1
|
Abstract
BACKGROUND Immune checkpoint inhibitors, single or in combination, have recently become a cornerstone for the treatment of many malignancies. Ipilimumab, a CTLA-4 inhibitor, was initially FDA approved for treatment of unresectable or metastatic melanoma and subsequently in combination therapy for other cancers. Ipilimumab-induced hypophysitis (IH) risk of development varies in different studies between 0 and 17%. Furthermore, little is known on how to predict which patients will develop IH and its impact on efficacy of Ipilimumab and survival for these patients. Here we reviewed IH and its impact on progression-free survival (PFS) and overall survival (OS). METHODS Retrospective, IRB- approved review of consecutive 117 melanoma patients who received ipilimumab between 2011 and 2016 was undertaken. Demographic and clinical characteristics, treatment timing and doses, time to progression after therapy, and survival data were reviewed. Patients were predefined in two groups: patients with and without IH. Descriptive statistics were used to summarize the demographic and clinical characteristics of the study sample. All values are shown as means and standard deviation [mean (SD)] unless indicated otherwise. P < 0.05 was considered to be statistically significant. RESULTS Of the 117 patients, 15 (12.8%) with a median age of 62.1 years developed IH. In the IH cohort, 10 (66.7%) were male and were significantly older than females (median 67.7 vs. 50.8; P = 0.009). This difference was not seen in non-IH group. Male patients with IH were significantly older than males without IH (67.7 vs. 56.4 years, P = 0.020), however this difference was not observed in females. No patient who received prior cancer systemic therapy (0/30) developed IH vs. 17.2% (15/72) without prior therapy developed IH (OR 0.00; 95% CI 0.00 to 0.73, P = 0.011). Between IH and non-IH patients, there was no difference in gender, race, ethnicity, BMI, diabetes or autoimmune disease at baseline, number of administered ipilimumab cycles, presence of primary melanoma lesion, or BRAF status. IH and non-IH patients had a similar median PFS (8.1 vs. 6.8 months, HR = 0.51, 95% CI 0.24 to 1.05 P = 0.062) and OS (53.3 vs. 29.5 months; HR 0.66, 95% CI 0.30 to 1.46; P = 0.307). CONCLUSION In this study of melanoma patients treated with Ipilimumab, risk of developing IH was high (almost 13%). Older age in men and no prior cancer therapy were associated with IH higher risk. Development of IH was not associated with PFS or OS. Increased use of immune checkpoint inhibitors in the future will impact IH overall risk, thus awareness is needed. Given the lack of reliable identifiable risk factors, close monitoring of signs and symptoms after each therapy cycle is critical for early detection and treatment of hypophysitis.
Collapse
Affiliation(s)
- Travis Snyders
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
| | - Daniel Chakos
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Umang Swami
- Division of Oncology, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Emile Latour
- Biostatistics Shared Resource, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Yiyi Chen
- Biostatistics Shared Resource, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA
| | - Maria Fleseriu
- Division of Endocrinology, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Mohammed Milhem
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Yousef Zakharia
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Roula Zahr
- Division of Endocrinology, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| |
Collapse
|
2
|
Suarez M, Zahr R, Purnell J, Liu W. SUN-321 Rare Case of Hypoglycemia Induced by IGF2 Secreted by an Ovarian Tumor. J Endocr Soc 2019. [PMCID: PMC6552802 DOI: 10.1210/js.2019-sun-321] [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: 11/19/2022] Open
Affiliation(s)
- Maria Suarez
- Oregon Health & Science University, Portland, OR, United States
| | - Roula Zahr
- Oregon Health & Science University, Portland, OR, United States
| | - Jonathan Purnell
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, United States
| | - Winnie Liu
- Oregon Health & Science University, Portland, OR, United States
| |
Collapse
|
3
|
Abstract
Acromegaly is a rare disease, caused largely by a growth hormone (GH) pituitary adenoma. Incidence is higher than previously thought. Due to increased morbidity and mortality, if not appropriately treated, early diagnosis efforts are essential. Screening is recommended for all patients with clinical features of GH excess. There is increased knowledge that classical diagnostic criteria no longer apply to all, and some patients can have GH excess with normal GH response to glucose. Treatment is multifactorial and personalised therapy is advised.
