1
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Thoma ED, Wright RS, George I, Krause M, Presezzi D, Villa V, Preston W, Deshmukh P, Kauppi P, Zemek PG. Pyrolysis processing of PFAS-impacted biosolids, a pilot study. J Air Waste Manag Assoc 2022; 72:309-318. [PMID: 34870569 PMCID: PMC9128340 DOI: 10.1080/10962247.2021.2009935] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 09/30/2021] [Accepted: 10/19/2021] [Indexed: 05/12/2023]
Abstract
Concentrations of per- and poly-fluoroalkyl substances (PFAS) present in wastewater treatment biosolids are a growing concern. Pyrolysis is a thermal treatment technology for biosolids that can produce a useful biochar product with reduced levels of PFAS and other contaminants. In August 2020, a limited-scope study investigated target PFAS removal of a commercial pyrolysis system processing biosolid with the analysis of 41 target PFAS compounds in biosolids and biochar performed by two independent laboratories. The concentrations of 21 detected target compounds in the input biosolids ranged between approximately 2 µg/kg and 85 µg/kg. No PFAS compounds were detected in the biochar. The PFAS concentrations in the biochar were assumed to equal the compounds' minimum detection limits (MDLs). The pyrolysis system's target PFAS removal efficiencies (REs) were estimated to range between >81.3% and >99.9% (mean >97.4%) with the lowest REs being associated with the lowest detected PFAS concentrations and the highest MDLs. No information on non-target PFAS compounds in influent or effluent media or products of incomplete combustion was considered. Selected gaseous emissions were measured by Fourier transform infrared spectroscopy and gas chromatography time-of-flight mass spectrometry to provide additional information on air emissions after process controls. This limited-scope study indicated that additional research to further understand this process is warranted.Implications: Development of alternative approaches to manage PFAS-impacted biosolids is of emerging international importance. A commercially operating biosolid pyrolysis process was shown to lower target PFAS levels in produced biochar. Additional research is warranted to understand all potential PFAS transformation emission routes and optimal air pollution emissions control strategies for this technology class.
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Affiliation(s)
- Eben D. Thoma
- U.S. Environmental Protection Agency, Office of Research and Development, Center for Environmental Measurement and Modeling, Research Triangle Park (EPA-RTP), NC, USA
| | - Robert S. Wright
- U.S. Environmental Protection Agency, Office of Research and Development, Center for Environmental Measurement and Modeling, Research Triangle Park (EPA-RTP), NC, USA
| | - Ingrid George
- U.S. Environmental Protection Agency, Office of Research and Development, Center for Environmental Measurement and Modeling, Research Triangle Park (EPA-RTP), NC, USA
| | - Max Krause
- U.S. Environmental Protection Agency, Office of Research and Development, Center for Environmental Solutions and Emergency Response, Cincinnati, OH, USA
| | | | | | | | | | - Phil Kauppi
- Montrose Air Quality Services, Mt. Pleasant MI and Irvine CA, USA
| | - Peter G. Zemek
- Montrose Air Quality Services, Mt. Pleasant MI and Irvine CA, USA
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2
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Koenig W, Ray KK, Kallend DG, Landmesser U, Leiter LA, Schwartz GG, Wright RS, Garcia Conde L, Jaros M, Raal FJ. Efficacy and safety of inclisiran in patients with established cerebrovascular disease: pooled, post hoc analysis of the ORION-9, ORION-10 and ORION-11, phase 3 randomised clinical trials. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Patients (pts) with hyperlipidaemia and established cerebrovascular disease (CeVD) are at an increased risk of future strokes or other cardiovascular events.[1] In ischaemic stroke survivors, statins and inhibitors of proprotein convertase subtilisin-kexin type 9 (PCSK9) reduce recurrent cardiovascular events including stroke.[2–4] With guidelines increasingly advocating lower LDL-C goals, add-on lipid lowering therapies to statins may be needed. Inclisiran, a first-in-class small interfering RNA (siRNA) targeting PCSK9 messenger RNA, when added to maximally tolerated statin therapy, may provide further LDL-C lowering with a convenient, infrequent dosing schedule in pts with established CeVD.
Purpose
To assess efficacy and safety of inclisiran in pts with established CeVD.
Methods
Pts with HeFH, ASCVD or its risk equivalents from ORION-9 (NCT03397121]), ORION-10 (NCT03399370), and ORION-11 (NCT03400800) were randomised 1:1 to receive inclisiran sodium 300 mg (equivalent to 284 mg inclisiran) or placebo (pbo) at Days 1, 90 and 6-monthly thereafter to Day 540. This post hoc analysis included pts with established CeVD (ischaemic stroke, and/or carotid artery stenosis by angiography or ultrasound >70%, and/or prior percutaneous or surgical carotid artery revascularisation). Percentage LDL-C change from baseline to Day 510 and corresponding time-averaged percentage change from baseline after Day 90 to Day 540 were evaluated. Safety was assessed over 540 days.
Results
Of 202 pts with established CeVD, 110 and 92 received inclisiran and pbo, respectively. At baseline, 90.0% (99/110) of pts in inclisiran and 84.8% (78/92) in pbo group reported prior ischaemic stroke(s); others had carotid artery stenosis and/or carotid revascularisation (Table 1). Mean (95% CI) pbo-corrected LDL-C percentage change from baseline at Day 510 with inclisiran was −55.2% (−64.5 to −45.9); corresponding time-averaged change from baseline after Day 90 to Day 540 was −55.2% (−62.4 to −47.9) (P<0.0001 for each; Table 2). Treatment-emergent adverse event (TEAE) and treatment-emergent serious adverse event (TESAE) were more frequent in the inclisiran vs pbo group but were consistent with the overall pooled (N=3655) population of the combined trials. Clinically relevant TEAEs at the injection site were reported more frequently with inclisiran (3.6% [4/110]) vs pbo (0% [0/92]), but none were severe. Percentage of pts with clinically relevant laboratory measurements was low and similar between treatment groups and consistent with the overall pooled population (Table 2).
Conclusions
In pts with established CeVD, a twice-yearly dosing with inclisiran (after the initial and 3-month doses) provided sustained additional LDL-C reduction of ∼55%. A modest excess of mild/moderate TEAEs at the injection site were reported with inclisiran. The cardiovascular benefits of inclisiran among patients with established CeVD are being evaluated in ongoing trials.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Novartis Pharma AG, Basel, Switzerland.
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Affiliation(s)
- W Koenig
- German Heart Centre of Munich, Munich, Germany
| | - K K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Imperial College, Department of Primary Care and Public Health, London, United Kingdom
| | | | - U Landmesser
- Charité-University Medicine Berlin, Berlin Institute of Health (BIH), DZHK, Partner Site Berlin, Department of Cardiology, Berlin, Germany
| | - L A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Lipid Clinic, Toronto, Canada
| | - G G Schwartz
- University of Colorado School of Medicine, Division of Cardiology, Aurora, United States of America
| | - R S Wright
- Mayo Clinic, Division of Preventive Cardiology and Department of Cardiology, Rochester, United States of America
| | | | - M Jaros
- Summit Analytical, Denver, United States of America
| | - F J Raal
- University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
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3
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Koenig W, Ray KK, Kallend DG, Landmesser U, Leiter LA, Schwartz GG, Wright RS, Garcia Conde L, Jaros M, Raal FJ. Efficacy and safety of inclisiran in patients with polyvascular disease: pooled, post hoc analysis of the ORION-9, ORION-10 and ORION-11, phase 3 randomised controlled trials. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2025] [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
Approximately 25% of patients (pts) with atherosclerotic cardiovascular disease (ASCVD) have polyvascular disease (PVD), which involves ≥2 coronary, cerebrovascular, and peripheral artery beds. PVD is an independent predictor of major adverse cardiovascular (CV) events (MACE) and death.[1,2] Agents that inhibit proprotein convertase subtilisin-kexin type 9 (PCSK9) resulted in reduced low-density lipoprotein cholesterol (LDL-C) concentration and MACE incidence in pts with PVD.[3,4] Inclisiran is a small interfering RNA (siRNA) agent targeting PCSK9 messenger RNA that provided effective and sustained reduction in LDL-C concentration and was well tolerated.[5]
Purpose
To describe the effect inclisiran versus placebo (pbo) in pts with and without PVD.
Methods
This was a post hoc analysis from the ORION-9 (NCT03397121), ORION-10 (NCT03399370) and ORION-11 (NCT03400800) trials. Pts with heterozygous familial hypercholesterolaemia, ASCVD or risk equivalents were randomised 1:1 to receive 300 mg inclisiran sodium (equivalent to 284 mg inclisiran) or pbo at baseline, Day 90, and 6-monthly thereafter. LDL-C percentage change from baseline to Day 510 and corresponding time-averaged change from Day 90 and to Day 540 were evaluated by presence or absence of PVD (intention-to-treat population). Safety was assessed over 540 days (safety population).
