WJ, Narayan SM. Quantifying a spectrum of clinical response in atrial tachyarrhythmias using spatiotemporal synchronization of electrograms. Europace 2023; 25:euad055. [PMID: 36932716 PMCID: PMC10227659 DOI: 10.1093/europace/euad055] [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: 09/23/2022] [Accepted: 02/09/2023] [Indexed: 03/19/2023] Open
Abstract
AIMS There is a clinical spectrum for atrial tachyarrhythmias wherein most patients with atrial tachycardia (AT) and some with atrial fibrillation (AF) respond to ablation, while others do not. It is undefined if this clinical spectrum has pathophysiological signatures. This study aims to test the hypothesis that the size of spatial regions showing repetitive synchronized electrogram (EGM) shapes over time reveals a spectrum from AT, to AF patients who respond acutely to ablation, to AF patients without acute response. METHODS AND RESULTS We studied n = 160 patients (35% women, 65.0 ± 10.4 years) of whom (i) n = 75 had AF terminated by ablation propensity matched to (ii) n = 75 without AF termination and (iii) n = 10 with AT. All patients had mapping by 64-pole baskets to identify areas of repetitive activity (REACT) to correlate unipolar EGMs in shape over time. Synchronized regions (REACT) were largest in AT, smaller in AF termination, and smallest in non-termination cohorts (0.63 ± 0.15, 0.37 ± 0.22, and 0.22 ± 0.18, P < 0.001). Area under the curve for predicting AF termination in hold-out cohorts was 0.72 ± 0.03. Simulations showed that lower REACT represented greater variability in clinical EGM timing and shape. Unsupervised machine learning of REACT and extensive (50) clinical variables yielded four clusters of increasing risk for AF termination (P < 0.01, χ2), which were more predictive than clinical profiles alone (P < 0.001). CONCLUSION The area of synchronized EGMs within the atrium reveals a spectrum of clinical response in atrial tachyarrhythmias. These fundamental EGM properties, which do not reflect any predetermined mechanism or mapping technology, predict outcome and offer a platform to compare mapping tools and mechanisms between AF patient groups.
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Affiliation(s)
- Prasanth Ganesan
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Brototo Deb
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Ruibin Feng
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Miguel Rodrigo
- Electronic Engineering Department, Universitat de Valencia, Av. de Blasco Ibáñez, 13, 46010 València, Spain
| | - Samuel Ruiperez-Campillo
- Electronic Engineering Department, Universitat de Valencia, Av. de Blasco Ibáñez, 13, 46010 València, Spain
- Department of Bioengineering, University of California, Berkeley, CA 94720, USA
| | - Albert J Rogers
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Paul Clopton
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Paul J Wang
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Stef Zeemering
- Department of Physiology, Maastricht University, 6211 LK Maastricht, 616 6200, Netherlands
| | - Ulrich Schotten
- Department of Physiology, Maastricht University, 6211 LK Maastricht, 616 6200, Netherlands
| | - Wouter-Jan Rappel
- Department of Physics, University of California, 9500 Gilman Dr, La Jolla, CA 92093, USA
| | - Sanjiv M Narayan
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
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Sandhya L, Devi Sreenivasan N, Goenka L, Dubashi B, Kayal S, Solaiappan M, Govindarajalou R, Kt H, Ganesan P. Randomized Double-Blind Placebo-Controlled Study of Olanzapine for Chemotherapy-Related Anorexia in Patients With Locally Advanced or Metastatic Gastric, Hepatopancreaticobiliary, and Lung Cancer. J Clin Oncol 2023; 41:2617-2627. [PMID: 36977285 DOI: 10.1200/jco.22.01997] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 02/17/2023] [Indexed: 03/30/2023] Open
Abstract
PURPOSE Anorexia occurs in 30%-80% of patients with advanced malignancies, which may be worsened with chemotherapy. This trial assessed the efficacy of olanzapine in stimulating appetite and improving weight gain in patients receiving chemotherapy. METHODS Adults (≥18 years) with untreated, locally advanced, or metastatic gastric, hepatopancreaticobiliary (HPB), and lung cancers were randomly assigned (double-blind) to receive olanzapine (2.5 mg once a day for 12 weeks) or placebo along with chemotherapy. Both groups received standard nutritional assessment and dietary advice. The primary outcomes were the proportion of patients with weight gain > 5% and the improvement in appetite (assessed by the visual analog scale [VAS] and the Functional Assessment of Chronic Illness Therapy system of Quality-of-Life questionnaires Anorexia Cachexia subscale [FAACT ACS]). Secondary end points were change in nutritional status, quality of life (QOL), and chemotherapy toxicity. RESULTS We enrolled 124 patients (olanzapine, 63 and placebo, 61) with a median age of 55 years (18-78 years), of whom 112 (olanzapine, 58 and placebo, 54) were analyzable. The majority (n = 99, 80%) had metastatic cancer (gastric [n = 68, 55%] > lung [n = 43, 35%] > HPB [n = 13, 10%]). The olanzapine arm had a greater proportion of patients with a weight gain of > 5% (35 of 58 [60%] v 5 of 54 [9%], P < .001) and improvement in appetite by VAS (25 of 58 [43%] v 7 of 54 [13%], P < .001) and by FAACT ACS (scores ≥37:13 of 58 [22%] v 2 of 54 [4%], P = .004). Patients on olanzapine had better QOL, nutritional status, and lesser chemotoxicity. Side effects attributable to olanzapine were minimal. CONCLUSION Low-dose, daily olanzapine is a simple, inexpensive, well-tolerated intervention that significantly improves appetite and weight gain in newly diagnosed patients on chemotherapy.
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Affiliation(s)
- Lakshmi Sandhya
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Nirmala Devi Sreenivasan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Luxitaa Goenka
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Biswajit Dubashi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Smita Kayal
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Manikandan Solaiappan
- Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Ramkumar Govindarajalou
- Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Harichandrakumar Kt
- Biostatistics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Verma SK, Ganesan P, Kishore P, Remya S, Mohan CO, Padmavathy P, Muralidhran N, Bindu J. Effects of different cooking methods on the proximate composition and physical properties of Brown shrimp ( Metapenaeus dobsonii) during cooking and freezing cycle. FOOD SCI TECHNOL INT 2023:10820132231166972. [PMID: 37041697 DOI: 10.1177/10820132231166972] [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] [Indexed: 04/13/2023]
Abstract
Present study aimed to evaluate the changes in proximate composition and physical attributes in brown shrimp (Metapenaeus dobsonii) exposed to different methods of cooking followed by freezing. For this, three different grades (100/200, 200/300, and 300/500 numbers per kg) of brown shrimp were cooked at 90°C till the core temperature of the product reaches 85°C using hot water, steam, and microwave (400W) techniques. The changes in yield, cooking loss, proximate composition, textural, and colour profile were assessed for cooked shrimps. The cooking loss was higher for larger grades of shrimp, whereas shrimp cooked using hot water exhibited the highest cooking loss. Lowest cooking loss was observed for microwave-cooked shrimp. Moisture content decreased after cooking whereas protein, fat, ash, and calorie content increased. After cooking, different grades of shrimp showed an increase in their lightness (L*), redness (a*), and yellowness (b*) values. The smaller grade shrimp exhibited lower value for cohesiveness, hardness, chewiness, and gumminess. Different cooking techniques yielded cooked shrimp of varying hardness values.
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Affiliation(s)
- Sumit Kumar Verma
- Fisheries College and Research Institute, Tamil Nadu Dr. J. Jayalalithaa Fisheries University (TNJFU), Thoothukkudi, Tamil Nadu, India
| | - P Ganesan
- Fisheries College and Research Institute, Tamil Nadu Dr. J. Jayalalithaa Fisheries University (TNJFU), Thoothukkudi, Tamil Nadu, India
| | - Pankaj Kishore
- ICAR-Central Institute of Fisheries Technology, Cochin, Kerala, India
| | - S Remya
- ICAR-Central Institute of Fisheries Technology, Cochin, Kerala, India
| | - C O Mohan
- ICAR-Central Institute of Fisheries Technology, Cochin, Kerala, India
| | - Pandurengan Padmavathy
- Fisheries College and Research Institute, Tamil Nadu Dr. J. Jayalalithaa Fisheries University (TNJFU), Thoothukkudi, Tamil Nadu, India
| | - Nagarajan Muralidhran
- Department of Fish Processing Technology, Dr. MGR Fisheries College and Research Institute, Tamil Nadu Dr. J. Jayalalithaa Fisheries University (TNJFU), Ponneri, Tamil Nadu, India
| | - J Bindu
- ICAR-Central Institute of Fisheries Technology, Cochin, Kerala, India
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Shukkur N, Penumadu P, Ganesan P, Srinivas BH. Growing teratoma syndrome - ovarian germ cell tumor. Am J Med Sci 2023; 365:e65-e66. [PMID: 36347301 DOI: 10.1016/j.amjms.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 08/12/2022] [Accepted: 11/01/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Naveeth Shukkur
- Department of Surgical Oncology, Jawaharlal Institute of Postgraduate Medical Education & Research, Dhanvantari Nagar, Puducherry, India
| | - Prasanth Penumadu
- Department of Surgical Oncology, Jawaharlal Institute of Postgraduate Medical Education & Research, Dhanvantari Nagar, Puducherry, India.
| | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education & Research, Dhanvantari Nagar, Puducherry, India
| | - Bheemanathi Hanuman Srinivas
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education & Research, Dhanvantari Nagar, Puducherry, India
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Saj F, Nisha Y, Ganesan P, Kayal S, Kar R, Halanaik D, Dubashi B. Efficacy and safety of pomalidomide, bortezomib, and dexamethasone combination chemotherapy for newly diagnosed multiple myeloma: POMACE Phase II Study. Blood Cancer J 2023; 13:45. [PMID: 36964143 PMCID: PMC10039009 DOI: 10.1038/s41408-023-00816-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 03/05/2023] [Accepted: 03/10/2023] [Indexed: 03/26/2023] Open
Abstract
Bortezomib, lenalidomide, and dexamethasone induction chemotherapy (VRd), followed by autologous stem cell transplantation (ASCT), are the standard of care for patients with newly diagnosed multiple myeloma (NDMM). Pomalidomide is currently approved for relapsed-refractory multiple myeloma. This single-arm, open-label, phase 2 study was the prospective evaluation of the efficacy and safety of bortezomib, pomalidomide, and dexamethasone (VPd) induction for NDMM. We used Fleming's two-stage design for sample size calculation. We included transplant-eligible and ineligible patients aged 18-75 years in the study. The patients received four cycles of VPd induction followed by response assessment. Thirty-four patients were included in the study, of which 31 completed all four cycles of induction. The median age was 52 years (32-72). Thirty (91%) patients had multiple myeloma, and three had multiple plasmacytomas with less than 10% bone marrow involvement. Nine (27%) had ISS-I, 9 (27%) had ISS-II, and 15 (46%) had ISS-III myeloma. Three patients had high-risk cytogenetic abnormalities. After four cycles of VPd induction, ten patients (32%) achieved stringent CR, nine had CR (29%), eight (26%) had VGPR, and 4 (13%) had PR. Fifteen (48%) had a complete metabolic response (CMR) on PET-CT. Two patients developed SAEs. Anemia was the most common hematological toxicity. Peripheral neuropathy and constipation were the most common non-hematological toxicities. Patients with ≥VGPR had significantly better 12-month PFS than those with PR. Patients with ≥VGPR and CMR on PET-CT had significantly better 12-month OS. Our study showed VPd induction is safe and efficacious in NDMM. Further Phase 3 studies are necessary to establish the superiority and survival benefits.
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Affiliation(s)
- Fen Saj
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Yadav Nisha
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Smita Kayal
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Rakhee Kar
- Department of Pathology, Puducherry, India
| | | | - Biswajit Dubashi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India.
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Gnanaraj J, Basavarajegowda A, Kayal S, Sahoo D, Toora E, Dubashi B, Ganesan P. Optimising platelet usage during the induction therapy of acute myeloid leukaemia: Impact of physician education. Transfus Med 2023. [PMID: 36942594 DOI: 10.1111/tme.12967] [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: 08/22/2022] [Revised: 02/07/2023] [Accepted: 03/08/2023] [Indexed: 03/23/2023]
Abstract
INTRODUCTION Platelet products are scarce and expensive resources to be used judiciously. However, inappropriate usage is common. Lack of physician awareness is an important issue. We implemented a physician education program (PEP) along with repeated WhatsApp reminders at our centre. We audited the platelet usage practise before and after the intervention. METHODS Charts of patients with acute myeloid leukaemia (AML) treated between January 2020 and August 2020 was reviewed, and the mean platelet usage per patient per day was calculated. Physician education was implemented between September 2020 and December 2020 (2 PowerPoint lectures of 20 min each and weekly WhatsApp messages containing the guidelines). Data of patients treated between Jan 2021 and August 2021 was prospectively audited to understand platelet usage and the indications for transfusions. The British Committee for the Standards in Haematology (BCSH) platelet transfusion guidelines were used as the adjudication tool to evaluate compliance. The mean platelet usage per day per kg body weight of a patient before and after the PEP was compared using the t-test. RESULTS Group A (before physician education) consisted of 22 patients, and group B (after physician education) consisted of 23 patients. The mean number of platelet transfusions for each patient in a day per kg body weight was 125.7 × 108 in group A whereas, after the PEP, it had reduced to 73.9 × 108 amounting to an absolute reduction of 51 × 108 (58.8%) from the baseline with a statistical significance of P = 0.001. After implementing the PEP, the mean number of random donor platelets used reduced by 10.25 units (34% reduction), and the mean single donor platelets used reduced by 0.83 units (19% reduction). The 190 requests for platelet transfusion received during this period were classified as appropriate (157/190), which constituted 82.63% of the requests, or inappropriate (33/190), which accounted for 17.36%. CONCLUSIONS A short-duration education programme supplemented with weekly WhatsApp messages and an active feedback mechanism on the rationale of platelet transfusion by the treating physician and transfusion specialist could significantly reduce platelet consumption during the therapy of acute myeloid leukaemia patients. This is a measure that can be considered by all high-volume haematology centres, which can improve patient safety and reduce costs.
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Affiliation(s)
- John Gnanaraj
- Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Abhishekh Basavarajegowda
- Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Smita Kayal
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Dibyajyothi Sahoo
- Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Esha Toora
- Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Biswajit Dubashi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Nisha Y, Dubashi B, Bobby Z, Sahoo JP, Kayal S, Ananthakrishnan R, Ganesan P. Cytotoxic chemotherapy is associated with decreased bone mineral density in postmenopausal women with early and locally advanced breast cancer. Arch Osteoporos 2023; 18:41. [PMID: 36899284 PMCID: PMC10004442 DOI: 10.1007/s11657-023-01231-z] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 03/01/2023] [Indexed: 03/12/2023]
Abstract
PURPOSE The burden and mechanisms of endocrine therapy-related bone loss have been studied in detail. However, there is limited data regarding cytotoxic chemotherapy's impact on bone health. There are no definitive guidelines for bone mineral density (BMD) monitoring and treatment with bone-modifying agents during cytotoxic chemotherapy. The study's primary objective was to evaluate the changes in BMD and fracture risk assessment tool (FRAX) scores among breast cancer women on cytotoxic chemotherapy. METHODS One hundred and nine newly diagnosed early and locally advanced postmenopausal breast cancer patients planned for anthracycline and taxane-based chemotherapy were recruited prospectively during the study period from July 2018 to December 2021. BMD of the lumbar spine, the femoral neck, and the total hip were assessed by dual-energy X-ray absorptiometry scan. BMD and FRAX scores were evaluated at baseline, end of chemotherapy, and 6 months of follow-up. RESULTS The median age of the study population was 53 (45-65) years. Early and locally advanced breast cancers were seen in 34 (31.2%) and 75 (68.8%) patients, respectively. The duration of follow-up between two BMD measurements was 6 months. The percentage of decrease in BMD at the lumbar spine, femoral neck, and total hip were - 2.36 ± 2.90, - 2.63 ± 3.79, and - 2.08 ± 2.80, respectively (P-value = 0.0001). The median risk of major osteoporotic fracture (MOF) at 10 years (FRAX score) increased from 1.7 (1.4) to 2.7% (2.4) (P-value = 0.0001). CONCLUSION This prospective study in postmenopausal breast cancer women shows a significant association of cytotoxic chemotherapy with the worsening of bone health in terms of BMD and FRAX score.
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Affiliation(s)
- Yadav Nisha
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, 605006, India
| | - Biswajit Dubashi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, 605006, India.
| | - Zachariah Bobby
- Department of Biochemistry, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, 605006, India
| | - Jaya Prakash Sahoo
- Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, 605006, India
| | - Smita Kayal
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, 605006, India
| | - Ramesh Ananthakrishnan
- Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, 605006, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, 605006, India
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Azizi Z, Deb B, Feng R, Ganesan P, Rogers AJ, Chang HJ, Clopton P, Narayan SM. VENTRICULAR TACHYCARDIA PREDICTS ATRIAL FIBRILLATION RECURRENCE POST ABLATION: A PROPENSITY SCORE-MATCHED ANALYSIS OF A LARGE PROSPECTIVE STUDY. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)00630-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Goyal H, Kishore S, Ganesan P, Halanaik D. Complete Metabolic Response in Adenocarcinoma Lung With Lymphangitic Carcinomatosis. Clin Nucl Med 2023; 48:e133-e134. [PMID: 36252925 DOI: 10.1097/rlu.0000000000004463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
ABSTRACT Pulmonary lymphangitic carcinomatosis refers to the tumor spread into the lymphatic system of the lungs and is considered a poor prognostic marker. We present an interesting case of adenocarcinoma of right lung evaluated with 18 F-FDG PET/CT for baseline staging, with extensive bilateral lung involvement and lymphangitic carcinomatosis pattern. Subsequently, the patient received 3 cycles of carboplatin- and pemetrexed-based chemotherapy regimen along with oral ceritinib. Complete metabolic response and significant reduction in size of the primary lung lesion was noted on response evaluation with 18 F-FDG PET/CT, which is a rare phenomenon.
