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Matza MA, Dagincourt N, Mohan SV, Pavlov A, Han J, Stone JH, Unizony SH. Outcomes during and after long-term tocilizumab treatment in patients with giant cell arteritis. RMD Open 2023; 9:rmdopen-2022-002923. [PMID: 37024237 PMCID: PMC10083869 DOI: 10.1136/rmdopen-2022-002923] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/08/2023] [Indexed: 04/08/2023] Open
Abstract
OBJECTIVE To assess outcomes in giant cell arteritis (GCA) patients during and after long-term tocilizumab (TCZ) treatment. METHODS Retrospective analysis of GCA patients treated with TCZ at a single centre (2010-2022). Time to relapse and annualised relapse rate during and after TCZ treatment, prednisone use, and safety were assessed. Relapse was defined as reappearance of any GCA clinical manifestation that required treatment intensification, regardless of C reactive protein levels and erythrocyte sedimentation rate. RESULTS Sixty-five GCA patients were followed for a mean (SD) of 3.1 (1.6) years. The mean duration of the initial TCZ course was 1.9 (1.1) years. The Kaplan-Meier (KM)-estimated relapse rate at 18 months on TCZ was 15.5%. The first TCZ course was discontinued due to satisfactory remission achievement in 45 (69.2%) patients and adverse events in 6 (9.2%) patients. KM-estimated relapse rate at 18 months after TCZ discontinuation was 47.3%. Compared with patients stopping TCZ at or before 12 months of treatment, the multivariable adjusted HR (95% CI) for relapse in patients on TCZ beyond 12 months was 0.01 (0.00 to 0.28; p=0.005). Thirteen patients received >1 TCZ course. Multivariable adjusted annualised relapse rates (95% CI) in all periods on and off TCZ aggregated were 0.1 (0.1 to 0.2) and 0.4 (0.3 to 0.7), respectively (p=0.0004). Prednisone was discontinued in 76.9% of patients. During the study, 13 serious adverse events occurred in 11 (16.9%) patients. CONCLUSION Long-term TCZ treatment was associated with remission maintenance in most patients with GCA. The estimated relapse rate by 18 months after TCZ discontinuation was 47.3%.
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Affiliation(s)
- Mark A Matza
- Rheumatology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Andrey Pavlov
- Everest Clinical Research Corporation, Markham, Ontario, Canada
| | - Jian Han
- Genentech Inc, South San Francisco, California, USA
| | - John H Stone
- Rheumatology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sebastian H Unizony
- Rheumatology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Mohan SV, Freedman J. A Review of the Evolving Landscape of Inclusive Research and Improved Clinical Trial Access. Clin Pharmacol Ther 2023; 113:518-527. [PMID: 36536992 DOI: 10.1002/cpt.2832] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022]
Abstract
Current clinical research does not reflect the diversity of patient populations, despite continued recommendations to increase enrollment of under-represented racial and ethnic groups. The ramifications of this lack of trial diversity are important because of potential differences between races and ethnicities in response to therapies, which have been observed for drugs across indications. Nonrepresentative research populations limit the generalizability of study results, which may lead to questions about safety and efficacy in certain subgroups of patients and hinder regulators, healthcare providers, and patients in their ability to adequately consider the benefits and risks of a therapeutic treatment across all populations. Renewed efforts to address healthcare disparities and increase diversity in clinical trials have demonstrated that inclusive trials are achievable and can provide scientifically rigorous results, and, thus, should stimulate greater action across all stakeholders. Ensuring that studies throughout the clinical development process include representative populations is a scientific imperative to advance health equity, racial justice, and trust in the safety and efficacy of medical therapies. This article reviews the long-standing lack of diversity and barriers to enrollment of diverse and representative populations in clinical trials, outlines the current evolving trial landscape and the efforts of stakeholders, and provides examples from scientifically rigorous inclusive trials. The goal is to share learnings in a wider context of opportunities to enhance diversity, equity, and inclusion in clinical development while ensuring the safety and efficacy of medical therapies in all populations of patients, and in doing so, provide wider patient access to therapeutic treatments.
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Butler MJ, Best JH, Mohan SV, Jonas JA, Arader L, Yeh J. Mechanical ventilation for COVID-19: Outcomes following discharge from inpatient treatment. PLoS One 2023; 18:e0277498. [PMID: 36608047 PMCID: PMC9821470 DOI: 10.1371/journal.pone.0277498] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 10/01/2022] [Indexed: 01/07/2023] Open
Abstract
Though mechanical ventilation (MV) is used to treat patients with severe coronavirus disease 2019 (COVID-19), little is known about the long-term health implications of this treatment. Our objective was to determine the association between MV for treatment of COVID-19 and likelihood of hospital readmission, all-cause mortality, and reason for readmission. This study was a longitudinal observational design with electronic health record (EHR) data collected between 3/1/2020 and 1/31/2021. Participants included 17,652 patients hospitalized for COVID-19 during this period who were followed through 6/30/2021. The primary outcome was readmission to inpatient care following discharge. Secondary outcomes included all-cause mortality and reason for readmission. Rates of readmission and mortality were compared between ventilated and non-ventilated patients using Cox proportional hazards regression models. Differences in reasons for readmission by MV status were compared using multinomial logistic regression. Patient characteristics and measures of illness severity were balanced between those who were mechanically ventilated and those who were not utilizing 1-to-1 propensity score matching. The sample had a median age of 63 and was 47.1% female. There were 1,131 (6.4%) patients who required MV during their initial hospitalization. Rates (32.1% versus 9.9%) and hazard of readmission were greater for patients requiring MV in the propensity score-matched samples [hazard ratio (95% confidence interval) = 3.34 (2.72-4.10)]. Rates (15.3% versus 3.4%) and hazard [hazard ratio (95% confidence interval) = 3.12 (2.32-4.20)] of all-cause mortality were also associated with MV status. Ventilated patients were more likely to be readmitted for reasons which were classified as COVID-19, infectious diseases, and respiratory diagnoses compared to non-ventilated patients. Mechanical ventilation is a necessary treatment for severely ill patients. However, it may be associated with adverse outcomes including hospital readmission and death. More intense post-discharge monitoring may be warranted to decrease this associational finding.
