Staged vs One-Time Multivessel Revascularization in Multivessel CAD

MedicalResearch.com Interview with:
Peter Hu MD Cleveland ClinicPeter T. Hu MD
Department of Cardiology
Cleveland Clinic

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Among patients with blockages in multiple coronary vessels, we studied predictors and outcomes of having a staged versus one-time multivessel percutaneous coronary intervention. By “staged” we mean performing coronary intervention only on one vessel, letting the patient recover, and fixing the other blockages at a later date. We know that multivessel coronary artery disease is very common – present in up to 2/3 of patients who require coronary interventions. Previous studies in patients with STEMI (ST-elevation myocardial infarction) suggested that staged multivessel PCI was associated with lower risk of death compared with one-time multivessel revascularization. Outside of STEMI patients, very little data exist in a broader group of patients who undergo coronary interventions to multiple vessels.

In our study, we found an association between doing a staged PCI and lower long-term mortality benefit compared with fixing multiple blockages at once. What was surprising was there seemed to be a correlation with the degree of benefit from staged PCI based on the symptoms and signs the patient presented with.

The association with improved outcomes was strongest in patients with STEMI, followed by those with NSTEMI, unstable angina, and stable angina, respectively. We also found that the decision to perform staged PCI was driven by patient and procedural characteristics, as well as other unmeasured site variation.  Continue reading

Mortality Decreases with Increased Aerobic Fitness

MedicalResearch.com Interview with:
"treadmill" by Jeff Blackler is licensed under CC BY 2.0Wael A. Jaber, MD FACC, FESC
Professor of Medicine
Cleveland Clinic Lerner College of Medicine
Fuad Jubran Endowed Chair in Cardiovascular Medicine
Heart and Vascular Institute 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: We evaluated treadmill tests on over 122, 000 patients between 1991 and 2014. We aimed to evaluate impact of functional capacity (time on treadmill) on all cause mortality.

We found that there is a gradual and incremental reduction in mortality with increased exercise capacity/aerobic fitness in all age groups, sexes, and in patients with and without history of heart disease.

MedicalResearch.com: What should readers take away from your report? 

Response: Maintaining a high aerobic functional class is associated with greater risk reduction than absence of many known traditional risk factors such as hypertension, diabetes, prior history of CAD.

The risk reduction appears to follow a dose response pattern with no upper limits of benefits; patients with highest functional class benefits most. 

MedicalResearch.com: What recommendations do you have for future research as a result of this work?

Response: We need to test whether an improvement in functional class over time with training can move an individual patients from one mortality curve to a better one. 

MedicalResearch.com: Is there anything else you would like to add?

Response: Maintaining a high functional aerobic class appears to be associated with low mortality in all age groups. Patients appear to derive gain in survival even with the smallest improvement in functional class. However, when it comes to aerobic functional class as measured by treadmill exercise testing, more appears to be better.

Of course, patients should always check with their healthcare provider before starting an exercise program.

No disclosures 

Citation:

Mandsager K, Harb S, Cremer P, Phelan D, Nissen SE, Jaber W. Association of Cardiorespiratory Fitness With Long-term Mortality Among Adults Undergoing Exercise Treadmill Testing. JAMA Network Open.2018;1(6):e183605. doi:10.1001/jamanetworkopen.2018.3605

Oct 20, 2018 @ 8:30 pm

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Association of Disorganization of Retinal Inner Layers With Visual Acuity Response to Anti-VGEF Therapy for Macular Edema Secondary to Retinal Vein Occlusion

MedicalResearch.com Interview with:

Amy Babiuch, M.D.  Medical Retina Specialist  |  Cole Eye Institute Assistant Professor Ophthalmology Case Western Reserve University WPSA Regional Focus Committee Chair Cleveland Clinic

Dr. Babiuch

Amy Babiuch, M.D.
Medical Retina Specialist  |  Cole Eye Institute
Assistant Professor Ophthalmology Case Western Reserve University
WPSA Regional Focus Committee Chair
Cleveland Clinic

MedicalResearch.com: What is the background for this study?

Response: In previous studies, the disorganization of retinal inner layers (DRIL) has demonstrated its ability to help determine visual acuity (VA) prognosis in diabetic macular edema that requires treatment. Given this association, the research group at Cole Eye Institute studied how DRIL may affect VA outcomes in patients with retinal vein occlusion (RVO) undergoing treatment for secondary macular edema.

DRIL is defined as the extent to which there is a failure in the recognition of any of the demarcations between the ganglion cell-inner plexiform layer complex, inner nuclear layer, and outer plexiform layer on optical coherence tomography (OCT).