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Affiliation(s)
| | | | - Prasanth Ganesan
- Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education Research, Puducherry, India
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Deb B, Vasireddi S, Bhatia NK, Rogers AJ, Clopton P, Baykaner T, Ganesan P, Feng R, Azizi Z, Narayan SM. OBSTRUCTIVE SLEEP APNEA PORTENDS STROKE IN YOUNG INDIVIDUALS WITHOUT ATRIAL FIBRILLATION: A LARGE REGISTRY STUDY. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)00574-0] [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: 03/06/2023]
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Dubashi B, L C, Nisha Y, Ganesh RN, Kate V, Penumadu P, Selvarajan S, Raja K, Kayal S, Ganesan P. Immunohistochemistry-based molecular classification of gastric cancer in India: How are we different? J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.4_suppl.462] [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: 01/25/2023] Open
Abstract
462 Background: TCGA and ACRG have classified gastric cancer (GC) into molecular subgroups using genomics. We attempted to classify GC from our region using IHC (Immunohistochemistry) to understand its prognostic significance and compare with similar data from other parts of the world. Methods: This was a retrospective cohort of GC patients from years 2017-18. EBV (LMP), MSI (MLH1, MSH2, PMS2, MSH6),p53, E-cadherin and PIK3CA were assessed by IHC. Clinicopathological characteristics and survival were evaluated for association with molecular subtypes as defined by TCGA and ACRG classification system. Results: A total of 191patients were included with EBV positivity 35 (18.3 %), MSI 33(17.3 %), p-53 aberration 25(13.1%), E-cadherin negative (29.3%). On univariate analysis, p53 aberration was associated with higher age (>60 yrs), E- cadherin negative with diffuse histology & antro-pyloric region as predominant site. MSI with intestinal histology & antro-pyloric region as predominant site with MSI. The TCGA classification revealed EBV 35 (18%), MSI 28 (15 % ), GS 48 (25 %) and CIN 80 (42% ) subtypes respectively. CIN subtype was seen predominantly above 40 yrs of age (P=0.04), GS subtype was frequently associated with diffuse histology P<0.0001. The ACRG classification revealed MSI 33(17%), MSS/EMT 51 (26.7%), MSS/ p53 normal 91 (47.6%) and MSS/p53 aberrant 16 (8.4) subtypes. MSS/E-cad- subtype was associated with diffuse histology. PIK3CA positivity was higher in CIN (TCGA )& MSI (dmr) (ACRG) respectively. The median OS in MSI was 35 and 32 months higher compared to other subtypes (P<0.0001) in TCGA and ACRG classification respectively. Conclusions: The TCGA and ACRG classification identified molecular subtypes based on IHC from our region and significantly correlated with clinical factors and survival. PIK3CA as an additional marker may be further explored to be included in the classification system. Abbreviation: EBV - Epstein–Barr-virus, MSI – Microsatellite-Instability, GS- Genomic-instability, CIN- Chromosomal-instability, MSS- Microsatellite-stable, EMT-Epithelial-mesenchymal-transition.[Table: see text]
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Affiliation(s)
- Biswajit Dubashi
- Jawaharlal Institute of Post-Graduate Medical Education and Research, Puducherry, India
| | - Charles L
- Jawaharlal Institute of Post-Graduate Medical Education and Research, Puducherry, India
| | - Yadav Nisha
- Jawaharlal Institute of Post-Graduate Medical Education and Research, Puducherry, India
| | | | | | - Prasanth Penumadu
- Jawaharlal Institute of Post-Graduate Medical Education and Research Jipmer, Puducherry, India
| | - Sandhiya Selvarajan
- Jawaharlal Institute of Post-Graduate Medical Education and Research, Puducherry, India
| | - Kalayarasan Raja
- Jawaharlal Institute of Post-Graduate Medical Education and Research, Puducherry, India
| | | | - Prasanth Ganesan
- Department of Medical Oncology, Regional Cancer Centre, Dhanavantri Nagar, JIPMER, Puducherry, India
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Mathews V, Korula A, Chakrapani A, Bhurani D, Bhattacharyya J, Sengar M, Malhotra P, Boyella PK, Singh PK, Ganesan P, Dhawan R, Melinkeri S, Damodar S, Dolai TK, Radhakrishnan V. Management of B-cell lineage acute lymphoblastic leukemia: expert opinion from an Indian panel via Delphi consensus method. Front Oncol 2023; 13:1171568. [PMID: 37168381 PMCID: PMC10166232 DOI: 10.3389/fonc.2023.1171568] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/11/2023] [Indexed: 05/13/2023] Open
Abstract
Introduction Currently, there are no guidelines for the management of B-cell lineage acute lymphoblastic leukemia (B-ALL) from an Indian perspective. The diagnostic workup, monitoring, and treatment of B-ALL vary among different physicians and institutes. Objective To develop evidence-based practical consensus recommendations for the management of B-ALL in Indian settings. Methods Modified Delphi consensus methodology was considered to arrive at a consensus. An expert scientific committee of 15 experts from India constituted the panel. Clinically relevant questions belonging to three major domains were drafted for presentation and discussion: (i) diagnosis and risk assignment; (ii) frontline treatment; and (iii) choice of therapy (optimal vs. real-world practice) in relapsed/refractory (R/R) settings. The questionnaire was shared with the panel members through an online survey platform. The level of consensus was categorized into high (≥ 80%), moderate (60%-79%), and no consensus (< 60%). The process involved 2 rounds of discussion and 3 rounds of Delphi survey. The questions that received near or no consensus were discussed during virtual meetings (Delphi rounds 1 and 2). The final draft of the consensus was emailed to the panel for final review. Results Experts recommended morphologic assessment of peripheral blood or bone marrow, flow cytometric immunophenotyping, and conventional cytogenetic analysis in the initial diagnostic workup. Berlin-Frankfurt-Münster (BFM)-based protocol is the preferred frontline therapy in pediatric and adolescent and young adult patients with B-ALL. BFM/German Multicenter Study Group for Adult Acute Lymphoblastic Leukemia-based regimen is suggested in adult patients with B-ALL. Immunotherapy (blinatumomab or inotuzumab ozogamicin) followed by allogeneic hematopoietic cell transplantation (allo-HCT) is the optimal choice of therapy that would yield the best outcomes if offered in the first salvage in patients with R/R B-ALL. In patients with financial constraints or prior allo-HCT (real-world practice) at first relapse, standard-intensive chemotherapy followed by allo-HCT may be considered. For subsequent relapses, chimeric antigen receptor T-cell therapy or palliative care was suggested as the optimal choice of therapy. Conclusion This expert consensus will offer guidance to oncologists/clinicians on the management of B-ALL in Indian settings.
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Affiliation(s)
- Vikram Mathews
- Department of Haematology, Christian Medical College, Vellore, Tamil Nadu, India
- *Correspondence: Vikram Mathews,
| | - Anu Korula
- Department of Haematology, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Dinesh Bhurani
- Department of Hemato-Oncology & Bone Marrow Transplant (BMT) Unit, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi, India
| | - Jina Bhattacharyya
- Department of Clinical Hematology, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Manju Sengar
- Medical Oncology Department, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Pankaj Malhotra
- Department of Clinical Hematology and Medical Oncology, Nehru Hospital, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Pavan Kumar Boyella
- Department of Medical Oncology, Basavatarakam Indo American Cancer Hospital and Research Centre, Hyderabad, Telangana, India
| | - Pawan Kumar Singh
- Haemato-Oncology & Bone Marrow Transplant (BMT), B.L. Kapur (BLK)-Max Center for Bone Marrow Transplant, BLK-Max Superspeciality Hospital, New Delhi, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Rishi Dhawan
- Clinical Hematology, All India Institute of Medical Sciences, Delhi, India
| | - Sameer Melinkeri
- Department of Hematology, Deenanath Mangeshkar Hospital & Research Center, Pune, India
| | - Sharat Damodar
- Mazumdar Shaw Medical Center, Narayana Health City, Bengaluru, Karnataka, India
| | - Tuphan Kanti Dolai
- Department of Haematology, Nil Ratan Sarkar (NRS) Medical College and Hospital, Kolkata, India
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Singh J, Rajesh NG, Dubashi B, Maroju NK, Ganesan P, Matta KK, Charles I, Kayal S. Pattern of expression of CDX2 in colorectal cancer and its role in prognosis. J Cancer Res Ther 2022; 18:S420-S427. [PMID: 36510997 DOI: 10.4103/jcrt.jcrt_1723_20] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background CDX2, a nuclear protein, is essential for the proliferation and development of intestinal epithelial cells and is frequently down-regulated during tumorigenesis. We have evaluated the pattern of CDX2 expression in all stages of colorectal cancer (CRC) and its association with prognosis. Methods We performed CDX2 staining by immunohistochemistry (IHC) on the available biopsy blocks of patients of CRC registered in our institute from January 2014 to January 2018. CDX2 scoring was done using the semi-quantitative method. Results A total of 286 patients were registered during the study period, of which only 110 biopsy blocks were available for staining. Of 110 patients, 77 (70%) had colon cancer and 33 (30%) had rectal cancer. The median age was 54.2 years, with 62 (56.4%) being male and 48 (43.6%) female with a male to female ratio of 1.3:1. In the study cohort, 33 (30%) patients had stage II disease, 30 (27.3%) had stage III, and 47 (42.7%) had stage IV. Seventy-three (66.4%) were positive for CDX2 and 37 (33.4%) were negative. Loss of CDX2 expression was significantly associated with advanced stage, rectal site, poor grade of differentiation, and presence of lymphovascular invasion. With a median follow-up of 16 months, progression-free survival (PFS) at 2 years was 30% for CDX2-negative patients compared to 67% for CDX2-positive patients (P = 0.009), whereas the overall survival (OS) at 2 years was 46% for CDX2-negative versus 77% for CDX2-positive patients (P = 0.01). Conclusion Loss of CDX2 expression is associated with advanced stage, higher tumor grade, presence of LVSI, worse PFS, and OS and thereby functions as a poor prognostic factor in CRC.