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Affiliation(s)
- Mark J. Butler
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States of America
- * E-mail:
| | - Jennie H. Best
- Genentech Inc., South San Francisco, CA, United States of America
| | - Shalini V. Mohan
- Genentech Inc., South San Francisco, CA, United States of America
| | - Jennifer A. Jonas
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States of America
| | - Lindsay Arader
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States of America
- St. John’s University, Jamaica, NY, United States of America
| | - Jackson Yeh
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States of America
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Shankar-Hari M, Vale CL, Godolphin PJ, Fisher D, Higgins JPT, Spiga F, Savovic J, Tierney J, Baron G, Benbenishty JS, Berry LR, Broman N, Cavalcanti AB, Colman R, De Buyser SL, Derde LPG, Domingo P, Omar SF, Fernandez-Cruz A, Feuth T, Garcia F, Garcia-Vicuna R, Gonzalez-Alvaro I, Gordon AC, Haynes R, Hermine O, Horby PW, Horick NK, Kumar K, Lambrecht BN, Landray MJ, Leal L, Lederer DJ, Lorenzi E, Mariette X, Merchante N, Misnan NA, Mohan SV, Nivens MC, Oksi J, Perez-Molina JA, Pizov R, Porcher R, Postma S, Rajasuriar R, Ramanan AV, Ravaud P, Reid PD, Rutgers A, Sancho-Lopez A, Seto TB, Sivapalasingam S, Soin AS, Staplin N, Stone JH, Strohbehn GW, Sunden-Cullberg J, Torre-Cisneros J, Tsai LW, van Hoogstraten H, van Meerten T, Veiga VC, Westerweel PE, Murthy S, Diaz JV, Marshall JC, Sterne JAC. Association Between Administration of IL-6 Antagonists and Mortality Among Patients Hospitalized for COVID-19: A Meta-analysis. JAMA 2021; 326:499-518. [PMID: 34228774 PMCID: PMC8261689 DOI: 10.1001/jama.2021.11330] [Citation(s) in RCA: 397] [Impact Index Per Article: 132.3] [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] [Received: 05/21/2021] [Accepted: 06/24/2021] [Indexed: 12/23/2022]
Abstract
Importance Clinical trials assessing the efficacy of IL-6 antagonists in patients hospitalized for COVID-19 have variously reported benefit, no effect, and harm. Objective To estimate the association between administration of IL-6 antagonists compared with usual care or placebo and 28-day all-cause mortality and other outcomes. Data Sources Trials were identified through systematic searches of electronic databases between October 2020 and January 2021. Searches were not restricted by trial status or language. Additional trials were identified through contact with experts. Study Selection Eligible trials randomly assigned patients hospitalized for COVID-19 to a group in whom IL-6 antagonists were administered and to a group in whom neither IL-6 antagonists nor any other immunomodulators except corticosteroids were administered. Among 72 potentially eligible trials, 27 (37.5%) met study selection criteria. Data Extraction and Synthesis In this prospective meta-analysis, risk of bias was assessed using the Cochrane Risk of Bias Assessment Tool. Inconsistency among trial results was assessed using the I2 statistic. The primary analysis was an inverse variance-weighted fixed-effects meta-analysis of odds ratios (ORs) for 28-day all-cause mortality. Main Outcomes and Measures The primary outcome measure was all-cause mortality at 28 days after randomization. There were 9 secondary outcomes including progression to invasive mechanical ventilation or death and risk of secondary infection by 28 days. Results A total of 10 930 patients (median age, 61 years [range of medians, 52-68 years]; 3560 [33%] were women) participating in 27 trials were included. By 28 days, there were 1407 deaths among 6449 patients randomized to IL-6 antagonists and 1158 deaths among 4481 patients randomized to usual care or placebo (summary OR, 0.86 [95% CI, 0.79-0.95]; P = .003 based on a fixed-effects meta-analysis). This corresponds to an absolute mortality risk of 22% for IL-6 antagonists compared with an assumed mortality risk of 25% for usual care or placebo. The corresponding summary ORs were 0.83 (95% CI, 0.74-0.92; P < .001) for tocilizumab and 1.08 (95% CI, 0.86-1.36; P = .52) for sarilumab. The summary ORs for the association with mortality compared with usual care or placebo in those receiving corticosteroids were 0.77 (95% CI, 0.68-0.87) for tocilizumab and 0.92 (95% CI, 0.61-1.38) for sarilumab. The ORs for the association with progression to invasive mechanical ventilation or death, compared with usual care or placebo, were 0.77 (95% CI, 0.70-0.85) for all IL-6 antagonists, 0.74 (95% CI, 0.66-0.82) for tocilizumab, and 1.00 (95% CI, 0.74-1.34) for sarilumab. Secondary infections by 28 days occurred in 21.9% of patients treated with IL-6 antagonists vs 17.6% of patients treated with usual care or placebo (OR accounting for trial sample sizes, 0.99; 95% CI, 0.85-1.16). Conclusions and Relevance In this prospective meta-analysis of clinical trials of patients hospitalized for COVID-19, administration of IL-6 antagonists, compared with usual care or placebo, was associated with lower 28-day all-cause mortality. Trial Registration PROSPERO Identifier: CRD42021230155.
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Affiliation(s)
- Manu Shankar-Hari
- Guy's and St Thomas' NHS Foundation Trust, ICU Support Offices, St Thomas' Hospital, London, England
- School of Immunology and Microbial Sciences, Kings College London, London, England
| | - Claire L Vale
- University College London, MRC Clinical Trials Unit at UCL, London, England
| | - Peter J Godolphin
- University College London, MRC Clinical Trials Unit at UCL, London, England
| | - David Fisher
- University College London, MRC Clinical Trials Unit at UCL, London, England
| | - Julian P T Higgins
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
- NIHR Bristol Biomedical Research Centre, Bristol, England
- National Institute for Health Research Applied Research Collaboration West at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England
| | | | - Jelena Savovic
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
- National Institute for Health Research Applied Research Collaboration West at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England
| | - Jayne Tierney
- University College London, MRC Clinical Trials Unit at UCL, London, England
| | - Gabriel Baron
- Assistance Publique-Hôpitaux de Paris, Centre for Clinical Epidemiology, Hôpital Hôtel-Dieu, Paris, France
- INSERM UMRS-1153, Centre de Recherche Epidémiologie et Statistique Université de Paris, METHODS Team, Paris, France
| | - Julie S Benbenishty
- Department of Nursing, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | | | - Niklas Broman
- Turku University Hospital, Department of Infectious Diseases, Turku, Finland
| | | | - Roos Colman
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | | | - Lennie P G Derde
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Pere Domingo
- Department of Infectious Diseases, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Ana Fernandez-Cruz
- Infectious Diseases Unit, Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Thijs Feuth
- Department of Pulmonary Diseases, Turku University Hospital, Turku, Finland
| | - Felipe Garcia
- Infectious Diseases Department, Hospital Clinic Barcelona-IDIBAPS, Barcelona, Spain
| | | | | | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, England
| | - Richard Haynes
- Nuffield Department of Population Health, University of Oxford, Oxford, England
- MRC Population Health Research Unit, University of Oxford, Oxford, England
| | - Olivier Hermine
- Department of Hematology, Necker Hospital, Paris, France
- Imagine Institute, University of Paris, INSERM U1153, Paris, France
| | - Peter W Horby
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England
- International Severe Acute Respiratory and Emerging Infections Consortium, University of Oxford, Oxford, England
- Pandemic Sciences Centre, University of Oxford, Oxford, England
| | - Nora K Horick
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Kuldeep Kumar
- Medanta-The Medicity, Institute of Liver Transplantation and Regenerative Medicine, Gurugram, India
- Research Department, Medanta Institute of Education and Research, Gurugram, India
| | - Bart N Lambrecht
- VIB Center for Inflammation Research, Ghent University, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | - Martin J Landray
- Nuffield Department of Population Health, University of Oxford, Oxford, England
- MRC Population Health Research Unit, University of Oxford, Oxford, England
| | - Lorna Leal
- Infectious Diseases Department, Hospital Clinic Barcelona-IDIBAPS, Barcelona, Spain
| | | | | | - Xavier Mariette
- Centre for Immunology of Viral Infections and Autoimmune Diseases, Université Paris-Saclay, INSERM UMR1184, Le Kremlin-Bicêtre, Paris, France
- Department of Rheumatology, Assistance Publique-Hôpitaux de Paris, Le Le Kremlin-Bicêtre, Paris, France
| | - Nicolas Merchante
- Unit of Infectious Diseases and Microbiology, Valme University Hospital, Institute of Biomedicine of Sevilla, Seville, Spain
| | | | | | | | - Jarmo Oksi
- Turku University Hospital, Department of Infectious Diseases, Turku, Finland
| | - Jose A Perez-Molina
- Hospital Universitario Ramón y Cajal IRYCIS, Infectious Diseases Department, Madrid, Spain
| | - Reuven Pizov
- Department of Anesthesilogy Critical Care and Pain Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Raphael Porcher