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Ibudilast Slowed Brain Atrophy Progressive Multiple Sclerosis in Phase 2 Study

MedicalResearch.com Interview with:

Robert J. Fox, MD, FAAN Principal Investigator | SPRINT-MS Trial Mellen Center for MS  |  Cleveland Clinic Cleveland, OH 44195  

Dr. Fox

Robert J. Fox, MD, FAAN
Principal Investigator | SPRINT-MS Trial
Mellen Center for MS  |  Cleveland Clinic
Cleveland, OH 44195 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: The current treatment options for progressive multiple sclerosis are very limited. The SPRINT-MS trial sought to obtain proof-of-concept evidence that ibudilast has beneficial activity in progressive multiple sclerosis. In a placebo-controlled, 96-week trial of 255 people living with progressive MS, treatment with ibudilast slowed the progression of brain atrophy (brain shrinkage) by 48% compared to placebo. Side-effects of ibudilast included gastrointestinal symptoms, headache, and depression. 

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Cardiovascular Prediction Tool Underestimated Risk In Poor Socioeconomic Groups

MedicalResearch.com Interview with:

Jarrod Dalton PhD Department of Quantitative Health Sciences Cleveland Clinic , Cleveland 

Dr. Dalton

Jarrod Dalton PhD
Department of Quantitative Health Sciences
Cleveland Clinic , Cleveland

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Accurate risk assessment is critical for identifying patients who are at high risk of cardiovascular events such as heart attacks and strokes.

We evaluated the performance of a widely-used risk assessment tool against the socioeconomic position of patients’ neighborhoods of residence. This tool, called the Pooled Cohort Equations Risk Model, or PCERM, was developed in 2013 jointly by the American College of Cardiology and the American Heart Association (ACC/AHA).

We found that the PCERM model accurately characterized risk among patients from affluent communities, but performed more poorly among patients from disadvantaged communities. In particular, for these patients, major cardiovascular events occurred at rates that were as much as 2-3 times than predicted from the PCERM model.

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Long Acting Local Anesthetic Reduced Need For Opioids After Knee Replacement

MedicalResearch.com Interview with:

Michael A. Mont, MD Department of Orthopaedic Surgery Cleveland Clinic Cleveland, OH

Dr. Mont

Michael A. Mont, MD
Department of Orthopaedic Surgery
Cleveland Clinic
Cleveland, OH 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Postoperative pain after total knee arthroplasty (TKA) is a major hurdle for both the patients and the orthopaedists. Many analgesic modalities are currently in use, and can be used alone or in combination in order to augment their effect. Addition of local anesthetic analgesia has been shown to improve pain control and reduce opioid consumption during postoperative period. However, the effects of this analgesia tend to dissipate with time, with the longest duration of action (bupivacaine) of approximately 12 hours. Therefore, long acting local anesthetic (liposomal bupivacaine) has been developed in order to expand the duration of effectiveness of pain relief for up to 96 hours. Many studies evaluated the effectiveness of this anesthetic and demonstrated contradictory results, however, they did not use the same methods and infiltration technique. Therefore, we conducted a prospective, randomized, double-blind, controlled study at 16 hospitals using optimal infiltration techniques. Our study demonstrated significant improvement in pain, decreased opioid consumption, increased time to first opioid rescue, more opioid free patients in liposomal bupivacaine cohort. In addition, there were no unexpected safety concerns.

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MRI Biomarkers Track Cognitive Impairment Due to Head Trauma

MedicalResearch.com Interview with:

Virendra Mishra, Ph.D. Department of Imaging Research Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas

Dr. Virendra Mishra

Virendra Mishra, Ph.D.
Department of Imaging Research
Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Repetitive head trauma has been shown to be a risk factor for various neurodegenerative disorders, mood swings, depression and chronic traumatic encephalopathy. There has been a significant amount of research into identifying an imaging biomarker of mild traumatic brain injury (mTBI) due to repetitive head trauma. Unfortunately, most of the biomarkers have not been able to find a successful translation to clinics. Additionally, the quest for the mTBI imaging biomarker especially using Magnetic Resonance Imaging (MRI) techniques has been done by looking at either the gray matter (T1-weighted) or the white matter (Diffusion Tensor Imaging) independently; and both have shown changes that are associated with repetitive head trauma.

Hence in this study, we wanted to investigate if combining gray matter and white matter information enables us to better predict the fighters who are more vulnerable to cognitive decline due to repetitive head trauma. Our method found seven imaging biomarkers that when combined together in a multivariate sense were able to predict with greater than 73% accuracy those fighters who are vulnerable to cognitive decline both at baseline and follow-up. The imaging biomarkers were indeed a combination of gray and white matter measures of regions reported previously in the literature. A key point in our study was we found the regions predicting cognitive decline without enforcing any assumptions on the regions previously reported.

