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Matloob SA, Paraskevopoulos D, O'Toole SM, Drake W, Plowman N, Foroglou N. VHL: Trends and Insight into a Multi-Modality, Interdisciplinary Approach for Management of Central Nervous System Hemangioblastoma. Acta Neurochir Suppl 2023; 135:81-88. [PMID: 38153453 DOI: 10.1007/978-3-031-36084-8_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
Von Hippel-Lindau (VHL) is a multi-system disease which results in significant morbidity from central nervous system (CNS) involvement as well as ocular, renal and neuro-endocrine effects. Haemangioblastomas of the CNS present a number of challenges. The natural history of these lesions is varied, as is the size and location within the CNS. Whilst surgery is considered the mainstay of treatment and best chance at curing these lesions, this is also often associated with significant risks due to the anatomical location of these lesions, most commonly the posterior fossa and spinal cord.We review the literature and describe our experience across two separate European VHL referral centres. Alternative treatment options and combined modalities are increasingly being used in the context of managing CNS haemangioblastomas. We analyse the increasing use of stereotactic radiosurgery and the evolution of medical treatments as potential future adjuncts to surgery. The availability of multiple modalities in our armamentarium is essential in tailoring a personalised treatment approach to these patients. Owing to the multi-systemic nature of the disease, in our experience, managing the care of patients with VHL is best delivered using an interdisciplinary approach utilising multiple specialties and adopting an individually tailored holistic approach.
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Affiliation(s)
- S A Matloob
- Department of Neurosurgery, Barts Health NHS Trust, London, UK.
- Department of Neurosurgery, Royal London Hospital, London, UK.
| | | | - S M O'Toole
- Department of Endocrinology, The Royal Hallamshire Hospital, Sheffield, UK
| | - W Drake
- Department of Endocrinology, Barts Health NHS Trust, London, UK
| | - N Plowman
- Department of Oncology, Barts Health NHS Trust, London, UK
| | - N Foroglou
- Department of Neurosurgery, AHEPA University Hospital, Thessaloniki, Greece
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Gray V, Drake W, Allardice JR, Zhang Z, Xiao J, Congrave DG, Royakkers J, Zeng W, Dowland S, Greenham NC, Bronstein H, Anthony JE, Rao A. Triplet transfer from PbS quantum dots to tetracene ligands: is faster always better? J Mater Chem C Mater 2022; 10:16321-16329. [PMID: 36562020 PMCID: PMC9648495 DOI: 10.1039/d2tc03470k] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/28/2022] [Indexed: 06/17/2023]
Abstract
Quantum dot-organic semiconductor hybrid materials are gaining increasing attention as spin mixers for applications ranging from solar harvesting to spin memories. Triplet energy transfer between the inorganic quantum dot (QD) and organic semiconductor is a key step to understand in order to develop these applications. Here we report on the triplet energy transfer from PbS QDs to four energetically and structurally similar tetracene ligands. Even with similar ligands we find that the triplet energy transfer dynamics can vary significantly. For TIPS-tetracene derivatives with carboxylic acid, acetic acid and methanethiol anchoring groups on the short pro-cata side we find that triplet transfer occurs through a stepwise process, mediated via a surface state, whereas for monosubstituted TIPS-tetracene derivative 5-(4-benzoic acid)-12-triisopropylsilylethynyl tetracene (BAT) triplet transfer occurs directly, albeit slower, via a Dexter exchange mechanism. Even though triplet transfer is slower with BAT the overall yield is greater, as determined from upconverted emission using rubrene emitters. This work highlights that the surface-mediated transfer mechanism is plagued with parasitic loss pathways and that materials with direct Dexter-like triplet transfer are preferred for high-efficiency applications.
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Affiliation(s)
- Victor Gray
- Cavendish Laboratory, University of Cambridge J. J. Thomson Avenue Cambridge CB3 0HE UK
- Department of Chemistry - Ångström Laboratory, Uppsala University Box 523 751 20 Uppsala Sweden
| | - William Drake
- Cavendish Laboratory, University of Cambridge J. J. Thomson Avenue Cambridge CB3 0HE UK
| | - Jesse R Allardice
- Cavendish Laboratory, University of Cambridge J. J. Thomson Avenue Cambridge CB3 0HE UK
| | - Zhilong Zhang
- Cavendish Laboratory, University of Cambridge J. J. Thomson Avenue Cambridge CB3 0HE UK
| | - James Xiao
- Cavendish Laboratory, University of Cambridge J. J. Thomson Avenue Cambridge CB3 0HE UK
| | - Daniel G Congrave
- Department of Chemistry, University of Cambridge Lensfield Road Cambridge CB2 1EW UK
| | - Jeroen Royakkers
- Department of Chemistry, University of Cambridge Lensfield Road Cambridge CB2 1EW UK
| | - Weixuan Zeng
- Department of Chemistry, University of Cambridge Lensfield Road Cambridge CB2 1EW UK
| | - Simon Dowland
- Cambridge Photon Technology J. J. Thomson Avenue Cambridge CB3 0HE UK
| | - Neil C Greenham
- Cavendish Laboratory, University of Cambridge J. J. Thomson Avenue Cambridge CB3 0HE UK
| | - Hugo Bronstein
- Department of Chemistry, University of Cambridge Lensfield Road Cambridge CB2 1EW UK
| | - John E Anthony
- University of Kentucky Center for Applied Energy Research 2582 Research Park Dr Lexington Kentucky 40511 USA
| | - Akshay Rao
- Cavendish Laboratory, University of Cambridge J. J. Thomson Avenue Cambridge CB3 0HE UK
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Goodchild E, Aizan E, Wu X, Drake W, Brown M. LBMON299 Aldosterone Production Is Regulated By Gap Junctions In Human Adrenal Cells. J Endocr Soc 2022. [PMCID: PMC9627756 DOI: 10.1210/jendso/bvac150.1479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Aldosterone plays a critical role in blood pressure regulation via the renin-angiotensin-aldosterone system. Autonomous production of aldosterone, primary aldosteronism (PA), is the commonest curable cause of hypertension worldwide. Two cell types in the adrenal cortex produce aldosterone: zona glomerulosa (ZG) cells and aldosterone producing nodules (APN), and in cells of aldosterone producing adenomas (APA). Adrenal cortex cells undergo phenotypic metamorphosis as they migrate from the subcapsular region, centripetally, towards the corticomedullary junction, changing from aldosterone- to cortisol- producing cells as they go. Gap junctions (GJs) are specialised channels of cytoplasmic communication between cells, permitting the regulated transfer of substrates. Loss-of-function mutations in the CADM1 gene, which affects GJ protein CX43, have been found in APAs, implicating CX43 in aldosterone regulation. This study aims to demonstrate the dysregulation of aldosterone production by CX43 inhibition in human adrenal cell line, H295R, and elucidate GJ distribution in human adrenal cortex. Methodology H295R cells were treated with 1×10-8M angiotensin II and connexin mimetic GJ inhibitor, GAP27, at 0µM, 25µM, 83µM and 250µM. Immunofluorescence (IF) was used to identify the abundance of CX43 in different cell types of the adrenal cortex, performed on ex-vivo para-APA adrenal tissue, using antibodies against CX43 (GJA1), colocalised with markers of aldosterone-producing cells (aldosterone synthase, CYP11B2), cells of the zona glomerulosa (ZG) (VSNL1, and DAB2) and zona fasciculata (ZF) (CYP7A1). Results Inhibition of CX43 with Gap27 results in a dose-dependent increase in CYP11B2 mRNA expression and aldosterone production. At the highest concentration of 250µM GAP27, CYP11B2 mRNA expression increased by 133-fold (p=<0. 00001) and aldosterone production by 29-fold (p=0. 0006). IF studies demonstrate a crescendo gradient of CX43 in a centripetal direction from cells of APN to ZF. The abundance was lowest in aldosterone-producing APN cells, moderate in non-aldosterone-producing ZG cells and highest in cortisol-producing ZF cells. GJ distribution was pan-membranous in ZF, but, where present, mostly cytoplasmic in APN. Evidence of recent active communication, in the form of annular gap junctions (AJG), was present in all three cell types. Conclusion The CX43 inhibition-induced upregulation of CYP11B2 expression and aldosterone synthesis indicates that it has an important regulatory role in physiological aldosterone production via CYP11B2 expression. The distribution of CX43 in adrenal tissue suggests its transport substrate not only regulates aldosterone synthesis, but also in adrenal cortex cell phenotypic metamorphosis/migration. Future work will investigate the substrate of CX43 in adrenal cells and its possible effect on adrenal cell phenotype. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.
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Yeoh P, Dwyer AA, Anghel E, Bouloux PM, Khoo B, Chew S, Wernig F, Carroll P, Aylwin SJB, Baldeweg SE, Drake W, Todd J, Mangena L, Grossman A. A Comparison of the Blood Glucose, Growth Hormone, and Cortisol Responses to Two Doses of Insulin (0.15 U/kg vs. 0.10 U/kg) in the Insulin Tolerance Test: A Single-Centre Audit of 174 Cases. Int J Endocrinol 2022; 2022:7360282. [PMID: 35465075 PMCID: PMC9019435 DOI: 10.1155/2022/7360282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/10/2022] [Accepted: 01/17/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The insulin tolerance test (ITT) is the gold standard endocrine test used to assess the integrity of the growth hormone (GH) and cortisol axes. The ITT has potential risks, and severe hypoglycaemia may necessitate intravenous glucose rescue. There is no clear consensus as to the optimal insulin dose for the ITT. Therefore, we sought to compare the standard dose (0.15 U/kg) and a low-dose ITT (0.1 U/kg). DESIGN Single-centre audit of ITT data (2012-2021). Patients and Measurements. Patients who underwent an ITT to assess possible GH deficiency/adrenal insufficiency were included. Glucose, GH, and cortisol were measured at baseline and 30, 45, 60, 90, and 120 minutes following I.V. insulin bolus (0.15 U/kg or 0.10 U/kg). RESULTS Of the ITTs performed, only 3/177 (1.7%) did not achieve adequate hypoglycaemia (≤2.2 mmol/L) with a single insulin dose. In total, 174 patients (43.5 ± 12.1 yrs, mean ± standard deviation) were included for analysis (0.15 U/kg: n = 113, 0.10 U/kg: n = 61). All 174 subjects had adequate hypoglycaemia regardless of baseline fasting blood glucose level or insulin dose. Neither nadir glucose nor glucose delta (i.e., baseline minus nadir) differed between insulin doses. Trends in both cortisol and GH responses over time were similar between groups, and a greater proportion of patients receiving the standard dose had an adequate cortisol response (77/106 (72.6%) vs. 32/60 (53.3%), p=0.01). The rates of glucose rescue did not differ in a subset of 79 patients, with on-demand glucose rescue in 4/35 (11%) for the standard dose and 2/44 (5%) for the low dose (p=0.25). CONCLUSIONS Our results suggest that the low-dose ITT produces comparable glucose, cortisol, and GH responses to the higher dose. Given the risks associated with hypoglycaemia, the low dose appears to be preferable to the standard dose ITT in most circumstances.
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Affiliation(s)
- Phillip Yeoh
- The London Clinic Centre for Endocrinology, London, UK
- Florence Nightingale School of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Andrew A. Dwyer
- Boston College William F. Connell School of Nursing, Chestnut Hill, MA, USA
- Munn Center for Nursing Research, Massachusetts General Hospital, Boston, MA, USA
| | - Ella Anghel
- Boston College, Department of Measurement, Evaluation, Statistics and Assessment, Chestnut Hill, MA, USA
| | - Pierre M. Bouloux
- The London Clinic Centre for Endocrinology, London, UK
- Royal Free London NHS Foundation Trust, London, UK
- National Hospital for Neurology and Neurosurgery, London, UK
| | - Bernard Khoo
- The London Clinic Centre for Endocrinology, London, UK
- Royal Free London NHS Foundation Trust, London, UK
- Division of Medicine, University College London, London, UK
| | - Shern Chew
- The London Clinic Centre for Endocrinology, London, UK
- OneWelbeck Endocrine Partners, London, UK
| | - Florian Wernig
- The London Clinic Centre for Endocrinology, London, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Paul Carroll
- The London Clinic Centre for Endocrinology, London, UK
- Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Simon J. B. Aylwin
- The London Clinic Centre for Endocrinology, London, UK
- King's College Hospital NHS Foundation Trust, London, UK
| | - Stephanie E. Baldeweg
- The London Clinic Centre for Endocrinology, London, UK
- Division of Medicine, University College London, London, UK
- Department of Diabetes & Endocrinology, University College London NHS Foundation Trust, London, UK
| | - William Drake
- The London Clinic Centre for Endocrinology, London, UK
- Barts Health NHS Trust, Saint Bartholomew's Hospital, London, UK
| | - Jeannie Todd
- The London Clinic Centre for Endocrinology, London, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | | | - Ashley Grossman
- The London Clinic Centre for Endocrinology, London, UK
- Centre for Endocrinology, Barts and the London School of Medicine, Queen Mary University of London, UK
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Cordova R, Kiekens K, Burrell S, Drake W, Kmeid Z, Rice P, Rocha A, Diaz S, Yamada S, Yozwiak M, Nelson OL, Rodriguez GC, Heusinkveld J, Shih IM, Alberts DS, Barton JK. Sub-millimeter endoscope demonstrates feasibility of in vivo reflectance imaging, fluorescence imaging, and cell collection in the fallopian tubes. J Biomed Opt 2021; 26:JBO-200404R. [PMID: 34216135 PMCID: PMC8253554 DOI: 10.1117/1.jbo.26.7.076001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 06/15/2021] [Indexed: 06/13/2023]
Abstract
SIGNIFICANCE Most cases of high-grade serous ovarian carcinoma originate as serous tubal intraepithelial carcinoma (STIC) lesions in the fallopian tube epithelium (FTE), enabling early endoscopic detection. AIM The cell-acquiring fallopian endoscope (CAFE) was built to meet requirements for locating potentially pathological tissue indicated by an alteration in autofluorescence or presence of a targeted fluorophore. A channel was included for directed scrape biopsy of cells from regions of interest. APPROACH Imaging resolution and fluorescence sensitivity were measured using a standard resolution target and fluorescence standards, respectively. A prototype was tested in ex vivo tissue, and collected cells were counted and processed. RESULTS Measured imaging resolution was 88 μm at a 5-mm distance, and full field of view was ∼45 deg in air. Reflectance and fluorescence images in ex vivo porcine reproductive tracts were captured, and fit through human tracts was verified. Hemocytometry counts showed that on the order of 105 cells per scrape biopsy could be collected from ex vivo porcine tissue. CONCLUSIONS All requirements for viewing STIC in the FTE were met, and collected cell counts exceeded input requirements for relevant analyses. Our benchtop findings suggest the potential utility of the CAFE device for in vivo imaging and cell collection in future clinical trials.