- Assistance Publique-Hôpitaux de Paris, Centre for Clinical Epidemiology, Hôpital Hôtel-Dieu, Paris, France
- INSERM UMRS-1153, Centre de Recherche Epidémiologie et Statistique Université de Paris, METHODS Team, Paris, France
- University de Paris, CRESS UMR1153, INSERM, INRA, Paris, France
| | - Simone Postma
- Department of Rheumatology and Clinical Immunology, University Hospital Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Reena Rajasuriar
- Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Australia
| | - Athimalaipet V Ramanan
- Department of Paediatric Rheumatology, University Hospitals Bristol, NHS Foundation Trust, Bristol, England
| | - Philippe Ravaud
- Assistance Publique-Hôpitaux de Paris, Centre for Clinical Epidemiology, Hôpital Hôtel-Dieu, Paris, France
- INSERM UMRS-1153, Centre de Recherche Epidémiologie et Statistique Université de Paris, METHODS Team, Paris, France
- University de Paris, CRESS UMR1153, INSERM, INRA, Paris, France
| | - Pankti D Reid
- Department of Medicine (Rheumatology), University of Chicago Medical Center, Chicago, Illinois
| | - Abraham Rutgers
- Department of Rheumatology and Clinical Immunology, University Hospital Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Aranzazu Sancho-Lopez
- Department of Clinical Pharmacology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Todd B Seto
- Center for Outcomes Research and Evaluation, Queen's Medical Center, Honolulu, Hawaii
| | | | - Arvinder Singh Soin
- Medanta-The Medicity, Institute of Liver Transplantation and Regenerative Medicine, Gurugram, India
| | - Natalie Staplin
- Nuffield Department of Population Health, University of Oxford, Oxford, England
- MRC Population Health Research Unit, University of Oxford, Oxford, England
| | - John H Stone
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston
- Department of Medicine (Rheumatology), Massachusetts General Hospital, Boston
| | - Garth W Strohbehn
- VA Ann Arbor, Center for Clinical Management and Research, Ann Arbor, Michigan
| | - Jonas Sunden-Cullberg
- Department of Infectious Diseases, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Julian Torre-Cisneros
- Maimonides Institute for Biomedical Research of Cordoba/Reina Sofia University Hospital/University of Córdoba, Córdoba, Spain
| | | | | | - Tom van Meerten
- Department of Hematology, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Peter E Westerweel
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Srinivas Murthy
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Janet V Diaz
- Clinical Unit, Health Emergencies Programme, World Health Organization, Geneva, Switzerland
| | - John C Marshall
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan A C Sterne
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
- NIHR Bristol Biomedical Research Centre, Bristol, England
- Health Data Research UK South-West, Bristol, England
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Best JH, Kong AM, Kaplan-Lewis E, Brawley OW, Baden R, Zazzali JL, Miller KS, Loveless J, Jariwala-Parikh K, Mohan SV. Treatment patterns in US patients hospitalized with COVID-19 and pulmonary involvement. J Med Virol 2021; 93:5367-5375. [PMID: 33913536 PMCID: PMC8242555 DOI: 10.1002/jmv.27049] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/01/2021] [Accepted: 04/26/2021] [Indexed: 12/25/2022]
Abstract
This study describes the baseline characteristics and treatment patterns of US patients hospitalized with a diagnosis of coronavirus disease 2019 (COVID‐19) and pulmonary involvement. Patients hospitalized with pulmonary involvement due to COVID‐19 (first hospitalization) were identified in the IBM Explorys® electronic health records database. Demographics, baseline clinical characteristics, and in‐hospital medications were assessed. For evaluation of in‐hospital medications, results were stratified by race, geographic region, age, and month of admission. Of 6564 hospitalized patients with COVID‐19‐related pulmonary involvement, 50.4% were male, and mean (SD) age was 62.6 (16.4) years; 75.2% and 23.6% of patients were from the South and Midwest, respectively, and 50.2% of patients were African American. Compared with African American patients, a numerically higher proportion of White patients received dexamethasone (19.7% vs. 31.8%, respectively), nonsteroidal anti‐inflammatory drugs (NSAIDs; 27.1% vs. 34.9%), bronchodilators (19.8% vs. 29.5%), and remdesivir (9.3% vs. 21.0%). Numerically higher proportions of White patients than African American patients received select medications in the South but not in the Midwest. Compared with patients in the South, a numerically higher proportion of patients in the Midwest received dexamethasone (20.1% vs. 34.5%, respectively), NSAIDs (19.6% vs. 55.7%), bronchodilators (15.9% vs. 41.3%), and remdesivir (10.6% vs. 23.1%). Inpatient use of hydroxychloroquine decreased over time, whereas the use of dexamethasone and remdesivir increased over time. Among US patients predominantly from the South and Midwest hospitalized with COVID‐19 and pulmonary involvement, differences were seen in medication use between different races, geographic regions, and months of hospitalization. In this retrospective, electronic health records study, including US patients hospitalized with COVID‐19 and pulmonary involvement, a numerically higher proportion of patients in the Midwest received dexamethasone, nonsteroidal anti‐inflammatory drugs, bronchodilators, and remdesivir than patients in the South.
Analysis of select medication use by the US region showed that, in the South, numerically higher proportions of White patients than African American patients received multiple select medications, including dexamethasone and remdesivir; however, in the Midwest, select medication use was generally comparable among White and African American patients.
These study results demonstrating differences in rates of medication use between different geographic regions, in addition to differences in the race within some regions and among different age groups, warrant further study.
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Affiliation(s)
- Jennie H Best
- US Medical Affairs, Genentech, Inc, South San Francisco, California, USA
| | - Amanda M Kong
- Life Sciences, IBM Watson Health, Cambridge, Massachusetts, USA
| | - Emma Kaplan-Lewis
- Department of Medicine, NYC Health and Hospitals, Elmhurst Hospital Center, Queens, New York, USA
| | - Otis W Brawley
- Department of Oncology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Rachel Baden
- Department of Medicine, Alameda Health System-Highland Hospital, Oakland, California, USA
| | - James L Zazzali
- US Medical Affairs, Genentech, Inc, South San Francisco, California, USA
| | - Karen S Miller
- Idaho Pulmonary Associates, St. Luke's Health System, Boise, Idaho, USA
| | - James Loveless
- Idaho Pulmonary Associates, St. Luke's Health System, Boise, Idaho, USA
| | | | - Shalini V Mohan
- US Medical Affairs, Genentech, Inc, South San Francisco, California, USA
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Craig G, Knapp K, Salim B, Mohan SV, Michalska M. Treatment Patterns, Disease Burden, and Outcomes in Patients with Giant Cell Arteritis and Polymyalgia Rheumatica: A Real-World, Electronic Health Record-Based Study of Patients in Clinical Practice. Rheumatol Ther 2021; 8:529-539. [PMID: 33638132 PMCID: PMC7991019 DOI: 10.1007/s40744-021-00290-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/10/2021] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Because of the chronic nature of giant cell arteritis (GCA) and/or polymyalgia rheumatica (PMR), patients may require continued glucocorticoid treatment to achieve treatment targets or prevent disease relapse, resulting in high cumulative doses. This study evaluated patterns of glucocorticoid use and outcomes in patients with GCA, PMR, or both. METHODS This retrospective study used electronic medical records from a US rheumatology clinic utilizing the JointMan® (Discus Analytics, LLC) rheumatology software. Patients aged ≥ 50 years with a diagnosis of GCA or PMR and ≥ 1 entry for a glucocorticoid prescription after diagnosis were included. Outcomes at 2 years after glucocorticoid initiation included the proportion of patients discontinuing glucocorticoids for ≥ 6 months, proportion of patients discontinuing glucocorticoids for ≥ 6 months and remaining off glucocorticoids at 2 years, time to discontinuation of glucocorticoids for ≥ 6 months, and prednisone dose and were compared between patients with GCA only, PMR only, or GCA and PMR. RESULTS At 2 years after the initiation of glucocorticoids, 32% of patients (26/91) with GCA, 32% (248/779) with PMR, and 27% (26/97) with GCA and PMR discontinued glucocorticoids for ≥ 6 months; 17, 23, and 18% discontinued glucocorticoids for ≥ 6 months and remained off glucocorticoids at 2 years, respectively. Median (range) time to discontinuation of glucocorticoids for ≥ 6 months was 202.5 (0-635) days and shorter in patients with both GCA and PMR vs. GCA or PMR only. The majority of patients required daily prednisone at 2 years, with similar doses observed between groups. CONCLUSIONS Fewer than one-third of patients with GCA and/or PMR discontinued glucocorticoids for ≥ 6 months; the majority of patients required prednisone therapy for ≥ 2 years after its initiation. These data highlight the need for the use of more efficacious and glucocorticoid-sparing therapies in patients with GCA and/or PMR.
