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Association Between Travel Distance and Use of Postoperative Radiation Therapy for Incompletely Resected Non-Small Cell Lung Cancer

McGunigal, M; Singh, T; Amarell, K; Aghdam, N; Paudel, N; Lischalk, J W
PURPOSE/OBJECTIVE(S): Postoperative radiation (PORT) is recommended by consensus guidelines for incompletely resected stage II-III non-small cell lung cancer (NSCLC) to optimize local control. Prior data across disease sites has suggested disparities exist in receipt of beneficial adjuvant therapies based on sociodemographic barriers including geography. We sought to explore if receipt of PORT in margin positive locally advanced NSCLC was related to travel distance from the treating facility. MATERIALS/METHODS: We identified patients with pathologic stage II-III NSCLC within the National Cancer Data Base who underwent treatment with upfront surgery (lobectomy or pneumonectomy) found to have microscopic (R1) or macroscopic (R2) residual tumor. Only patients coded as receiving adjuvant external-beam PORT (50-74 Gy) or no radiation were included. Multivariable logistic regression was utilized to determine factors associated with PORT receipt. Cox regression was used to identify predictors of survival.
RESULT(S): We identified 7,270 pathologic stage II-III NSCLC patients who underwent R1/R2 resections from 2004-2015; of these, 36% received PORT. Median overall survival in these patients was significantly improved with the addition of PORT, from 22.3 months to 32.8 months and this persisted when stratified by distance traveled (see table 1). Of the patients who did not receive PORT, 43.4% did receive adjuvant chemotherapy and < 1% received immunotherapy. Reason for why PORT was not given was largely unknown, but stated reasons included: contraindicated due to risk factors (3.6%) and patient refusal (4.2%). In contrast, 79.1% of PORT patients also received chemotherapy. Half of PORT patients resided within 10 miles of treatment facility. Progressively father travel distance was associated with decreased likelihood of PORT (OR 0.89, P=0.002). Other factors associated with decreased PORT receipt included older age and decreased level of education. On Cox regression, higher co-morbidity score was predictive of death, while receipt of PORT was protective (HR 0.87, P < 0.001).
CONCLUSION(S): For NSCLC patients with margin positive disease after surgery, increasing distance was associated with decreased likelihood of receiving PORT, despite being routinely recommended in this setting and proven survival benefit irrespective of geography in our patient cohort. Decreased likelihood to receive PORT with increasing travel distance suggests location may play a role in the decision to undergo PORT for these patients with adverse pathology.
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EMBASE:636627141
ISSN: 1879-355x
CID: 5082142

Predictors and Consequences of Refusing Recommended Radiation for Locally Advanced Inoperable Non-Small Cell Lung Cancer

McGunigal, M; Amarell, K; Singh, T; Chou, J; Aghdam, N; Paudel, N; Lischalk, J W
PURPOSE/OBJECTIVE(S): Definitive chemoradiation is standard-of-care treatment for locally advanced inoperable non-small cell lung cancer (NSCLC). However, some patients refuse radiation therapy (RT) and this information is captured in the National Cancer Database (NC
EMBASE:636624207
ISSN: 1879-355x
CID: 5082262

Warfarin use and prevalence of coronary artery calcification assessed by multislice computed tomography