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Affiliation(s)
- Ricky Cordova
- University of Arizona, Department of Biomedical Engineering, Tucson, Arizona, United States
| | - Kelli Kiekens
- University of Arizona, Department of Biomedical Engineering, Tucson, Arizona, United States
| | - Susan Burrell
- University of Arizona, Department of Biomedical Engineering, Tucson, Arizona, United States
| | - William Drake
- University of Arizona, Department of Biomedical Engineering, Tucson, Arizona, United States
| | - Zaynah Kmeid
- University of Arizona, Department of Biomedical Engineering, Tucson, Arizona, United States
| | - Photini Rice
- University of Arizona, Department of Biomedical Engineering, Tucson, Arizona, United States
| | - Andrew Rocha
- University of Arizona, Department of Biomedical Engineering, Tucson, Arizona, United States
| | - Sebastian Diaz
- University of Arizona, Department of Biomedical Engineering, Tucson, Arizona, United States
| | - Shigehiro Yamada
- Johns Hopkins University, Department of Biomedical Engineering, Baltimore, Maryland, United States
| | - Michael Yozwiak
- University of Arizona, Department of Medicine, Tucson, Arizona, United States
| | - Omar L. Nelson
- NorthShore University HealthSystem, Evanston, Illinois, United States
- University of Chicago, Pritzker School of Medicine, Chicago, Illinois, United States
| | - Gustavo C. Rodriguez
- NorthShore University HealthSystem, Evanston, Illinois, United States
- University of Chicago, Pritzker School of Medicine, Chicago, Illinois, United States
| | - John Heusinkveld
- Banner–University Medical Center, Tucson, Arizona, United States
| | - Ie-Ming Shih
- Johns Hopkins University, Department of Biomedical Engineering, Baltimore, Maryland, United States
| | - David S. Alberts
- University of Arizona, Department of Medicine, Tucson, Arizona, United States
| | - Jennifer K. Barton
- University of Arizona, Department of Biomedical Engineering, Tucson, Arizona, United States
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Azizan EAB, Zhou J, Cabrera CP, Fernandes-Rosa FL, Boulkroun S, Argentesi G, Cottrell E, Amar L, Wu X, Marker A, Garg S, Akerstrom T, Backman S, Jordan S, Gluck AK, Lines KE, Thakker RV, Tuthill AA, Joyce CM, Metherell L, Teo A, Gurnell M, Parvanta L, Drake W, Wozniak E, Kuan JL, Tiang Z, Hellman P, Foo R, Mein C, Kinsler V, Bjorklund P, Storr HL, Zennaro MC, Brown MJ. Somatic Mutations of GNA11 and GNAQ in CTNNB1-Mutant Aldosterone-Producing Adenomas Increases Aldosterone and Aldosterone Synthase (CYP11B2). J Endocr Soc 2021. [DOI: 10.1210/jendso/bvab048.145] [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: 11/19/2022] Open
Abstract
Abstract
Most aldosterone-producing adenomas (APA) have gain-of-function somatic mutations of ion channels or transporters. However, their frequency in aldosterone-producing cell-clusters of normal adrenals suggests the existence of co-driver mutations which influence the development or phenotype of APAs.
Gain-of-function mutations in both CTNNB1 and GNA11 were found by whole exome sequencing in 3 of 41 APAs from a UK/Irish cohort. Targeted sequencing for exon 3 mutations of CTNNB1 and p.Gln209 mutations of either GNA11 or closely homologous GNAQ confirmed these and 7 further double mutant APAs in this discovery cohort. The presence of GNA11/Q p.Gln209 mutations in CTNNB1 mutant APAs were replicated in 2 cohorts from France (n=14) and Sweden (n=3). In total, 16 (59%) of the 27 CTNNB1 mutant APAs investigated had a mutation at p.Gln209 of GNA11 (n=11) or GNAQ (n=5). Interestingly, CTNNB1-mutant APAs were more commonly present in women (23/27), and of these, those with GNA11/Q mutations were all women except for a pubertal boy. To also note, 9 of 10 of the UK/Irish double mutant APAs in the discovery cohort presented in puberty, pregnancy, or menopause.
Mutation of p.Gln209, or homologous p.Gln in GNAS, GNA12-14, impair hydrogen bonds between G-protein α and β subunits. Transfection of H295R cells, an immortalised adrenocortical cell line heterozygous for the p.Ser45Pro mutation of CTNNB1 but wild-type for GNA11-14/Q/S, by each of the GNA11/Q mutations increased aldosterone secretion and CYP11B2 expression (encoding aldosterone synthase) by 1.93-6.1-fold and 8.0-9.8-fold respectively, compared to vector or wild-type -transfected cells. In ZG, GNA11/Q mediate the aldosterone response to angiotensin II, via stimulation of intracellular Ca2+ release by inositol trisphosphate. In the mutant-transfected cells, the stimulatory effect of angiotensin II 10 nM was retained. In order to determine whether the p.Gln209 mutations stimulate aldosterone production even in the absence of CTNNB1 activation, the transfections of H295R cells were repeated after either 24-h treatment with the CTNNB1 inhibitor, ICG-001, or silencing of CTNNB1 using the ONTARGETplus SMARTpool SiRNAs (Dharmacon). Both interventions reduced the aldosterone production relative to vehicle/control-treated cells; however neither ICG-001 nor silencing of CTNNB1 blunted the fold-increase in aldosterone secretion seen in mutant-transfected cells compared to wild-type.
In summary, we report the discovery of gain-of-function mutations of the G-protein, GNA11, or its close homologue, GNAQ, in multiple APAs which majority presented during periods of high LH/HCG. To date, the mutation is always residue p.Gln209, and associated with a gain-of-function mutation of CTNNB1. These GNA11/Q p.Gln209 mutations increase aldosterone and CYP11B2 production both in the presence and in the absence of CTNNB1 activation.
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Affiliation(s)
- Elena A B Azizan
- The National University of Malaysia (UKM) Medical Centre, Kuala Lumpur, Malaysia
| | - Junhua Zhou
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Claudia P Cabrera
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | | | | | - Giulia Argentesi
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Emily Cottrell
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | | | - Xilin Wu
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | | | - Sumedha Garg
- Welcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | | | | | | | | | | | | | | | | | - Louise Metherell
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Ada Teo
- National University of Singapore, Singapore, Singapore
| | - Mark Gurnell
- Welcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | | | | | - Eva Wozniak
- Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Jyn L Kuan
- National University of Singapore, Singapore, Singapore
| | - Zenia Tiang
- National University of Singapore, Singapore, Singapore
| | | | - Roger Foo
- National University of Singapore, Singapore, Singapore
| | - Chaz Mein
- Blizard Institute, Queen Mary University of London, London, United Kingdom
| | | | | | | | | | - Morris Jonathan Brown
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
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Zhou J, Boulkroun S, Cabrera CP, Azizan EAB, Fernandes-Rosa F, Cottrell E, Argentesi G, Wu X, O’Toole S, Marker A, Jordan S, Berney DM, Lines K, Metherell L, Teo A, Thakker RV, Drake W, Wozniak E, Mein CA, Storr HL, Zennaro MC, Brown MJ. CTNNB1-Mutant Aldosterone-Producing Adenomas With Somatic Mutations of GNA11/GNAQ Have Distinct Phenotype and Genotype. J Endocr Soc 2021. [PMCID: PMC8089757 DOI: 10.1210/jendso/bvab048.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: We report (this meeting) somatic mutation of GNA11/Q in CTNNB1-mutant APAs. The recurrent co-driver mutation causes reversible hypertension in puberty, pregnancy, or menopause. We have investigated the molecular mechanism of this association. Methods: Gene expression profiles in 3 double mutant APAs were studied by unsupervised hierarchical clustering analysis and enrichment analysis of 362 differentially expressed genes and validated by qPCR, IFC and IHC in 10 double mutant APAs or transfected primary adrenal cells. Multiple region biopsies were performed in 7 adrenals adjacent to double-mutant APAs and 4 APAs with KCNJ5 or CACNA1D mutations. The findings of APA mutations in adjacent adrenals were replicated in each case by ddPCR ± NGS. Results: Unsupervised hierarchical clustering analysis showed clustering of the double-mutant APAs, and a high proportion of genes were many-fold upregulated compared to other APAs. LHCGR, TMEM132E, DKK1, C9orf84, FAP, GNRHR and MPP3 are among the genes with high expression. A small number of genes are down-regulated in the double-mutant APAs, including CYP11B1. qPCR confirmed an average of ~10 to 1000-fold higher expression of the hallmark genes in double-mutants. Enrichment analysis showed significant enrichment of features or terms concerned with cell junction and cell adhesion (P<10–8). IFC confirmed LHCGR intensity was 31–144 fold higher in primary adrenal cells with GNA11-p.Gln209Pro transfection and high CTNNB1 intensity. LHCGR intensity was qualitatively and quantitatively associated with immunofluorescence for CTNNB1. IHC of double-mutant APAs showed absent CYP11B1 but strong staining of CYP11B2. qPCR confirmed a lower CYP11B1/CYP11B2 ratio and a higher LHCGR expression (P<10–3, both). IHC confirmed LHCGR positivity in double-mutant APAs but distribution varied both within and between cells. Adjacent ZG was hyperplastic, with absence of both CYP11B1 and CYP11B2 staining, but weak/moderate staining for LHCGR. The same GNA11 ± CTNNB1 somatic mutations were detected in multiple regions of the adjacent adrenals to 3 double mutant APAs. qPCR of hallmark APA genes differed from the APAs. High concordance between ddPCR, NGS and Sanger sequencing of the findings of APA mutations in adjacent adrenals when analysed in the same sample. No mutations were found in 4 adrenals adjacent to APAs with KCNJ5 or CACNA1D mutations, nor in other 4 adrenals adjacent to double-mutant APAs. Conclusions: Patients harboring APAs with somatic mutations in both GNA11/GNAQ Q209 and CTNNB1 have distinct phenotype in both the APAs and their adjacent adrenals. Same GNA11 ± CTNNB1 somatic mutations were found in the adjacent adrenals to double mutant APAs. We infer that a double-hit within related pathways is more likely than a single-hit to cause large increases in expression of LHCGR, and of other genes which may influence clinical presentation.