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Affiliation(s)
- Jagdeep Singh
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - N G Rajesh
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Biswajit Dubashi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Nanda Kishore Maroju
- Department of General Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Kiran Kumar Matta
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - I Charles
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Smita Kayal
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
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Nakka T, Bhattacherjee A, Krishnamoorthi N, Tumathy DB, Dahagama S, Dubashi B, Ganesan P, Kayal S. Outcomes of Allogeneic Stem Cell Transplant in Chronic Myeloid Leukemia - Blast Phase: A Single-center Experience from South India. Indian J Med Paediatr Oncol 2022. [DOI: 10.1055/s-0042-1743508] [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: 11/30/2022] Open
Abstract
AbstractThe blast phase (BP) is challenging to treat and leads to inferior survival in chronic myeloid leukemia (CML). Allogeneic hematopoietic stem cell transplant (AlloSCT) is the only curative option for CML-BP. We are sharing our experience of AlloSCT in seven patients with CML-BP who underwent transplants during the period from January 2017 to December 2019. Three patients each had myeloid-BP, lymphoid-BP, and one patient had mixed phenotypic BP. Donors were matched siblings in four, mismatched siblings in one, and haploidentical in two. All patients received peripheral blood stem cell grafts. The median CD34+ dose was 7.6 (range: 6.6–8.9) × 106 cells/kg. Neutrophil engraftment was observed at a median of 15 (10–20) days and platelet engraftment at 19 days (10–22). At a median follow-up of 24 months, the 2-year leukemia-free survival (LFS) and overall survival (OS) were 43% and 57%, respectively. Transplant-related, non-relapse mortality was observed in three patients. AlloSCT results in promising survival for carefully selected patients of CML-BP, especially with a matched sibling donor.
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Affiliation(s)
- Thejeswar Nakka
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Arnab Bhattacherjee
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Narendran Krishnamoorthi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Divya Bala Tumathy
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Sindhu Dahagama
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Biswajit Dubashi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Smita Kayal
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Singh J, Rajesh NG, Dubashi B, Maroju NK, Ganesan P, Matta KK, Charles I, Kayal S. Pattern of Expression of CDX2 in Colorectal Cancer and its Role in Prognosis: An Ambispective Observational Study. Indian J Med Paediatr Oncol 2022. [DOI: 10.1055/s-0042-1750207] [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: 11/30/2022] Open
Abstract
Abstract
Introduction Caudal-type homeobox 2 (CDX2), a nuclear protein, is essential for the proliferation and development of intestinal epithelial cells and is frequently downregulated during tumorigenesis. CDX2 inhibits cell growth as well as stimulates differentiation by activating intestinal specific genes, thus lack of CDX2 favors tumor growth and aggressiveness.
Objectives We aimed to evaluate the pattern of CDX2 expression in all stages of colorectal cancer (CRC) and study its association with baseline characteristics and prognosis.
Materials and Methods Study was conducted as an ambispective observational study, enrolling cases of CRC retrospectively from January 2014 to July 2016 (30 months), and prospectively during next 18-month period till January 2018. We performed CDX2 staining by immunohistochemistry on the available biopsy blocks of CRC patients during the study period. Total 286 patients were registered during the study period, of which only 110 biopsy blocks were available for staining. CDX2 scoring was done by a semiquantitative method on whole tissue section for the intensity and percentage of the cells showing positivity. Correlation of CDX2 expression was done with baseline clinical and histopathologic characteristics, and survival.
Results Of 110 patients, 77 (70%) constituted colon cancer and 33 (30%) were rectal cancer. The median age was 54.2 years, 62 (56.4%) being male and 48 (43.6%) female with male-to-female ratio 1.3:1. In the study cohort, 33 (30%) patients had stage II disease, 30 (27.3%) stage III, and 47 (42.7%) were stage IV. Seventy-three (66.4%) were positive for CDX2 and 37 (33.4%) were negative. Loss of CDX2 expression was significantly associated with advanced stage, rectal site, poor grade of differentiation, and presence of lymphovascular invasion (LVSI). With median follow-up of 16 months, progression-free survival (PFS) at 2 years was 30% for CDX2 negative patients compared with 67% for CDX2 positive (p = 0.009), while overall survival (OS) at 2 years was 46% for CDX2 negative versus 77% for positive patients (p = 0.01).
Conclusion Loss of CDX2 expression is associated with advanced stage, higher tumor grade, presence of LVSI, and worse PFS and OS and thereby functions as a poor prognostic factor in CRC.
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Affiliation(s)
- Jagdeep Singh
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
- Department of Medical Oncology, Dayanand Medical College, Ludhiana, Punjab, India
| | - N G. Rajesh
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Biswajit Dubashi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Nanda K. Maroju
- Department of General Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Kiran K. Matta
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - I Charles
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Smita Kayal
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Saj F, Reddy VN, Kayal S, Dubashi B, Singh R, Joseph NM, Ganesan P. Double Infection in a Patient with Chronic GVHD Post Allogeneic Transplant: “Hickam's Dictum” Trumps “Occam's Razor”!—A Case Report with Review of Literature. Indian J Med Paediatr Oncol 2022. [DOI: 10.1055/s-0042-1748166] [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: 11/30/2022] Open
Abstract
AbstractDouble pneumonia with Pneumocystis jirovecii (PCP) and Mycobacterium tuberculosis (MTB) has been reported in patients with acquired immune deficiency syndrome. A similar immune-suppressed state exists in allogeneic transplant survivors treated for graft-versus-host disease (GVHD). The clinical features and imaging findings could be quite similar in both the etiologies. Reaching a timely diagnosis and initiation of appropriate therapy is essential to prevent complications. We report a patient who had concurrent PCP and MTB pneumonia while on treatment for chronic GVHD. We describe the diagnostic challenge, the treatment, and outcome of this patient. We intend to sensitize physicians to consider more than one etiology in this subset of patients.
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Affiliation(s)
- Fen Saj
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Vendoti Nitheesha Reddy
- Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Smita Kayal
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Biswajit Dubashi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Rakesh Singh
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Noyal Mariya Joseph
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Kappel C, Reiss M, Rodrigo M, Ganesan P, Narayan SM, Rappel WJ. Predicting acute termination and non-termination during ablation of human atrial fibrillation using quantitative indices. Front Physiol 2022; 13:939350. [PMID: 36483297 PMCID: PMC9725096 DOI: 10.3389/fphys.2022.939350] [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: 05/09/2022] [Accepted: 11/10/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Termination of atrial fibrillation (AF), the most common arrhythmia in the United States, during catheter ablation is an attractive procedural endpoint, which has been associated with improved long-term outcome in some studies. It is not clear, however, whether it is possible to predict termination using clinical data. We developed and applied three quantitative indices in global multielectrode recordings of AF prior to ablation: average dominant frequency (ADF), spectral power index (SPI), and electrogram quality index (EQI). Methods: In N = 42 persistent AF patients (65 ± 9 years, 14% female) we collected unipolar electrograms from 64-pole baskets (Abbott, CA). We studied N = 17 patients in whom AF terminated during ablation ("Term") and N = 25 in whom it did not ("Non-term"). For each index, we determined its ability to predict ablation by computing receiver operating characteristic (ROC) and calculated the area under the curve (AUC). Results: The ADF did not differ for Term and Non-term patients at 5.28 ± 0.82 Hz and 5.51 ± 0.81 Hz, respectively (p = 0.34). Conversely, the SPI for these two groups was. 0.85 (0.80-0.92) and 0.97 (0.93-0.98) and the EQI was 0.61 (0.58-0.64) and 0.56 (0.55-0.59) (p < 0.0001). The AUC for predicting AF termination for the SPI was 0.85 ([0.68, 0.95] 95% CI), and for the EQI, 0.86 ([0.72, 0.95] 95% CI). Conclusion: Both the EQI and the SPI may provide a useful clinical tool to predict procedural ablation outcome in persistent AF patients. Future studies are required to identify which physiological features of AF are revealed by these indices and hence linked to AF termination or non-termination.
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Affiliation(s)
- Cole Kappel
- Department of Physics, UC Irvine, Irvine, CA, United States
| | - Michael Reiss
- Department of Physics, UC San Diego, La Jolla, CA, United States
| | - Miguel Rodrigo
- CoMMLab, Electronic Engineering Department, Universitat de Valencia, Valencia, Spain
| | - Prasanth Ganesan
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, United States
| | - Sanjiv M. Narayan
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, United States
| | - Wouter-Jan Rappel
- Department of Physics, UC San Diego, La Jolla, CA, United States,*Correspondence: Wouter-Jan Rappel,
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Panda S, Sehrawat A, Kayal S, Sundriyal D, Khanna M, Philips A, Jain D, Moharana L, Tiwari K, Kaaviya D, Cyriac S, Jose A, Saju S, Rathnam K, Ganesan P. 56P Clinico-pathological profile of adolescent and young adult colorectal cancer patients: Multicentre collaborative registry data from India. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.10.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
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Saj F, Dubashi B, Kayal S, Ganesan P. 293P Generic dabigatran for cancer-associated venous thromboembolism: Real-world data. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.10.318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
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34
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Panda S, Moharana L, Biswas G, Parida P, Mishra S, Pattnaik J, Devaraj S, Mohanty S, Karunanidhi S, Singuluri S, Saju S, Sehrawat A, Mudgal S, Subudhi G, Rathnam K, Cyriac S, Philips A, Jose A, Ganesan P. 382P Real-world data on treatment outcome of ALK positive non-small cell lung cancer from an Indian multi-centric cancer registry. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.10.419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
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35
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Ramesh R, Kayal S, Manivannan P, Choudhary A, Ganesan P, Sahadevan S, Dubashi B. 218P Prognostic role of apoptotic index in acute lymphoblastic leukemia. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.10.253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
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36
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Goenka L, Ganesan P, Dubashi B, Chaturvedula L, Rajappa M, Manivannan P, Gochhait D, Vellathussery Chakkalakkoombil S. 203TiP Autophagy as a target for therapy in ovarian cancer: A phase II randomized trial with biomarker correlation (ATOC Trial). Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.10.501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
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Ruiperez-Campillo S, Deb B, Feng R, Ganesan P, Tjong FVY, Clopton P, Rogers AJ, Narayan SM. Reduction of artifacts and noise in small electrogram datasets without manual annotation using transfer machine learning. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background/Introduction
Mapping AF is challenging. Monophasic action potentials (MAPs) show that most of the recorded signals are not representing the atrial activity, and arise from far-field or other artifacts. Thus, reducing noise in electrophysiological signals is essential, yet it can be difficult for cross-talk from other chambers and pacing. Strategies to reduce noise include template matching, averaging, and smoothing, but all of them have major limitations. Furthermore, expert interpretation requires knowledge to discriminate signals from noise, but is subjective.