Results
Of 3454 pts, 470 (13.6%) had PVD and 2984 (86.4%) did not. Baseline characteristics were generally balanced between treatment arms in both groups (Table 1). A greater proportion of pts with vs without PVD had CV risk factors at baseline. Mean LDL-C concentration at baseline was lower in pts with vs without PVD (Table 1). Mean (95% CI) pbo-corrected LDL-C percentage change from baseline to Day 510 with inclisiran was −48.9 (−55.6 to −42.2) in pts with PVD and −51.5 (−53.9 to −49.1) in pts without PVD (Table 2). Proportions of pts with treatment-emergent adverse events (TEAE) and treatment-emergent serious adverse events (TESAE) were similar between treatment arms irrespective of PVD status although reported TESAEs were numerically greater in both treatment arms for pts with PVD (Table 2). Clinically relevant TEAEs at the injection site were reported more frequently with inclisiran vs pbo in both groups but all were mild or moderate (Table 2). Proportions of pts with clinically relevant laboratory measurements were low and similar between treatment arms for both groups (Table 2).
Conclusions
Twice-yearly dosing with inclisiran (after the initial and 3-month doses) provided effective and sustained LDL-C lowering in pts, irrespective of their PVD status, with a safety profile similar to pbo, except for a modest excess of mainly mild TEAEs at the injection site. Notably, TESAEs were reported more frequently in pts with PVD, which was likely due to their more advanced disease. Since pts with PVD are at high risk of CV events, intensive LDL-C lowering may be beneficial to reduce this risk.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Novartis Pharma AG, Basel, Switzerland
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Affiliation(s)
- W Koenig
- German Heart Centre of Munich, Munich, Germany
| | - K K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Imperial College, Department of Primary Care and Public Health, London, United Kingdom
| | | | - U Landmesser
- Charité-University Medicine Berlin, Berlin Institute of Health (BIH), DZHK, Partner Site Berlin, Department of Cardiology, Berlin, Germany
| | - L A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Lipid Clinic, Toronto, Canada
| | - G G Schwartz
- University of Colorado School of Medicine, Division of Cardiology, Aurora, United States of America
| | - R S Wright
- Mayo Clinic, Division of Preventive Cardiology and Department of Cardiology, Rochester, United States of America
| | | | - M Jaros
- Summit Analytical, Denver, United States of America
| | - F J Raal
- University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
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4
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Stoekenbroek RM, Ray KK, Landmesser U, Leiter LA, Wright RS, Wijngaard PL, Kallend D, Kastelein JJ. 4945Inclisiran-mediated reductions in Lp(a) in the ORION-1 trial. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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
PCSK9 inhibitors and statins both lower LDL-C by increasing LDL-receptor (LDLR) function. PCSK9 inhibitors lower Lp(a) by 20–30%, whereas statins do not lower Lp(a). The mechanism by which PCSK9 inhibitors lower Lp(a) is unclear. We assessed the role of the LDLR in Lp(a) reductions produced by inclisiran, an siRNA which prevents hepatic synthesis of PCSK9.
Methods
ORION-1 was a phase 2 trial of inclisiran in subjects at high ASCVD risk with elevated LDL-C on optimized statin therapy. Subjects received one dose of inclisiran (200, 300, or 500 mg) or two doses at days 1 and 90 (100, 200, or 300 mg). We assessed the correlations between % change in Lp(a) and LDL-C at Day 180 for the inclisiran groups using Spearman correlation coefficients. We additionally assessed the correlation between % change in Lp(a) and absolute change in LDL-C as a proxy for LDLR expression. Lp(a) was measured using an isoform-independent assay and LDL-C with β-quantification.
Results
ORION-1 included 501 subjects; mean age 63; 65% male; 73% on statins. Median baseline Lp(a) was 37.0 nmol/l (IQR: 11.5–142.0 nmol/l), median LDL-C was 117.0 (IQR: 92.5–149.5 mg/dL). Inclisiran dose-dependently lowered Lp(a) by 14% to 26%. Overall, there was a significant but weak correlation between % change in Lp(a) LDL-C (Spearman coefficient 0.35, p<0.001). This correlation appeared to be stronger at higher inclisiran doses and with repeat dosing (table), as well as in statin-users versus non-users (Spearman coefficient 0.37 vs. 0.21). The correlation between % Lp(a) change and absolute LDL-C change was weaker (0.27, p<0.001).
Correlation coefficients LDL-C – Lp(a) Single-dose groups Two-dose groups Inclisiran overall 200 mg (n=60) 300 mg (n=60) 500 mg (n=60) 100 mg (n=59) 200 mg (n=60) 300 mg (n=59) Lp(a) ∼ % change LDL-C 0.22 0.26 0.22 0.29 0.47 0.51 0.35 Lp(a) ∼ absolute change LDL-C 0.35 0.12 0.04 0.22 0.45 0.24 0.27 Lp(a) ∼ % change LDL-C - Statin users 0.16 0.28 0.28 0.31 0.45 0.55 0.37 Lp(a) ∼ % change LDL-C - Non statin users 0.80 -0.08 0.09 0.10 0.63 0.09 0.21
Conclusion
The dose-dependent correlation between % changes in LDL-C and Lp(a) suggests that the LDLR may be partially responsible for Lp(a) reductions produced by inclisiran. The numerically stronger correlation in statin-users supports the idea that LDL-C may compete with Lp(a) for LDLR binding especially at low LDL-C levels.
Acknowledgement/Funding
The Medicines Company
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Affiliation(s)
- R M Stoekenbroek
- Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands (The)
| | - K K Ray
- Imperial College London, Department of Primary Care and Public Health, London, United Kingdom
| | - U Landmesser
- Charite University Hospital, Department of Cardiology, Berlin, Germany
| | - L A Leiter
- University of Toronto, Division of Endocrinology and Metabolism, Toronto, Canada
| | - R S Wright
- Mayo Clinic, Department of Cardiovascular Medicine, Rochester, United States of America
| | - P L Wijngaard
- The Medicines Company, Parsippany, United States of America
| | - D Kallend
- The Medicines Company, Parsippany, United States of America
| | - J J Kastelein
- Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands (The)
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5
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Wright RS, Waldstein SR, Gerassimakis CS, Sprung MR, Moody DLB, Taylor AD, Al'Najjar E, McNeely JM, Zhang Z, Evans MK, Zonderman AB. Multiple Influences on Cognitive Function Among Urban-Dwelling African Americans. J Racial Ethn Health Disparities 2019; 6:851-860. [PMID: 30915683 DOI: 10.1007/s40615-019-00584-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/14/2019] [Accepted: 03/18/2019] [Indexed: 10/27/2022]
Abstract
This study examined multiple influences on cognitive function among African Americans, including education, literacy, poverty status, substance use, depressive symptoms, and cardiovascular disease (CVD) risk factors. Baseline data were analyzed from the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study. Participants were 987 African Americans (mean age 48.5 years, SD = 9.17) who completed cognitive measures assessing verbal learning and memory, nonverbal memory, working memory, verbal fluency, perceptuo-motor speed, attention, and cognitive flexibility. Using preplanned hierarchical regression, cognitive performance was regressed on the following: (1) age, sex, education, poverty status; (2) literacy; (3) cigarette smoking, illicit substance use; (4) depressive symptoms; and (5) number of CVD risk factors. Results indicated that literacy eliminated the influence of education and poverty status in select instances, but added predictive utility in others. In fully adjusted models, results showed that literacy was the most important influence on cognitive performance across all cognitive domains (p < .001); however, education and poverty status were related to attention and cognitive flexibility. Depressive symptoms and substance use were significant predictors of multiple cognitive outcomes, and CVD risk factors were not associated with cognitive performance. Overall, findings underscore the need to develop cognitive supports for individuals with low literacy, educational attainment, and income, and the importance of treating depressive symptoms and thoroughly examining the role of substance use in this population.