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Affiliation(s)
- Junhua Zhou
- Endocrine Hypertension, Department of Clinical Pharmacology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | | | - Claudia P Cabrera
- Centre for Translational Bioinformatics, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | | | | | - Emily Cottrell
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Giulia Argentesi
- Endocrine Hypertension, Department of Clinical Pharmacology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Xilin Wu
- Endocrine Hypertension, Department of Clinical Pharmacology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Sam O’Toole
- Endocrine Hypertension, Department of Clinical Pharmacology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Alison Marker
- Department of Histopathology, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Suzanne Jordan
- Cellular Pathology Department, Royal London Hospital,, London, United Kingdom
| | - Daniel M Berney
- Barts and The London NHS Trust, St Bartholomews Hospital, London, United Kingdom
| | - Kate Lines
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Louise Metherell
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Ada Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Rajesh V Thakker
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - William Drake
- Department of Endocrinology, Saint Bartholomew’s Hospital, London, United Kingdom
| | - Eva Wozniak
- Barts and London Genome Centre, Barts and The London School of Medicine and Dentistry, Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Charles A Mein
- Barts and London Genome Centre, Barts and The London School of Medicine and Dentistry, Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Helen L Storr
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | | | - Morris J Brown
- Endocrine Hypertension, Department of Clinical Pharmacology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
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Benza RL, Lickert CA, Xie L, Drake W, Ogbomo A, Yuce H, Cole MR. Comparative effectiveness of endothelin receptor antagonists on mortality in patients with pulmonary arterial hypertension in a US Medicare population: a retrospective database analysis. Pulm Circ 2020. [DOI: 10.1177/2045894020954158] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Raymond L. Benza
- Division of Cardiovascular MedicineThe Ohio State University Wexner Medical CenterColumbusOHUSA
| | - Cassandra A. Lickert
- Real World Value and EvidenceActelion Pharmaceuticals US, Inc.Janssen Pharmaceutical Company of Johnson & JohnsonSouth San FranciscoCAUSA
| | - Lin Xie
- Health Economics and Outcome ResearchSTATinMED ResearchAnn ArborMIUSA
| | - William Drake
- Real World Value and EvidenceActelion Pharmaceuticals US, Inc.Janssen Pharmaceutical Company of Johnson & JohnsonSouth San FranciscoCAUSA
| | - Adesuwa Ogbomo
- Health Economics and Outcome ResearchSTATinMED ResearchAnn ArborMIUSA
| | - Huseyin Yuce
- Department of MathematicsNew York City College of TechnologyThe City University of New YorkBrooklynNYUSA
| | - Michele R. Cole
- Real World Value and EvidenceActelion Pharmaceuticals US, Inc.Janssen Pharmaceutical Company of Johnson & JohnsonSouth San FranciscoCAUSA
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9
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Kiekens KC, Romano G, Galvez D, Cordova R, Heusinkveld J, Hatch K, Drake W, Kmeid Z, Barton JK. Reengineering a falloposcope imaging system for clinical use. Translational Biophotonics 2020. [DOI: 10.1002/tbio.202000011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Kelli C. Kiekens
- Wyant College of Optical Science University of Arizona Tucson Arizona USA
| | | | - Dominique Galvez
- Wyant College of Optical Science University of Arizona Tucson Arizona USA
| | - Ricky Cordova
- Biomedical Engineering University of Arizona Tucson Arizona USA
| | - John Heusinkveld
- Obstetrics and Gynecology University of Arizona Tucson Arizona USA
| | - Kenneth Hatch
- Obstetrics and Gynecology University of Arizona Tucson Arizona USA
| | - William Drake
- Wyant College of Optical Science University of Arizona Tucson Arizona USA
| | - Zaynah Kmeid
- Biomedical Engineering University of Arizona Tucson Arizona USA
| | - Jennifer K. Barton
- Wyant College of Optical Science University of Arizona Tucson Arizona USA
- Biomedical Engineering University of Arizona Tucson Arizona USA
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Bothou C, Anand G, Li D, Kienitz T, Seejore K, Simeoli C, Ebbehoj A, Ward EG, Paragliola RM, Ferrigno R, Badenhoop K, Bensing S, Oksnes M, Esposito D, Bergthorsdottir R, Drake W, Wahlberg J, Reisch N, Hahner S, Pearce S, Trainer P, Etzrodt-Walter G, Thalmann SP, Sævik ÅB, Husebye E, Isidori AM, Falhammar H, Meyer G, Corsello SM, Pivonello R, Murray R, Bancos I, Quinkler M, Beuschlein F. Current Management and Outcome of Pregnancies in Women With Adrenal Insufficiency: Experience from a Multicenter Survey. J Clin Endocrinol Metab 2020; 105:5840404. [PMID: 32424397 PMCID: PMC7320831 DOI: 10.1210/clinem/dgaa266] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 05/15/2020] [Indexed: 12/31/2022]
Abstract
CONTEXT Appropriate management of adrenal insufficiency (AI) in pregnancy can be challenging due to the rarity of the disease and lack of evidence-based recommendations to guide glucocorticoid and mineralocorticoid dosage adjustment. OBJECTIVE Multicenter survey on current clinical approaches in managing AI during pregnancy. DESIGN Retrospective anonymized data collection from 19 international centers from 2013 to 2019. SETTING AND PATIENTS 128 pregnancies in 113 women with different causes of AI: Addison disease (44%), secondary AI (25%), congenital adrenal hyperplasia (25%), and acquired AI due to bilateral adrenalectomy (6%). RESULTS Hydrocortisone (HC) was the most commonly used glucocorticoid in 83% (97/117) of pregnancies. Glucocorticoid dosage was increased at any time during pregnancy in 73/128 (57%) of cases. In these cases, the difference in the daily dose of HC equivalent between baseline and the third trimester was 8.6 ± 5.4 (range 1-30) mg. Fludrocortisone dosage was increased in fewer cases (7/54 during the first trimester, 9/64 during the second trimester, and 9/62 cases during the third trimester). Overall, an adrenal crisis was reported in 9/128 (7%) pregnancies. Cesarean section was the most frequent mode of delivery at 58% (69/118). Fetal complications were reported in 3/120 (3%) and minor maternal complications in 15/120 (13%) pregnancies without fatal outcomes. CONCLUSIONS This survey confirms good maternal and fetal outcome in women with AI managed in specialized endocrine centers. An emphasis on careful endocrine follow-up and repeated patient education is likely to have reduced the risk of adrenal crisis and resulted in positive outcomes.
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Affiliation(s)
- Christina Bothou
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Zürich, Switzerland
| | - Gurpreet Anand
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Zürich, Switzerland
| | - Dingfeng Li
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Tina Kienitz
- Endocrinology in Charlottenburg, Berlin, Germany
| | - Khyatisha Seejore
- Department of Endocrinology, Leeds Teaching Hospitals NHS Trust, St James’s University Hospital, Leeds, UK
| | - Chiara Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Andreas Ebbehoj
- Department of Clinical Medicine, Department of Endocrinology and Diabetes, Aarhus University, Aarhus, Denmark
| | - Emma G Ward
- Department of Endocrinology, Leeds Teaching Hospitals NHS Trust, St James’s University Hospital, Leeds, UK
| | - Rosa Maria Paragliola
- Unit of Endocrinology, Università Cattolica del Sacro Cuore – Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Rosario Ferrigno
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Klaus Badenhoop
- Department of Internal Medicine I, Division of Endocrinology, Diabetes and Metabolism, University Hospital, Frankfurt, Germany
| | - Sophie Bensing
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Inflammation and Infection Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Marianne Oksnes
- Endocrinology in Charlottenburg, Berlin, Germany
- Department of Clinical Science and K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Jonas Liesvei, Bergen, Norway
| | - Daniela Esposito
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska, University Hospital, Gothenburg, Sweden
| | - Ragnhildur Bergthorsdottir
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska, University Hospital, Gothenburg, Sweden
| | - William Drake
- Department of Endocrinology, St Bartholomew’s Hospital, London, UK
| | - Jeanette Wahlberg
- Department of Endocrinology, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Nicole Reisch
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Stefanie Hahner
- Department of Internal Medicine I, Endocrinology and Diabetes Unit, University Hospital of Würzburg, University of Würzburg, Germany
| | - Simon Pearce
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Peter Trainer
- The Christie NHS Foundation, MAHSC, Wilmslow Road, Manchester, UK
| | | | | | - Åse B Sævik
- Department of Clinical Science and K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Jonas Liesvei, Bergen, Norway
| | - Eystein Husebye
- Department of Clinical Science and K.G. Jebsen Center for Autoimmune Disorders, University of Bergen, Jonas Liesvei, Bergen, Norway
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Inflammation and Infection Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Gesine Meyer
- Department of Internal Medicine I, Division of Endocrinology, Diabetes and Metabolism, University Hospital, Frankfurt, Germany
| | - Salvatore M Corsello
- Unit of Endocrinology, Università Cattolica del Sacro Cuore – Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Robert Murray
- Department of Endocrinology, Leeds Teaching Hospitals NHS Trust, St James’s University Hospital, Leeds, UK
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
| | | | - Felix Beuschlein
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Zürich, Switzerland
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
- Correspondence and Reprint Requests: Prof. Felix Beuschlein, MD, Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Raemistrasse 100, CH-8091 Zürich, Switzerland. E-mail:
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Zhou J, Cabrera CP, Azizan EAB, Fernandes-Rosa F, Cottrell E, Amar L, Argentesi G, Wu X, Marker A, Jordan S, Polubothu S, Berney DM, Tuthill A, Karet FE, Metherell L, Teo A, Thakker RV, Drake W, Boulkroun S, Kinsler V, Storr HL, Zennaro MC, Brown MJ. SAT-224 Recurrent Co-Driver Mutation in CTNNB1-Mutant Aldosterone-producing Adenomas (APA), Causing Reversible Hypertension in Puberty, Pregnancy or Menopause. J Endocr Soc 2020. [PMCID: PMC7208125 DOI: 10.1210/jendso/bvaa046.1231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background: Three patients with a syndrome of LH/HCG-activated primary aldosteronism in pregnancy or menopause carrying somatic CTNNB1 mutations were reported four years ago (Teo et al. NEJM 2015). This proved but half the story. Diagnosis of an APA in a 12-year old boy with severe hypertension revealed an apparently essential co-driver mutation. Methods: WES of tumour and blood was performed in the pubertal boy. Candidate genes were Sanger sequenced in other APAs from GB/Ireland, and France with known or suspected CTNNB1 mutations. LHCGR, GNRHR and CYP11B2 expression were measured in all available patients’ APAs and the adjacent adrenal gland (AAG) by RT-PCR. RNA and gDNA from the zona glomerulosa (ZG) of the proband’s AAG were collected by laser capture microdissection for Sanger sequencing of GNA11 and CTNNB1. Function of mutant genes was assessed by measurement of aldosterone production and LHCGR expression by immunofluorescence (IFC) in NCI-H295R adrenocortical cells and primary human APA cells. Results: The proband’s APA contained a p.(S45F) somatic mutation in CTNNB1, and a p.(Q209P) somatic mutation of the GTPase-activating residue (Q209) in GNA11. Mutations of Q209, to P or H, were also found in six other GB/Irish patients with previously identified mutations of CTNNB1 (S33C, G34R, T41A, S45F, or S45P). All seven patients remain normotensive 2-12 years post-adrenalectomy, including some with long-standing pre-operative hypertension. Four of the 13 French patients with CTNNB1 exon 3 mutant APAs have somatic mutation of Q209 of either GNA11 (n=3) or GNAQ. In comparison with their own AAG, the GB/Irish double mutant APAs showed an increase in expression of LHCGR, CYP11B2 and GNRHR by 32-166, 158-18980, and 1174-6642 fold, respectively. All four French double-mutants had >10 fold higher LHCGR than APAs with single mutations of CTNNB1 or other genes. Hyperplasia of ZG was observed in the ZG of the boy’s AAG but no APCC was detected. Homozygous or heterozygous Q209P mutation of GNA11 was detected in multiple ZG samples in RNA and/or gDNA but WT in CTNNB1 exon 3. H295R cells (CTNNB1 S45P) were GNA11 WT. Overexpression of GNA11 Q209 mutation increased aldosterone secretion to 465% of GNA11 WT overexpressing cells (n=6, P<0.001) and CYP11B2 expression was also increased several-fold. Smaller increases were seen in primary human adrenal cells after double-transfection by GNA11 and CTNNB1 mutants (n=3, P<0.001). This also caused membrane expression of LHCGR, visualised by IFC. Conclusions: APAs with double mutation of GNA11/GNAQ Q209 and CTNNB1 have a distinct phenotype, in which hypertension is triggered by high LH or HCG, and cured in all cases by adrenalectomy. GNA11/Q mediates the aldosterone response to ANGII, and the Q209 codon is analogous to the Q227 of GNAS, mutated in McCune Albright. Mosaicism for GNA11 may cause ZG hyperplasia.
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Affiliation(s)
- Junhua Zhou
- Endocrine Hypertension, Department of Clinical Pharmacology, William Harvey Research Institute and NIHR Barts Cardiovascular Biomedical Research Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Claudia P Cabrera
- NIHR Barts Cardiovascular Biomedical Research Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom, London, United Kingdom
| | - Elena A B Azizan
- Endocrine Hypertension, Department of Clinical Pharmacology, William Harvey Research Institute and Department of Medicine, The National University of Malaysia Medical Centre, Kuala Lumpur., Kuala Lumpur, Malaysia
| | | | - Emily Cottrell
- Centre for Endocrinology, William Harvey Research Institute,, London, United Kingdom
| | - Laurence Amar
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Unité Hypertension artérielle, Paris, France
| | - Giulia Argentesi
- Endocrine Hypertension, Department of Clinical Pharmacology, William Harvey Research Institute and NIHR Barts Cardiovascular Biomedical Research Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Xilin Wu
- Endocrine Hypertension, Department of Clinical Pharmacology, William Harvey Research Institute and NIHR Barts Cardiovascular Biomedical Research Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Alison Marker
- Department of Pathology, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Suzanne Jordan
- Department of Pathology, Barts Hospital, 80 Newark St, Whitechapel, London, United Kingdom
| | - Satyamaanasa Polubothu
- Genetics and Genomic Medicine, University College London GOS Institute of Child Health and Paediatric Dermatology, Great Ormond St Hospital for Children NHS Foundation Trust, London, United Kingdom
| | | | | | - Fiona E Karet
- Cambridge Institute for Medical Research, Cambridge, United Kingdom
| | | | - Ada Teo
- National University Health System, singapore, Singapore
| | | | | | | | - Veronica Kinsler
- Genetics and Genomic Medicine, University College London GOS Institute of Child Health and Paediatric Dermatology, Great Ormond St Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Helen Louise Storr
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University London, London, United Kingdom
| | - Maria-Christina Zennaro
- Université de Paris, PARCC, INSERM, and Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Génétique, Paris, France
| | - Morris Jonathan Brown
- Endocrine Hypertension, Department of Clinical Pharmacology, William Harvey Research Institute and NIHR Barts Cardiovascular Biomedical Research Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
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12
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Wu X, Goodchild E, Senanayake R, Bashari W, Salsbury J, Argentesi G, O’Toole SM, Matson M, Parvanta L, Marker A, Berney D, Sadhev A, Bird N, McConnachie A, Cruickshank K, Cheow HK, Gurnell M, Drake W, Brown MJ. OR34-07 Prospective Multicentre Study Comparing 11C-metomidate PET CT with Adrenal Vein Sampling (AVS) in the Detection of Unilateral Aldosterone-Producing Adenomas (APAs). J Endocr Soc 2020. [PMCID: PMC7208751 DOI: 10.1210/jendso/bvaa046.519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Approximately 50% of Primary Aldosteronism (PA) cases are unilateral, potentially curable by adrenalectomy. However far fewer patients progress to surgery, partly due to difficulties in identifying unilateral disease. AVS is the current criterion standard method for lateralisation. However it is an invasive procedure, technically difficult to perform, and only available in few specialist centres. MATCH is a prospective, multicentre study comparing the diagnostic accuracy of AVS with 11C-metomidate PET-CT, a non-invasive functional scan (ClinicalTrials.gov Identifier NCT02945904).
Patients fulfilling Endocrine Society criteria for PA undergo both investigations in random order. At a multidisciplinary meeting PET-CT results are scored first, followed by AVS. Patients are offered surgery if one or both investigations indicate unilateral disease. Each investigation will be re-scored by an independent, blinded endpoints committee, without knowledge of other investigations or outcomes in the same patient. Hierarchical primary outcomes are the change in aldosterone renin ratio (ARR) and average home SBP readings. If no superiority is observed for either investigation, non-inferiority of PET-CT will be tested. MATCH is powered to detect 25% superiority, or non-inferiority within a margin of 18%. Factors predicting cure will be assessed as secondary outcomes. These include BP response to aldosterone antagonists, correlation of standardised uptake value (SUV) max ratio of adenoma to adjacent normal adrenal, and phenotyping / genotyping of tumours.