Purpose
We hypothesised a) that atrial and ventricular electrograms with varying artifact and noise can be denoised using autoencoder neural networks (NNs) without requiring manual annotation and in a reproducible manner, and b) we could train these NNs on a large available dataset ventricular signals, then apply transfer learning to the original smaller atrial dataset. We applied this approach to MAPs, which have interpretable shapes and would help identifying local from far-field signals helping in diagnosis, mapping and ablation.
Methods
We first trained with 5706 left and right ventricular MAPs from 42 patients with ischemic cardiomyopathy (age 65±13y; Fig. 1A), with 60% for training, 20% (validation) and 20% (testing). Transfer learning and parameter-tuning were then used to apply this NN to a smaller sample of atrial MAPs (N=641 from 21 patients, 67±5y, 13 women; Fig. 2B, D, F). The autoencoder was used to eliminate pacing artifacts in ventricular MAPs (Fig. 1B, C) and denoise atrial MAPs (Fig. 2C, E, G) by reconstructing key learned features. The accuracy of the reconstruction was evaluated using Pearson Correlation Coefficient (PCC) and a novel similarity coefficient (SC). No manual annotation was required to identify noisy signals.
Results
The trained NN encoder learned key features of ventricular MAPs and reconstructed these clean signals with a SC=0.91±0.16 and PCC=0.99±0.01 (Fig. 1A). With this training, the NN was able to denoise ventricular MAPs with pacing artifact (Fig. 1B, C). After fine-tuning, the NN learned key signal features (upstroke, triangular descent, terminus) and thus reduced diverse noise without specific training or manual annotation. Namely, it was able to reconstruct atrial MAPs eliminating ventricular noise, high frequency noise and truncated signals (Fig. 2).
Conclusions
Machine learned encoder-decoders are powerful tools that can learn essential features of atrial and ventricular signals and hence isolate noise. Transfer learning is effective when large datasets are unavailable for training. This approach can separate atrial beats from far-field ventricular beats and other sources of noise. The ability to eliminate a diverse range of noise improves this approach over existing techniques and may have far-reaching applications in electrophysiology, such as mapping and ablation.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NIH
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Affiliation(s)
- S Ruiperez-Campillo
- Stanford University School of Medicine , Palo Alto , United States of America
| | - B Deb
- Stanford University School of Medicine , Palo Alto , United States of America
| | - R Feng
- Stanford University School of Medicine , Palo Alto , United States of America
| | - P Ganesan
- Stanford University School of Medicine , Palo Alto , United States of America
| | - F V Y Tjong
- Stanford University School of Medicine , Palo Alto , United States of America
| | - P Clopton
- Stanford University School of Medicine , Palo Alto , United States of America
| | - A J Rogers
- Stanford University School of Medicine , Palo Alto , United States of America
| | - S M Narayan
- Stanford University School of Medicine , Palo Alto , United States of America
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Ganesan P, Rogers AJ, Deb B, Feng R, Ruiperez-Campillo S, Tjong FV, Bhatia N, Clopton P, Rappel WJ, Narayan SM. Novel electrogram featurization reveals a spectrum of response to ablation from atrial tachycardia to types of atrial fibrillation. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Although atrial tachycardia (AT) may interconvert with fibrillation (AF) in many patients, it is undefined if this represents a pathophysiological spectrum of organization, or whether it indicates that AF will respond better to ablation.
Objective
To test the hypothesis that the spatial area within which electrograms (EGMs) repeat in synchronized fashion over time indicates a spectrum from AT, in which areas span the entire atria, to AF, in which areas are limited. We further hypothesized that repetitive areas would be larger in AF patients with acute termination than in those with poor response to ablation.
Methods
We studied N=234 patients (47% women, 64±10Y), of whom (i) N=10 had AT, (ii) N=120 had AF that terminated with ablation (“Term”), (ii) N=104 had AF that did not terminate (“Non-term”). All patients had global left atrial mapping by 64 pole baskets (Abbott, IL). Spatial areas of repetitive activity (REACT) were calculated by correlating unipolar EGMs in 2x2 grids for 4 sec, repeated for the entire atria (Figure 1A, B). We quantified global organization by averaging the REACT map for each patient.
Results
Figure 1C shows progressively decreasing areas of repetitive EGM from AT to AF Term to AF Non-term (p<0.001, ANOVA). Figure 1D shows a case of AT in a 71 YO male and global REACT >0.90, a case of AF REACT 0.45 in a 65 YO male with termination by ablation, and a case of AF with REACT 0.19 in an 85 YO male that did not terminate. Further, ROC analysis of REACT analysis in AF cases predicted termination with an AUC of 0.71.
Conclusion
Spatial areas of repeating electrogram shapes indicates a spectrum from AT to AF with good and AF with poor acute response to ablation. Future studies should investigate whether REACT areas can be identified non-invasively, such as by body surface ECG, to guide ablation or prognosis.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): US National Institutes of Health
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Affiliation(s)
- P Ganesan
- Stanford University School of Medicine , Palo Alto , United States of America
| | - A J Rogers
- Stanford University School of Medicine , Palo Alto , United States of America
| | - B Deb
- Stanford University School of Medicine , Palo Alto , United States of America
| | - R Feng
- Stanford University School of Medicine , Palo Alto , United States of America
| | | | - F V Tjong
- Stanford University School of Medicine , Palo Alto , United States of America
| | - N Bhatia
- Emory University , Atlanta , United States of America
| | - P Clopton
- Stanford University School of Medicine , Palo Alto , United States of America
| | - W J Rappel
- University of California San Diego , San Diego , United States of America
| | - S M Narayan
- Stanford University School of Medicine , Palo Alto , United States of America
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Ganesan P, Rogers AJ, Deb B, Feng R, Rodrigo M, Ruiperez-Campillo S, Tjong FV, Bhatia N, Clopton P, Rappel WJ, Narayan SM. Spatiotemporal signatures of response to atrial fibrillation ablation. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Atrial fibrillation (AF) can have organized regions, in the form of consistent dominant frequency sites, focal or reentrant sites, but it is unclear how these overlap with or differ from focal atrial tachycardias (AT) or potential drivers. We set out to develop an intuitive method based on fundamental electrogram shape and timing to separate types of AF.
Objective
To test the hypothesis that spatial regions of electrogram (EGM) in AF that show similar shapes over time based on cross-correlation analysis may separate patients with differing response to ablation.
Methods
We recruited N=133 patients (63.8±12.1 Y, 32% women), (i) N=10 had AT, (ii) N=122 AF that was or was not terminated by ablation, and (iii) N=1 pacing. All patients had left atrial mapping by 64 pole baskets. We applied repetitive activity (REACT) mapping that correlates EGMs in contiguous 2x2 regions (Fig. 1A) over 4sec. To calibrate REACT, we introduced simulated variations in shape (gaussian noise) and timing (gaussian delay) to pacing EGMs and computed nomograph over 100 random trials (Fig. 1C).
Results
Fig. 1B shows that REACT in a 71-year-old man with AT is more organized than in a 65 YO man with AF (100% vs 40% mapped field). Overall, REACT was higher in AT than AF (0.63±0.15 vs 0.36±0.22, p<0.001). There were 24 cases in which global REACT between AF and AT groups had the overlapping range of values, indicating organized “islands” in AF analogous to AT. From nomograph in Fig. 1C we identified that this overlap reflects 15 ms variation in cycle length and 20% variation in EGM shape (labelled “x” in Fig. 1C).
Conclusion
Basic electrogram properties in AF of similar shapes in spatial areas over time can separate response to ablation and may represent “islands” of AT. Future studies should investigate the mechanisms for such islands and whether they may be targeted for therapy.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): US National Institutes of Health
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Affiliation(s)
- P Ganesan
- Stanford University School of Medicine , Palo Alto , United States of America
| | - A J Rogers
- Stanford University School of Medicine , Palo Alto , United States of America
| | - B Deb
- Stanford University School of Medicine , Palo Alto , United States of America
| | - R Feng
- Stanford University School of Medicine , Palo Alto , United States of America
| | - M Rodrigo
- University of Valencia , Valencia , Spain
| | | | - F V Tjong
- Stanford University School of Medicine , Palo Alto , United States of America
| | - N Bhatia
- Emory University , Atlanta , United States of America
| | - P Clopton
- Stanford University School of Medicine , Palo Alto , United States of America
| | - W J Rappel
- University of California San Diego , San Diego , United States of America
| | - S M Narayan
- Stanford University School of Medicine , Palo Alto , United States of America
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Feng R, Deb B, Ganesan P, Rogers AJ, Ruiperez-Campillo S, Clopton P, Tjong FV, Chang HJ, Rodrigo M, Zaharia M, Narayan SM. Automatic left atrial segmentation from cardiac CT using computer graphics imaging and deep learning. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Segmenting left atrial (LA) substructures, including the LA body, appendage (LAA), and pulmonary veins (PVs), from computed tomography (CT) is central to electroanatomic mapping for ablation and functional studies in patients with atrial fibrillation (AF). However, this process requires manual outlining which needs special training, is subjective, and is difficult to scale. Computer graphics imaging (CGI) has been applied in media, film, and computer-aided design to reliably segment complex structures using their basic geometric representations.