Palaniswamy, Chandrasekar; Aronow, Wilbert S; Sekhri, Arunabh; Adapa, Sreedhar; Ahn, Chul; Singh, Tarunjit; Malhotra, Bharat; Lerner, Robert
Warfarin inhibits the synthesis and function of matrix Gla protein, a vitamin K-dependent protein, which is a potent inhibitor of tissue calcification. We had earlier reported the association of warfarin use with valvular calcification in patients with nonvalvular atrial fibrillation. The aim of our present study was to investigate the association of warfarin use with the presence and severity of coronary artery calcification. A total of 233 patients underwent computed tomography scan (CT) at our institution for the assessment of coronary artery calcium score (CACS). Of 233 patients, the mean age was 63 years, 28 patients (12%) were treated with warfarin, and 205 patients (88%) were not on warfarin. Based on their total CACS, the patients were subsequently stratified into 59 with no coronary calcium (CACS = 0), 63 with low CACS (1-100), 49 with moderate CACS (101-400), 33 with severe CACS (410-1000), and 29 with very severe CACS (>1000). The chi test and Student t-test were used for the comparison of categorical and continuous variables, respectively, between warfarin users and nonusers. Using the variables age, gender, race, smoking, hypertension, diabetes, dyslipidemia, glomerular filtration rate, calcium-phosphorus product, alkaline phosphatase, use of aspirin, beta blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins, stepwise logistic regression analysis did not show any association of coronary calcification with use of warfarin. In our study, warfarin use was not associated with a higher prevalence or severity of CACS assessed by coronary computed tomography.
PMID: 22820716
ISSN: 1075-2765
CID: 1072732

ST-elevation myocardial infarction in the elderly--temporal trends in incidence, utilization of percutaneous coronary intervention and outcomes in the United States

Khera, Sahil; Kolte, Dhaval; Palaniswamy, Chandrasekar; Mujib, Marjan; Aronow, Wilbert S; Singh, Tarunjit; Gotsis, William; Silverman, Gary; Frishman, William H
BACKGROUND: Elderly patients with ST-elevation myocardial infarction (STEMI) are often underrepresented in major percutaneous coronary intervention (PCI) trials. Use of PCI for STEMI, and associated outcomes in patients aged >/=65 years with STEMI needed further investigation. METHODS: We used the 2001-2010 United States Nationwide Inpatient Sample (NIS) database to examine the temporal trends in STEMI, use of PCI for STEMI, and outcomes among patients aged 65-79 and >/=80 years. RESULTS: During 2001-2010, of 4,017,367 patients aged >/=65 years with acute myocardial infarction (AMI), 1,434,579 (35.7%) had STEMI. Over this period, among patients aged 65-79 and >/=80 years, STEMI decreased by 16.4% and 19%, whereas the use of PCI for STEMI increased by 33.5% and 22%, respectively (Ptrend<0.001). There was a significant decrease in age-adjusted in-hospital mortality (per 1000) in patients aged >/=80 years (150 versus 116, Ptrend=0.02) but not in patients aged 65-79 years (63 versus 59, Ptrend=0.886). Stepwise logistic regression identified intra-aortic balloon pump use, acute renal failure, acute cerebrovascular disease, age >/=80 years, peripheral vascular disease, gastrointestinal bleeding, female gender, congestive heart failure, chronic lung disease, weekend admission and multivessel PCI as independent predictors of in-hospital mortality among all patients >/=65 years of age who underwent PCI for STEMI. CONCLUSIONS: In this large, multi-institutional cohort of elderly patients, a decreasing trend in STEMI, an increasing trend in PCI utilization for STEMI, and reduction in in-hospital mortality were observed from 2001 to 2010.
PMID: 23838593
ISSN: 0167-5273
CID: 1072712

Use of antiplatelet therapy after percutaneous coronary intervention with bare-metal stents and different types of drug-eluting stents

Singh, Tarunjit; Cuomo, Linda; Cohen, Martin; Ahmad, Hasan A; Aronow, Wilbert S
Dual antiplatelet therapy (DAPT) with a thienopyridine and aspirin has been the standard of care post coronary stent implantation. DAPT has been shown to reduce the risk of stent thrombosis (ST) and complications of myocardial infarction and death after placement of a drug-eluting stent (DES) and bare-metal stent (BMS). This article reviews the available clinical efficacy and safety data of antiplatelet therapies. The aim of this review is to highlight not only the importance of antiplatelets in the prevention of early and late thrombosis but also emphasize the importance of newer more potent antiplatelet agents and their role in the setting of clopidogrel resistance. MEDLINE, and EMBASE were searched for studies related to the clinical efficacy and safety of antiplatelet therapy after DES and BMS placement using the terms dual antiplatelet therapy, thienopyridine, aspirin, clopidogrel, prasugrel, ticagrelor,elinogrel, bare-metal stents, drug-eluting stent, stent thrombosis and myocardial infarction.
PMID: 22946865
ISSN: 1574-8847
CID: 1072722