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Affiliation(s)
- R S Wright
- School of Nursing, University of Delaware, Newark, DE, USA.
| | - S R Waldstein
- Department of Psychology, University of Maryland Baltimore County, Baltimore, MD, USA.,Geriatric Research Education & Clinical Center, Baltimore Veterans Affairs Medical Center, Baltimore, MD, USA
| | - C S Gerassimakis
- Department of Behavioral Health and Nutrition, University of Delaware, Newark, DE, USA
| | - M R Sprung
- Department of Psychology, University of Maryland Baltimore County, Baltimore, MD, USA
| | - D L Beatty Moody
- Department of Psychology, University of Maryland Baltimore County, Baltimore, MD, USA
| | - A D Taylor
- Department of Psychology, University of Maryland Baltimore County, Baltimore, MD, USA
| | - E Al'Najjar
- Department of Psychology, University of Maryland Baltimore County, Baltimore, MD, USA
| | - J M McNeely
- Department of Psychology, University of Maryland Baltimore County, Baltimore, MD, USA
| | - Z Zhang
- Christiana Care Value Institute, Newark, DE, USA
| | - M K Evans
- Laboratory of Epidemiology and Population Sciences, National Institute on Aging Intramural Research Program, National Institutes of Health, Baltimore, MD, USA
| | - A B Zonderman
- Laboratory of Epidemiology and Population Sciences, National Institute on Aging Intramural Research Program, National Institutes of Health, Baltimore, MD, USA
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6
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Bygrave D, Bygrave DC, Wright RS, Aiken-Morgan AT, Gamaldo AA, Gerassimakis CS. RELATIONS OF CAROTID INTIMA-MEDIA THICKNESS AND SOCIODEMOGRAPHIC FACTORS TO COGNITIVE PERFORMANCE. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.2317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- D Bygrave
- University of Delaware, Newark, Delaware, United States
| | | | | | - A T Aiken-Morgan
- North Carolina A&T State University, Greensboro, NC, USA; Duke University, Durham, NC, USA
| | - A A Gamaldo
- The Pennsylvania State University, University Park, PA, USA
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7
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Wright RS. VASCULAR, CARDIOMETABOLIC, AND SLEEP HEALTH RELATIONS TO BRAIN AND COGNITIVE OUTCOMES AMONG OLDER ADULTS. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.2314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- R S Wright
- University of Delaware, Newark, Delaware
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8
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Gerassimakis C, Gerassimakis CS, Bygrave DC, Gamaldo AA, Aiken-Morgan AT, Wright RS. OVERVIEW OF THE HEALTHY HEART AND MIND STUDY. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.2315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | | | - A A Gamaldo
- The Pennsylvania State University, University Park, PA, USA
| | - A T Aiken-Morgan
- North Carolina A&T State University, Greensboro, NC, USA; Duke University, Durham, NC, USA
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9
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Aiken-Morgan AT, Gamaldo AA, Bygrave DC, Gerassimakis C, Wright RS. RELATIONSHIPS BETWEEN AGE, BODY MASS INDEX, AND COGNITION IN THE HEALTHY HEART AND MIND STUDY. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.2318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- A T Aiken-Morgan
- North Carolina A&T State University, Greensboro, North Carolina,United States
| | - A A Gamaldo
- The Pennsylvania State University, University Park, PA, USA
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10
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Gamaldo AA, Aiken-Morgan AT, Bygrave DC, Gerassimakis C, Wright RS. SELF-REPORTED SLEEP AS IT RELATES TO COGNITIVE FUNCTION IN OLDER BLACK AND WHITE ADULTS. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.2319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- A A Gamaldo
- The Pennsylvania State University, State College, Pennsylvania, United States
| | - A T Aiken-Morgan
- North Carolina A&T State University, Greensboro, NC, USA; Duke University, Durham, NC, USA
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11
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Wright RS, Bygrave DC, Gerassimakis C, Aiken-Morgan AT, Gamaldo AA. THE INFLUENCE OF ENDOTHELIAL FUNCTION ON BRAIN VOLUMES IN THE HEALTHY HEART AND MIND STUDY. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.2316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- R S Wright
- University of Delaware, Newark, Delaware, United States
| | | | | | - A T Aiken-Morgan
- North Carolina A&T State University, Greensboro, NC, USA; Duke University, Durham, NC, USA
| | - A A Gamaldo
- The Pennsylvania State University, University Park, PA, USA
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12
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Achamallah N, Wright RS, Fried J. Chasing the wrong dragon: A new presentation of heroin-induced toxic leukoencephalopathy mimicking anoxic brain injury. J Intensive Care Soc 2018; 20:80-85. [PMID: 30792768 DOI: 10.1177/1751143718774714] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [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: 11/17/2022] Open
Abstract
Toxic leukoencephalopathy associated with heroin inhalation has been extensively described in the literature. This syndrome is characterized by progressive motor symptoms and dysautonomia that develop over weeks to months. We present three cases of abrupt-onset inhaled heroin-associated toxic leukoencephalopathy, a previously undescribed entity. These likely represent a subset of "found down" patients with acute neurologic changes not attributable to hypoxemic encephalopathy. All three had magnetic resonance imaging findings characteristic of toxic leukoencephalopathy, which has a relatively favorable prognosis. Prolonged unresponsiveness in patients "found down" after heroin overdose is often attributed to hypoxic brain injury. Brain magnetic resonance imaging is not generally included as part of routine workup. It should, however, be considered in patients with suspected inhaled heroin use due to the relatively favorable prognosis of toxic leukoencephalopathy. This is especially relevant in the setting of the current opioid epidemic and related increase in overdose-related intensive care unit admissions. The result may have significant impact on decisions about therapeutic options or continuation of care.
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Affiliation(s)
- Natalie Achamallah
- Department of Medical Education, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA
| | - Robert S Wright
- Department of Medical Education, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA.,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jeffrey Fried
- Department of Medical Education, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA.,Department of Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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13
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14
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Chen HH, Martin FL, Gibbons RJ, Schirger JA, Wright RS, Schears RM, Redfield MM, Simari RD, Lerman A, Cataliotti A, Burnett JC. Low-dose nesiritide in human anterior myocardial infarction suppresses aldosterone and preserves ventricular function and structure: a proof of concept study. Heart 2009; 95:1315-9. [PMID: 19447837 DOI: 10.1136/hrt.2008.153916] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [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: 01/06/2023] Open
Abstract
BACKGROUND B-type natriuretic peptide (BNP, nesiritide) has anti-fibrotic, anti-hypertrophic, anti-inflammatory, vasodilating, lusitropic and aldosterone-inhibiting properties but conventional doses of BNP cause hypotension, limiting its use in heart failure. OBJECTIVE To determine whether infusion of low-dose BNP within 24 h of successful reperfusion for anterior acute myocardial infarction (AMI) would prevent adverse left ventricular (LV) remodelling and suppress aldosterone. METHODS A translational proof-of-concept study was carried out to determine tolerability and biological activity of intravenous BNP at 0.003 and 0.006 microg/kg/min, without bolus started within 24 h of successful reperfusion for anterior AMI. 24 patients with first anterior wall ST elevation AMI and successful revascularisation were randomly assigned to receive 0.003 (n = 12) or 0.006 (n = 12) microg/kg/min of IV BNP for 72 h in addition to standard care during hospitalisation for anterior AMI. RESULTS Baseline characteristics, drugs and peak cardiac biomarkers for myocardial damage were similar between both groups. Infusion of BNP at 0.006 microg/kg/min resulted in greater biological activity than infusion at 0.003 microg/kg/min as measured by higher mean (SEM) plasma cGMP levels (8.6 (1) vs 5.5 (1) pmol/ml, p<0.05) and suppression of plasma aldosterone (8.0 (2) to 4.6 (1) ng/dl, p<0.05), which was not seen in the 0.003 microg/kg/min group. LV ejection fraction (LVEF) improved significantly from baseline to 1 month (40 (4)% to 54 (5)%, p<0.05) in the 0.006 group but not in the 0.003 group. Infusion of BNP at 0.006 microg/kg/min was associated with a decrease of LV end-systolic volume index (61 (9) to 43 (8) ml/m(2), p<0.05) at 1 month, which was not seen in the 0.003 group. No drug-related serious adverse events occurred in either group. CONCLUSIONS 72 h infusion of low BNP at the time of anterior AMI is well tolerated and biologically active. Patients treated with low-dose BNP had improved LVEF and smaller LV end-systolic volume at 1 month.
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Affiliation(s)
- H H Chen
- Cardiorenal Research Laboratory, Mayo Clinic, Rochester, MN 55904, USA.
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Dyer ZA, Wright RS, Rong IH, Jacobs A. Back pain associated with endobronchial mucus impaction due to Bipolaris australiensis colonization representing atypical Allergic Bronchopulmonary Mycosis. Med Mycol 2009; 46:589-94. [PMID: 19180752 DOI: 10.1080/13693780801968563] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
A 40-year-old white male had a two-year history of right sided upper back pain without dyspnea or coughing. His past history was significant for allergic rhinitis and asthma. Conservative outpatient management of the back pain including medications, rest and physical therapy were ineffective. CT scan of the chest revealed a mass in the lower lobe of the right lung. Bronchial biopsy and lavage revealed eosinophilic and neutrophilic inflammation without tissue invasion. A pure culture of Bipolaris australiensis was confirmed by DNA typing. Hematological, serological and radiological studies were not compatible with Allergic Bronchopulmonary Mycosis (ABPM), fungus ball, hypersensitivity pneumonitis or invasive fungal infection. However, the mucus plugging may have represented an atypical localized form of ABPM. Resolution of the endobronchial mucus impaction occurred after three bronchoscopies with vigorous suction, anti fungal therapy and prednisone.
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Affiliation(s)
- Zeb A Dyer
- Department of Allergy and Immunology, Sansum Clinic, Santa Barbara, California, USA.