Purpose
We hypothesized that LA substructures can be “virtually” dissected using CGI to separate geometric contours of the “convex ellipsoid” LA, “tubular” PVs, and “conical” LAA. We further hypothesized that the results of virtual dissection can be used to train a deep learning (DL) model to segment raw CT scans.
Methods
First, a mathematical method based on CGI techniques – erosion and dilation – was developed to “virtually dissect” the convex LA body from the original concave shell in publicly available digital atria with diverse simulated morphologies (Fig. 1A). The PVs and LAA were then automatically revealed and labeled by a 3D subtraction approach. Second, we refined precise LA/PV/LAA boundaries by tuning hyper-parameters from N=5 patient shells (Fig. 1B). Third, we used virtual dissection to train a DL model to segment CTs in N=20 patient atria (Fig. 1C). Finally, we applied this pipeline to segment raw CTs in a validation cohort of N=105 patients (23.8% women, 63.8±10.3Y; Fig. 1D).
Results
Virtual dissection accurately identified LA/PV/LAA boundaries in the training set (Dice coefficients 89–98%). In the independent test cohort (N=105), this automated pipeline accurately segmented raw CTs with Dice 81–95% (Fig. 1D) compared to a panel of experts (p<0.001).
Conclusion
CGI of basic cardiac geometry combined with deep learning in small datasets can accurately segment raw CT scans in large populations. This computational pipeline may automate and simplify cardiac image processing and ablation procedures, and could be applied to the ventricle or other organ systems for diverse therapeutic strategies or to train machine learning.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institutes of Health
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Affiliation(s)
- R Feng
- Stanford University, School of Medicine , Palo Alto , United States of America
| | - B Deb
- Stanford University, School of Medicine , Palo Alto , United States of America
| | - P Ganesan
- Stanford University, School of Medicine , Palo Alto , United States of America
| | - A J Rogers
- Stanford University, School of Medicine , Palo Alto , United States of America
| | | | - P Clopton
- Stanford University, School of Medicine , Palo Alto , United States of America
| | - F V Tjong
- Amsterdam UMC , Amsterdam , The Netherlands
| | - H J Chang
- Stanford University, School of Medicine , Palo Alto , United States of America
| | - M Rodrigo
- University of Valencia , Valencia , Spain
| | - M Zaharia
- Stanford University, Computer Science , Palo Alto , United States of America
| | - S M Narayan
- Stanford University, School of Medicine , Palo Alto , United States of America
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Ruiperez-Campillo S, Deb B, Feng R, Ganesan P, Tjong FVY, Clopton P, Rogers AJ, Narayan SM. Artificial intelligence to reduce artifact in cardiac electrophysiological signals. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background/Introduction
Signals in Electrophysiology cases are often noisy despite laboratory shielding and filtering, and current noise-reduction methods are suboptimal. Template matching can identify a “nearest type” of electrogram, but libraries of signal shapes may be unavailable. Beat averaging can reduce noise but obscures beat-to-beat variations and is not optimal to analyze dynamically changing signals, such as when moving a catheter in the heart. Smoothing reduces noise yet blurs high frequency components.
Purpose
We set out to test if machine learned autoencoders could reduce noise in single beats without requiring massive training data or beat libraries. Specifically, we hypothesised that noisy electrograms in small datasets of atrial signals could be de-noised using an encoder-decoder neural network (NN) using transfer learning of machines trained to recognize key features in larger datasets of related signals.
Methods
We applied NN to monophasic action potentials (MAPs), because they have visually verifiable shapes. The NN was first trained to reconstruct 5706 left and right ventricular MAPs in 42 patients (67±13y; Fig. 1A). Transfer learning was then used to apply the NN to a much smaller dataset of 641 atrial MAPs in 21 patients (67±5y, 13 women; Fig. 1B, D, F).
Results
NN reconstructed atrial MAPs with a Pearson correlation of 0.87±0.11. After fine-tuning, NN reconstruction accuracy improved dramatically (Pearson 0.99±0.01; p<0.001). In Fig. 1B–G the NN learned key MAP features (upstroke, triangular descent, terminus) and thus could eliminate ventricular artifact and electrical circuit noise without specific training or manual annotation.
Conclusion
Machine learned autoencoders are a novel and powerful approach to de-noise electrophysiological signals in a dynamic, beat-to-beat fashion. The ability to learn fundamental signal features from models trained in large datasets, and apply them via transfer learning to small datasets in different heart chambers may have wide ranging applications for automated signal annotation, mapping and ablation.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NIH
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Affiliation(s)
- S Ruiperez-Campillo
- Stanford University School of Medicine , Palo Alto , United States of America
| | - B Deb
- Stanford University School of Medicine , Palo Alto , United States of America
| | - R Feng
- Stanford University School of Medicine , Palo Alto , United States of America
| | - P Ganesan
- Stanford University School of Medicine , Palo Alto , United States of America
| | - F V Y Tjong
- Stanford University School of Medicine , Palo Alto , United States of America
| | - P Clopton
- Stanford University School of Medicine , Palo Alto , United States of America
| | - A J Rogers
- Stanford University School of Medicine , Palo Alto , United States of America
| | - S M Narayan
- Stanford University School of Medicine , Palo Alto , United States of America
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Nakka T, Goenka L, Dubashi B, Kayal S, Mathaiyan J, Barathi D, Krishnamoorthy N, Thumaty DB, Dahagama S, Ganesan P. Phase II study of sodium valproate in combination with oral etoposide in platinum-resistant ovarian cancer. Med Oncol 2022; 39:233. [PMID: 36175588 PMCID: PMC9522437 DOI: 10.1007/s12032-022-01833-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/26/2022] [Indexed: 11/21/2022]
Abstract
Patients with platinum-resistant ovarian cancer (PROC) have limited therapeutic options and poor survival. There is a need for the development of newer therapies. Sodium valproic acid (VPA) is a short-chain fatty acid histone deacetylase (HDAC) inhibitor with antitumor activity in preclinical models of PROC. Synergism with conventional cytotoxic agents like etoposide has been demonstrated. In this prospective, single-arm, open-label, phase 2 study, we included patients ≥ 18 years with histologically or cytologically confirmed PROC and Eastern Cooperative Oncology Group performance status (ECOG-PS) 0–3. Patients received oral VPA 60 mg/kg/day in three divided doses for 3 days (D1–D3), followed by oral etoposide 50 mg once daily for two consecutive weeks (D4–D17). Serum samples were collected to assess peak VPA drug levels. The primary endpoint was the overall response rate (ORR). The secondary endpoints were progression-free survival (PFS), overall survival (OS), and toxicity. We sought to show an improvement in response rate from 25% (historically with oral etoposide) to 40% with the addition of VPA. 27 patients were enrolled in the study, and 18 [median age: 52 (45–59) years; serous histology:17 (94%); ECOG-PS 2 or 3: 14 (78%)] were evaluable for the response after 4 months. Nine patients were lost from follow-up before achieving the primary endpoint (mainly due to Covid-related lockdown issues). The median number of prior lines of treatment was 2 (1–3). ORR was 0% according to GCIG criteria. The disease was stable in two patients [clinical benefit rate (CBR) of 11%]. The median OS and PFS were 7 months and 2 months, respectively. Grade ≥ 3 adverse events were reported in 6 (33%) patients. The addition of valproic acid to oral etoposide in patients with PROC and poor general condition was not helpful and failed to improve responses compared to those historically achieved with single-agent etoposide. However, further phase 2 randomized controlled trials with larger sample size can be done to confirm the findings.
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Affiliation(s)
- Thejeswar Nakka
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), 3rd Floor, Super Speciality Block, Dhanvantari Nagar, Puducherry, 605006, India
| | - Luxitaa Goenka
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), 3rd Floor, Super Speciality Block, Dhanvantari Nagar, Puducherry, 605006, India
| | - Biswajit Dubashi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), 3rd Floor, Super Speciality Block, Dhanvantari Nagar, Puducherry, 605006, India
| | - Smita Kayal
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), 3rd Floor, Super Speciality Block, Dhanvantari Nagar, Puducherry, 605006, India
| | - Jayanthi Mathaiyan
- Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Deepak Barathi
- Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Narendran Krishnamoorthy
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), 3rd Floor, Super Speciality Block, Dhanvantari Nagar, Puducherry, 605006, India
| | - Divya Bala Thumaty
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), 3rd Floor, Super Speciality Block, Dhanvantari Nagar, Puducherry, 605006, India
| | - Sindhu Dahagama
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), 3rd Floor, Super Speciality Block, Dhanvantari Nagar, Puducherry, 605006, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), 3rd Floor, Super Speciality Block, Dhanvantari Nagar, Puducherry, 605006, India.
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Goenka L, Thejeswar N, Dubashi B, Kayal S, Ganesan P. Systemic Immune-Inflammation Index Predicts Outcomes in Platinum-Resistant Relapsed Ovarian Cancer. Indian J Med Paediatr Oncol 2022. [DOI: 10.1055/s-0042-1749399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
AbstractWe explored the prognostic impact of simple indices that reflect the immunological milieu (neutrophils to lymphocyte ratio [NLR] and systemic immune-inflammation [SII]) in 49 platinum-resistant relapsed ovarian cancer patients. The median progression-free survival (PFS) and overall survival (OS) were 4 and 8 months, respectively. Patients with a lower NLR (≤2.89) had a better PFS (5 vs. 2 months [p = 0.02]) and OS (9 vs. 5 months [p = 0.20]). Factors associated with a worse PFS were NLR > 2.8 (hazard ratio [HR] =2.32, p = 0.02) and SII > 639 (HR =3.70, p = 0.002). SII > 639 independently predicted PFS (HR =4.13, p = 0.03). Future studies should study the validity of inflammatory markers and could consider incorporating it as a biomarker in clinical trials.