Collapse
Affiliation(s)
- Roula Zahr
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition
| | - Maria Fleseriu
- Department of Medicine, Division of Endocrinology, Diabetes and Clinical Nutrition
- Department of Neurological Surgery
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, US
| |
Collapse
|
4
|
Saeed D, Shalli S, Fumoto H, Ootaki Y, Horai T, Anzai T, Zahr R, Horvath DJ, Massiello AL, Chen JF, Dessoffy R, Catanese J, Benefit S, Golding LAR, Fukamachi K. In vivo evaluation of zirconia ceramic in the DexAide right ventricular assist device journal bearing. Artif Organs 2010; 34:512-6. [PMID: 20482709 DOI: 10.1111/j.1525-1594.2009.00918.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Zirconia is a ceramic with material properties ideal for journal bearing applications. The purpose of this study was to evaluate the use of zirconium oxide (zirconia) as a blood journal bearing material in the DexAide right ventricular assist device. Zirconia ceramic was used instead of titanium to manufacture the DexAide stator housing without changing the stator geometry or the remaining pump hardware components. Pump hydraulic performance, journal bearing reliability, biocompatibility, and motor efficiency data of the zirconia stator were evaluated in six chronic bovine experiments for 14-91 days and compared with data from chronic experiments using the titanium stator. Pump performance data including average in vivo pump flows and speeds using a zirconia stator showed no statistically significant difference to the average values for 16 prior titanium stator in vivo studies, with the exception of a 19% reduction in power consumption. Indices of hemolysis were comparable for both stator types. Results of coagulation assays and platelet aggregation tests for the zirconia stator implants showed no device-induced increase in platelet activation. Postexplant evaluation of the zirconia journal bearing surfaces showed no biologic deposition in any of the implants. In conclusion, zirconia ceramic can be used as a hemocompatible material to improve motor efficiency while maintaining hydraulic performance in a blood journal bearing application.
Collapse
Affiliation(s)
- Diyar Saeed
- Department of Biomedical Engineering, Lerner Research Institute, The Cleveland Clinic, Cleveland, OH 44195, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Zahr R, Saeed D, Fumoto H, Horai T, Shalli S, Anzai T, Arakawa Y, Dessoffy R, Catanese J, Massiello A, Litwak KN, Fukamachi K. A pilot study for inducing chronic heart failure in calves by means of oral monensin. Int J Biomed Sci 2010; 6:1-7. [PMID: 23675169 PMCID: PMC3614725] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Accepted: 08/13/2009] [Indexed: 12/03/2022]
Abstract
INTRODUCTION Heart failure remains a major cause of mortality in the United States, despite advancing technologies, newer methods of treatment, and novel devices. To evaluate such novel devices, a large-animal model of chronic heart failure is critical in carrying out preclinical animal studies. METHODS We evaluated the efficacy of oral monensin in inducing stable heart failure in five Jersey calves. Various doses of monensin were administered. Hemodynamics, pressure-volume loops, echocardiographic measurements, extent of tissue perfusion, and histopathologic data were recorded before and after induction of heart failure. RESULTS Responses were variable in the animals. One experiment showed a significant decrease in cardiac output within one week, associated with simultaneous increases in left atrial pressure, central venous pressure, and mean pulmonary artery pressure. Left ventricular pressure-volume loops showed that the slope of the end-systolic pressure-volume relation decreased markedly between the baseline and terminal study, suggesting a decrease in contractility. Echocardiographic studies indicated a decrease in ejection fraction. Histopathologic analysis in cardiac tissue showed extensive fibrosis and necrosis. CONCLUSION We demonstrated the feasibility of inducing and maintaining severe yet stable heart failure for up to 3 weeks in a calf model by administration of oral monensin.
Collapse
Affiliation(s)
- Roula Zahr
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA;
| | - Diyar Saeed
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA;
| | - Hideyuki Fumoto
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA;
| | - Tetsuya Horai
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA;
| | - Shanaz Shalli
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA;
| | - Tomohiro Anzai
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA;
| | - Yoko Arakawa
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA;
| | - Raymond Dessoffy
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA;
| | - Jacquelyn Catanese
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA;
| | - Alex Massiello
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA;
| | | | - Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA;
| |
Collapse
|
6
|
Horai T, Fumoto H, Saeed D, Zahr R, Anzai T, Arakawa Y, Shalli S, Ootaki C, Catanese J, Akiyama M, Tan CD, Rodriguez ER, Young JB, Fukamachi K. Novel implantable device to detect cardiac allograft rejection. Circulation 2009; 120:S185-90. [PMID: 19752366 DOI: 10.1161/circulationaha.108.827170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Allograft rejection remains the nemesis of solid organ transplantation. Soul Mate is a novel implantable wireless data transmission system that analyzes 9 intramyocardial electrogram parameters recorded from 4 or 6 configurations of 2 or 3 epicardial leads to detect allograft rejection. This study determined the ability of the Soul Mate to detect early rejection of transplanted hearts. METHODS AND RESULTS Five dogs underwent heterotopic cervical heart transplantation and simultaneous implantation of the Soul Mate's Cardiac Rejection Monitoring Device. Dogs were initially immunosuppressed, but subsequent drug discontinuation allowed allograft rejection to appear. Allograft biopsies were performed at regular intervals to determine rejection grade, which was compared to a calculated rejection score determined as percent change from baseline of values for each intramyocardial electrogram. There was significant correlation between the biopsy results and the evolution of 5 parameters. The strongest correlation (r=0.939; P<0.001) was obtained using the "general median" parameter from 4 configurations, assessed 1 day before the biopsy, with a sensitivity of 85.7% and a specificity of 100% compared to the myocardial biopsy results. CONCLUSIONS The Soul Mate allograft rejection monitoring system accurately detected transplanted heart rejection in a canine model noninvasively with continuous sampling. This proof-of-concept study suggests that the Soul Mate could be used to more intensely and more frequently monitor cardiac allografts for rejection.