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Abstract
BACKGROUND The continuing applicability of the Killip classification system to the effective stratification of long-term and short-term outcome in patients with acute myocardial infarction (MI) and its influence on treatment strategy calls for reanalysis in the setting of today's primary reperfusion treatments. HYPOTHESIS Our study sought to test the hypothesis that Killip classification, established on admission in patients with acute MI, is an effective tool for early prediction of in-hospital mortality and long-term survival. METHODS A series of 909 consecutive Olmsted County patients admitted with acute MI to St. Marys Hospital, Mayo Clinic, between January 1988 and March 1998 was analyzed. Killip classification was the primary variable. Endpoints were in-hospital death, major in-hospital complications, and post-hospital death. RESULTS Patients analyzed included 714 classified as Killip I, 170 classified as Killip II/III, and 25 classified as Killip IV. Increases in in-hospital mortality and prevalence of in-hospital complications correspond significantly with advanced Killip class (p < 0.01), with in-hospital mortality 7% in class I, 17.6% in classes II/III, and 36% in class IV patients (p < 0.001). Killip classification was strongly associated with mode of therapy administered within 24 h of admission (p < 0.01). Killip IV patients underwent primary angioplasty most commonly and were less likely to receive medical therapy. CONCLUSIONS Killip classification remains a strong independent predictor of in-hospital mortality and complications, and of long-term survival. Early primary angioplasty has contributed to a decrease in mortality in Killip IV patients, but effective adjunctive medical therapy is underutilized.
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Affiliation(s)
- W L Miller
- Division of Cardiovascular Diseases, Mayo Clinic and Foundation, Rochester, MN 55905, USA
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17
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Abstract
BACKGROUND The American Heart Association has classified obesity as a major modifiable risk factor for coronary artery disease, but its relationship with age at presentation with acute myocardial infarction (AMI) is poorly documented. HYPOTHESIS The study was undertaken to evaluate the impact of obesity on age at presentation, and on in-hospital morbidity and mortality in patients with AMI. METHODS Our analysis includes a consecutive series of 906 Olmsted County patients (mean age 67.7 years, 51% male) admitted with AMI to the Mayo Clinic Coronary Care Unit (CCU). The patients were entered into the Mayo CCU Database, a prospective registry of data pertaining to patients admitted to the Mayo Clinic CCU with AMI. Age at AMI occurrence and in-hospital morbidity and mortality were noted. RESULTS Obese patients (body mass index [BMI] >30) with AMI were significantly younger than patients with AMI in the overweight (BMI 25-30) and normal-weight (BMI < 30) groups (62.3+/-13.1 vs. 66.9+/-13.2 and 72.9+/-13.4, respectively. p < 0.001). Obesity and overweight status were associated with male gender, diabetes mellitus, hypercholesterolemia, and smoking history; however, after multivariate adjustment for these risk factors, excess weight and premature AMI remained significantly associated. Compared with normal-weight patients, overweight patients presenting with AMI were 3.6 years younger (p < 0.001, confidence interval [CI] 1.9-5.4) and obese patients 8.2 years younger (p < 0.001, Cl 6.2-10.1). No significant increase in in-hospital morbidity and mortality was seen. CONCLUSION In this population-based study, overweight and obese status are independently associated with the premature occurrence of AMI, but not with an increased incidence of in-hospital complications.
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Affiliation(s)
- J A Suwaidi
- Coronary Care Unit Group and the Mayo Physician Alliance for Clinical Trials (MPACT), Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55902, USA
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18
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Williams BA, Wright RS, Murphy JG, Brilakis ES, Reeder GS, Jaffe AS. A new simplified immediate prognostic risk score for patients with acute myocardial infarction. Emerg Med J 2006; 23:186-92. [PMID: 16498154 PMCID: PMC2464431 DOI: 10.1136/emj.2005.027326] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Immediate risk stratification of patients with myocardial infarction in the emergency department (ED) at the time of initial presentation is important for their optimal emergency treatment. Current risk scores for predicting mortality following acute myocardial infarction (AMI) are potentially flawed, having been derived from clinical trials with highly selective patient enrollment and requiring data not readily available in the ED. These scores may not accurately represent the spectrum of patients in clinical practice and may lead to inappropriate decision making. METHODS This study cohort included 1212 consecutive patients with AMI who were admitted to the Mayo Clinic coronary care unit between 1988 and 2000. A risk score model was developed for predicting 30 day mortality using parameters available at initial hospital presentation in the ED. The model was developed on patients from the first era (training set--before 1997) and validated on patients in the second era (validation set-during or after 1997). RESULTS The risk score included age, sex, systolic blood pressure, admission serum creatinine, extent of ST segment depression, QRS duration, Killip class, and infarct location. The predictive ability of the model in the validation set was strong (c = 0.78). CONCLUSION The Mayo risk score for 30 day mortality showed excellent predictive capacity in a population based cohort of patients with a wide range of risk profiles. The present results suggest that even amidst changing patient profiles, treatment, and disease definitions, the Mayo model is useful for 30 day risk assessment following AMI.
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Affiliation(s)
- B A Williams
- Division of Biostatistics, Mayo Clinic and Foundation, Rochester, MN, USA
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19
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Abstract
An experienced intensivist performed an emergency endotracheal intubation on a 72-year-old woman without difficulty. The vocal cords were visualized during the intubation. An esophageal detector device was used to confirm correct airway placement. After aspiration of the device, it was impossible to easily ventilate the patient. The endotracheal tube was removed and found to be occluded by a mucus plug. It is postulated that aspiration of the syringe on the esophageal detector device suctioned the mucus plug from the bronchial tree into the endotracheal tube and precluded ventilation of the airway. This complication has not been previously reported. The utility and possible hazards of the esophageal detector device are discussed.
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Affiliation(s)
- Robert S Wright
- Department of Pulmonary and Critical Care Medicine, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA.
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Wright RS. Application of data quality objectives and measurement quality objectives to research projects. Qual Assur 2003; 10:177-92. [PMID: 15764553 DOI: 10.1080/10529410390892098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
This paper assists systematic planning for research projects. It presents planning concepts in terms that have some utility for researchers. For example, measurement quality objectives are more familiar to researchers than data quality objectives because these quality criteria are more closely associated with the measurement systems being used. Because of the diverse nature of research, it is not possible to describe cookbook-style planning procedures to be used in all cases. Instead, several general concepts and techniques are presented and researchers can choose those techniques that best fit their specific projects. Examples are presented to illustrate the techniques.
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Affiliation(s)
- Robert S Wright
- U.S. Environmental Protection Agency, National Risk Management Research Laboratory, Air Pollution Prevention and Control Division, Research Triangle Park, NC 27711, USA.
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Gumina RJ, Wright RS, Kopecky SL, Miller WL, Williams BA, Reeder GS, Murphy JG. Strong predictive value of TIMI risk score analysis for in-hospital and long-term survival of patients with right ventricular infarction. Eur Heart J 2002; 23:1678-83. [PMID: 12398825 DOI: 10.1053/euhj.2002.3231] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND While right ventricular myocardial infarction is associated with increased in-hospital morbidity and mortality, prognostic risk factors for in-hospital and long-term mortality are poorly defined. OBJECTIVES To evaluate the prognostic value of TIMI (Thrombolysis in Myocardial Infarction) risk score analysis in patients with right ventricular myocardial infarction (RVI). DESIGN Retrospective analysis of a community population. SETTING Mayo Clinic Coronary Care Unit. PATIENTS One hundred and two patients with RVI from 580 consecutive patients from Rochester, Minnesota admitted to the Coronary Care Unit with acute inferior or lateral wall myocardial infarction from January 1988 through March 1998. MEASUREMENT Combined TIMI risk score analysis with in-hospital and long-term mortality. RESULTS In-hospital morbidity (RVI: 54.9% vs non-RVI: 22.2%; P<0.001) and mortality (RVI: 21.6% vs non-RVI: 6.9%;P <0.001) were increased in patients with RVI. The TIMI risk score predicted risk (per one point increase in TIMI score) for in-hospital mortality (OR 1.23, 95% CI 1.02-1.51, P=0.037) and long-term mortality (OR 1.57, 95% CI 1.25-1.96, P<0.001). Patients with RVI whose TIMI risk score was >or=4 had significantly worse long-term survival compared to those patients with RVI and TIMI score <4 (P=0.006). CONCLUSIONS In-hospital morbidity and mortality, and long-term mortality are increased by right ventricular infarction and can be accurately predicted by the initial TIMI risk score.
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Affiliation(s)
- R J Gumina
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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22
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Wright RS, Abraham JL, Harber P, Burnett BR, Morris P, West P. Fatal asbestosis 50 years after brief high intensity exposure in a vermiculite expansion plant. Am J Respir Crit Care Med 2002; 165:1145-9. [PMID: 11956059 DOI: 10.1164/ajrccm.165.8.2110034] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [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: 11/16/2022] Open
Abstract
The authors report the case of a 65-year-old accountant whose only asbestos exposure was during a summer job 50 years earlier in a California vermiculite expansion plant. Vermiculite is a silicate material that is useful in building and agriculture as a filler and insulating agent. He developed extensive fibrocalcific pleural plaques and end-stage pulmonary fibrosis, with rapidly progressive respiratory failure. Careful occupational and environmental history revealed no other source of asbestos exposure, and the initial clinical diagnosis was idiopathic pulmonary fibrosis; open lung biopsy shortly before his death confirmed asbestosis. Electron microscopic lung fiber burden analysis revealed over 8,000,000 asbestos fibers per gram dry lung, 68% of which were tremolite asbestos. Additional asbestiform fibers of composition not matching any of the standard asbestos varieties were also present at over 5,000,000 fibers per gram dry lung. Comparison analysis of a sample of Libby, Montana, vermiculite showed a similar mix of asbestiform fibers including tremolite asbestos. This case analysis raises several concerns: risks of vermiculite induced disease among former workers of the more than 200 expansion plants throughout the United States; health effects of brief but very high-intensity exposures to asbestos; and possible health effects in end-users of consumer products containing vermiculite.