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Affiliation(s)
- Gary Craig
- Arthritis Northwest, PLLC, Spokane, WA, USA.
- Discus Analytics, LLC, Spokane, WA, USA.
| | | | - Bob Salim
- Axio Research, LLC, Seattle, WA, USA
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Salama C, Han J, Yau L, Reiss WG, Kramer B, Neidhart JD, Criner GJ, Kaplan-Lewis E, Baden R, Pandit L, Cameron ML, Garcia-Diaz J, Chávez V, Mekebeb-Reuter M, Lima de Menezes F, Shah R, González-Lara MF, Assman B, Freedman J, Mohan SV. Tocilizumab in Patients Hospitalized with Covid-19 Pneumonia. N Engl J Med 2021; 384:20-30. [PMID: 33332779 PMCID: PMC7781101 DOI: 10.1056/nejmoa2030340] [Citation(s) in RCA: 837] [Impact Index Per Article: 279.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Coronavirus disease 2019 (Covid-19) pneumonia is often associated with hyperinflammation. Despite the disproportionate incidence of Covid-19 among underserved and racial and ethnic minority populations, the safety and efficacy of the anti-interleukin-6 receptor antibody tocilizumab in patients from these populations who are hospitalized with Covid-19 pneumonia are unclear. METHODS We randomly assigned (in a 2:1 ratio) patients hospitalized with Covid-19 pneumonia who were not receiving mechanical ventilation to receive standard care plus one or two doses of either tocilizumab (8 mg per kilogram of body weight intravenously) or placebo. Site selection was focused on the inclusion of sites enrolling high-risk and minority populations. The primary outcome was mechanical ventilation or death by day 28. RESULTS A total of 389 patients underwent randomization, and the modified intention-to-treat population included 249 patients in the tocilizumab group and 128 patients in the placebo group; 56.0% were Hispanic or Latino, 14.9% were Black, 12.7% were American Indian or Alaska Native, 12.7% were non-Hispanic White, and 3.7% were of other or unknown race or ethnic group. The cumulative percentage of patients who had received mechanical ventilation or who had died by day 28 was 12.0% (95% confidence interval [CI], 8.5 to 16.9) in the tocilizumab group and 19.3% (95% CI, 13.3 to 27.4) in the placebo group (hazard ratio for mechanical ventilation or death, 0.56; 95% CI, 0.33 to 0.97; P = 0.04 by the log-rank test). Clinical failure as assessed in a time-to-event analysis favored tocilizumab over placebo (hazard ratio, 0.55; 95% CI, 0.33 to 0.93). Death from any cause by day 28 occurred in 10.4% of the patients in the tocilizumab group and 8.6% of those in the placebo group (weighted difference, 2.0 percentage points; 95% CI, -5.2 to 7.8). In the safety population, serious adverse events occurred in 38 of 250 patients (15.2%) in the tocilizumab group and 25 of 127 patients (19.7%) in the placebo group. CONCLUSIONS In hospitalized patients with Covid-19 pneumonia who were not receiving mechanical ventilation, tocilizumab reduced the likelihood of progression to the composite outcome of mechanical ventilation or death, but it did not improve survival. No new safety signals were identified. (Funded by Genentech; EMPACTA ClinicalTrials.gov number, NCT04372186.).
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Affiliation(s)
- Carlos Salama
- From Elmhurst Hospital Center-Icahn School of Medicine at Mount Sinai Hospital (C.S.), and Elmhurst Hospital Center-New York City Health and Hospitals (E.K.-L.) - both in New York; Genentech, South San Francisco (J.H., L.Y., W.G.R., B.K., B.A., J.F., S.V.M.), and Highland Hospital, Oakland (R.B.) - both in California; San Juan Oncology Associates, Farmington, NM (J.D.N); Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); Michael E. DeBakey Houston VA Medical Center, Houston (L.P.); Holy Cross Health, Silver Spring, MD (M.L.C.); Ochsner Clinic Foundation, New Orleans (J.G.-D.); Central Military Hospital, Lima, Peru (V.C.); Stellenbosch University, Cape Town, South Africa (M.M.-R); BR Trials-Clinical Research, São Paulo (F.L.M.); Aga Khan University Hospital, Nairobi (R.S.); and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City (M.F.G.-L.)
| | - Jian Han
- From Elmhurst Hospital Center-Icahn School of Medicine at Mount Sinai Hospital (C.S.), and Elmhurst Hospital Center-New York City Health and Hospitals (E.K.-L.) - both in New York; Genentech, South San Francisco (J.H., L.Y., W.G.R., B.K., B.A., J.F., S.V.M.), and Highland Hospital, Oakland (R.B.) - both in California; San Juan Oncology Associates, Farmington, NM (J.D.N); Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); Michael E. DeBakey Houston VA Medical Center, Houston (L.P.); Holy Cross Health, Silver Spring, MD (M.L.C.); Ochsner Clinic Foundation, New Orleans (J.G.-D.); Central Military Hospital, Lima, Peru (V.C.); Stellenbosch University, Cape Town, South Africa (M.M.-R); BR Trials-Clinical Research, São Paulo (F.L.M.); Aga Khan University Hospital, Nairobi (R.S.); and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City (M.F.G.-L.)
| | - Linda Yau
- From Elmhurst Hospital Center-Icahn School of Medicine at Mount Sinai Hospital (C.S.), and Elmhurst Hospital Center-New York City Health and Hospitals (E.K.-L.) - both in New York; Genentech, South San Francisco (J.H., L.Y., W.G.R., B.K., B.A., J.F., S.V.M.), and Highland Hospital, Oakland (R.B.) - both in California; San Juan Oncology Associates, Farmington, NM (J.D.N); Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); Michael E. DeBakey Houston VA Medical Center, Houston (L.P.); Holy Cross Health, Silver Spring, MD (M.L.C.); Ochsner Clinic Foundation, New Orleans (J.G.-D.); Central Military Hospital, Lima, Peru (V.C.); Stellenbosch University, Cape Town, South Africa (M.M.-R); BR Trials-Clinical Research, São Paulo (F.L.M.); Aga Khan University Hospital, Nairobi (R.S.); and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City (M.F.G.-L.)
| | - William G Reiss
- From Elmhurst Hospital Center-Icahn School of Medicine at Mount Sinai Hospital (C.S.), and Elmhurst Hospital Center-New York City Health and Hospitals (E.K.-L.) - both in New York; Genentech, South San Francisco (J.H., L.Y., W.G.R., B.K., B.A., J.F., S.V.M.), and Highland Hospital, Oakland (R.B.) - both in California; San Juan Oncology Associates, Farmington, NM (J.D.N); Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); Michael E. DeBakey Houston VA Medical Center, Houston (L.P.); Holy Cross Health, Silver Spring, MD (M.L.C.); Ochsner Clinic Foundation, New Orleans (J.G.-D.); Central Military Hospital, Lima, Peru (V.C.); Stellenbosch University, Cape Town, South Africa (M.M.-R); BR Trials-Clinical Research, São Paulo (F.L.M.); Aga Khan University Hospital, Nairobi (R.S.); and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City (M.F.G.-L.)