Collapse
Affiliation(s)
- Tetsuya Horai
- Department of Biomedical Engineering, Heart & Vascular Institute, Cleveland Clinic, Ohio 44195, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Saeed D, Zahr R, Shalli S, Fumoto H, Horai T, Anzai T, Arakawa Y, Dessoffy R, Catanese J, Golding LAR, Fukamachi K. Median sternotomy approach for chronic bovine experiments. ASAIO J 2008; 54:585-8. [PMID: 19033770 PMCID: PMC2782521 DOI: 10.1097/mat.0b013e31818a30d9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Lateral thoracotomy is the traditional surgical approach for preclinical animal testing of various ventricular assist devices. Median sternotomy, however, is regarded from a functional standpoint as the most appropriate approach for cardiac surgical procedures, particularly for device implantation. The purpose of this study was to evaluate the outcomes of performing a median sternotomy in chronic bovine studies. Three chronic studies using the sternotomy approach were performed. Surgical access was compared to the lateral thoracotomy approach used in three other animal experiments. Postoperative speed of recovery, pain management, sternotomy incision, and monitoring line exit site healing and infection were also evaluated. With sternotomy, better surgical access to all cardiac chambers and great vessels and more room for device placement were achieved. The recovery time was similar to that using the lateral thoracotomy approach, with no additional difficulties observed in standing or recumbency and no need for increased pain management. At the time of autopsy, the sternum was well healed without any sign of infection. In conclusion, these studies showed that a median sternotomy can be used successfully for chronic bovine studies. This approach will be used for our future biventricular assist device implantation surgeries.
Collapse
Affiliation(s)
- Diyar Saeed
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Fukamachi K, Saeed D, Massiello AL, Horvath DJ, Fumoto H, Horai T, Zahr R, Shalli S, Anzai T, Dessoffy R, Catanese J, Chen JF, Zhou Q, Benefit S, Alfini S, Golding LA. Development of DexAide right ventricular assist device: update II. ASAIO J 2008; 54:589-93. [PMID: 19033771 PMCID: PMC2678065 DOI: 10.1097/mat.0b013e31818a30f1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The DexAide right ventricular assist device (RVAD) is a magnetically and hydrodynamically levitated implantable centrifugal pump. Recent progress includes 1) redesign of the inflow/outflow conduits, which yielded two successful 3-month experiments, 2) development of alternative journal bearing materials, and 3) completion of an 18-month duration of in vitro endurance testing. Verification testing of the RVAD electronics has been completed, and a prototype biventricular assist device (BVAD) system has been tested. Acute DexAide/CorAide BVAD implantations via median sternotomy in two calves documented BVAD control algorithms and anatomical fit. A drug-induced chronic calf heart failure model, currently under development in our laboratory, resulted in a successful BVAD implantation in a calf with heart failure. Our future plans are to complete in vitro and in vivo validation of alternative bearing materials, perform preclinical DexAide in vivo and in vitro reliability studies, and obtain Food and Drug Administration (FDA) approval for an Investigational Device Exemption to conduct a clinical pilot study. In conclusion, two successful 3 month in vivo experiments and an 18-month in vitro endurance test were completed. After final bearing material selection, the DexAide design will be "frozen" so that preclinical systems can be manufactured. BVAD experiments using a chronic heart failure model are in progress.
Collapse
Affiliation(s)
- Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195
| | - Diyar Saeed
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195
| | - Alex L. Massiello
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195
| | - David J. Horvath
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195
| | - Hideyuki Fumoto
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195
| | - Tetsuya Horai
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195
| | - Roula Zahr
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195
| | - Shanaz Shalli
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195
| | - Tomohiro Anzai
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195
| | - Raymond Dessoffy
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195
| | - Jacquelyn Catanese
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195
| | - Ji-Feng Chen
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195
| | - Qun Zhou
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195
| | - Stephen Benefit
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195
| | | | - Leonard A.R. Golding
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195
| |
Collapse
|