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Affiliation(s)
- Robert S Wright
- Department of Medicine, UCLA School of Medicine, Los Angeles, USA.
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Xue J, Taha B, Reddy S, Wright RS, Aufderheide T. A new method to incorporate age and gender into the criteria for the detection of acute inferior myocardial infarction. J Electrocardiol 2002; 34 Suppl:229-34. [PMID: 11781961 DOI: 10.1054/jelc.2001.28904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [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: 11/18/2022]
Abstract
Recent studies have shown that younger women are more likely to die during and after hospitalization for acute myocardial infarction (MI) than older women and men of all ages. This may be partly due to incorrect diagnosis or late detection of acute MI in younger women. At high specificity levels (>98%), the sensitivity of the initial ECG to detect acute MI may be as low as 30% when using traditional criteria by both physicians and computerized interpretation programs. This study examines if women of different age groups have a similar ECG presentation to men during acute inferior MI and if the diagnostic accuracies of the initial ECG are comparable. We analyzed chest pain ECGs from Mayo Clinic and Medical College of Wisconsin, which included 1,339 patients with acute inferior MI and 1,169 age-matched controls with noncardiac chest pain. We subdivided all groups by age (below and above 60 years) and compared ECG parameters (ST elevation, ST depression, QRS duration, R-wave amplitude, Q-wave duration and amplitude, QT interval) between genders. For inferior MI patients under age 60, women had lower ST elevations at the J point in lead II than men (57 +/- 91 microV vs. 86 +/- 117 microV, P < .02). This trend was reversed for patients over age 60 (lead a VF: 102 +/- 126 microV vs. 84+/-117 microV, P < .04; Lead III: 130+/-146 microV vs. 103+/-131 microV, P < .007). A neural network method was used to identify the most significant group of ECG parameters for detecting acute MI. An adaptive fuzzy logic method was developed for adapting to the threshold differences among the different gender and age groups. The new algorithm improved the sensitivity of acute inferior MI detection by more than 25% relative to old algorithm, while maintaining the high specificity around 98% for noncardiac chest pain patients.
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Affiliation(s)
- J Xue
- GE Medical Systems-Information Technologies, Milwaukee, WI 53223, USA
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25
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Miller WL, Wright RS, McGregor CG, Dispenzieri A, McConnell JP, Burritt MF, Jaffe AS. Troponin levels in patients with amyloid cardiomyopathy undergoing cardiac transplantation. Am J Cardiol 2001; 88:813-5. [PMID: 11589859 DOI: 10.1016/s0002-9149(01)01877-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- W L Miller
- Division of Cardiovascular Diseases, Mayo Clinic and Mayo Foundation, 200 First Street, SW, Rochester, Minnesota 55905, USA.
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Wright RS, Kopecky SL, Timm M, Pflaum DD, Carr C, Evers K, Bell J. Impact of community-based education on health care evaluation in patients with acute chest pain syndromes: the Wabasha Heart Attack Team (WHAT) project. Fam Pract 2001; 18:537-9. [PMID: 11604379 DOI: 10.1093/fampra/18.5.537] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Community education programmes focused on raising public awareness of the symptomatology of acute coronary syndromes have had mixed results. OBJECTIVES The Wabasha Heart Attack Team project, a unique multidisciplinary public education effort in Minnesota, sought to educate area citizens about signs and symptoms of acute myocardial infarction (MI). METHODS After an intensive 1-month education period, we compared presentations for emergency evaluation of chest pain during the study period with baseline data from the same seasonal period of the preceding year. RESULTS Visits to the Emergency Room for symptomatic heart disease increased significantly during the study period (56 patients versus 46 patients during the baseline period), as did the percentage of patients presenting with acute MI (18% versus 12%, P < 0.05). Use of emergency medical services for pre-hospital evaluation was significantly increased (41% versus 27%, P < 0.05). CONCLUSION A community education campaign can significantly increase use of pre-hospital emergency medical service resources and may increase the number of patients presenting with acute chest pain symptoms, including MI.
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Affiliation(s)
- R S Wright
- Division of Cardiovascular Diseases and the Mayo Physician Alliance for Clinical Trials (MPACT) Coordinating Center, Mayo Clinic and Mayo Foundation, Rochester, MN 55902, USA
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Abstract
Using a community-based population of patients with acute myocardial infarction (AMI), we sought to: (1) determine the prevalence of bundle branch block (BBB) on the presenting electrocardiogram (ECG), (2) compare the clinical characteristics and the treatment administered to patients with and without BBB, and (3) determine the association of BBB with mortality. We analyzed the admission ECGs of 894 consecutive patients with AMI from Olmsted County, Minnesota, seen at our institution from January 1988 to March 1998. Of these, 53 had left BBB (LBBB) (5.9%) and 60 had right BBB (RBBB) (6.7%). Patients with BBB were more likely to be older, have a history of AMI or hypertension, and to be in Killip class >I at presentation. They were less likely to receive primary reperfusion therapy, beta blockers, or heparin, but more likely to receive angiotensin-converting enzyme inhibitors. They had lower mean predischarge ejection fractions (38 +/- 16% vs 50 +/- 15%, p <0.0001). In-hospital mortality was 13.3%, 17.0%, and 9.1% for patients with RBBB, LBBB, and no BBB, respectively (p = 0.11). Respective postdischarge survival at 1, 3, and 5 years was 80%, 60%, and 50% in the RBBB group, 78%, 56%, and 51% in the LBBB group, and 92%, 85%, and 76% in the group without BBB (p <0.0001). Although BBB was not an independent predictor of mortality on multivariate analysis, the presence of transient or persistent BBB with AMI is an easily recognized clinical marker of increased mortality. Our conclusion from this study is that in a community-based population, patients who had LBBB or RBBB at the time of AMI had lower predischarge ejection fractions and higher in-hospital and long-term unadjusted mortality.
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Affiliation(s)
- E S Brilakis
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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Wright RS, Nichol JS, Papp ML, Groff PW, Tufts MW. Annual recertification program for audit standards used in the EPA PM2.5 Performance Evaluation Program. Qual Assur 2001; 9:129-35. [PMID: 12553075] [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] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
This paper describes procedures used to perform 152 annual recertifications of temperature, pressure, and flow rate audit standards. It discusses the metrology laboratories and the uncertainty of their recertifications. It describes the data base for the standards that tracks their recertifications and shipments. Finally, it presents some illustrative recertification results and describes what these results reveal about the audit standards and the recertifications.
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Affiliation(s)
- R S Wright
- RTI International, P.O. Box 12194, Research Triangle Park, NC 27709-2194, USA.
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Sgura FA, Wright RS, Kopecky SL, Grill JP, Reeder GS. Length of stay in myocardial infarction. Cost Qual 2001:12-20, 25. [PMID: 11482251] [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] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
OBJECTIVE We evaluated the association between length of hospital stay (LOS) and clinical factors, treatment intensity, and use of percutaneous coronary revascularization from 1988 to 1997. BACKGROUND Multiple factors contribute to the observed reduction in LOS for patients with myocardial infarction. METHODS We studied a series of 849 consecutive patients admitted with acute myocardial infarction to the Mayo Clinic Coronary Care Unit within three time periods: period I (1988-1990), period II (1991-1993), and period III (1994-1997). RESULTS Median LOS decreased significantly between 1988 and 1997 (9 days to 5 days, 36% reduction, p < 0.0001), with significant reductions (p < 0.001) associated with certain therapies: primary reperfusion (6 days vs 7 days), b-blockers (6 days vs 8 days), and aspirin (6 days vs 8 days). Hospitalizations were lengthened by coronary artery bypass grafting (12 vs 6 days) and by serious complications (10 vs 6 days). The era of the admission (period I vs II vs III) is a significant, powerful predictor of LOS, even after adjustment for other key variables. CONCLUSION The 36% reduction in LOS for acute myocardial infarction between 1988 and 1997 is related both to therapeutic modalities and temporal trends. Further study is needed to clarify whether the trend for decreasing LOS persists and influences outcome and health care quality variables.