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Synthetic Human Angiotensin II for the Treatment of Vasodilatory Shock

MedicalResearch.com Interview with:

Ashish Khanna, MD, FCCP Assistant Professor of Anesthesiology, Cleveland Clinic Lerner College of Medicine Staff Intensivist Center for Critical Care and Department of Outcomes Research Cleveland Clinic, Cleveland

Dr. Khanna

Ashish Khanna, MD, FCCP
Assistant Professor of Anesthesiology, Cleveland Clinic Lerner College of Medicine
Staff Intensivist
Center for Critical Care and Department of Outcomes Research
Cleveland Clinic, Cleveland

MedicalResearch.com: How did you become interested in this topic?

Response: Anesthesia forms the basis of my training but I also completed a fellowship in critical care and, at the present time, I do more work in critical care than anesthesia. About 75% of my time is spent in the Cleveland Clinic critical care units, including the Medical and surgical ICUs (Intensive Care Units).

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Elevated Kidney Biomarker Creatinine Predicts Worse Outcome in STEMI Heart Attack

MedicalResearch.com Interview with:

MedicalResearch.com Interview with: Mohamed Khayata, MD Internal Medicine Resident PGY-3 Cleveland Clinic Akron General, Akron, Ohio MedicalResearch.com: What is the background for this study? What are the main findings? Response: Previous studies showed that patients with ST-elevation myocardial infarction (STEMI) who had elevated creatinine and/or impaired creatinine clearance on presentation had higher short- and long-term mortality independent of other cardiovascular risk factors. We used the National Cardiovascular Database Registry to investigate the impact of creatinine levels at the time of presentation on the cardiovascular outcomes in patients who presented with STEMI. Our study showed that elevated creatinine levels correlated with higher incidence of atrial fibrillation, bleeding, heart failure, and cardiogenic shock during hospital stay after the percutaneous intervention. MedicalResearch.com: What should readers take away from your report? Response: Creatinine level is being checked in almost all patients who present with STEMI within few hours of presentation. Based on previous reports and our results, creatinine is a critical marker that correlate not only with mortality, but is also with morbidity during hospital stay. This marker should be used as a predictor of worse outcomes; thus, patients with higher creatinine levels should be provided higher attention. MedicalResearch.com: What recommendations do you have for future research as a result of this study? Response: Based on our study limitations, I would encourage performing similar outcomes analysis in larger group, multi-center registries. I would also suggest extending outcomes to post-discharge status including quality of life besides cardiovascular compilcations. MedicalResearch.com: Is there anything else you would like to add? Response: MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community. Citation: Abstract presented at the 2017 National Kidney Foundation Spring Clinical Meeting https://www.kidney.org/spring-clinical The Impact of Admission Serum Creatinine on Major Adverse Clinical Events in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions. More Medical Research Interviews on MedicalResearch.com

Dr. Khayata

Mohamed Khayata, MD
Internal Medicine Resident PGY-3
Cleveland Clinic Akron General
Akron, Ohio

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Previous studies showed that patients with ST-elevation myocardial infarction (STEMI) who had elevated creatinine and/or impaired creatinine clearance on presentation had higher short- and long-term mortality independent of other cardiovascular risk factors.

We used the National Cardiovascular Database Registry to investigate the impact of creatinine levels at the time of presentation on the cardiovascular outcomes in patients who presented with STEMI.

Our study showed that elevated creatinine levels correlated with higher incidence of atrial fibrillation, bleeding, heart failure, and cardiogenic shock during hospital stay after the percutaneous intervention.

Continue reading

The Capillary Index Score as a Marker of Viable Cerebral Tissue in Stroke

MedicalResearch.com Interview with:

Firas Al-Ali, MD Departments of Neuro Interventional Surgery Cleveland Clinic Akron General, Akron, OH

Dr. Firas Al-Ali

Firas Al-Ali, MD
Departments of Neuro-Interventional Surgery
Cleveland Clinic Akron General, Akron, OH

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: The Capillary Index Score (CIS) is based on the simple following assumption: “ the presence of capillary blush on diagnostic cerebral angiography, in an ischemic area, is an indicator of ischemic BUT viable cerebral tissue, while its absence indicate NONE- no viable tissue”

In previous publication we demonstrated that the CIS is a strong predictor of clinical outcome (CO) in patients presented acute ischemic stroke (AIS) . In previous studies AIS patients presented with Poor CIS (pCIS) did not have a good clinical outcome despite timely and full recanalization, while when patients presented with favorable CIS (fCIS) had 80-90% good clinical outcome when achieved good recanalization.

In this latest paper we tried to test our original assumption mentioned above. i.e. If the absence of capillary blush in a certain vascular cerebral territory signify no viable cerebral tissue then when an area on diagnostic cerebral cerebral angiogram (DCA) lack capillary blush BEFORE endovascular treatment, it will progress to infarcted tissue despite timely and full recanalization, seen as an area of hypodensity on the POST treatment Cat-Scan (CT).