Psoriasis induced by losartan therapy: a case report and review of the literature [Case Report]

Lamba, Gurpreet; Palaniswamy, Chandrasekar; Singh, Tarunjit; Shah, Dhaval; Lal, Sonia; Vinnakota, Ravi; Charrow, Elliott J; Forman, Leanne
Psoriasis is a papulosquamous disease of multifactorial etiology. A combination of genetic and environmental agents is implicated in its pathogenesis. A variety of triggers, including infection, stress, and medications, have been recognized as precipitants of this disease. Nonsteroidal anti-inflammatory drugs, beta-blockers, lithium, synthetic antimalarials, and gold are the most common drugs implicated in precipitating psoriasis. We report a patient with psoriasis induced by initiation of losartan therapy, which resolved with discontinuation of the drug. The Naranjo adverse drug reaction probability scale score indicated that the association between losartan use and psoriasis was probable.
PMID: 20027103
ISSN: 1075-2765
CID: 1072762

Patients with ischemic stroke have a higher prevalence of a planar QRS-T angle >90 degrees than patients with transient ischemic attack

Gandhi, Kaushang; Aronow, Wilbert S; Desai, Harit; Palaniswamy, Chandrasekar; Singh, Tarunjit; Amin, Harshad; Sharma, Mala; Lai, Hoang M
BACKGROUND: The aim of the study was to investigate the prevalence of a planar QRS-T angle >90 degrees in patients with ischemic stroke versus transient ischemic attack (TIA). MATERIAL/METHODS: In a prospective study of 279 consecutive patients who had ischemic stroke (197 patients) or TIA (82 patients), the planar QRS-T angle was measured from a 12-lead electrocardiogram taken at the time of the stroke or TIA. All QRS-T angle measurements were made by 3 authors who agreed on the measurements and who were blinded to the clinical findings. A QRS-T angle >90 degrees was considered abnormal. RESULTS: The mean age was 66+/-6 years in patients with ischemic stroke versus 62+/-6 years in patients with TIA (p=0.04). The mean body mass index and the prevalence of gender, smoking, hypertension, diabetes mellitus, dyslipidemia, and coronary artery disease were not significantly different between patients with ischemic stroke versus TIA. A QRS-T angle >90 degrees was present in 55 of 197 patients (28%) with ischemic stroke and in 10 of 82 patients (12%) with TIA (p=0.004). CONCLUSIONS: The prevalence of a planar QRS-T angle >90 degrees was higher in patients with ischemic stroke than in patients with TIA (p=0.004).
PMID: 21119576
ISSN: 1234-1010
CID: 1072742

Prevalence of in-hospital complications in 500 patients undergoing percutaneous coronary intervention treated with heparin 5000 IU administered systemically versus 500 age-matched and sex-matched patients treated with heparin 70 IU/kg administered systemically