Target recruitment of 140 patients has been achieved. Interesting observations to date include a high prevalence of hypokalaemia (73%), reflective of our referral base and inclusion criteria. The surgery rate is also high at 66%, consistent with finding frequent patients in whom only one investigation yields a positive result. The following case illustrates such a patient. A slim 45-year-old lady with PA and failed ONDST had inconclusive AVS (selectivity index in right adrenal vein 2.6). PET-CT revealed a 29mm metomidate-avid left adrenal nodule (SUVmax ratio 1.52, >1.25 suggestive of unilateral disease). Left adrenalectomy was recommended based on PET-CT, and achieved biochemical and clinical cure. However she required hydrocortisone replacement for 14 months. Her relatively low right adrenal vein cortisol, despite successful cannulation, was attributed to contralateral suppression by co-secretion of cortisol from her adenoma. This was confirmed by finding high CYP11B1 and CYP11B2 mRNA expression in her tumour, typical of a KCNJ5 mutation, confirmed as L168R on Sanger sequencing.
PA is a high risk subset of hypertension. Under-treatment has serious public health consequences. 11C-Metomidate PET CT has the potential to simplify the investigation pathway and allow more patients to receive potentially curable treatment.
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Affiliation(s)
- Xilin Wu
- Queen Mary University of London, London, United Kingdom
| | | | | | | | | | | | | | | | | | - Alison Marker
- University of Cambridge NHS Foundation Trust, Cambridge, United Kingdom
| | | | - Anju Sadhev
- St Bartholomew’s Hospital, London, United Kingdom
| | | | | | | | - Heok K Cheow
- Cambridge University NHS Foundation Trust, London, United Kingdom
| | - Mark Gurnell
- University of Cambridge, Wellcome Trust-MRC Institute of Metabolic Science & School of Clinical Medi, Cambridgeshire, United Kingdom
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Goodchild E, Stoetaert J, Drake W, Linton K, Brown MJ. OR09-05 Expression of SLC35F1 in the Plasma Membrane of Cells of Aldosterone Producing Cell Clusters (APCCs) and Its Possible Role in Aldosterone Synthesis. J Endocr Soc 2020. [PMCID: PMC7209706 DOI: 10.1210/jendso/bvaa046.885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Genetic mutations and histological appearances suggest that APCCs are precursors to some aldosterone producing adenomas (APA). They are hypothesised to contribute to post-operative non-cure and recurrence of primary aldosteronism (PA) but are currently undetectable pre-operatively. SLC35F1 is a possible nucleotide sugar transporter. On microarray it is highly expressed in APCCs, but not in the rest of the adrenal cortex (1). Our aim was to investigate the role of SLC35F1 in APCCs, determine its subcellular localisation and establish whether expression is consistent with pathological APCC subtypes (as suggested by recent evidence from in situ metabolomic studies (2)). Methods Comparative bioinformatic analysis of the SLC35F1 amino acid sequence was carried out. Ex vivo 4uM adrenal sections, from 6 PA patients in the MATCH study, were stained on serial sections with anti-CYP11B2 (Gomez-Sanchez) or anti-SLC35F1 (Novus NBP1-86755). In vitro, H295R cells were transfected with SLC35F1 cDNA. Subcellular localisation of SLC35F1-GFP was studied by comparison to organelle markers (golgin 97, RAB11, wheat germ agglutinin, calnexin and Tom20) using confocal microscopy. Overexpression and siRNA knock-down in H295R cells was correlated to aldosterone production. Results SLC35F1 is a decamembrane-spanning transporter molecule predicted to have a negatively charged pocket in the substrate binding site, implying a transport substrate with a positive charge. Strong staining of CYP11B2 in clusters of cells in adrenal cortex, consistent with APCCs, were present in all six adrenal glands (25 APCCs). Serial sections showed specific SLC35F1 staining of APCCs, in cytoplasm and plasma membrane. SLC35F1 staining was absent from normal cortex. 12 APCCs (48%) were SLC35F1-negative. Visualisation of transiently expressed SLC35F1 demonstrated localisation to the endoplasmic reticulum in H295R cells (Pearson’s coefficient r=0.758) with no plasma membrane localisation (r=-0.07). Preliminary transfection data suggest direct involvement in aldosterone production. Conclusions Expression of SLC35F1 in the plasma membrane and cytosol of APCC cells supports a role in pathological aldosterone production by APCCs. The inferred transport substrate of SLC35F1 is the NAD(P)(H) precursor, nicotinamide riboside, a positively-charged nucleotide sugar. If confirmed, the essential requirement for NAD(P)H in steroidogenesis, and heterogeneity of SLC35F1-staining in APCCs, is consistent with a metabolically active, possibly pathological, subtype of APCCs. Detection of SLC35F1 in vivo may therefore facilitate sub-classification of PA patients. 1). Nishimoto et. al. PNAS. 2015 Aug 18;112(33):E4591-9. 2). Murakami et. al. 2019 Hypertension. In press.
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Affiliation(s)
| | - Jan Stoetaert
- Queen Mary University London, London, United Kingdom
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14
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Wu X, Ney A, Argentesi G, Jackie S, Goodchild E, O’Toole SM, Patrizia E, Bird N, Chung TT, Cheow HK, Drake W, Pereira S, Brown MJ. SAT-546 Endoscopic Ultrasound-Guided Radiofrequency Ablation (EUS-RFA) as an Alternative to Adrenalectomy for the Treatment of Aldosterone-Producing Adenomas (APAs). J Endocr Soc 2020. [PMCID: PMC7208897 DOI: 10.1210/jendso/bvaa046.514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Primary Aldosteronism (PA) carries significant cardiometabolic risk, over and above those attributable to hypertension alone. The Endocrine Society guidelines recommend adrenalectomy in those with unilateral disease. However surgery is likely to become unsustainable in public healthcare systems as more patients are diagnosed with PA. Already, surgery may not be feasible in some patients due to co-morbidities, others are reluctant to have the whole adrenal gland removed when excess aldosterone can be localised to small APA(s) in 1 gland. The FABULAS Study explores if EUS-RFA is a safe alternative to left-sided adrenalectomy (ClinicalTrials.gov ID NCT03405025). This multicentre phase-1 study comprises 3 groups of 10 patients with proven PA and left APAs. Successive groups have an increasing benefit:risk ratio for surgery. The first 4 ablation procedures are assessed by an independent safety committee before progression into the next, overlapping group. The primary outcomes are safety and feasibility of EUS-RFA. Safety is assessed throughout the study, including measures of intra-procedure adrenomedullary activation. Efficacy is evaluated by biochemistry, home / clinic BPs, and quantitative 11C-metomidate PET-CT at baseline and 6 months post-ablation. RFA is performed using a Starmed catheter, small enough to pass through a 19-gauge needle, through the stomach. Ablation has been performed in 6 patients (median age 63-years). Mean tumour size was 17mm (range 12-36mm). Plasma metanephrine levels remained stable during RFA. 2 adverse events occurred within the first 48hours post-ablation: AF in a patient with known paroxysmal AF, and an episode of pyrexia and raised CRP attributed to tissue infarction. Both events were deemed ‘not unexpected’ by the safety committee. Most patients have benefited clinically post-ablation. This is illustrated by a 65-year-old man with previously uncontrolled hypertension despite 4 antihypertensive medications, including spironolactone. Baseline aldosterone/renin ratio (ARR) was >200 (PA likely if ARR>60). PET CT revealed a 15mm left adrenal nodule with avid metomidate uptake and an SUVmax ratio of 1.92 (SUVmax ratio >1.25 suggestive of unilateral disease). He underwent uneventful EUS-RFA. 6 months post-ablation his ARR has normalised to 26. On repeat PET CT the metomidate avid adenoma is no longer hot, with a drop in both the SUVmax measured over the APA (31 pre-, and 5 post-ablation) and a reduction in the SUVmax ratio to 1.04. Most importantly, his home BP averages 124/83mmHg and he is thrilled to be off all treatment. Retrospective reports exist of successful percutaneous and retroperitoneal RFA of APAs. FABULAS is the first prospective study, using a minimally invasive, endoscopic route. If proven to be safe and effective EUS-RFA will open the doors for more patients to receive definitive treatment, potentially even those with bilateral disease.
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Affiliation(s)
- Xilin Wu
- Queen Mary University of London, London, United Kingdom
| | | | | | | | | | | | | | - Nicholas Bird
- University of Cambridge NHS Foundation Trust, Cambridge, United Kingdom
| | | | - Heok K Cheow
- Cambridge University NHS Foundation Trust, Cambridge, United Kingdom
| | - William Drake
- Saint Bartholomew’s Hospital, London, United Kingdom
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Nikoi ENA, Drake W, Glynn N. SUN-306 The Interaction Between Thiazide-Associated Hyponatremia and Acute Illness in Hospitalised Patients. J Endocr Soc 2020. [PMCID: PMC7208147 DOI: 10.1210/jendso/bvaa046.1095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Thiazide diuretics, widely used in the management of hypertension, are associated with a five times greater risk of hyponatremia (serum Na <135mmol/L) than in the general population. Hyponatremia in hospitalised patients warrants special consideration since it is associated with increased morbidity and mortality. The aim of this study was to describe the clinical characteristics and outcomes in acutely ill medical patients with thiazide-associated hyponatremia (TAH). We performed a retrospective, case control study examining all acute, unselected medical admissions, over a six week period, to The Royal London Hospital. Cases were defined as adults admitted to hospital with TAH (hyponatremia and a history of being prescribed thiazide diuretic pre-admission). Each case was matched by age, gender and degree of hyponatremia to a similar control - admitted with hyponatremia and no pre-admission exposure to thiazide (non-TAH). Clinical characteristics and treatment outcomes were compared between TAH and non-TAH cohorts. A total of 1,341 consecutive acute medical admissions (49.7% men) were evaluated. Hyponatremia was detected in 240 (17.9%) admissions. Median (±SD) length of stay was longer among patients with hyponatremia compared to normonatremic patients (5.0±12.4 versus 3.0±9.2 days; p=<0.0001). In-hospital mortality was higher in the hyponatremic group (8.8% versus 4.4% p=0.005). Twenty-two cases (11 men) of TAH accounted for 9.2% of patients with hyponatremia. Median age 64±14 years was similar to other patients with hyponatremia 68±20 years. The median admission serum sodium for TAH cases was 131.5 mmol/L (IQR 126.8 - 134) with a discharge serum sodium of 136.5 mmol/L (IQR 133.8 - 139.3). When compared to matched controls, patients with TAH had similar presenting symptoms - most commonly confusion, headache and dizziness. Length of stay among TAH cases was similar to controls; 5.5±5.1 versus 4.0±3.7 days; p=0.24. Mortality (10%) was the same in both groups. Thiazide was withdrawn during admission in 14 (64%) cases. In conclusion, acute, clinical outcomes for hospitalised patients with TAH are similar to those with comparable degrees of hyponatremia due to other causes.
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Affiliation(s)
| | | | - Nigel Glynn
- St Bartholomew’s & The Royal London Hospital, London, United Kingdom
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Naruse M, Beuschlein F, Caprino MP, Deinum J, Drake W, Fallo F, Fuss CT, Grytaas MA, Ichijo T, Inagaki N, Ohno Y, Kakutani M, Kastelan D, Kraljevic I, Katabami T, Kocjan T, Mulatero P, O’Toole SM, Sone M, Tsuiki M, Wada N, Tanabe A, Maccario M. OR34-04 Efficiency of Adrenal Venous Sampling in the Treatment Choice of Primary Aldosteronism (AVSTAT Study). J Endocr Soc 2020. [PMCID: PMC7209038 DOI: 10.1210/jendso/bvaa046.480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND: Adrenal venous sampling (AVS) is strongly recommended for a subtype diagnosis of primary aldosteronism (PA) if adrenalectomy (ADX) is desired by the patient. Given various issues related to AVS such as technical demand, invasive nature, expensive cost and radiation exposure, AVS is expected to lead efficiently to the subtype diagnosis and ADX. Aim: Primary objective was to assess the performance of AVS to determine treatment of PA by investigating the ratio of unilateral disease and rate of ADX following AVS in patients with unilateral disease. Methods: Sixteen major referral centers in ENS@T (n=10) and Japan (n=6) participated in the study. Study period was from 2006 to 2018. Data on total number of PA patients, AVS (total number and number of successful procedures), number of patients with unilateral diseases, and number of patients that underwent ADX were collected by a questionnaire-based survey. In addition, reasons for not proceeding to ADX in patients with a unilateral diagnosis were investigated. The diagnosis of PA was based on the positive case detection and at least one positive result in confirmatory testing. Results: Total number of confirmed PA patients and conducted AVS showed a dramatic increase during the past decade (PA: 1061 pts/ 2006–2011 to 3718 pts/ 2012–2018; AVS: 720/ 2006–2011 to 2448/ 2012–2018). Success rate of AVS was improved from 79.0% (2006–2011) to 92.5% (2012–2018). Both rate of unilateral PA and ADX of successful procedures decreased from 42.7% (2006–2011) to 37.3% (2012–2018) and from 40.8% (2006–2011) to 34.9% (2012–2018), respectively. Of the patients with successful AVS, bilateral disease was diagnosed in 63.5% (1812/2854 pts). Of the unilateral PA patients, 11.9% (125/ 1054 pts) were not subjected to ADX. The rate of the patients not subjected to ADX was significantly higher in Japan than in ENS@T centers both in patients with successful AVS (75.8% vs. 53.4%) and with unilateral disease (19.9% vs. 8.6%). Clinical decision against ADX in unilateral disease was made by the physicians in 33.3%, the patients in 33.3%, and both in 33.3%. Medical factors for Dr.’s decision against ADX in unilateral disease included good blood pressure control, normokalemia, comorbidities (e.g. DM, CKD), non-lateralized CT findings (e.g. no tumor, contralateral tumor), and discordant results among different criteria of AVS. Conclusions: High prevalence of bilateral disease and change of treatment policy after implementation affected the efficiency of AVS as an essential diagnostic procedure prior to ADX. Development of non-invasive procedures to exclude bilateral PA and more strict indication of AVS are warranted.