While an area with Capillary blush in an ischemic area seen on the pre treatment DCA, will not show infarction on POST treatment CT if we obtain successful and timely recanalization.

In this paper we matched areas on the Pre and post -treatment CT to its corresponding location on the Pre-treatment DCA, and we demonstrated that when an area lacked capillary blush on the pre-treatment DCA had a very high chance to progress from normal on the Pre-treatment CT to hypodensity on the post treatment CT (infarcted cerebral tissue). while the areas with capillary blush on the rep treatment CT stayed normal on the post treatment CT when we achieve timely recanalization of the occluded vessel.

MedicalResearch.com: What should readers take away from your report?

Response: The Capillary Index Score is a powerful tool to assess residual viable tissue in a ischemic area, and has a great prognostic value for clinical outcome.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Response: We are now enrolling patient in a multi-center prospective trial, the Capillary Index Score Trial, phase I, to prove the value of CIS prospectively, and to demonstrate that:
1- CIS is a powerful indicator of clinical outcome
2- Treatment patients with pCIS could harmful by demonstrating that most complications happen in the pCIS group.

In The CIS Trial, phase II, we will try to demonstrate that treating patients with pCIS is futile by randomizing them into two groups:
One offered endovascular treatment plus usual medical management and the second group offered only usual medical management.

MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.

Citation:

The Capillary Index Score as a Marker of Viable Cerebral Tissue
Proof of Concept—The Capillary Index Score in the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Trial
Firas Al-Ali, Olvert A. Berkhemer, Wina P. Yousman, John J. Elias, Evin N. Bender, Hester F. Lingsma, Aad van der Lugt, Diederik W.J. Dippel,Yvo B.W.E.M. Roos, Robert J. van Oostenbrugge, Wim H. van Zwam, William P. Dillon and Charles B.L.M. Majoie
Stroke: http://dx.doi.org/10.1161/STROKEAHA.116.013513
Published: September 1, 2016

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

More Medical Research Interviews on MedicalResearch.com

Activating Scavenger System May Treat Blocked Blood Vessels Without Surgery

MedicalResearch.com Interview with:

MedicalResearch.com Interview with: Qing Kenneth Wang PhD, MBA Huazhong University of Science and Technology Wuhan, P. R. China and Department of Molecular Cardiology The Cleveland Clinic Cleveland, Ohio

Dr. Qing Kenneth Wang

Qing Kenneth Wang PhD, MBA
Huazhong University of Science and Technology
Wuhan, P. R. China and
Department of Molecular Cardiology
The Cleveland Clinic
Cleveland, Ohio

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Coronary Artery Disease (CAD) and its complication myocardial infarction (MI or so called heart attacks) are the most common causes of deaths in the US and other parts of the world. Based on the American Heart Association statistics, 620,000 Americans have a new MI each year in the United States alone, 295 000 have a recurrent MI, and nearly 400,000 of them will die from it suddenly. Moreover, an estimated 150,000 silent first MI occur each year.

CAD and MI are caused by an occlusion or blockage of a coronary artery, which disrupts blood flow to the heart region, leading to damage or death of cardiac cells, impairment of cardiac function and sudden death. Current treatment of CAD and MI relies on reperfusion therapy with reopening of the occluded coronary artery with percutaneous coronary intervention (PCA) and coronary artery bypass surgery (CABG). However, 12% of patients are not candidates for PCA or CABG due to an unfavorable occlusive pattern, diffuse coronary atherosclerosis, small distant vessels and co-morbidities. An alternative revascularization strategy has to be developed to benefit these patients.

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Study Addresses Appropriate Treatment Setting for Hypertensive Urgency

MedicalResearch.com Interview with:
Krishna Patel, MD, PG Y3 Resident
Internal Medicine Residency Program
Cleveland Clinic
Cleveland, OH 44195

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Patel: In our outpatient resident clinic practice, we found that patients with poorly controlled hypertension presenting with blood pressures in the hypertensive urgency range (SBP>=180mmHg or DBP >=110 mmHg) but with no symptoms of end-organ damage were common, however there was no clear cut manner in which these patient’s blood pressures were treated. According to the comfort level of the physician, these patients were managed in the office and on serial outpatient visits and some of the patients would be referred to the emergency department for management of these elevated blood pressures. Given there was not much prior literature on this topic, we decided to study the prevalence and short term cardiovascular outcomes for this population of patients.

We found that hypertensive urgency is quite common in the office setting (4.6% in our study). In absence of symptoms of end organ damage, the short term risk of major cardiovascular events was very low around 1%, and patients who were referred to the ED for management of blood pressures had a lot of unnecessary testing and more hospital admissions than those who were managed as an outpatient.

