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.

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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.

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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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