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Affiliation(s)
- Luxitaa Goenka
- Department of Medical Oncology, JIPMER, Puducherry, India
| | | | | | - Smita Kayal
- Department of Medical Oncology, JIPMER, Puducherry, India
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Radhakrishnan V, Lagudu PBB, Gangopadhyay D, Vijaykumar V, Rajaraman S, Perumal Kalaiyarasi J, Ganesan P, Ganesan TS. Neutropenic versus regular diet for acute leukaemia induction chemotherapy: randomised controlled trial. BMJ Support Palliat Care 2022; 12:421-430. [PMID: 35803707 DOI: 10.1136/spcare-2022-003833] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Restriction of raw fruits and vegetables (neutropenic diet) is advised for patients receiving treatment for acute leukaemia in low-income and middle-income countries (LMICs) to reduce infections despite evidence to the contrary from high-income countries. We, therefore, conducted a randomised controlled trial to ascertain the efficacy of the neutropenic diet in an LMIC setting. METHODS Patients aged 1-60 years receiving induction chemotherapy for acute leukaemia were randomised to a regular or neutropenic diet. The study's primary objective was to compare the incidence of major infections among patients receiving the two diets during induction chemotherapy. The secondary objectives were to compare stool microbial flora and induction mortality rates. RESULTS We randomised 200 patients, 98 patients to the regular diet arm and 102 to the neutropenic diet arm. Major infections occurred in 32 (32%) patients in the regular diet arm and 26 (25%) patients in the neutropenic diet arm (p=0.26). There were no statistically significant differences between patients receiving a regular diet versus neutropenic diet for blood culture positivity (n=6 vs 9), inotropic support (17 vs 12), mechanical ventilation (8 vs 5), third-line antibiotic use (28 vs 20), minor infections (12 vs 9), induction mortality (9 vs 4) and remission status (94% vs 94%). The stool culture on day 15 of induction grew multidrug-resistant bacteria in 38% of patients in the regular diet arm and 35% in the neutropenic diet arm (p=0.67). CONCLUSIONS A neutropenic diet did not prevent infections, reduce mortality or change stool microbial flora in patients with acute leukaemia.
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Affiliation(s)
| | | | | | | | - Swaminathan Rajaraman
- Epidemiology, Biostatistics and Cancer Registry, Cancer Institute-WIA, Chennai, Tamil Nadu, India
| | | | - Prasanth Ganesan
- Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education, Puducherry, India
| | - Trivadi S Ganesan
- Sri Ramachandra Institute of Higher Education and Research (Deemed to be University), Chennai, Tamil Nadu, India
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Sengar M, Fundytus A, Hopman W, Pramesh CS, Radhakrishnan V, Ganesan P, Mathew A, Lombe D, Jalink M, Gyawali B, Trapani D, Roitberg F, De Vries EGE, Moja L, Ilbawi A, Sullivan R, Booth CM. Cancer Medicines: What Is Essential and Affordable in India? JCO Glob Oncol 2022; 8:e2200060. [PMID: 35853192 PMCID: PMC9812506 DOI: 10.1200/go.22.00060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE The WHO essential medicines list (EML) guides selection of drugs for national formularies. Here, we evaluate which medicines are considered highest priority by Indian oncologists and the extent to which they are available in routine practice. METHODS This is a secondary analysis of an electronic survey developed by the WHO EML Cancer Medicine Working Group. The survey was distributed globally using a hierarchical snowball method to physicians who prescribe systemic anticancer therapy. The survey captured the 10 medicines oncologists considered highest priority for population health and their availability in routine practice. RESULTS The global study cohort included 948 respondents from 82 countries; 98 were from India and 67 were from other low- and middle-income countries. Compared with other low- and middle-income countries, the Indian cohort was more likely to be medical oncologist (70% v 31%, P < .001) and work exclusively in the private health system (52% v 17%, P < .001). 14/20 most commonly selected medicines were conventional cytotoxic drugs. Universal access to these medicines was reported by a minority of oncologists; risks of significant out-of-pocket expenditures for each medicine were reported by 19%-58% of oncologists. Risk of catastrophic expenditure was reported by 58%-67% of oncologists for rituximab and trastuzumab. Risks of financial toxicity were substantially higher within the private health system compared with the public system. CONCLUSION Most high-priority cancer medicines identified by Indian oncologists are generic chemotherapy agents that provide substantial improvements in survival and are already included in WHO EML. Access to these treatments remains limited by major financial burdens experienced by patients. This is particularly acute within the private health system. Strategies are urgently needed to ensure that high-quality cancer care is affordable and accessible to all patients in India.
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Affiliation(s)
- Manju Sengar
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Adam Fundytus
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Canada.,Department of Oncology, Queen's University, Kingston, Canada
| | - Wilma Hopman
- Department of Public Health Sciences, Queen's University, Kingston, Canada
| | - C S Pramesh
- Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | | | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Aju Mathew
- Malankara Orthodox Syrian Church Medical College, Kolenchery, India
| | | | - Matthew Jalink
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Canada
| | - Bishal Gyawali
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Canada.,Department of Oncology, Queen's University, Kingston, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Canada
| | - Dario Trapani
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy
| | - Felipe Roitberg
- Department of Noncommunicable Diseases, World Health Organization, Geneva, Switzerland
| | - Elisabeth G E De Vries
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Lorenzo Moja
- Department of Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - André Ilbawi
- Department of Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Richard Sullivan
- Institute of Cancer Policy, King's College London, London, United Kingdom
| | - Christopher M Booth
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Canada.,Department of Oncology, Queen's University, Kingston, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Canada
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Deb B, Vasireddi SK, Clopton P, Ganesan P, Feng R, Rogers AJ, Baykaner T, Bhatia NK, Narayan SM. Sleep apnea is associated with stroke in young patients with or without atrial fibrillation:A population study of >2 million individuals. Europace 2022. [DOI: 10.1093/europace/euac053.162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NIH, R01 HL149134, R01HL83359
Background
Both Sleep Apnea (SA) and Atrial Fibrillation/flutter (AF) are known risk factors for stroke, and both are increasing in prevalence. They are both under-diagnosed in young adults <60 Y. There is an urgent need to define stroke risk portended by SA and AF yet there a paucity of data in adults aged 20-60 years.
Purpose
To define the relationship between stroke, SA, and AF in a very large cohort of 2 million young-middle aged adults aged 20-60 Y in Northern California.
Methods
We probed the Stanford Research Repository of electronic health data from 01/01/2008 to 11/30/2021 for the diagnoses of stroke, transient ischemic attacks, AF and SA using relevant codes (stroke: 433.X, 434.X, 436.X, I63.X, I65.X, I66.X, G45.X, G46.X; AF: I48.X; SA: G47.X, 327.27).
Results
We identified 2267485 patients aged 20-60Y (55% F; 32% White, 12% Asian, 3% Black), of whom SA was diagnosed in 52730 (2.3%), AF in 10230 (0.4%) and incident stroke in 10385 (0.4%) (Figure 1A)
In patients with SA, 1.5% developed incident stroke. Stroke was more common in patients with SA than those without, regardless of co-existing diagnosis of AF; OR with AF: 1.5 [1.3-1.7, p<0.001] and OR without AF: 3.0 [2.8-3.3 p<0.0001]. Risk of stroke with SA than without was noted to be higher in the younger age subgroups (Figure 1B) regardless of AF.
Although AF was more common in patients with SA than without (odds ratio, OR: 10.1 [9.6-10.6, p<0.0001]), the majority of SA patients (63% with CHADS2VASC ≥2) with stroke did not have a diagnosis of AF (75%), of whom 96% were not anticoagulated (Fig 1, left panel). Of the remaining patients with SA and incident stroke, who did have AF (25%), only 26% were taking OACs at the time of stroke despite median CHADS2 VASC score=3 (Fig 1A, left panel).
Finally, 7% of AF patients developed incident stroke. Of these, 73% had CHADS2VASC ≥2, yet 44% were not anticoagulated. Patients with SA comprised a third of all AF patients with stroke and, compared to AF patients with stroke and without SA, had higher CHADS2VASC (median 3 vs 2, p<0.001) and a similarly low use of anticoagulation (56% vs 54% on OAC) (Fig 1A, right panel).
Conclusions
In >2 million young individuals, we uncover a novel association between SA and incident stroke, regardless of the diagnosis of AF. Surprisingly, three quarters of patients with SA developed incident stroke in the absence of AF, and were not anticoagulated. These results underscore the need to screen for AF and sleep apnea in young adults.