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Intestinal Metabolite Associated With Diffuse Atherosclerosis

MedicalResearch.com Interview with:

Dr. W.H. Wilson Tang M.D. Department of Cellular and Molecular Medicine (NC10) Cleveland Clinic Lerner Research Institute Cleveland, Ohio 44195

Dr. W.H.Wilson Tang

Dr. W.H. Wilson Tang M.D.
Department of Cellular and Molecular Medicine (NC10)
Cleveland Clinic Lerner Research Institute
Cleveland, Ohio 44195

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Our group has recently described the mechanistic link between intestinal microbe-generated phosphatidylcholine metabolite, trimethylamine N-oxide (TMAO), and the pathogenesis of atherosclerotic coronary artery disease (CAD) and its adverse clinical outcomes. Here in a separate, independent, contemporary cohort of patients undergoing coronary angiography, we demonstrated the association between elevated fasting TMAO levels and quantitative atherosclerotic burden (as measured by SYNTAX and SYNTAX II scores) in stable cardiac patients and is an independent predictor for the presence of diffuse (but not focal) lesion characteristics.

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Decipher Genomic Testing Moves Prostate Cancer Prognosis into Precision Medicine Era

MedicalResearch.com Interview with:

Eric A. Klein, MD Chairman, Glickman Urological and Kidney Institute Cleveland Clinic

Dr. Eric Klein

Eric A. Klein, MD
Chairman, Glickman Urological and Kidney Institute
Cleveland Clinic

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Klein: Prostate cancer is an enigma. While this tumor is the second leading cause of cancer death among American men, most newly diagnosed disease detected by PSA screening is biologically indolent and does not require immediate therapy. Currently, the main clinical challenge in these men is to distinguish between those who can be managed by active surveillance from those who require curative intervention. Current clinical and pathological tools used for risk stratification are limited in accuracy for distinguishing between these scenarios.

An abundance of research in the last decade has provided evidence that genomics can offer meaningful and clinically actionable biological information to help inform decision making, and current National Comprehensive Cancer Network (NCCN) guidelines on prostate cancer endorse the use of commercially available genomic tools for men considering active surveillance.[1] It has been previously shown that the 22-gene genomic classifier, Decipher, accurately predicts the likelihood of metastasis and prostate cancer specific mortality when measured on tissue from radical prostatectomy specimens.[2] In multiple validation studies, it performed with higher accuracy and discrimination compared to clinical risk factors alone.

The current study[3] is the first to examine whether the use of Decipher might aid decision making when measured on biopsy tissue at the time of diagnosis. Men with available needle biopsy samples were identified from a study cohort that previously had Decipher performed on their matched radical prostatectomy tissue. In this cohort of mixed low, intermediate and high risk men, Biopsy Decipher predicted the risk of metastasis 10 years post RP with high accuracy, outperforming NCCN clinical risk categorization, biopsy Gleason score and pre-operative PSA. Furthermore, this study showed that Decipher reclassified 46% of patients into lower or higher risk classification compared to NCCN classification alone. The study also showed that Biopsy Decipher can identify men that are at high risk for adverse pathology as defined by the presence of primary Gleason pattern 4 or greater.

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Immune Modulator Ozanimod Shows Promise in Multiple Sclerosis

MedicalResearch.com Interview with:

Dr Jeffrey A Cohen MD Neurological Institute Cleveland Clinic, Cleveland OH 44195, USA

Dr. Jeffrey Cohen

Dr Jeffrey A Cohen MD
Mellen Center, Neurological Institute
Cleveland Clinic, Cleveland
OH 44195, USA

Medical Research: What is the background for this study? What are the main findings?

Dr. Cohen: Fingolimod, a non-selective sphingosine 1-phosphate receptor (S1PR) modulator, was the first oral medication approved to treat relapsing multiple sclerosis.  Though generally well tolerated, fingolimod’s first dose cardiac effects and other potential adverse effects complicate its use.  Ozanimod is a selective S1PR modulator with several other potentially advantageous pharmacologic properties.

The results of phase 2 RADIANCE trial were recently published.  In this trial, participants were randomized to placebo (n=88), ozanimod 0.5 mg (n=87), or ozanimod 1 mg (n=83) PO once daily for 24 weeks.  The mean cumulative number of gadolinium-enhancing lesions on monthly MRI scans at weeks 12-24, the primary endpoint, was reduced from 11.1 +/- 29.9 with placebo to 1.5 +/- 3.7 with ozanimod 0.5 mg and 1.5 +/- 3.4 with ozanimod 1 mg (both p<0.0001).  Other MRI endpoints supported the primary endpoint.  Ozanimod was well tolerated with good safety.  Importantly, the dose up-titration protocol effectively mitigated first dose cardiac effects.