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Gussak I, Wright RS, Bjerregaard P, Chaitman BR, Zhou SH, Hammill SC, Kopecky SL. False-negative and false-positive ECG diagnoses of Q wave myocardial infarction in the presence of right bundle-branch block. Cardiology 2001; 94:165-72. [PMID: 11279322 DOI: 10.1159/000047312] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Right bundle-branch block (RBBB) has not traditionally been seen as an obstacle to ECG diagnosis of Q wave myocardial infarction (MI)--in clinical electrocardiography and vectorcardiography--because this conduction disturbance is not believed to cause significant alterations in the spatial orientation of initial excitation wavefronts. In the era of large-scale clinical trials, however, where serial ECG analysis is among the major diagnostic tools in MI classification, both false-positive and false-negative diagnoses of MI in the presence of RBBB have become increasingly evident. Because of the limited detectability of Q wave MI by ECG in the presence of RBBB, the electrocardiographic finding of Q wave MI should not be regarded as an independent diagnostic tool. It is best to utilize independent corroboration to establish the diagnosis of transmural infarction when RBBB is present. Further investigations are warranted to better delineate sensitivity, specificity, and predictive value of Q wave MI in the presence of RBBB.
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Affiliation(s)
- I Gussak
- Mayo Physician Alliance for Clinical Trials, Mayo Clinic (Stabile 5), 150 Third Street SW, Rochester, MN 55902, USA.
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Miller WL, Sgura FA, Kopecky SL, Asirvatham SJ, Williams BA, Wright RS, Reeder GS. Characteristics of presenting electrocardiograms of acute myocardial infarction from a community-based population predict short- and long-term mortality. Am J Cardiol 2001; 87:1045-50. [PMID: 11348600 DOI: 10.1016/s0002-9149(01)01459-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
To investigate the relevance of presenting electrocardiographic (ECG) patterns to short- and long-term mortality in nonreferral patients with acute myocardial infarction (AMI), 6 ECG patterns were analyzed. A consecutive series of 907 patients from Olmsted County, Minnesota, admitted to the Mayo Clinic Cardiac Care Unit from January 1, 1988 to March 31, 1998 for acute myocardial infarction comprised the study population. ECG patterns and distribution in the population were: (1) ST elevation alone (20.8%), (2) ST elevation with ST depression (35.2%), (3) normal or nondiagnostic electrocardiograms (18.5%), (4) ST depression alone (11.8%), (5) T-wave inversion only (10.7%), and (6) new left bundle branch block (LBBB) (3.0%). Seven- and 28-day mortalities varied significantly (p <0.01) among the 6 ECG groups. Respective mortalities were 3.0% and 6.0% for patients with normal or nondiagnostic electrocardiograms, 3.1% and 5.2% for T-wave inversion only, 7.4% and 10.6% for ST elevation alone, 9.4% and 13.1% for ST depression alone, 10.3% and 13.8% for ST elevation with ST depression, and 18.5% and 22.2% for new LBBB. Length of hospital stay (LOS) also varied among the ECG pattern groups (p <0.001) with the longest average LOS being in the new LBBB group (12.5 days). Long-term survival was similar among 5 ECG pattern groups (45% to 55% at 8 years from discharge) with the exception of LBBB (20% at 8 years). Among non-LBBB groups, ST-segment depression with or without ST elevation was associated with increased short-term mortality. Also, in this community-based population, 18.5% of patients had normal or nondiagnostic electrocardiograms.
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Affiliation(s)
- W L Miller
- Coronary Care Unit Group, Mayo Clinic and Mayo Foundation, Division of Cardiovascular Diseases, Department of Internal Medicine, Rochester, Minnesota 55905, USA.
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Abstract
In this first clinical report of an idiopathic familial persistently short QT interval (QTI), we describe three members of one family (a 17-year-old female, her 21-year-old brother, and their 51-year-old mother) demonstrating this ECG phenomenon, associated in the 17-year-old with several episodes of paroxysmal atrial fibrillation requiring electrical cardioversion. Similar ECG changes seen in an unrelated 37-year-old patient were associated with sudden cardiac death. Our report also describes other manifestations of abnormal shortening of the QTI and considers the possible arrhythmogenic potential of the short QTI.
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Affiliation(s)
- I Gussak
- Mayo Physician Alliance for Clinical Trials, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA.
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Bybee KA, Wright RS, Williams BA, Murphy JG, Holmes DR, Kopecky SL. Effect of concomitant or very early statin administration on in-hospital mortality and reinfarction in patients with acute myocardial infarction. Am J Cardiol 2001; 87:771-4, A7. [PMID: 11249901 DOI: 10.1016/s0002-9149(00)01501-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
In a retrospective analysis, 66 patients identified as having received a statin drug within 24 hours of admission for acute myocardial infarction were matched 3:1 with a control group of 198 patients not treated with a statin agent. End points of in-hospital mortality and in-hospital reinfarction were significantly lower in the statin-treated group, pointing to a benefit from very early statin treatment in acute myocardial infarction.
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Affiliation(s)
- K A Bybee
- Department of Internal Medicine, Mayo Physician Alliance for Clinical Trials, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Gussak I, Wright RS, Kopecky SL, Hammill SC. Exercise-induced ST segment elevation in Q wave leads in postinfarction patients: defining its meaning and utility in today's practice. Cardiology 2001; 93:205-9. [PMID: 11025345 DOI: 10.1159/000007028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Most attempts to identify qualitative and quantitative techniques for assessing myocardial viability and the likelihood of improved function after revascularization in patients with healed myocardial infarcts have focused on treatment strategies and prognosis. This review examines the true value of the electrocardiographic phenomenon of exercise-induced ST segment elevation (EISTE) in Q wave leads as a diagnostic tool for the assessment of myocardial viability. The prognostic potential and clinical utility of the EISTE phenomenon are inhibited both by the heart's electrophysiologic response to exercise-induced metabolic and hemodynamic changes, and by the ECG's limited facility in assessing myocardial preservation. The use of EISTE as an independent indicator for surgical intervention is proscribed by these limitations. The EISTE phenomenon could serve as a useful tool in the first line of discrimination in patients with healed Q wave myocardial infarction, and may justify further diagnostic work-up in patients under consideration for a revascularization procedure. In the era of sophisticated nuclear and echo techniques, accurate imaging studies should not be replaced by ECG analysis alone in the search for viable tissue, except when financial costs are of major importance.
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Affiliation(s)
- I Gussak
- Mayo Physician Alliance for Clinical Trials, Rochester, MN 55905, USA.
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Abstract
Intravenous fibrinolytic therapy is used widely in the treatment of ST-elevation acute myocardial infarction. Advances in this therapeutic modality during the past 5 years include new third-generation fibrinolytic agents and creative strategies to enhance administration and efficacy of fibrinolytic therapy. Several of the new agents allow for single- or double-bolus injection. A number of ongoing large randomized trials are attempting to determine whether the combination of fibrinolytic therapy with low-molecular-weight heparin or a glycoprotein IIb/IIIa antagonist enhances coronary reperfusion and reduces mortality and late reocclusion. One large prospective trial is investigating the potential benefit of prehospital administration of fibrinolytic therapy. This article summarizes recent safety and efficacy data on fibrinolytic therapy, with particular emphasis on the new third-generation fibrin-specific agents; reviews the preliminary data on facilitated fibrinolysis; and discusses the rationale for prehospital administration of fibrinolytic therapy.
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Affiliation(s)
- R S Wright
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minn 55905, USA.
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Gussak I, Wright RS, Kopecky SL. Should we revise our diagnostic methods for Q-wave myocardial infarction in the presence of right bundle branch block? Am Heart J 2000; 140:10-1. [PMID: 10874256 DOI: 10.1067/mhj.2000.106913] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
The evaluation of patients with recurrent chest pain accounts for a significant proportion of the $274 billion annual cost of cardiovascular services in the United States. Our investigation examines the impact of coronary angiography on subsequent use of medical resources for evaluation of chest pain symptoms. The study seeks to determine whether a finding of noncritical coronary artery disease on cardiac catheterization leads to a reduced use of resources for subsequent evaluation and treatment of chest pain syndromes. Our study included 22 consecutive patients who had sought evaluation for chest pain symptoms, and who had persistence of symptoms after functional testing. Cardiac catheterization demonstrated angiographically mild coronary artery disease (stenosis less than 50%) in these patients. The patient cohort accounted for 22 emergency room evaluations and 41 ambulatory clinic evaluations in the 2.5 years before cardiac catheterization. In the 2.5-year period after catheterization, these patients had only 3 emergency room visits and 1 ambulatory clinic visit for chest pain evaluation (P < 0.001). There was a significant reduction in the number of prescriptions written for topical and oral nitrates (32% precatheterization vs. 5% postcatheterization, P < 0.04), but not of beta-blockers (26% vs. 21%, P = 0.53) or calcium blockers (32% vs. 32%, P = 1.0). Furthermore, most of the 21 surviving patients were found subsequently to have a noncardiac basis for their pain: pericarditis was felt to be the cause of chest pain in 4 patients, pulmonary disease in 7 patients, and gastrointestinal conditions in 8 patients. Diagnostic coronary arteriography may identify a subset of patients in whom a finding of noncritical coronary artery disease leads to a reduction in physician visits for evaluation of chest pain syndromes and reduced use of nitrates. In addition, when coronary artery disease is known to be mild, a noncardiac etiology for the chest pain can be sought. These results may decrease the use of expensive medical resources and encourage full occupational and lifestyle rehabilitation.