Kalapatapu, Kumar; Shao, John; Aronow, Wilbert S; Sandhu, Rasham; Singh, Tarunjit; Pucillo, Anthony L; Weiss, Melvin B; Sorbera, Carmine; Monsen, Craig E
We investigated the prevalence of in-hospital complications in 500 patients undergoing percutaneous coronary intervention (PCI) treated with heparin 5000 IU administered systemically (group 1) at the time of PCI versus in 500 age-matched and sex-matched patients undergoing PCI treated with heparin 70 IU/kg administered systemically (group 2) at the time of PCI. There was no significant difference in baseline characteristics, indications for PCI, cardiovascular drug therapy at the time of PCI, prevalence of 1-vessel, 2-vessel, and 3-vessel obstructive coronary artery disease, and in-hospital complications between the 2 groups. In-hospital death occurred in 0.2% of group 1 patients versus 0.8% of group 2 patients. Non-ST-segment elevation myocardial infarction occurred in 0.2% of group 1 patients versus 0.4% of group 2 patients. Stroke occurred in 0.2% of group 1 patients versus 0.2% of group 2 patients. Stent thrombosis occurred in 0.2% of group 1 patients versus 0.8% of group 2 patients. Occlusion of a side branch occurred in 0.2% of group 1 patients versus 0.4% of group 2 patients. A hematoma needing intervention occurred in 0.2% of group 1 patients versus 0.2% of group 2 patients. Regression analysis showed that none of the differences between the 2 groups were significant. The sample size was adequate to conclude that a fixed low dose of heparin 5000 IU administered systemically at the time of PCI is noninferior to standard therapy with heparin.
PMID: 19352143
ISSN: 1075-2765
CID: 1072812

Brugada electrocardiographic pattern induced by amitriptyline overdose [Case Report]

Palaniswamy, Chandrasekar; Selvaraj, Dhana Rekha; Chugh, Tarun; Singh, Tarunjit; Khalique, Omar; Tsai, Fausan; Sandhu, Rasham
Tricyclic antidepressants (TCAs) remain a common cause of fatal drug poisoning as a result of their cardiovascular toxicity manifested by electrocardiographic abnormalities, arrhythmias, and hypotension. The principal mechanism of toxicity is cardiac sodium channel blockade. Brugada electrocardiographic pattern (BEP) has also been described in TCA overdose. Currently, very little is known about the relationship between the Brugada syndrome and TCAs. We report the case of a patient who presented with BEP after intake of a high dose of amitriptyline. The patient was treated with continuous sodium bicarbonate infusion leading to resolution of BEP.
PMID: 19636245
ISSN: 1075-2765
CID: 1072782

Major adverse cardiac events in patients with moderate to severe renal insufficiency treated with first-generation drug-eluting stents

Sukhija, Rishi; Aronow, Wilbert S; Palaniswamy, Chandrasekar; Singh, Tarunjit; Sukhija, Rashmi; Kalapatapu, Kumar; Mohan, Diwakar; Pucillo, Anthony L; Sorbera, Carmine; Kakar, Priyanka; Weiss, Melvin B; Lal, Purshotam; Monsen, Craig E
No data are available comparing the long-term outcome of sirolimus-eluting stents (SESs) versus paclitaxel-eluting stents (PESs) in patients with moderate to severe renal insufficiency. The incidence of major adverse cardiac events (MACE), including death, myocardial infarction, and target vessel revascularization, during long-term follow-up were studied in patients with a glomerular filtration rate of <60 ml/min/1.73 m(2), as measured by the Modification of Diet in Renal Disease (MDRD) study equation, who also underwent percutaneous coronary intervention with drug-eluting stents. Of 428 patients studied, PESs were placed in 287 patients and SESs in 141 patients. Stepwise Cox regression analyses were performed to identify significant independent risk factors for MACE. At 47 + or - 19 months of follow-up, MACE had occurred in 49 (17%) of 287 patients in the PES group (mean age 71 + or - 11 years, 55% men) and in 31 (22%) of 141 patients in the SES group (mean age 71 + or - 12 years, 53% men). No significant difference was found in the MACE rate between the PES and SES groups. This persisted even after controlling for stent length, lesion complexity, and other co-morbidities. Also, all-cause mortality was not significantly different between the PES and SES groups (7.1% vs 8.5%, respectively). In conclusion, during long-term follow-up of patients with moderate to severe renal insufficiency, the rates of MACE and all-cause mortality were similar in the PES and SES groups.
PMID: 20102937
ISSN: 0002-9149
CID: 1072752