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Affiliation(s)
| | | | | | - Jaap Deinum
- Radboud Univ Nijmegen, Nijmegen, Netherlands
| | | | | | - Carmina Teresa Fuss
- Department of Medicine I, Division of Endocrinology and Diabetologie, university Hospital, Wuerzburg, Dettelbach, Germany
| | | | | | - Nobuya Inagaki
- Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Youichi Ohno
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University, JAPAN, Kyoto, Japan
| | | | | | | | - Takuyuki Katabami
- St. Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohamai, Japan
| | - Tomaz Kocjan
- DEPT. OF ENDOCRINOLOGY, DIABETES AND METABOLIC DISEASES, Ljubljana, Slovenia
| | | | | | | | | | - Norio Wada
- Sapporo City General Hospital, SAPPORO, Japan
| | - Akiyo Tanabe
- National Center for Global Health and Medicine, Tokyo, Japan
| | - Mauro Maccario
- University of Turin, Endocrinology, Diabetology and Metabolism, Italy
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17
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Runkel B, Shwaish N, Raghuveer G, Drake W. BRAIN ABSCESS IN A NONFENESTRATED FONTAN PATIENT. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)33034-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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18
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Studer S, Hull M, Pruett J, Elliott C, Tsang Y, Drake W. Retrospective Database Analysis of Treatment Patterns Among Patients with Pulmonary Arterial Hypertension. Pulm Ther 2020; 6:79-92. [PMID: 32048240 PMCID: PMC7229082 DOI: 10.1007/s41030-019-00106-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Indexed: 11/01/2022] Open
Abstract
INTRODUCTION Release of the 2015 European Society of Cardiology (ESC)/European Respiratory Society (ERS) guidelines put increased emphasis on using combination therapy, either as upfront or sequential therapy among patients with pulmonary arterial hypertension (PAH). However, with these recommendations and the therapy advances made in the last several years, little is known on the real-world treatment patterns among patients with PAH, particularly before and after publication of the 2015 ESC/ERS guidelines. METHODS This was a retrospective study of adult commercial and Medicare Advantage with Part D (MAPD) enrollees with at least one claim for a PAH-related medication from January 01, 2012 to March 31, 2017, at least one medical claim with a pulmonary hypertension diagnosis, and continuous health plan enrollment at least 6 months prior to and at least 12 months following the date of the first pharmacy claim for PAH-related therapy (index date). Patients were divided into cohorts based on prescription of monotherapy or combination therapy and index date category (2012-2013, January 2014-July 2015, and August 2015-March 2017). RESULTS Out of 1878 patients, 90.8% initiated with monotherapy and 9.2% initiated with combination therapy. The percentage of patients with index combination therapy increased from 5.7% in 2012-2013 to 13.0% in August 2015-March 2017. Patients with index combination therapy had better persistence (11.6 months versus 10.3 months) and adherence (0.95 versus 0.85). Overall, the discontinuation rate was 40% and was higher in monotherapy versus combination therapy patients (42.8% versus 12.2%). Approximately 30.2% of patients had a second regimen, of which 50% were combination regimens. The time to combination therapy initiation decreased from 10.5 months in 2012-2013 to 3.4 months in August 2015-March 2017. CONCLUSIONS The majority of patients initiated monotherapy treatment for PAH, most often a phosphodiesterase 5 inhibitor (PDE5i). Patients with upfront combination therapy increased following publication of the 2015 ESC/ERS guidelines, indicating that physicians responded to the guideline's option of prescribing upfront combination therapy.
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Affiliation(s)
- Sean Studer
- NYC Health + Hospitals/Kings County, New York, NY, USA
| | | | - Janis Pruett
- Actelion Pharmaceuticals US, Inc, South San Francisco, CA, USA
| | | | - Yuen Tsang
- Actelion Pharmaceuticals US, Inc, South San Francisco, CA, USA
| | - William Drake
- Actelion Pharmaceuticals US, Inc, South San Francisco, CA, USA
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19
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Frantz RP, Hill JW, Lickert CA, Wade RL, Cole MR, Tsang Y, Drake W. Medication adherence, hospitalization, and healthcare resource utilization and costs in patients with pulmonary arterial hypertension treated with endothelin receptor antagonists or phosphodiesterase type-5 inhibitors. Pulm Circ 2020; 10:2045894019880086. [PMID: 32274010 PMCID: PMC7114296 DOI: 10.1177/2045894019880086] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 06/03/2019] [Indexed: 12/14/2022] Open
Abstract
Adherence to therapy for pulmonary arterial hypertension is essential to optimize patient outcomes, but data on real-world adherence to different pulmonary arterial hypertension drug classes are limited. This retrospective database analysis evaluated relationships between adherence, hospitalization, and healthcare costs in pulmonary arterial hypertension patients treated with endothelin receptor antagonists or phosphodiesterase type-5 inhibitors. From the IQVIA Adjudicated Health Plan Database, patients with pulmonary arterial hypertension were identified based on diagnostic codes and prescriptions for endothelin receptor antagonists (ambrisentan, bosentan, macitentan) or phosphodiesterase type-5 inhibitors (sildenafil, tadalafil) approved for pulmonary arterial hypertension. Patients were assigned to the class of their most recently initiated (index) pulmonary arterial hypertension therapy between 1 January 2009 and 30 June 2015. Medication adherence was measured by proportion of days covered; patients with proportion of days covered ≥80% were considered adherent. The proportion of adherent patients was higher for endothelin receptor antagonists (571/755; 75.6%) than for phosphodiesterase type-5 inhibitors (970/1578; 61.5%; P < 0.0001). In both groups, hospitalizations declined as proportion of days covered increased. Among adherent patients, those on endothelin receptor antagonists had a significantly lower hospitalization rate than those on phosphodiesterase type-5 inhibitors (23.1% versus 28.5%, P = 0. 0218), fewer hospitalizations (mean (standard deviation) 0.4 (0.8) versus 0.5 (0.9); P = 0.02), and mean hospitalization costs during the six-month post-index ($9510 versus $15,726, P = 0.0318). Increasing adherence reduced hospitalization risk more for endothelin receptor antagonists than for phosphodiesterase type-5 inhibitors (hazard ratio 0.176 versus 0.549, P = 0.001). Rates and numbers of rehospitalizations within 30 days post-discharge were similar between groups. Mean total costs were higher with endothelin receptor antagonists than phosphodiesterase type-5 inhibitors in all patients ($91,328 versus $72,401, P = 0.0003) and in adherent patients ($88,867 versus $56,300, P < 0.0001), driven by higher drug costs.
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Affiliation(s)
- Robert P. Frantz
- Department of Cardiovascular Diseases,
Mayo Clinic, Rochester, USA
| | | | | | | | | | - Yuen Tsang
- Actelion Pharmaceuticals US, Inc., South
San Francisco, USA
| | - William Drake
- Actelion Pharmaceuticals US, Inc., South
San Francisco, USA
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20
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Lim ES, Shah SG, Waterhouse M, Akker S, Drake W, Plowman N, Berney DM, Richards P, Adams A, Nowosinska E, Brennan C, Druce M. Impact of thyroiditis on 131I uptake during ablative therapy for differentiated thyroid cancer. Endocr Connect 2019; 8:571-578. [PMID: 30965284 PMCID: PMC6499916 DOI: 10.1530/ec-19-0053] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 04/09/2019] [Indexed: 01/08/2023]
Abstract
CONTEXT Differentiated thyroid cancer (DTC) is usually treated by thyroidectomy followed by radioiodine ablation and generally has a good prognosis. It may now be possible to limit the amount of treatment without impacting on efficacy. It is not known whether coexistent thyroiditis impacts on radioiodine uptake or on its potential efficacy, but this could provide a rationale for modification to current therapeutic protocols. DESIGN This was a retrospective cohort study of radioiodine uptake on imaging after radioiodine ablation for DTC in patients with and without concurrent thyroiditis. All patients with histologically confirmed DTC treated with radioiodine ablation after thyroidectomy in a single centre from 2012 to 2015 were included. The primary outcome assessed was the presence of low or no iodine uptake on post-ablation scan, as reported by a nuclear medicine physician blinded to the presence or absence of thyroiditis. RESULTS One hundred thirty patients with available histopathology results were included. Thyroiditis was identified in 42 post-operative specimens and 15 of these patients had low or no iodine uptake on post-ablation scan, compared to only 2 of 88 patients without thyroiditis (P < 0.0001) with further data analysis dividing the groups by ablation activity received (1100 MBq or 3000 MBq). CONCLUSIONS Concurrent thyroiditis may impair the uptake of radioactive iodine in management of DTC. Given that patients with DTC and thyroiditis already have a good prognosis, adopting a more selective approach to this step in therapy may be indicated. Large, longitudinal studies would be required to determine if omitting radioactive iodine therapy from those patients with concurrent thyroiditis has a measurable impact on mortality from thyroid cancer.
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Affiliation(s)
- Eugenie S Lim
- Barts Health NHS Trust, Barts and the London School of Medicine and Dentistry, London, UK
| | - Shanty G Shah
- Barts and the London School of Medicine and Dentistry, QMUL, London, UK
| | - Mona Waterhouse
- Barts Health NHS Trust, Barts and the London School of Medicine and Dentistry, London, UK
| | - Scott Akker
- Barts Health NHS Trust, Barts and the London School of Medicine and Dentistry, London, UK
- Barts and the London School of Medicine and Dentistry, QMUL, London, UK
| | - William Drake
- Barts Health NHS Trust, Barts and the London School of Medicine and Dentistry, London, UK
- Barts and the London School of Medicine and Dentistry, QMUL, London, UK
| | - Nick Plowman
- Barts Health NHS Trust, Barts and the London School of Medicine and Dentistry, London, UK
- Barts and the London School of Medicine and Dentistry, QMUL, London, UK
| | - Daniel M Berney
- Barts Health NHS Trust, Barts and the London School of Medicine and Dentistry, London, UK
- Barts and the London School of Medicine and Dentistry, QMUL, London, UK
| | - Polly Richards
- Barts Health NHS Trust, Barts and the London School of Medicine and Dentistry, London, UK
| | - Ashok Adams
- Barts Health NHS Trust, Barts and the London School of Medicine and Dentistry, London, UK
| | - Ewa Nowosinska
- Barts Health NHS Trust, Barts and the London School of Medicine and Dentistry, London, UK
| | - Carmel Brennan
- Barts Health NHS Trust, Barts and the London School of Medicine and Dentistry, London, UK
| | - Maralyn Druce
- Barts Health NHS Trust, Barts and the London School of Medicine and Dentistry, London, UK
- Barts and the London School of Medicine and Dentistry, QMUL, London, UK
- Correspondence should be addressed to M Druce:
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21
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Steeds R, Stiles C, Sharma V, Chambers J, Lloyd G, Drake W. Echocardiography and monitoring patients receiving dopamine agonist therapy for hyperprolactinaemia: A joint position statement of the British Society of Echocardiography, the British Heart Valve Society and the Society for Endocrinology. Clin Endocrinol (Oxf) 2019; 90:662-669. [PMID: 30818417 DOI: 10.1111/cen.13940] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 12/13/2018] [Accepted: 12/13/2018] [Indexed: 11/29/2022]
Abstract
This is a joint position statement of the British Society of Echocardiography, the British Heart Valve Society and the Society for Endocrinology on the role of echocardiography in monitoring patients receiving dopamine agonist (DA) therapy for hyperprolactinaemia. Evidence that DA pharmacotherapy causes abnormal valve morphology and dysfunction at doses used in the management of hyperprolactinaemia is extremely limited. Evidence of clinically significant valve pathology is absent, except for isolated case reports around which questions remain. Attributing change in degree of valvar regurgitation, especially in mild and moderate tricuspid regurgitation, to adverse effects of DA in hyperprolactinaemia should be avoided if there are no associated pathological changes in leaflet thickness, restriction or retraction. Note must be taken that even where morphological change in leaflet structure and function may be suspected, grading is semi-quantitative on echocardiography and may vary between different machines, ultrasound settings and operators. Decisions regarding discontinuation of medication should only be made after review of serial imaging by an echocardiographer experienced in analysing drug-induced valvulopathy or carcinoid heart disease. A standard transthoracic echocardiogram should be performed before a patient starts DA therapy for hyperprolactinaemia. Repeat transthoracic echocardiography should then be performed at 5 years after starting cabergoline in patients taking a total weekly dose less than or equal to 2 mg. If there has been no change on the 5-year scan, repeat echocardiography could continue at 5-yearly intervals. If a patient is taking more than a total weekly dose of 2 mg, then annual echocardiography is recommended.
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Affiliation(s)
- Richard Steeds
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Craig Stiles
- Department of Endocrinology, Saint Bartholomew's Hospital, London, UK
| | - Vishal Sharma
- Royal Liverpool and Broadgreen University Hospital, Liverpool, UK
| | - John Chambers
- Cardiothoracic Centre, Guy's and St Thomas' Hospitals, London, UK
| | - Guy Lloyd
- Cardiology Department, Saint Bartholomew's Hospital, London, UK
| | - William Drake
- Department of Endocrinology, Bartholomew's Hospital, London, UK
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22
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Highland KB, Hull M, Pruett J, Elliott C, Tsang Y, Drake W. Baseline history of patients using selexipag for pulmonary arterial hypertension. Ther Adv Respir Dis 2019; 13:1753466619843774. [PMID: 30983530 PMCID: PMC6466463 DOI: 10.1177/1753466619843774] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction: Since its introduction to the market in 2016, selexipag has been an
alternative oral therapy among both treatment-naïve patients and those with
mono or dual therapy failure; however, limited information is available
regarding the presentation and management of patients with pulmonary
arterial hypertension (PAH) prior to selexipag initiation. This study
examined treatment patterns, healthcare utilization, and costs in the 12
months prior to and the 6 months following selexipag initiation. Methods: This was a retrospective study of adult commercial and Medicare Advantage
with Part D (MAPD) health plan members with a medical or pharmacy claim for
selexipag from 1 January 2016 through 31 May 2017, a diagnosis of pulmonary
hypertension, and continuous health plan enrollment for 12 months prior to
selexipag initiation (baseline period). Treatment patterns, healthcare
utilization, and costs were measured over the baseline period and the 6
months following selexipag initiation (among patients with ⩾6 months of
follow up). Results: After inclusion and exclusion criteria were applied, 95 patients were
included in the analysis. At study start, 57.9% of patients were prescribed
combination therapy, increasing to 69.5% immediately prior to selexipag
initiation. Approximately 60% of patients had one baseline regimen.