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Affiliation(s)
- B Deb
- Stanford University School of Medicine, Cardiology, Palo Alto, United States of America
| | - SK Vasireddi
- Stanford University School of Medicine, Cardiology, Palo Alto, United States of America
| | - P Clopton
- Stanford University School of Medicine, Cardiology, Palo Alto, United States of America
| | - P Ganesan
- Stanford University School of Medicine, Cardiology, Palo Alto, United States of America
| | - R Feng
- Stanford University School of Medicine, Cardiology, Palo Alto, United States of America
| | - AJ Rogers
- Stanford University School of Medicine, Cardiology, Palo Alto, United States of America
| | - T Baykaner
- Stanford University School of Medicine, Cardiology, Palo Alto, United States of America
| | - NK Bhatia
- Stanford University School of Medicine, Cardiology, Palo Alto, United States of America
| | - SM Narayan
- Stanford University School of Medicine, Cardiology, Palo Alto, United States of America
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Ruiperez-Campillo S, Deb B, Feng R, Ganesan P, Clopton P, Rogers AJ, Narayan SM. Noise reduction in electrophysiological signals using transfer machine learning. Europace 2022. [DOI: 10.1093/europace/euac053.125] [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: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NIH
Background/Introduction
Reducing electrophysiological signal noise is essential for diagnosis, mapping and ablation, yet most approaches are suboptimal. Template matching requires libraries of known signal types, that are difficult to obtain. Beat averaging can reduce noise, yet cannot be applied to single beats and obscures beat-to-beat variations. Beat smoothing can lose critical and subtle signal features. We set out to use neural networks (NN) based on encoder-decoders, which are able to extract key signal features and hence reconstruct them without noise and artifact.
Purpose
We hypothesised that electrograms with varying sources of artifact can be denoised using autoencoder neural networks. We further hypothesised that this could be achieved in a small data set by developing the method in a larger dataset of related signals, then using transfer learning. We tested this approach for atrial monophasic action potentials (MAPs) that have verifiable shapes.
Methods
The NN was first trained with 5706 left and right ventricular MAPs from 42 patients with ischemic cardiomyopathy (age 65±13y; fig 1.A): 60% for training, 20% (validation) and 20% (testing). Transfer learning and parameter-tuning were then used to apply this NN to a smaller sample of atrial MAPs (N=641, 21 patients, 67±5y, 13 women; fig D,F,H).
Results
The autoencoder was able to learn key features of MAPs, and hence reconstruct them without artifacts. NN learned ventricular MAPs with similarity coefficient 0.91±0.16, Pearson correlation 0.99± 0.01 (fig A) and learned key features (upstroke, triangular descent, terminus) to reduce noise (fig B-C). Applying this trained NN to atrial MAPs, the approach automatically eliminated ventricular artifact (fig E), high frequency noise (fig G), truncation (fig I), saturation and other artifacts. After fine-tuning, the NN reconstructed atrial MAPs with Pearson correlation = 0.99±0.01 (p<0.001).
Conclusions
Machine learned encoder-decoders are powerful tools that can automatically eliminate diverse types of noise in single beats by learning essential signal features. Transfer learning makes this possible without large datasets for training, even from signals in a different cardiac chamber. This approach may have far-reaching applications for mapping and ablation.
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Affiliation(s)
| | - B Deb
- Stanford University School of Medicine, Palo Alto, United States of America
| | - R Feng
- Stanford University School of Medicine, Palo Alto, United States of America
| | - P Ganesan
- Stanford University School of Medicine, Palo Alto, United States of America
| | - P Clopton
- Stanford University School of Medicine, Palo Alto, United States of America
| | - AJ Rogers
- Stanford University School of Medicine, Palo Alto, United States of America
| | - SM Narayan
- Stanford University School of Medicine, Palo Alto, United States of America
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Ruiperez-Campillo S, Deb B, Feng R, Ganesan P, Clopton P, Rogers AJ, Narayan SM. Defining refractoriness in single atrial beats using autoencoder neural networks. Europace 2022. [DOI: 10.1093/europace/euac053.614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NIH
Background
Mapping atrial fibrillation (AF) is complicated by signals which may be local or far-field, but which cannot currently be separated. This could be clarified by a knowledge of atrial refractory periods, yet these are difficult to define from monophasic action potentials (MAP) in patients. We hypothesized that transfer learning using an autoencoder neural network (ANN), first trained with less-noisy ventricular signals, can be applied to de-noise and classify atrial MAPs.
Methods
We first developed an ANN to encode MAPs in 5706 ventricular MAPs from N=42 patients (age 65±13y) during pacing (fig1. A-B). This created a latent feature space. We now tuned the ANN to classify atrial MAPs in a different cohort of patients with AF. We used a statistical loss function based on mathematical optimization to evaluate the accuracy of final representations of the MAP and classify the different signals.
Results
The autoencoder ANN reconstructed ventricular MAPs with an average similarity of 0.85 (range 0-1) (an example is shown in fig 1.B). We tested on 3000 atrial MAPs in AF patients (N=21; 67±5y, 13 women). Atrial MAPs were accurately represented (fig 1.E-F) with similarity indices that were higher than those obtained by a panel of 3 experts. Fig. 1 shows the reconstruction of different signals: ventricular MAP (fig 1.A-B), ventricular MAP with pacing artifact (fig. 1.C-D), atrial MAP (transfer learning is assumed in here; fig 1.E-F) and noise or signals with morphologies of no interest (fig 1.G-H). Fig. 2 shows the classification of signals according to the similarity metric that allows distinguishing among the different types of signals without manual annotation (p<0.05 between groups).
Conclusion
Atrial refractory periods can be defined in single beats in AF patients using autoencoder neural networks and transfer learning. This approach can separate atrial beats from far-field ventricular beats and other sources of noise. Future work can study if this approach can be used to improve AF mapping or define novel physiological phenotypes.
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Affiliation(s)
| | - B Deb
- Stanford University School of Medicine, Palo Alto, United States of America
| | - R Feng
- Stanford University School of Medicine, Palo Alto, United States of America
| | - P Ganesan
- Stanford University School of Medicine, Palo Alto, United States of America
| | - P Clopton
- Stanford University School of Medicine, Palo Alto, United States of America
| | - AJ Rogers
- Stanford University School of Medicine, Palo Alto, United States of America
| | - SM Narayan
- Stanford University School of Medicine, Palo Alto, United States of America
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Deb B, Selvalingam A, Alhusseini M, Rogers A, Ganesan P, Feng R, Clopton P, Ruiperez-Campillo S, Narayan S. Machine-learned physiological signatures from the ECG predict sudden death in ischemic cardiomyopathy. Europace 2022. [DOI: 10.1093/europace/euac053.021] [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: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute of Health (NIH)
Background
Low left ventricular ejection fraction (LVEF) is an imperfect predictor of sudden cardiac death (SCD) in patients with ischemic cardiomyopathy. Novel features from the ECG might provide a readily available tool to better predict risk.
Purpose
We hypothesized that machine learning (ML) of the ECG can be used to predict SCD, and the ML-learned ECG features could be referenced to interpretable intracardiac signals (monophasic action potentials: MAP) to provide mechanistic insights.
Methods
We studied 5603 ECG Lead V1 beats in 41 patients (64±10 Y) with coronary disease and LVEF≤40% in steady-state pacing. Patients were randomly allocated to independent training and test cohorts in a 70:30 ratio, repeated K=10-fold. Support vector machines were trained to predict mortality at 3Y from the top 20 features derived from these beats. Patient-level predictions were made by computing an ECG score that indicates the proportion of test set beats in that patient computed by the beat-level model to predict death. Explainability analysis was performed using the arithmetic mean of MAP and ECG beats that predicted SCD versus those that predicted survival.
Results
Fig 1A. shows ECG lead V1 and MAP in a 79 Y man with LVEF 29%. Fig 1B shows the dataflow in the study. Predictive accuracies of ML models were 78 and 70% and optimal with 20 features for both ECG and MAP models respectively (Fig. 1C). Beat-level predictions in the validation (n=1678 Lead I beats) cohorts yielded c-statistics of 0.78 with the ECG (95% CI, 0.62–0.91) and 0.75 with MAPs (95% CI, 0.75-0.76) (data not shown). In multivariable patient-level models, c-statistic was 0.87 with ECGs (95% CI, 0.76-0.98) (Fig 1D) and 0.82 with MAPs. On explainability analysis, ECG beats that predicted SCD (Fig 2; red) had lower amplitude and more notched T-waves in lead V1 than beats that predicted no SCD (Fig 2; blue). MAP that predicted SCD had higher repolarization current at the same time points. Both QT duration (ECG) and action potential duration (MAP) did not differ (Fig 2).
Conclusions
Machine learning of the ECG reveals novel predictors of SCD risk in patients with ischemic cardiomyopathy analogous to those identified in intracardiac signals. This approach can be used as a point-of-care ECG risk tool to improve risk stratification and allocation for ICD therapy beyond LVEF alone and may shed insights into the pathophysiology of ventricular arrhythmias.
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Affiliation(s)
- B Deb
- Stanford University School of Medicine, Cardiology, Palo Alto, United States of America
| | - A Selvalingam
- Stanford University School of Medicine, Cardiology, Palo Alto, United States of America
| | - M Alhusseini
- Stanford University School of Medicine, Cardiology, Palo Alto, United States of America
| | - A Rogers
- Stanford University School of Medicine, Cardiology, Palo Alto, United States of America
| | - P Ganesan
- Stanford University School of Medicine, Cardiology, Palo Alto, United States of America
| | - R Feng
- Stanford University School of Medicine, Cardiology, Palo Alto, United States of America
| | - P Clopton
- Stanford University School of Medicine, Cardiology, Palo Alto, United States of America
| | - S Ruiperez-Campillo
- Stanford University School of Medicine, Cardiology, Palo Alto, United States of America
| | - S Narayan
- Stanford University School of Medicine, Cardiology, Palo Alto, United States of America
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50
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Vasireddi SK, Deb B, Ganesan P, Feng R, Rogers AJ, Baykaner T, Bhatia NK, Clopton P, Narayan SM. BS-400-31 ASSOCIATION BETWEEN SLEEP APNEA, ATRIAL FIBRILLATION AND INCIDENT STROKE IN A VERY LARGE POPULATION OF YOUNG INDIVIDUALS. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.1206] [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: 11/27/2022]
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