| | - Benjamin Kramer
- From Elmhurst Hospital Center-Icahn School of Medicine at Mount Sinai Hospital (C.S.), and Elmhurst Hospital Center-New York City Health and Hospitals (E.K.-L.) - both in New York; Genentech, South San Francisco (J.H., L.Y., W.G.R., B.K., B.A., J.F., S.V.M.), and Highland Hospital, Oakland (R.B.) - both in California; San Juan Oncology Associates, Farmington, NM (J.D.N); Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); Michael E. DeBakey Houston VA Medical Center, Houston (L.P.); Holy Cross Health, Silver Spring, MD (M.L.C.); Ochsner Clinic Foundation, New Orleans (J.G.-D.); Central Military Hospital, Lima, Peru (V.C.); Stellenbosch University, Cape Town, South Africa (M.M.-R); BR Trials-Clinical Research, São Paulo (F.L.M.); Aga Khan University Hospital, Nairobi (R.S.); and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City (M.F.G.-L.)
| | - Jeffrey D Neidhart
- From Elmhurst Hospital Center-Icahn School of Medicine at Mount Sinai Hospital (C.S.), and Elmhurst Hospital Center-New York City Health and Hospitals (E.K.-L.) - both in New York; Genentech, South San Francisco (J.H., L.Y., W.G.R., B.K., B.A., J.F., S.V.M.), and Highland Hospital, Oakland (R.B.) - both in California; San Juan Oncology Associates, Farmington, NM (J.D.N); Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); Michael E. DeBakey Houston VA Medical Center, Houston (L.P.); Holy Cross Health, Silver Spring, MD (M.L.C.); Ochsner Clinic Foundation, New Orleans (J.G.-D.); Central Military Hospital, Lima, Peru (V.C.); Stellenbosch University, Cape Town, South Africa (M.M.-R); BR Trials-Clinical Research, São Paulo (F.L.M.); Aga Khan University Hospital, Nairobi (R.S.); and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City (M.F.G.-L.)
| | - Gerard J Criner
- From Elmhurst Hospital Center-Icahn School of Medicine at Mount Sinai Hospital (C.S.), and Elmhurst Hospital Center-New York City Health and Hospitals (E.K.-L.) - both in New York; Genentech, South San Francisco (J.H., L.Y., W.G.R., B.K., B.A., J.F., S.V.M.), and Highland Hospital, Oakland (R.B.) - both in California; San Juan Oncology Associates, Farmington, NM (J.D.N); Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); Michael E. DeBakey Houston VA Medical Center, Houston (L.P.); Holy Cross Health, Silver Spring, MD (M.L.C.); Ochsner Clinic Foundation, New Orleans (J.G.-D.); Central Military Hospital, Lima, Peru (V.C.); Stellenbosch University, Cape Town, South Africa (M.M.-R); BR Trials-Clinical Research, São Paulo (F.L.M.); Aga Khan University Hospital, Nairobi (R.S.); and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City (M.F.G.-L.)
| | - Emma Kaplan-Lewis
- From Elmhurst Hospital Center-Icahn School of Medicine at Mount Sinai Hospital (C.S.), and Elmhurst Hospital Center-New York City Health and Hospitals (E.K.-L.) - both in New York; Genentech, South San Francisco (J.H., L.Y., W.G.R., B.K., B.A., J.F., S.V.M.), and Highland Hospital, Oakland (R.B.) - both in California; San Juan Oncology Associates, Farmington, NM (J.D.N); Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); Michael E. DeBakey Houston VA Medical Center, Houston (L.P.); Holy Cross Health, Silver Spring, MD (M.L.C.); Ochsner Clinic Foundation, New Orleans (J.G.-D.); Central Military Hospital, Lima, Peru (V.C.); Stellenbosch University, Cape Town, South Africa (M.M.-R); BR Trials-Clinical Research, São Paulo (F.L.M.); Aga Khan University Hospital, Nairobi (R.S.); and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City (M.F.G.-L.)
| | - Rachel Baden
- From Elmhurst Hospital Center-Icahn School of Medicine at Mount Sinai Hospital (C.S.), and Elmhurst Hospital Center-New York City Health and Hospitals (E.K.-L.) - both in New York; Genentech, South San Francisco (J.H., L.Y., W.G.R., B.K., B.A., J.F., S.V.M.), and Highland Hospital, Oakland (R.B.) - both in California; San Juan Oncology Associates, Farmington, NM (J.D.N); Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); Michael E. DeBakey Houston VA Medical Center, Houston (L.P.); Holy Cross Health, Silver Spring, MD (M.L.C.); Ochsner Clinic Foundation, New Orleans (J.G.-D.); Central Military Hospital, Lima, Peru (V.C.); Stellenbosch University, Cape Town, South Africa (M.M.-R); BR Trials-Clinical Research, São Paulo (F.L.M.); Aga Khan University Hospital, Nairobi (R.S.); and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City (M.F.G.-L.)
| | - Lavannya Pandit
- From Elmhurst Hospital Center-Icahn School of Medicine at Mount Sinai Hospital (C.S.), and Elmhurst Hospital Center-New York City Health and Hospitals (E.K.-L.) - both in New York; Genentech, South San Francisco (J.H., L.Y., W.G.R., B.K., B.A., J.F., S.V.M.), and Highland Hospital, Oakland (R.B.) - both in California; San Juan Oncology Associates, Farmington, NM (J.D.N); Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); Michael E. DeBakey Houston VA Medical Center, Houston (L.P.); Holy Cross Health, Silver Spring, MD (M.L.C.); Ochsner Clinic Foundation, New Orleans (J.G.-D.); Central Military Hospital, Lima, Peru (V.C.); Stellenbosch University, Cape Town, South Africa (M.M.-R); BR Trials-Clinical Research, São Paulo (F.L.M.); Aga Khan University Hospital, Nairobi (R.S.); and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City (M.F.G.-L.)
| | - Miriam L Cameron
- From Elmhurst Hospital Center-Icahn School of Medicine at Mount Sinai Hospital (C.S.), and Elmhurst Hospital Center-New York City Health and Hospitals (E.K.-L.) - both in New York; Genentech, South San Francisco (J.H., L.Y., W.G.R., B.K., B.A., J.F., S.V.M.), and Highland Hospital, Oakland (R.B.) - both in California; San Juan Oncology Associates, Farmington, NM (J.D.N); Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); Michael E. DeBakey Houston VA Medical Center, Houston (L.P.); Holy Cross Health, Silver Spring, MD (M.L.C.); Ochsner Clinic Foundation, New Orleans (J.G.-D.); Central Military Hospital, Lima, Peru (V.C.); Stellenbosch University, Cape Town, South Africa (M.M.-R); BR Trials-Clinical Research, São Paulo (F.L.M.); Aga Khan University Hospital, Nairobi (R.S.); and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City (M.F.G.-L.)
| | - Julia Garcia-Diaz
- From Elmhurst Hospital Center-Icahn School of Medicine at Mount Sinai Hospital (C.S.), and Elmhurst Hospital Center-New York City Health and Hospitals (E.K.-L.) - both in New York; Genentech, South San Francisco (J.H., L.Y., W.G.R., B.K., B.A., J.F., S.V.M.), and Highland Hospital, Oakland (R.B.) - both in California; San Juan Oncology Associates, Farmington, NM (J.D.N); Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); Michael E. DeBakey Houston VA Medical Center, Houston (L.P.); Holy Cross Health, Silver Spring, MD (M.L.C.); Ochsner Clinic Foundation, New Orleans (J.G.-D.); Central Military Hospital, Lima, Peru (V.C.); Stellenbosch University, Cape Town, South Africa (M.M.-R); BR Trials-Clinical Research, São Paulo (F.L.M.); Aga Khan University Hospital, Nairobi (R.S.); and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City (M.F.G.-L.)