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Very Early Preterm Births More Common In Black Mothers

More on Racial Disparities in Health Care on MedicalResearch.com

Emily A. DeFranco, D.O., M.S. Associate Professor Maternal-Fetal Medicine Center for Prevention of Preterm Birth, Perinatal Institute Cincinnati Children's Hospital Medical Center University of Cincinnati College of Medicine Department of Obstetrics and Gynecology Medical Sciences Building, Room 4553B Cincinnati, OH

Dr. Emily DeFranco

MedicalResearch.com Interview with:
Emily A. DeFranco, D.O., M.S
.
Associate Professor Maternal-Fetal Medicine
Center for Prevention of Preterm Birth, Perinatal Institute
Cincinnati Children’s Hospital Medical Center
University of Cincinnati College of Medicine
Department of Obstetrics and Gynecology
Medical Sciences Building, Room 4553B
Cincinnati, OH

Medical Research: What is the background for this study?

Dr. DeFranco: The Infant Mortality Rate in the state of Ohio is higher than many other states.  Additionally, there is a large disparity in the IMR with black infants impacted to a higher degree compared to white infants. For this reason, we are particularly interested in identifying factors that contribute to this disparity in order to identify potential areas where public health efforts can be focused.

We know that preterm birth is a major contributor to infant mortality, and that all babies born alive prior to 23 weeks of gestational age, i.e. “previable”, die after birth and contribute to the infant mortality rate.  In this study, we wanted to assess whether black women are more likely to have early preterm births at less than 23 weeks, and if so whether that may be part of the explanation of why black mothers are at higher risk of experiencing an infant mortality.

Medical Research: What are the main findings?

Dr. DeFranco: In this study, we found that black mothers were more likely to deliver than white mothers  at very early preterm gestational ages, less than 23 weeks.  We also found that the earlier the delivery, the larger the disparity with black mothers being at higher risk for the earliest deliveries compared to white mothers.  From this data, we estimated that in Ohio, 44% of all infant mortality in black mothers is caused by previable preterm birth, whereas only 28% of infant mortality in white mothers is attributed to the same cause.  We concluded that very early preterm birth in black mothers is a large contributor to the racial disparity observed in the infant mortality dilemma here in Ohio.

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Telemedicine Can Support Rapid Stroke Treatment in Ambulances

Ken Uchino, MD FAHA FANA Director, Vascular Neurology Fellowship Research Director, Cerebrovascular Center, Cleveland Clinic Associate Professor of Medicine (Neurology) Cleveland Clinic Lerner College of Medicine of CWRU Cleveland, OH 44195

Dr. Ken Uchino

MedicalResearch.com Interview with:
Ken Uchino, MD FAHA FANA

Director, Vascular Neurology Fellowship
Research Director, Cerebrovascular Center, Cleveland Clinic
Associate Professor of Medicine (Neurology)
Cleveland Clinic
Lerner College of Medicine of CWRU
Cleveland, OH 44195

Medical Research: What is the background for this study? What are the main findings?

Dr. Uchino: Treatment for acute ischemic stroke is time dependent. Multiple studies have reported strategies to improve time to treatment after arrival in the hospital. Mimicking pre-hospital thrombolysis of acute myocardial infarction pioneered 30 years ago, two groups in Germany have implemented pre-hospital ischemic stroke thrombolysis using mobile stroke unit (“stroke ambulance”) that includes CT scan and laboratory capabilities. These units have been demonstrated to provide stroke treatment earlier than bringing patients to the emergency departments.

Our report extends the concept mobile stroke unit further by using telemedicine for remote physician presence. The other mobile stroke units were designed to have at least one physician on board. This allows potential multiple or geographically distant units to be supported by stroke specialists.

The study demonstrates that after patient arrival in the ambulance, the time to evaluation (CT scanning and blood testing) and to thrombolytic treatment is as quick or better as patient arrival in emergency department door. We are reporting the overall time efficiency after emergency medical service notification (911 call) in a separate paper.

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Cancer Patients Should Be Screened For Heart Disease

Sadeer G Al-Kindi, MD Fellow, Harrington Heart and Vascular Institute Onco-Cardiology Program, Advanced Heart Failure and Transplant Center, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center Cleveland, OH

Dr. Al-Kindi

MedicalResearch.com Interview with:
Sadeer G Al-Kindi, MD
Fellow, Harrington Heart and Vascular Institute
Onco-Cardiology Program, Advanced Heart Failure and Transplant Center, Harrington Heart and Vascular Institute,
University Hospitals Case Medical Center
Cleveland, OH

Medical Research: What is the background for this study?