Emergency visits and inpatient admissions during the baseline period
occurred in 63.2% and 48.4% of patients, respectively. Baseline medical
costs rose steadily, increasing 266.8% in commercial and 26.7% in MAPD
enrollees from the beginning to the end of the 12-month baseline period.
PAH-related healthcare costs accounted for more than 80% of total costs.
Mean medical costs in the 6 months following selexipag initiation were
US$17,215 in commercial and US$23,976 in MAPD enrollees. Conclusions: The majority of patients with PAH remained on the same therapy in the 12
months prior to selexipag initiation despite high rates of healthcare
utilization and increasing costs. Mean medical costs appeared to decrease
after adding or switching to selexipag.
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Affiliation(s)
| | - Michael Hull
- Health Economics and Outcomes Research, Optum, 11000 Optum Circle, Eden Prairie, MN 55344, USA
| | - Janis Pruett
- Actelion Pharmaceuticals US, Inc., South San Francisco, CA, USA
| | | | - Yuen Tsang
- Actelion Pharmaceuticals US, Inc., South San Francisco, CA, USA
| | - William Drake
- Actelion Pharmaceuticals US, Inc., South San Francisco, CA, USA
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23
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Steeds RP, Stiles CE, Sharma V, Chambers JB, Lloyd G, Drake W. Echocardiography and monitoring patients receiving dopamine agonist therapy for hyperprolactinaemia: a joint position statement of the British Society of Echocardiography, the British Heart Valve Society and the Society for Endocrinology. Echo Res Pract 2019; 6:G1-G8. [PMID: 30825409 PMCID: PMC6391931 DOI: 10.1530/erp-18-0069] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 12/20/2018] [Accepted: 01/28/2019] [Indexed: 12/12/2022] Open
Abstract
This is a joint position statement of the British Society of Echocardiography, the British Heart Valve Society and the Society for Endocrinology on the role of echocardiography in monitoring patients receiving dopamine agonist (DA) therapy for hyperprolactinaemia. (1) Evidence that DA pharmacotherapy causes abnormal valve morphology and dysfunction at doses used in the management of hyperprolactinaemia is extremely limited. Evidence of clinically significant valve pathology is absent, except for isolated case reports around which questions remain. (2) Attributing change in degree of valvular regurgitation, especially in mild and moderate tricuspid regurgitation, to adverse effects of DA in hyperprolactinaemia should be avoided if there are no associated pathological changes in leaflet thickness, restriction or retraction. It must be noted that even where morphological change in leaflet structure and function may be suspected, grading is semi-quantitative on echocardiography and may vary between different machines, ultrasound settings and operators. (3) Decisions regarding discontinuation of medication should only be made after review of serial imaging by an echocardiographer experienced in analysing drug-induced valvulopathy or carcinoid heart disease. (4) A standard transthoracic echocardiogram should be performed before a patient starts DA therapy for hyperprolactinaemia. Repeat transthoracic echocardiography should then be performed at 5 years after starting cabergoline in patients taking a total weekly dose less than or equal to 2 mg. If there has been no change on the 5-year scan, repeat echocardiography could continue at 5-yearly intervals. If a patient is taking more than a total weekly dose of 2 mg, then annual echocardiography is recommended.
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Affiliation(s)
- Richard P Steeds
- University Hospital Birmingham, Birmingham, UK.,Institute of Cardiology, University of Birmingham, Birmingham, UK
| | - Craig E Stiles
- Department of Endocrinology, Saint Bartholomew's Hospital, London, UK
| | - Vishal Sharma
- Department of Cardiology, Royal Liverpool and Broadgreen University Hospital, Liverpool, UK
| | - John B Chambers
- Cardiothoracic Centre, Guy's and St Thomas' Hospitals - London, UK
| | - Guy Lloyd
- Department of Cardiology, Saint Bartholomew's Hospital, London, UK
| | - William Drake
- Department of Endocrinology, Bartholomew's Hospital, London, UK
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24
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Studer S, Hull M, Pruett J, Koep E, Tsang Y, Drake W. Treatment patterns, healthcare resource utilization, and healthcare costs among patients with pulmonary arterial hypertension in a real-world US database. Pulm Circ 2018; 9:2045894018816294. [PMID: 30421652 PMCID: PMC6432690 DOI: 10.1177/2045894018816294] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Several new medications for pulmonary arterial hypertension (PAH) have recently been introduced; however, current real-world data regarding US patients with PAH are limited. We conducted a retrospective administrative claims study to examine PAH treatment patterns and summarize healthcare utilization and costs among patients with newly diagnosed PAH treated in US clinical practice. Patients newly treated for PAH from 1 January 2010 to 31 March 2015 were followed for ≥12 months. Patient characteristics, treatment patterns, healthcare resource utilization, and costs were described. Adherence (proportion of days covered), persistence (months until therapy discontinuation/modification), and the probability of continuing the index regimen were analyzed by index regimen cohort (monotherapy versus combination therapy). Of 1637 eligible patients, 93.8% initiated treatment with monotherapy and 6.2% with combination therapy. The most common index regimen was phosphodiesterase type 5 inhibitor (PDE-5I) monotherapy (70.0% of patients). A total of 581 patients (35.5%) modified their index regimen during the study. Most patients (55.4%) who began combination therapy did so on or within six months of the index date. Endothelin receptor agonists (ERAs) and combination therapies were associated with higher adherence than PDE-5Is and monotherapies, respectively. Healthcare utilization was substantial across the study population, with costs in the combination therapy cohort more than doubling from baseline to follow-up. The majority of patients were treated with monotherapies (most often, PDE-5Is), despite combination therapies and ERAs being associated with higher medication adherence. Index regimen adjustments occurred early and in a substantial proportion of patients, suggesting that inadequate clinical response to monotherapies may not be uncommon.
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Affiliation(s)
- Sean Studer
- 1 NYC Health + Hospitals/Kings County, New York, NY, USA
| | | | - Janis Pruett
- 3 Actelion Pharmaceuticals US, Inc., South San Francisco, CA, USA
| | | | - Yuen Tsang
- 3 Actelion Pharmaceuticals US, Inc., South San Francisco, CA, USA
| | - William Drake
- 3 Actelion Pharmaceuticals US, Inc., South San Francisco, CA, USA
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Trainer PJ, Newell-Price JDC, Ayuk J, Aylwin SJB, Rees A, Drake W, Chanson P, Brue T, Webb SM, Fajardo C, Aller J, McCormack AI, Torpy DJ, Tachas G, Atley L, Ryder D, Bidlingmaier M. A randomised, open-label, parallel group phase 2 study of antisense oligonucleotide therapy in acromegaly. Eur J Endocrinol 2018; 179:97-108. [PMID: 29789410 PMCID: PMC6063983 DOI: 10.1530/eje-18-0138] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 05/22/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE ATL1103 is a second-generation antisense oligomer targeting the human growth hormone (GH) receptor. This phase 2 randomised, open-label, parallel-group study assessed the potential of ATL1103 as a treatment for acromegaly. DESIGN Twenty-six patients with active acromegaly (IGF-I >130% upper limit of normal) were randomised to subcutaneous ATL1103 200 mg either once or twice weekly for 13 weeks and monitored for a further 8-week washout period. METHODS The primary efficacy measures were change in IGF-I at week 14, compared to baseline and between cohorts. For secondary endpoints (IGFBP3, acid labile subunit (ALS), GH, growth hormone-binding protein (GHBP)), comparison was between baseline and week 14. Safety was assessed by reported adverse events. RESULTS AND CONCLUSIONS Baseline median IGF-I was 447 and 649 ng/mL in the once- and twice-weekly groups respectively. Compared to baseline, at week 14, twice-weekly ATL1103 resulted in a median fall in IGF-I of 27.8% (P = 0.0002). Between cohort comparison at week 14 demonstrated the median fall in IGF-I to be 25.8% (P = 0.0012) greater with twice-weekly dosing. In the twice-weekly cohort, IGF-I was still declining at week 14, and remained lower at week 21 than at baseline by a median of 18.7% (P = 0.0005). Compared to baseline, by week 14, IGFBP3 and ALS had declined by a median of 8.9% (P = 0.027) and 16.7% (P = 0.017) with twice-weekly ATL1103; GH had increased by a median of 46% at week 14 (P = 0.001). IGFBP3, ALS and GH did not change with weekly ATL1103. GHBP fell by a median of 23.6% and 48.8% in the once- and twice-weekly cohorts (P = 0.027 and P = 0.005) respectively. ATL1103 was well tolerated, although 84.6% of patients experienced mild-to-moderate injection-site reactions. This study provides proof of concept that ATL1103 is able to significantly lower IGF-I in patients with acromegaly.
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Affiliation(s)
- Peter J Trainer
- Department of EndocrinologyThe Christie NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Correspondence should be addressed to P J Trainer;
| | - John D C Newell-Price
- Department of Oncology and MetabolismThe Medical School, University of Sheffield, Sheffield, UK
- Royal Hallamshire HospitalSheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John Ayuk
- Medicine EndocrinologyQueen Elizabeth Hospital Birmingham, Edgbaston, UK
| | | | - Aled Rees
- Neuroscience and Mental Health Research InstituteSchool of Medicine, Cardiff University, Hadyn Ellis Building, Cardiff, UK
| | - William Drake
- Department of EndocrinologySt Bartholomew’s Hospital, London, UK
| | - Philippe Chanson
- Assistance Publique-Hôpitaux de ParisHôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Service d’Endocrinologie et des Maladies de la Reproduction, Le Kremlin-Bicêtre, France
- Inserm 1185Fac Med Paris Sud, Univ Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Thierry Brue
- Aix-Marseille UniversitéCNRS, CRN2M UMR 7286, Marseille, France
- APHMHôpital Conception, Service d’Endocrinologie, Diabète et Maladies Métaboliques, Centre de Référence des Maladies Rares d’Origine Hypophysaire, Marseille, France
| | - Susan M Webb
- Department of EndocrinologyCIBERER Group 747, IIB-S Pau, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Carmen Fajardo
- Servicio de EndocrinologíaHospital Universitario de La Ribera, Alzira, Valencia, Spain
| | - Javier Aller
- Endocrinology DepartmentHospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Spain
| | - Ann I McCormack
- Garvan Institute of Medical Research and St Vincent’s HospitalDarlinghurst Sydney, New South Wales, Australia
| | - David J Torpy
- Royal Adelaide HospitalNorth Terrace, Adelaide, Australia
| | - George Tachas
- Antisense Therapeutics LimitedToorak, Victoria, Australia
| | - Lynne Atley
- Antisense Therapeutics LimitedToorak, Victoria, Australia
| | - David Ryder
- Manchester Academic Health Science Centre (MAHSC) Clinical Trials UnitThe Christie NHS Foundation Trust, University of Manchester, Manchester, UK
| | - Martin Bidlingmaier
- Endocrine LaboratoryMedizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität München, Munich, Germany
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Ruiz G, Yeaw J, Lickert CA, De AP, Wade RL, Pruett J, Drake W. Using Real World Evidence to Describe Pulmonary Arterial Hypertension Treatment Patterns, Healthcare Resource Utilization, and Costs Associated with PDE-5 Inhibitor Monotherapy. J Health Econ Outcomes Res 2018; 5:206-219. [PMID: 35620777 PMCID: PMC9090461 DOI: 10.36469/9812] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Background: Pulmonary arterial hypertension (PAH) is described by proliferation of small pulmonary arteries leading to increased pulmonary vascular resistance, right ventricular failure, and death. Research confirms long-term improvement in composite morbidity and mortality endpoints on some endothelin receptor antagonists alone and in combination with phosphodiesterase type 5 inhibitors (PDE-5is) but not with PDE-5i monotherapy. While current treatment guidelines incorporate these findings, a substantial number of patients are started or maintained on PDE-5i monotherapy. Objectives: This study describes real-world clinical practice and treatment patterns with PDE-5i monotherapy including events indicative of clinical worsening, treatment modifications, adherence, allcause healthcare resource utilization, and costs. Methods: This retrospective study analyzed PharMetrics Plus claims data including 150 million lives; study period was January 1, 2009 through December 31, 2013. Eligible patients were ≥18 years with ≥1 inpatient or ≥2 outpatient claims ≥30 days apart, a diagnosis of pulmonary hypertension or other chronic pulmonary heart disease, and an initial PDE-5i prescription. To include only World Health Organization group 1 PAH patients, ≥1 encounter for right-heart catheterization or Doppler echocardiogram was required during the pre-index period. Results: PDE-5i monotherapy for PAH treatment was associated with high treatment modification rates, low adherence, increased healthcare resource utilization, and high costs. At 12 months post index, 41.5% of patients experienced treatment modification. For the index therapy, 47% of patients had ≥80% adherence to therapy. Almost 50% of patients had ≥1 hospitalization, with costs increased three fold to $197 111 compared to $59 164 for non-hospitalized patients. Conclusions: Initial treatment with PDE-5i monotherapy was associated with substantial direct medical costs, including hospitalizations and emergency department visits, low therapy adherence and a high rate of treatment modifications.