| | - Victoria Chávez
- From Elmhurst Hospital Center-Icahn School of Medicine at Mount Sinai Hospital (C.S.), and Elmhurst Hospital Center-New York City Health and Hospitals (E.K.-L.) - both in New York; Genentech, South San Francisco (J.H., L.Y., W.G.R., B.K., B.A., J.F., S.V.M.), and Highland Hospital, Oakland (R.B.) - both in California; San Juan Oncology Associates, Farmington, NM (J.D.N); Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); Michael E. DeBakey Houston VA Medical Center, Houston (L.P.); Holy Cross Health, Silver Spring, MD (M.L.C.); Ochsner Clinic Foundation, New Orleans (J.G.-D.); Central Military Hospital, Lima, Peru (V.C.); Stellenbosch University, Cape Town, South Africa (M.M.-R); BR Trials-Clinical Research, São Paulo (F.L.M.); Aga Khan University Hospital, Nairobi (R.S.); and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City (M.F.G.-L.)
| | - Martha Mekebeb-Reuter
- From Elmhurst Hospital Center-Icahn School of Medicine at Mount Sinai Hospital (C.S.), and Elmhurst Hospital Center-New York City Health and Hospitals (E.K.-L.) - both in New York; Genentech, South San Francisco (J.H., L.Y., W.G.R., B.K., B.A., J.F., S.V.M.), and Highland Hospital, Oakland (R.B.) - both in California; San Juan Oncology Associates, Farmington, NM (J.D.N); Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); Michael E. DeBakey Houston VA Medical Center, Houston (L.P.); Holy Cross Health, Silver Spring, MD (M.L.C.); Ochsner Clinic Foundation, New Orleans (J.G.-D.); Central Military Hospital, Lima, Peru (V.C.); Stellenbosch University, Cape Town, South Africa (M.M.-R); BR Trials-Clinical Research, São Paulo (F.L.M.); Aga Khan University Hospital, Nairobi (R.S.); and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City (M.F.G.-L.)
| | - Ferdinando Lima de Menezes
- From Elmhurst Hospital Center-Icahn School of Medicine at Mount Sinai Hospital (C.S.), and Elmhurst Hospital Center-New York City Health and Hospitals (E.K.-L.) - both in New York; Genentech, South San Francisco (J.H., L.Y., W.G.R., B.K., B.A., J.F., S.V.M.), and Highland Hospital, Oakland (R.B.) - both in California; San Juan Oncology Associates, Farmington, NM (J.D.N); Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); Michael E. DeBakey Houston VA Medical Center, Houston (L.P.); Holy Cross Health, Silver Spring, MD (M.L.C.); Ochsner Clinic Foundation, New Orleans (J.G.-D.); Central Military Hospital, Lima, Peru (V.C.); Stellenbosch University, Cape Town, South Africa (M.M.-R); BR Trials-Clinical Research, São Paulo (F.L.M.); Aga Khan University Hospital, Nairobi (R.S.); and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City (M.F.G.-L.)
| | - Reena Shah
- From Elmhurst Hospital Center-Icahn School of Medicine at Mount Sinai Hospital (C.S.), and Elmhurst Hospital Center-New York City Health and Hospitals (E.K.-L.) - both in New York; Genentech, South San Francisco (J.H., L.Y., W.G.R., B.K., B.A., J.F., S.V.M.), and Highland Hospital, Oakland (R.B.) - both in California; San Juan Oncology Associates, Farmington, NM (J.D.N); Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); Michael E. DeBakey Houston VA Medical Center, Houston (L.P.); Holy Cross Health, Silver Spring, MD (M.L.C.); Ochsner Clinic Foundation, New Orleans (J.G.-D.); Central Military Hospital, Lima, Peru (V.C.); Stellenbosch University, Cape Town, South Africa (M.M.-R); BR Trials-Clinical Research, São Paulo (F.L.M.); Aga Khan University Hospital, Nairobi (R.S.); and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City (M.F.G.-L.)
| | - Maria F González-Lara
- From Elmhurst Hospital Center-Icahn School of Medicine at Mount Sinai Hospital (C.S.), and Elmhurst Hospital Center-New York City Health and Hospitals (E.K.-L.) - both in New York; Genentech, South San Francisco (J.H., L.Y., W.G.R., B.K., B.A., J.F., S.V.M.), and Highland Hospital, Oakland (R.B.) - both in California; San Juan Oncology Associates, Farmington, NM (J.D.N); Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); Michael E. DeBakey Houston VA Medical Center, Houston (L.P.); Holy Cross Health, Silver Spring, MD (M.L.C.); Ochsner Clinic Foundation, New Orleans (J.G.-D.); Central Military Hospital, Lima, Peru (V.C.); Stellenbosch University, Cape Town, South Africa (M.M.-R); BR Trials-Clinical Research, São Paulo (F.L.M.); Aga Khan University Hospital, Nairobi (R.S.); and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City (M.F.G.-L.)
| | - Beverly Assman
- From Elmhurst Hospital Center-Icahn School of Medicine at Mount Sinai Hospital (C.S.), and Elmhurst Hospital Center-New York City Health and Hospitals (E.K.-L.) - both in New York; Genentech, South San Francisco (J.H., L.Y., W.G.R., B.K., B.A., J.F., S.V.M.), and Highland Hospital, Oakland (R.B.) - both in California; San Juan Oncology Associates, Farmington, NM (J.D.N); Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); Michael E. DeBakey Houston VA Medical Center, Houston (L.P.); Holy Cross Health, Silver Spring, MD (M.L.C.); Ochsner Clinic Foundation, New Orleans (J.G.-D.); Central Military Hospital, Lima, Peru (V.C.); Stellenbosch University, Cape Town, South Africa (M.M.-R); BR Trials-Clinical Research, São Paulo (F.L.M.); Aga Khan University Hospital, Nairobi (R.S.); and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City (M.F.G.-L.)
| | - Jamie Freedman
- From Elmhurst Hospital Center-Icahn School of Medicine at Mount Sinai Hospital (C.S.), and Elmhurst Hospital Center-New York City Health and Hospitals (E.K.-L.) - both in New York; Genentech, South San Francisco (J.H., L.Y., W.G.R., B.K., B.A., J.F., S.V.M.), and Highland Hospital, Oakland (R.B.) - both in California; San Juan Oncology Associates, Farmington, NM (J.D.N); Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); Michael E. DeBakey Houston VA Medical Center, Houston (L.P.); Holy Cross Health, Silver Spring, MD (M.L.C.); Ochsner Clinic Foundation, New Orleans (J.G.-D.); Central Military Hospital, Lima, Peru (V.C.); Stellenbosch University, Cape Town, South Africa (M.M.-R); BR Trials-Clinical Research, São Paulo (F.L.M.); Aga Khan University Hospital, Nairobi (R.S.); and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City (M.F.G.-L.)
| | - Shalini V Mohan
- From Elmhurst Hospital Center-Icahn School of Medicine at Mount Sinai Hospital (C.S.), and Elmhurst Hospital Center-New York City Health and Hospitals (E.K.-L.) - both in New York; Genentech, South San Francisco (J.H., L.Y., W.G.R., B.K., B.A., J.F., S.V.M.), and Highland Hospital, Oakland (R.B.) - both in California; San Juan Oncology Associates, Farmington, NM (J.D.N); Lewis Katz School of Medicine at Temple University, Philadelphia (G.J.C.); Michael E. DeBakey Houston VA Medical Center, Houston (L.P.); Holy Cross Health, Silver Spring, MD (M.L.C.); Ochsner Clinic Foundation, New Orleans (J.G.-D.); Central Military Hospital, Lima, Peru (V.C.); Stellenbosch University, Cape Town, South Africa (M.M.-R); BR Trials-Clinical Research, São Paulo (F.L.M.); Aga Khan University Hospital, Nairobi (R.S.); and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City (M.F.G.-L.)