Dr. Al-Kindi: Cardiovascular disease and cancer are the most common causes of death in the United States. They often have the same risk factors (for example, smoking, advancing age, obesity). Many cancers are treated with drugs that can have detrimental effect on the heart thus limiting their use. Some studies have suggested that cardiovascular diseases can worsen outcomes in patients with cancer. The emergence of onco-cardiology programs led to multidisciplinary care of patients with cancer and heart disease. Given this tight relationship between cancers and cardiovascular disease, we hypothesized that heart disease and its risk factors are very common in patients diagnosed with cancer.

Medical Research: What are the main findings?

Dr. Al-Kindi: Using a very large clinical database of 1/8th of the US population, we identified patients with most common cancers that are treated with cardiotoxic medications and identified the prevalence of cardiovascular diseases. Overall, prevalence was 33% for hematologic malignancies (leukemia and lymphoma), 43% for lung cancers, 17% for breast cancers, 26% for colon cancers, 35% for renal cancers, and 26% for head and neck cancers. Peripheral artery disease, coronary artery disease and cerebrovascular diseases were the most common, followed by heart failure, and carotid artery disease. Despite the high prevalence, only about a half of these patients were on the cardiovascular medicines and half were referred to cardiologists.

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Generic Multiple Sclerosis Drug Found Equivalent To Brand Medication

Dr. Jeffrey Cohen MD Director Mellen Center for Multiple Sclerosis Treatment and Research Director of the Experimental Therapeutics Program Cleveland Clinic Main CampusMedicalResearch.com Interview with:
Dr. Jeffrey Cohen MD
Director
Mellen Center for Multiple Sclerosis Treatment and Research
Director of the Experimental Therapeutics Program
Cleveland Clinic Main Campus

MedicalResearch: What is the background for this study? What are the main findings?

Dr. Cohen: Medications are a major contributor to the high cost of Multiple Sclerosis (MS) care.  As medications go off patent, there is the opportunity to develop generic versions with lower cost.  This trial was conducted after extensive in vitro and animal studies supported the equivalence of a generic glatiramer acetate to the brand drug Copaxone. The trial showed that generic and brand glatiramer acetate have equivalent efficacy as measured by MRI and clinical endpoints, safety, and tolerability.

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ESRD Patients May Experience Cardiac Improvement After Transplant

W.H. Wilson Tang, MD, FACC Assistant Professor in Medicine, Cleveland Clinic Lerner College of Medicine Staff, Section of Heart Failure & Cardiac Transplant Medicine Assistant Program Director, General Clinical Research Center (GCRC) The Cleveland Clinic Cleveland, OHMedicalResearch.com Interview with:
W.H. Wilson Tang, MD, FACC 

Assistant Professor in Medicine,
Cleveland Clinic Lerner College of Medicine
Staff, Section of Heart Failure & Cardiac Transplant Medicine
Assistant Program Director, General Clinical Research Center
The Cleveland Clinic  Cleveland, OH

Medical Research: What is the background for this study? What are the main findings?

Dr. Tang: Cardiac function is a key determinant of outcomes after surgery, especially transplantation. End-stage renal disease (ESRD) poses a unique scenario, as the metabolic and uremic derangements that result from this condition lead to adverse cardiac remodeling, and kidney transplantation offers a potential for reverse remodeling. We studied patients who underwent kidney transplantation and found that echocardiogram following transplantation demonstrated consistent and significant improvement in cardiac structure and function. Post-transplant improvement in anemia was a vital factor that independently predicted such positive changes, whereas post-transplant changes in blood pressure, renal function at 12 months, and dialysis duration duration did not. Moreover, patients that demonstrated reverse remodeling had outcomes comparable to those with normal baseline cardiac function.

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Biomarker Identifies Kidney Injury In Heart Failure Patients

Dr. Wilson Tang MD Professor of Medicine Cleveland Clinic Lerner College of Medicine Case Western Reserve University Director of the Center for Clinical Genomics Cleveland ClinicMedicalResearch.com Interview with:
Dr. Wilson Tang MD
Professor of Medicine
Cleveland Clinic Lerner College of Medicine
Case Western Reserve University
Director of the Center for Clinical Genomics
Cleveland Clinic 

Medical Research: What is the background for this study? What are the main findings?

Dr. Tang: Renal impairment has long been associated with worse outcomes in acute heart failure. Administration of diuretic therapy often obscures accurate assessment of renal function by urine output.  Despite extensive literature suggesting the poor outcomes in those with a rise in creatinine following treatment, recent data has suggested that in the presence of effective diuresis, this phenomenon likely represents hemoconcentration and azotemia rather than acute kidney injury.  We observed that using a novel and sensitive biomarker that identified acute kidney injury, specific to tubular injury, we can identify those at higher risk of adverse outcomes in patents admitted for acute heart failure.   However, after adjusting for standard risk factors, the prognostic value was clearly attenuated.