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Affiliation(s)
- George Ruiz
- Pulmonary Hypertension Program, Medstar Heart Institute, Washington, DC, USA
| | | | | | | | | | - Janis Pruett
- Actelion Pharmaceuticals US, Inc., South San Francisco, CA, USA
| | - William Drake
- Actelion Pharmaceuticals US, Inc., South San Francisco, CA, USA
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Burger CD, Pruett JA, Lickert CA, Berger A, Murphy B, Drake W. Prostacyclin Use Among Patients with Pulmonary Arterial Hypertension in the United States: A Retrospective Analysis of a Large Health Care Claims Database. J Manag Care Spec Pharm 2017; 24:291-302. [PMID: 29406840 PMCID: PMC10397685 DOI: 10.18553/jmcp.2017.17228] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Prostacyclins play an important role in the management of pulmonary arterial hypertension (PAH). Intravenous prostacyclin was the first disease-specific treatment for patients with PAH. Subcutaneous and nonparenteral (oral or inhaled) formulations have subsequently become available. However, data are lacking on how these different prostacyclin formulations are being used in clinical practice. OBJECTIVES To (a) conduct retrospective analyses of a large U.S. health care claims database to describe the characteristics of patients with PAH initiating prostacyclin therapy, and (b) evaluate their treatment patterns, health care resource use, and associated costs. METHODS Truven Commercial and Medicare databases were used to define annual cohorts of adults with PAH between January 1, 2010, and October 31, 2015. These patients were identified based on claims with ICD-9-CM diagnoses indicative of PAH (codes 416.0 or 416.8) and claims for PAH-specific medications and PAH-related procedures. Patients with evidence of receiving a prostacyclin were identified, and prostacyclin use was categorized as parenteral versus nonparenteral. Health care costs were assessed alternatively employing an all-cause and PAH-related perspective. RESULTS Of 13,633 adults with identified PAH, 3,006 (22.0%) received a prostacyclin during at least 1 year of the study period, and annual prevalence of prostacyclin use ranged from 19.9% to 22.6%. Across calendar years, the median age of prostacyclin users ranged from 56 to 58 years, and 71.9%-75.8% were female. Among prostacyclin users, parenteral prostacyclin use declined from 63.2% in 2010 to 46.5% in 2015, while use of nonparenteral prostacyclins increased from 39.7% to 56.2% over the same period (both P < 0.001). Few patients (2.7%-4.1%) received both parenteral and nonparenteral formulations in a given calendar year. Among patients using prostacyclins, receipt of other PAH-specific medications increased from 62.1% in 2010 to 79.2% in 2015. Comparing the 6 months preceding the first prostacyclin prescription (any formulation) to the 6 months subsequent, mean overall health care costs rose from $61,243 to $119,283, and PAH-related health care costs increased from $58,815 to $116,661, driven mainly by PAH-specific medications, spending on which increased from $15,053 to $73,705 (all P < 0.001). CONCLUSIONS While overall use of prostacyclins was relatively constant from 2010 to 2015, our findings revealed a shift from parenteral to nonparenteral formulations, coupled with increased prescribing of PAH-related medications from other drug classes. Further research is needed to better understand how these changes in patterns of prostacyclin use affect levels of health care resource utilization and costs and patients' overall quality of life. DISCLOSURES This research was funded by Actelion Pharmaceuticals US, a Janssen pharmaceutical company of Johnson & Johnson. Burger has received grant funding from Actelion, Gilead Sciences, and United Therapeutics; personal fees from Actelion and Gilead Sciences; and nonfinancial support from Actelion. Pruett, Lickert, and Drake are employees of Actelion. Pruett and Lickert own shares in Actelion. Berger and Murphy are employees of Evidera, a consultancy that received payment from Actelion to conduct this research. Pruett, Lickert, Berger, and Drake contributed to study conception and participated with Burger in study design. Lickert and Murphy performed the data analyses. Burger, Pruett, Lickert, Murphy, and Drake interpreted the data. All authors participated in manuscript drafting and/or critical revision, approved the final manuscript, and agree to be accountable for all aspects of the work.
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Affiliation(s)
| | - Janis A Pruett
- 2 Actelion Pharmaceuticals US, South San Francisco, California
| | | | | | | | - William Drake
- 2 Actelion Pharmaceuticals US, South San Francisco, California
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Dufour R, Pruett J, Hu N, Lickert C, Stemkowski S, Tsang Y, Lane D, Drake W. Healthcare resource utilization and costs for patients with pulmonary arterial hypertension: real-world documentation of functional class. J Med Econ 2017; 20:1178-1186. [PMID: 28762848 DOI: 10.1080/13696998.2017.1363049] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND AIMS Pulmonary arterial hypertension (PAH) is a rare medical disease in which patients experience increased pulmonary vascular resistance (PVR) and pulmonary arterial pressure that can result in remodeling of the pulmonary vasculature and heart, and eventually lead to right heart failure and death. As PAH progresses, patients become unable to perform even routine daily tasks without severe shortness of breath (dyspnea), fatigue, dizziness, and fainting (syncope). Treatment strategies largely depend on assessment of an individual patient's WHO Functional Class. The aim of the present study was to determine whether PAH functional decline, as described by the WHO Functional class (FC), is associated with increased healthcare costs for patients. METHODS Patients with a prescription for a FDA-approved treatment for PAH and a medical claim indicating chronic pulmonary heart disease or right heart catheterization were identified from an administrative claims database. Provider-reported data from prior authorization forms required for advanced PAH therapies and medical charts were examined for reported FC. Healthcare resource utilization and costs were the primary outcomes of interest. Costs were accounted in 2014 US dollars ($) from a healthcare payer perspective. RESULTS Patients with a reported FC-IV were observed to have the worst outcomes; averaging significantly more inpatient admissions, longer average lengths of stay, and more emergency department visits than the other FC sub-groups, resulting in higher medical costs. CONCLUSIONS Using administrative data to document disease severity, this study replicates and expands on findings obtained from the registry study; disease severity was associated with higher healthcare resource utilization and costs. Stakeholders' implications for patient management are discussed.
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Affiliation(s)
- Robert Dufour
- a Comprehensive Health Insights, Humana Inc. , Louisville , KY , USA
| | - Janis Pruett
- b Actelion Pharmaceuticals US, Inc. , San Francisco , CA , USA
| | - Nan Hu
- a Comprehensive Health Insights, Humana Inc. , Louisville , KY , USA
| | | | | | - Yuen Tsang
- b Actelion Pharmaceuticals US, Inc. , San Francisco , CA , USA
| | - Daniel Lane
- a Comprehensive Health Insights, Humana Inc. , Louisville , KY , USA
| | - William Drake
- b Actelion Pharmaceuticals US, Inc. , San Francisco , CA , USA
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Hussain S, Hallam S, Beltran L, Haroon A, Majumdar K, Shamash J, Sivapackianathan R, Drake W. Intravascular large B-cell lymphoma presenting as a pituitary mass with bilateral adrenal enlargement and haemophagocytic lymphohistiocytosis. Br J Haematol 2017; 181:851-852. [PMID: 28439895 DOI: 10.1111/bjh.14715] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Shazia Hussain
- Department of Endocrinology, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, UK
| | - Simon Hallam
- Department of Haemato-oncology, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, UK
| | - Luis Beltran
- Department of Cellular Pathology, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, UK
| | - Athar Haroon
- Department of Radiology, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, UK
| | - Kalpita Majumdar
- Department of Endocrinology, Whipps Cross Hospital, Barts Health NHS Trust, London, UK
| | - Jonathan Shamash
- Department of Oncology, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, UK
| | - Rasheeta Sivapackianathan
- Department of Endocrinology, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, UK
| | - William Drake
- Department of Endocrinology, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, UK
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Daniel E, Aylwin S, Mustafa O, Ball S, Munir A, Boelaert K, Chortis V, Cuthbertson DJ, Daousi C, Rajeev SP, Davis J, Cheer K, Drake W, Gunganah K, Grossman A, Gurnell M, Powlson AS, Karavitaki N, Huguet I, Kearney T, Mohit K, Meeran K, Hill N, Rees A, Lansdown AJ, Trainer PJ, Minder AEH, Newell-Price J. Effectiveness of Metyrapone in Treating Cushing's Syndrome: A Retrospective Multicenter Study in 195 Patients. J Clin Endocrinol Metab 2015; 100:4146-54. [PMID: 26353009 PMCID: PMC5393433 DOI: 10.1210/jc.2015-2616] [Citation(s) in RCA: 132] [Impact Index Per Article: 14.7] [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
BACKGROUND Cushing's syndrome (CS) is a severe condition with excess mortality and significant morbidity necessitating control of hypercortisolemia. There are few data documenting use of the steroidogenesis inhibitor metyrapone for this purpose. OBJECTIVE The objective was to assess the effectiveness of metyrapone in controlling cortisol excess in a contemporary series of patients with CS. DESIGN This was designed as a retrospective, multicenter study. SETTING Thirteen University hospitals were studied. PATIENTS We studied a total of 195 patients with proven CS: 115 Cushing's disease, 37 ectopic ACTH syndrome, 43 ACTH-independent disease (adrenocortical carcinoma 10, adrenal adenoma 30, and ACTH-independent adrenal hyperplasia 3). MEASUREMENTS Measurements included biochemical parameters of activity of CS: mean serum cortisol "day-curve" (CDC) (target 150-300 nmol/L); 9 am serum cortisol; 24-hour urinary free cortisol (UFC). RESULTS A total of 164/195 received metyrapone monotherapy. Mean age was 49.6 ± 15.7 years; mean duration of therapy 8 months (median 3 mo, range 3 d to 11.6 y). There were significant improvements on metyrapone, first evaluation to last review: CDC (91 patients, 722.9 nmol/L [26.2 μg/dL] vs 348.6 nmol/L [12.6 μg/dL]; P < .0001); 9 am cortisol (123 patients, 882.9 nmol/L [32.0 μg/dL] vs 491.1 nmol/L [17.8 μg/dL]; P < .0001); and UFC (37 patients, 1483 nmol/24 h [537 μg/24 h] vs 452.6 nmol/24 h [164 μg/24 h]; P = .003). Overall, control at last review: 55%, 43%, 46%, and 76% of patients who had CDCs, UFCs, 9 am cortisol less than 331 nmol/L (12.0 μg/dL), and 9 am cortisol less than upper limit of normal/600 nmol/L (21.7 μg/dL). Median final dose: Cushing's disease 1375 mg; ectopic ACTH syndrome 1500 mg; benign adrenal disease 750 mg; and adrenocortical carcinoma 1250 mg. Adverse events occurred in 25% of patients, mostly mild gastrointestinal upset and dizziness, usually within 2 weeks of initiation or dose increase, all reversible. CONCLUSIONS Metyrapone is effective therapy for short- and long-term control of hypercortisolemia in CS.
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Affiliation(s)
- Eleni Daniel
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Simon Aylwin
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Omar Mustafa
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Steve Ball
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Atif Munir
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Kristien Boelaert
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Vasileios Chortis
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Daniel J Cuthbertson
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Christina Daousi
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Surya P Rajeev
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Julian Davis
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Kelly Cheer
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - William Drake
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Kirun Gunganah
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Ashley Grossman
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Mark Gurnell
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Andrew S Powlson
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Niki Karavitaki
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Isabel Huguet
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Tara Kearney
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Kumar Mohit
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Karim Meeran
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Neil Hill
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Aled Rees
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Andrew J Lansdown
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Peter J Trainer
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - Anna-Elisabeth H Minder
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
| | - John Newell-Price
- The Medical School (E.D., J.N.-P.), University of Sheffield, S10 2RX Sheffield, United Kingdom; King's College Hospital NHS Foundation Trust (S.A., O.M.), B15 2TT London, United Kingdom; The Medical School (S.B.), Newcastle University, NE2 4HH Newcastle, United Kingdom; Royal Victoria Infirmary (S.B., A.M.), SE5 9RS Newcastle, United Kingdom; College of Medical and Dental Sciences (K.B., V.C., N.K.), Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, M13 9PT Birmingham, United Kingdom; Department of Obesity and Endocrinology (D.J.C., C.D., S.P.R.), University of Liverpool, NE1 4LP Liverpool, United Kingdom; Centre for Endocrinology and Diabetes (J.D.), University of Manchester, L69 3GA Manchester, United Kingdom; Manchester Royal Infirmary (K.C.), M13 9WL Manchester, United Kingdom; Department of Endocrinology (W.D., K.G.), St Bartholomew's Hospital, EC1A 7BE London, United Kingdom; Oxford Centre for Diabetes (A.G., N.K., I.H.), Endocrinology and Metabolism, Churchill Hospital, M6 8HD Oxford, United Kingdom; Wellcome Trust-MRC Institute of Metabolic Science (M.G., A.S.P.), University of Cambridge, Addenbrooke's Hospital, OX3 7LE Cambridge, United Kingdom; Salford Royal Foundation Trust (T.K., K.Mo.), CB2 0QQ Salford, United Kingdom; Imperial College (K.Me., N.H.), SW7 2AZ London, United Kingdom; School of Medicine (A.R., A.J.L.), Cardiff University, CF14 4XN Cardiff, United Kingdom; and The Christie NHS Foundation Trust (P.J.T., A.-E.H.M.), M20 4BX Manchester, United Kingdom
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Affiliation(s)
| | - Clare Coyle
- Barts Health, Royal London Hospital, London, UK
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Limkakeng A, Lokhnygina Y, Sandesara H, Drake W, Christenson R, Newby L. 111 Delayed Stress-Delta High Sensitivity Troponin Does Not Elevate With Myocardial Ischemia. Ann Emerg Med 2015. [DOI: 10.1016/j.annemergmed.2015.07.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Stemkowski S, Pruett J, Dufour R, Lane DC, Raspa S, Drake W. A Chart Abstraction Based Method to Classify Real World Patients With Pulmonary Arterial Hypertension Based on Who Functional Classification. Value Health 2014; 17:A547. [PMID: 27201773 DOI: 10.1016/j.jval.2014.08.1776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- S Stemkowski
- Comprehensive Health Insights, Humana, Louisville, KY, USA
| | - J Pruett
- Actelion Pharmaceuticals US Inc., San Francisco, CA, USA
| | - R Dufour
- Comprehensive Health Insights, Humana, Louisville, KY, USA
| | - D C Lane
- Comprehensive Health Insights, Humana, Louisville, KY, USA
| | - S Raspa
- Actelion Pharmaceuticals US Inc., San Francisco, CA, USA
| | - W Drake
- Actelion Pharmaceuticals US Inc., San Francisco, CA, USA
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Amirsadri A, Chapman T, Breen M, Drake W, Arfken CL. Economic grand rounds: experience with mandated use of generic medications for patients covered by the mental health safety net. Psychiatr Serv 2014; 65:850-2. [PMID: 26037001 DOI: 10.1176/appi.ps.201400075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 11/30/2022]
Abstract
Reducing pharmacy costs without increasing adverse outcomes would relieve some pressure on mental health budgets. This column describes the experience of a publicly funded provider network in a Michigan county that mandated generic use of psychotropic medications to address financial challenges. The percentage of brand-name medications and cost per prescription declined with the policy change, resulting in lower total pharmacy expenditures. No increase was noted in prescriptions per patient or psychiatric hospitalizations. Changes were sustained after the initial implementation period. Mandating generic use may be feasible as a tool for constraining pharmacy costs in mental health budgets.