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Best JH, Mohan SV, Kong AM, Patel K, Pagel JM, Ivanov B, Brawley OW, Jariwala-Parikh K, Zazzali JL, Pauk J. Baseline Demographics and Clinical Characteristics Among 3471 US Patients Hospitalized with COVID-19 and Pulmonary Involvement: A Retrospective Study. Adv Ther 2020; 37:4981-4995. [PMID: 33044691 PMCID: PMC7548311 DOI: 10.1007/s12325-020-01510-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/16/2020] [Indexed: 12/19/2022]
Abstract
Introduction Coronavirus disease 2019 (COVID-19) can present as a range of symptoms, from mild to critical; lower pulmonary involvement, including pneumonia, is often associated with severe and critical cases. Understanding the baseline characteristics of patients hospitalized with COVID-19 illness is essential for effectively targeting clinical care and allocating resources. This study aimed to describe baseline demographics and clinical characteristics of US patients hospitalized with COVID-19 and pulmonary involvement. Methods US patients with COVID-19 and pulmonary involvement during an inpatient admission from December 1, 2019, to May 20, 2020, were identified using the IBM Explorys® electronic health records database. Baseline (up to 12 months prior to first COVID-19 hospitalization) demographics and clinical characteristics and preadmission (14 days to 1 day prior to admission) pulmonary diagnoses were assessed. Patients were stratified by sex, age, race, and geographic region. Results Overall, 3471 US patients hospitalized with COVID-19 and pulmonary involvement were included. The mean (SD) age was 63.5 (16.3) years; 51.2% of patients were female, 55.0% African American, 81.6% from the South, and 16.8% from the Midwest. The most common comorbidities included hypertension (27.7%), diabetes (17.3%), hyperlipidemia (16.3%), and obesity (9.7%). Cough (27.3%) and dyspnea (15.2%) were the most common preadmission pulmonary symptoms. African American patients were younger (mean [SD], 62.5 [15.4] vs. 67.8 [6.2]) with higher mean (SD) body mass index (33.66 [9.46] vs. 30.42 [7.86]) and prevalence of diabetes (19.8% vs. 16.7%) and lower prevalence of chronic obstructive pulmonary disease (5.6% vs. 8.2%) and smoking/tobacco use (28.1% vs. 37.2%) than White patients. Conclusions Among US patients primarily from the South and Midwest hospitalized with COVID-19 and pulmonary involvement, the most common comorbidities were hypertension, diabetes, hyperlipidemia, and obesity. Differences observed between African American and White patients should be considered in the context of the complex factors underlying racial disparities in COVID-19. Electronic supplementary material The online version of this article (10.1007/s12325-020-01510-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - John Pauk
- Swedish Medical Center, Seattle, WA, USA
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9
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Gale S, Wilson JC, Chia J, Trinh H, Tuckwell K, Collinson N, Dimonaco S, Jick S, Meier C, Mohan SV, Sarsour K. Risk Associated with Cumulative Oral Glucocorticoid Use in Patients with Giant Cell Arteritis in Real-World Databases from the USA and UK. Rheumatol Ther 2018; 5:327-340. [PMID: 29752705 PMCID: PMC6251855 DOI: 10.1007/s40744-018-0112-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Indexed: 10/29/2022] Open
Abstract
INTRODUCTION Treatment of giant cell arteritis (GCA) involves immediate initiation of high-dose glucocorticoid therapy with slow tapering of the dose over many months. Chronic exposure to glucocorticoids is associated with serious comorbidities. The objective of this analysis was to determine the glucocorticoid exposure and risk of glucocorticoid-related adverse events (AEs) in real-world patients with GCA. METHODS Data from the Truven Healthcare MarketScan® database (from January 1, 2000, to June 30, 2015) and the Clinical Practice Research Datalink (CPRD; from January 1, 1995, to August 31, 2013) were used to retrospectively analyze patients aged ≥ 50 years with GCA in the USA and UK, respectively. Outcomes included oral glucocorticoid use (cumulative prednisone-equivalent exposure), glucocorticoid-related AEs and the association of AE risk with glucocorticoid exposure over 52 weeks. RESULTS Of the 4804 patients in the US MarketScan database and 3973 patients in the UK CPRD database included, 71.3 and 74.6% were women and mean age was 73.4 and 73.0 years, respectively. Median starting glucocorticoid dose and cumulative glucocorticoid dose at 52 weeks were 20-50 mg/day and 4000-4800 mg, respectively. The most frequent glucocorticoid-related AEs were hypertension and eye, bone health, and glucose tolerance conditions. In the first year after diagnosis, the likelihood of any glucocorticoid-related AE was significantly increased for each 1 g increase in cumulative glucocorticoid dose in the US and UK cohorts (odds ratio [95% CI], 1.170 [1.063, 1.287] and 1.06 [1.03, 1.09], respectively; P < 0.05 for both). Similar trends were observed for the risk of glucocorticoid-related AEs over full follow-up (mean, USA: 3.9 years, UK: 6.3 years). CONCLUSIONS In real-world patients with GCA, increased cumulative glucocorticoid exposure was associated with an increased risk of glucocorticoid-related AEs. FUNDING F. Hoffmann-La Roche Ltd. Plain language summary available for this article.
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Affiliation(s)
- Sara Gale
- Genentech, Inc., South San Francisco, CA, USA.
| | - Jessica C Wilson
- Basel Pharmacoepidemiology Unit, University of Basel, Basel, Switzerland
| | - Jenny Chia
- Genentech, Inc., South San Francisco, CA, USA
| | - Huong Trinh
- Genentech, Inc., South San Francisco, CA, USA
| | | | | | | | - Susan Jick
- Boston Collaborative Drug Surveillance Program, Boston University School of Public Health, Lexington, MA, USA
| | - Christoph Meier
- Basel Pharmacoepidemiology Unit, University of Basel, Basel, Switzerland.,Boston Collaborative Drug Surveillance Program, Boston University School of Public Health, Lexington, MA, USA
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Mohan SV, Chang J, Li S, Henry AS, Wood DJ, Chang ALS. Increased Risk of Cutaneous Squamous Cell Carcinoma After Vismodegib Therapy for Basal Cell Carcinoma. JAMA Dermatol 2016; 152:527-32. [DOI: 10.1001/jamadermatol.2015.4330] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [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]
Affiliation(s)
- Shalini V. Mohan
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California2currently with Genentech-Roche, South San Francisco, California
| | - Julia Chang
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California
| | - Shufeng Li
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California3Department of Urology, Stanford University School of Medicine, Redwood City, California
| | - A. Solomon Henry
- Department of Health Research and Policy, Stanford University School of Medicine, Palo Alto, California
| | - Douglas J. Wood
- Department of Health Research and Policy, Stanford University School of Medicine, Palo Alto, California
| | - Anne Lynn S. Chang
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California
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Affiliation(s)
| | | | - Anne Lynn S. Chang
- Correspondence to: Anne Lynn S. Chang, MD, Stanford University School of Medicine, Department of Dermatology, 450 Broadway St, MC 5334, Pavilion C, 2nd floor, Redwood City, CA 94063.Stanford University School of MedicineDepartment of Dermatology450 Broadway St, MC 5334, Pavilion C, 2nd floorRedwood CityCA94063
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Mohan SV, Chang ALS. Management of Cutaneous and Extracutaneous Side Effects of Smoothened Inhibitor Therapy for Advanced Basal Cell Carcinoma. Clin Cancer Res 2015; 21:2677-83. [DOI: 10.1158/1078-0432.ccr-14-3180] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 03/03/2015] [Indexed: 11/16/2022]
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Mohan SV, Chang ALS. Precision medicine and precision therapeutics: hedgehog signaling pathway, basal cell carcinoma and beyond. ACTA ACUST UNITED AC 2014; 33:68-71. [PMID: 25085664 DOI: 10.12788/j.sder.0082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Precision medicine and precision therapeutics is currently in its infancy with tremendous potential to improve patient care by better identifying individuals at risk for skin cancer and predict tumor responses to treatment. This review focuses on the Hedgehog signaling pathway, its critical role in the pathogenesis of basal cell carcinoma, and the emergence of targeted treatments for advanced basal cell carcinoma. Opportunities to utilize precision medicine are outlined, such as molecular profiling to predict basal cell carcinoma response to targeted therapy and to inform therapeutic decisions.