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Herpes Zoster/Shingles Vaccine Not Found Cost Effective In Patients Under 60

Phuc Le, Ph.D., M.P.H. Center for Value-Based Care Research, Medicine Institute Cleveland, OHMedicalResearch.com Interview with:
Phuc Le, Ph.D., M.P.H.
Center for Value-Based Care Research, Medicine Institute
Cleveland, OH 

Medical Research: What is the background for this study? What are the main findings?

Dr. Phuc Le: The live attenuated herpes zoster vaccine is approved by the FDA for persons aged 50 years and above. However, the Advisory Committee on Immunization Practices recommends it for only persons aged 60 years and older. Therefore, we aimed to analyze the vaccine’s cost-effectiveness among persons aged 50-59 years to see if ACIP’s recommendation is reasonable. We found that the vaccine is not cost-effective among people at aged 50 years, having an incremental costs of $323,000 per QALY gained, which is 3 times more than a commonly accepted threshold ($100,000/QALY).

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New Drug Combination Studied To Treat Agitation in Alzheimer’s Disease

Jeffrey L. Cummings, M.D., Sc.D. Director, Lou Ruvo Center for Brain Health Camille and Larry Ruvo Chair for Brain Health Cleveland Clinic Las Vegas, NV 89106MedicalResearch.com Interview with:
Jeffrey L. Cummings, M.D., Sc.D.
Director, Lou Ruvo Center for Brain Health
Camille and Larry Ruvo Chair for Brain Health
Cleveland Clinic  Las Vegas, NV 89106 

Medical Research: What is the background for this study? What are the main findings?

Dr. Cummings: Agitation is a common problem in Alzheimer’s disease (AD); approximately 70% of patients with AD will experience periods of agitation.  This difficult behavior challenges patients and caregivers, adversely affects quality of life, and may precipitate institutionalization.  There are not drugs approved for treatment of agitation in Alzheimer’s disease.

The study reported in JAMA showed that a drug based on a combination of dextromethorphan and quinidine (DM/Q) produced statistically significant and clinically meaningful reduction in agitation in Alzheimer’s disease patients.  The study met its primary outcome (decline in the Neuropsychiatric Inventory agitation scale in drug compared to placebo) and many of its secondary outcomes (e.g, decreases in caregiver stress).  The agent was safe and well tolerated.

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Routine Nuclear Stress Testing in Asymptomatic Atrial Fibrillation Has Low Yield

Wael A. Jaber, MD FACC, FAHA Professor of Medicine Cleveland Clinic Lerner College of Medicine Fuad Jubran Endowed Chair in Cardiovascular Medicine Heart and Vascular Institute Cleveland Clinic Cleveland, OH

MedicalResearch.com Interview with:
Wael A. Jaber, MD FACC, FAHA
Professor of Medicine
Cleveland Clinic Lerner College of Medicine
Fuad Jubran Endowed Chair in Cardiovascular Medicine
Heart and Vascular Institute
Cleveland Clinic  Cleveland, OH

Medical Research: What is the background for this study? What are the main findings?

Prof. Jaber: Risk stratification of patients presenting with atrial fibrillation often includes a non-invasive evaluation for coronary artery disease. However, the yield of such testing in patients without angina or anginal-equivalent symptoms is uncertain. That is, how often do we find silent myocardial ischemia?

In our cohort of 1700 consecutive patients with atrial fibrillation, less than 5% had ischemia on nuclear stress testing, even though comorbidities were prevalent. Moreover, in patients with ischemia that had invasive coronary angiography, less than half had obstructive coronary artery disease.

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Elders Also Benefit When Young Adults Get Flu Vaccine

Dr. Glen Taksler, PhD Medicine Institute Cleveland Clinic Main CampusMedicalResearch.com Interview with:
Dr. Glen Taksler, PhD
Medicine Institute
Cleveland Clinic Main Campus

Medical Research: What is the background for this study? What are the main findings?

Dr. Taksler: Although young, healthy adults who develop influenza are usually able to recover, they may spread the flu to other people in the community who have a higher risk of hospitalization or other serious complications. These higher-risk people have a limited ability to protect themselves from influenza, because flu vaccines are less effective in the elderly and in people with weakened immune systems.

To better understand whether young, healthy adults could help the community-at-large by getting a flu vaccine, we looked at data on more than 3 million Medicare beneficiaries across 8 influenza seasons.

We found that the elderly had 21% lower odds of developing influenza if they lived in areas where more nonelderly adults (people aged 18-64 years old) got a flu vaccine.

Importantly, we found these benefits even in elderly adults who obtained an influenza vaccine, perhaps because flu vaccines are less effective in the elderly.  This means that elderly adults who were proactive to try to prevent influenza still benefited from communitywide vaccination.

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