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Affiliation(s)
- Alireza Amirsadri
- Dr. Amirsadri and Dr. Arfken are with the Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit. Dr. Chapman is with Gateway Community Health, Detroit. Mr. Breen and Dr. Drake are with Advanced Care, Shelby Township, Michigan. Send correspondence to Dr. Arfken (e-mail: ). Steven S. Sharfstein, M.D., Haiden A. Huskamp, Ph.D., and Alison Evans Cuellar, Ph.D., are editors of this column
| | - Timothy Chapman
- Dr. Amirsadri and Dr. Arfken are with the Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit. Dr. Chapman is with Gateway Community Health, Detroit. Mr. Breen and Dr. Drake are with Advanced Care, Shelby Township, Michigan. Send correspondence to Dr. Arfken (e-mail: ). Steven S. Sharfstein, M.D., Haiden A. Huskamp, Ph.D., and Alison Evans Cuellar, Ph.D., are editors of this column
| | - Michael Breen
- Dr. Amirsadri and Dr. Arfken are with the Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit. Dr. Chapman is with Gateway Community Health, Detroit. Mr. Breen and Dr. Drake are with Advanced Care, Shelby Township, Michigan. Send correspondence to Dr. Arfken (e-mail: ). Steven S. Sharfstein, M.D., Haiden A. Huskamp, Ph.D., and Alison Evans Cuellar, Ph.D., are editors of this column
| | - William Drake
- Dr. Amirsadri and Dr. Arfken are with the Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit. Dr. Chapman is with Gateway Community Health, Detroit. Mr. Breen and Dr. Drake are with Advanced Care, Shelby Township, Michigan. Send correspondence to Dr. Arfken (e-mail: ). Steven S. Sharfstein, M.D., Haiden A. Huskamp, Ph.D., and Alison Evans Cuellar, Ph.D., are editors of this column
| | - Cynthia L Arfken
- Dr. Amirsadri and Dr. Arfken are with the Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit. Dr. Chapman is with Gateway Community Health, Detroit. Mr. Breen and Dr. Drake are with Advanced Care, Shelby Township, Michigan. Send correspondence to Dr. Arfken (e-mail: ). Steven S. Sharfstein, M.D., Haiden A. Huskamp, Ph.D., and Alison Evans Cuellar, Ph.D., are editors of this column
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Sattar A, Saleem A, Pettorini B, Pizer B, Bhatti I, Narenthiran G, Mallucci C, Hoffmann A, Gebhardt U, Sterkenburg A, Warmuth-Metz M, Muller HL, Postma FP, Hoffmann A, Gebhardt U, Muller HL, Hoffmann A, Warmuth-Metz M, Gebhardt U, Pietsch T, Pohl F, Kortmann RD, Calaminus G, Muller HL, Sterkenburg AS, Hoffmann A, Gebhardt U, Muller HL, Muller HL, Gebhardt U, Faldum A, Warmuth-Metz M, Pietsch T, Pohl F, Calaminus G, Perelberg D, Morillon P, Ederies A, Aquilina K, Dorward N, Michalski A, Hargrave D, Chang YC, Bozorgi N, James S, Korbonits M, Drake W, Akker S, Mallucci C, Pizer B, Blair J, Kamaly I, Clayton P, Spoudeas H, Wisoff J, Elliott R, Gump J, Donson A, Birks D, Handler M, Foreman N, Hankinson T. CRANIOPHARYNGIOMA. Neuro Oncol 2014. [DOI: 10.1093/neuonc/nou067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kharod AM, Ramlogan SR, Kumar S, Raghuveer T, Drake W, Dai H, Raghuveer G. Childhood obesity increases left-ventricular mass irrespective of blood pressure status. Pediatr Cardiol 2014; 35:353-60. [PMID: 23989657 DOI: 10.1007/s00246-013-0782-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [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] [Received: 06/13/2013] [Accepted: 08/14/2013] [Indexed: 12/13/2022]
Abstract
Adults with a left-ventricular mass index (LVMI) in grams normalized to height in meters(2.7) (LVMI g/m(2.7)) >51 g/m(2.7) are more prone to cardiovascular and cerebrovascular events. We delineated the odds for cardiac structural sequelae amongst apparently normal white and African-American (AA) children with varying body mass indices (BMI) and office blood pressures. A total of 2,071 children with normal echocardiograms were categorized into risk groups based on BMI and systolic blood pressures (SBPs). Predictors of cardiac sequelae examined were age, sex, race, and z-scores (z) for BMI, SBP, and diastolic blood pressure. Cardiac sequelae measures included (LVMI g/m(2.7)) >51 g/m(2.7), (LVMI) (g/m(2.7)) z, left atrial size (LA(ht)) (mm) z, and relative wall thickness z. Mean age was 14 ± 2 years with 56 % being male and 13 % being AA. Children were divided into "controls" (n = 1,059) and risk groups based on BMI and SBP. Odds ratio for LVMI (g/m(2.7)) > 51.0 g/m(2.7), varied from 5.3 up to 8.5 in children with increased BMI. Both increased BMI and SBP z were associated with increased LVMI (g/m(2.7)) z; however, BMI z had a stronger association. Increased BMI z and AA race were associated with greater LA(ht) (mm) z. AA controls had a nonsignificantly increased LVMI z and a significantly increased LA(ht) (mm) and RWT z. Being overweight or obese is associated with cardiac sequelae in children to the extent known to be associated with adverse outcomes in adults. Healthy AA children have unique cardiac structural differences.
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Affiliation(s)
- A M Kharod
- University of Missouri, Kansas City School of Medicine, Kansas City, MO, USA
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Drake VC, Drake W. Amour. (2012). Written and directed by Michael Haneke. Psychological Perspectives 2014. [DOI: 10.1080/00332925.2014.874930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Freeman D, Diskina M, Drake W, Jones A, Limkakeng A. The Protocol Acuity Scoring Tool for Prediction of Emergency Medicine Research Study Workload. Ann Emerg Med 2013. [DOI: 10.1016/j.annemergmed.2013.07.242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Anwuzia-Iwegbu C, Nadarasa K, Drake W. Re-occurrence of pancreatic insulinoma: an usual cause of hypoglycaemia. BMJ Case Rep 2013; 2013:bcr-2012-008287. [PMID: 23378552 DOI: 10.1136/bcr-2012-008287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 42-year-old woman presented to her general practitioner (GP) with episodes of feeling 'shaky' exacerbated by physical exercise and prolonged fast. She was previously diagnosed with an insulinoma in 2006 (serum glucose 1.6 mmol/l, serum insulin 3.1 mIU/l and serum C peptide <165 pmol/l). CT abdomen/transabdominal ultrasound revealed a 1 cm insulinoma in the uncinate process of the pancreas and the patient later underwent pancreatic enucleation in 2006. Postpancreatic enucleation, 72 h fast was negative. The patient remained asymptomatic postoperation and re-presented to a locum GP 6 years later with initial symptoms. She was reviewed during her annual follow-up and, owing to concerns relating to her background, she was admitted to the specialist endocrine department for further investigations. A 72 h fast was positive for hypoglycaemia with serum glucose level 1.8 mmol/l, serum insulin 8.6 mIU/l and serum C peptide 443 pmol/l.
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Cavlan D, Vijayaraghavan S, Gelding S, Drake W. GH replacement causing acute hyperglycaemia and ketonuria in a type 1 diabetic patient. Endocrinol Diabetes Metab Case Rep 2013; 2013:130047. [PMID: 24616775 PMCID: PMC3922345 DOI: 10.1530/edm-13-0047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 09/11/2013] [Indexed: 11/30/2022] Open
Abstract
A state of insulin resistance is common to the clinical conditions of both chronic growth hormone (GH) deficiency and GH excess (acromegaly). GH has a physiological role in glucose metabolism in the acute settings of fast and exercise and is the only anabolic hormone secreted in the fasting state. We report the case of a patient in whom knowledge of this aspect of GH physiology was vital to her care. A woman with well-controlled type 1 diabetes mellitus who developed hypopituitarism following the birth of her first child required GH replacement therapy. Hours after the first dose, she developed a rapid metabolic deterioration and awoke with hyperglycaemia and ketonuria. She adjusted her insulin dose accordingly, but the pattern was repeated with each subsequent increase in her dose. Acute GH-induced lipolysis results in an abundance of free fatty acids (FFA); these directly inhibit glucose uptake into muscle, and this can lead to hyperglycaemia. This glucose–fatty acid cycle was first described by Randle et al. in 1963; it is a nutrient-mediated fine control that allows oxidative muscle to switch between glucose and fatty acids as fuel, depending on their availability. We describe the mechanism in detail.
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Affiliation(s)
- Dominic Cavlan
- Department of Endocrinology St Bartholomew's Hospital West Smithfield, London UK
| | - Shanti Vijayaraghavan
- Department of Endocrinology Newham University Hospital, Glen Road London E13 8SL, UK UK
| | - Susan Gelding
- Department of Endocrinology Newham University Hospital, Glen Road London E13 8SL, UK UK
| | - William Drake
- Department of Endocrinology St Bartholomew's Hospital West Smithfield, London UK
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Abstract
We present a case of a late-preterm infant admitted for suspected cyanotic heart disease who was found to have a thrombosed ductus arteriosus. Maternal history was significant for heterozygosity for Factor V Leiden, treated with enoxaparin during her pregnancy, and congenital hearing loss. The neonate did not have a Factor V Leiden mutation detected, but was found to have a heterozygous mutation within the MFTHR gene. He was treated with anticoagulation, with improving hemodynamics measured by echocardiogram. This case presents a rare disease, which is potentially fatal if diagnosis is delayed.
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Affiliation(s)
- M F Nyp
- Section of Neonatalogy, Children's Mercy Hospital and Clinics, Kansas City, MO 64108, USA.
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Alibhai M, Cheng L, Ho H, Haider D, Ali E, Anderson J, Medici F, Emery M, Drake W, Collins A, Parker G. Retrosternal thyroidectomy—a local survey. Br J Oral Maxillofac Surg 2011. [DOI: 10.1016/j.bjoms.2011.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Chandra A, Freeman D, Mani G, Drake W, Limkakeng A. 177: A Comparative Analysis of Screening Hypertensive Patients for Left Ventricular Abnormality With Electrocardiograph and NT-proBNP. Ann Emerg Med 2009. [DOI: 10.1016/j.annemergmed.2009.06.205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Limkakeng A, Glickman S, Freeman D, Drake W, Mani G, Chandra A, Cairns C. 161: Do Prolonged Emergency Department Waiting Times Reduce Emergency Research Consent Rates? Ann Emerg Med 2009. [DOI: 10.1016/j.annemergmed.2009.06.189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cheng L, Anderson J, Drake W, McColl I, Parker G. A comparative survey in thyroid surgery between developed and developing world. Int J Oral Maxillofac Surg 2009. [DOI: 10.1016/j.ijom.2009.03.311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Limkakeng A, Saraswat A, Glickman S, Molinar G, Drake W, Freeman D, Chandra A. 150: Blood Pressure Response in Hypertensive Emergency Department Patients With a History of End Organ Disease. Ann Emerg Med 2008. [DOI: 10.1016/j.annemergmed.2008.06.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Alusi G, Sabin I, Drake W. Extended Endoscopic Transnasal Hypophysectomy. Skull Base 2008. [DOI: 10.1055/s-2008-1093184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Carlisle J, Evans W, Hajizadeh R, Nadaf M, Shepherd B, Ott RD, Richter K, Drake W. Multiple Mycobacterium antigens induce interferon-gamma production from sarcoidosis peripheral blood mononuclear cells. Clin Exp Immunol 2007; 150:460-8. [PMID: 17924974 PMCID: PMC2219367 DOI: 10.1111/j.1365-2249.2007.03510.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2007] [Indexed: 11/29/2022] Open
Abstract
Studies of sarcoidosis immunology have noted oligoclonal T cell populations, suggesting cell-mediated immunity that is antigen-specific. Sarcoidosis immunology and pathology are most similar to mycobacterial infections. Mycobacterium tuberculosis infection in mice and humans reflects T helper 1 (Th1) immune responses to multiple cell wall and secreted antigens. We investigated if the oligoclonal immune response in individual sarcoidosis subjects could be elicited by multiple secreted mycobacterial antigens by performing ex vivo enzyme-linked immunospot assay (ELISPOT) on peripheral blood mononuclear cells (PBMC) from 30 sarcoidosis, 26 purified protein derivative negative (PPD-) control and 10 latent tuberculosis subjects (PPD+) to assess Th1 responses to mycobacterial superoxide dismutase A (sodA), catalase-peroxidase (katG) and early secreted antigenic target protein (ESAT-6). A significant difference was noted among the sarcoidosis and PPD- control subjects to ESAT-6 [12 of 30 versus one of 26 (P = 0.0014)], katG [nine of 30 versus none of 26 (P = 0.002)] and sodA [12 of 30 versus none of 26 (P = 0.002)]. There was no significant difference between sarcoidosis and PPD+ subjects. Twelve sarcoidosis subjects recognized two or more mycobacterial proteins, as well as multiple distinct epitopes within individual proteins. One sarcoidosis subject on whom we collected bronchoalveolar lavage (BAL) fluid and PBMC had no recognition of mycobacterial antigens using PBMC, but BAL fluid demonstrated strong Th1 immune responses to ESAT-6 and katG. Individual sarcoidosis subjects recognized not only multiple mycobacterial proteins, but multiple distinct peptides within a specific protein, thus demonstrating that multiple mycobacterial epitopes elicit the Th1 immune response observed. Immune responses by sarcoidosis T cells to mycobacterial proteins may have an important role in sarcoidosis pathogenesis.
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Affiliation(s)
- J Carlisle
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
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