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Affiliation(s)
- R S Wright
- Mayo Physician Alliance for Clinical Trials Coordinating Center, Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA.
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Abstract
A previously healthy woman developed severe dyspnea and was found to have restrictive lung disease and evidence of alveolitis. Open lung biopsy revealed extrinsic allergic alveolitis (hypersensitivity pneumonitis). The etiology was not initially apparent, but a home inspection showed an unusual mushroom growing in the patient's basement. Air sampling and serum precipitins against the fungal antigens confirmed that Pezizia domiciliana was the cause of the patient's hypersensitivity pneumonitis. This is the first described case of hypersensitivity pneumonitis cause by P. domiciliana. We speculate that unprecedented rainfall and flooding of the patient's basement as a result of El Niño rains produced ideal factors for the growth of this fungus.
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Affiliation(s)
- R S Wright
- Department of Medicine, University of California, Los Angeles School of Medicine, Los Angeles, California, USA.
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Wright RS, Kong EJ, Bahner MA, Clayton CA, Nuñez CM, Ramsey GH. Comparison of Analytical Techniques for Measuring Hydrocarbon Emissions from the Manufacture of Fiberglass-Reinforced Plastics. J Air Waste Manag Assoc 1999; 49:1110-1115. [PMID: 29073863 DOI: 10.1080/10473289.1999.10463888] [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] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Research Triangle Institute and the U.S. Environmental Protection Agency conducted several projects to measure hydrocarbon emissions associated with the manufacture of fiberglass-reinforced plastics. The purpose of these projects was to evaluate pollution prevention techniques to reduce emissions by altering raw materials, application equipment, and operator technique. Analytical techniques were developed to reduce the cost of these emission measurements. Emissions from a small test mold in a temporary total enclosure (TTE) correlated with emissions from full-size production molds in a separate TTE. Gravimetric mass balance measurements inside the TTE generally agreed to within ± 30 % with total hydrocarbon (THC) measurements in the TTE exhaust duct. Pure styrene evaporation tests served as quality control checks for THC measurements and generally agreed to within ± 5 %.
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Affiliation(s)
- Robert S Wright
- a Research Triangle Institute , Research Triangle Park , North Carolina , USA
| | - Emery J Kong
- a Research Triangle Institute , Research Triangle Park , North Carolina , USA
| | - Mark A Bahner
- a Research Triangle Institute , Research Triangle Park , North Carolina , USA
| | - C Andrew Clayton
- a Research Triangle Institute , Research Triangle Park , North Carolina , USA
| | - Carlos M Nuñez
- b U.S. Environmental Protection Agency , Research Triangle Park , North Carolina , USA
| | - Geddes H Ramsey
- b U.S. Environmental Protection Agency , Research Triangle Park , North Carolina , USA
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Nunez CM, Ramsey GH, Kong EJ, Bahner MA, Wright RS, Clayton CA, Baskir JN. Evaluation of pollution prevention options to reduce styrene emissions from fiber-reinforced plastic open molding processes. J Air Waste Manag Assoc 1999; 49:256-267. [PMID: 10202452 DOI: 10.1080/10473289.1999.10463800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Pollution prevention (P2) options to reduce styrene emissions, such as new materials and application equipment, are commercially available to the operators of open molding processes. However, information is lacking on the emissions reduction that these options can achieve. To meet this need, the U.S. Environmental Protection Agency's (EPA) Air Pollution Prevention and Control Division, working in collaboration with Research Triangle Institute, measured styrene emissions for several of these P2 options. In addition, the emission factors calculated from these test results were compared with the existing EPA emission factors for gel coat sprayup and resin applications. Results show that styrene emissions can be reduced by up to 52% by using controlled spraying (i.e., reducing overspray), low-styrene and styrene-suppressed materials, and nonatomizing application equipment. Also, calculated emission factors were 1.6-2.5 times greater than the mid-range EPA emission factors for the corresponding gel coat and resin application. These results indicate that facilities using existing EPA emission factors to estimate emissions in open molding processes are likely to underestimate actual emissions. Facilities should investigate the applicability and feasibility of these P2 options to reduce their styrene emissions.
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Affiliation(s)
- C M Nunez
- U.S. Environmental Protection Agency, National Risk Management Research Laboratory, Research Triangle Park, North Carolina, USA.
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Liebhaber MI, Wright RS, Gelberg HJ, Dyer Z, Kupperman JL. Polymyalgia, hypersensitivity pneumonitis and other reactions in patients receiving HMG-CoA reductase inhibitors: a report of ten cases. Chest 1999; 115:886-9. [PMID: 10084510 DOI: 10.1378/chest.115.3.886] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [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: 11/01/2022] Open
Abstract
Ten patients who take hydroxy-methylglutaryl coenzyme A reductase inhibitors, or statin medications, and experience adverse reactions are described. All patients experienced various manifestations of hypersensitivity while receiving the drugs. One patient is described with hypersensitivity pneumonitis, which was graphically demonstrated by both high resolution computerized axial tomography and open lung biopsy.
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Affiliation(s)
- M I Liebhaber
- Department of Medicine and Pediatrics, UCLA School of Medicine, Los Angeles, CA, USA.
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Wright RS, Howe GB, Jayanty RKM. Evaluation of a Portable Fourier Transform Infrared Gas Analyzer for Measurements of Air Toxics in Pollution Prevention Research. J Air Waste Manag Assoc 1998; 48:1077-1084. [PMID: 28076221 DOI: 10.1080/10473289.1998.10463764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
A portable Fourier transform infrared gas analyzer with a photoacoustic detector performed reliably during pollution prevention research at two industrial facilities. It exhibited good agreement (within approximately 6%) with other analytical instruments (dispersive infrared and flame ionization) when analyte concentrations were high and relatively steady. It did not show good agreement when analyte concentrations were low (approximately 10 parts per million [ppm]) or were varying rapidly (less than 1.5 min). The precision for total acetates measurements was estimated to be approximately 40 ppm for measurements in the 0- to 700-ppm region. The precision for styrene measurements was estimated to be approximately 10 ppm for measurements in the 0- to 90-ppm region.
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Affiliation(s)
- Robert S Wright
- a Research Triangle Institute , Research Triangle Park , North Carolina , USA
| | - Gary B Howe
- a Research Triangle Institute , Research Triangle Park , North Carolina , USA
| | - R K M Jayanty
- a Research Triangle Institute , Research Triangle Park , North Carolina , USA
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Wright RS, Howe GB, Jayanty RK. Evaluation of a portable Fourier transform infrared gas analyzer for measurements of air toxics in pollution prevention research. J Air Waste Manag Assoc 1998; 48:1077-1084. [PMID: 9846131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
A portable Fourier transform infrared gas analyzer with a photoacoustic detector performed reliably during pollution prevention research at two industrial facilities. It exhibited good agreement (within approximately 6%) with other analytical instruments (dispersive infrared and flame ionization) when analyte concentrations were high and relatively steady. It did not show good agreement when analyte concentrations were low (approximately 10 parts per million [ppm]) or were varying rapidly (less than 1.5 min). The precision for total acetates measurements was estimated to be approximately 40 ppm for measurements in the 0- to 700-ppm region. The precision for styrene measurements was estimated to be approximately 10 ppm for measurements in the 0- to 90-ppm region.
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Affiliation(s)
- RS Wright
- Research Triangle Institute, Research Triangle Park, North Carolina, USA
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44
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Verneuil A, Boeve BF, Fulgham JR, Johnson CM, Wright RS. Persistent cauda equina syndrome following bilateral aortoiliac dissection as a complication of cardiac angiography. Cathet Cardiovasc Diagn 1997; 40:377-9. [PMID: 9096939 DOI: 10.1002/(sici)1097-0304(199704)40:4<377::aid-ccd12>3.0.co;2-k] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Cardiac angiography is accepted as an invasive yet safe procedure with well-characterized complications. We present a complication heretofore not described to our knowledge, in which a patient experienced the cauda equina syndrome following bilateral aortoiliac dissection during cardiac angiography. Similarities are noted between this complication and those documented in abdominal aortic aneurysm repair surgery.