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Affiliation(s)
| | - Anne Lynn S Chang
- Department of Dermatology, Stanford University School of Medicine, Redwood City, CA USA.
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Abstract
Advanced basal cell carcinomas are a subset of basal cell carcinomas that can be difficult to treat either due to their local invasiveness, proximity to vital structures, or metastasis. The incidence of all basal cell carcinoma is increasing in the United States, although it is not known whether advanced basal cell carcinomas (aBCCs) are also increasing. Recently, highly targeted therapy based on knowledge of the basal cell carcinoma pathogenesis has become available either commercially or through human clinical trials. These orally available drugs inhibit the Hedgehog signaling pathway, and lead to advanced basal cell carcinoma shrinkage that can enable preservation of adjacent vital organs. In this review, we outline the role of Hedgehog pathway inhibitors as well as other treatment modalities such as excision, radiotherapy and more traditional chemotherapy in treating advanced basal cell carcinomas. We also highlight current gaps in knowledge regarding the use and side effects of this targeted therapy.
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Affiliation(s)
- Shalini V. Mohan
- Department of Dermatology, Stanford University School of Medicine, 450 Broadway St, MC 5334, Pavilion C, 2nd floor, Redwood City, CA 94063 USA
| | - Anne Lynn S. Chang
- Department of Dermatology, Stanford University School of Medicine, 450 Broadway St, MC 5334, Pavilion C, 2nd floor, Redwood City, CA 94063 USA
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Yang Z, Fujii H, Mohan SV, Goronzy JJ, Weyand CM. Phosphofructokinase deficiency impairs ATP generation, autophagy, and redox balance in rheumatoid arthritis T cells. ACTA ACUST UNITED AC 2013; 210:2119-34. [PMID: 24043759 PMCID: PMC3782046 DOI: 10.1084/jem.20130252] [Citation(s) in RCA: 244] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
In the HLA class II-associated autoimmune syndrome rheumatoid arthritis (RA), CD4 T cells are critical drivers of pathogenic immunity. We have explored the metabolic activity of RA T cells and its impact on cellular function and fate. Naive CD4 T cells from RA patients failed to metabolize equal amounts of glucose as age-matched control cells, generated less intracellular ATP, and were apoptosis-susceptible. The defect was attributed to insufficient induction of 6-phosphofructo-2-kinase/fructose-2,6-bisphosphatase 3 (PFKFB3), a regulatory and rate-limiting glycolytic enzyme known to cause the Warburg effect. Forced overexpression of PFKFB3 in RA T cells restored glycolytic flux and protected cells from excessive apoptosis. Hypoglycolytic RA T cells diverted glucose toward the pentose phosphate pathway, generated more NADPH, and consumed intracellular reactive oxygen species (ROS). PFKFB3 deficiency also constrained the ability of RA T cells to resort to autophagy as an alternative means to provide energy and biosynthetic precursor molecules. PFKFB3 silencing and overexpression identified a novel extraglycolytic role of the enzyme in autophagy regulation. In essence, T cells in RA patients, even those in a naive state, are metabolically reprogrammed with insufficient up-regulation of the glycolytic activator PFKFB3, rendering them energy-deprived, ROS- and autophagy-deficient, apoptosis-sensitive, and prone to undergo senescence.
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Affiliation(s)
- Zhen Yang
- Division of Immunology & Rheumatology, Stanford University School of Medicine, Stanford, CA 94305
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Abstract
Susceptibility for giant cell arteritis increases with chronological age, in parallel with age-related restructuring of the immune system and age-induced remodeling of the vascular wall. Immunosenescence results in shrinkage of the naïve T-cell pool, contraction of T-cell diversity, and impairment of innate immunity. Aging of immunocompetent cells forces the host to take alternative routes for protective immunity and confers risk for pathogenic immunity that causes chronic inflammatory tissue damage. Dwindling immunocompetence is particularly relevant as the aging host is forced to cope with an ever growing infectious load. Immunosenescence coincides with vascular aging during which the arterial wall undergoes dramatic structural changes and medium and large arteries lose their pliability and elasticity. On the molecular level, elastic fibers deteriorate and matrix proteins accumulate biochemical modifications. Thus, the aging process impacts the two major biologic systems that liaise to promote giant cell arteritis; the immune system and the vessel wall niche.
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Affiliation(s)
- Shalini V Mohan
- Department of Medicine, Division of Immunology and Rheumatology, Stanford University School of Medicine, Stanford, CA 94305-5166, USA
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Mohan SV, Prakasham RS, Satyavathi B, Annapurna J, Ramakrishna SV. Biotreatability studies of pharmaceutical wastewater using an anaerobic suspended film contact reactor. Water Sci Technol 2001; 43:271-276. [PMID: 11380190] [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: 05/23/2023]
Abstract
The pharmaceutical industrial effluents, which include several organic solvents and other toxic chemicals, are generally treated by aerobic process, which is cost intensive in nature. The alternative anaerobic route to degrade the toxic effluents is attractive due to the lower cost of treatment and the generation of gas, which can supplement the energy requirements. There are few reports on the anaerobic treatment of the pharmaceutical effluents. In the present investigation, the effluents from a bulk drug industry, which utilizes several organic chemicals, have been taken to assess their applicability for anaerobic treatment. The organic loading rates were varied from 0.25 kg/m3/day to 2.5 kg/m3/day and the COD reduction was found to be in the range of 60 to 80%. Long term operation of an anaerobic suspended film contact reactor carried out with 1.25 kg/m3/day was found to be optimum. The biogas generated during the degradation process was monitored and the methane content was found to be 60-70%.
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Affiliation(s)
- S V Mohan
- Biochemical and Environmental Engineering Group, Indian Institute of Chemical Technology, Hyderabad 500 007, India
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Kumari TP, Mohan SV, Shanavas A, Kumari PK. Intussusception at the onset of acute lymphoblastic leukemia in a child. Indian Pediatr 1998; 35:470-2. [PMID: 10216632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Affiliation(s)
- T P Kumari
- Department of Pediatric Oncology, Regional Cancer Centre, Trivandrum
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Mohan SV, Karthikeyan J. Removal of lignin and tannin colour from aqueous solution by adsorption onto activated charcoal. Environ Pollut 1997; 97:183-7. [PMID: 15093393 DOI: 10.1016/s0269-7491(97)00025-0] [Citation(s) in RCA: 115] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/1996] [Accepted: 01/31/1997] [Indexed: 05/22/2023]
Abstract
Sorptive uptake of lignin and tannin from an aqueous phase by activated charcoal was investigated in the laboratory. The sorption reaction was found to be of a first order. The influence on the rate of sorption of various factors, such as amount of sorbent and pH of the system, have been investigated. Sorption data fit well into the Langmuir adsorption isotherm, indicating formation of a monolayer over a homogeneous sorbent surface. Sorption capacity, rate constant, intraparticle diffusion coefficient, etc. were calculated from the sorption data. Desorption studies indicate the irreversible nature of the sorption reaction, whereas interruption studies suggest film diffusion to be rate limiting.
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Affiliation(s)
- S V Mohan
- Environmental Engineering Division, Department of Civil Engineering, Sri Venkateswara University, Tirupati-517 502 (A.P.), India
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