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Affiliation(s)
- A Verneuil
- Department of Otorhinolaryngology, University of California at Los Angeles, USA
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45
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Wright RS, Wei CM, Kim CH, Kinoshita M, Matsuda Y, Aarhus LL, Burnett JC, Miller WL. C-type natriuretic peptide-mediated coronary vasodilation: role of the coronary nitric oxide and particulate guanylate cyclase systems. J Am Coll Cardiol 1996; 28:1031-8. [PMID: 8837586 DOI: 10.1016/s0735-1097(96)00241-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES We tested the hypothesis that C-type natriuretic peptide (CNP) mediates coronary vasodilation through activation of cyclic guanosine monophosphate (cGMP) by way of particulate guanylate cyclase. BACKGROUND CNP has known peripheral vasodilator properties, and preliminary data have suggested that it can function as a coronary vasodilator. METHODS The actions of CNP were studied in instrumented dogs and in organ chamber rings in the presence and absence of a known antagonist to particulate guanylate cyclase, HS-142-1. Additionally, the actions of HS-142-1 were tested on acetylcholine-mediated coronary vasodilation, and immunohistochemical staining was utilized to localize the presence of CNP in the coronary endothelium. RESULTS CNP relaxed isolated coronary arteries with (mean +/- SEM 45.9 +/- 7%*) and without (72.0 +/- 7%*) an endothelium (*p < 0.05 for CNP effect alone, p < 0.05 for endothelium vs. no endothelium with CNP). Intracoronary infusions increased coronary blood flow (baseline, 64.6 +/- 5.1 ml/min; CNP-5, 79.9 +/- 6.1*; CNP-20, 103.3 +/- 13.6* [*p < 0.05 vs. baseline value]) and reduced coronary vascular resistance (baseline, 1.6 +/- 0.3 mm Hg/ml per min; CNP-5, 1.4 +/- 0.3*; CNP-20, 1.2 +/- 0.3*). Intracoronary injections increased coronary blood flow (delta baseline coronary flow, 30 +/- 9* ml/min [*p < 0.05]). HS-142-1 significantly attenuated these increases (delta coronary flow, 30 +/- 9* ml/min [CNP] to 14 +/- 6 [CNP + HS-142-1] [p < 0.05 CNP vs. CNP + HS-142-1]) and the relaxation of organ chamber rings (56 +/- 7% [CNP] to 18 +/- 6% [HS-142-1 + CNP]). Finally, CNP was localized to the coronary endothelium and smooth muscle by immunohistochemical staining. CONCLUSIONS CNP functions as a coronary vasodilator through activation of cGMP by way of particulate guanylate cyclase. CNP-mediated coronary vasodilation is attenuated by intracoronary HS-142-1. Intracoronary HS-142-1 does not affect acetylcholine-mediated coronary vasodilation. These observations support a role for exogenous CNP as a potent coronary vasodilator.
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Affiliation(s)
- R S Wright
- Department of Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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Wright RS, Quinones-Baldrich WJ, Anders AJ, Danovitch GM. Pleural effusion associated with ipsilateral breast and arm edema as a complication of subclavian vein catheterization and arteriovenous fistula formation for hemodialysis. Chest 1994; 106:950-2. [PMID: 8082387 DOI: 10.1378/chest.106.3.950] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
A 38-year-old woman with end-stage kidney disease presented with a pleural effusion and profound edema of the ipsilateral arm and breast. A patent hemodialysis arteriovenous fistula access was present in the involved extremity. Brachiocephalic vein stenosis, as a result of previous dialysis catheter placement in the subclavian vein, was demonstrated by ultrasound imaging and Doppler analysis. Takedown of the arteriovenous fistula in the edematous arm along with living-related kidney transplantation caused immediate resolution of the breast and arm edema and rapid clearing of the effusion. An anatomic explantation for the findings is offered.
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Affiliation(s)
- R S Wright
- Department of Medicine, UCLA School of Medicine, UCLA Hospital
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48
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Tashkin DP, Clements PJ, Wright RS, Gong H, Simmons MS, Lachenbruch PA, Furst DE. Interrelationships between pulmonary and extrapulmonary involvement in systemic sclerosis. A longitudinal analysis. Chest 1994; 105:489-95. [PMID: 8306752 DOI: 10.1378/chest.105.2.489] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
PURPOSE (1) To evaluate the relationship between the degree of pulmonary involvement by systemic sclerosis (SSc) and the degree of involvement of other organ systems by SSc at baseline. (2) To assess the degree of impairment in lung function at presentation and the annual rate of change in lung function to predict the rate of progression of involvement of extrapulmonary organ systems by SSc over time. (3) To determine whether survival in patients with SSc can be predicted from the degree of lung function impairment at baseline or from the annual rate of change in lung function. METHODS Semiquantitative indices of pulmonary and extrapulmonary involvement and pulmonary function tests (PFTs) were analyzed and compared in 62 nonsmoking scleroderma patients enrolled in a 3-year prospective drug trial, vs 47 in a "study group" who underwent serial evaluation. The other 16 "early withdrawals" withdrew prior to the second evaluation. The indices of organ system involvement were based on clinical, physiologic, and biochemical findings as previously published. The PFTs included total lung capacity (TLC), forced vital capacity (FVC), FEV1, and single-breath diffusing capacity for carbon monoxide (Dsb). Annualized rates of change in PFTs and indices of extrapulmonary involvement were calculated for each subject from data collected on at least 2 separate occasions at least 6 months apart. Spearman rank correlations were performed between individual baseline PFTs (expressed as percent predicted) and (a) indices of extrapulmonary involvement at baseline, (b) annualized rates of change in PFTs, and (c) annualized rates of change in indices of extrapulmonary involvement. Correlations also were performed between the rate of change in each lung function measure and rates of change in indices of extrapulmonary involvement. The ability of PFTs at baseline and their rates of change to predict cumulative survival was assessed by Cox stepwise regression. RESULTS The degree of impairment in baseline PFTs was related to involvement of the right side of the heart but not to other extrapulmonary system involvement. Baseline PFTs were not related to the rate of subsequent decline of lung function or worsening of extrapulmonary organ system involvement. Subsequent annual rates of decline in lung function were related to worsening skin and upper gastrointestinal involvement. Cumulative survival may be related to the rate of decline in DCO, TLC, and FVC, but was not predicted by impairment in any measure of lung function. CONCLUSION With the exception of involvement of the right side of the heart consistent with cor pulmonale, the degree of pulmonary involvement by SSc was not correlated with the extent of extrapulmonary involvement. The degree of pulmonary involvement by SSc did not predict subsequent worsening of either pulmonary or extrapulmonary involvement. Worsening pulmonary involvement by SSc, in general, does not correlate with worsening involvement of extrapulmonary organ systems, except for the skin and upper gastrointestinal tract. A rapid decline in DCO or lung volumes may predict poor survival.
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Affiliation(s)
- D P Tashkin
- Department of Medicine, UCLA School of Medicine 90024-1690
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Abstract
Atrial natriuretic peptide hormone of cardiac origin, which is released in response to atrial distension and serves to maintain sodium homeostasis and inhibit activation of the renin-angiotensin-aldosterone system. Congestive heart failure is a clinical syndrome characterized by increased cardiac volume and pressure overload with an inability to excrete a sodium load, which is associated with increased activity of systemic neurohumoral and local autocrine and paracrine mechanisms. Circulating atrial natriuretic peptide is greatly increased in congestive heart failure as a result of increased synthesis and release of this hormone. Atrial natriuretic peptide has emerged as an important diagnostic and prognostic serum marker in congestive heart failure. In early heart failure, it may play a key role in preserving the compensated state of asymptomatic left ventricular dysfunction. Despite increased circulating atrial natriuretic peptide in heart failure, the kidney retains sodium and is hyporesponsive to exogenous and endogenous atrial natriuretic peptide. The mechanism for the attenuated renal response is multifactorial and includes renal hypoperfusion, activation of the renin-angiotensin-aldosterone and sympathetic nervous systems. Therapeutic strategies to potentiate the biologic actions of atrial natriuretic peptide may prolong the asymptomatic phase and delay progression to overt congestive heart failure.
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Affiliation(s)
- R R Brandt
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905
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50
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Abstract
BACKGROUND Recent studies have reported that asymptomatic left ventricular dysfunction (ALVD) in humans is characterized by early neurohumoral activation. Specifically, atrial natriuretic factor (ANF) and norepinephrine are activated without activation of the renin-angiotensin-aldosterone system (RAAS). The current study describes hemodynamic and renal function associated with this neurohumoral profile in a canine model of early and presumably "asymptomatic" ventricular dysfunction. We hypothesized that the neurohumoral profile observed in ALVD is associated with preservation of renal function despite significant hemodynamic compromise. METHODS AND RESULTS ALVD was produced by ventricular pacing at 180 beats per minute for 10 days. Intravascular volume expansion was performed before and after producing ALVD in eight conscious dogs. The model of ALVD was characterized by decreases in ejection fraction (48 +/- 2 to 29 +/- 4%), cardiac output (4.64 +/- 0.29 to 2.89 +/- 0.17 L/min), and mean arterial pressure (119 +/- 4 to 108 +/- 4 mm Hg). Atrial pressures and systemic vascular resistance were increased. ANF (60 +/- 19 to 165 +/- 27 pg/mL) and norepinephrine (382 +/- 127 to 690 +/- 211 pg/mL) were activated, whereas the RAAS was not. Creatinine clearance and sodium excretion (UNa V) were unchanged after producing ALVD. The natriuretic response to volume expansion in ALVD was completely intact, with increases in UNa V similar to that observed with volume expansion in ALVD was completely intact, with increases in UNa V similar to that observed with volume expansion before producing ALVD. CONCLUSIONS The current study demonstrates that significant ventricular dysfunction with peripheral vasoconstriction can be associated with normal renal function and thus suggests an important functional role for the neurohumoral profile of ALVD in preserving sodium balance.
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Affiliation(s)
- M M Redfield
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minn
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